CROWN FRACTURES

Classifications
Enamel
Infraction

Clinical

Radiograph

Very common but

often overlooked

Cannot be
detected

Lines in en
-vertical
-horizontal
-diverging

Take to exclude
any concomitant
luxation

Direct light beam

parallel to the long
axis of tooth

Short-term
Management
Soft diet
Sensitivity to cold
will disappear
OHI
Restoration
1. No txn
2. Seal the cracks
-prevent bacterial
invasion
-prevent stains

Can be associated with

luxation

Enamel #

More often in primary

& permanent
47% of all crown #
Single tooth
Can be associated with
luxation
Mx central incisor
-mesial
-distal

Long-term Management

Prognosis

Follow-up after
-1 week
-1,2,6,12 mths
-every year

Very good

RG + vitality control
To disclose pulp & PDL
damage

If necrosis
occurred, possible
luxation may
have been
overlooked

If no symptoms appear
on follow-up then
regular 6/12 recall
-mobility
-discoloration
-TTP
-signs of infection

Pulp survival 97100%

Reassurance

Reassurance

Very good

No damage to
pulp & PDL

Small #
Smoothening the
roughened en edges
Prevent laceration of
tongue & lips
Good cosmetic result

Pulp survival 99100%

Large #
Restore with AECR
Esthetic
Prevent space loss

If necrosis
occurred, possible
luxation may
have been
overlooked

Enamel-dentin
#

17% of all tooth #

Mx acclusal
PA

Single tooth
Can be associated with
luxation

Exclude
-root #
-luxation

Mx central incisor
-mesial
-distal

BIOLOGY

Sensitivity proportional
to area of exposed dn
& maturity of tooth
Search for minor pulp
exposures
Thin dn layer covering
pulp (pinkish)
-dont probing the area
-pulp perforation may
occur

Exposed dn
tubules permit
invasion of
bacteria to pulp
cause pulp
inflammation
Severity depends
on pulpal
vascularity
presence/absenc
e of luxation
injury

Objectives
1. Protect pulp from external environment
-chemical
-thermal
-bacteria
2. Prevent pain
3. Prevent tilting of adjacent teeth
4. Restore function & esthetics
Principles
1. If no luxation, restore tooth immediately
with AECR
2. In case of luxation (mobility & bleeding)
-temporary restoration (GIC, Vitrebond)
-difficulty in maintaining isolation control
Large # + retained
Reattached with DBA
AECR
Not retained
GIC liner / Vitrebond
AECR

No luxation
Follow-up after 2 mths
Vitality + RG
If normal vitality
-regular 6/12 recall
-at least 5 years
With luxation
Follow-up after
-1 week
-1,2,6 mths
-every year
-at least 5 years
RG + vitality control
If no symptoms
appear on follow-up
then regular 6/12
recall

Pulp survival 9498%

Occurrence of
pulp necrosis
depends on:
1. Amount of dn
exposed
2. Associated
luxation
3. Stage of root
development
Immature root
-high blood
supply
High healing
chance
Rare PDL
complications
-only surface
resorption
-tooth is pushed
against bone

Enameldentine # with
pulp exposure
(complicated
crown #)

Depending of
presence/absence of
luxation
Pulp
Bright red
Cyanotic
Ischemic appearance
Spontaneous bleeding
(may be)
5% of all trauma
Proliferation of pulp
tissue can occur
-when txn is delayed
for long time
Pulp exposure followed
by sensitivity
-thermal changes
-mastication

Lost tooth
substance
PDL changes
(luxation case)
BIOLOGY
Exposed dentinal
tubules & pulp
-direct & indirect
access to pulp
-inflammatory
response
-granulation
tissue formation
Pulpal response
(first few days)
1. Proliferative
Pulpal
hyperplasia
More common
Irrespective of
exposure size
Abscess
formation if
untreated
2. Destructive
Abscess
formation in
subsurface layer
Superficial tissue
necrosis

Objectives maintenance of pulp vitality

1. Immature teeth continue rrot development
2. Mature teeth RCT is avoided
Factors affecting healing + txn options
1. Associated with injury
-size of exposure
-time since accident
-degree of bacterial contamination
-associated injuries (eg: luxation)
2. Associated with txn
-presence of blood clot
-presence of inflammation
-operative technique
-type of drill used
-level of pulp amputation
-choice of pulp medicament
Techniques
1. DPC
2. Pulpotomy
-partial (Cvek)
-cervical (Apexogenesis)
3. Pulpectomy
-RCT
-Apexification

FOLLOW-UP
To ensure no
problems to the
developing
permanent tooth.
Assess
Mobility
Vitality
TTP
Ankylosis
Discoloration
Sign of infections
-clinical
-RG
If tooth is mobile
-evaluate
hyperocclusion
-need of splinting
If hyperocclusion
-relieve it
-soft diet
If mobility to
zero
-suspect ankylosis
If spontaneous
pain /
Pain associated
with hot/cold
-pulp
degeneration

During 1st hours

& days after
trauma,
favorable
potential for pulp
recovery
Healing
sequence (zone)
after 2-3 weeks
of Ca(OH)2
placement
1. Coagulation
necrosis in layer
beneath Ca(OH)2
2. Differentiated
odontoblasts
-wound healing
response
-form new dentin
*5m of dn/day
*hard tissue
barrier forms
after 2-3 mths

Discoloration
-yellow (PCO)
-pink (hyperemia)
-grey/black (pulp
death)
RG
Root development
PA infection
Pulp calcification
Ankylosis
Root resorption
-internal
-external
Interference with
development of
permanent tooth
bud
-if so, exo the
primary

COMPLICATED CROWN FRACTURE

Treatment
DPC
Exposed pulp is
covered with a
dressing to protect
the pulp & permit
healing

Aim
Preservation of pulp
-vital
-inflammation-free
-biologically walled
off by a continuous
hard tissue barrier

Indications/Success
factors
Very small exposure
(1-1.5mm)
Shortly after injury
(few hours)
Sufficient crown
remaining
-to hold capping
material
-efficient seal
Healthy pulp before
trauma

Technique

Success

1. Rubber dam

SR 72-88%

2. Hemorrhage
controlled with
normal saline

RG
Hard tissue healing 3
mths after txn

3. Pulp covered with

Ca(OH)2
-setting or
-non setting

Prognosis depends on
Sterile technique
-RD
-disinfection with NS
Biocompatible
capping agent
Efficient seal

4. Dn covered with
GIC liner
5. AECR

No luxation
Mature vs immature
teeth
Partial Pulpotomy
Part of the coronal
pulp is removed to
eliminate inflamed &
contaminated tissue
that has been
exposed to oral
cavity

Preservation of pulp
-vital
-inflammation-free
-biologically walled
off by a continuous
hard tissue barrier
Leave only healthy
tissue
-enhance physiologic

Immature/mature
teeth
Irrespective of
exposure size & time
before txn
(up to 72 hours)
Pulp free from
inflammation

1. LA, RD(cuff
technique)
2. Cavity preparation
-diamond bur
-2-3mm deep
3. irrigation with NS
-until bleeding stop
-dry the cavity
4. Place Ca(OH)2 on
pulp & dentin

SR 96%

maturation of root
-maintain tooth
vitality

-trauma
-caries
No luxation

Formation of dentinal
bridge under
Ca(OH)2
Cervical Pulpotomy
(Apexogenesis)
Complete coronal
pulp is removed up to
the constriction of
the root canal

Preservation of pulp
-vital
-inflammation-free
-biologically walled
off by a continuous
hard tissue barrier
Apical closure in
immature teeth
Root development

Later apply to
carious, immature
perm. 1st M
Immature teeth
where necrotic tissue
is seen at exposure
site (deeper than
2mm)
Immature teeth, vital
pulp but large
exposure
Immature teeth, vital
pulp, small exposure
but pt didnt seek txn
(>72hours)
Immature teeth, vital
pulp but insufficient
crown structure (nonrestorable tooth)

-no coagulum
between them
5. AECR
6. Review after
-3,6,12 months
-for 5 years
1. LA, RD(cuff
technique)
2. Pulp amputation to
cervical level
-diamond bur
3. Irrigation with NS
-until bleeding stop
-dry cavity
4. Place Ca(OH)2 on
pulp & dentin
-no coagulum
between them
5. Seal with GIC/ZOE
cement
6. AECR

No luxation
7. Review after
-3,6,12 months
-for 5 years

SR 72%
6 weeks early ca
barrier
1 year ca barrier +
root development
10 years mature
root

Pulpectomy
Complete removal of
pulp

Removal of necrotic
tissue
Immature teeth
-apexification
-stimulate root
development (apical
closure by ca barrier)
-for routine endo
later on
Mature teeth
-RCT
-place root canal
filling
-prevent further
pathosis

Apexification
-immature tooth
-necrotic pulp or
-irreversible pulpitis
RCT
-mature tooth
-necrotic pulp or
-irreversible pulpitis
-damage to blood
vessels (luxation)

1. LA, RD (cuff
technique)
2. Pulp chamber
amputated
-tapered diamond bur
3. Place non-setting
Ca(OH)2
-within 1-2mm apex
4. seal cavity with GP
& GIC
5. Repeat above
every
-3/12 for 12-18
months
-take PA to verify
apical barrier
-check clinically with
small paper point
6. When apical
closure achieved, fill
root
-thermoplastic/
conventional GP
-lateral condensation

Successful result
1. Closure of apex to
normal appearance
2. Dome-shaped
apical closure
3. Positive stop RG
evidence of barrier
coronal to apex
4. No RG change but
positive stop in apical
area
Apexification occur in
6-18 months
SR 74-100%
Long-term success
depends on
1. Quality apical seal
2. Amount root
structure present
-length
-thickness
3. Type of restoration
-coronal seal
Largest long-term
risks

Vertical root # of
immature tooth
during function