Crown-root fracture with pulp involvement - Treatment Guidelines
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.
- 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.
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)
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 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).
- 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 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.
|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.
||Can be used in cases where the root cannot support a post-retained crown restoration.
||Preserves the alveolar process.
||Postpones definitive restoration.
||Extraction in cases of extensive deep crown-root fractures.
- 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.
6-8 weeks and 1 year.