Treatment of complicated crown or crown-root fracture: some additional information

The article entitled Dental Trauma Part 2: Acute Management of Fracture Injuries in the December 2016 issue of Dental Update was an interesting read.¹ Indeed, it is very well summarized and highlights the acute management of various tooth fractures associated with trauma. The presentation of information together with a series of illustrations describing various injuries and their management is impressive. However, I would like to highlight an important fact about Cvek pulpotomy which should have been mentioned in the article. Cvek pulpotomy can be carried out in immature permanent teeth irrespective of the time elapsed since the injury, provided that the tooth is still vital.² However, Cvek pulpotomy proves to be very successful only if carried out within 24–48 hours following injury to young permanent teeth with completely formed roots,² although some success has been achieved when teeth with traumatic pulp exposure for as long as four days were treated by Cvek pulpotomy. However, the success rate is greatly reduced after 48 hours following traumatic pulp exposure.^2,3 Nevertheless, every attempt should be made to preserve the vitality of young permanent teeth as it will result in continued dentine deposition in the cervical area, thus strengthening the tooth.⁴ Besides, as already mentioned in the article by Djemal et al,¹ upon pulp excavation, if healthy pulp tissue cannot be reached up to the cervical level, root canal treatment should be carried out. This is because the cell rich coronal pulp tissue is more likely to facilitate healing after Cvek pulpotomy as the radicular pulp is more fibrous and unicellular.⁴ Hence, the judgement of whether to perform Cvek pulpotomy or pulpectomy on a young permanent tooth with completely formed roots eventually lies with the treating physician.

In addition to Cvek pulpotomy, an additional treatment option is direct pulp capping which was not mentioned in the article.¹ Direct pulp capping can be performed instead of pulpotomy if the pulp exposure is pin point and the treatment is carried out within one hour following injury.⁴ Furthermore, the importance of isolation when carrying out direct pulp capping or Cvek pulpotomy cannot be overemphasized. In the article by Djemal et al,¹ the use of rubber dam was not mentioned. Moreover, the illustrations also do not depict the use of rubber dam while Cvek pulpotomy was carried out. Ideally, during any form of treatment involving the pulp tissue, use of rubber dam is mandatory to ensure long-term success.