Combined treatment of Surgical Extrusion and Crown Lengthening Procedure for Severe Crown-root Fracture of a Growing Patient: A Case Report

Combined treatment of Surgical Extrusion and Crown Lengthening Procedure for Severe Crown-root Fracture of a Growing Patient: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Combined treatment of Surgical Extrusion and Crown Lengthening Procedure for Severe Crown-root Fracture of a Growing Patient: A Case Report Bumjoon Lee, Jonghyun Shin, Taesung Jeong, Soyoung Park, Eungyung Lee This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5068913/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2024 Read the published version in BMC Oral Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Preservation of a healthy periodontium is critical for the long-term success of restored teeth. In cases of extensive caries, tooth fracture, inadequate crown length, and increased esthetic demands, the restorative margins need to be placed apical to the gingival margin. Violation of the biological width due to dental trauma frequently appears in clinical practice. There are three treatment options for preserving biological width and the ferrule effect: crown lengthening, orthodontic extrusion, and surgical extrusion. This case report describes the surgical intervention and fixed prostheses for crown-root fractured maxillary incisors in a growing patient. Case presentation A fourteen-year-old boy was referred from Department of Oral and Maxillofacial Surgery and visited the Department of Pediatric Dentistry after emergency dental treatment. He got hit with a baseball bat and his upper right central and lateral incisors were fractured with pulp exposure. A vertical fracture line extended below gingival margin on each tooth was observed. Surgical extrusion and conventional root canal treatments were performed on both fractured teeth. Surgical crown lengthening was additionally done to preserve the biological width and to make sure of the ferrule effect. Then, these teeth were finally restored with porcelain fused metal crowns. Conclusions Surgical extrusion and crown lengthening may be considered the most effective treatments to save the teeth instead of coronectomy or extraction for severely fractured teeth. The case described here showed satisfactory esthetic and periodontal outcomes during two years of follow-up, and the patient was satisfied that he could retain his natural teeth. Biologic width Crown-root fracture Crown lengthening procedure Ferrule effect Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Crown–root fracture (CRF) is a fracture involving the enamel, dentin, and cementum with or without pulp involvement, whereas cervical root fracture involves the cementum, dentin, and pulp extending from the alveolar bone crest up to 5 mm below ( 1 ). The prevalence of CRF is 5% in permanent dentition, while all root fractures affect 0.5–7% of permanent teeth ( 2 ). The fracture line positioned in the gingival connective tissue of crown root and cervical root fractures makes it difficult for clinicians to achieve satisfactory restorations. Restoration margins located in the gingival connective tissue can violate the biological width, resulting in gingival inflammation, clinical attachment loss, and bone loss, clinically manifesting as gingival bleeding, deepening of the periodontal pocket, or gingival recession ( 3 ). In some growing patients with severe crown-root fractures, space maintenance is recommended after extraction or coronectomy to preserve the width of the alveolar bone ( 4 ). Nonetheless, the need for additional bone grafting during implant placement is frequent even after coronectomy. Both the width and height of the alveolar bone are lost during the extraction for implant placement ( 5 ). During implantation in the anterior region, bone grafting is performed in conjunction with extraction and onlay grafting of connective tissue harvested from the palate to compensate for bone volume ( 6 ). The complexity of the implant surgery process and the possibility of failure due to technical sensitivity, and above all, the esthetically unpleasing results of surgery, can impose additional esthetic burdens on patients. Thus, prioritizing the preservation of natural teeth is important when considering the long-term effects of treatment. This case report describes a complicated crown-root fracture of the right maxillary central incisor. Surgical intervention using surgical extrusion with tooth rotation and crown lengthening was performed on the maxillary right central and lateral incisors of a growing patient instead of coronectomy or tooth extraction. Satisfactory esthetic and functional outcomes were observed. During follow-up, clinical and radiographic examinations revealed stable and good periodontal health. Case Presentation A 14-year-old male patient was referred to the Department of Pediatric Dentistry at Pusan National University Dental Hospital, Yangsan, South Korea, for further treatment of crown-root fractures of the maxillary anterior teeth following a baseball bat hit. In the emergency room, a pulpectomy procedure was performed on the affected teeth, and sutures were applied for lower lip laceration. The fractured teeth included the maxillary right central, lateral, and left central incisors (Fig. 1 ). Clinical and radiographic examinations were also performed. Examination revealed complicated crown fractures in the right maxillary central and lateral incisors. The margins of the fractures extended apically to the gingival margin, and periodontal ligament (PDL) space widening on both incisors (Fig. 2 ). Radiographic examination revealed a vertical crown-root fracture of the right maxillary central incisor. The fracture line was located 2 mm subgingivally, at the level of the alveolar crest at the distal aspect. The mobile crown-root fragment was removed and surgical exposure was performed. Temporary root canal therapy using a calcium hydroxide dressing was performed on the affected teeth, which were then sealed with a Caviton (Fig. 3 ). After local anesthesia, mucoperiosteal flaps were reflected, and the teeth were carefully luxated to avoid traumatizing the marginal bone or root surface. The luxated teeth were carefully switched and rotated 180-degree atraumatically so that their palatal aspects were buccally turned (Fig. 4 ). Consequently, fracture margins were placed at least 2 mm above the bone crests. A resilient splint was applied for semi-fixation of the teeth. An antibiotic regimen was prescribed for the first week to prevent postoperative infections. Postoperatively, the soft tissue healing process was uneventful. Ten days after the surgery, the sutures were removed. Three additional weeks later, postoperative mobility was stable. Therefore, the splint was removed, and the root canals were treated. In this case, despite performing surgical extraction due to the extension of the fracture line into the alveolar bone, there was insufficient supracrestal dental structure remaining for restoration. Therefore, additional consideration had to be given to crown-lengthening surgery. A clinical crown-lengthening procedure was performed to level the gingival line and expose a sufficiently sound tooth structure for the subsequent prosthesis. During the osteotomy procedure, a surgical stent was fabricated after diagnostic wax-up on a prepared model to minimize bone removal and establish surgical landmarks for the surgeon (Fig. 5 ) ( 7 ). The teeth were simultaneously prepared for the prosthesis. A temporary crown was fabricated using self-curing acrylic resin (Tokuso Curefast, Tokyo, Japan). Provisional restorations were maintained for six months before the final prosthesis treatment was performed to ensure gingival and bone tissue healing. The teeth were successfully rehabilitated using porcelain metal-fixed prostheses (Fig. 6 ). The patient was examined at 1, 3, and every 6 months after treatment. The stability and esthetics of the crowns were maintained. Discussion For growing patients, saving severely fractured teeth is valuable not only for the restoration of function and esthetics, but also for the prevention of psychological trauma associated with tooth extraction. Moreover, it can reduce time and opportunity costs. Dental professionals must consider the psychological burden and social inconvenience that adolescents endure during implant surgery after reaching adulthood. The concept of the biological width was derived from the histological description of the dentogingival complex by Gargiulo et al. The mean sulcus depth was 0.69 mm, epithelial attachment was 0.97 mm, and connective tissue was 1.07 mm ( 8 ). Therefore, the total length of the dentogingival complex was 2.73 mm. Gingival inflammation occurs when the restorative margins invade the biological width. Several authors have recommended that a crown-lengthening procedure should aim to obtain a minimum supracrestal tooth structure of 3 mm according to these criteria ( 3 , 9 , 10 ). Sorensen and Engelman defined the ferrule as “a 360-degree metal collar of the crown surrounding the parallel walls of the dentine extending coronal to the shoulder of the preparation.” ( 11 ) (Fig. 7 ). It offers a form of resistance to the crown and serves a protective function by minimizing stress, which is known as the 'ferrule effect.’ Libman and Nicholls recommended a ferrule of at least 1.5 mm ( 12 ). Therefore, dentists need to remove both hard and soft tissue to allow for the establishment of a 3 mm biological width and a 1.5 mm ferrule length during the crown-lengthening procedure ( 7 ). Different treatments are available to maintain the biological width and ferrule effect, depending on the location of the fracture line. These treatments include orthodontic extrusion, surgical extrusion, and crown-lengthening procedures ( 13 ). Orthodontic extrusion has been described as a treatment option for CRF. The entire attachment apparatus follows the fractured tooth as it is moved coronally to avoid elongation of the clinical crown or loss of supportive tissues ( 14 ). In most cases, additional surgical correction of both the gingival and bone margins is necessary to complete the treatment. The treatment usually takes four to eight months to complete ( 15 ). A period of stabilization is also required to prevent a relapse ( 16 ). Surgical extrusion is defined as the ‘procedure in which the remaining tooth structure is repositioned at a more coronal/supragingival position in the same socket in which the tooth was located originally’ ( 17 ). Before replantation, the tooth may be completely extracted from the socket to assess the integrity of the root structure and to identify any additional fractures. Minimally invasive extraction with minimal damage to the cementoblast layer on the root surface is key to successful surgical extrusion ( 18 ). 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 ( 19 ). 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 ( 20 ). Although surgical extrusion is considered a feasible treatment approach for non-restorable teeth, a balanced risk–benefit analysis, including other alternatives such as surgical crown lengthening or orthodontic extrusion (forced eruption), is recommended ( 19 ). In the crown-lengthening procedure, tooth preparation can extend in a more apical direction by 1–2 mm. This surgically exposed tooth structure is provided, in addition to the exposure of the biological width, so that the crown does not invade the attachment apparatus. The goal of the procedure is to improve the retention of restorations and esthetics in patients with an uneven gingival margin or excessive gingival display, thereby facilitating a more predictable prosthetic outcome ( 21 ). A conventional crown-lengthening procedure involves resective osseous surgery and the removal of a large amount of supportive periodontal tissue, including the gingiva and underlying bone, around the injured teeth to obtain a biologic width. When osseous surgery is performed to reconstruct the positive architecture around a single-rooted anterior tooth, the stability of the treated dentition may be affected, and the interdental papillae are likely lost ( 16 ). A hyperplastic excess gingival contour can occur when the crown-lengthening procedure is delayed after a severe crown-root fracture. This results in the appearance of short clinical crowns. This is more noticeable in the presence of medium or high lip lines. If the patient wants a normal tooth length, resection that exposes the anatomical crowns may be warranted ( 22 ). In these procedures, the dentist may require a surgical stent as a guide to determine the position of the new crown margins. An altered morphology of the interdental papillae of the anterior teeth after surgery can cause esthetic concerns. Black triangles may develop if the post-resection distance between the contact area and interdental osseous crest is greater than 5 mm ( 23 ). Dentists can conceal or correct the widened embrasure areas that may result after healing from the surgical procedure by lengthening and widening the crown contact areas to accommodate the new morphology of the interproximal papillae ( 7 ). Researchers have observed that if the margin of the flap is positioned at the level of the osseous crest, postoperative vertical gain or rebound in the supracrestal soft tissues occurs, averaging 3 mm ( 24 ). Lanning et al. demonstrated that the coronal advancement of healing tissues from the osseous crest averages 3 mm by three months after surgery. They also determined that six months after surgery, no further significant changes in the vertical position of the free gingival margin were apparent ( 25 ). Brägger et al. also noted that during the six-month healing period after crown-lengthening, periodontal tissues were stable, with minimal changes in the level of the gingival margin. From these findings, one can conclude that regarding the final prosthetic treatment in the esthetic zone, the waiting period after a crown-lengthening procedure should be six months ( 10 ). Therefore, temporary restorations were placed for six months before the final prosthetic restoration treatment for this patient, aiming to promote the stability of the periodontal tissues. Morrow et al. investigated the relationship between age, sex, and clinical crown height in a longitudinal study that examined 456 sets of models ( 26 ). Each set of models corresponded to subjects of three ages: 11–12, 14–15, and 18–19 years. The data in this study indicate that passive eruptions continue at least until the age of 18–19 years in both male and female participants. Because it was not possible to determine whether the gingival levels were stable at this age, the authors compared the clinical crown heights reported in their study with those reported by Gillen et al. In the female patient population, passive eruptions were essentially completed by the age of 18– 19 years. Evian et al. compared the anterior and posterior teeth and found that, for the former, gingival stability was achieved by 20 years of age, whereas for the latter, gingival maturation could continue into the third decade. Robbins (1999) suggested that it may not be prudent to diagnose altered passive eruption until growth is complete but did not specify the age at which this should be ( 27 ). Therefore, regular examinations are necessary in the future to monitor the potential exposure of the margins of porcelain-fused-to-metal restorations owing to the increased length of the anterior crown. Additionally, after growth completion, reassessment is required to determine the need for crown retreatment. Conclusions Surgical extrusion and crown lengthening may be considered effective treatments to save teeth instead of coronectomy or extraction for severely fractured teeth. The key factors in the successful functional and esthetic rehabilitation of complicated crown and crown-root fractures are multidisciplinary approaches, which involve surgery, endodontics, periodontics, orthodontics, and prosthodontics. Abbreviations CRF crown–root fracture PDL periodontal ligament Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Pusan Nation-al University Dental Hospital (IRB approval number: PNUDH-2024-09-002), and the approval date was 2024-09-06. Consent for publication Written informed consent for publication was obtained from the patient and his legal guardian to publish all clinical data and accompanying images. Availability of data and materials No datasets were generated or analysed during the current study. Competing interests All authors declare that they have no competing interests. Funding This work was supported by a National Research Foundation of Korea (NRF) grant from the Korean Government (MSIT; No. 2022R1F1A1074271). Author’s contributions B.L. performed the surgery, collected data and drafted the manuscript. E.L. performed the final editing of the manuscript. J.S., S.P. and T.J. provided assistance and advice regarding the manuscript. All the authors have read and approved the final version of the manuscript. Acknowledgments We are grateful to the patient for his permission to use his clinical data. References Malhotra N, Kundabala M, Acharaya S. A review of root fractures: diagnosis, treatment and prognosis. Dent Update. 2011;38(9):615–28. 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. Dent Traumatol. 2014;30(1):1–14. Ganji KK, Patil VA, John J. A Comparative Evaluation for Biologic Width following Surgical Crown Lengthening Using Gingivectomy and Ostectomy Procedure. Int J Dent. 2012;2012:479241. Bourguignon C, Cohenca N, Lauridsen E, Flores MT, O'Connell AC, Day PF, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020;36(4):314–30. Van der Weijden F, Dell'Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol. 2009;36(12):1048–58. Kan JYK, Rungcharassaeng K, Deflorian M, Weinstein T, Wang H-L, Testori T. Immediate implant placement and provisionalization of maxillary anterior single implants. Periodontol 2000. 2018;77(1):197–212. Hempton TJ, Dominici JT. Contemporary Crown-Lengthening Therapy: A Review. J Am Dent Association. 2010;141(6):647–55. Gargiulo AW, Wentz FM, Orban B. Dimensions and Relations of the Dentogingival Junction in Humans. J Periodontology. 1961;32(3):261–7. Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical Crown Lengthening: Evaluation of the Biological Width. J Periodontol. 2003;74(4):468–74. Brägger U, Lauchenauer D, Lang NP. Surgical lengthening of the clinical crown. J Clin Periodontol. 1992;19(1):58–63. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent. 1990;63(5):529–36. Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont. 1995;8(2):155–61. Güngör HC. Management of crown-related fractures in children: an update review. Dent Traumatol. 2014;30(2):88–99. Stern N, Becker A. Forced eruption: biological and clinical considerations. J Rehabil. 1980;7(5):395–402. Bach N, Baylard J-F, Voyer R. Orthodontic extrusion: periodontal considerations and applications. J Can Dent Assoc. 2004;70(11):775–80. Lee J-H, Yoon S-M. Surgical extrusion of multiple teeth with crown-root fractures: a case report with 18-months follow up. Dent Traumatol. 2015;31(2):150–5. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, Gambarini G. Present status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation. Int Endod J. 2022;55(Suppl 3):827–42. Oikarinen KS, Stoltze K, Andreasen JO. Influence of conventional forceps extraction and extraction with an extrusion instrument on cementoblast loss and external root resorption of replanted monkey incisors. J Periodontal Res. 1996;31(5):337–44. Krug R, Connert T, Soliman S, Syfrig B, Dietrich T, Krastl G. Surgical extrusion with an atraumatic extraction system: A clinical study. J Prosthet Dent. 2018;120(6):879–85. Das B, Muthu MS. Surgical extrusion as a treatment option for crown–root fracture in permanent anterior teeth: a systematic review. Dent Traumatol. 2013;29(6):423–31. Wagenberg BD, Eskow RN, Langer B. Exposing adequate tooth structure for restorative dentistry. Int J Periodontics Restor Dent. 1989;9(5):322–31. McGuire MK. Periodontal plastic surgery. Dental Clin N Am. 1998;42(3):411–65. Tarnow DP, Magner AW, Fletcher P. The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interproximal Dental Papilla. J Periodontol. 1992;63(12):995–6. Pontoriero R, Carnevale G. Surgical Crown Lengthening: A 12-Month Clinical Wound Healing Study. J Periodontol. 2001;72(7):841–8. Shobha K, Mahantesha, Seshan H, Mani R, Kranti K. Clinical evaluation of the biological width following surgical crown-lengthening procedure: A prospective study. J Indian Soc Periodontology. 2010;14(3):160–7. Morrow LA, Robbins JW, Jones DL, Wilson NHF. Clinical crown length changes from age 12–19years: a longitudinal study. J Dent. 2000;28(7):469–73. Mele M, Felice P, Sharma P, Mazzotti C, Bellone P, Zucchelli G. Esthetic treatment of altered passive eruption. Periodontol 2000. 2018;77(1):65–83. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2024 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 17 Sep, 2024 Editor assigned by journal 14 Sep, 2024 Submission checks completed at journal 14 Sep, 2024 First submitted to journal 11 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5068913","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":355267650,"identity":"5c13eaff-b39e-4f95-9025-3d5785c442ff","order_by":0,"name":"Bumjoon Lee","email":"","orcid":"","institution":"Pusan National University Dental Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bumjoon","middleName":"","lastName":"Lee","suffix":""},{"id":355267651,"identity":"8d911411-c899-42de-83d3-b07864e41006","order_by":1,"name":"Jonghyun Shin","email":"","orcid":"","institution":"Pusan National University Dental Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jonghyun","middleName":"","lastName":"Shin","suffix":""},{"id":355267652,"identity":"8413cb80-ac13-45df-8880-a03be7bcb289","order_by":2,"name":"Taesung Jeong","email":"","orcid":"","institution":"Pusan National University Dental Hospital","correspondingAuthor":false,"prefix":"","firstName":"Taesung","middleName":"","lastName":"Jeong","suffix":""},{"id":355267653,"identity":"d23d3867-e389-43fd-ba43-3397881becd2","order_by":3,"name":"Soyoung Park","email":"","orcid":"","institution":"Pusan National University Dental Hospital","correspondingAuthor":false,"prefix":"","firstName":"Soyoung","middleName":"","lastName":"Park","suffix":""},{"id":355267654,"identity":"ae941499-676e-44cf-bcce-23e9dd87816c","order_by":4,"name":"Eungyung Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDADfgSTjUgtkg0kazE4QKwWfoncw6952+7Ybb7dY/zh5w4Gef4GtrQPeN0zIy/NmrftWfK2O2fMJHvPMBjOOMB2eAZe99zIMTPmbTucbAZkMPC2MTBuYGBvxuswe5gW4xk5xh//tjHYE9RiIJFj/BioxQ7IMJAG2pK4gYHtMF4tEmfemDHOOXc4QeLOsTJp2TaJ5BmH2ZLxauFvzzH+8KbssD3/7ObNH9+22dj2t7cZ49UCBGxSPAwMiQ0SEFsZGJgJaQAq+fgDGAwMEoRVjoJRMApGwQgFAIKpRlHoFDmkAAAAAElFTkSuQmCC","orcid":"","institution":"Pusan National University Dental Hospital","correspondingAuthor":true,"prefix":"","firstName":"Eungyung","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2024-09-11 07:06:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5068913/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5068913/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-024-05277-4","type":"published","date":"2024-12-18T15:57:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68878817,"identity":"d8b67a83-0bf4-4585-9187-2010969f74cf","added_by":"auto","created_at":"2024-11-13 05:23:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":603207,"visible":true,"origin":"","legend":"\u003cp\u003eClinical photograph on the day of initial visit. (A) Intraoral frontal view of the patient taken in an emergency room, (B) Crown-root fractures of maxillary right central and lateral incisors.\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/8a2e8d268ef44151fa957cf6.png"},{"id":68877782,"identity":"c2b5b39e-3f31-4782-9a70-537cb35f240e","added_by":"auto","created_at":"2024-11-13 05:07:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":169593,"visible":true,"origin":"","legend":"\u003cp\u003eThe margins of the fractures were extended apically to the gingival margin and periodontal ligament space widening on the both incisors. (A) Periapical standard film, (B) Right maxillary lateral incisor CBCT cross-sectional cut\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/b3d52ef9fac3dec92a9a5325.png"},{"id":68879597,"identity":"767b34e8-0b4d-4034-801f-9d9ae3abfa2b","added_by":"auto","created_at":"2024-11-13 05:32:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33284,"visible":true,"origin":"","legend":"\u003cp\u003eRadiographic examination revealed a vertical crown-root fracture in the maxillary right central incisor.\u003c/p\u003e","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/bbd4d2e607760143ad9369be.png"},{"id":68877786,"identity":"4966ec57-4091-4765-942e-8c85f11883af","added_by":"auto","created_at":"2024-11-13 05:07:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":86117,"visible":true,"origin":"","legend":"\u003cp\u003eThe luxated teeth were carefully switched and rotated 180 degree atraumatically so that the palatal aspects of the teeth were turned buccally. Despite performing surgical extraction, there was insufficient remaining supracrestal dental structure for restoration (shown by the arrow).\u003c/p\u003e","description":"","filename":"Fig.4.png","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/c0b831f25a31c65c4bc3eaf9.png"},{"id":68877788,"identity":"bfe6d6e6-58cc-4939-848f-68e4fffe06aa","added_by":"auto","created_at":"2024-11-13 05:07:53","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":688372,"visible":true,"origin":"","legend":"\u003cp\u003eClinical crown-lengthening procedure was performed to level the gingival line and to expose sufficient sound tooth structure for a subsequent prosthesis with a surgical stent (A, B, C).\u003c/p\u003e","description":"","filename":"Fig.5.png","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/101ee23c2ab2832d7a880dc5.png"},{"id":68877787,"identity":"43d49e1d-de3f-4098-807d-c7ab504fffd4","added_by":"auto","created_at":"2024-11-13 05:07:53","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":732696,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient was successfully rehabilitated with porcelain-metal fixed prosthesis.\u003c/p\u003e","description":"","filename":"Fig.6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/98f4b69aa0a9f22448707f9c.jpg"},{"id":68877785,"identity":"63e844a4-f34a-4f64-bc30-f5b1974dc356","added_by":"auto","created_at":"2024-11-13 05:07:53","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":86985,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of (A) a prepared and restored tooth with a ferrule and (B) a prepared and restored tooth without a ferrule.\u003c/p\u003e","description":"","filename":"Fig.7.png","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/e5f5e39562b15aff112d4953.png"},{"id":72202088,"identity":"8071e6db-c8bb-40fe-81d5-360b155f2a32","added_by":"auto","created_at":"2024-12-23 16:14:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2718495,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5068913/v1/2d9a85f4-a85f-47cd-8d42-f528e120c740.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combined treatment of Surgical Extrusion and Crown Lengthening Procedure for Severe Crown-root Fracture of a Growing Patient: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eCrown\u0026ndash;root fracture (CRF) is a fracture involving the enamel, dentin, and cementum with or without pulp involvement, whereas cervical root fracture involves the cementum, dentin, and pulp extending from the alveolar bone crest up to 5 mm below (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The prevalence of CRF is 5% in permanent dentition, while all root fractures affect 0.5\u0026ndash;7% of permanent teeth (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe fracture line positioned in the gingival connective tissue of crown root and cervical root fractures makes it difficult for clinicians to achieve satisfactory restorations. Restoration margins located in the gingival connective tissue can violate the biological width, resulting in gingival inflammation, clinical attachment loss, and bone loss, clinically manifesting as gingival bleeding, deepening of the periodontal pocket, or gingival recession (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn some growing patients with severe crown-root fractures, space maintenance is recommended after extraction or coronectomy to preserve the width of the alveolar bone (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Nonetheless, the need for additional bone grafting during implant placement is frequent even after coronectomy. Both the width and height of the alveolar bone are lost during the extraction for implant placement (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). During implantation in the anterior region, bone grafting is performed in conjunction with extraction and onlay grafting of connective tissue harvested from the palate to compensate for bone volume (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The complexity of the implant surgery process and the possibility of failure due to technical sensitivity, and above all, the esthetically unpleasing results of surgery, can impose additional esthetic burdens on patients. Thus, prioritizing the preservation of natural teeth is important when considering the long-term effects of treatment.\u003c/p\u003e \u003cp\u003eThis case report describes a complicated crown-root fracture of the right maxillary central incisor. Surgical intervention using surgical extrusion with tooth rotation and crown lengthening was performed on the maxillary right central and lateral incisors of a growing patient instead of coronectomy or tooth extraction. Satisfactory esthetic and functional outcomes were observed. During follow-up, clinical and radiographic examinations revealed stable and good periodontal health.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 14-year-old male patient was referred to the Department of Pediatric Dentistry at Pusan National University Dental Hospital, Yangsan, South Korea, for further treatment of crown-root fractures of the maxillary anterior teeth following a baseball bat hit. In the emergency room, a pulpectomy procedure was performed on the affected teeth, and sutures were applied for lower lip laceration. The fractured teeth included the maxillary right central, lateral, and left central incisors (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Clinical and radiographic examinations were also performed. Examination revealed complicated crown fractures in the right maxillary central and lateral incisors. The margins of the fractures extended apically to the gingival margin, and periodontal ligament (PDL) space widening on both incisors (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRadiographic examination revealed a vertical crown-root fracture of the right maxillary central incisor. The fracture line was located 2 mm subgingivally, at the level of the alveolar crest at the distal aspect. The mobile crown-root fragment was removed and surgical exposure was performed. Temporary root canal therapy using a calcium hydroxide dressing was performed on the affected teeth, which were then sealed with a Caviton (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter local anesthesia, mucoperiosteal flaps were reflected, and the teeth were carefully luxated to avoid traumatizing the marginal bone or root surface. The luxated teeth were carefully switched and rotated 180-degree atraumatically so that their palatal aspects were buccally turned (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Consequently, fracture margins were placed at least 2 mm above the bone crests. A resilient splint was applied for semi-fixation of the teeth. An antibiotic regimen was prescribed for the first week to prevent postoperative infections. Postoperatively, the soft tissue healing process was uneventful. Ten days after the surgery, the sutures were removed. Three additional weeks later, postoperative mobility was stable. Therefore, the splint was removed, and the root canals were treated.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn this case, despite performing surgical extraction due to the extension of the fracture line into the alveolar bone, there was insufficient supracrestal dental structure remaining for restoration. Therefore, additional consideration had to be given to crown-lengthening surgery.\u003c/p\u003e \u003cp\u003eA clinical crown-lengthening procedure was performed to level the gingival line and expose a sufficiently sound tooth structure for the subsequent prosthesis. During the osteotomy procedure, a surgical stent was fabricated after diagnostic wax-up on a prepared model to minimize bone removal and establish surgical landmarks for the surgeon (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The teeth were simultaneously prepared for the prosthesis. A temporary crown was fabricated using self-curing acrylic resin (Tokuso Curefast, Tokyo, Japan). Provisional restorations were maintained for six months before the final prosthesis treatment was performed to ensure gingival and bone tissue healing.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe teeth were successfully rehabilitated using porcelain metal-fixed prostheses (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The patient was examined at 1, 3, and every 6 months after treatment. The stability and esthetics of the crowns were maintained.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor growing patients, saving severely fractured teeth is valuable not only for the restoration of function and esthetics, but also for the prevention of psychological trauma associated with tooth extraction. Moreover, it can reduce time and opportunity costs.\u003c/p\u003e \u003cp\u003eDental professionals must consider the psychological burden and social inconvenience that adolescents endure during implant surgery after reaching adulthood.\u003c/p\u003e \u003cp\u003eThe concept of the biological width was derived from the histological description of the dentogingival complex by Gargiulo et al. The mean sulcus depth was 0.69 mm, epithelial attachment was 0.97 mm, and connective tissue was 1.07 mm (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Therefore, the total length of the dentogingival complex was 2.73 mm. Gingival inflammation occurs when the restorative margins invade the biological width. Several authors have recommended that a crown-lengthening procedure should aim to obtain a minimum supracrestal tooth structure of 3 mm according to these criteria (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSorensen and Engelman defined the ferrule as \u0026ldquo;a 360-degree metal collar of the crown surrounding the parallel walls of the dentine extending coronal to the shoulder of the preparation.\u0026rdquo; (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). It offers a form of resistance to the crown and serves a protective function by minimizing stress, which is known as the 'ferrule effect.\u0026rsquo; Libman and Nicholls recommended a ferrule of at least 1.5 mm (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Therefore, dentists need to remove both hard and soft tissue to allow for the establishment of a 3 mm biological width and a 1.5 mm ferrule length during the crown-lengthening procedure (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDifferent treatments are available to maintain the biological width and ferrule effect, depending on the location of the fracture line. These treatments include orthodontic extrusion, surgical extrusion, and crown-lengthening procedures (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOrthodontic extrusion has been described as a treatment option for CRF. The entire attachment apparatus follows the fractured tooth as it is moved coronally to avoid elongation of the clinical crown or loss of supportive tissues (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In most cases, additional surgical correction of both the gingival and bone margins is necessary to complete the treatment. The treatment usually takes four to eight months to complete (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A period of stabilization is also required to prevent a relapse (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical extrusion is defined as the \u0026lsquo;procedure in which the remaining tooth structure is repositioned at a more coronal/supragingival position in the same socket in which the tooth was located originally\u0026rsquo; (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Before replantation, the tooth may be completely extracted from the socket to assess the integrity of the root structure and to identify any additional fractures. Minimally invasive extraction with minimal damage to the cementoblast layer on the root surface is key to successful surgical extrusion (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). 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 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). 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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Although surgical extrusion is considered a feasible treatment approach for non-restorable teeth, a balanced risk\u0026ndash;benefit analysis, including other alternatives such as surgical crown lengthening or orthodontic extrusion (forced eruption), is recommended (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the crown-lengthening procedure, tooth preparation can extend in a more apical direction by 1\u0026ndash;2 mm. This surgically exposed tooth structure is provided, in addition to the exposure of the biological width, so that the crown does not invade the attachment apparatus. The goal of the procedure is to improve the retention of restorations and esthetics in patients with an uneven gingival margin or excessive gingival display, thereby facilitating a more predictable prosthetic outcome (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A conventional crown-lengthening procedure involves resective osseous surgery and the removal of a large amount of supportive periodontal tissue, including the gingiva and underlying bone, around the injured teeth to obtain a biologic width. When osseous surgery is performed to reconstruct the positive architecture around a single-rooted anterior tooth, the stability of the treated dentition may be affected, and the interdental papillae are likely lost (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA hyperplastic excess gingival contour can occur when the crown-lengthening procedure is delayed after a severe crown-root fracture. This results in the appearance of short clinical crowns. This is more noticeable in the presence of medium or high lip lines. If the patient wants a normal tooth length, resection that exposes the anatomical crowns may be warranted (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn these procedures, the dentist may require a surgical stent as a guide to determine the position of the new crown margins. An altered morphology of the interdental papillae of the anterior teeth after surgery can cause esthetic concerns. Black triangles may develop if the post-resection distance between the contact area and interdental osseous crest is greater than 5 mm (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Dentists can conceal or correct the widened embrasure areas that may result after healing from the surgical procedure by lengthening and widening the crown contact areas to accommodate the new morphology of the interproximal papillae (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearchers have observed that if the margin of the flap is positioned at the level of the osseous crest, postoperative vertical gain or rebound in the supracrestal soft tissues occurs, averaging 3 mm (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Lanning et al. demonstrated that the coronal advancement of healing tissues from the osseous crest averages 3 mm by three months after surgery. They also determined that six months after surgery, no further significant changes in the vertical position of the free gingival margin were apparent (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Br\u0026auml;gger et al. also noted that during the six-month healing period after crown-lengthening, periodontal tissues were stable, with minimal changes in the level of the gingival margin. From these findings, one can conclude that regarding the final prosthetic treatment in the esthetic zone, the waiting period after a crown-lengthening procedure should be six months (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Therefore, temporary restorations were placed for six months before the final prosthetic restoration treatment for this patient, aiming to promote the stability of the periodontal tissues.\u003c/p\u003e \u003cp\u003eMorrow et al. investigated the relationship between age, sex, and clinical crown height in a longitudinal study that examined 456 sets of models (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Each set of models corresponded to subjects of three ages: 11\u0026ndash;12, 14\u0026ndash;15, and 18\u0026ndash;19 years. The data in this study indicate that passive eruptions continue at least until the age of 18\u0026ndash;19 years in both male and female participants. Because it was not possible to determine whether the gingival levels were stable at this age, the authors compared the clinical crown heights reported in their study with those reported by Gillen et al. In the female patient population, passive eruptions were essentially completed by the age of 18\u0026ndash; 19 years. Evian et al. compared the anterior and posterior teeth and found that, for the former, gingival stability was achieved by 20 years of age, whereas for the latter, gingival maturation could continue into the third decade. Robbins (1999) suggested that it may not be prudent to diagnose altered passive eruption until growth is complete but did not specify the age at which this should be (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, regular examinations are necessary in the future to monitor the potential exposure of the margins of porcelain-fused-to-metal restorations owing to the increased length of the anterior crown. Additionally, after growth completion, reassessment is required to determine the need for crown retreatment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSurgical extrusion and crown lengthening may be considered effective treatments to save teeth instead of coronectomy or extraction for severely fractured teeth. The key factors in the successful functional and esthetic rehabilitation of complicated crown and crown-root fractures are multidisciplinary approaches, which involve surgery, endodontics, periodontics, orthodontics, and prosthodontics.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecrown\u0026ndash;root fracture\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePDL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eperiodontal ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Pusan Nation-al University Dental Hospital (IRB approval number: PNUDH-2024-09-002), and the approval date was 2024-09-06.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient and his legal guardian\u0026nbsp;to publish all clinical data and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a National Research Foundation of Korea (NRF) grant from the Korean Government (MSIT; No. 2022R1F1A1074271).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eB.L. performed the surgery, collected data and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eE.L. performed the final editing of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJ.S., S.P. and T.J. provided assistance and advice regarding the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eWe are grateful to the patient for his permission to use his clinical data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMalhotra N, Kundabala M, Acharaya S. A review of root fractures: diagnosis, treatment and prognosis. Dent Update. 2011;38(9):615\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElkhadem A, Mickan S, Richards D. Adverse events of surgical extrusion in treatment for crown\u0026ndash;root and cervical root fractures: a systematic review of case series/reports. Dent Traumatol. 2014;30(1):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGanji KK, Patil VA, John J. A Comparative Evaluation for Biologic Width following Surgical Crown Lengthening Using Gingivectomy and Ostectomy Procedure. Int J Dent. 2012;2012:479241.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourguignon C, Cohenca N, Lauridsen E, Flores MT, O'Connell AC, Day PF, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020;36(4):314\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan der Weijden F, Dell'Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol. 2009;36(12):1048\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKan JYK, Rungcharassaeng K, Deflorian M, Weinstein T, Wang H-L, Testori T. Immediate implant placement and provisionalization of maxillary anterior single implants. Periodontol 2000. 2018;77(1):197\u0026ndash;212.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHempton TJ, Dominici JT. Contemporary Crown-Lengthening Therapy: A Review. J Am Dent Association. 2010;141(6):647\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGargiulo AW, Wentz FM, Orban B. Dimensions and Relations of the Dentogingival Junction in Humans. J Periodontology. 1961;32(3):261\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical Crown Lengthening: Evaluation of the Biological Width. J Periodontol. 2003;74(4):468\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBr\u0026auml;gger U, Lauchenauer D, Lang NP. Surgical lengthening of the clinical crown. J Clin Periodontol. 1992;19(1):58\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent. 1990;63(5):529\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLibman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont. 1995;8(2):155\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;ng\u0026ouml;r HC. Management of crown-related fractures in children: an update review. Dent Traumatol. 2014;30(2):88\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStern N, Becker A. Forced eruption: biological and clinical considerations. J Rehabil. 1980;7(5):395\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBach N, Baylard J-F, Voyer R. Orthodontic extrusion: periodontal considerations and applications. J Can Dent Assoc. 2004;70(11):775\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee J-H, Yoon S-M. Surgical extrusion of multiple teeth with crown-root fractures: a case report with 18-months follow up. Dent Traumatol. 2015;31(2):150\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, Gambarini G. Present status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation. Int Endod J. 2022;55(Suppl 3):827\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOikarinen KS, Stoltze K, Andreasen JO. Influence of conventional forceps extraction and extraction with an extrusion instrument on cementoblast loss and external root resorption of replanted monkey incisors. J Periodontal Res. 1996;31(5):337\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrug R, Connert T, Soliman S, Syfrig B, Dietrich T, Krastl G. Surgical extrusion with an atraumatic extraction system: A clinical study. J Prosthet Dent. 2018;120(6):879\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas B, Muthu MS. Surgical extrusion as a treatment option for crown\u0026ndash;root fracture in permanent anterior teeth: a systematic review. Dent Traumatol. 2013;29(6):423\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWagenberg BD, Eskow RN, Langer B. 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J Indian Soc Periodontology. 2010;14(3):160\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrow LA, Robbins JW, Jones DL, Wilson NHF. Clinical crown length changes from age 12\u0026ndash;19years: a longitudinal study. J Dent. 2000;28(7):469\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMele M, Felice P, Sharma P, Mazzotti C, Bellone P, Zucchelli G. Esthetic treatment of altered passive eruption. Periodontol 2000. 2018;77(1):65\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Biologic width, Crown-root fracture, Crown lengthening procedure, Ferrule effect","lastPublishedDoi":"10.21203/rs.3.rs-5068913/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5068913/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePreservation of a healthy periodontium is critical for the long-term success of restored teeth. In cases of extensive caries, tooth fracture, inadequate crown length, and increased esthetic demands, the restorative margins need to be placed apical to the gingival margin. Violation of the biological width due to dental trauma frequently appears in clinical practice. There are three treatment options for preserving biological width and the ferrule effect: crown lengthening, orthodontic extrusion, and surgical extrusion. This case report describes the surgical intervention and fixed prostheses for crown-root fractured maxillary incisors in a growing patient.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA fourteen-year-old boy was referred from Department of Oral and Maxillofacial Surgery and visited the Department of Pediatric Dentistry after emergency dental treatment. He got hit with a baseball bat and his upper right central and lateral incisors were fractured with pulp exposure. A vertical fracture line extended below gingival margin on each tooth was observed. Surgical extrusion and conventional root canal treatments were performed on both fractured teeth. Surgical crown lengthening was additionally done to preserve the biological width and to make sure of the ferrule effect. Then, these teeth were finally restored with porcelain fused metal crowns.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSurgical extrusion and crown lengthening may be considered the most effective treatments to save the teeth instead of coronectomy or extraction for severely fractured teeth. The case described here showed satisfactory esthetic and periodontal outcomes during two years of follow-up, and the patient was satisfied that he could retain his natural teeth.\u003c/p\u003e","manuscriptTitle":"Combined treatment of Surgical Extrusion and Crown Lengthening Procedure for Severe Crown-root Fracture of a Growing Patient: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-13 05:07:48","doi":"10.21203/rs.3.rs-5068913/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-17T14:27:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-14T12:37:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-14T12:36:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-09-11T07:04:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8889f827-4347-4f71-a275-98ab60dca5ff","owner":[],"postedDate":"November 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:07:30+00:00","versionOfRecord":{"articleIdentity":"rs-5068913","link":"https://doi.org/10.1186/s12903-024-05277-4","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2024-12-18 15:57:49","publishedOnDateReadable":"December 18th, 2024"},"versionCreatedAt":"2024-11-13 05:07:48","video":"","vorDoi":"10.1186/s12903-024-05277-4","vorDoiUrl":"https://doi.org/10.1186/s12903-024-05277-4","workflowStages":[]},"version":"v1","identity":"rs-5068913","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5068913","identity":"rs-5068913","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}