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Treatment of teeth with ‘hopeless’ crown-root fractures by surgical extrusion Treatment of teeth with ‘hopeless’ crown-root fractures by surgical extrusion Aukje Bouwman Bouwman and and Machteld Machteld Siers Siers Aukje Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands Introduction: Restoring a tooth with a traumatic crown fracture is usually possible, as isolation for the adhesive procedure is straightforward. However, in Introduction: Restoring a tooth with a traumatic crown fracture is usually possible, as isolation for the adhesive procedure is straightforward. However, in crown-root fractures the fracture outline often extends below the attachment level, rendering restoration impossible. Surgical extrusion is a procedure to save crown-root fractures the fracture outline often extends below the attachment level, rendering restoration impossible. Surgical extrusion is a procedure to save such teeth, by re-positioning the fracture outline to a restorable level such teeth, by re-positioning the fracture outline to a restorable level Case 1: A 21 year old female fell off her bike, resulting in an uncomplicated crown fracture of both upper lateral incisors, an extrusion of the right upper central Case 1: A 21 year old female fell off her bike, resulting in an uncomplicated crown fracture of both upper lateral incisors, an extrusion of the right upper central incisor and a complicated crown-root fracture of the left upper central incisor. At the first endodontic consultation the lateral incisors reacted sensitive to cold, incisor and a complicated crown-root fracture of the left upper central incisor. At the first endodontic consultation the lateral incisors reacted sensitive to cold, but the central incisors did not respond. The left central incisor had a deep subgingival fracture. It was surgically extruded and rotated to have the deep distal but the central incisors did not respond. The left central incisor had a deep subgingival fracture. It was surgically extruded and rotated to have the deep distal fracture margin on the labial side. A new splint was applied and oral hygiene instructions were given. After two weeks root canal treatments were performed in fracture margin on the labial side. A new splint was applied and oral hygiene instructions were given. After two weeks root canal treatments were performed in both central incisors. After six weeks the insicors were built up using a direct adhesive technique by Drs. Max Stel with an excellent esthetic result. Due to a preboth central incisors. After six weeks the insicors were built up using a direct adhesive technique by Drs. Max Stel with an excellent esthetic result. Due to a preexisting open bite there is no occlusal loading of the central incisors. After finishing the treatment a new orthodontic retention splint was placed. existing open bite there is no occlusal loading of the central incisors. After finishing the treatment a new orthodontic retention splint was placed. Courtesy Drs. Max Stel Courtesy Drs. Max Stel Case 2: Case 2: A 22 year old male received a beating, resulting in a deep subgingival fracture of tooth 22. A pulpectomie was performed. Tooth 22 was Case 2: Case 2: A 22 year old male received a beating, resulting in a deep subgingival fracture of tooth 22. A pulpectomie was performed. Tooth 22 was extruded and rotated 180 degrees for an optimal position for a new restoration. A root canal treatment was performed and after 6 weeks the splint was extruded and rotated 180 degrees for an optimal position for a new restoration. A root canal treatment was performed and after 6 weeks the splint was removed. The tooth was asymptomatic and showed limited mobility, and was restored with an esthetic composite restoration. removed. The tooth was asymptomatic and showed limited mobility, and was restored with an esthetic composite restoration. Discussion Discussion There are are several several treatment treatment options options for for aa deeply deeply fractured, fractured, unrestorable unrestorable tooth. tooth. The The tooth tooth can can be be extracted, extracted, but but as as the the patient patient is is often often immature, immature, permanent permanent There replacement is problematic. A second option is orthodontic extrusion. This allows for retaining pulp vitality, but rotation is not possible and it is a time replacement is problematic. A second option is orthodontic extrusion. This allows for retaining pulp vitality, but rotation is not possible and it is a time consuming process. process. A A third third option option is is surgical surgical extrusion. extrusion. During During this this procedure procedure the the root root can can be be optimally optimally positioned, positioned, predominantly predominantly rotated rotated in in order order to to relocate relocate de de consuming deepest fracture margin towards the buccal side where it can be more easily restored. An atraumatic luxation of the tooth and minimal extra-alveolar time are deepest fracture margin towards the buccal side where it can be more easily restored. An atraumatic luxation of the tooth and minimal extra-alveolar time are important to to avoid avoid replacement replacement resorption. resorption. important Conclusion Conclusion Surgical extrusion is a good alternative to extraction for teeth with a crown-root fractures Surgical extrusion is a good alternative to extraction for teeth with a crown-root fractures Clinical relevance Clinical relevance With this approach we can save teeth previously considered hopeless. The level of periodontal With this approach we can save teeth previously considered hopeless. The level of periodontal attachment is preserved which, enhances the esthetic result of the restoration and facilitates attachment is preserved which, enhances the esthetic result of the restoration and facilitates uncomplicated and and predictable predictable implant implant placement placement should should this this become become necessary. necessary. uncomplicated