2. Content
 Treatment of fractured enamel
 Treatment of uncomplicated crown fracture
 Treatment of complicated crown fracture with
minimal pulp exposure

4. Radiograph of lip or cheek lacerations to search for tooth
fragments or foreign material
Treatment options
1. Leave it
2. Rounded – sharp
enamel edges
3. Re-attach the fragment
4. Restore with CR
Follow-up
 Clinical and radiographic control -> 6-8 weeks & 1 year.

6. Radiograph of lip or cheek lacerations to search for tooth
fragments or foreign material
 Clean with water spray/
saline/ chlorhexidine
 Disinfect with
Chlorhexidie gluconate 0.12%
(Peridex ®)

7. Treatment options
 No tooth fragment – Covered with GIC (temporary)/
Restore with CR
 Tooth fragment saved – Re-attach the fragment
Follow-up
 Clinical and radiographic control -> 6-8 weeks & 1 year.

8. Reattachment of tooth fragment
 Good and long-lasting esthetics
 Can restore function
 Positive psychological response
 Simple procedure
 Less time-consuming
 More predictable long-term wear than when direct
composite is used

9. Steps
 Try tooth fragment intraorally
 Isolation
Tooth Fragment
Flour of pumice
Etching
Adhesive

10. Dentin and enamel
Flour of pumice
Etching
 Composite resin was applied
to both fragment and
tooth surfaces.
Adhesive

11.  Light-cured for 40 seconds
 Additional composite
 Finished with diamond burs
 Polished with Sof-Lex disks

13. Complicated Crown Fracture
Clinical appearance:
Pulp with bright red,cyanotic or ischemic
appearance respectively.

14. Diagnostic signs
Visual signs
Crown fracture extending below gingival margin.
Percussion test
Tenderness to percussion.
Mobility test
Coronal fragment is mobile.
Sensibility test
Primary teeth -Inconsistent results.
Permanent teeth -Positive for apical fragment.
Radiographs
recommended
An occlusal exposure.

15. Radiographic appearance:
Fracture at tooth 21
involving enamel dentine
and pulp.

16. Crown Fracture with Minimal
Pulp Exposure
Treatment Objective:
 To maintain pulp vitality
 In immature teeth - to continue root development.
 To restore normal esthetics and function.

17. Treatment:
1)Direct Pulp Capping
2)Pulpotomy
a)Cvek Pulpotomy
b)Cervical pulpotomy
3)Apexification
4)Root Canal Treatment
5)Extraction

18. 1)Direct Pulp Capping
Aim:
Preserve vital pulp tissue by physiologically walled off with calcific
barrier.

19. 1)Direct Pulp Capping
Indications: Exposure < 1mm
: Time elapsed since injury- within a few hours
: Vital pulp
: Complete root development
: Absence of root fracture

20. Apply rubber dam
Tooth gently cleaned with water
Calcium hyroxide is applied to the
pulp tissue
Cover exposed dentine with GIC
Restore with composite or strip crown in ant and SSC in
posterior teeth.
Review in 6-8 weeks
-No clinical sign & symptom
-Radiographically lesion not
showing any root resorption
Restore tooth with permanent
restoration.
Review in 1&5 years after injury
and monitor for pulpal sensibility
-Tooth symptomatic with sign of
pulp necrosis
-Radiographicaly,presence of lesion
Root canal treatment
Extraction

21. 2 a)Partial Pulpotomy/Cvek Pulpotomy
Aim:Remove only inflamed tissue , leaving healthy pulp
tissue for physiologic maturation of the root.

22. 2 a)Partial Pulpotomy/Cvek Pulpotomy
Indications : Exposure > 1mm
: Time elapsed since injury >24 hours
: Vital pulp
: Fractured primary teeth
: Young permanent teeth
with incomplete root development
: Absence of root fracture

23. Partial Pulpotomy Procedure
Pulp tissue removal
- 2mm apical to the exposure .
Haemorrhage control
- saline/diluted sodium
hypochlorite(2.5%)

24. Partial Pulpotomy Procedure
Pulp covered - MTA or calcium hydroxide
Restoration – GIC & CR
Re-evaluation- 1/12 and every 3/12 for the first
year.

25. 2 b) Full Coronal Pulpotomy
Aim:Amputation of inflamed pulp tissue from coronal chamber ,leaving
healthy tissue to enhance physiologic maturation of the root.
Indications :Large contaminated exposure
: Long duration of time elapsed since injury
: Vital pulp
: Fractured primary teeth
: Young permanent teeth with incomplete root development
: Absence of root fracture

27. Apply FS on a pledget of
cotton wool for 4 minutes
Step 7: Remove FS pledget after 4 mins
& check that haemorrhage has
stopped

28. 3)Apexification
Aims:to induce either closure of the open apical third of the root canal or the
formation of an apical “calcific barrier” against which obturation can be achieved.

29. 3)Apexification
Indications :Large contaminated exposure
: Exposure >24 hours
: Necrotic pulp
: Immature permanent teeth with open apex
: Absence of root fracture

30. 4)Root Canal Treatment
Aims:
To remove all the infected material from the pulp chamber and
root canal system and filling the root canal with inert filling material.

31. 4)Root Canal Treatment
Indications :Large contaminated exposure
: Exposure >24 hours since the injury
: Necrotic pulp
: Permanent teeth with mature and closed apex
: Absence of root fracture

32. 5)Extraction
If patient’s condition do not permit early intervention,
the potential for odontogenic infection must weight
against the advantages of preserving the fractured teeth.

33. References
 Macedo GV, Diaz PI, De O Fernandes CA, Ritter AV. Reattachment of anterior
teeth fragments: a conservative approach. J Esthet Restor Dent. 2008;20(1):5-18
 Terry DA. Adhesive reattachment of a tooth fragment: the biological restoration.
Pract Proced Aesthet Dent. 2003 Jun;15(5):403-9;
 Peterson,L.J. ,Ellis,E. ,Hupp,J.R and Tucker,M.R. Contemporary Oral and
Mazillofacial Surgery.3rd Edition.Mosby1998
 Andreasen JO,Andreasen FM,Bakland LK and Flores MT.Traumatic Dental
Injuries(A Manual)Munksgaard 2nd edition
 Michael G.Stewart Head,Face,Neck Trauma Comprehensive management
 http://www.dentaltraumaguide.com
 http://www.aapd.org/media/Policies_Guidelines/G_trauma.pdf

34. Thank you