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Tooth fracture: Should you ever just "wait and see?" (Proceedings)

May 01, 2011

Tooth fracture may affect the crown and/or the root. In most cases tooth fractures are painful to the patient. It is imperative that patients with tooth fractures have a diagnostic workup to assess the stage of the fracture and what treatment options are available.

Patients with pain from a tooth fracture can show these clinical signs: chewing on one side, dropping food, excessive drooling, tooth grinding, pawing at the face, facial swelling, regional lymphadenitis, head shy behavior, refusing hard food, treats or toys, aggressive behavior.

Crown fractures

There are two classifications of crown fracture-complicated and uncomplicated. Complicated fractures means the fracture line exposes the pulp and uncomplicated fractures do not have exposure of the pulp. Diagnosis of the fracture classification is done with the patient under anesthesia using a dental explorer to examine whether the pulp has been exposed.

Complicated fractures

When the pulp chamber is exposed, the pulp becomes inflamed and can spread into the root. Pulpitis and pulpal death can occur if no treatment is provided. Pulp exposure is painful to the patient. If treatment is not going to happen right away, antibiotics and pain medications should be dispensed.

If a complicated fracture occurs to a deciduous tooth, the deciduous tooth should immediately be extracted so as to not cause damage to the permanent tooth bud.

If a complicated fracture occurs to a permanent tooth, the treatment options are extraction or root canal therapy. If the fracture goes below the cementoenamel junction or the root is diseased, root canal therapy has a higher incidence of failure and extraction must be performed.

Immature permanent teeth are found in those patients up to 18 months old. The pulp chamber in these patients makes up the bulk of the tooth and as the patient ages, more dentin is laid down and the pulp chamber narrows and the root apex closes. It makes sense that these teeth should be allowed to finish the development of the root apex. Vital pulpotomy therapy is an endodontic procedure that can be done if the fracture is less than 48 hours old. The unhealthy portion of the pulp is removed and a material is placed to irritate the pulp and cause it to make a dentinal bridge to seal off the healthy pulp. A tooth colored restoration is then placed on top. These patients must be monitored radiographically at 6 and 12 months post operatively to check the stabilization of the tooth. If the therapy fails, root canal therapy or extraction must be performed.

Uncomplicated fractures

Teeth with uncomplicated fractures have exposure of the dentinal layer. The dentin is made up of microtubules that allow communication between the pulp and the oral environment. Exposure of the dentin can result in pulpitis or even pulpal death if left untreated. Minimally, the tooth is sensitive and may cause some pain to the patient.

Treatment usually involves sealing the dentin to stop any sensitivity. This can be done using a bonding agent or a restorative material if the defect is slightly larger. The treated tooth must be monitored with oral examinations and dental radiographs to make sure the pulp remains vital. If the pulp does not remain vital then extraction or root canal therapy must be recommended.