A Fall on Lag BaOmer and a Tooth Broken Below the Gum

Quick answer: A front tooth that breaks below the gum line is a different problem from an ordinary chip. Whether it can be saved depends on how far below the gum the fracture runs, and the answer is usually a longer plan than patients expect — but it is often still savable.

The call

Lag BaOmer night in RBS Gimmel. Crowds, darkness, uneven ground and a great deal of running about. Meir, 16, tripped over a kerb near the medura and went down onto a stone step.

He arrived with his father at half past eleven, bleeding, holding a piece of tooth in a tissue. The visible part of his upper front tooth was gone almost to the gum.

What we found

Upper left central incisor with a fracture running diagonally: high on the lip side, just under the gum margin, and considerably deeper on the palatal side, running about 3mm below the gum. The pulp was exposed and bleeding. A loose fragment of tooth was still attached by the gum on the palatal side.

That combination — enamel, dentine, pulp and root all involved, extending below the gum — is a complicated crown-root fracture. It is one of the more difficult injuries in a front tooth, and it is worth explaining why.

To restore a tooth you need a margin — a rim of solid tooth for a filling or crown to seal against — that sits above the bone with enough space for the gum to attach. That space is the biological width, roughly 2 to 3mm. If a fracture runs below the bone level and you simply crown it, the gum will never be healthy, the margin will always leak, and the restoration fails.

So the question is not "can this be filled" but "can we get the fracture margin to a level where a restoration can work".

Three ways to do that:

Orthodontic extrusion. Pull the root slowly upwards with light orthodontic force so the fracture line comes above the gum, then restore. Preserves bone and gum height. Takes months. Surgical crown lengthening. Remove gum and bone to expose more tooth. Faster, but it lowers the gum level on that tooth, which on a front tooth looks obviously wrong next to its neighbour. Extraction and replacement. Definitive, but at 16 an implant is not possible — implants are not placed until growth has finished, typically around 20 to 21 in males.

That last point drove the plan. A 16-year-old cannot have an implant, so a gap would mean years of a temporary appliance.

What we did

That night: removed the loose fragment, treated the exposed pulp — a partial pulpotomy, since he was young and the pulp was worth trying to keep — sealed it, and placed a temporary restoration to make him comfortable and presentable.

Three weeks later: the pulp had not settled and the tooth had become symptomatic, so a full root canal was completed.

Two months later: orthodontic extrusion. A bracket bonded to the remaining root, light elastic traction over ten weeks to draw the root up about 3mm, then three months of stabilisation to let the fibres reorganise.

Seven months from the injury: a post, a core and a crown.

The outcome

The tooth is in place, matches its neighbour, and the gum contour is symmetrical — which was the reason for choosing extrusion over crown lengthening.

He will very likely need this tooth revisited in his twenties, and he knows that. He has kept his own root and his own bone through the years when an implant was not an option, which was the whole objective.

What to do if this happens to you

1. Be seen the same night. An exposed pulp is time-critical, especially in a young person.
2. Keep any fragments in milk.
3. Ask how far below the gum the fracture runs. That single measurement determines everything.
4. Ask about extrusion before agreeing to extraction, particularly for a front tooth.
5. Expect a long plan. Six to twelve months is normal for these.
6. Remember implants wait for growth. For teenagers, saving the natural root has extra value.

Tooth broken at the gum line? Ramat Beit Shemesh Urgent Dental Care assesses whether it can be saved before recommending extraction. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh.

Based on real cases treated at the clinic. Names have been changed.