Ishik university Faculty of dentistry Department of pediatric dentistry

* Crown/Root Fracture in primay teeth *

Prepared by : Dr. Saya Mustafa Aziz

4th grade dental student

2014 – 2015

1

Introduction :

Traumatic injuries to teeth and their supporting tissues usually occur in young people , the greatest incidence of trauma to primary dentition between 2 to 3 years old children when motor coordination is developing , there is no significant sex difference in incidence of trauma in primary dentition and damage may vary from enamel fracture to avulsion, with or without pulpal involvement or bone fracture.

It is important to keep in mind that there is close relationship between the apex of the root of the injured primary tooth and the underlying permanent tooth germ ,tooth malformation , impacted teeth , and eruption disturbance in the developing permanent dentition are some of the consequences that can occur following severe injuries to the primary teeth and/or alveolar bone so because of these potentials sequelae , treatment selections should be aimed at minimizing any additional risks of further damage to the permanent successors.

A child’s maturity and ability to cope with the emergency situation , the time for shedding of the injured tooth , and the occlusion , are all important factors that influence treatment selection.

Epidemiology• 30% of preschoolers suffer dental injury

– At this age there is no difference between boys and girls.• 23% males age 6-20 years and 13% females suffer dental injuries• Prevalence and incidence peak at 2-4 years and 8-10 years• The way the tooth is injured is related to the activity level at each age.

– Patients with chronic conditions and mobility problems– Altercations– Abuse

• Most commonly injured teeth– Maxillary central incisors – Protruding teeth

The etiology of trauma : Dental trauma usually occurs from a direct hit to your mouth or jaw. Accidents, such as falling off a bicycle or a car accident, can cause dental trauma. A direct hit can also happen during sports activities or abuse to the child . Injuries to the teeth of children or adults present unique problems in diagnosis and treatment. The diagnosis of the extent of the injury after a blow to a tooth, regardless of loss of tooth structure, is difficult and often inconclusive. Trauma to a tooth is invariably followed by pulpal hyperemia, the extent of which cannot always be determined by available diagnostic methods. Congestion and alteration in the blood flow in the pulp may be sufficient to initiate irreversible degenerative changes, which over time can cause pulpal necrosis. In addition, the apical vessels may have been severed or damaged enough to interfere with the normal reparative process. Treatment of injuries causing pulp exposure or tooth displacement are particularly challenging, because the prognosis of the involved tooth is often uncertain. The treatment of fractured teeth, particularly in young patients, is further complicated by the often difficult but extremely

2

important restorative procedure. Although the dentist may prefer to delay the restoration because of a questionable prognosis for the pulp, often a malocclusion can develop within a matter of days as a result of a break in the normal proximal contact with adjacent teeth. Adjacent teeth may tip into the area created by the loss of tooth structure. This loss of space will create a problem when the final restoration is contemplated. There must often be a compromise of an ideal esthetic appearance, at least in the initial restoration, because the prognosis is questionable or because the tooth is young and has a large pulp or is still in the stage of active eruption. Often the likelihood of success depends on the rapidity with which the tooth is treated after the injury, regardless of whether the procedure involves protecting a large area of exposed dentin or treating a vital pulp exposure.

How to prevent dental trauma in primary teeth ?Do not use baby walkers.Do not let children use roller skates without protection.Teach your children to:- Look after their teeth as well as that of their friends’ teeth when playing by not knocking their teeth with heavy objects.- Watch out for possible obstructions that they can trip themselves up on.- Do not push when playing.- Stay seated on the swing and do not jump off when the swing is in motion.- Use the stairs when getting out of the swimming pool.If the child participates in sports such as rugby, hockey, karate, riding on a bike, wintersports (i.e. skiing) a skate board or any activity that involves potential trauma to the facial area, make sure that the child uses a helmet or mouth protector History and Examination :

History: 1-Medical history : The medical history should reveal possible allergies, blood disorders and other information that may influence treatment

2-Dental history :important information to get regarding the injury• Incidents surrounding injury• Any other injuries• How long ago the injury occurred• Last time the patient ate

• QUESTIONS RELATING TO THE INJURY :

Where did the injury occur? This information may have legal implication for the patient and may on occasion indicate the possibility of contamination.

How did the injury occur? This may lead to identification of the impact zones i.e. a chin injury is often combined with crown or crown-root fractures in premolar and molar regions.

3

When did the injury occur? This information may be essential in relation to many injury types. In relation to a tooth avulsion the extent of time and the extraoral storage condition becomes very decisive for later treatment.

Was there a period of unconsciousness? If so, for how long. Amnesia, nausea and vomiting are all signs of brain damage and require medical attention.

Is there any disturbance in the bite? An affirmative answer may indicate a luxation injury with displacement, an alveolar or jaw fracture or a fracture of the condylar region.

Is there any reaction in the teeth to cold and/or heat exposure? A positive finding indicates exposed dentin and/or pulp.

Physical Examination• Extraoral

• Inspection • Asymmetry • Nasal or orbital malalignments• Lacerations, hematomas, foreign bodies• Open and close mouth to evaluate for deviation during function• Lip competency

• Palpation• TemporoMandibular joint• Equal movements• Orbital rim intact• Nose for crepitus

• Note parasthesias or numbness

• Intraoral – Inspection : – Inspect the dental trauma region for fractures, abnormal tooth

position, tooth mobility, and abnormal response to percussion. Furthermore registration of direction of displacement in case of luxation injuries. In case of fractures their relation to the gingival sulcus area is noted as well as possible pulp involvement.

– Pulp testing (usually electrometric) completes the clinical examination– Color and quality of gums and mucosa– Note hematomas– Color, chips, cracks, bleeding, absent

4

– Palpation of :– Tongue– Mobility of teeth– Tooth percussion

Radiographic Examination :The completed clinical examination has now identified the trauma region and this site should now be examined with relevant radiographic techniques. Several clinical studies have shown that multiple radiographic procedures are needed to detect displacement of the tooth in its socket as well as presence of root fractures.It’s essential to consider the radiographic film format used in order to achieve a high quality image of the traumatized tooth. A steep occlusal exposure (using a size 2 film (DF 58, EP 21)) of the traumatized anterior region gives an excellent view of most lateral luxations, apical and mid-root fractures and alveolar fractures. The standard periapical bisecting angle exposure of each traumatized tooth (using a size 1 film (DF 56, EP 11)) provides information about cervical root fractures as well as other tooth displacements. Thus a radiographic examination comprising one steep occlusal exposure and three periapical bisecting angle exposures of the traumatized region will provide sufficient information in determining the extent of trauma to an incisor region.

Radiographs allow the clinician to detect :

Root fractures , Extent of root development , Size of pulp chambers ,Periapical radiolucencies , Resorptions , Degree of tooth

5

displacemen , Position of unerupted teeth , Jaw fractures , Presence of any tooth fragments or foreign material in soft tissues ,Kept as a document for comparison on follow-up.

Radiographic examination of soft tissue lesions :

In the presence of a penetrating lip lesion, a soft tissue radiograph is indicated in order to locate any foreign bodies. It should be noted that the orbicularis oris muscles close tightly around foreign bodies in the lip, making them impossible to palpate; they can only be identified radiographically. This is accomplished by placing a dental film between the lips and the dental arch and using 25% of the normal exposure time. If this exposure reveals foreign bodies (a radiographic examination will normally demonstrate foreign bodies such as tooth fragments, composite filling material, metal, gravel, whereas organic materials such as cloth and wood cannot be seen), a lateral radiograph can be added (at 50% normal exposure time) to visualize the foreign bodies in relation to the cutaneous and mucosal surfaces of the lips. With the combined information from the clinical and radiographic examinations, diagnosis, prognosis and treatment planning can then be accomplished.

Photographic registration

Finally, photographic registration of the trauma is recommended, as it offers an exact documentation of the extent of injury and can be used later in treatment planning, legal claims or clinical research. Note that a patient consent is required.

Types of trauma :

LUXATION INJURIES

Concussion Subluxation Extrusion Lateral luxation Intrusion Avulsion

FRACTURE INJURIES

Enamel infraction Enamel fracture Uncomplicated crown fracture (enamel-dentin fracture) Complicated crown fracture (enamel-dentin-pulp fracture) Uncomplicated crown root fracture Complicated crown root fracture Root fracture Alveolar fracture

6

INJURIES TO GINGIVA OR ORAL MUCOSA

Laceration of gingiva or oral mucosa Contusion of gingiva or oral mucosa Abrasion of gingiva or oral mucosa

Sequelae of dental trauma

Pulp necrosis (PN) Pulp canal obliteration (PCO) External surface resorption (repair-related external resorption) Ankylosis-related resorption (osseous replacement resorption) Transient external ankylosis (replacement resorption) Infection related resorption (Inflammatory resorption) Internal infection related resorption (internal inflammatory resorption) Internal repair related resorption (Internal surface resorption) Internal ankylosis (internal osseous replacement related resorption) Cervical invasive resorption Traumatic or infection-related loss of marginal bone Transient apical breakdown Transient marginal breakdown Pulp metaplasia Gingival reattachment Periodontal ligament regeneration Tooth discoloration

Treatment and test definitions

Dentin coverage Pulp capping Partial pulpotomy (shallow pulpotomy) Manual repositioning Surgical repositioning Orthodontic repositioning Partial repositioning Total repositioning Pulp extirpation (pulpectomy) Pulp testing

WOUND HEALING DEFINITIONS

Wound regeneration Wound repair Wound healing module Revascularization

DEFINITIONS OF TOOTH DEVELOPMENT AND ERUPTION DISTURBANCES OF PERMANENT TEETH RELATED TO INJURY TO PRIMARY PREDECESSORS

White or yellow-brown discoloration of enamel

7

White or yellow-brown discoloration of enamel and circular enamel hypoplasia

Crown dilaceration Odontoma-like malformation Root duplication Vestibular root angulation Lateral root angulation or dilaceration Partial or complete arrest of root formation Sequestration of permanent tooth germ Disturbance in eruption

One of the type of trauma of primary teeth :

A crown-root fracture in primary teeth :

is a type of dental trauma, usually resulting from horizontal impact, which involves enamel, dentin and cementum, occurs below the gingival margin . Epidemiological statistics revealed that crown-root fractures represent 5% of dental injuries and may be classified as : complicated or uncomplicated, depending on whether pulp involvement is present or absent

1-Crown-root fracture without pulp involvement

A fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp.

8

Diagnosis:

Visual signs Crown fracture extending below gingival margin.

Percussion test Tender.

Mobility test Coronal fragment mobile.

Sensibility pulp test Usually positive for apical fragment.

Radiographic findings Apical extension of fracture usually not visible.

Radiographs recommended Periapical, occlusal and eccentric exposures. They are recommended in order to detect fracture lines in the root. A cone beam exposure can reveal the whole fracture extension.

Treatment :

Localization of fracture line

The fracture involves the crown and root of the tooth and is in a horizontal or diagonal plane. A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion

A cone beam exposure can reveal the whole fracture extension

Emergency treatment

As an emergency treatment a temporary stabilization of a loose segment to adjacent teeth can be performed until a definitive treatment plan is made

DEFINITIVE TREATMENT

Depending on the clinical findings, six treatment scenarios may be considered. Most of these may be deferred to later treatment.

Fragment removal onlyRemoval of a superficial coronal crown-root fragment and subsequent restoration of exposed dentin above the gingival level.

Fragment removal and gingivectomy (sometimes ostectomy)Removal of coronal segment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy, ostectomy with osteoplasty. This treatment option is indicated in crown-root fractures with palatal subgingival extension.

Orthodontic extrusion of apical fragmentRemoval of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown.

Surgical extrusionRemoval of the mobile fractured fragment with subsequent surgical repositioning of the root in a morecoronal position. A rotation of the root

9

(90 or 180) may offter a better position for periodontal ligament healing. Because the fracture site becomes exposed labially and thereby more periodontal ligament can be saved (see reference 9)

Decoronation (Root submergence)Implant solution is planned, the root fragment may be left in situ after in order to avoid alveolar bone resorption and thereby maintaining the volume of the alveolar process for later optimal implant installation

ExtractionExtraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable crown-root fractures with a severe apical extension, the extreme being a vertical fracture

TIMING OF TREATMENT

All of the treatment modalities (except extraction) are technique sensitive and do not need to be performed during the acute phase. Instead, the coronal fragment can be temporarily bonded to the cervical portion of the tooth with a composite or resin. This may add to the comfort of the patient until final treatment. Prognosis will not be influenced by delay of treatment within a time frame of one to two weeks.

COMPARISON OF TREATMENT CHOICES FOR DEFINITIVE TREATMENT OF CROWN-ROOT FRACTURES WITHOUT PULP INVOLVEMENT

Procedure Indications Advantages Disadvantages

Fragment removal only

Superficial fractures (chisel-type fractures).

Easy to perform. Definitive restoration can be completed soon after injury.

Long-term prognosis has not been established.

Fragment removal and gingivectomy (sometimes ostectomy).

Fractures where denudation of the fracture site does not compromise esthetics (i.e. fractures with palatal extension).

Relatively easy procedure. Restoration can be completed soon after injury.

The restored toothThe restored tooth may migrate labially due to formation of a pseudo-pocket palatally.

Orthodontic extrusion of apical fragment.

All types of fractures, assuming that reasonable root length can be achieved after extrusion.

Stable position of the restored tooth. Optimal gingival health.

Time consuming procedure with late completion of final restoration.

Surgical extrusion of apical fragment.

All types of fractures (except crown-root fractures in young teeth with open apices where vitality should be preserved) assuming that reasonable root length can be achieved.

Rapid procedure. Stable position of the tooth. The method allows inspection of the root for additional fractures.

Limited risk for root resorption and marginal breakdown of the periodontium.

Decoronation Can be used in cases where the root cannot support a post-retained crown restoration.

Preserves the alveolar process.

Postpones definitive restoration.

Extraction Extraction in cases of None Tooth loss

10

extensive deep crown-root fractures

PATIENT INSTRUCTIONS

Soft food for 1 week Good healing following an injury to the teeth and oral tissues depends, in

part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

FOLLOW-UP

6-8 weeks and 1 year.

2-Crown root fracture with pulp involvement :

A fracture involving enamel, dentin, and cementum with loss of tooth structure, and exposure of the pulp.

11

Diagnosis :

Visual signs Crown fracture extending below gingival margin.

Percussion test Tender.

Mobility test Coronal fragment mobile.

Sensibility test Usually positive for apical fragment.

Radiographic findings Apical extension of fracture usually not visible.

Radiographs recommended

Periapical and occlusal exposure. A cone beam exposure can reveal the whole fracture extension.

Treatment :

LOCALIZATION OF FRACTURE LINE

The fracture involves the crown and root of the tooth and is in a horizontal or diagonal plane. A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion.

If available a cone beam exposure can reveal the whole fracture.

EMERGENCY TREATMENT

As an emergency treatment a temporary stabilization of a loose segments to adjacent teeth can be performed until a definitive treatment plan is made.

In young patients with open apices, it is advantageous to preserve pulp vitality by a partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide compounds are suitable pulp capping materials. In patients with mature root development root canal treatment can be the treatment of choice.

DEFINITIVE TREATMENT

Depending on the clinical findings, five treatment scenarios may be considered. Most of these may be deferred to later treatment.

Fragment removal and gingivectomy (sometimes ostectomy)Removal of coronal fragment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy and sometimes ostectomy with osteoplasty. This treatment option is only indicated in crown-root fractures with palatal subgingival extension.

Orthodontic extrusion of apical fragmentRemoval of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown.

Surgical extrusionRemoval of the mobile fractured fragment with subsequent repositioning of the root in a more coronal position. A rotation of the root (90 or 180) may offter a better position for periodontal ligament healing. Because the fracture site becomes exposed labially and thereby more periodontal ligament can be saved (see reference 9).

Decoronation (Root submergence)An implant solution is planned, the root fragment may be left in situ after decoronation in order to avoid alveolar resorption maintaining the volume of the alveolar process for later optimal implant installation.

ExtractionExtraction with immediate or delayed implant-retained crown restoration or a

12

conventional bridge. Extraction is inevitable in very deep crown-root fractures, the extreme being a vertical fracture.

TIMING OF TREATMENT

All of the treatment modalities (except extraction) are technique sensitive and do not need to be performed in the acute phase. Instead, the coronal fragment can be temporarily bonded to the cervical portion of the tooth with a composite or resin. This may add to the comfort of the patient until final treatment.

COMPARISON OF TREATMENT CHOICES FOR DEFINITIVE TREATMENT OF CROWN-ROOT FRACTURES WITH PULP INVOLVEMENT.

Procedure Indications Advantages Disadvantages

Fragment removal and gingivectomy (sometimes ostectomy).

Fractures where denudation of the fracture site does not compromise esthetics (i.e. fractures with palatal extension).

Relatively easy procedure. Restoration can be completed soon after injury.

The restored tooth tooth may migrate labially due to formation of a pseudo-pocket palatally.

Orthodontic extrusion of apical fragment. All types of fractures, assuming that reasonable root length can be achieved after extrusion.

Stable position of the restored tooth. Optimal gingival health.

Time consuming procedure with late completion of final restoration.

Surgical extrusion of apical fragment.

All types of fractures (except crown-root fractures in young teeth with open apices where vitality should be preserved) assuming that reasonable root length can be achieved.

Rapid procedure. Stable position of the tooth. The method allows inspection of the root for additional fractures.

Limited risk for root resorption and marginal breakdown of the periodontium.

Decoronation Can be used in cases where the root cannot support a post-retained crown restoration.

Preserves the alveolar process.

Postpones definitive restoration.

Extraction Extraction in cases of extensive deep crown-root fractures.

None. Tooth loss.

PATIENT INSTRUCTIONS

Soft food for 1 week. Good healing following an injury to the teeth and oral tissues depends, in

part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

FOLLOW-UP : 6-8 weeks and 1 year.

Use of Antibiotics

13

There is limited evidence for use of systemic antibiotics in the management of luxation injuries and no evidence that antibiotic coverage improves outcomes for root fractured teeth.

Antibiotic use remains at the discretion of the clinician as TDI’s are often accompanied by soft tissue and other associated injuries, which may require other surgical intervention. In addition, the patient’s medical status may warrant antibiotic coverage.

Parent’s instruction :

Good healing following an injury to the teeth and oral tissues depends , in a part , on good oral hygiene .To optimize healing , parents and carers should be advised regarding care of injured tooth/teeth and the prevention of further injury by supervising potentially hazardous activities . brushing with a soft brush and use of alcohol free 0.1% chlorhexidine gluconate topically on the affected area with cotton swabs twice a day for 1 week are recommended to prevent accumulation of plaque and debris . A soft diet for 10 days and restriction in the use of an intra-oral pacifier are also recommended .

Patient’s insruction :

• Avoid participating in contact sports• Patient compliance with follow-up visits• Good oral hygiene and rinsing with an antibacterial such

chlorohixidine gluconate 0.1% for 1-2 weeks• Should brush his teeth with sotf toothbrush.• Soft diet for two weeks.

References :

1.www.dentaltraumaguide.org

2.www.iadt-dentaltrauma.org

3.Book : Pediatric dentistry for adult and children

14

15

16

17

18

19

20

21

22

23

24

25

26