TOOTH FRACTURE AND ITS MANAGEMENT Prof Ashok Kumar

TOOTH FRACTURE AND ITS MANAGEMENT Prof. Ashok Kumar 27 -9 - 2014

Fracture Ø Ellis and Davey classification of crown fracture is useful in recording extent of damage to crown ü Class I – simple fracture of crown involving little or no dentin ü Class II – extensive fracture of crown involving considerable dentin but not dental pulp

Fracture ü Class III – extensive fracture of crown with an exposure of dental pulp ü Class IV – loss of entire crown

Fracture Ø Enamel-Dentin-Pulp Fracture Ø Root Fracture

Enamel Fracture Ø fracture confined to the enamel with loss of tooth structure

Enamel Fracture Ø Visual sign: ü visible loss of enamel ü no visible sign of exposed dentin Ø Percussion test: ü not tender ü if tenderness is observed evaluate tooth for a possible luxation or root fracture injury

Enamel Fracture Ø Mobility test: ü normal mobility Ø Sensibility test: ü usually positive ü test may be negative initially indicating transient pulpal damage

Enamel Fracture Ø Sensibility test: ü monitor pulpal response until definitive pulpal diagnosis can be made ü test is important in assessing risk of future healing complications ü lack of response at initial examination indicates an increased risk of later pulpal necrosis

Enamel Fracture Ø Radiographic findings: ü enamel lost is visible Ø Radiographs: ü occlusal ü periapical ü recommended to rule out possible presence of root fracture or a luxation injury

Enamel Fracture Ø Treatment: ü if tooth fragment is available, it can be bonded to the tooth ü grinding or restoration with composite resin depending on extent + location of fracture

Enamel-Dentin Fracture Ø fracture confined to enamel + dentin with loss of tooth structure, but not involving pulp

Enamel-Dentin Fracture Ø Visual sign: ü visible loss of enamel + dentin ü no visible sign of exposed pulp tissue Ø Percussion test: ü not tender ü if tenderness is observed evaluate tooth for a possible luxation or root fracture injury

Enamel-Dentin Fracture Ø Mobility test: ü normal mobility Ø Sensibility test: ü usually positive ü test may be negative initially indicating transient pulpal damage

Enamel-Dentin Fracture Ø Sensibility test: ü monitor pulpal response until definitive pulpal diagnosis can be made ü test is important in assessing risk of future healing complications ü lack of response at initial examination indicates an increased risk of later pulpal necrosis

Enamel-Dentin Fracture Ø Radiographic findings: ü enamel-dentin lost is visible Ø Radiographs: ü occlusal ü periapical ü recommended to rule out displacement or possible presence of root fracture

Enamel-Dentin Fracture Ø Treatment: ü if tooth fragment is available, it can be bonded to the tooth ü otherwise perform provisional treatment by covering exposed dentin with glass ionomer or a permanent restoration using a bonding agent + composite resin

Enamel-Dentin-Pulp Fracture Ø (Complicated Crown Fracture) Ø a fracture involving enamel + dentin with loss of tooth structure + exposure of pulp

Enamel-Dentin-Pulp Fracture Ø Visual sign: ü visible loss of enamel + dentin ü exposed pulp tissue Ø Percussion test: ü not tender ü if tenderness is observed evaluate tooth for a possible luxation or root fracture injury

Enamel-Dentin-Pulp Fracture Ø Mobility test: ü normal mobility Ø Sensibility test: ü usually positive

Enamel-Dentin-Pulp Fracture Ø Sensibility test: ü test is important in assessing risk of future healing complications ü lack of response at initial examination indicates an increased risk of later pulpal necrosis

Enamel-Dentin-Pulp Fracture Ø Radiographic findings: ü lost of tooth substance is visible Ø Radiographs: ü occlusal ü periapical ü recommended to rule out displacement or possible presence of luxation or root fracture

Enamel-Dentin-Pulp Fracture Ø Treatment: ü if young patients with open apices, it is very important to preserve pulp vitality by pulp capping or partial pulpotomy in order to secure further root development ü this treatment is also treatment of choice in patients with closed apices

Enamel-Dentin-Pulp Fracture Ø Treatment: ü Calcium hydroxide compunds + MTA are suitable materials for such procedures ü in older patients with closed apices + luxation injury with displacement, root canal treatment is usually treatment of choice

Crown-Root Fracture without pulp involvement Ø fracture involving: ü enamel ü dentin ü cementum ü with loss of tooth structure ü but not exposing pulp

Crown-Root Fracture without pulp involvement Ø Visual sign: ü crown fracture extending below gingival margin Ø Percussion test: ü tender

Crown-Root Fracture without pulp involvement Ø Mobility test: ü coronal fragment mobile Ø Sensibility test: ü usually positive for apical fragment

Crown-Root Fracture without pulp involvement Ø Radiographic findings: ü apical extension of fracture usually not visible Ø Radiographs: ü occlusal ü periapical ü recommended to detect fracture lines in root ü cone beam exposure can reveal whole fracture extension

Crown-Root Fracture without pulp involvement Ø Treatment: ü Fragment removal only • removal of superficial coronal crown-root fragment • subsequent restoration of exposed dentin above gingival level

Crown-Root Fracture without pulp involvement Ø Treatment: ü Fragment removal + gingivectomy (sometimes ostectomy) • removal of coronal segment with subsequent endodontic treatment + restoration with a post-retained crown

Crown-Root Fracture without pulp involvement Ø Treatment: ü Orthodontic extrusion of apical fragment • removal of coronal segment with subsequent endodontic treatment + orthodontic extrusion of remaining root with sufficient length after extrusion to support a postretained crown

Crown-Root Fracture without pulp involvement Ø Treatment: ü Surgical extrusion • removal of mobile fractured fragment • subsequent surgical repositioning of root in a more coronal position

Crown-Root Fracture without pulp involvement Ø Treatment: ü Decoronation (root submergence) • implant solution is planned, root fragment may be left in situ after in order to avoid alveolar bone resorption • thereby maintaining volume of alveolar process for later implant installation

Crown-Root Fracture without pulp involvement Ø Treatment: ü Extraction • with immediate or delayed implant-retained crown restoration or a coventional bridge • fractures with severe apical extension, the extreme being a vertical fracture

Crown-Root Fracture with pulp involvement Ø fracture involving: ü enamel ü dentin ü cementum ü with loss of tooth structure ü exposure of pulp

Crown-Root Fracture with pulp involvement Ø Visual sign: ü crown fracture extending below gingival margin Ø Percussion test: ü tender

Crown-Root Fracture with pulp involvement Ø Mobility test: ü coronal fragment mobile Ø Sensibility test: ü usually positive for apical fragment

Crown-Root Fracture without pulp involvement Ø Radiographic findings: ü apical extension of fracture usually not visible Ø Radiographs: ü occlusal ü periapical ü cone beam exposure can reveal whole fracture extension

Crown-Root Fracture with pulp involvement Ø Treatment: ü Fragment removal + gingivectomy (sometimes ostectomy) • removal of coronal segment with subsequent endodontic treatment + restoration with a post-retained crown

Crown-Root Fracture with pulp involvement Ø Treatment: ü Orthodontic extrusion of apical fragment • removal of coronal segment with subsequent endodontic treatment + orthodontic extrusion of remaining root with sufficient length after extrusion to support a postretained crown

Crown-Root Fracture with pulp involvement Ø Treatment: ü Surgical extrusion • removal of mobile fractured fragment • subsequent surgical repositioning of root in a more coronal position

Crown-Root Fracture with pulp involvement Ø Treatment: ü Decoronation (root submergence) • implant solution is planned, root fragment may be left in situ after in order to avoid alveolar bone resorption • thereby maintaining volume of alveolar process for later implant installation

Crown-Root Fracture with pulp involvement Ø Treatment: ü Extraction • with immediate or delayed implant-retained crown restoration or a coventional bridge • fractures with severe apical extension, the extreme being a vertical fracture

Root Fracture Ø fracture confined to the root of tooth involving: ü cementum ü dentin ü pulp

Root Fracture Ø Visual sign: ü coronal segment may be mobile ü some cases displaced ü transient crown discoloration (red or gray) may occur ü bleeding from gingival sulcus may be noted

Root Fracture Ø Percussion test: ü tooth may be tender Ø Mobility test: ü coronal segment may be mobile

Root Fracture Ø Sensibility test: ü the test is important in assessing risk of healing complications ü a positive sensibility test at the initial examination indicates a significantly reduced risk of later pulpal necrosis

Root Fracture Ø Sensibility test: ü may give negative results initially ü indicating transient or permanent neural damage ü pulp sensibility test is usually negative for root fractures except for teeth with minor displacements

Root Fracture Ø Radiographic findings: ü root fracture line is usually visible ü fracture involves root of the tooth in a horizontal or diagonal plane

Root Fracture Ø Treatment: ü rinse exposed root surface with saline before repositioning ü if displaced, reposition the coronal segment of the tooth as soon as possible ü check that correct position has been reached radiographically

Root Fracture Ø Treatment: ü stabilize the tooth with flexible splint for 4 weeks ü if the root fracture is near cervical area of the tooth stabilization is beneficial for a longer period of time (upto 4 months)

Root Fracture Ø Treatment: ü monitor healing for at least 1 year to determine pulpal status ü if pulp necrosis develops, then root canal treatment of the coronal tooth segment to the fracture is indicated