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Treatment of Traumatic Injuries

Restorative Aspects in Anterior Crown Fractures

Stabilization, improvement, or reestablishment of function and aesthetics in traumatized teeth (and their periodontal support) remains a challenging endeavor, particularly when restorative procedures must be performed in emergency situations, or within a limited period following the trauma. Numerous lesions can occur as a result of trauma that involves the hard tissue or -- in advanced cases -- the pulp, periodontal ligament, and bone. Provisional and permanent treatment planning is dependent upon the extent and severity of the dental and periodontal lesions. The long-term prognosis of traumatized tissues requires restoration of functional integrity, tooth vitality, and prevention of root resorption.1 This article discusses the more frequent complications following traumatic injuries, as well as various provisional and permanent treatment modalities for treatment of coronal fractures.

Crown Fractures

Crown fractures are the most common traumatic injuries encountered in the permanent dentition. Uncomplicated injuries of the hard dental tissues comprise enamel infraction (cracks without loss of substance), enamel fracture, and enamel-dentin fracture (without pulp exposure). Complicated crown fractures involve dentin and enamel with pulp exposure. Depending on the amount of hard tooth substance loss and soft tissue involvement, different restorative modalities have to be considered. Treatment may consist of grinding/polishing the fractured enamel (for minimal tissue loss), dentin sealing with or without pulp protection-capping, adhesive fragment reattachment, direct or indirect composite build-up of the missing hard tissues, or extended or prosthetic restoration of the tooth with veneers or crowns.

Priority is always given to the preservation of the pulp vitality and sealing of the dentin tubules which, if performed adequately, may allow the final restoration of the tooth to be delayed. When the tooth fragment is recovered, however, immediate reattachment provides biological protection as well as the restoration. The biological response to the trauma is related to the pulp vascularity; the risk of pulp necrosis is significantly enhanced in situations where a concomitant luxation injury with compromised neurovascular supply is present.

Dentin Sealing and Pulp Capping

Due to time constraints or psychological disturbances induced by trauma, immediate treatment requires cleansing of the fracture line with subsequent application of a modern adhesive and thin composite layer when no pulp exposure is present. The complete tooth restoration is then postponed. While the risk of pulp complication is normally minimal, in the absence of additional luxation, canal obliteration may be subsequently observed.2-6

If pulp exposure is evident, immediate treatment is necessary in order to reduce the exposure of tissue to bacteria in the buccal environment. With a normal pulp status, intact vascular supply, and absence of profuse hemorrhage prior to the trauma, the application of pulp capping or limited amputation should be successful in the majority of cases.1 When minimal pulp exposure and an absence of bleeding are evident, the adhesive agent can be applied directly on the pulp without a calcium hydroxide barrier. Pulp capping -- with or without partial pulpotomy -- is indicated for large pulp exposure, uncontrollable hemorrhage, or surface wetness, which prevent the successful application of an adhesive (Figures 1-2-3-4-5-6-7).

Fragment Reattachment

The last generation of bonding agents facilitated the bonding and satisfactory retention of the original tooth fragment to its initial position. To date, no other long-term provisional restorative material can more effectively recreate or imitate the texture, morphology, and tissue abrasion to the antagonist tooth than the natural fragment itself. In addition to these numerous advantages, reduced chairtime is required for fragment reattachment, which subsequently increases patient satisfaction (Figures 8-9-10).

A holder can be used to stabilize the fragment during restorative procedures (eg, leveling the fracture line, conditioning the enamel and dentin of the fragment, and adhesive application) prior to fragment fixation. While chamfer preparation has been recommended,7 it exposes the composite layer to wear and discoloration, which impairs the aesthetics of the repair and increases the need for additional maintenance. Moreover, control of fragment repositioning becomes challenging. A thin layer of color-matched or translucent composite resin is placed with the "sandwich" technique prior to fragment placement to ensure its stability. Scanning electron microscopy examinations have demonstrated enhanced resin infiltration and adhesion at the interface when composite resin was added in between (Figure 11).

Reinforcement of the fracture line at a second intention does not prolong fragment retention.8 The fracture strength of fragments bonded with a former generation adhesive was comparable to those of intact teeth.9 When submitted to more severe forces, the fracture strength was reduced by 30%.8,10 Nevertheless, increased strengths can be expected with the last generation of bonding agents (Figures 12-13-14-15).

Immediately following retrieval, the avulsed fragment should be stored in a humid environment (eg, water, saliva, milk) to prevent tissue desiccation and a color shift between the reattached piece and the remaining tooth structure. It must be noted that the fragment may not fully recover its original color following replacement in the oral environment. Since dentin apposition occurs at different rates, particularly underneath the fracture line, the vital aspect of the tooth and adjacent teeth may increase the perceived difference in color. If dentin apposition or pulpal obliteration occur, however, bleaching procedures can be incorporated (provided the pulp is stable).11 This concept can be applied to composite restorations placed following trauma in the absence of fragment retrieval.

Composite Restoration

Current composite systems produce satisfactory and predictable aesthetic results (Figures 16-17-18-19-20-21-22-23).12-17 For natural aesthetics, a silicone reference device obtained following fabrication of a composite mock-up will facilitate the correct placement of various increments of composite resin to control restoration form, color, and opacity.13,17 The use of different masses with specific colors, chroma, and opacities facilitates the development of internal shading and superficial light effects -- particularly in the incisal third -- to replicate natural aesthetics. Finishing and polishing are the final, crucial steps required to develop or refine the form and function, as well as to create the surface texture.

The ratio between the free and bonded restoration surface (configuration factor) is extremely favorable in the case depicted in figures 21 through 23, and subsequently facilitated achievement of a stable marginal integrity.18 Evidence of wear, discoloration, or restoration debonding indicate the need for replacement, and should -- in case of premature failure -- be attributed to improper composite material selection, adhesive agent, and placement techniques.

With the exception of severe loss of tooth structure, indirect techniques should not be considered for the treatment of young patients (under the age of 20 to 25), simply because they provide superior initial aesthetics. The preparations required for veneer or full-coverage crown restorations are considerably more invasive than the fracture line cleaning and tooth restoration with composite (in combination with bleaching procedures involved in direct treatment). In addition, the tooth's biomechanical integrity is subsequently compromised in indirect treatment. It is, therefore, highly recommended to allow full tissue maturation prior to treatment, following stabilization of the gingival profile and reduction of the pulpal volume.

Ceramic Restorations

Partial tooth coverage demonstrated advantages over full-tooth coverage with either a porcelain-fused-to-metal or all-ceramic crown restoration (Figures 24-25-26-27). Aesthetics, biological response, and absence of restoration interference with the periodontium justify the increased interest in this treatment approach. Placement of a ceramic veneer or a full-coverage crown restoration is not immediately indicated. This treatment modality is considered primarily for adult patients following an adequate observation period. A direct composite restoration will generally assume the pulpo-dentin protection, function, and aesthetics during the provisional phase.

The long-term cumulated expense of restoration replacement must also be considered, and this element must be integrated in the treatment planning process.19 Additional expenses can also develop from the correction of common prosthetic treatment "complications" (eg, gingival retraction or loss of tooth vitality) after tooth preparation and full-coverage crown placement. These aspects support the selection of more conservative adhesive procedures (eg, direct restorations or veneers).

Crown-Root Fractures

If the fracture extends below the gingiva, the severity of the trauma is increased, and treatment is subsequently complicated.1,20 The two types of situations that can be encountered are 1) the fracture line violates the biologic width yet extends close or only slightly beneath the bone level, facilitating conservative treatment modalities, or 2) the fracture line extends further apically and requires extraction or forced orthodontic eruption (prior restoration, extraction, and implant or fixed partial denture placement).

Following fragment removal, the extent of the fracture line, as well as the shape and length of the remaining root will be the determinant for the multidisciplinary treatment approach. In patients with immediate or delayed extraction, a thorough skeletal and dental diagnosis facilitates selection of the most appropriate solution, which might include orthodontic, periodontal, or implant surgery, as well as subsequent restorative procedures.21-23

Luxations Concomitant to Crown Fractures

According to studies, luxation injuries (a dislocation of the tooth due to traumatic impact), can account for between 15% and 61% of dental trauma to permanent teeth.24 Luxation injuries can cause frequent complications in the crown or crown-root fractures, and may affect the periodontal structures and the blood supply of the pulp.24 As the impact incidence resulting in a crown fracture is more perpendicular than vertical, and since the energy of the trauma dissipates partly during the fracture process, slight to moderate luxations are the most frequently associated types of injuries. It must be stressed, however, that luxation injuries can be complicated by temporary or permanent loss of marginal alveolar bone support, which can greatly affect the prognosis of the luxated teeth.


Therapeutic difficulties caused by mutilated anterior teeth and traumatic loss, as well as the rising socioeconomic expense of dental trauma, reinforce the need to increase clinicians' knowledge of emergency primary dental care and the multidisciplinary approach in related restorative procedures. These restorative procedures provide predictable and functional aesthetic results that will subsequently enhance patient satisfaction, while improving the clinician's ability to provide optimum service and support.


*Senior Lecturer, Department of Cariology, Endodontics, and Pediatric Dentistry, University of Geneva, Geneva, Switzerland.

†Senior Lecturer, Department of Orthodontics, University of Geneva, Geneva, Switzerland.




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