DiAngelis AJ, Andreasen JO, Ebeleseder KA Guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Pediatr Dent. 2016; 38:358-368
Andreasen JO. Traumatic Injures of the Teeth, 2nd edn. Copenhagen: Munksgaard; 1981
Borum MK, Andreasen JO. Therapeutic and economic implications of traumatic dental injuries in Denmark: an estimate based on 7549 patients treated at a major trauma centre. Int J Paediatr Dent. 2001; 11:249-258 https://doi.org/10.1046/j.1365-263x.2001.00277.x
, 5th edn. In: Andreasen JO, Andreasen FM, Andersson L (eds). Chichester: John Wiley; 2019
Cvek M, Lundberg M. Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing. J Endod. 1983; 9:8-11 https://doi.org/10.1016/S0099-2399(83)80005-3
Güngör HC. Management of crown-related fractures in children: an update review. Dent Traumatol. 2014; 30:88-99 https://doi.org/10.1111/edt.12079
Bourguignon C, Cohenca N, Lauridsen E International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020; 36:314-330 https://doi.org/10.1111/edt.12578
Bakland LK. Revisiting traumatic pulpal exposure: materials, management principles, and techniques. Dent Clin North Am. 2009; 53:661-673 https://doi.org/10.1016/j.cden.2009.06.006
Fuks AB, Bielak S, Chosak A. Clinical and radiographic assessment of direct pulp capping and pulpotomy in young permanent teeth. Pediatr Dent. 1982; 4:240-244
Wang G, Wang C, Qin M. Pulp prognosis following conservative pulp treatment in teeth with complicated crown fractures – a retrospective study. Dent Traumatol. 2017; 33:255-260 https://doi.org/10.1111/edt.12332
Pitt Ford TR, Roberts GJ. Immediate and delayed direct pulp capping with the use of a new visible light-cured calcium hydroxide preparation. Oral Surg Oral Med Oral Pathol. 1991; 71:338-342 https://doi.org/10.1016/0030-4220(91)90311-y
Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978; 4:232-237 https://doi.org/10.1016/S0099-2399(78)80153-8
Krastl G, Filippi A, Zitzmann NU Current aspects of restoring traumatically fractured teeth. Eur J Esthet Dent. 2011; 6:124-41
Fuks AB, Gavra S, Chosack A. Long-term followup of traumatized incisors treated by partial pulpotomy. Pediatr Dent. 1993; 15:334-336
Dean JA. Treatment of deep caries, vital pulp exposure, and pulpless teeth, 10th edn. In: Dean JA (ed). St Louis: Mosby; 2016
Krastl G, Weiger R. Vital pulp therapy after trauma. Endod Pract Today. 2014; 8:293-300
Fuks AB, Cosack A, Klein H, Eidelman E. Partial pulpotomy as a treatment alternative for exposed pulps in crown-fractured permanent incisors. Endod Dent Traumatol. 1987; 3:100-102 https://doi.org/10.1111/j.1600-9657.1987.tb00610.x
Partial pulpotomy in crown-fractured incisors – results 3–15 years after trauma. Acta Stomatol Croat. 1993; 27:167-173
Bogen G, Chandler NP. Pulp preservation in immature permanent teeth. Endod Topics. 2010; 23:131-152
Andreasen FM, Kahler B. Pulpal response after acute dental injury in the permanent dentition: clinical implications-a review. J Endod. 2015; 41:299-308 https://doi.org/10.1016/j.joen.2014.11.015
Robertson A, Andreasen FM, Andreasen JO, Norén JG. Long-term prognosis of crown-fractured permanent incisors. The effect of stage of root development and associated luxation injury. Int J Paediatr Dent. 2000; 10:191-199 https://doi.org/10.1046/j.1365-263x.2000.00191.x
Bimstein E, Chen S, Fuks AB. Histologic evaluation of the effect of different cutting techniques on pulpotomized teeth. Am J Dent. 1989; 2:151-155
Mente J, Hufnagel S, Leo M Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp capping: long-term results. J Endod. 2014; 40:1746-1751 https://doi.org/10.1016/j.joen.2014.07.019
Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. Int Endod J. 2008; 41:128-150 https://doi.org/10.1111/j.1365-2591.2007.01329.x
Hilton TJ, Ferracane JL, Mancl L Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial. J Dent Res. 2013; 92:(7 Suppl)16S-22S https://doi.org/10.1177/0022034513484336
Camilleri J. Staining potential of Neo MTA Plus, MTA Plus, and Biodentine used for pulpotomy procedures. J Endod. 2015; 41:1139-1145 https://doi.org/10.1016/j.joen.2015.02.032
Cox CF, Keall CL, Keall HJ Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent. 1987; 57:1-8 https://doi.org/10.1016/0022-3913(87)90104-1
Demarco FF, Fay RM, Pinzon LM, Powers JM. Fracture resistance of re-attached coronal fragments – influence of different adhesive materials and bevel preparation. Dent Traumatol. 2004; 20:157-163 https://doi.org/10.1111/j.1600-4469.2004.00221.x
Complicated crown fractures of permanent teeth following dental trauma in children are a common presentation in the dental practice. The prognosis of these teeth largely depends on the emergency management provided by the dentist. Treatment options include direct pulp capping and partial pulpotomy. While both have been suggested as possible vital pulp therapies for the management of complicated crown fractures, there are no clear recommendations as to when each procedure is indicated to aid the clinician in decision making. This narrative review aims to provide evidence-based recommendations for the optimal management of complicated crown fractures in children. The factors affecting success rates of both direct pulp capping and partial pulpotomy are discussed and a step-by-step guide to carrying out a partial pulpotomy is presented.
CPD/Clinical Relevance: This article will assist clinicians in making an evidence-based decision for the optimal management of complicated crown fractures of permanent teeth in children.
Article
Ioanna Politi Rona Leith
A complicated crown fracture is a fracture involving loss of tooth structure and exposure of the pulp (Figure 1a).1 The reported prevalence is 5–8% in the permanent dentition, and the maxillary central incisors are the most frequently affected.2,3 Approximately 25% of dental traumatic injuries to the permanent dentition occur before the age of 9 years, when the maxillary incisors have not yet fully formed.4 While apical closure of the maxillary permanent incisor is expected by the age of 10–11,5 the root walls may still be immature and thin.
Figure 1.
(a) A clinical case of an 8 year old with a complicated crown fracture of UL1. (b) Initial radiograph showing immature root with wide open apex. (c) Following a pulpotomy procedure and reattachment of the tooth fragment. (d) Final radiographic follow up after 3 years showing successful apexogenesis and completed root development of UL1.
Histological studies have shown that if exposed pulps are appropriately managed at the time of injury, they have the ability to heal.6 Dental practitioners should, therefore, always attempt to maintain the vitality of traumatized immature incisors to allow apexogenesis. Continued root formation will lead to a more favourable crown root ratio, decrease the risk of fracture, and facilitate future root canal treatment if required. Fully matured teeth with exposed pulps can also be preserved with vital pulp therapy if the pulp is healthy.7
The prognosis of teeth that have sustained a complicated crown fracture will largely depend on the emergency management provided by the dentist. A number of contemporary guidelines for management of dental trauma are available8,9,10 with updates from the International Association of Dental traumatology (IADT)9 and the British Society of Paediatric Dentistry (BSPD),8 published in 2020. Direct pulp capping or pulpotomy is suggested as the treatment of choice for permanent teeth with complicated crown fractures in an attempt to maintain pulp vitality. However, there are no specific guidelines to assist the clinician in deciding whether direct pulp cap or pulpotomy should be chosen based on the exposure size or the time since the injury.1,7 This article provides evidence-based recommendations for the optimal management of complicated crown fractures in children.
Treatment options for complicated crown fractures
Direct pulp capping, partial pulpotomy, coronal pulpotomy and pulpectomy have all being proposed as therapeutic approaches for the treatment of traumatically exposed pulps.7 Before deciding on treatment for a complicated crown fracture, the clinician should consider four main factors: time elapsed since the accident; stage of root development; size of the exposure; and the amount of remaining tooth structure.10 Other considerations include the procedure itself, the materials used, efficacy of the coronal seal, the effect of concomitant injuries and patient compliance.
Direct pulp capping involves the placement of a biocompatible material directly over the exposed pulp. The rationale is that the capping material will disinfect the superficially inflamed pulp, therefore, allowing the pulp to heal and maintain its vitality. The reported success rate of direct pulp capping in permanent teeth with complicated crown fractures ranges from 42.9% to 81.5%.11,12,13 It has been traditionally indicated for small exposures that can be treated shortly after injury. It has been suggested in the literature that if a small exposure is treated quickly, the depth of the damage from the traumatic injury and the subsequent inflammation is not greater than the depth of the penetrating effects of calcium hydroxide.5 Good success rates have been reported for pulps that have been exposed up to 24 hours.14,15 The advantages of direct pulp capping in the management of a complicated crown fracture is that it is an easy, quick and cost-effective procedure to carry out. It is a simpler procedure, and in emergency situations, it does not require local anaesthesia.13 However, direct pulp capping has lower success rates than partial pulpotomy (Table 1). The higher rate of pulp necrosis and infection that is associated with direct pulp capping is thought to be related to the lack of removal of the contaminated superficial layer of the exposed pulp.16 While primary contamination of the pulp may not be critical for healing, microleakage of a defective restoration can subsequently jeopardize pulpal health.19 It has been suggested that because the pulp cap material overlies enamel and dentine, it may compromise the seal of the restoration and allow bacterial leakage.13 Additionally, the indications for choosing a pulp cap are unclear. First, while traditionally it has been indicated for small exposures, there are no guidelines to quantify how and what constitutes ‘small’. Furthermore, while studies indicated that it can have high success rates with pulps that have been exposed up to 24 hours,14,15 these were of low-quality evidence from animal studies. More recent studies suggest that direct pulp capping should be limited to pulps that have been exposed for less than 2 hours.17 Finally, since this procedure involves no preparation of the pulp space, there is no mechanical retention to aid holding of the pulp capping material. When retention of the dressing is questionable, a pulpotomy should be considered instead to maximize pulpal protection.7,18
Retrospective study (n=33 teeth; 17 open apex + 16 closed apex)
Traumatic pulp exposures in teeth treated with direct pulp capping or partial pulpotomy
5 years
Pulp capping resulted in approximately a three-fold higher rate of pulp necrosis and infection compared with partial pulpotomy (54.5% SR of direct pulp cap versus 86.4% SR of partial pulpotomy)
Retrospective (n=375 teeth; 333 open apex + 42 closed apex)
Traumatic pulp exposures in teeth treated with direct pulp capping, partial or coronal pulpotomy and direct pulp capping retreated by pulpotomy
6–140 months (median=23 months)
Direct pulp capping had a rate of pulp necrosis and infection nearly five times higher than that of pulpotomy(42.9% SR of direct pulp capping versus 89.9% SR of partial pulpotomy)
SR: success rate.
Partial pulpotomy, also called ‘Cvek’ pulpotomy, is a procedure where the superficial 1–3 mm of the coronal pulp located adjacent to the pulp exposure is removed.16 The aim is to remove the coronal inflamed pulp tissue to the level of a healthy pulp in an attempt to maintain pulp vitality and encourage apexogenesis (Figure 1). Histological observations have shown that inflammation is limited to the coronal 2–3 mm of the pulp up to 168 hours following a traumatic pulp exposure.6 A partial pulpotomy is indicated for pulp exposures that are bigger than a pinpoint16,19 and have been exposed for more than 2 hours.20 Up to 9 days post exposure, success rate remains high.21Figure 2 describes the steps for a partial pulpotomy.5 Partial pulpotomy has higher success rates than direct pulp capping in the management of complicated crown fractures (Table 1). Success rates of partial pulpotomy in permanent teeth with complicated crown fractures have been reported to be in the range of 86.4–100% (Table 2).6,11,12,13,16,22,23,24 The available evidence, despite being limited, suggests that neither the size of the exposure nor the time interval have significant effect on the success rate of partial pulpotomy following traumatic pulp exposure, if the pulp is healthy.16,22,23 Also, preparation of the superficial pulp space aids in the mechanical retention of the pulpotomy agent. For the above reasons, it seems reasonable for partial pulpotomy to be the first line of treatment in all traumatic pulp exposures in immature teeth. However, unlike direct pulp capping, partial pulpotomy requires local anaesthesia, and therefore, patient cooperation. In addition, it is more technique sensitive and requires more steps and an increased time compared to the direct pulp capping technique. If a pulpotomy is not possible at the emergency visit, a direct pulp cap can be performed and the tooth re-treated with a pulpotomy at a later date.13 Success rates for a deferred pulpotomy have been found to be similar to that of an immediate one.13
Figure 2. Partial pulpotomy technique (adapted from Andreasen et al6). The clinical photos of a 9 year old who presented with an complicated crown fracture of the immature UR2 are used to illustrate the procedure.
Coronal pulpotomy involves a deeper amputation of the pulp, up to the cervical area of the tooth. Coronal pulpotomy should only be performed if a partial pulpotomy has not been sufficient to remove the inflammation. A deeper pulpotomy in other situations is unnecessary and should be avoided because it has been shown that neither exposure size nor time elapsed since injury is critical for healing when only the superficial layer of the pulp is removed.16,22,23 Partial pulpotomy is preferred to coronal pulpotomy because it preserves the coronal pulp tissue, which is rich in cells, subsequently providing a better healing potential.25 Additionally, it allows for continuous deposition of dentine in the critical cervical area of the tooth. Partial pulpotomy also preserves the natural colour and translucency of the tooth, and gives the clinician the opportunity for continued pulp sensitivity testing.5,7,22
Pulpectomy should only be used in patients who had complicated crown fractures and present late showing signs of pulp necrosis. It may also need to be carried out if pulp haemorrhage cannot be controlled following pulpotomy, indicating that the pulp is irreversibly inflamed. Additionally, in teeth with fully matured roots, pulpectomy may be indicated if the tooth will need a post to retain a coronal restoration.10
Factors affecting success rates following vital pulp therapy
Stage of root development
The stage of root development is important because immature teeth have a better prognosis following vital pulp therapy. This is due to the abundant apical blood supply associated with the open apices of immature teeth. The high vascularity prevents or arrests bacterial invasion and subsequent spread of inflammation.26 A retrospective study showed that while only 10.8% of immature teeth developed pulp necrosis and infection following vital pulp therapy of complicated crown fractures, this incidence was raised to 31% for mature teeth.13 The findings of this study were consistent with the results of previous studies.12,22,27
Size of pulp exposure
The size of the pulp exposure should also be considered. A healthy pulp has a significant ability to survive once it is protected from bacterial ingress regardless of how much tissue was exposed.10 While, theoretically, a bigger pulp exposure may lead to greater bacterial accumulation compromising pulp survival following vital pulp therapy, evidence to support this is poor. The limited evidence available seems to support that the size of pulp exposure is important for the success rate of direct pulp capping, but not for the success of partial pulpotomy. Pulp exposures that are bigger than a pinpoint have poorer success rates if treated with direct pulp capping and, therefore, some authors suggest that they are treated with partial pulpotomy.16,19 It appears that size of the pulp exposure is not a critical factor when partial pulpotomy is performed.16 Nevertheless, no studies could be identified examining the success of partial pulpotomy for exposures that are greater than 4 mm.
Time delays
The effect of time delay with regard to treatment of complicated crown fractures is debatable. An increase in the duration of pulp exposure may lead to a greater bacterial accumulation, increasing the risk of pulp infection; however, there are few studies examining the effect of time delay. Time delay appears to play a role in the success of direct pulp cap but not in the success of partial pulpotomy.16,22,23 Direct pulp capping should only be performed in pulps that have been exposed for 2–24 hours.14,15,17 However, studies have shown that the time interval is not a critical factor if partial pulpotomy is carried out following a complicated crown fracture in healthy pulps.13,16,27 A literature review suggested that the ‘safe’ interval for Cvek pulpotomy, where high success rate is maintained, is 9 days.21
Concomitant injuries
Concomitant injuries can have a direct effect on the prognosis of a complicated crown fracture. During luxation injuries, the blood vessels that supply the pulp through the apical foramen may be torn or ruptured. As a result, the compromised blood supply decreases the pulp's regenerative capacity. In addition, the periodontal ligament is also damaged. Therefore, traumatized teeth with complicated crown fractures that have also sustained a concomitant luxation injury have a poorer prognosis following vital pulp therapy. A study by Robertson et al reported an increased incidence of pulp necrosis from 0% to 14% in teeth with complicated crown fractures if there was a concomitant luxation injury.27
Technique
The technique used to carry out the pulpotomy procedure may also affect the outcome. The use of hand instruments (eg spoon excavator), slowly rotating round burs and high-speed diamond burs have all been suggested. Hand instruments and slowly rotating round burs have been reported to cause injury to the pulp that is greater than that of the exposure itself, decreasing the chance of survival.28 Therefore, clinicians are advised to use a diamond bur with high speed under copious irrigation when removing pulp tissue.28
Materials
The materials used may also influence the success of vital pulp therapy procedures. Traditionally, calcium hydroxide was the agent of choice; however, its antibacterial properties decrease with time, and tunneling defects within the hard tissue barrier may allow ingress of bacteria from a defective restoration to the pulp.5 More recently, bioceramic materials, such as MTA, have shown superior success rates29 and therefore, many authors have suggested that bioceramic materials should be the gold standard agents for vital pulp therapy.29,30,31 The higher success rates reported with MTA are thought to be related to its biocompatibility, which allows for tissue repair and stimulates the formation of a hard tissue barrier. Additionally, MTA is an excellent antibacterial agent and offers good resistance to microleakage without breaking down over time.5,30,31 The problem with traditional MTA is that both the white and grey version can cause tooth discolouration. Additionally, MTA has a high cost, poor handling properties and a long setting time. Newer bioceramics like Biodentine (Septodont, Saint-Maur-des-Fosses, France) and Neo MTA Plus (Avalon Biomed Inc, Bradenton, FL, USA) appear to be less prone to causing staining in vitro;32 however, more high-quality evidence is needed. Calcium hydroxide continues to be a suitable pulp dressing material and can be used where aesthetic requirements are high or if bioceramic materials are not available.5 BSPD and IADT trauma guidelines suggest that both non-setting calcium hydroxide and non-staining calcium silicate cement are suitable agents.8,9
Quality of coronal restoration
A good-quality coronal restoration following vital pulp therapy is of paramount importance for the survival of the pulp. An effective coronal seal will ensure no leakage and will, therefore, prevent bacterial ingress. A study reported that if the coronal restoration failed within 6 months, then the pulp had less chance of survival.13 It has been reported in the literature that the quality of the coronal restoration has a greater effect on pulp survival than the material used for the vital pulp therapy.33 Depending on the extent of the complicated crown fracture, the coronal seal can be achieved in various ways, including composite restorations or full coverage crowns. If the original tooth fragment is available, then reattachment of the fragment should be considered.5 If done properly, reattachment of the original tooth fragment can lead to excellent aesthetic results by preserving the original tooth anatomy, while potentially also saving chair time (Figure 1c). With advancements in the bonding agents, successful results with fragment bonding can be achieved provided manufacturer's instructions are followed.34 Beveling along the fracture line prior to fragment reattachment can improve aesthetic outcome, increase the surface area for bonding and, according to some in vitro studies, can potentially increase the fracture resistance.34 A systematic review concluded that use of an intermediate material between the tooth fragment and the dentine resulted in an increased bond strength.35
Follow-up
Close monitoring of these teeth following provision of emergency treatment is essential to ensure that pulp vitality is maintained, and to check for complications. Following emergency treatment, these cases are reviewed remotely at 6–8 weeks to assess oral hygiene and healing. Subsequent clinical review, unless otherwise indicated, should then follow at 3, 6 and 12 months.8
Conclusion
Vital pulp therapy should be the treatment of choice, not only for immature permanent teeth with complicated crown fractures, but also for mature permanent teeth.9 In immature teeth, the aim is to ensure continued root development, while in mature teeth the aim is to avoid complex, expensive endodontic and restorative procedures. Partial pulpotomy has shown superior success rates to direct pulp capping and coronal pulpotomy and is therefore recommended as the first line of treatment in the management of all complicated crown fractures, as long as the pulp is vital. Additionally, in contrast to direct pulp capping, it appears from the literature that the exposure size and the time delay are not critical factors in affecting the success rate of partial pulpotomy. Preparation of the superficial pulp during partial pulpotomy also helps in retaining the pulp capping agent. Dental practitioners should be familiar with the partial pulpotomy technique because complicated crown fractures following trauma in children are a common presentation in the dental practice. While direct pulp capping has decreased success rates, it may be of use where partial pulpotomy cannot be performed owing to poor cooperation.
