Treatment of crown fractures often requires a multidisciplinary approach. In the anterior teeth, reestablishment of proper esthetics and function is quite important for the patient. However, crown-root fractures with fracture line below the gingival attachment or alveolar bone crest presents restorative difficulties. This case report presents a cervical tooth fracture that had been treated with minimal invasive approach with different disciplines. The tooth had endodontic treatment and a glass-fiber post, and a composite core was accomplished. Then, the tooth was extruded to the desired level with orthodontic forced eruption before definitive restoration.

Invasive cervical resorption (ICR) is a significant and often aggressive pathologic process that, unfortunately, might lead to tooth loss. The presence of such a lesion in the cervical area is always a clinical challenge. This article presents an ICR case in which successful treatment was achieved by combining 4 disciplines: endodontics, orthodontics, periodontics, and prosthetics. Forced eruption combined with fiberotomy was used in this case for pulling the root rapidly from within the alveolar socket, thus exposing sound and healthy tooth material beyond the affected zone suitable for crown preparation. The presented interdisciplinary technique is offered for the prudent clinician as a solution in ICR cases of severe destructive nature.

Forced eruption can be performed in teeth with caries, fracture, resorption or perforation in the cervical third of the root or isolated teeth with one- or two-walled vertical periodontal defects. The purpose of this case report is to introduce an innovative orthodontic appliance which enables forced eruption. This appliance is easy to fabricate, cost-effective and very effective in forced eruption of non-restorable teeth.

To understand why the crown lengthening may be desirable, a review of periodontal anatomy is in order. The odontologists know, but often underestimate importance of periodontal tissues health to restoration of defected teeth or dental arches. In order to avoid pathological changes, to predict treatment results more precisely, it is necessary to keep gingival biological width unaltered during teeth restoration. If there are less than 2 mm from restoration's margin to marginal bone clinical crown lengthening possibility should be considered in dental treatment plan. The choice depends on relationship of crown-root-alveolar bone and esthetical expectations. In order to keep margins of restoration supragingivally the distance from marginal bone to margins of restoration should not be less than 3 mm. Ideally the margins of restoration should be supragingivally or in the same level as marginal gingiva. When the margins of restoration are prepared subgingivally, the distance from marginal gingiva to margins of restoration should not be more than 0.7 mm. To continue dental treatment in operated area is recommended not earlier than in 4 weeks, and making restorations in esthetical area--not earlier than in 6 weeks.

Background: It is clinically challenging to place and restore an implant when the mesio-distal space is limited or reduced at the occlusal plane and/or the bone level. Placing implants in these cases while ignoring the clinical difficulties and compromising treatment could limit the successful outcome. Treatment options include strategic extractions, sectional orthodontics, and minor orthodontic movements. Purpose: To discuss the clinical problems and difficulties arising from limited edentulous mesio-distal space interdentally and to present a treatment modality and technique. Materials and Methods: Orthodontic elastic separating rings are used to open interdental space between teeth and implants, exerting forces against implants for regaining the needed space and restoring implants with ease. Results: The advantages of this technique are illustrated by clinical cases. Conclusions: Implants placed in limited interdental edentulous ridges may well assist in regaining lost spaces after loading. Neither an orthodontic background nor special instruments are required for this technique.

As the use of dental implants became a widespread and acceptable treatment modality, with an overall good long-term prognosis, treatment concepts changed reciprocally. Nowadays, dental implants are considered routine and are preferred over other modalities such as removable or fixed partial dentures or etched cast restorations supported by neighboring teeth. However, we often find clinical situations that challenge the placement of an implant because of insufficient space. Congenitally missing tooth, loss of a tooth because of periodontal disease, long-lasting extracted sites, or lost tooth structures caused by caries or trauma may give rise to teeth drifting and loss of coronal space that may hamper implant placement. Minimal or minor orthodontic procedures may be used to regain adequate space for implant placement. The 3 clinical cases presented in this article discuss the various considerations and the use of teeth as mediators in small scale orthodontic treatment performed to achieve enhanced results for single implant restorations to replace missing teeth.

Periodontal surgery may be accompanied with some postoperative complications such as pain, swelling and sloughing, purulence or infection, transient bacteremia, nerve trauma, and hemorrhage. In general, a resective surgical intervention may implicate reduction in the attachment apparatus. Migration as a postoperative complication has never been addressed in the literature. This paper presents a case report detailing migration of a tooth, following a surgical preprosthetic clinical crown-lengthening procedure, which was repositioned using adjunctive orthodontics with a removable maxillary modified Hawley appliance. It is incumbent upon the dentist to examine meticulously the occlusal status of the teeth prior to a planned surgical intervention and to take measures preventing any possible tooth migration during the healing process. Failure to achieve occlusal and intra-arch stability may lead to undesired tooth movement in the arch postsurgery, affecting future prognosis and complicating any planned prosthetic work.

PURPOSE This article describes an original solution for a tooth with an existing cast post and core placed subgingivally. MATERIALS AND METHODS The tooth was erupted rapidly using a simplified and easy technique that incorporates fiberotomy during the process of movement. RESULTS The distal finish line of the core, which was subgingival before movement onset, was elevated, allowing the placement of crown margins on sound tooth structure. Clinical evaluation of the tooth after a period of 4 weeks, during which a provisional acrylic resin crown was used for retention, showed no need for corrective surgery, and fabrication of a metal-ceramic crown (Captek) was begun. CONCLUSION When failing to place crown margins on sound tooth structure, the existence of a cast post and core in such a nonrestorable tooth may serve as an anchor in the process of rapid extrusion. Following the need to respect the biologic width and fulfill the obligatory ferrule effect circumferentially, this extrusive treatment modality was applied to meet high treatment standards.

Access to the pulp chamber for endodontic treatment is indicated inter alia as a result of extensive caries, trauma to the tooth causing fracture or loss of vitality, requiring restoration of the missing tooth structure. Different approaches and materials are described in the literature for foundation restorations, either with a cast post and core or immediately, with a chairside post-and-core system. This article briefly reviews the current data regarding the microbiologic, prosthetic, mechanical, and periodontal aspects while emphasizing the immediate approach using amalgam, resin composites, and glass ionomers. Factors affecting retention of the post are presented to guide the clinician in selecting a suitable post-and-core system to preserve optimal root structure and prevent root fracture. Three clinical cases are presented in which tooth structure was restored using different techniques: in the first two, provisional acrylic resin shells, one custom made and the other prefabricated, were used to house an amalgam coronal-radicular dowel core, where in the third case, a copper band was used for a composite post-and-core system. All cases emphasize the ease of production and short chairtime in the stages of crown fabrication.

Restoring a tooth with an inadequate contact point and root proximity is a challenge to the practitioner. Ignoring such situations or making compromises in the treatment plan may hinder a successful treatment outcome. Treatment options include strategic extractions, sectional orthodontics, and minor orthodontic movements. The purpose of this article is to discuss the clinical problems and difficulties arising from this situation and to present a modified treatment modality through two case reports. Elastic separating rings, which open an interdental space for placing orthodontic appliances, can be modified to serve as a preprosthetic means for solving mesiodistal crowding of teeth in daily practice. The classic method is modified by the use of elastic rings in sequentially increased thickness, so that the space gained with one ring is followed and increased with a thicker one. An orthodontic background and special instruments are not necessary.

BACKGROUND Osteonecrosis of the jaw (ONJ) is a painful condition secondary to bisphosphonate (BP) therapy. It occurs at a much higher rate in patients receiving intravenous (IV) versus oral BP treatment. BPs are prescribed in the treatment of bone diseases such as osteoporosis, multiple myeloma, cancer metastases and Paget disease. Patients' risk of developing ONJ is of concern to medical and dental teams alike and requires open communication between the disciplines. If dental surgery is indicated, it must be performed before commencement of IV BP therapy, and it should be considered for patients receiving oral BP therapy. However, the dental literature pertaining to the two therapeutic modalities stresses the low risk of ONJ's developing in patients receiving oral BP therapy (especially in the early stages) compared with that in patients receiving IV administration. CASE DESCRIPTION The authors used forced eruption to extrude hemisected hopeless distal roots of first and second mandibular molars from within their alveolar sockets in a patient receiving long-term oral BP therapy. Just before the extraction, they placed orthodontic separating bands around the distal roots to further exfoliate the roots. This so-called bloodless extraction is an alternative treatment for patients at risk of developing ONJ. CLINICAL IMPLICATIONS The combination of orthodontic extrusion and bloodless extraction is aimed at minimizing trauma and enhancing the health of the surrounding tissues in patients at risk of developing ONJ or when the patient refuses to undergo conventional tooth extraction.

The loss of an entire tooth in the anterior region is accompanied by impairment of esthetics, function, phonetics, and self-esteem. It is common knowledge that treatment with implants during childhood or early adolescence is not an option. Splinting of adjacent teeth during growth and development may interfere with the independent process of teeth realignment and repositioning during that phase of life. Other creative solutions must be offered, such as free-standing composite buildup restorations on compromised broken teeth or single wing/cantilevered restorations adhered to one neighboring tooth during the growth period. The positive effects of reinforced composite materials were researched and presented in the literature. Their use is clearly indicated for interim and economical restorations. Long-term follow-up on a mandibular incisor that experienced trauma, losing its clinical crown and vitality when the patient was 12 years of age, is discussed with all the various aspects of material selection, future considerations, and long-term follow-up to adulthood, when a conventional crown was prepared and delivered.

Objective: Sites in which bone is reduced in quality or height create challenges in esthetic reconstruction and loading support, which leads to a higher risk of failure. The Mk IV system with a TiUnite surface was designed specifically for placement in soft bone. This paper describes postloading outcomes of 103 Mk IV implants, with a focus on bone preservation in compromised bone sites during early remodeling, stability after abutment connection, and a 3- to 7-year follow-up from implant placement. Method and Materials: A series of 103 4-mm (diameter), ≤ 10-mm (length) Mk IV implants were placed in the maxillae of 25 females and 14 males. Twenty-three patients also received staged bone grafts, and two underwent socket augmentation as well as grafts. Areas of previous infection were prepared mechanically and chemically. To ensure primary implant stability, the size of the osteotomy and the number of entries were minimized. Following a delayed loading protocol, all patients were restored with fixed partial dentures. For analysis of bone stability, the marginal levels on the mesial and distal aspects of the implants were measured at 7x magnification by a radiologist not involved in the treatment. Results: Three implants were lost, 1 implant was never loaded although it integrated, 14 implants were not available for follow-up after abutment correction, and 5 had poor-quality radiographs. The mean marginal bone loss between implant insertion and loading was 1.21 ± 0.86 mm (n = 80). The differences in bone-remodeling levels in grafted and nongrafted sites were not significant. Data are reported on 103 implants in 39 consecutive patients through abutment connection, with radiographic follow-up from 3 to 7 years postimplant placement on 27 patients. Conclusion: It is critical to ensure optimal three-dimensional orientation and minimize site preparation, particularly when placing implants in compromised bone. With bone of poor preoperative density using a customized site preparation technique, excellent short-term implant survival and long-term bone stability have been demonstrated. Further follow-up will determine whether the Mk IV implant is the optimal design for compromised bone, including associated soft tissue stability.(Quintessence Int 2012;43:293?303).

International Journal of Paediatric Dentistry 2012; 22: 271-279 Background.  Midazolam sedation poses a significant dilemma in paediatric dentistry, which is to find out the optimal dosing with minimal undesirable adverse events. In this study, we aimed to compare the effect of three doses of oral midazolam (0.5, 0.75, and 1 mg/kg) on the sedative state and cooperative behaviour of children during dental treatment. We further compared completion rates, parent satisfaction, and all adverse events. Design.  Ninety children aged 3-10 years were randomised to three equal groups. Groups A, B, and C received 0.5, 0.75, and 1 mg/kg of oral midazolam, respectively. Levels of sedation, cooperative behaviour, procedures completion rates, parent satisfaction, and adverse events were prospectively recorded. Results.  Sedation scores in B and C were higher (P < 0.001) than in A. Cooperation scores (CS) in B and C were higher (P < 0.001) than in A. Significant increase in completion rates was observed between A and C (P = 0.025). Parent satisfaction was greater in B and C (P < 0.001) compared to A. Adverse events were higher in C (P < 0.05) than in A or B. Conclusion.  Amount of 0.75 mg/kg oral midazolam appears to be the optimal oral dose in terms of effectiveness, acceptability, and safety for dental treatments in paediatric patients, when administered by an experienced, paediatric anaesthetist.

SUMMARY External cervical resorption (ECR) is a sequela of dentoalveolar trauma that may cause functional, esthetic, and psychologic alterations. The aim of this study was to report a successful multidisciplinary treatment approach performed in a 12-year-old patient who presented with posttraumatic ECR associated with extensive opened cavity, pulp necrosis, and periapical lesion of tooth number 9, with an initial unfavorable prognosis. Crown lengthening was done to enable restoration of vestibular surface with resin composite, forming a barrier that allowed endodontic treatment. Afterwards, a prefabricated fiberglass post was cemented and esthetic restoration was performed using the adhesive technique and direct composite veneer. Reconstructive periodontal surgery was performed to correct irregular gingival contour. After treatment and successive follow-up sessions, it was concluded that although the tooth had been indicated for extraction, low invasive direct techniques were effective to recover function and esthetics and to maintain the tooth in the oral cavity.

The choice of the most appropriate restoration for anterior teeth is often a difficult decision. Numerous clinical and technical factors play an important role in selecting the treatment option that best suits the patient and the restorative team. Experienced clinicians have developed decision processes that are often more complex than may seem. Less experienced professionals may find difficulties making treatment decisions because of the widely varied restorative materials available and often numerous similar products offered by different manufacturers. The authors reviewed available evidence and integrated their clinical experience to select relevant factors that could provide a logical and practical guideline for restorative decisions in anterior teeth. The presented concept of restorative volume is based on structural, optical, and periodontal factors. Each of these factors will influence the short- and long-term behavior of restorations in terms of esthetics, biology, and function. Despite the marked evolution of esthetic restorative techniques and materials, significant limitations still exist, which should be addressed by researchers. The presented guidelines must be regarded as a mere orientation for risk analysis. A comprehensive individual approach should always be the core of restorative esthetic treatments. CLINICAL SIGNIFICANCE: The complex decision process for anterior esthetic restorations can be clarified by a systematized examination of structural, optical, and periodontal factors. The basis for the proposed thought process is the concept of restorative volume that is a contemporary interpretation of restoration categories and their application.(J Esthet Restor Dent ••:••-••, 2012).

BACKGROUND- Previous studies on crown lengthening (CL) report contradictory results regarding stability of crown length gained at the time of surgery. The "3 mm rule" has dictated the amount of alveolar bone to be removed during CL surgery for decades. With the current understanding of wide variations in supracrestal gingival tissue (SGT) dimensions, bone removal can be customized to the situation. The purpose of this study was to assess alterations in periodontal tissue levels six months after CL surgery and to evaluate factors that may influence stability of CL achieved over time. METHODS- 64 patients requiring CL surgery on 64 teeth were included in this study. Clinical parameters were recorded along six surfaces of treated tooth and neighboring teeth. Sites were labeled as treated sites, adjacent sites and non adjacent sites. Bone was reduced based on the minimal amount of tooth structure required for restorative purpose and SGT dimensions at each site. Patients were again evaluated at 3 and 6 months. RESULTS- Significant soft tissue rebound (0.77 ± 0.58 mm) was observed 6 months after CL surgery. This rebound was found to be significantly correlated with periodontal biotype (r = 0.325, p = 0.000) and post suturing flap position (r =-0.601, p=0.000). SGT was not reestablished to its preoperative dimensions by the end of 6 months (p=0.001). CONCLUSION- Crown length gained during surgery significantly decreased at 6 months. Suturing the flap ≤ 3 mm from the osseous crest and thick-flat biotype were associated with greater tissue rebound.

Surgical crown lengthening has been proposed as a means of facilitating restorative procedures and preventing injuries in teeth with structurally inadequate clinical crown or exposing tooth structure in the presence of deep, subgingival pathologies which may hamper the access for proper restorative measures. Histological studies utilizing animal models have shown that postoperative crestal resorption allowed reestablishment of the biologic width. However, very little has been done in humans. Aims. The purpose of the study was to evaluate the potential changes in the periodontal tissues, particularly the biologic width, following surgical crown lengthening by two surgical procedures before and after crown placement. Methods and Material. Twenty (20) patients who needed surgical crown lengthening to gain retention necessary for prosthetic treatment and/or to access caries, tooth fracture, or previous prosthetic margins entered the study. The following parameters were obtained from line angles of treated teeth (teeth requiring surgical crown lengthening) and adjacent sites: Plaque and Gingival Indices (PI)&(GI), Position of Gingival Margin from reference Stent (PGMRS), Probing depth (PD), and Biologic Width (BW). Statistical Analysis Used. Student "t" Test. Results. Initial baseline values of biologic width were 2.55 mm (Gingivectomy procedure B1 Group) and 1.95 mm (Ostectomy procedure B2 Group) and after surgical procedure the values were 1.15 mm and 1.25 mm. Conclusions. Within the limitations of the study the biologic width, at treated sites, was re-established to its original vertical dimension by 3 months. Ostectomy with apically positioned flap can be considered as a more effective procedure than Gingivectomy for Surgical Crown Lengthening.

The paper presents the strength tests, in terms of in vitro examinations, of restored mesial incisor crowns after endodontic treatment with modelled orthodontic extrusion procedure. The strength tests were carried out for 25 teeth randomly divided into groups with various degree of root reduction. The analysis was done for the following quantities: the force to fracture, the work to fracture, the energy of the first micro-crackings and breaking, the total displacement. Statistical analysis with the use of the Kruskal-Wallis test was done in order to assess the significance level in four tooth groups. Numerical simulations of periodontal ligament effort due to the orthodontic extrusion have also been carried out.

The aim of this clinical report is to describe the successful treatment of a mandibular first molar presenting an extensive fracture at the buccal aspect in a young patient. The extension of the fracture was a negative prognostic factor for tooth maintenance. An alternative clinical treatment was proposed since the patient was young and presented with good oral hygiene and periodontal health. The treatment was based on orthodontic forced eruption associated with odontoplasty. A 3-year follow-up after the surgical procedure demonstrated the maintenance of periodontal health and good plaque control. It can be concluded that orthodontic forced eruption associated with odontoplasty promoted favorable conditions for prosthetic rehabilitation and is a feasible procedure in the treatment of tooth fracture extended below the cementoenamel junction.

Orthodontic extrusion (OE), which is performed in many different clinical situations to move a tooth or its periodontal tissues coronally, is often associated with supracrestal fiberotomy and root planing (OEFRP) or followed by surgical crown lengthening. The OEFRP procedure must be carried out every 2 weeks during the entire extrusive orthodontic phase, and precise control of the technique itself can be quite difficult, especially when this approach is to be performed on a limited portion of the root perimeter in teeth affected by angular defects. The aim of this study was to show a new nonsurgical crown-lengthening technique, performed shortly after the completion of OE, to simultaneously achieve proper hard and soft tissue architecture. Three different illustrative situations (periodontal pocket, root fracture, and root perforation) are described.

INTRODUCTION Preserving intact coronal and radicular tooth structure, especially maintaining cervical tissue to create a ferrule effect, is considered to be crucial for the optimal biomechanical behavior of restored teeth. The ferrule effect has been extensively studied and still remains controversial from many perspectives. The purpose of this study was to summarize the results of research conducted on different issues related to the ferrule effect and published in peer-reviewed journals listed in PubMed. METHODS The search was conducted using the following key words:"ferrule" and "ferrule effect" alone or in combination with "literature review,""fracture resistance,""fatigue,""finite element analysis," and "clinical trials." RESULTS The findings from reviewed articles were categorized into three main categories: laboratory studies, computer simulation, and clinical trials. Laboratory studies were further classified into subchapters based on the main aspect investigated in relation to the ferrule effect. CONCLUSIONS The presence of a 1.5- to 2-mm ferrule has a positive effect on fracture resistance of endodontically treated teeth. If the clinical situation does not permit a circumferential ferrule, an incomplete ferrule is considered a better option than a complete lack of ferrule. Including a ferrule in preparation design could lead to more favorable fracture patters. Providing an adequate ferrule lowers the impact of the post and core system, luting agents, and the final restoration on tooth performance. In teeth with no coronal structure, in order to provide a ferrule, orthodontic extrusion should be considered rather than surgical crown lengthening. If neither of the alternative methods for providing a ferrule can be performed, available evidence suggests that a poor clinical outcome is very likely.

Extrusion of fractured anterior teeth with fracture line extending subgingivally requires exposure of sound tooth structure. Orthodontic extrusion is the preferred method of choice. Conventional orthodontic appliance is usually unesthetic because of exposure of brackets. This case report describes an esthetic management of such a tooth with a lingually placed orthodontic appliance which also allows placement of a labial composite resin laminate so as to restore esthetics at the earliest. This was followed by a post-endodontic restoration. This approach enabled us to establish not only to a long-term restorative success, but also an immediate replacement of esthetics so that the patient is able to confidently smile during the course of treatment also.

The biologic width is an essential dental space that always needs to be maintained to ensure periodontal health in any dental prosthetic restorations. An iatrogenic partial fixed prosthesis constructed in lower posterior teeth predisposed the development of subgingival caries, which induced violation of the biologic width in involved teeth, resulting in an uncontrolled inflammatory process and periodontal tissue destruction. This clinical report describes a periodontal surgical technique to recover a violated biologic width in lower posterior teeth, by crown lengthening procedure associated with free gingival graft procedure, to ensure the possibility to place a modified partial fixed prosthesis in treated area. The procedure applied to recover the biologic width was crown lengthening with some modifications, associated with modified partial fixed prosthesis to achieve health in treated area. The modified techniques in both surgical and prosthetic procedures were applied to compensate the contraindications to recover biologic width by osteotomy in lower posterior teeth. The result, after 4 years under periodic control, seems to achieve the projected goal. Treating a dental diseased area is necessary to diagnose, eliminate, or control all etiologic factors involved in the process. When the traditional methods are not effective to recover destructed tissues, an alternative, compensatory, and adaptive procedure may be applied to restore the sequelae of the disease, applying a restorative method that respects the biology of involved tissues.