7.1
Complicated Crown Fracture
Elizabeth Shin Perry
Objectives
At the end of this case the reader should understand the diagnosis and management of a complicated crown fracture. In addition, the reader should understand the treatment decisions involved in determining whether vital pulp therapy should be performed in such cases.
Introduction
A 13‐year‐old male patient presented with an enamel–dentine fracture and pulp exposure of the upper left central incisor (UL1) after an accident playing basketball two days previously. He was seen by his dentist, who recommended that he be seen by the endodontist for treatment.
Chief Complaint
The patient reported that the tooth was sensitive to hot and cold for less than 10 seconds. There was no lingering or spontaneous pain.
Medical History
Unremarkable.
Dental History
The patient was a regular attender and visited his dentist every six months.
Clinical Examination
Extraoral examination was unremarkable and intraoral examination revealed a mixed dentition with good oral hygiene. The incisal half of the crown of the UL1 had fractured off (Figure 7.1.1) and there was a 2 mm exposure of the pulp (Figure 7.1.2a). All four upper incisors were non‐tender to percussion or palpation. The teeth had a positive response to thermal testing (cold). Tooth UL1 responded normally to pulp sensibility testing. The patient’s mother had saved the fractured segment of tooth with the hope that it could be used in the repair of the tooth.
What did the radiograph reveal about tooth UL1?
- An angulated fracture across the mesial pulp horn with loss of half of the crown.
- A large root canal space with an open apex (Figure 7.1.3).
- Thin root walls.
Diagnosis and Treatment Planning
Diagnosis of tooth UL1 was reversible pulpitis associated with a complicated enamel–dentine fracture. The root apex appeared to be open and the tooth had an immature root anatomy with a large root canal space.
What are the treatment options for tooth UL1?
- Vital pulp therapy
- Pulp cap
- Partial pulpotomy
- Deep pulpotomy
- Root canal treatment
- Extraction
In cases of complicated crown fracture and exposure of the pulp, vital pulp therapy is the preferred option when possible. By maintaining the vitality of the pulp in a tooth with immature root anatomy, the physiological development of the root continues. In mature teeth with complicated crown fracture, the vitality of the pulp may be maintained and is desirable in many cases over complete removal of the pulp. In these patients, removal of the pulp should only be performed if the pulp appears to be irreversibly inflamed, vital pulp therapy is not successful and the pulp becomes necrotic, or if the patient exhibits symptoms that are not resolving.
Conversations with the parents of the young patient should include the possibility that root canal treatment may become necessary in the future, but that vital pulp therapy gives the tooth the best chance for maturation of the root and long‐term survival. In addition, due to the nature of traumatic dental injuries, the neighbouring teeth should be assessed regularly for clinical and radiographic changes.
What is the difference between an uncomplicated and a complicated crown fracture?
An uncomplicated crown fracture is a fracture of the enamel and dentine only, while a complicated crown fracture is a fracture of the enamel and dentine with exposure of the pulp (Figure 7.1.2b).
Treatment
Local anaesthetic was administered and dental dam isolation was performed. The external surface of the tooth was disinfected with sodium hypochlorite. The exposed pulp appeared to be inflamed and bled easily. The exposed pulp was removed stepwise using a sterile round diamond bur in a high‐speed dental handpiece with water coolant until haemostasis could be achieved. Placement of a cotton pellet moistened with 2.5% sodium hypochlorite gently over the exposed pulp for several minutes controls the bleeding in healthy non‐inflamed pulp tissue.
In this case the pulp tissue was removed to the level of the cemento‐enamel junction before healthy non‐bleeding tissue was observed (Figure 7.1.4). Subsequently, 3 mm of Biodentine was placed directly over the exposed pulp followed by glass ionomer (Figures 7.1.5 and 7.1.6
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