Trauma to the teeth may result in different types of injuries to the teeth and supporting structures.[1] Anterior teeth fractures represent the most common type of dental trauma. Crown–root fractures (CRFs) are frequently encountered in the dentist’s daily practice. [2] Crown–root fracture can be classified as uncomplicated and complicated based on the degree of pulpal involvement [3] Complicated crown root fractures involve the enamel, dentin, and cementum with pulp involvement, whereas cervical root fracture involves the cementum, dentin, and pulp extending from the alveolar bone crest up to 5 mm below.  The prevalence of CRF is 5% in permanent dentition, while all root fractures affect 0.5–7% of permanent teeth.[4] These fractures are most commonly seen in maxillary anteriors, which possess major concerns regarding aesthetics and emotional concerns. [5]

Fracture lines located in the gingival connective tissue, as seen in crown-root and cervical root fractures, complicate restoration by risking biological width violation, which can lead to gingival inflammation, attachment and bone loss, and clinical signs such as bleeding, pocket deepening, or recession.[6]

Several treatment options exist for managing crown-root fractures—such as gingivectomy, apically positioned flap surgery, surgical or orthodontic extrusion, and extraction for extensive fractures but each has limitations, particularly in aesthetically sensitive areas.[2] .

The factors that determine the choice of treatment are type of severity of fracture, the extent of fracture line, time, and cost [7]. Surgical extrusion is a procedure that repositions the remaining tooth structure coronally within the same socket to expose sound tooth structure, enhancing restorability and allowing reestablishment of the biological width. [8] The technique, available in various forms as a one-step procedure, has proven effective and can be applied to roots typically considered non-restorable, thereby enabling bone preservation. [9]. Surgical extrusion offers potential advantages over crown lengthening and orthodontic methods, demonstrating predictable outcomes in both short- and long-term scenarios. [10]

In this case report we describe a complicated crown-root fracture of the left maxillary canine which was managed with surgical intervention using surgical extrusion with tooth rotation followed by crown lengthening instead of coronectomy or tooth extraction.

A 34-year-old female patient reported to the outpatient department of Amrita institute of dental sciences with a fractured left maxillary canine while having food the previous day. She gave a history of root canal treatment a month back. No clicking or deviation of the temporomandibular joint was noted. The patient was not having any medical history.

On clinical examination fractured coronal tooth structure was seen in relation to #23, with the fracture line extending subgingivally. (Fig 1.a) Tenderness on percussion and palpation was noted. RVG showed loss of coronal tooth structure involving enamel, dentin extending subgingivally. Widening of the pulp chamber and root canal space were noted suggestive of attempted root canal treatment of the tooth. Widening of the periodontal ligament space was also noted. (Fig 1.b)

A diagnosis of Ellis Class 8 fracture with asymptomatic apical periodontitis was made about #23. [11] Various treatment options were explained to the patient. Due to an aesthetic concern and the need for an immediate result, the patient opted for surgical extrusion. Hence surgical extrusion of #23 followed by post & core and crown was decided upon.

Procedure Steps

Local anaesthesia (2% lignocaine with adrenaline (1:80,000), Septodont) was administered, and the loosened tooth fragments were removed, and the extent of the fracture was inspected.

After local anaesthesia, mucoperiosteal flaps were reflected, and the teeth were carefully luxated using curved periotomes to prevent damage to the marginal bone or root surface. The luxated teeth were carefully switched and rotated 180 degrees atraumatically using bayonet forceps so that their palatal aspects were buccally turned. Consequently, the fracture margins were positioned at least 2 mm above the bone crests. Interdental sutures were also placed (Black silk 2/0 suture, SC242). [Figure 2]

A semi-rigid splint using 0.012 NiTi wire (NiTi Spool, USA) was applied to stabilize the extruded tooth, spanning three teeth from the maxillary left first premolar to the maxillary left lateral incisor, and was bonded to the adjacent teeth with composite resin (IVOCLAR Tetric-N-Flow). [Fig 3]

Immediately tooth was reaccessed, and non-setting calcium hydroxide medicament (Prime Dental Rc) was placed inside the canal to prevent inflammatory root resorption. Closed dressing with zinc oxide eugenol given (Kalzinol).

Recall visit 1: After one week, sutures were removed.

Recall visit 2: 3 weeks later, once the tooth was stabilized and there were no signs of inflammation, semi-flexible splint was removed. In the same visit, chemo-mechanical preparation of #23 was done. Working length was determined using the radiographic method and estimated to be about 17.5 mm [Fig 4.a] The canals were prepared up to 40k file and then filled with non-setting calcium hydroxide paste (Prime Dental Rc) up to the prepared canal length using lentulo-spiral.

The canal orifice was sealed with a cotton plug and zinc oxide eugenol (Kalzinol), and the patient was reviewed after 1 week.

Recall visit 3: Since the patient was asymptomatic, Gutta-percha master cone (40,2) (Dentsply Sirona, USA) [Figure 4.b] was selected and obturation was done using the lateral compaction technique and bioceramic sealer (Safe Endo Bioactive RCS) [Figure 4.c]. Post endo restoration with Type IX GIC (GC Gold Label 9 Posterior Restorative) given.

Recall visit 4: Post space preparation was done using peso reamers and enlarged up to size 3 [Fig 5.a]. Following this resin wax pattern (GC Pattern Resin Ls) was recorded for cast post fabrication. [Fig 5.b].

Recall visit 5:  After 2 days, a cast post (base metal alloy) trial check [Fig 5.c] was done, and it was luted using Type 1 GIC (GC Gold Label Type 1 Luting) [Fig 5.d]. After this tooth preparation was done for metal ceramic crown and after 5 days the crown was cemented using Type 1 GIC. [Fig 6]

The patient was kept under follow-up every three months to check for further complications, and it was noted that in 12^th month follow up she was completely asymptomatic and there was good periodontal attachment.

Complex crown-root fractures require meticulous consideration of treatment options, accounting for fracture placement, expected crown-root ratio, patient's age, preferences, and overall health. Surgical extrusion represents the separation of bone-root periodontal attachment using surgical instruments such as fine elevators, periotomes, forceps, scalpel, for placing the tooth in a more coronal position with the aim to obtain supra gingival sound structure to be able to perform a proper long time lasting final restoration, without risk of damaging periodontal tissues and invading biologic width. [11] Once the extruded root has been stabilized, the tooth can be restored.[9]

In maxillary anterior teeth, crown-root fractures have a typical fracture line: on the labial side, the fracture is localized paragingivally or supragingivally, while palatally, the defect often extends into the intraosseous root region. In contrast, the bone level of the alveolar process in the upper anterior region is more coronally on the palatal side compared to the labial side. For that reason, rotation of the root by 180 degrees before replantation is ideal to expose the defect margin on both aspects while minimizing the extrusion distance at the same time. [12]

A flexible splint allowing physiologic tooth mobility is applied to reduce the risk of ankylosis. [13] Due to a mismatch between the socket and the extruded root, the splinting period may be longer than that after replantation of avulsed teeth and can be extended up to 6 weeks, particularly in cases of high mobility of the extruded root.[14][15] Endodontic treatment should be initiated following the treatment of avulsed teeth within the first 2 weeks after replantation to avoid infection-related root resorption. [16][17] Restorative treatment is usually performed 6 to 8 weeks after surgical extrusion.

Surgical extrusion treatment outcome is considered successful when periodontal healing is present, without root resorption or ankylosis. Age did not appear to have an impact on these results. [18] Previous studies, including most clinical studies that evaluated the success rates of surgical extrusion over the last four decades, have concluded that this treatment should be considered an important technique for managing teeth with subgingival fractures or caries. [18-22]

Success in surgical extrusion with 180-degree rotation requires proper case selection, contraindicating the procedure in cases of pronounced mobility, gingival inflammation, and teeth with divergent roots or dilacerations.[19] To mitigate risks of root resorption and ankylosis, preserving the periodontal ligament’s integrity is imperative. This involves minimizing extra alveolar time, preventing contamination, and implementing atraumatic extraction procedures. [5]

A recent systematic review focusing on the adverse events of surgical extrusion based on 11 case reports and 8 case series involving 226 mostly young patients with 243 teeth revealed that nonprogressive root resorption was the most common finding, with an event rate of 30%, followed by tooth loss (5%), slight mobility (4.6%), marginal bone loss (3.7%), and progressive root resorption (3.3%). [20] However, Tegsjo et al. considered it as a “healed” root resorption and a reparative event rather than a harmful one. [21]

In the presented case, surgical extrusion was chosen due to the unfavourable subgingival extension of the fracture line, which compromised restoration without violating the biologic width. The procedure was completed atraumatically, preserving the periodontal ligament, which is critical for minimizing root resorption and promoting periodontal healing. Follow-up showed successful healing with stable periodontal support and no signs of pathology, indicating the viability of this technique in appropriate cases

Thus, this approach of treatment offers many advantages, as it is a conservative method that allows retention of the tooth, restores the periodontal attachment, and alveolar bone is preserved.  As aesthetics is the main concern in the anterior region, it maintains the gingiva in position.

Surgical extrusion can be suggested as a suitable treatment option in the management of highly damaged anterior teeth. The present case demonstrates the success of surgical extrusion with a 180° rotation in teeth with complex crown-root fractures. The precise intra-alveolar replantation, combined with thorough treatment planning, achieved favourable outcomes. Strategic tooth rotation optimized the restoration process, particularly for oblique fractures. This strongly implies surgical extrusion as an effective and cost-efficient therapeutic alternative, providing valuable insights into managing complicated crown-root fractures and also emphasizes the significance of tailored approaches for successful outcomes in challenging cases.

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