Conservative Restoration of a Maxillary Central Incisor With Severe Crown Dilaceration

Dilaceration refers to a sharp angulation between the root and crown of a formed tooth.¹ Trauma is a common cause of root dilacerations, particularly in the maxillary anterior region. While dilaceration can occur anywhere along the length of the tooth, crown dilaceration constitutes 3% of all traumatic dental injuries, and is more common in maxillary anterior teeth compared with mandibular anterior dentition.^2–7

The treatment of maxillary crown dilaceration is complicated and often involves multidisciplinary care.⁸ Depending on the clinical status of a dilacerated tooth, various treatment modalities may be necessary, including orthodontic, surgical, endodontic and restorative therapies.^8–13 Although treatment might involve different disciplines, restorative interventions are necessary in most crown dilaceration cases to provide acceptable functional and esthetic outcomes.^14–18 Furthermore, while replacing missing teeth or teeth with poor prognoses with dental implants is a common and predictable treatment, placing implants in young adults who are still growing is a challenge, especially in the esthetic zone.^19–22

This clinical report describes a conservative and predictable treatment to restore function and esthetics in a maxillary central incisor with severe crown dilaceration.

CLINICAL REPORT

An 18-year-old male was referred by the Texas A&M College of Dentistry’s Orthodontic Department for an extraction and replacement of a maxillary left central incisor (tooth #9) with a dental implant. A comprehensive examination and all necessary radiographs were completed. The patient had a low caries risk, with no active caries or signs of periodontal disease. A comprehensive medical history revealed no contraindication for elective dental treatment. Reviewing the cone beam computed tomography report revealed a 90-degree root dilaceration of tooth #9.

After considering the patient’s skeletal maturation index at the time, a surgical consult with a periodontist was also completed due to concerns over tooth extraction and implant placement, as this patient will continue to grow.²³ Following a complete clinical evaluation and multidisciplinary discussion, various treatment options were reviewed with the patient. These included restoring the existing tooth (with or without root canal treatment), post core and crown, replacing the existing tooth with an implant-supported crown (considering the consequences of growing), resin bonded fixed dental prosthesis (FDP), conventional tooth-supported FDP, or removable prosthesis (Figure 1 and Figure 2).

The final treatment plan was to use a partial or full-coverage all-ceramic crown, noting the potential risk of pulpal exposure during tooth preparation. This treatment plan included orthodontic extrusion of the involved tooth, and the goal was leveling the soft tissue with the contralateral maxillary central incisor (Figure 3 and Figure 4).

After completion of orthodontic treatment, initial diagnostic impressions were taken using an irreversible hydrocolloid impression material and poured with type III dental stone. Casts were articulated on a semi-adjustable articulator, with a face-bow transfer. A diagnostic wax-up was completed.

The tooth was prepared with minimal axial reduction of 0.5 mm and 0.3 mm at the gingival margin, and 2 mm reduction of the incisal edge using a round-ended diamond cutting instrument. Soft tissue management was achieved with a #0 single-cord technique (Figure 5). A master impression of the prepared tooth was taken using polyvinyl siloxane (PVS) impression material. The opposing mandibular impression was taken using an irreversible hydrocolloid impression material. The clinical team recorded interocclusal registration in maximum intercuspation using PVS bite registration material. After an IM2 shade was selected, a master impression and all clinical photos were sent to the laboratory for fabrication of a lithium disilicate, single anterior veneer with surface characterization.

A provisional restoration was fabricated using an interim bis-acryl material. The provisional partial veneer was tried intraorally and cemented using a spot-etch technique (midfacial) and bonded with flowable resin composite. After removing the excess material, the composite was polymerized with an LED curing light, after which occlusion was checked and adjusted.²⁴

The final restoration/veneer was reviewed first on the working cast (Figure 6), and occlusion was checked carefully (Figure 7 and Figure 8). At the insertion appointment, marginal adaptation, restoration fit, interproximal contacts and occlusion were verified using a translucent try-in paste (Figure 9). Upon final approval by the patient, the internal bonding surface of the laminate veneers were etched with 10% hydrofluoric acid for 25 seconds and silanated. After the enamel was etched for 15 seconds, the veneer was luted with resin cement following the manufacturer’s recommendations for veneer cementation. All excess cement was removed from the margins and the restoration was cured with a curing light.²⁴ Figure 10 shows the final cemented veneer at the follow-up appointment.

DISCUSSION

Treatment of severely dilacerated maxillary central incisors is a challenge, chiefly due to the difficult position and abnormality of the root. Therapy often involves surgical removal, with subsequent orthodontic treatment to either close the space or maintain space for further restorative treatment. A dilacerated tooth is more resistant to extrusion than a normal tooth and has a higher chance of apical resorption.¹⁵ While impacted maxillary central incisors with severe dilaceration can be treated with orthodontic therapy in some cases, restorative treatment may be necessary for an optimal esthetic outcome.^14,15

Replacing a missing single tooth with implant-supported crown is a common, acceptable and reliable treatment,²⁵ and the 94.5% success rate makes it an attractive option.²⁶ In addition to a high success rate, this approach does not required preparation of adjacent teeth — and this is important in young patients with unrestored dentition and large pulps.^27,28 However, the growth factor must be considered when placing implants in young patients. This is because placing implants in young adults whose growth continues may cause esthetic and functional challenges as they get older. Studies have shown that osseointegrated implants do not follow the eruptive path of adjacent natural dentition. This will cause progressive infraposition of implant-supported crowns and discrepancy of surrounding tissue.^19–22 The skeletal maturation assessment did not confirm the complete growth of the patient presented in this clinical report, and, as a result, an implant-supported crown was not considered to be a treatment with a predictable outcome.²⁹

A paper presenting three cases proposed direct composite restoration for maxillary central incisors with crown dilaceration.¹⁴ Although direct composite resin may provide an acceptable and cost-effective option, porcelain (i.e., ceramic) veneers have a higher survival rate and patient satisfaction.³⁰ Thus, a glass ceramic with a full bonding cementation protocol was the treatment option chosen for this patient.

CONCLUSION

Paying close attention to occlusion and anterior guidance is essential when restoring maxillary central incisors with severe dilaceration. In this clinical scenario, occlusion in maximum intercuspation and anterior guidance were not effected by the treatment (as illustrated in Figure 7 and Figure 8).

A maxillary central incisor with a dilacerated crown compromises the patient’s esthetics and function, and could be challenging to treat. While many treatment options are available, using a conservative approach for properly selected patients — such as a bonded ceramic veneer — can restore function and esthetics with a predictable outcome.

KEY TAKEAWAYS

• Treatment of severely dilacerated maxillary central incisors is a challenge, chiefly due to the difficult position and abnormality of the root.
• Trauma is a common cause of root dilacerations, particularly in the maxillary anterior region, and various treatment approaches may be necessary — including orthodontic, surgical, endodontic and restorative therapies.^8–13
• Paying close attention to occlusion and anterior guidance is essential when restoring maxillary central incisors with severe dilaceration.
• Using a conservative approach for properly selected patients — such as a bonded ceramic veneer — can restore esthetics and function with predictable outcomes.

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The authors have no commercial conflicts of interest to disclose.

From Decisions in Dentistry. June 2019;5(6):10,12,14,17.