Crown fractures

Crown fractures represent a hazard to the pulp

• Uncomplicated enamel fractures: minor chips may need no treatment or selective grinding of the incisal edge, others may require the placement of acid-etch composite.

• Uncomplicated enamel-dentine fractures: these need coverage of the exposed dentine as soon as possible. This will relieve sensitivity cause by exposed dentinal tubules and will stop the ingress of bacteria and over-stimulation of the pulp which can lead to irreversible pulpitis. Therefore, coverage of exposed dentine should be bacteria-tight.

• Complicated enamel-dentine fractures: These, by definition, have pulpal exposure but can be treated successfully by formation of a calcific bridge by placement of CaOH over the exposed pulp. This is more likely to be successful if no inflammation was present prior to trauma and the vascular supply remains intact. Management depends on size and time the pulp has been exposed:

1. Pulp capping — small exposure < 1mm, soon after injury, cover with CaOH and dressing to cover exposed dentine (Composite/GIC)
2. Cvek Pulpotomy — larger exposure, likely necrosis of superficial part of exposed pulp - if you have access to a high speed handpiece and diamond bur, amputate pulp 2mm below exposure and obtain haemostasis. Then apply CaOH and dress with Composite/GIC
3. Pulpal extirpation — indicated with profound fractures of a mature tooth with associated periodontal ligament injuries, and in older injuries where there is evidence of irreversible pulpitis.
4. Extraction - teeth with extensive crown fractures may have a hopeless prognosis and require extraction

Pulp capping and pulpotomies require regular follow up with the patient's GDP