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-INTERDISCIPLINARY MANAGEMENT OF SUBGINGIVAL FRACTURES

Subgingival crown-root fractures comprise 5% of traumatic injuries affecting the permanent dentition.
The fracture line involves enamel, dentin, cementum, and may or may not involve the pulp. Such
fractures are usually due to direct horizontal impact to the anterior teeth, whereas in posterior teeth,
they are due to indirect trauma to the chin 1.

DIAGNOSIS
Clinical diagnosis is easily made due to the mobility of the coronal fragment.

Radiographic diagnosis is difficult, especially if the fracture line is perpendicular to the X-ray beam.
Therefore, it is recommended to take atleast 4 radiographs (3 peri-apicals in different vertical
angulations & one steep occlusal) for any injury. Nowadays, cone beam computed radiography is
preferred as it provides accurate 3D information 2.

Grossly mutilated teeth pose mechanical, biological and esthetic challenges during restoration.

Gargiulo 3 reported average measurements of 2mm of biological width as the distance between base of
gingival sulcus to alveolar bone crest. Since the sulcus depth may be difficult to assess, a 3mm distance
from free gingival margin to crestal bone is taken as reference. To compensate for individual variability,
bone sounding followed by subtraction of sulcus depth from the value can be used to assess biological
width 4.

Restorations must be placed on sound tooth structure to be effective but due to proximity of fractures
to the alveolar bone crest, achieving minimum ferrule height of 1.5-2mm for post-retained crowns 5
without risking violation of biological width is impossible. Violating width leads to periodontal
complications over time, resulting in restorative failure. Additional concerns include moisture control,
isolation and esthetic concerns of the patient.

Therefore, exposure of the fracture margins by removal of the coronal fragment is key in order to assess
restorability of the tooth and for placement of margins atleast 3-4 mm (2 mm biological width+ 2mm
ferrule) from the bone crest5.

Tackling such cases requires a collaborative approach by a team including an endodontist, periodontist,
orthodontist and prosthodontist is indicated.

MANAGEMENT
UNCOMPLICATED CROWN-ROOT FRACTURE (Fractures that do not involve pulp):

1. REMOVAL OF CORONAL FRAGMENT FOLLOWED BY RESTORATION SUPRAGINGIVALLY /

ADHESIVE FRAGMENT REATTACHMENT:
-allows subgingival part of the fracture area to heal by formation of a long junctional epithelium
-coronal part of fracture area can be restored to a supragingival level using either the tooth
fragment itself after trimming off the subgingival portion or with composite resin
 ADVANTAGES:
• Quickest way to achieve esthetic and functional results in a single visit
• Soliman et al 6 concluded that it was a conservative approach with functional survival of 76.5%
at 9 years but found mild gingivitis in most cases, suggesting that it may work as a long-term
temporary which allows for future prosthetic interventions

COMPLICATED CROWN-ROOT FRACTURE (Fractures that involve pulp):

1. SURGICAL CROWN LENGTHENING

• It is a procedure done to increase height of clinical crown above alveolar bone crest by
atleast 3-4 mm through removal of soft /hard tissue or both in order to preserve biological
width (2 mm), thereby converting subgingival fracture margin into a supragingival one.
• The 3 methods to achieve crown lengthening are: gingivectomy, apically positioned flap
without /with osseous reduction. The first 2 have limited applications as they do not
increase distance between the bone and the margins of the defect.
• Apically positioned flap with osseous reduction is the method of choice.
• Although predictable & faster, its use in the esthetic zone for correction of a single tooth
issue is avoided due to the following complications7:

➢ Unnecessary loss of periodontal ligament & marginal bone of adjacent teeth

➢ Higher gingival contour than adjacent teeth

➢ Unfavorable crown root ratio (<1:1)

➢ Gingival recession (if gingival margin was already at CEJ level prior to surgery)

➢ Loss of interdental papilla leading to black triangles

2. ORTHODONTIC EXTRUSION/FORCED ERUPTION

This modality produces traction forces in the periodontal ligament and by doing so,
stretches them and stimulates osteoblasts to deposit bone.
Types:
• Slow
• Rapid

Low, continuous forces< 30 g cause slow extrusion of the tooth along with periodontal
apparatus at a rate of 1-2mm per month. Once the desired level is reached, a long
stabilization period aids in remodelling of tissues to the new coronal position. A week of
stabilization per mm extruded is advisable.

Higher forces>50 g allow tooth migration alone leaving behind the periodontium to achieve
an extrusion rate of around 1mm a week. Supracrestal fibrotomy may need to be carried out
every 7-10 days to excise the gingival fibres away from the tooth. This removes tensile stress
on the bone and sustains a level of inflammation which allows the tooth to erupt on its own.
A longer stabilization period of 8-12 weeks is needed for remodelling to occur.
 Advantages:
• Conservative approach that preserves periodontal support of adjacent teeth
• Natural biological width formation
• Favourable crown:root ratio

Disadvantages:
• Longer duration of treatment
• produces reverse bone architecture which requires additional surgery to correct
bone height around the tooth (slow extrusion)
• crowns may be over-contoured at the cervical area due to increased convergence

Extrusion can be achieved through a variety of appliances, both removable and fixed with
various attachments such as hooks, elastics, magnets. Fixed appliances tend to have more
predictable outcomes.

3. SURGICAL EXTRUSION/ INTRALVEOLAR TRANSPLANTATION

It is defined as “purposeful removal of a tooth & its almost immediate replacement with the
objective of obturating the canals apically when the tooth is out of its socket”.
Performing the extrusion before endodontic treatment is better to avoid more trauma to the
tooth 1. Following removal, pulp may be extirpated and the tooth can be placed back in a more
coronal position & stabilized using a splint for upto 2 weeks. Palatally inclined fractures are
often rotated 180° before stabilization so that it faces labially making it easier to restore. The
Benex extraction system is favored due to its exclusively vertical force during extraction without
damage to bone9.

Advantages:
• Decreased treatment time

Disadvantages:
• Risk of damage to periodontal ligament leading to ankylosis, resorption

Elkhadem et al reported that resorption was the most common adverse effect, occurring at
a rate of 30%10.

4. EXTRACTION
• Indicated when the fracture involves more than a third of the root length or if there is
an intra-alveolar root fracture with communication to sulcus in coronal third of the root.
• It must always remain a last resort option for young permanent dentition where there is
insufficient bone to support an implant12.

5. VITAL ROOT SUBMERGENCE

 It is an alternate to tooth extraction, wherein the fractured root (following endodontic therapy)
is left behind within bone under a pontic in order to preserve it until further replacement by an
implant11.

*in case of immature permanent teeth, all attempts to allow for closure of apex through
apexogenesis /apexification must be carried out along with any of the above-mentioned
procedures as indicated by the clinical condition12.

6. POST-ENDODONTIC RESTORATION:
Following endodontic therapy, a post is needed to provide retention form and support for
future crowns5. Cast posts have declined over time and have been replaced with pre-fabricated
posts due to esthetics, time efficiency, similar elastic modulus to dentin, and relatively lesser
number of catastrophic failures13.

CONCLUSION
Management of subgingival fractures depends on a number of factors such as depth and level of
fracture, pulpal and periodontal status of the tooth, root development status, esthetic demands
of the patient & time. Addressing these concerns through the concerted efforts of a
multidisciplinary team helps deliver the best possible treatment which may add several years of
service to badly broken-down teeth.

REFERENCES:
1. Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John
Wiley & Sons; 2018 Dec 17.
2. Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology-E-Book. Elsevier Health Sciences; 2006 Oct 2.
3. Gargiulo A, Krajewski J, Gargiulo M. Defining biologic width in crown lengthening. CDS review. 1995 Jun;88(5):20-3.
4. Kois JC. The restorative‐periodontal interface: biological parameters. Periodontology 2000. 1996 Jun;11(1):29-38.
5. Juloski J, Radovic I, Goracci C, Vulicevic ZR, Ferrari M. Ferrule effect: a literature review. Journal of endodontics. 2012
Jan 1;38(1):11-9.
6. Soliman S, Lang LM, Hahn B, Reich S, Schlagenhauf U, Krastl G, Krug R. Long‐term outcome of adhesive fragment
reattachment in crown‐root fractured teeth. Dental Traumatology. 2020 Feb 7.
7. Nobre CM, de Barros Pascoal AL, Souza EA, Shaddox LM, dos Santos Calderon P, de Aquino Martins AR, de
Vasconcelos Gurgel BC. A systematic review and meta-analysis on the effects of crown lengthening on adjacent and non-
adjacent sites. Clinical oral investigations. 2017 Jan;21(1):7-16.
8. Canjau S, Stefan C, Szuhanek CA. Alternative treatment approach for anterior subgingival dental lesions: Forced eruption
using attractive magnets. American Journal of Orthodontics and Dentofacial Orthopedics. 2020 Jul 1;158(1):126-33.
9. Dietrich T, Krug R, Krastl G, Tomson PL. Restoring the unrestorable! Developing coronal tooth tissue with a minimally
invasive surgical extrusion technique. British dental journal. 2019 May;226(10):789-93.
10. Elkhadem A, Mickan S, Richards D. Adverse events of surgical extrusion in treatment for crown–root and cervical root
fractures: a systematic review of case series/reports. Dental Traumatology. 2014 Feb;30(1):1-4.
11. Choi S, Yeo IS, Kim SH, Lee JB, Cheong CW, Han JS. A root submergence technique for pontic site development in fixed
dental prostheses in the maxillary anterior esthetic zone. Journal of periodontal & implant science. 2015 Aug 1;45(4):152-
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12. Koyuturk AE, Malkoc S. Orthodontic extrusion of subgingivally fractured incisor before restoration. A case report: 3‐years
follow‐up. Dental traumatology. 2005 Jun;21(3):174-8.
13. Figueiredo FE, Martins-Filho PR, Faria-e-Silva AL. Do metal post–retained restorations result in more root fractures than
fiber post–retained restorations? A systematic review and meta-analysis. Journal of endodontics. 2015 Mar 1;41(3):309-
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