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Forced eruption in the treatment of transverse root fractures
,W )A
C l in ic a l R e p o r t s
Forced eruption in the treatment of transverse root fractures G. Bradley Garrett, DDS
Orthodontic eruption was used to treat teeth in two patients to facilitate restoration and avoid extraction or periodontal surgery.
A
JL A . root fracture near the alveolar bone
is a difficult restorative problem. Peri o d o n ta l surgery has been used to lengthen the clinical crown, thereby al lowing the tooth to be restored. However, as a result of periodontal surgery the crown of the restored tooth may be longer than the contralateral tooth. The appear ance may not be esthetically pleasing, es pecially if the involved tooth is a central incisor. A new approach, presented in the past decade, permits erupting the tooth with orthodontic treatment, thus exposing sound tooth structure to facilitate restora tion.1-7The forced eruption approach has an esthetic advantage over the periodon tal surgery approach as the length of the clinical crown remains the same. Also, as the tooth and surrounding periodontium are erupted, the length of the tooth seg ment above the alveolar crest becomes shorter, resulting in a more favorable crown-to-root ratio.4 The two cases presented here show dif ferent aspects of this new approach. In the first case presented, a periodontal pocket is reduced as the tooth is erupted and in the second case, the technique is mod ified to accommodate the patient wearing a partial denture. R e p o rt o f case CASE 1 . A 16-year-old Hispanic male had pain
and mobility in the maxillary right central in cisor. Radiographs disclosed a fracture in the cervical area at the level of the crestal bone with a 6-mm pocket on the mesiolingual aspect 270 ■ JA D A , V ol. I l l , A ugust 1985
(Fig 1). A football injury caused trauma to the patient’s mouth 11 months before. The patient stated that the tooth was initially sensitive to cold, but that this sensitivity subsided after 1 month. No previous dental treatment had been sought regarding this injury. The entire crown was removed and end odontic therapy was initiated. To help main tain isolation, three thread-mate-system pins were placed and glass ionomer cement was placed on the tooth. The canal was filled with gutta-percha and zinc oxide-eugenol. The tooth was also scaled and root planed. An extrusion postwithahook was fabricated from .036-inch orthodontic wire. A post hole was prepared in the tooth, and the loosely fit ting extrusion post was cemented into place with zinc phosphate cement. An anchor bar, previously adapted to a study model of the tooth, was positioned to pass over the center of the involved tooth. The anchor bar was then attached to the two adjacent teeth with acidetch composite resin (Fig 2). An elastic band was attached to the hook, over the anchor bar, and to the hook again, to provide the eruption force (Fig 3). A temporary polycarboxylate crown was constructed for the patient to wear during the forced eruption phase. Most of the lingual as pect of the polycarboxylate crown was re moved, and slots were made in the mesial and distal aspects of the crown so that the crown would fit over the anchor wire and not interfere with the elastic band. The temporary crown was then cemented to the anchor bar and adja cent teeth with glass ionomer cement (Fig 4). Thus, the crown could be easily removed and recemented for adjustments, and provided an esthetically acceptable temporary appliance for the patient between visits. The patient was seen every 3 to 5 days to adjust the elastic band. Initially, the extrusion post was 2.5 mm from the anchor bar; by the 21st day, the tooth had erupted so that the extrusion post was 0.5 mm from the anchor bar (Fig 5). During this period, the periodontal pocket on the mesiolingual aspect decreased from 6.0 to 4.0 mm. The decrease in pocket depth (2 mm) is the same as the distance the tooth was extruded. The tooth was then stabil ized by adapting acrylic resin around the an
chor wire and hook. The acrylic resin was built up and shaped into the form of a tooth; the resin appliance served as a temporary crown during the stabilization period. After an 8-week stabilization period, the anchor bar and acrylic temporary appliance were removed. The extrusion post was twisted with a hemostat, loosening the post and allowing the post to be easily removed from the tooth. A post and core were placed, and a gingivectomy was per formed on the lingual aspect to further expose sound tooth structure. The tooth was slightly mobile after the stabilization period, but the mobility was negligible by the time the final restoration was placed 2xk months later. The tooth was restored with a porcelain-fused-tometal crown (Fig 6). The final depth of the gingival crevice was 2.0 mm. CASE 2. A 62-year-old white female had a frac ture of the maxillary left canine, which had been previously treated endodontically. The facial aspect of the tooth had fractured from the tooth to the level of the alveolar crestal bone (Fig 7). Replacing the silver point fill with gutta-percha was considered to place a post and core, which would have been the preferred treatment. However, financial considerations on the part of the patient determined a less expensive treatment. In addition, sufficient tooth structure remained to allow a composite pin buildup to be adequate. Conventional treatment consisting of periodontal surgery was performed to expose sound tooth struc ture, and a composite pin buildup was placed. Because of periodontal surgery, the gingival contour was superior to that of adjacent teeth and would produce an unesthetic end result. If the tooth was erupted, however, the gingiva and supporting periodontium would erupt with the tooth, allowing the gingiva to be at the same level as adjacent tissues. Thus, after de termining that the conventional treatment for such a fracture would not produce the desired esthetic results, the newer approach of forced eruption was used before the final restoration was placed. The second premolar distal to the fractured canine was one of the abutments for a partial denture; if the anchor bar was attached to the second premolar, the patient would not be able
C L I NI CA L
REPORTS
Case 1
Fig 3 ■ Elastic band in place.
Fig 1 ■ Radiograph of maxillary right central incisor with trans verse fracture.
Fig 2 ■ Anchor bar and extrusion post in place, before eruption.
Fig 4 ■ Temporary acrylic appliance in place (erup tion phase).
Fig 5 ■ Clinical appearance after eruption.
Fig 6 ■ Radiograph of final res toration.
Case 2
_______ Fig 9 ■ After eruption, tooth is in contact with anchor bar. Fig 8 ■ Anchor bar and extrusion post in place, but not yet attached to lateral incisor. Fig 7 ■ Radiograph of maxillary left canine fractured on facial as pect to level of crestal bone.
Fig 10 ■ Radiograph of final restoration, 2 months after eruption; radiolucent area at apex is associated with tooth movement.
Fig 11 ■ Final restoration has porcelain-fusedto-metal crown.
Garrett : ERUPTION IN TRANSVERSE ROOT FRACTURE ■ 271
C L I NI CA L
REPORTS
to wear the partial denture. To avoid move ment of the tooth during the eruption and stabilization phase of treatment, the anchor bar was attached to the central and lateral incisors and adapted so that the partial denture could be worn (Fig 8). The tooth was reduced on the lingual and incisal aspects to allow room for eruption; a post hole was prepared in the crown of the tooth, and an extrusion post was cemented in place. An elastic band was then attached to the anchor bar and to the extrusion post to provide the eruptive force. The patient was seen every 3 to 5 days to adjust the elastic band. After 16 days, the extrusion post was in contact with the anchor bar (Fig 9); the extrusion post had orig inally been positioned 2.0 mm from the anchor bar. The tooth was stabilized with composite resin for an additional 6 weeks, and restored with a porcelain-fused-to-metal crown (Fig 10, 11).
Discussion The forced eruption technique presented is not without problems. Some mobility was present in the first case and was the main factor in the decision to not erupt the tooth further. In retrospect, however, the tooth should have been erupted more slowly, stabilized after the mobility was noted, and then erupted further after the tooth had been stabilized. This would have made sound tooth structure more accessible, and would have allowed con struction of a more biologically compati ble restoration. In the second case, there was no mobil
ity throughout the procedure. Sound tooth structure was obtained in an ideal position, thus allowing construction of a more biologically compatible restoration. A side benefit of this technique is that the periodontal status of the tooth may improve. This was seen to some extent in the first case in which the 6-mm pocket was reduced by 2 mm by erupting the tooth (the pocket was reduced further after minor periodontal surgery). As shown by Ingberg,4 the peridontium may erupt with the tooth so that a periodontal bony defect may be greatly improved or eliminated. Many times, the gingiva and crestal bone of the erupted tooth may be erupted into a position higher than the adjacent teeth, in which case periodontal surgery w ould be required to obtain proper contour of the gingival tissues and crestal bone. This treatment modality may allow the practitioner to adapt to different clinical situations, as the technique does not re quire the tooth to be immediately mesial and distal to the involved tooth. With proper case selection, forced eruption can be a useful treatment modality in the treatment of transverse root fractures.
Summary A relatively new method for treating transverse root fractures near the gingival crevice is reviewed. Two cases are de scribed in which the fractured teeth are
orthodontically erupted to facilitate res toration. A periodontal pocket was re duced in the first case, and the technique was modified to accommodate a patient wearing a partial denture in the second case. The technique appears to be a favor able alternative to extraction or periodon tal surgery.
__________________________ JRO& The author thanks Drs. Diana Compton, Gerald Froemming, and Jack Turne, for their assistance and support of this m anuscript. Dr. Garrett is in private practice, 6918 W Military Dr, San A ntonio, TX 78227. Address requests for re prints to the author. 1. Delivanis, P.; Delivanis, H.; and Kuftinec, M. E ndodontic-orthodontic m anagem ent of fractured anterior teeth. JADA 97(3):483-485, 1978. 2. Hartwell, G.R., and Cecie, P.A. An esthetic re storative technique for use during the stabilization period after vertical root extrusion. JADA 107(1):5960, 1983. 3. H e ith e rs a y , G.S. C o m b in e d e n d o d o n tic orthodontic treatm ent of transverse root fractures in the region of the alveolar crest. Oral Surg 36:404-415, 1973. 4. Ingberg, J.S. Forced eruption. A m ethod of treat ing nonrestorable teeth—periodontal and restorative considerations. J Periodontol 47(4):203-216, 1976. 5. Ivey, D.W., and others. O rthodontic extrusion: its u se in resto rativ e d en tistry . J P ro sth et D ent 43(4):401-407, 1980. 6. Simon, J.H., and others. Extrusion of endodontically treated teeth. JADA 97(l):17-23, 1978. 7. Tofsky, N.S., and Tsam tsouris, A. O rthodontic treatm ent of an Ellis Class VIII fracture. J Pedod 3(2):165-175, 1979.
Cyclosporine-induced gingival hyperplasia: case report and literature review Joel A. Bennett, DDS James M. Christian, DDS The diagnosis and treatm ent o f a patient receiving immunosuppressive therapy fo r the prevention of renal allograft rejection are discussed.
r
%. J vclosporine is a potent im m uno suppressive agent that prolongs the sur vival of allogeneic transplants in humans. It is a cyclic polypeptide comprised of 11 amino acids and is produced as a metabo 272 ■ JA D A , V ol. I l l , A ugust 1985
lite of the fungus Tolypocladium inf la tum Gams. The agent’s proposed mechanism of action is via its specific and reversible inhibition of im m uno competent lymphocytes. T-lymphocytes are preferentially inhibited, and it is this suppression of the cellular immune re sponse and the subsequent sparing of the humoral response and bone marrow that make cyclosporine an ideal agent to use in the prevention of allograft rejection. Cyclosporine is available both in intra venous and oral formulas. It is recom mended that the initial oral dose be given 4 to 12 hours before surgery, as a single loading dose of 15 mg/kg/day. This dos age should be continued through the sec
ond postoperative week and then de creased by 5% a week until a maintenance dosage of 5 to 10 mg/kg/day is reached. The drug concentration can be measured in the patient’s serum by radioimmuno assay. Normal trough plasma levels of cyclosporine are 50 to 150 mg/ml. The drug level as well as plasma blood urea nitrogen, creatinine, and liver function tests should be monitored periodically. Cyclosporine has several side effects. In a study by Ota and Bradley,1 which re viewed the cyclosporine treatment of 100 renal allograft recipients, the following complication rates were reported: hepatotoxicity, 53%; nephrotoxicity, 50%; trem ors, 15%; hirsutism , 12%; g in g iv a l
C l in ic a l R e p o r t s
Forced eruption in the treatment of transverse root fractures G. Bradley Garrett, DDS
Orthodontic eruption was used to treat teeth in two patients to facilitate restoration and avoid extraction or periodontal surgery.
A
JL A . root fracture near the alveolar bone
is a difficult restorative problem. Peri o d o n ta l surgery has been used to lengthen the clinical crown, thereby al lowing the tooth to be restored. However, as a result of periodontal surgery the crown of the restored tooth may be longer than the contralateral tooth. The appear ance may not be esthetically pleasing, es pecially if the involved tooth is a central incisor. A new approach, presented in the past decade, permits erupting the tooth with orthodontic treatment, thus exposing sound tooth structure to facilitate restora tion.1-7The forced eruption approach has an esthetic advantage over the periodon tal surgery approach as the length of the clinical crown remains the same. Also, as the tooth and surrounding periodontium are erupted, the length of the tooth seg ment above the alveolar crest becomes shorter, resulting in a more favorable crown-to-root ratio.4 The two cases presented here show dif ferent aspects of this new approach. In the first case presented, a periodontal pocket is reduced as the tooth is erupted and in the second case, the technique is mod ified to accommodate the patient wearing a partial denture. R e p o rt o f case CASE 1 . A 16-year-old Hispanic male had pain
and mobility in the maxillary right central in cisor. Radiographs disclosed a fracture in the cervical area at the level of the crestal bone with a 6-mm pocket on the mesiolingual aspect 270 ■ JA D A , V ol. I l l , A ugust 1985
(Fig 1). A football injury caused trauma to the patient’s mouth 11 months before. The patient stated that the tooth was initially sensitive to cold, but that this sensitivity subsided after 1 month. No previous dental treatment had been sought regarding this injury. The entire crown was removed and end odontic therapy was initiated. To help main tain isolation, three thread-mate-system pins were placed and glass ionomer cement was placed on the tooth. The canal was filled with gutta-percha and zinc oxide-eugenol. The tooth was also scaled and root planed. An extrusion postwithahook was fabricated from .036-inch orthodontic wire. A post hole was prepared in the tooth, and the loosely fit ting extrusion post was cemented into place with zinc phosphate cement. An anchor bar, previously adapted to a study model of the tooth, was positioned to pass over the center of the involved tooth. The anchor bar was then attached to the two adjacent teeth with acidetch composite resin (Fig 2). An elastic band was attached to the hook, over the anchor bar, and to the hook again, to provide the eruption force (Fig 3). A temporary polycarboxylate crown was constructed for the patient to wear during the forced eruption phase. Most of the lingual as pect of the polycarboxylate crown was re moved, and slots were made in the mesial and distal aspects of the crown so that the crown would fit over the anchor wire and not interfere with the elastic band. The temporary crown was then cemented to the anchor bar and adja cent teeth with glass ionomer cement (Fig 4). Thus, the crown could be easily removed and recemented for adjustments, and provided an esthetically acceptable temporary appliance for the patient between visits. The patient was seen every 3 to 5 days to adjust the elastic band. Initially, the extrusion post was 2.5 mm from the anchor bar; by the 21st day, the tooth had erupted so that the extrusion post was 0.5 mm from the anchor bar (Fig 5). During this period, the periodontal pocket on the mesiolingual aspect decreased from 6.0 to 4.0 mm. The decrease in pocket depth (2 mm) is the same as the distance the tooth was extruded. The tooth was then stabil ized by adapting acrylic resin around the an
chor wire and hook. The acrylic resin was built up and shaped into the form of a tooth; the resin appliance served as a temporary crown during the stabilization period. After an 8-week stabilization period, the anchor bar and acrylic temporary appliance were removed. The extrusion post was twisted with a hemostat, loosening the post and allowing the post to be easily removed from the tooth. A post and core were placed, and a gingivectomy was per formed on the lingual aspect to further expose sound tooth structure. The tooth was slightly mobile after the stabilization period, but the mobility was negligible by the time the final restoration was placed 2xk months later. The tooth was restored with a porcelain-fused-tometal crown (Fig 6). The final depth of the gingival crevice was 2.0 mm. CASE 2. A 62-year-old white female had a frac ture of the maxillary left canine, which had been previously treated endodontically. The facial aspect of the tooth had fractured from the tooth to the level of the alveolar crestal bone (Fig 7). Replacing the silver point fill with gutta-percha was considered to place a post and core, which would have been the preferred treatment. However, financial considerations on the part of the patient determined a less expensive treatment. In addition, sufficient tooth structure remained to allow a composite pin buildup to be adequate. Conventional treatment consisting of periodontal surgery was performed to expose sound tooth struc ture, and a composite pin buildup was placed. Because of periodontal surgery, the gingival contour was superior to that of adjacent teeth and would produce an unesthetic end result. If the tooth was erupted, however, the gingiva and supporting periodontium would erupt with the tooth, allowing the gingiva to be at the same level as adjacent tissues. Thus, after de termining that the conventional treatment for such a fracture would not produce the desired esthetic results, the newer approach of forced eruption was used before the final restoration was placed. The second premolar distal to the fractured canine was one of the abutments for a partial denture; if the anchor bar was attached to the second premolar, the patient would not be able
C L I NI CA L
REPORTS
Case 1
Fig 3 ■ Elastic band in place.
Fig 1 ■ Radiograph of maxillary right central incisor with trans verse fracture.
Fig 2 ■ Anchor bar and extrusion post in place, before eruption.
Fig 4 ■ Temporary acrylic appliance in place (erup tion phase).
Fig 5 ■ Clinical appearance after eruption.
Fig 6 ■ Radiograph of final res toration.
Case 2
_______ Fig 9 ■ After eruption, tooth is in contact with anchor bar. Fig 8 ■ Anchor bar and extrusion post in place, but not yet attached to lateral incisor. Fig 7 ■ Radiograph of maxillary left canine fractured on facial as pect to level of crestal bone.
Fig 10 ■ Radiograph of final restoration, 2 months after eruption; radiolucent area at apex is associated with tooth movement.
Fig 11 ■ Final restoration has porcelain-fusedto-metal crown.
Garrett : ERUPTION IN TRANSVERSE ROOT FRACTURE ■ 271
C L I NI CA L
REPORTS
to wear the partial denture. To avoid move ment of the tooth during the eruption and stabilization phase of treatment, the anchor bar was attached to the central and lateral incisors and adapted so that the partial denture could be worn (Fig 8). The tooth was reduced on the lingual and incisal aspects to allow room for eruption; a post hole was prepared in the crown of the tooth, and an extrusion post was cemented in place. An elastic band was then attached to the anchor bar and to the extrusion post to provide the eruptive force. The patient was seen every 3 to 5 days to adjust the elastic band. After 16 days, the extrusion post was in contact with the anchor bar (Fig 9); the extrusion post had orig inally been positioned 2.0 mm from the anchor bar. The tooth was stabilized with composite resin for an additional 6 weeks, and restored with a porcelain-fused-to-metal crown (Fig 10, 11).
Discussion The forced eruption technique presented is not without problems. Some mobility was present in the first case and was the main factor in the decision to not erupt the tooth further. In retrospect, however, the tooth should have been erupted more slowly, stabilized after the mobility was noted, and then erupted further after the tooth had been stabilized. This would have made sound tooth structure more accessible, and would have allowed con struction of a more biologically compati ble restoration. In the second case, there was no mobil
ity throughout the procedure. Sound tooth structure was obtained in an ideal position, thus allowing construction of a more biologically compatible restoration. A side benefit of this technique is that the periodontal status of the tooth may improve. This was seen to some extent in the first case in which the 6-mm pocket was reduced by 2 mm by erupting the tooth (the pocket was reduced further after minor periodontal surgery). As shown by Ingberg,4 the peridontium may erupt with the tooth so that a periodontal bony defect may be greatly improved or eliminated. Many times, the gingiva and crestal bone of the erupted tooth may be erupted into a position higher than the adjacent teeth, in which case periodontal surgery w ould be required to obtain proper contour of the gingival tissues and crestal bone. This treatment modality may allow the practitioner to adapt to different clinical situations, as the technique does not re quire the tooth to be immediately mesial and distal to the involved tooth. With proper case selection, forced eruption can be a useful treatment modality in the treatment of transverse root fractures.
Summary A relatively new method for treating transverse root fractures near the gingival crevice is reviewed. Two cases are de scribed in which the fractured teeth are
orthodontically erupted to facilitate res toration. A periodontal pocket was re duced in the first case, and the technique was modified to accommodate a patient wearing a partial denture in the second case. The technique appears to be a favor able alternative to extraction or periodon tal surgery.
__________________________ JRO& The author thanks Drs. Diana Compton, Gerald Froemming, and Jack Turne, for their assistance and support of this m anuscript. Dr. Garrett is in private practice, 6918 W Military Dr, San A ntonio, TX 78227. Address requests for re prints to the author. 1. Delivanis, P.; Delivanis, H.; and Kuftinec, M. E ndodontic-orthodontic m anagem ent of fractured anterior teeth. JADA 97(3):483-485, 1978. 2. Hartwell, G.R., and Cecie, P.A. An esthetic re storative technique for use during the stabilization period after vertical root extrusion. JADA 107(1):5960, 1983. 3. H e ith e rs a y , G.S. C o m b in e d e n d o d o n tic orthodontic treatm ent of transverse root fractures in the region of the alveolar crest. Oral Surg 36:404-415, 1973. 4. Ingberg, J.S. Forced eruption. A m ethod of treat ing nonrestorable teeth—periodontal and restorative considerations. J Periodontol 47(4):203-216, 1976. 5. Ivey, D.W., and others. O rthodontic extrusion: its u se in resto rativ e d en tistry . J P ro sth et D ent 43(4):401-407, 1980. 6. Simon, J.H., and others. Extrusion of endodontically treated teeth. JADA 97(l):17-23, 1978. 7. Tofsky, N.S., and Tsam tsouris, A. O rthodontic treatm ent of an Ellis Class VIII fracture. J Pedod 3(2):165-175, 1979.
Cyclosporine-induced gingival hyperplasia: case report and literature review Joel A. Bennett, DDS James M. Christian, DDS The diagnosis and treatm ent o f a patient receiving immunosuppressive therapy fo r the prevention of renal allograft rejection are discussed.
r
%. J vclosporine is a potent im m uno suppressive agent that prolongs the sur vival of allogeneic transplants in humans. It is a cyclic polypeptide comprised of 11 amino acids and is produced as a metabo 272 ■ JA D A , V ol. I l l , A ugust 1985
lite of the fungus Tolypocladium inf la tum Gams. The agent’s proposed mechanism of action is via its specific and reversible inhibition of im m uno competent lymphocytes. T-lymphocytes are preferentially inhibited, and it is this suppression of the cellular immune re sponse and the subsequent sparing of the humoral response and bone marrow that make cyclosporine an ideal agent to use in the prevention of allograft rejection. Cyclosporine is available both in intra venous and oral formulas. It is recom mended that the initial oral dose be given 4 to 12 hours before surgery, as a single loading dose of 15 mg/kg/day. This dos age should be continued through the sec
ond postoperative week and then de creased by 5% a week until a maintenance dosage of 5 to 10 mg/kg/day is reached. The drug concentration can be measured in the patient’s serum by radioimmuno assay. Normal trough plasma levels of cyclosporine are 50 to 150 mg/ml. The drug level as well as plasma blood urea nitrogen, creatinine, and liver function tests should be monitored periodically. Cyclosporine has several side effects. In a study by Ota and Bradley,1 which re viewed the cyclosporine treatment of 100 renal allograft recipients, the following complication rates were reported: hepatotoxicity, 53%; nephrotoxicity, 50%; trem ors, 15%; hirsutism , 12%; g in g iv a l