Dental Trauma: Crown Fractures: Mai.A.S.Dama BDS, Mfdsrcsi, High Specialty in Pediatric Dentistry, PLB (Pead), Job (Pead)

Mai.A.S.
Dama
BDS, MFDsRCSI, High specialty in pediatric dentistry,
PLB(Pead), JOB(Pead).
Dental trauma: crown

fractures
outline
• Classification of dental injuries.

• Crown fractures:
• Epidemiology.
• Classification.
• Follow up.
• For each crown fracture entity:
• Definitions and clinical appearance.
• Radiographic appearance.
• Biologic considerations.
• Treatment options
• Prognosis and treatment outcomes.
• Crown root fractures.
Classification of dental injuries
• Injuries to the dental hard tissues and pulp.

1. Enamel infarction.
2. Enamel fracture.
3. Enamel-Dentine fracture.
4. Complicated crown fracture.
• Injuries to the dental hard-tissues, pulp and alveolar process.
1. Crown-root fracture.
2. Root fracture.
3. Alveolar socket wall fracture.
4. Alveolar process fracture.
[Andreasen JO et al (2007). Textbook and Color Atlas of Traumatic Injuries to the Teeth. Copenhagen, Denmark: Wiley-
Blackwell.]
[Casamassimo Paul S.(2013). Pediatric Dentistry: Infancy Through Adolescence. St. Louis,Missouri.USA: Elsevier/Saunders]
Classification of dental injuries
• Injuries to periodontal tissues.

1. Concussion.
2. Subluxation.
3. Luxation (intrusive, extrusive, lateral)
4. Avulsion.
• Injuries to gingiva or oral mucosa.
1. Abrasion.
2. Contusion.
3. Laceration.
Blackwell.]
Epidemiology of crown fractures
• Primary dentition.
• Frequency ranges from 4-38%.
• Uncomplicated fractures occur more often than complicated crown fractures.
• Most common cause is falls.
• Permanent dentition.
• Frequency ranges from 26-76%.
• Uncomplicated fractures occur more often than complicated crown fractures.
• Most common cause is falls, contact sports, RTA.
Blackwell.]
Crown fractures- classification
• Andreasen, 1981:
1. Crown infraction.
2. Uncomplicated crown fracture.
3. Complicated crown fracture.
• Ellis, 1960:
1. Class I: fracture of enamel.
2. Class II: fracture of enamel and dentine.
3. Class III: fracture of enamel, dentine and pulp.
[Andreasen JO et al (2007). Textbook and Color Atlas of Traumatic Injuries to the Teeth. Copenhagen, Denmark: Wiley-Blackwell.]
Ellis RG, 1960. The classification and treatment to injuries of the teeth of children, 4 th edition. Year book Publishers, Chicago.
Crown fractures- classification
• Uncomplicated crown fractures (not involving the pulp):

1. Enamel fracture.
2. Enamel-dentine fracture.
3. Enamel-dentine and cementum fracture (Crown-root fracture).
• Complicated crown fractures (involving the pulp):
1. Enamel-dentine fracture with pulp exposure.
2. Enamel-dentine, cementum and pulp exposure (Crown-root fracture).
Enamel infraction- definition
• It is a disruption of enamel prisms without loss of tooth substance from the enamel surface to the dentine-enamel junction.
Blackwell.]
Enamel infraction- clinical appearance
• Very common but often overlooked.

• Infractions are best seen.
• When the light beam is directed perpendicular to the long axis of the tooth form the incisal edge.
• Appear as crazing within the enamel substance which don`t cross DEJ.
• Appear as lines in the enamel, vertical, horizontal or diverging.
• Could be associated with other types of injuries especially luxation injuries.
Enamel infraction- radiographic appearance
• Enamel infraction cannot be detected radiographically.

• Take a RG to exclude any concomitant luxation injuries.
Blackwell.]
Enamel infraction- treatment options
• Short-term management (Emergency):

• Radiographic and vitality control to disclose pulp and PDL damage.
• Patient instructions.
1. Soft diet.
2. Sensitivity to cold will disappear.
3. OHI.
• Restorative treatment !!!!
1. No treatment (Andreasen, 1981)
2. Sealing the cracks with an unfilled resin and acid etch technique.
1. These tracts may be a portal for bacterial invasion in vitro. (Love RM, 1996)
2. To prevent stains. (Rauschenberger C & Hovland E, 1995)
Enamel infraction- treatment options
• Long-term management:
• No follow up is needed for infractions unless there is a concomitant luxation injury.
• Follow up after 1 week, 1,2, 6 & 12 months, and every year thereafter.
• If no symptoms appear on follow up (e.g. mobility, discoloration, TTP, signs of infection), then regular 6/12 recall.
[IADT guidelines, 2012]
Enamel infraction- prognosis
• Prognosis is very good.

• Prevalence of pulp survival after enamel infraction ranges from 97-100%.
• If necrosis occurred, possible luxation injuries may have been overlooked.
Blackwell.]
[Olsburgh S et al., 2002]
Enamel fracture- definition
• Enamel fracture is loss of tooth substance confined to enamel.
Blackwell.]
Enamel fracture- Clinical appearance.
• Consists 47% of all crown fractures.

• More often than complicated crown fractures in primary and permanent teeth.
• Usually confined to a single tooth.
• Usually affect the maxillary central incisors.
• Especially mesial or distal corners.
• May be associated with concomitant luxation injuries.
Enamel fracture- Radiographic findings.
• RGs are important to reassure the patient that there is no other damage to PDL or pulp.
• Occlusal, PA and eccentric exposures are obtained to exclude any concomitant luxation injury or root fracture.
• RGs for the lips and cheeks could be indicated to search for foreign bodies or fragment material.
Blackwell.]
Enamel fracture- treatment options
• Short term management (Emergency):

• Reassurance.
• If fracture is small.
• Smoothening (grinding) of the roughened enamel edges.
1. Prevent laceration of the tongue and lips.
2. Good esthetic result can be achieved.
• If large areas of enamel are lost especially at the contact point.
• Restore with composite resin or you can bond the tooth fragment if available.
1. Esthetic reasons.
2. Prevent space loss.
Blackwell.]
Enamel fracture- treatment options
• Long term management:

• No luxation injury.
• Follow up with both clinical and radiographic examination.
• 6-8 weeks.
• 1 year.
• Luxation injury.
• Follow up after 1 week, 1,2,6 and 12 months, and every year thereafter.
• If no symptoms appear on follow up (e.g. mobility, discoloration, TTP, signs of infection), then regular 6/12 recall.
Blackwell.]
Enamel fracture- prognosis
• Prognosis is very good.

• Prevalence of pulp survival after enamel fracture ranges from 99-100%.
• If necrosis occurred, possible luxation injuries may have been overlooked.
[Olsburgh S et al., 2002]

Enamel-dentine fractures- definition
• Enamel-dentine fracture is the loss of tooth substance confined to enamel and dentine.
Enamel-dentine fracture- clinical appearance
• Comprises 17% of all tooth fractures.

• Usually confined to a single tooth.
• Usually affect the maxillary central incisors.
• Especially mesial or distal corners.
• May be associated with concomitant luxation injuries.
Enamel-dentine fracture- clinical appearance
• Exposed dentine may give rise to sensitivity to thermal stimuli and mastication.
• Sensitivity is proportional to
1. The area of exposed dentine.
2. Maturity of the tooth.
• Search for minor pulp exposures.
• The dentine layer covering the pulp may be so thin that it can be seen as a pinkish tinge, in this case DON`T BERFORATE THE
PULP WITH A PROBE DURING EXAMINATION.
Enamel-dentine fracture- Radiographic appearance
• Enamel- dentine loss is visible.

• Occlusal, PA and eccentric exposures are obtained to exclude any concomitant luxation injury or root fracture.
• RGs for the lips and cheeks could be indicated to search for foreign bodies or fragment material.

Enamel-dentine fracture- biologic considerations
• Exposed dentinal tubules can result in pulpal inflammation

1. Permit invasion of bacteria or bacterial toxins to the pulp.
2. Thermal irritants.
3. Chemical irritants.
• The severity of this response depends on pulpal vascularity.
• Absence or presence of PDL injury (luxation injury).
Blackwell.]
Enamel-dentine fracture- treatment options
• Treatment objectives :
1. To protect the pulp from external environment (chemical, thermal insults and bacteria).
2. To prevent pain (sensitivity).
3. To prevent tilting of adjacent teeth.
4. To restore function and esthetics.
• Principles of management.
1. No concomitant luxation injury,
• Tooth can be restored immediately with composite resin.
2. In cases of luxation injuries (mobility and bleeding).
• A temporary restoration (GIC, vitebond) is indicated due to difficult dry field for composite resin (bleeding).
• Provisional treatment (Resin patch/ GIC bandage)

• Definition.
• An interim covering to temporize the tooth until a final restoration can be placed.
• Covering the exposed dentin with glass- Ionomer or a more permanent restoration using a bonding agent and composite resin,
or other accepted dental restorative materials.
• Aim.
• Ensure an adequate seal.
• It ensures an appropriate post-treatment evaluation when the patient returns for the final restoration.
• It could be used if adequate time, isolation or cooperation is not available to restore the tooth completely.
• Short term management (Emergency ).

• If fracture is large and fragment retained.
• Reattach retained coronal fragment with dental adhesives.
• If fragment not retained.
• GIC liner and composite resin.
• Placement of calcium hydroxide or GIC vs dentine bonding agent.

• Recent research indicates that sealing exposed dentin with a bonding agent enables the unexposed pulp to form reparative dentin.
• Acid etching of dentin and enamel followed by dentin and enamel bonding without placement of CaOH or glass ionomer.
• Drawbacks according to a recent systematic review.
1. Increased inflammatory reactions.
2. Delay in pulp healing.
3. Failure of dentin bridge formation.
[Casamassimo Paul S.(2013). Pediatric Dentistry: Infancy Through Adolescence. St. Louis,Missouri.USA:
Elsevier/Saunders]
• Recommendations.
• Cover the deepest portion of dentin fractures with glass ionomer cement, followed by a dentin bonding agent.
• If the exposed dentin is within 0.5mm of the pulp (pink, no bleeding) place calcium hydroxide base and cover with a material such as a
glass ionomer.
• The tooth can then be restored with an acid etch/composite resin technique.
[Casamassimo Paul S.(2013). Pediatric Dentistry: Infancy Through Adolescence. St. Louis,Missouri.USA:
Elsevier/Saunders]
• Long-term management.
• No associated luxation injury
• Follow up and monitoring 2 months after injury, vitality and RG control important.
• If vitality is normal no further control is needed and regular 6/12-12/12 recall at least 5 years.
• If there is an associated luxation injury.
• Follow up after 1 week, 1,2,6 months and every year thereafter for 5 years at least.
• If no symptoms appear on follow up (e.g. mobility, discoloration, TTP, signs of infection), then regular 6/12 recall .
Enamel-dentine fracture- prognosis (pulp)
• Prognosis of pulp survival after enamel-dentine fracture ranges from 97-98%. (Olsburgh S et al., 2001)
• Prognosis and occurrence of pulp necrosis depends on: (Andreasen, 1981,1995, 2000),(Ravn JJ, 1981)
1. Amount of dentine exposed.
2. Stage of root development.
3. Associated luxation injuries.
Enamel-dentine fracture- prognosis (PDL)
• Periodontal complications are rare after crown fractures and consist only of surface resorption. (Andreasen, 1981)
Enamel-dentine fracture with pulp exposure - definition
• A fracture involving enamel, dentine and pulp.

complicated crown fracture- clinical appearance
• Comprises 5% of all trauma episodes.

• Clinical picture.
• Depending on the absence or presence of a concomitant luxation injury, the pulp will present with a bright red, cyanotic or ischemic
appearance.
• There may be spontaneous bleeding from the pulp.
• Proliferation of pulp tissue can occur when treatment of complicated crown fractures is delayed for long periods of time.
• Clinical symptoms.
• Pulp exposure is usually followed by symptoms, such as sensitivity to thermal
changes and mastication.
Complicated crown fracture- Radiographic appearance
• Lost tooth substance is apparent.

• Periodontal changes in the case of concomitant luxation injuries.
• RGs serves as a record for follow up of hard tissue barrier formation over the exposed pulp.
Complicated crown fracture- biologic considerations
• The early changes in the pulp are hemorrhage and local inflammation caused by breakdown products from lacerated tissue and
bacterial toxins.
• The subsequent changes could be either proliferative or destructive.
Complicated crown fracture- biologic considerations
• In the first few days after exposure, pulpal response

• Proliferative.
• Pulpal hyperplasia and formation of granulation tissue.
• More common irrespective of size of exposure.
• May lead to abscess formation if untreated.
• In case of treatment delay.
• Destructive.
• Superficial tissue necrosis.
• Subsurface abscess.
• Therefore during the first hours and days after trauma the potential for pulp recovery
is favorable.
Complicated crown fracture- biologic considerations: healing
• Healing sequence after 2-3 weeks of Ca(OH)2 placement, 2 layers/zones:

1. Zone of coagulation necrosis in layer beneath calcium hydroxide.
2. A wound healing response (zone of differentiated odontoblasts) that form new dentine.
• 5 ℳm of dentine/day can be deposited.
• After 2-3 months a hard tissue barrier forms.
Complicated crown fracture- treatment options
• Treatment objectives.
• Preservation of vital, inflammation-free pulp, biologically walled off by a continuous hard tissue barrier.
• The primary objective is maintenance of pulp vitality, so that:
• In immature teeth: dentine deposition and root development may continue.
• In mature teeth: RCT is avoided
• Factors affecting healing and choice of treatment:

• Factors associated with tooth.
1. Vitality of the exposed pulp.
2. Degree of root maturation of the fractured tooth.
3. Restorability of the fractured crown.
• Factors associated with injury.

1. Size of exposure.
2. Time since accident.
3. Degree of bacterial/foreign body contamination.
4. Associated injuries.
• Factors associated with treatment.

1. Presence of blood clot.
2. Presence of inflammation.
3. Operative technique and type of drill used.
4. Level of pulp amputation.
5. Choice of pulp medicament.
• Treatment alternatives:
1. Direct pulp capping (DPC)
2. Pulpotomy.
1. Cvek pulpotomy.
2. Cervical pulpotomy.
3. Pulpectomy (apexification/ revascularization/ RCT )
Complicated crown fracture/treatment options- DPC
• Definition.
• A procedure where an exposed pulp is covered with a dressing to protect the
pulp and permit healing.
• Aim.
• Preservation of vital, inflammation-free pulp, biologically walled off by a
continuous hard tissue barrier (Andreasen, 1981)
• Indications/ success factors (Olsburgh et al., 2002; Cvek, 1993)

1. Size: if exposure is very small (1-1.5 mm)
2. Time: treatment shortly after injury (few hours/ 24 hours) (Donly, 2000)
3. Root development: mature vs immature teeth.
4. Sufficient crown remaining to hold the capping material and efficient seal.
5. Healthy pulp before trauma : trauma, caries
6. No concomitant luxation injuries.
• Technique:
1. Isolation with rubber dam.
2. Pulp tissue washed with NS and hemorrhage controlled.
3. Pulp covered with calcium hydroxide (setting or non-setting)/MTA.
4. Exposed dentine covered with liner (GIC)
5. Crown restored with AECR.
DPC/ success
• SR= 72% (Kozlowska, 1980)- 88% (Ravn, 1973)

• A calcific bridge stimulated by the capping material should be evident radiographically in 2 to 3 months.
• Prognosis depends on [Olsburgh, 2002 (SE=63-88%)] :
1. Sterile technique (RD, disinfection of cavity with NS)
2. Biocompatible capping agent.
3. Efficient seal.
DPC/ success
• In fractures exposing pulps of immature permanent teeth with incomplete

root development, a direct cap is no longer the treatment of choice.
• Failure in these cases leads to total pulpal necrosis and a fragile, immature
root with thin dentinal walls.
• Thus the preferred treatment in pulp exposures of immature permanent
teeth is pulpotomy.
Complicated crown fracture/treatment options-Cvek pulpotomy
• Definition.
• A procedure where part of the coronal pulp is removed to eliminate inflamed
and contaminated tissue that has been exposed to the oral cavity.
• Aims.
1. Preservation of vital, inflammation free pulp, biologically walled off by a
continuous hard tissue barrier. (Andreasen, 1981)
2. Leave only healthy tissue to enhance physiologic maturation of the root and
maintain vitality of tooth. (Andreasen, 1981 and Camp, 1995)
3. Formation of the dentinal bridge under calcium hydroxide. (Camp, 1995)
• Indications. (Cvek, 1978,1993)

1. Immature teeth, irrespective of exposure size and time interval between injury
and treatment.
2. Pulp free from inflammation (trauma, caries).
3. No concomitant luxation injuries.
4. Technique later applied to carious, immature permanent first molars also
(Cvek, 1993).
• Technique.
1. LA and RD (cuff technique).
2. Cavity prepared with diamond bur 1.5-2 mm deep.
3. Irrigate with NS to stop bleeding, dry cavity.
4. Place calcium hydroxide on pulp and dentine (NO COAGULUM BETWEEN CALCIUM HYDROXIDE AND PULP)
5. Restore tooth with AECR.
6. Review after 3,6 and 12 months for next 5 years at least.
• SR= 96% (Cvek, 1978)

Cervical pulpotomy -apexogenesis
• Definition.
• A procedure where complete coronal pulp is removed up to the constriction of the root
canal.
• Aim.
1. Preservation of vital, inflammation-free pulp, biologically walled off by a continuous hard
tissue barrier (Andreasen, 1981)
2. Apical closure in immature teeth and root development (apexogenesis)
• Indications.
1. Immature teeth where
1. Necrotic tissue is seen at exposure site.
2. Vital pulp, but exposure is large.
3. Vital pulp with small exposure but patient didn`t seek treatment until several hours or days.
4. Vital pulp with insufficient crown structure to hold restoration.
2. No luxation injury.
• Technique.
1. LA, RD (cuff technique), pulp amputation with diamond bur to cervical level.
2. Irrigate with NS until bleeding stops, dry cavity.
3. Place calcium hydroxide on pulp and dentine (NO COAGULUM BETWEEN CLCIUM
HYDROXIDE AND PULP)
4. Seal access cavity with GIC or ZOE cement.
5. Restore tooth with AECR
6. Review after 3,6 and 12 months for next 5 years at least.
• Cervical pulpotomy
1. Calcium hydroxide.
2. ZOE/GIC.
3. AECR
Cervical pulpotomy –apexogenesis/ success rate
• SR= 72% (Hallet and Porteous, 1963)

pulpectomy
• Definition.
• Complete removal of pulp.
• Aim.
1. Removal of necrotic tissue and in immature teeth (Apexification)
2. Stimulate process of root development (apical closure by calcific barrier) for
routine endo to be performed later on.
3. In mature teeth (RCT).
4. Place a conventional root canal filling to prevent further pathosis.
indications
• Apexification. (Heithersa, 1970; Cvek, 1972,1974; Sheehy and Roberts, 1997; Mackie and Blinkhorn, 1996)
• Immature necrotic pulp (or irreversible pulpitis).

• RCT.
• Mature teeth with necrotic pulp (or irreversible pulpitis).
Apexification technique
1. LA, RD (cuff technique), pulp chamber amputated with tapered diamond bur
2. Extirpate pulp with BB, find WL, file canals and irrigate with 1 % NaOCL and NS,
dry with paper points.
3. Place non-setting calcium hydroxide within 1-2mm of apex, seal cavity with CP
and GIC.
4. Take PA to check dressing: most important is apical content of canal.
5. Repeat above every 3/12 for 12-18 months, take PA every 3/12 to verify apical
barrier and check clinically using small paper point.
6. When apical closure achieved, fill root with thermoplastic/conventional GP
with lateral condensation.
Apexification- success
• Successful results of apexification (Frank 1966 )
1. Closure of apex to normal appearance.

2. A dome-shaped apical closure
3. A positive stop and RG evidence of a barrier coronal to anatomic apex of tooth
4. No RG change but a positive stop in apical area.
• Apexification will occur in 9-18 months.
Apexification- success
• SR= 74-100% (Sheehy and Roberts, 1997)

• Long term success depends on:
1. Quality of apical seal.
2. Amount of root structure present (length and thickness)
3. Type of restoration placed (coronal seal)
• Largest long-term risks is that of vertical root fracture of immature tooth during function.
Follow up- general points
• Rationale.
• To ensure no problem to the developing permanent tooth have arisen.
• Assess.
1. Mobility.
2. Vitality.
3. TTP.
4. Discoloration.
5. Signs of infection (clinical and RG).
• Mobility.
• If tooth is mobile.
1. Hyper-occlusion.
• Occlusion should be relieved and patient on soft diet.
2. Need for splinting.
• If mobility decreases to zero.
• Ankylosis is suspected
• Pulp degeneration.
• Symptoms of spontaneous pain, pain with hot /cold.
• Discoloration.
1. Yellow (PCO).
2. Pink (hyperemia).
3. Grey or black (pulp death).
• Dental radiographs.
1. Root development.
2. Pulp calcification.
3. Internal/external RR.
4. Ankylosis.
5. PA infection.
6. Check for interference with the development of the permanent tooth bud, if
so, extract the primary tooth.
POSTERIOR CROWN FR ACTURES
• Causes.
• These fractures usually occur secondary to hard blows to the underside of the
chin, and vertical crown fractures may result.
• Treatment alternatives.
1. Bonding with posterior composite resins
2. Full coverage with stainless steel or cast metal crowns is the best approach.

Dental Trauma: Crown Fractures: Mai.A.S.Dama BDS, Mfdsrcsi, High Specialty in Pediatric Dentistry, PLB (Pead), Job (Pead)

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Mai.A.S.

Dental trauma: crown

• Classification of dental injuries.

• Injuries to the dental hard tissues and pulp.

• Injuries to periodontal tissues.

• Uncomplicated crown fractures (not involving the pulp):

• Very common but often overlooked.

• Enamel infraction cannot be detected radiographically.

• Short-term management (Emergency):

• Prognosis is very good.

• Enamel fracture is loss of tooth substance confined to enamel.

• Consists 47% of all crown fractures.

• Short term management (Emergency):

• Long term management:

• Prognosis is very good.

[Olsburgh S et al., 2002]

• Comprises 17% of all tooth fractures.

• Enamel- dentine loss is visible.

[IADT guidelines, 2012]

• Exposed dentinal tubules can result in pulpal inflammation

• Provisional treatment (Resin patch/ GIC bandage)

• Short term management (Emergency ).

• Placement of calcium hydroxide or GIC vs dentine bonding agent.

• A fracture involving enamel, dentine and pulp.

• Comprises 5% of all trauma episodes.

• Lost tooth substance is apparent.

• In the first few days after exposure, pulpal response

• Healing sequence after 2-3 weeks of Ca(OH)2 placement, 2 layers/zones:

• Factors affecting healing and choice of treatment:

• Factors associated with injury.

• Factors associated with treatment.

• Indications/ success factors (Olsburgh et al., 2002; Cvek, 1993)

• SR= 72% (Kozlowska, 1980)- 88% (Ravn, 1973)

• In fractures exposing pulps of immature permanent teeth with incomplete

• Indications. (Cvek, 1978,1993)

• SR= 96% (Cvek, 1978)

• SR= 72% (Hallet and Porteous, 1963)

• Immature necrotic pulp (or irreversible pulpitis).

• Successful results of apexification (Frank 1966 )

1. Closure of apex to normal appearance.

• SR= 74-100% (Sheehy and Roberts, 1997)

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