Cvek M A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978; 4:232-237
Walker M Fractured-tooth fragment reattachment. Gen Dent. 1996; 44:434-436
Tsukiboshi M, 2nd edn. Chicago: Quintessence; 2012
MSc, FDSRCS, FDSRCPS, FDSRCS, FCGDent, Specialist in Restorative Dentistry and Prosthodontics, Consultant in Restorative Dentistry, King's College Dental Hospital, London
Fortunately, traumatic dental injuries are a relatively uncommon occurrence in general dental practice. However, when they do present, timely diagnosis and treatment of such injuries is essential to maximize the chance of a successful outcome. This is the second part of a two-part series on traumatic dental injuries that are commonly encountered in the clinical setting. Part one covered the management of acute luxation/displacement injuries affecting the supporting structures of the tooth, while part two will cover the management of fracture injuries associated with teeth and the alveolar bone.
CPD/Clinical Relevance: Traumatic dental injuries are uncommon occurrences in everyday general dental practice. This article aims to provide a simple, step-by-step approach in the diagnosis and clinical management of acute fracture injuries.
Article
This is the second part of a two-part series on traumatic dental injuries. Part one focused on acute management of luxation/displacement dental injuries. Part two will deal with the acute management of dental fractures.
Fracture injuries usually affect the substance of the tooth itself and/or the supporting alveolar bone. These injuries include infraction, enamel fracture, enamel-dentine fracture, enamel-dentine-pulp fracture, crown-root fracture with or without pulpal involvement and root fracture. Fracture injuries also include dento-alveolar fractures and jaw fractures, but the latter are outside the scope of this article and patients with a suspected jaw fracture should be referred to the nearest oral and maxillofacial unit.
Traumatic dental injuries do not always occur in isolation and often present as multiple injury types in one or multiple teeth. A patient could attend with a cervical third root fracture on one tooth and an enamel and dentine fracture on another, while another patient could present with a lateral luxation injury together with an enamel, dentine and pulp fracture associated with the same tooth.
In 2012, the International Association of Dental Traumatology (IADT) revised its guidelines in a publication that is considered to present the best evidence based on literature and professional opinion (www.iadt-dentaltrauma.org).1 This article is based on those guidelines and a quick reference guide for permanent tooth fracture injuries is provided in Table 1. The aim of the guidelines is to maximize the chances of a successful outcome for each individual patient.
Type of Injury
Permanent Tooth Treatment
Infraction
Reassure
Enamel fracture
Re-attach fragment, rebuild with composite or re-contour
Enamel and dentine fracture
Re-attach fragment, rebuild with composite or place a glass ionomer ‘bandage’
Enamel, dentine and pulp fracture
A Cvek style pulptomy is recommended in immature teeth or those in young patients followed by calcium hydroxide/mineral trioxide aggregate and glass ionomer cement; then follow enamel and dentine fracture treatment (pulp extirpation may be indicated in mature teeth in older patients)
Root fracture
Reposition displaced segment and splint for 4 weeks (mid and apical third fractures) or up to 4 months (coronal third fractures)
Crown-root fracture without pulp exposure
Temporarily stabilize loose fragment to adjacent teeth
Crown-root fracture with pulp exposure
Temporarily stabilize loose fragment to adjacent teeth; a Cvek style pulpotomy is recommended in immature teeth or those in young patients (pulp extirpation may be indicated in mature teeth in older patients)
Alveolar fracture
Reposition and splint for 4 weeks
Infractions
An infraction is an incomplete fracture (crack line) of the enamel without loss of any tooth structure.2Figure 1 shows the UL1 with an infraction in the incisal third.
Figure 1. Infractions in the UL1.
Clinical findings
Teeth with infractions often present without any symptoms at all or may be slightly sensitive to cold air and touch. When infractions are seen, it is important to rule out any associated luxation/displacement or root fracture injuries.
Radiographic findings
The radiographic appearance of a tooth with an infraction injury is normal, as seen in Figure 2, with no change in the periodontal ligament space.
Figure 2. Upper occlusal of UL1 with extensive infraction injuries (seen in Figure 1).
Treatment of secondary teeth
No active treatment is usually necessary, except in the case of extreme sensitivity when etching and sealing with unfilled resin can be useful. If aesthetics is a concern, then creating a small channel using a small round diamond and sealing with composite resin may seal the crack line, improve the appearance of the tooth and satisfy the patient. In extreme cases with multiple infractions, a labial composite veneer to seal the infractions and ‘splint’ the fragments together may be sensible.
Treatment of primary teeth
Infractions in primary teeth should be monitored with no need for active intervention.
Enamel fractures
An enamel fracture is loss of enamel with no visible sign of dentine exposure,2 as seen in the UL1 in Figure 3.
Figure 3. Enamel fracture of the UL1.
Clinical findings
A tooth with an enamel fracture is usually asymptomatic and this is evidenced by many patients not presenting for treatment.3 A tooth with an enamel fracture is not normally tender to touch and there is no increase in mobility seen. If a tooth with an enamel fracture is tender to touch, then a combined luxation/displacement injury should be suspected and signs and symptoms investigated, as outlined in part one of this two-part series.
Radiographic findings
A periapical radiograph of a tooth with an isolated enamel fracture will appear normal (Figure 4). If a combined luxation/displacement injury or root fracture is suspected, an upper standard occlusal can be a helpful radiograph to aid diagnosis.4
Figure 4. Periapical radiograph of UL1 showing normal periodontal ligament outline.
If there is a soft tissue laceration, particularly in the lip (Figure 5), soft tissue imaging should also be considered to eliminate the possibility of tooth fragment(s) or debris being embedded in the soft tissues. A radiograph taken at 30–50% of the normal exposure5 will demonstrate radio-opaque masses, if present, as seen in Figure 6 (tooth fragments in this case). These would normally be referred to an oral surgeon for management.
Figure 5. Lower lip laceration in a patient with crown fracture of the UR1.Figure 6. Radiograph showing presence of radio-opaque mass in lower lip.
Treatment of secondary teeth
If the tooth fragment is available, an attempt could be made to bond it to the tooth, if it can be relocated with ease. The technique will be described in detail under enamel-dentine fractures.
If the fragment cannot be repositioned with ease because it is too small or has been lost, the tooth can be restored with composite resin, as seen in Figure 7, or simply smoothed down, particularly in the case of minor fractures.
Figure 7. UL1 enamel fracture restored with composite resin.
A one-year follow-up period is advised as part of routine care.
Treatment of primary teeth
In primary teeth it is usually sufficient to smooth sharp edges to prevent trauma to the lip and tongue.
Enamel–dentine fractures
This is a fracture involving both enamel and dentine but with no visible pulpal exposure2 as seen in the UR1 and UR2 in Figure 8.
Figure 8. Enamel dentine fracture of the UR1.
Clinical findings
Also known as an uncomplicated crown fracture, a tooth with an enamel-dentine fracture is usually sensitive to cold air due to the exposure of the dentine. The tooth will be firm and there should not be any tenderness to palpation. If the tooth is tender to touch and/or slightly mobile, this is suggestive of an associated luxation injury (see part one of this two-part series for more details).
Radiographic findings
The radiographic appearance of a tooth with an enamel-dentine fracture would show the volume loss of tooth tissue, but the root and the periodontal ligament will appear normal, as seen in Figure 9.
Figure 9. Radiograph of UR1 and UR2 enamel dentine fractures.
If an associated luxation injury is suspected, multiple projection radiographs are advised.
If the fragment has not been accounted for and is in the presence of a soft tissue laceration, it would be prudent to obtain soft tissue views as described under enamel fractures above.
Treatment of secondary teeth
If the tooth fragment is not available, the tooth can be restored with direct composite resin (Figure 10). If time is short, then covering the exposed dentine with glass ionomer will reduce the risk of bacterial contamination, as well as make the tooth more comfortable for the patient. This glass ionomer ‘bandage’6 could be replaced with composite at a later date.
Figure 10. Composite restoration for enamel dentine fracture UR1.
If the patient has the tooth fragment, every attempt should be made to re-attach the fragment and this will be described in detail in the next section.
Treatment of primary teeth
Primary teeth with enamel-dentine fractures should be managed in a similar way to permanent teeth.
Enamel, dentine and pulp fractures
An enamel dentine and pulp fracture involves loss of tooth structure with exposure of enamel, dentine and pulp (Figure 11).2
Figure 11. Enamel dentine fracture of UL1 with pulpal involvement.
Clinical findings
Also referred to as a complicated crown fracture, a tooth with a complicated crown fracture will be sensitive to thermal and tactile stimuli and be tender to touch, but there should not be any labial tenderness. Labial tenderness is suggestive of an associated luxation injury (see part one of this two-part series for more details).
Radiographic findings
As with enamel only and enamel-dentine fractures, multiple projection radiographs are advised to eliminate the possibility of root fracture or a luxation injury. Enamel and dentine loss will be visible with a breach of the pulp chamber (Figure 12). Again, if the tooth fragment(s) cannot be accounted for, and in the presence of a lip laceration, a soft tissue radiograph is indicated, as previously described.
Figure 12. Periapical radiograph of UL1 showing even width of periodontal ligament.
Treatment of secondary teeth
With exposed or near-exposed pulps in adults and children, a Cvek pulpotomy should be performed, in the first instance aiming to remove the inflamed superficial pulp.7 This is particularly important in immature, developing teeth to try to preserve pulp vitality and facilitate root development.
There are three steps to a Cvek pulpotomy:
– Step 1: Remove 2–3 mm of pulp using a small round diamond bur (Figure 13);
– Step 2: Apply pressure with a small pledget of cotton wool soaked in sodium hypochlorite;
– Step 3: Inspect the area and look for healthy pulp tissue with no bleeding (Figure 14).
Figure 13. Small round diamond bur being used to open up access to the pulp in the UL1.Figure 14. Healthy pulp tissue UL1.
If bleeding continues, remove a further 1–2 mm of pulp, and repeat application of pressure and continue the process until healthy pulp tissue is obtained. If, however, pulp is removed down to the cervical level, pulp extirpation should be carried out (except in teeth with open apices).
The healthy pulp should then be covered with a suitable material, such as calcium hydroxide, mineral trioxide aggregate (MTA) or Biodentine (Septodont, Saint Maur des Fosses, France) and then sealed with glass ionomer (Figure 15). The author's preference is to use calcium hydroxide powder mixed into a thick paste with water. The tooth can then be restored with composite resin. If a crown fragment is being re-attached, the glass ionomer should be confined to the prepared area of the pulp chamber so that it does not prevent the exact repositioning of the fragment.
Figure 15. Glass ionomer sealing the calcium hydroxide pulp cap.
If the tooth fragment is available (Figure 16), every attempt should be made to re-attach the fragment. This is achieved by checking that it can be relocated accurately and with ease (Figure 17). When this is possible, a quick way of re-attaching the fragment is to carry out the following steps under local anaesthesia:
Etch and bond the tooth fragment (Figures 18 and 19) and etch (Figure 20) and bond the tooth;
Paint flowable composite onto the fragment and then onto the tooth;
Reposition the fragment with firm pressure.
Figure 16. Tooth fragment UL1.Figure 17. UL1 fragment checked for repositioning.Figure 18. Etching the tooth fragment UL1.Figure 19. Bonding tooth fragment UL1.Figure 20. Etching UL1.
Following a short-burst of light curing for a few seconds, the excess composite can be removed and then the tooth fully cured from both labial and palatal aspects (Figure 21). The re-attached fragment will appear opaque (Figure 22) compared to the main tooth tissue due to dehydration. Normal appearance will be restored after a period of rehydration (Figure 23).
Figure 21. Excess composite removed after a short-burst cure.Figure 22. Re-attached fragment UL1 with opaque appearance.Figure 23. Rehydration of re-attached UL1 tooth fragment after one year.
A slightly more complicated approach to avoid a visible join line has been described. This involves making a temporary index incisally to hold the fragment in position, bevelling the edges of the tooth and fragment and then repositioning the fragment with the index, filling in the resultant gap with composite resin.8 Whilst the aim is commendable, the authors find this approach technique-sensitive. If after using the simpler approach the patient subsequently complains about a visible join line, this can be camouflaged by creating a little channel along the join line with a small round diamond bur and filling the space created with composite.9
Long-term follow-up is advised to check for loss of vitality. Two signs or symptoms are needed to diagnose pulp necrosis, at which point root canal treatment is indicated. Figure 24 shows the radiograph of the UL1 at one-year review showing no changes in the periodontal ligament space.
Figure 24. Periapical radiograph of UL1 at one-year review.
Treatment of primary teeth
If possible, pulp vitality should be preserved with a Cvek pulpotomy as described above. If this is not possible, pulpectomy or extraction may be indicated.
Root fractures
Root fractures are fractures located in the root only2 and may be horizontal or oblique from the long axis of the tooth. They have been classified according to the location in the root as apical third (Figure 25), middle third (Figure 26), or cervical third (Figure 27), depending on the level in the root relative to the cement-enamel junction and the level of the crestal bone.
Figure 25. Periapical showing apical third root fracture of the UR1.Figure 26. Radiograph showing middle third root fracture of the UL1.Figure 27. Radiograph showing cervical third root fracture of the UR1.
Clinical findings
Depending on the location of the root fracture, the coronal fragment may be mobile, with obvious displacement resulting in an occlusal interference. Bleeding from the gingival crevice of the affected tooth is common and, in the absence of radiographs, can be mistaken for a pure extrusion injury. Discoloration of the crown (red or grey) may also occur and is often transient.
Radiographic findings
The findings on a radiograph are variable and dependent on the type of fracture (horizontal or oblique), the position of the fracture, separation of the fragments, as well as the direction of the X-ray beam.
If a root fracture is suspected but not clear on a periapical radiograph (Figure 28), an upper occlusal view should be taken which, due to the bisecting angle, will show the fracture (Figure 29). The fracture will appear as a radiolucent line and thin lines in the absence of an occlusal interference often indicates no displacement of the coronal fragment. Obvious wider radiolucent lines, in the presence of an occlusal interference, is suggestive of extrusion of the coronal fragment.
Figure 28. Periapical radiograph of UR1 with a middle third root fracture.Figure 29. Upper occlusal radiograph of UR1 seen in Figure 28 with a middle third root fracture.
Treatment of secondary teeth
If the coronal fragment is displaced, it should be digitally repositioned using a watch-winding motion with pressure in an apical direction under local anaesthesia. Temporarily holding the fragment in position using Triad™ (Dentsply Prosthetics, Pennsylvania, USA) on the incisal edges, as described in part one, can aid taking a radiograph to check that the fragments are fully apposed. If repositioning the coronal fragment is good, the temporary splint of Triad™ should be left in situ whilst the tooth is splinted to the adjacent teeth, as described in part one.
For apical third and middle third root fractures, a flexible splint is recommended for 4 weeks (Table 2). Cervical third root fractures have the poorest prognosis and, if splinting is attempted, the splinting time is 4 months and, in adults, the authors prefer to use rectangular stainless steel wire to act as a rigid splint (applied in the same manner with composite).
Root Fracture
Splinting Time
Apical third
4 weeks
Mid third
4 weeks
Cervical third
4 months
The follow-up period for root fractures should be up to 5 years.
Treatment of primary teeth
In primary teeth the management is dependent on the stability and degree of displacement of the coronal fragment. If the coronal fragment is firm and not displaced, careful monitoring is indicated. If, however, the coronal fragment is displaced or mobile, the coronal fragment should be extracted and the remaining apical fragment left to be resorbed by the developing successor.
Crown-root fractures
This is a fracture involving enamel, dentine and cementum and may or may not involve the pulp2 (Figures 30 and 31).
Figure 30. Labial view of UL1 suggestive of a crown-root fracture.Figure 31. Occlusal view of UL1 confirming a crown-root fracture.
Clinical findings
The clinical presentation is variable and the true extent may not be immediately obvious. This will depend on the extent and location and whether the coronal aspect is in one or multiple pieces (Figure 31). As a result, there may be very little mobility and separation of the fractured tooth or frank mobility and separation of the fractured parts. This is related directly to the depth of the fracture line as it extends palatally.
Such teeth are often tender to touch and exquisitely tender on separation of the fractured parts. It is, therefore, one of the most difficult fractures to ascertain the true extent of the fracture and this is usually achieved once the tooth has been anaesthetized allowing pain-free exploration.
Radiographic findings
The appearance of a crown-root fracture on a periapical radiograph is therefore very variable and may show the fracture line, as seen in Figure 32. In these cases, multiple projection radiographs may be necessary, including an upper standard occlusal view.
Figure 32. Periapical radiograph of UL1 (seen in Figure 31).
Treatment of secondary teeth
Treatment of crown-root fractures can vary and is dependent upon the clinical time available. It can take the form of remedial action to make the tooth more comfortable for the patient, providing an intermediate solution and allowing more time for a long-term solution to be planned. Exploration under local anaesthetic will allow loose fragments to be removed and the full extent of the fracture assessed.
The following treatment options are possible and will be dictated by the extent of the injury:
If the coronal part of the tooth is in many pieces and attachment not possible (Figure 31), root canal treatment (Figure 33) and composite build-up may be possible (Figure 34) if there is good moisture control (electrosurgery can be very useful).
Re-attaching the fragment with or without pulp management. This is dependent on good moisture control. Again, electrosurgery may be useful to help in this regard.
Root canal treatment followed by provision of a post-crown.
Bonding the fragments together using composite resin to provide a satisfactory stop-gap whilst planning for further exploration. Figure 35 shows a crown-root fracture of the UR2, which was stabilized using a labial veneer of composite (Figure 36) to enable an impression to be taken for an immediate denture to be constructed. Once available, confident exploration of the injury can take place.
If the tooth is rendered unrestorable and there has been loss of coronal tooth tissue, application of a temporary filling over the tooth/root with glass ionomer and taking an impression for an immediate denture for tooth replacement can be planned.
Figure 33. UL1 root canal treated.Figure 34. Composite build-up of UL1 following root canal treatment.Figure 35. Buccal view of UR2 with crown-root fracture with labial fracture line seen close to the gingival margin.Figure 36. Composite veneer placed on UR2 to help ‘splint’ the fragments together temporarily.
Treatment of primary teeth
Treatment of crown-root fractures in primary teeth would involve either removal of the coronal fragment, leaving the root to be resorbed by the successor, or indeed extraction of the entire tooth.
Alveolar fractures
Alveolar fractures involve the alveolar bone and may extend to the adjacent bone.2
Clinical findings
A common presentation of alveolar fractures is segment mobility and dislocation, with several teeth moving en-bloc with a change in the occlusion due to misalignment of the fractured alveolar segment. Alveolar fractures are commonly seen with the luxation injuries, notably lateral luxations and avulsions.
Radiographic findings
Multiple projection views, including a panoramic radiograph, can be helpful in determining the course and position of the fracture. The fracture lines may be located at any level from the marginal bone to the root apex and may be seen as vertical or horizontal radiolucent lines (Figure 37) in between or over the roots of the teeth.
Figure 37. Alveolar fracture in the region of the apices of the lower incisors.
Treatment of secondary teeth
The displaced segment should be digitally repositioned under local anaesthesia and flexibly splinted for 4 weeks. The follow-up period advised is yearly for 5 years.
Treatment of primary teeth
The displaced segment is repositioned and then splinted for 4 weeks. Follow-up is advised until exfoliation of the primary teeth.
General advice for all traumatic dental injuries
General advice for all traumatic dental injuries should include a soft diet for up to 4 weeks, to avoid biting with the front teeth and establishing and maintaining good oral hygiene. Brushing/massaging the area with a toothbrush (with adjunctive rinsing with dilute chlorhexidine in the presence of extensive soft tissue injuries) is beneficial to prevent accumulation of plaque and debris that is likely to hinder soft tissue healing. Contact sports should be avoided for 3 months and the importance of follow-up should be stressed.1,2,10
Patients must also be made aware of the possible and often inevitable sequelae after traumatic dental injuries and advised to watch for signs of swelling, colour change, increased mobility and pain.1,2,10
Dental Trauma UK has prepared patient information leaflets for members to download for free to use in their clinics (www.dentaltrauma.co.uk).10
Conclusion
Timely and appropriate acute management of dental fractures will offer the best prognosis for the patient. A definite clear knowledge of the different traumatic dental injuries and a systematic approach to management can turn a very daunting task into an excellent clinical outcome for most injuries.
