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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
Thank you