Multidisciplinary Approach to Complicated Crown-root Fracture Treatment: A Case Report

SUMMARY Treatment of complicated crown-root fractures is one of the most challenging within the various types of dental trauma and requires a multidisciplinary approach. This paper reports the complicated crown-root fracture of a maxillary right central incisor, in which there was esthetic, functional, and biologic (endodontic and biologic width invasion) involvement. A 15-year-old male patient presented to the dental clinic one month after suffering trauma with a complicated crown-root fracture on tooth 8. The patient had previously undergone endodontic treatment and was sent to have periodontal surgery to reestablish the biological width on the palatal surface. Following the surgery, a fiberglass post was cemented, and the fragment was reattached. This approach allows the exposure of the cervical margin, adequate isolation, and subsequent fragment reattachment in the same clinical appointment. Fragment reattachment is a viable approach as it is a simple and conservative procedure that restores the natural esthetic of the tooth and has superior resistance compared to a composite restoration. The patient’s cooperation in understanding the limitations of the treatment and maintaining adequate oral hygiene are very important to achieving a good prognosis of the case. After a 2-year clinical and radiographic follow-up period, the clinical protocol was found to be successful, and the tooth remained functional, esthetically favorable and asymptomatic.

Integrated clinical treatment of external cervical resorption: Case report

External cervical resorption (ECR) has an inflammatory nature and the proximity to the gingival sulcus favors contamination and progression of the lesion. Change in crown color, inflammation of the marginal gingiva or even the presence of secretion in the gingival sulcus are the main clinical signs. Being an asymptomatic lesion, it can be neglected and its progression can jeopardize the tooth involved. This report describes the treatment of a patient who presented two teeth with ECR. On clinical examination, the crown of tooth 17 showed a pinkish translucency on the occlusal surface. On tooth 12, this spot was dark and located in the cervical third of the labial surface of the crown. Both the teeth were asymptomatic, and the radiographic examination showed an image comparable with root resorption in the cervical third of the crown. On tooth 17, the middle and cervical third of the crown was compromised and the pulp vitality test was negative. The treatment for the case was extraction. A tomographic examination of tooth 12 demonstrated pulpal involvement and biologic width violation. The vitality test was positive. After endodontic treatment, the tooth was extruded by 4 mm, the resorbed area was exposed and restored with composite resin. A 39-month clinical and radiographic control showed integrity of the root surface and the periodontium. It was found that early diagnosis influences the prognosis of treatment considering the speed of progression of resorption. It emphasizes the importance of clinical and radiographic control of the clinical conditions that predispose to ECR.

RECENT ADVANCES ON GINGIVAL TISSUE MANAGEMENT IN RESTORATIVE DENTISTRY

Marginal integrity is one of the main factors that contribute to the outcome of a restoration and longevity of the restoration and cast restorations. An increased significance on the perio–restorative interface in restorative dentistry is essential to enable the utilization of the concept of biologic width in a practical manner. The goal, regarding the management of gingival tissues, is to ensure that the peridontium is in a healthy state. The oral cavity is a difficult to treat because of lips, cheeks, and tongue that hinders and makes it difficult to visualize and manipulate instruments in the area to be treated related. Gingival retraction is essential to perform better when the finish lines of the restoration is below the gingival margin. There are various gingival retractions that have been employed previously like mechanical, chemical, surgical and chemomechanical procedures. These methods not only provide an ideal working environment and ample vision, but also maintain hemostasis to certain extent. The choice of a retraction method depends on clinical situation and accessibility. The purpose of this review is to demonstrate the recent retraction materials and techniques.

BIOLOGIC WIDTH CONCEPT IN GINGIVECTOMY

Background: Relationship between periodontal tissue and aesthetic considerations is an important thing to determine the form, function and aesthetics of periodontal tissue itself. For orthodontic cases with gingival enlargement, using the biological width concept in gingivectomy to facilitate an optimal oral hygiene maintenance, function and aesthetic. Bone sounding before gingival recontouring is dictated by the distance from the gingiva crest to alveolar crest. Recommended distance between margins restoration and alveolar bone crest is 3 mm to avoid breaching the biologic width.Case and Case Management: Case 1: A 21 years old female patient whom referred from orthodontist with gingival enlargement in upper front teeth after treated with fixed orthodontic for 1.5 years. PBI: 1,6. After clinical examination, bone sounding was performed = 7mm and gingivectomy without ostectomy was determined. Case 2: A male patient, 24 years old, with gingival enlargement in upper front teeth while treated with fixed orthodontic. After determined the problem, bone sounding (6 mm) was performed along with gingivectomy without ostectomy also for anterior upper right site.Conclusion: The purpose of this report is to provide a diagnostic rationale for gingival recontouring. When gingivectomy is determined, the concept of biological width must be applied achieve a harmonious gingival contour with an optimal oral hygiene maintenance.

Crown Lengthening Procedure: Report of Two Cases

Crown lengthening is a surgical procedure designed to increase the extent of the supragingival tooth structure, so that the clinician can restore the tooth. Crown lengthening procedure is done to maintain normal biologic width and increase crown length for retention of prosthesis. Various techniques have been proposed to perform CLP, such as gingivectomy, undisplaced flap with or without osseous reduction, apically repositioned flap with or without bone reduction, and orthodontic forced eruption with or without fibrotomy. Selection of one of this CLP technique depends upon esthetics, clinical ratio of crown to root, structure of root, location of furcation, position of tooth and the capacity of the tooth to be restored. This case report illustrate two different methods of doing crown lengthening procedure the selection of case depends upon various soft tissue and hard tissue parameters. Owing to the various advantages, disadvantages and associated limitation with different methods, we opted for surgical CLP with scalpel method. Uneventful healing was observed in both our cases. No post-operative complications was observed in both cases. Thus to conclude success rate of CLP is high but appropriate selection of case is required. In our case report both the methods of CLP shows significant result in increasing the crown length and maintaining the biological width.

Prevalence of different methods of crown lengthening and its preference among dental specialties

Short clinical crowns often lead to poor retention form, leading to improper tooth preparation. Crown lengthening is carried out to increase the clinical crown length without violating the biologic width. Several techniques have been proposed for crown lengthening such as gingivectomy procedures. A Cross-sectional, descriptive study was conducted in a university, on randomly selected individuals. The study group consisted of patients getting treated at the Department of Prosthodontics from June 2019 – March 2020. 86,000 case sheets were reviewed, and samples were selected using simple random sampling. The two variables were compared using the chi-square test. Laser gingivectomy was the most common 55.9% form of crown lengthening procedure. Awareness of crown lengthening was found more among postgraduates at 78.7%. Among all the departments, crown lengthening was required more for periodontal procedures 42.3%. In this era of quickly developing technologies and innovative ideas, the requirement for faster treatment has not only become a requirement but a necessity. Treatment with lasers is well accepted by patients as it is less time-consuming and painless. Lasers have taken over a lot of procedures so is crown lengthening. Postgraduates know more about crown lengthening and hence do in more number of cases. There are various reasons to get crown lengthening done with periodontitis being the most common specialty for its need.

The Complications of Biologic Width in Esthetic Anterior Restorations: A Case Report and Review

The biologic width is a specific concept that refers to the dimensional relationship between epithelial attachment, sulcus depth, connective tissue attachment, and alveolar crest. A harmony and precise relationship between periodontal tissue and the restoration of the teeth is fundamental to ensure function and esthetic. Biologic width includes both the connective tissue attachment and the junctional epithelium and has a mean dimension of approximately 2 mm. Violation of biologic width can result in localized crestal bone loss, gingival recession, localized gingival hyperplasia, or a combination of these three. Maintenance of gingival health is one of the keys to the longevity of both the teeth and restorations. A clinical crown lengthening procedure is needed to establish the biologic width, in a condition where a restored tooth developed a subgingival caries, fractured below the gingival attachment or failed crown restoration. This article presents a case reports and review that utilized gingivectomy procedures to corrected the complications because of the violation of biologic width.

Biologic width-A Review

Replacement of missing, damaged, or unaesthetic tooth by dental prostheses helps the patient to rehabilitate the structure and function of the lost tissues. During delivery of the prostheses, the overall health of the oral tissues, including the periodontium, must be considered. The gingival tissues must be healthy and it is of paramount importance to respect the biologic width of the tissues. The biologic width varies among different individuals and at different sites of the same individual. Instead of following a mean value, each patient should be examined to determine the biologic width. In case violation of biologic width is anticipated, appropriate measures should be adopted to maintain the dimensions of the biologic width.