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

Introduction :
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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 childs 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
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difficult but extremely 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.
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 :
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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
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.
Its 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 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
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 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

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)
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 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

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.

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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 only

Removal 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 fragment
Removal 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.
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 Surgical extrusion
Removal of the mobile fractured fragment with subsequent surgical
repositioning of the root in a morecoronal 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)
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
Extraction
Extraction 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

Fragment removal
only

Superficial fractures (chisel-type

fractures).

Easy to perform. Definitive Long-term prognosis has

restoration can be
not been established.
completed soon after injury.

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. The restored toothThe

Restoration can be
restored tooth may
completed soon after injury. migrate labially due to
formation of a pseudopocket 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 All types of fractures (except

of apical fragment. 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

Preserves the alveolar

Postpones definitive

Can be used in cases where the

Disadvantages

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Extraction

root cannot support a postretained crown restoration.

process.

restoration.

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.

2-Crown root fracture with pulp involvement :

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

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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 postretained 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 fragment

Removal 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 extrusion
Removal 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).

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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.

Extraction
Extraction with immediate or delayed implant-retained crown restoration or a 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 pseudopocket palatally.

Orthodontic extrusion of
Stable position of the restored
apical fragment. All types
tooth. Optimal gingival health.
of fractures, assuming that
reasonable root length can
be achieved after extrusion.

Time consuming
procedure with late
completion of final
restoration.

Surgical extrusion of apical All types of fractures (except

fragment.
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 postretained 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.
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Use of Antibiotics
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 TDIs are often
accompanied by soft tissue and other associated injuries, which may require
other surgical intervention. In addition, the patients medical status may
warrant antibiotic coverage.

Parents 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 .

Patients 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

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