29 The fractured immature permanent incisor crown

SUMMARYShay is 8 years old. While saving a penalty for his school team he collided with the goalpost and sus-tained enamel-dentine-pulp and enamel-dentine fractures to his upper central incisors. How would you manage the injuries? Outline a follow-up treat-ment plan.

History

ComplaintThe upper right and left permanent central incisors are frac-tured (Fig. 29.1).

History of complaintThe injury was sustained during a game of soccer. There were no other injuries.

Medical historyShay is a healthy boy with no history of illness. He has had all his vaccinations including a pre-school booster for tetanus.

Dental historyShay is a regular attender at his dentist and has had local anaesthetic for a restoration.

� What specific questions would you ask and why?

Was there any loss of consciousness?

Was the fractured piece of tooth located?

A history of loss of consciousness together with a missing tooth fragment is an indication for a chest radiograph to check that there has not been inhalation of the tooth fragment.

When did the injury occur?

The time from the injury to presentation may affect the treatment options.

Did Shay cope well with his previous experience of local anaesthetic? The answer to this will dictate what treatment strategies will be possible.

Examination

Extraoral

� Why is the presence of lip swelling together with a mucosal laceration important?

This could indicate that the missing tooth fragment is retained in the lip.

� How would you demonstrate there was a fragment of tooth in the lip?

By soft tissue radiography using two views at right angles to each other. A simple anteroposterior view using a peri-apical film placed behind the lip and in front of the teeth, followed by a lateral soft tissue view using a lateral occlusal film (Fig. 29.2). Clinically, a fragment of tooth is often best located by ‘feel’ with a probe.

Fig. 29.1 Trauma to the central incisors. Fig. 29.2 Fragments of tooth in lower lip (different case).

KeypointMissing tooth fragments could:• Be within the soft tissues if there is a laceration.• Have been inhaled if there was loss of consciousness.

29T H E F R A C T U R E D I M M A T U R E P E R M A N E N T I N C I S O R C R O W N

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Intraoral

� What injuries are visible in Figure 29.1?

There is an enamel-dentine fracture of 1 and an enamel-dentine-pulp fracture of 1 of greater than 1 mm in diameter.

� Are the roots of 1 and 1 likely to have open or closed apices?

Open. Apices are not usually closed on upper permanent central incisors before the age of 11 years.

� How would you confirm apical status?

Periapical radiograph.

� What other injuries must you exclude on the periapical radiograph?

Root fractures.

� What other features of the anterior teeth are important at examination?

Mobility. In a buccopalatal direction. Excessive mobility suggests either a periodontal ligament injury or a root fracture.

Colour. This will indicate whether any direct pulpal damage causing haemorrhage into the dentinal tubules has occurred.

Percussion. Tenderness suggests periapical damage and oedema. A dull note may suggest a clinically undiagnosed vertical crown fracture or root fracture.

Vitality. Following trauma there may be a period of apparent loss of vitality on testing with hot and cold stimuli or the electric pulp tester even in teeth without obvious crown fractures. Nevertheless, the readings serve as a baseline against which subsequent tests can be compared.

� What teeth should be examined after trauma affecting only the upper centrals?

All upper and lower incisors should be included in an examination after any trauma to the anterior region.

Investigations• Radiographs (previously mentioned) for:

— Foreign body in soft tissues if applicable.

— Apical status of teeth.

— Presence or absence of root fractures.

• Vitality testing of all upper and lower incisors.

Treatment� What is the prime consideration for both the upper central

incisors?

To maintain vital pulp within the root, which will allow physiological dentine deposition. This will result in full root growth with normal dentinal wall thickness, which will not be prone to fracture.

� What is the appropriate immediate treatment for 1 (that has an enamel-dentine fracture)?

Reattachment of the fragment.

orA bonded restoration/‘bandage’, which will produce a hermetic seal. Glass ionomer cement is not an adequate material for a ‘bandage’ and will fracture or be lost resulting in thermal damage to the pulp from hot and cold stimuli. A layer of setting calcium hydroxide cement should be placed over dentine where a pulpal shadow is visible prior to placement of an adhesive bandage.

� What are the treatment options for 1 (that has a pulpal exposure)?

• Direct pulp capping.

• Complete pulpotomy.

• Partial pulpotomy.

Direct pulp capping, the placement of wound dressings on an exposed pulp, is considered very unpredictable by many authors. Partial pulpotomy (subtotal or Cvek) is the removal of only the outer layer of damaged and hyperaemic tissue in the exposed pulps and will also allow continued full root growth. Partial pulpotomy is a highly successful technique. Complete pulpotomy (cervical pulpotomy) is the removal of coronal pulp tissue and the placement of a wound dressing on the canal orifice. Complete pulpotomy will arrest dentine formation in the pulp chamber but allow full root growth. Complete endodontic treatment will then only be necessary in the future if the root canal is required for retention of a coronal restoration.

� What are the indications for permanent tooth pulpotomy?

No history of spontaneous pain.

Acute minor pain that subsides with analgesics.

No discomfort to percussion, no sulcus swelling, no mobility.

Radiographic examination shows normal periodontal ligament.

Pulp is exposed during caries removal or subsequent to recent trauma.

Tissue appears vital.

Bleeding from the pulp excision site stops with isotonic saline irrigation within 2 minutes.

� How would you carry out a pulpotomy?

Local analgesia and rubber dam. Flush exposed pulp tissue initially with isotonic saline. Then excise a 2 mm superficial layer of exposed pulp and surrounding dentine with a high speed diamond bur using a light touch under water spray cooling (partial pulpotomy). Irrigate the surface of remain-ing pulp with isotonic saline. If bleeding ceases then dry carefully with a dry sterile cotton pellet prior to applying a pulpal medicament with biologically available calcium hydroxide and seal coronal cavity with a bonded restora-tion. However, if there is either no bleeding at all or the bleeding does not cease then the remaining pulp tissue within the pulp chamber should be removed with a sharp excavator (coronal pulpotomy). Irrigate, dry and reassess. If healthy bleeding occurs which ceases then cover with a medicament as above. However, if after a coronal pulpot-omy there is still either no bleeding at all or the bleeding does not cease, the remaining pulp tissue should be removed (pulpectomy).

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The time from injury to presentation for treatment has been reported to be important with regard to the success of partial pulpotomy, with treatment within 24 hours giving the best results. However, proper treatment of pulp tissue and careful case selection are likely to be the key issues for a good outcome. Pulp tissue compromised by infection and inflammation must be removed to facilitate physiological haemostasis during saline irrigation. The larger and the deeper an access cavity needs to be to reach healthy tissue, the more likelihood there is of widespread infection and thus suggests a likely clinical contraindication to vital pulp therapy.

� How should the crown of 1 be restored?

If the crown fragment has been retrieved then this can be stored in normal saline while the partial (subtotal) pulpot-omy is completed. The fragment can then be reattached.

If the crown fragment is not available or the fracture extends significantly subgingivally, a bonded composite restoration should be provided.

Figures 29.3 and 29.4 show the crown fragments before and after reattachment in Shay’s case. 1 had a partial pul-potomy as described.

� How should the upper centrals be reviewed and how often?

Definitive crown morphology should be restored as soon as possible after emergency treatment to re-establish normal sagittal relations with the lower incisors.

One-, 3-, and then 6-monthly clinical and radiographic examinations should be done to check for continued vitality and normal root growth. If there is evidence of non-vitality

Fig. 29.3 Fragments found at scene of incident.

Fig. 29.4 Fragments reattached.

KeypointPartial or complete pulpotomy:• Has a high success rate.• Is more successful if completed within 24 hours of an

injury.• Allows full root growth with a vital radicular pulp.

Recommended readingCurzon MEJ (ed) 1999 Handbook of dental trauma.

Wright, Oxford.

Roberts G, Longhurst P 1996 Oral and dental trauma in children and adolescents. Oxford University Press, Oxford.

Welbury RR, Whitworth JM 2005 Traumatic injuries to the teeth. In: Welbury RR, Duggal MS, Hosey MT (eds) Paediatric Dentistry, 3rd edn. Oxford University Press, Oxford.

For revision, see Mind Map 29, page 191.

then the immature tooth must be extirpated and non-setting calcium hydroxide used to stimulate root end closure prior to obturation with gutta percha.

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M I N D M A P 2 9

periapicalcheck for root fracturescheck periapical statusRadiographs

previous treatment

previous local anaesthetic

attitude totreatment

Dental history

enamel fracturesmooth/restore

reattach fragment

temporary adhesive bandage

acid etch tippulp cap

partial pulpotomy

complete coronal pulpotomycalcium hydroxide pulpectomy

enamel / dentine fracture

enamel / dentine /pulp fracture

Treatment

extraoral

swelling

lip laceration – checkfor teeth fragments

asymmetry

occlusion

soft tissue

teeth

occlusionbone

colour

mobility

percussion

sensibility

intraoral

Examination

Review

how

monitor vitality

monitor rootmaturation

monitor adjacent teeth

whenwhere

previous injuryfragments

chest X-rayloss of consciousness and

missing fragment

History

congenital heartdisease / rheumatic fever

immunosuppression

bleeding disorders

allergies

Medical history

Fractured Immature Permanent Incisor Crown