Management of complicated crown fracture with pulpotomy and fragment reattachment [Dr. VJ]

 A 9 year-old patient was referred for endodontic management of her traumatised tooth 21.  The patient was accidentally hit in the face by a cricket bat which had resulted in a complicated crown fracture.  She had sought emergency management on the day, with the pulpal wound disinfected and temporised with GIC by her referring dentist and was subsequently referred.  The fractured coronal fragment was stored in milk and I saw her three days later for her ongoing care.

Clinical examination revealed that the patient was asymptomatic with tooth 21 found to be responding normally to pulp testing.  The tooth was found to have complete root development but immature root maturation with thin axial root walls and a wide canal system.  All adjacent and lower incisor teeth were found to be responding normally to pulp and percussion testing. 

Considering the nature of her trauma and the patient’s age, a decision was made to attempt a pulpotomy procedure to try to preserve the radicular pulp tissue to facilitate further root maturation.  Under rubber dam isolation, the existing GIC provisional was carefully removed down to the fracture line and a 2mm pulpotomy performed of the exposed coronal pulp tissue.  The pulp stump was irrigated with NaOCl/EDTA to facilitate debridement, disinfection and haemostasis of the pulpal wound.  Hard-setting Ca(OH)2 (Dycal) was used over the pulpal wound and this was covered by a layer of RMGIC (Vitrebond). The fractured coronal fragment was subsequently reshaped and rebonded over the pulpotomy using microhybrid flowable composite resin, resulting in a pleasing aesthetic outcome.

                            Maya1     Maya2

  • Pre-operative and post-treatment PAs of tooth 21 following calcium hydroxide pulpotomy and reattachment of coronal fragment.

 

     Maya6 Maya7 Maya8

  • Clinical images taken during pulpotomy procedure of tooth 21 prior to fragment reattachment: (a) following removal of provisional restoration showing hyperaemic coronal pulp; (b) following pulpotomy – disinfection/heamostasis achieved; (c) following Ca(OH)2 and GIC placement.

 

                       Maya5 

  • Clinical image of fractured coronal fragment which was reshaped and recontoured prior to rebonding procedure.

 

  Maya4 Maya3

  • Pre-operative and post-treatment clinical images of tooth 21 following calcium hydroxide pulpotomy and reattachment of coronal fragment.  Pleasing aesthetic outcome achieved.

 The patient and her parents have been informed of possible long-term complications and the possibility of further treatment in the future, but at this stage, I am hopeful that we are able to maintain pulp vitality and facilitate ongoing root development. I have also advised on trauma prevention strategies and the use of a custom-fitted mouthguard as a preventive measure when playing sports.

 

Calcium hydroxide pulpotomies have been well documented as a predictable procedure in managing complicated crown fractures following trauma (Cvek (1978), Andreason and Andreason (2007)).  In recent years, Mineral Trioxide Aggregate (MTA) has been advocated as being an alternative material for such cases due to its favourable biocompatibility, sealing and dentinogenic properties.  While MTA does possess some very beneficial biologic properties, a significant issue with its use in such cases is its tendency to result in discoloration of the surrounding tooth structure, even with the use of white MTA (see case below).

        MTA pulp1 MTA pulp2 

  •  Clinical images following white MTA pulpotomy and coronal fragment reattachment post-treatment and at 1 year review showing progressive cervical discolouration as a result of MTA.

 

Calcium hydroxide pulpotomies have been well documented as a sound procedure in such cases prior to MTA being available.  Cvek (1978) reported a 96% success of mature and immature teeth treated with partial pulpotomy and capping with calcium hydroxide for traumatic exposures. The interval between accident and treatment varied from 1 hour to 90 days. Traditional calcium hydroxide pulpotomies do not lead to excessive discolouration, which is an important consideration in the management of traumatic injuries in the aesthetic zone. 

Dr. Vijay John