Treatment of uncomplicated crown fracture & complicated crown fracture (minimal pulp

exposure)

ContentTreatment of fractured enamelTreatment of uncomplicated crown

fractureTreatment of complicated crown fracture

with minimal pulp exposure

Treatment of fractured enamel

Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material

Treatment options1. Leave it2. Rounded – sharp

enamel edges3. Re-attach the fragment4. Restore with CR

Follow-upClinical and radiographic control -> 6-8 weeks &

1 year.

Treatment of uncomplicated crown

fracture

Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material

Clean with water spray/ saline/ chlorhexidine

Disinfect with Chlorhexidie gluconate 0.12% (Peridex ®)

Treatment optionsNo tooth fragment – Covered with GIC

(temporary)/ Restore with CR

Tooth fragment saved – Re-attach the fragmentFollow-upClinical and radiographic control -> 6-8 weeks

& 1 year.

Reattachment of tooth fragmentGood and long-lasting esthetics Can restore function Positive psychological responseSimple procedureLess time-consuming More predictable long-term wear than when

direct composite is used

StepsTry tooth fragment

intraorallyIsolation

Flour of pumice AdhesiveEtching

Tooth Fragment

Composite resin was applied to both fragment and tooth surfaces.

Dentin and enamel

Flour of pumice Etching Adhesive

Light-cured for 40 secondsAdditional compositeFinished with diamond bursPolished with Sof-Lex disks

Treatment of complicated crown fracture with

minimal pulp exposure

Complicated Crown Fracture

Clinical appearance:

Pulp with bright red,cyanotic or ischemic

appearance respectively.

Diagnostic signs

Visual signs Crown fracture extending below gingival margin.

Percussion test Tenderness to percussion.

Mobility test Coronal fragment is mobile.

Sensibility test Primary teeth -Inconsistent results. Permanent teeth -Positive for apical fragment.

Radiographs recommended

An occlusal exposure.

Radiographic appearance:

Fracture at tooth 21

involving enamel

dentine and pulp.

Crown Fracture with Minimal Pulp Exposure

Treatment Objective:

To maintain pulp vitality In immature teeth - to continue root

development.To restore normal esthetics and function.

Treatment:

1)Direct Pulp Capping

2)Pulpotomy

a)Cvek Pulpotomy

b)Cervical pulpotomy

3)Apexification

4)Root Canal Treatment

5)Extraction

1)Direct Pulp Capping

Aim: Preserve vital pulp tissue by physiologically walled off with calcific barrier.

1)Direct Pulp Capping

Indications: Exposure < 1mm

: Time elapsed since injury- within a few hours

: Vital pulp

: Complete root development

: Absence of root fracture

Apply rubber dam

Tooth gently cleaned with water

Calcium hyroxide is applied to the pulp tissue

Cover exposed dentine with GIC

Review in 6-8 weeks

-No clinical sign & symptom-Radiographically lesion not showing any root resorption

-Tooth symptomatic with sign of pulp necrosis

-Radiographicaly,presence of lesionRestore tooth with

permanent restoration.Review in 1&5 years after injury and monitor for pulpal sensibility

Root canal treatment

Extraction

Restore with composite or strip crown in ant and SSC in posterior teeth.

2 a)Partial Pulpotomy/Cvek Pulpotomy

Aim:Remove only inflamed tissue , leaving

healthy pulp tissue for physiologic maturation

of the root.

2 a)Partial Pulpotomy/Cvek Pulpotomy

Indications : Exposure > 1mm

: Time elapsed since injury >24 hours

: Vital pulp

: Fractured primary teeth

: Young permanent teeth

with incomplete root development

: Absence of root fracture

Pulp tissue removal- 2mm apical to the exposure .

Haemorrhage control - saline/diluted sodium hypochlorite(2.5%)

Partial Pulpotomy Procedure

Pulp covered - MTA or calcium hydroxide

Restoration – GIC & CR

Re-evaluation- 1/12 and every 3/12 for the first year.

Partial Pulpotomy Procedure

2 b) Full Coronal PulpotomyAim:Amputation of inflamed pulp tissue from coronal

chamber ,leaving healthy tissue to enhance physiologic

maturation of the root.

Indications :Large contaminated exposure

: Long duration of time elapsed since injury

: Vital pulp

: Fractured primary teeth

: Young permanent teeth with incomplete root

development

: Absence of root fracture

Apply FS on a pledget of cotton wool for 4 minutes

Step 7: Remove FS pledget after 4 mins & check that haemorrhage has stopped

3)Apexification

Aims:to induce either closure of the open apical third of the root canal

or the formation of an apical “calcific barrier” against which obturation

can be achieved.

3)Apexification

Indications :Large contaminated exposure

: Exposure >24 hours

: Necrotic pulp

: Immature permanent teeth with open apex

: Absence of root fracture

4)Root Canal Treatment

Aims:

To remove all the infected material from the pulp chamber

and

root canal system and filling the root canal with inert

filling material.

4)Root Canal Treatment

Indications :Large contaminated exposure

: Exposure >24 hours since the injury

: Necrotic pulp

: Permanent teeth with mature and closed apex

: Absence of root fracture

5)Extraction

If patient’s condition do not permit early

intervention,

the potential for odontogenic infection must

weight against the advantages of preserving

the fractured teeth.

References Macedo GV, Diaz PI, De O Fernandes CA, Ritter AV. Reattachment of anterior

teeth fragments: a conservative approach. J Esthet Restor Dent. 2008;20(1):5-

18

Terry DA. Adhesive reattachment of a tooth fragment: the biological

restoration. Pract Proced Aesthet Dent. 2003 Jun;15(5):403-9;

Peterson,L.J. ,Ellis,E. ,Hupp,J.R and Tucker,M.R. Contemporary Oral and

Mazillofacial Surgery.3rd Edition.Mosby1998

Andreasen JO,Andreasen FM,Bakland LK and Flores MT.Traumatic Dental

Injuries(A Manual)Munksgaard 2nd edition

Michael G.Stewart Head,Face,Neck Trauma Comprehensive management

http://www.dentaltraumaguide.com

http://www.aapd.org/media/Policies_Guidelines/G_trauma.pdf

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