Crown fracture, complicated

COMPLICATED CROWN FRACTURE

DIRECT PULP CAPPING is indicated when:
* Pulp status was normal prior to trauma
* No associated luxation injury with damage to the apical blood supply
* Pulp exposure is less than 1 mm
* Interval between pulp exposure and treatment is less than 24 hours
* Restoration ensures a bacteria-tight seal

Technique:
* Isolate the tooth with rubber dam
* Clean the fracture surface with sterile cotton pellets moistened with saline or chlorhexidine
* Dry the exposure site using sterile cotton pellets
* Cover the perforation with calcium hydroxide (e.g. Calasept®)
* Cover exposed dentin with a hard-setting calcium hydroxide cement
* Apply the protective restoration (temporary restoration, crown reattachment or composite-build up)

PARTIAL PULPOTOMY implies removal of inflamed pulp tissue. Usually the level of amputation should be about 2 mm below the exposure site. Partial pulpotomy is indicated in both immature and mature teeth provided the pulp has a bright red appearance. Neither size of the exposure nor interval between injury and treatment is critical for the prognosis.

Technique:
* Anaesthetize the tooth
* Isolate with rubber dam and clean the fracture surface with sterile cotton pellets moistened with saline or chlorhexidine
* Prepare a box-like cavity at the exposure site
* Use an air-rotor with a diamond bur, ensuring copious water supply
* Remove the pulp to a depth of about 2 mm
* Achieve hemostasis either by irrigation with sterile saline or by slight pressure from cotton pellets soaked in saline or anaesthetic solution with vasoconstrictor
* Cover the wound with calcium hydroxide (e.g. Calasept®). Over this a hard-setting calcium hydroxide cement is applied
* Apply the protective restoration (temporary restoration, crown reattachment or composite build up)

Follow-up:
All traumatized teeth are carefully observed for clinical and radiographic signs of complications. The intervals between re-examinations should be individualised depending upon the severity of traume, the expected type of complication and the age of the patient. In many complicated crown fracture cases clinical and radiographic investigation can be taken at 3 weeks, 3 months, 6 months and 1 year, thereafter the tooth is controlled once every year. A negative response to pulp test must be accompanied by other clinical and/or radiographic signs before necrosis can be diagnosed. If pulpal necrosis develops, endodontic therapy is performed.