crown/root fracture in primary teeth

1. 1
Ishik university
Faculty of dentistry
Departmentof pediatric dentistry
* Crown/Root Fracture in primay teeth *
Prepared by : Dr. Saya Mustafa Aziz
4th grade dental student
2014 – 2015

2. 2
Introduction :
Traumatic injuriesto teeth and their supporting tissues usually occur in young
people , the greatestincidence of trauma to primary dentition between 2 to 3
yearsold children when motor coordination isdeveloping , there is no significant
sex difference in incidence of trauma in primary dentition and damage may vary
from enamelfracture to avulsion, with or withoutpulpal involvement or bone
fracture.
It is importantto keep in mind that there is close relationship between the apex of
the rootof the injured primarytooth and the underlying permanenttooth germ
,tooth malformation , impacted teeth , and eruption disturbance in the developing
permanentdentition are some of the consequencesthatcan occur following
severe injuriesto the primary teeth and/or alveolar bone so because of these
potentials sequelae , treatmentselections should be aimed at minimizing any
additionalrisks of further damage to the permanentsuccessors.
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 importantfactorsthat
influence treatmentselection.
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 peakat 2-4 years and 8-10 years
• The waythe 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. Adirect
hit can also happenduring sportsactivities or abuse to the child .
Injuriesto the teeth of childrenor adultspresent unique problemsindiagnosis
and treatment. The diagnosisof the extentof the injury after a blow to a tooth,
regardless of lossof tooth structure, isdifficult and ofteninconclusive. Trauma
to a tooth isinvariably followed by pulpal hyperemia,the extent of which cannot
alwaysbe determined by available diagnosticmethods. Congestionand
alterationinthe blood flow inthe pulp may be sufficient to initiate irreversible
degenerativechanges, which over time cancause pulpal necrosis. In addition,
the apical vesselsmay have beensevered or damaged enough to interferewith
the normal reparative process. Treatment of injuriescausing pulp exposure or
tooth displacement are particularly challenging, because the prognosisof the
involved tooth isoftenuncertain. The treatment of fractured teeth, particularly
in young patients, isfurther complicated by the oftendifficultbut extremely

3. 3
important restorative procedure.Although the dentistmay prefer to delaythe
restorationbecause of a questionableprognosis for the pulp, oftena
malocclusioncan develop withina matter of daysasa result of a breakin the
normal proximal contact with adjacent teeth. Adjacent teeth may tip into the
area created by the lossof tooth structure. Thislossof space will create a
problemwhenthe final restorationiscontemplated.There must oftenbe a
compromise of anideal estheticappearance, at least inthe initial restoration,
because the prognosisis questionable or because the tooth isyoung and has a
large pulp or is still in the stage of active eruption. Oftenthe likelihood of success
dependsonthe rapidity with which the tooth is treated after the injury,
regardlessof whether the procedureinvolvesprotecting a large area of exposed
dentinor 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 obstructionsthatthey can trip themselves up on.
- Do not push when playing.
- Stay seated on the swing and do notjump off when the swing is in motion.
- Use the stairs when getting out of the swimming pool.
If the child participatesin sportssuch as rugby, hockey, karate, riding on a bike,
wintersports(i.e. skiing) a skate board or any activity that involves potential
trauma to the facialarea, make sure that the child uses a helmet or mouth
protector
History and Examination :
History:
1-Medical history :
The medicalhistory should reveal possible allergies, blood disordersand other
information thatmay influence treatment
2-Dental history :important information to get regarding theinjury
• Incidents surrounding injury
• Any other injuries
• How long ago the injury occurred
• Last time the patient ate
• QUESTIONSRELATINGTO 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.

4. 4
 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 extraoralstorage condition becomes very decisive for later treatment.
 Wasthere 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 disturbancein the bite? An affirmativeanswer may indicate a
luxation injury with displacement, an alveolar or jaw fractureor 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
• Nasalor orbital malalignments
• Lacerations, hematomas, foreign bodies
• Open and close mouth to evaluate for deviation during function
• Lip competency
• Palpation
• TemporoMandibularjoint
• Equalmovements
• Orbital rim intact
• Nose for crepitus
• Note parasthesiasor numbness
• Intraoral
– Inspection :
– Inspect the dentaltrauma region for fractures, abnormaltooth
position, tooth mobility, and abnormalresponse to percussion.
Furthermore registration of direction of displacementin 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 qualityof gumsand mucosa
– Note hematomas
– Color, chips, cracks, bleeding, absent

5. 5
– Palpation of :
– Tongue
– Mobility of teeth
– Tooth percussion
Radiographic Examination :
The completed clinical examination hasnow identified the trauma region and this
site should now be examined with relevant radiographic techniques. Several
clinical studies have shown that multiple radiographic proceduresare needed to
detect displacementof the tooth in its socket as well as presence of rootfractures.
It’s essential to consider the radiographic film formatused in order to achieve a
high quality image of the traumatized tooth. A steep occlusalexposure (using a
size 2 film (DF 58, EP 21)) of the traumatized anterior region givesan
excellent view of most lateral luxations, apicaland mid-rootfracturesand alveolar
fractures. The standard periapicalbisecting angle exposure of each traumatized
tooth (using a size 1 film (DF 56, EP 11)) providesinformation aboutcervicalroot
fracturesaswell as other tooth displacements. Thus a radiographic examination
comprising one steep occlusalexposure and three periapical bisecting angle
exposuresof the traumatized region willprovide sufficient information in
determining the extent of trauma to an incisor region.
 Radiographs allow the clinician to detect :
Root fractures , Extent of rootdevelopment , Size of pulp chambers
,Periapicalradiolucencies , Resorptions , Degree of tooth displacemen ,

6. 6
Position of unerupted teeth , Jaw fractures , Presence of any tooth fragments
or foreign materialin soft tissues ,Keptas a documentfor comparison on
follow-up.
Radiographic examination of soft tissue lesions :
In the presence of a penetrating lip lesion, a soft tissue radiograph isindicated in
order to locate any foreign bodies. Itshould be noted that the orbicularisoris
muscles close tightly around foreign bodiesin the lip, making them impossible to
palpate; they can only be identified radiographically. Thisis accomplished by
placing a dentalfilm between the lips and the dental arch and using 25% of the
normalexposure time. If this exposure revealsforeign bodies(a radiographic
examination will normally demonstrate foreign bodiessuch astooth fragments,
composite filling material, metal, gravel, whereasorganic materialssuch as cloth
and wood cannotbe seen), a lateralradiograph can be added (at50% normal
exposure time) to visualize the foreign bodiesin relation to the cutaneousand
mucosalsurfacesof the lips. With the combined information from the clinicaland
radiographic examinations, diagnosis, prognosisand treatmentplanning can then
be accomplished.
Photographic registration
Finally, photographic registration of the trauma is recommended, asit offersan
exact documentation of the extent of injury and can be used later in treatment
planning, legalclaims or clinical research. Note thata patient consentis required.
Types of trauma :
LUXATION INJURIES
 Concussion
 Subluxation
 Extrusion
 Lateralluxation
 Intrusion
 Avulsion
FRACTURE INJURIES
 Enamel infraction
 Enamel fracture
 Uncomplicated crown fracture (enamel-dentin fracture)
 Complicated crown fracture (enamel-dentin-pulp fracture)
 Uncomplicated crown rootfracture
 Complicated crown rootfracture
 Root fracture
 Alveolar fracture

7. 7
INJURIES TO GINGIVA OR ORAL MUCOSA
 Laceration of gingiva or oralmucosa
 Contusion of gingiva or oralmucosa
 Abrasion of gingiva or oralmucosa
Sequelae of dental trauma
 Pulp necrosis (PN)
 Pulp canalobliteration (PCO)
 Externalsurface resorption (repair-related externalresorption)
 Ankylosis-related resorption (osseousreplacementresorption)
 Transientexternal ankylosis(replacementresorption)
 Infection related resorption (Inflammatory resorption)
 Internalinfection related resorption (internalinflammatoryresorption)
 Internalrepair related resorption (Internalsurface resorption)
 Internalankylosis(internalosseousreplacementrelated resorption)
 Cervical invasive resorption
 Traumatic or infection-related lossof marginalbone
 Transientapical breakdown
 Transientmarginalbreakdown
 Pulp metaplasia
 Gingival reattachment
 Periodontalligamentregeneration
 Tooth discoloration
Treatmentand test definitions
 Dentin coverage
 Pulp capping
 Partialpulpotomy (shallow pulpotomy)
 Manualrepositioning
 Surgicalrepositioning
 Orthodontic repositioning
 Partialrepositioning
 Total repositioning
 Pulp extirpation (pulpectomy)
 Pulp testing
WOUND HEALING DEFINITIONS
 Wound regeneration
 Wound repair
 Wound healingmodule
 Revascularization
DEFINITIONS OF TOOTH DEVELOPMENT AND ERUPTION DISTURBANCES OF
PERMANENT TEETH RELATED TO INJURY TO PRIMARY PREDECESSORS
 White or yellow-brown discoloration of enamel

8. 8
 White or yellow-brown discoloration of enamel and circular enamel
hypoplasia
 Crown dilaceration
 Odontoma-likemalformation
 Root duplication
 Vestibular root angulation
 Lateral root angulation or dilaceration
 Partial or complete arrestof root formation
 Sequestration of permanent tooth germ
 Disturbancein 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 horizontalimpact, which involves
enamel, dentin and cementum, occursbelow the gingivalmargin . Epidemiological
statistics revealed that crown-rootfracturesrepresent5% of dentalinjuries and
may be classified as : complicated or uncomplicated, depending on whetherpulp
involvement is presentor absent
1-Crown-root fracture without pulp involvement
A fracture involving enamel, dentin and cementum with loss of tooth structure,
but notexposing the pulp.

9. 9
Diagnosis:
Visual signs Crown fracture extending below gingival
margin.
Percussiontest 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 rootof the tooth and is in a horizontal
or diagonalplane. A radiographic examination usually only revealsthe
coronalpartof the fracture and notthe apical portion
 A cone beam exposure can reveal the whole fracture extension
Emergency treatment
 As an emergency treatmenta temporarystabilization of a loose segment to
adjacentteeth can be performed untila definitive treatmentplan is made
DEFINITIVE TREATMENT
Depending on the clinical findings, six treatmentscenariosmay be considered.
Most of these may be deferred to later treatment.
 Fragment removal only
Removal of a superficialcoronalcrown-rootfragmentand subsequent
restoration of exposed dentin above the gingival level.
 Fragment removal and gingivectomy (sometimesostectomy)
Removal of coronalsegmentwith subsequentendodontic treatmentand
restoration with a post-retained crown. Thisprocedure should be preceded
by a gingivectomy, ostectomy with osteoplasty. This treatment option is
indicated in crown-rootfractureswith palatalsubgingivalextension.
 Orthodontic extrusion of apical fragment
Removal of the coronalsegmentwith subsequentendodontic treatment
and orthodontic extrusion of the remaining rootwith sufficient length after
extrusion to supporta post-retained crown.
 Surgical extrusion
Removal of the mobile fractured fragmentwith subsequentsurgical
repositioning of the rootin a morecoronalposition. A rotation of the root

10. 10
(90 or 180) may offter a better position for periodontalligamenthealing.
Because the fracture site becomesexposed labially and thereby more
periodontalligamentcan be saved (see reference 9)
 Decoronation (Root submergence)
Implantsolution is planned, the rootfragmentmay be left in situ after in
order to avoid alveolar bone resorption and thereby maintaining the volume
of the alveolar processfor later optimal implant installation
 Extraction
Extraction with immediate or delayed implant-retained crown restorationor
a conventionalbridge. Extraction is inevitable crown-rootfractureswith a
severe apicalextension, the extreme being a vertical fracture
TIMING OF TREATMENT
All of the treatmentmodalities (except extraction) are technique sensitive and do
not need to be performed during the acute phase. Instead, the coronalfragment
can be temporarily bonded to the cervicalportion of the tooth with a composite or
resin. This may add to the comfortof the patientuntil finaltreatment. Prognosis
will not be influenced by delay of treatmentwithin 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

11. 11
extensive deep crown-root
fractures
PATIENT INSTRUCTIONS
 Softfood for 1 week
 Good healing following an injury to the teeth and oraltissues depends, in
part, on good oralhygiene. Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to preventaccumulation 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.

12. 12
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 involvesthe crownand root of the tooth and isin a
horizontal or diagonal plane. Aradiographicexaminationusually only
revealsthe coronal part of the fractureand not the apical portion.
 If available a cone beam exposure canreveal the whole fracture.
EMERGENCY TREATMENT
 As an emergency treatment a temporary stabilizationof a loose segments
to adjacent teeth canbe performed until a definitive treatment planis
made.
 In young patientswith openapices, it is advantageousto preservepulp
vitality by a partial pulpotomy. Thistreatmentisalso the choice in young
patientswith completely formed teeth. Calciumhydroxide compoundsare
suitable pulp capping materials. Inpatientswith mature root
development root canal treatment canbe 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 fragment
Removal of the coronal segment with subsequent endodontic treatment and
orthodontic extrusion of the remaining root with suffic ient 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).
 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.

13. 13
 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 treatmentmodalities (except extraction) are technique sensitive and do
not need to be performed in the acute phase. Instead, the coronalfragmentcan
be temporarily bonded to the cervicalportion of the tooth with a composite or
resin. This may add to the comfortof the patientuntil finaltreatment.
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
 Softfood for 1 week.
 Good healing following an injury to the teeth and oraltissues depends, in
part, on good oralhygiene. Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to preventaccumulation of plaque and
debris.
FOLLOW-UP : 6-8 weeks and 1 year.

14. 14
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 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

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 21

22. 22

23. 23

24. 24

25. 25

26. 26