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Crown fractures

How to manage crown fractures to primary teeth in children. Watch Susan Parekh explain more.
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Hello. So the first talk was talking about primary teeth and just thinking that general principles of management. This talk, I’m going to focus now on permanent teeth, and in particular thinking that crown fractures. So what are the principles we need to think about when we think about crown fractures, with permanent teeth? Really it’s all about reducing bacterial contamination. What we want is to try and stop bacteria getting into that pulp, so that we can allow the pulp to heal itself. And the pulp actually has a really good potential to heal itself, if we give it the right environments. So it’s about preventing further contamination.
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It’s about allowing continued root development, particularly if this is happening in a child with developing permanent incisor, still immature. And what it comes down to is about the seal. So endodontists love to say that seal is the deal. It’s all about getting a really good seal, because that will get the right environment for the pulp. And so we think really the seal gets the best environment in a composite restoration. So, as you can see in this image, here, trying to restore teeth with GIC is never going to work, long term, because you will end up with margins that leak. And then you’ll get bacterial contamination. And eventually that pulp will die.
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So you really want to make sure you’re getting composite on as soon as you can. Now, if they turn up as emergency appointment, and they’re very uncooperative, you may need to reboot back in and to do it with inhalation sedation and so on. Then you may, as a really temporary emergency measure, may have a couple of GICs. But you really want to get them back as soon as possible, because the longer the glass lonomer is on that tooth, more chances of having bacteria contamination and more problems pulp. The whole point is we want to get the pulp to heal itself and not have to go anywhere near it if possible.
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So the key factors we need to consider, the size of the exposure and the time since the injury. That’s going to give us some idea of how much bacteria contamination there’s been. Obviously a really big fracture, where you’ve got lots of exposed to dentinal tubules, will mean that you’ve got more likelihood of getting bacterial contamination. Likewise if it’s been a long time since the injury, and dentine has not been covered, higher chance of bacterial contamination. And then when we think about the pulp’s ability to heal itself, that really comes down to well is that tooth been open or closed.
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Is it immature or mature, because, obviously, if it’s an open apex immature tooth, it’s lots of blood vessels going through the apex. And so it’s got more of an ability to try and heal itself. And likewise, if that tooth is vital or non-vital. Clearly if the tooth is already non-vital then it’s not going to heal itself. The pulp is dead. So you’ve got to take all these factors into consideration. So that’s where that trauma history the when, where, the how, really helps, as well as sort of your sensibility tests and radiographs, to really get an idea what you’re looking through. So you can think about what is the prognosis for this tooth going to be.
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So let’s think about scenario with a child or young adult, here, and they’ve come with a fractured incisor. And I don’t know about you, but when I used to work in practise would, invariably happen at sort of quarter to 5 on a Friday or when I was on call over the weekend. So it’s one of those situations, where you may not see trauma for ages, and they’re a little bit like busses. You may get three in a week. So it’s sort of thing that you want to think about. Well, may not do this all the time. It may not be the best sort of timing. But I want to get the best management I can for this child.
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So things we need to consider is. Is the pulp exposed or not? And how soon can we get that composite restoration on there?
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Crown, in terms of if it’s a complicated crown fracture, so the pulp is involved, what we do, again, will depend on those factors we’ve talked about. What is the size of that exposure? How long since the injuries? How much bacterial contamination are we dealing with here? Is it an open or closed apex? And is that pulp vital? Because depending on those factors, it may be that if it’s a really small exposure, and it just happened, literally they fell outside, and they come into you. You may think, well actually risk of bacteria contamination is really low. I may do a direct pulp cap. Or it may be that you think, actually it’s got a wider exposure, or it’s been 24 hours.
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There’s going to be some bacterial contamination. I may have to do a partial or Cvek pulpotomy. And if you’re thinking further bacterial contamination, then you may need to think about a coronal pulpotomy, or what we call conventional pulpotomy, or maybe a low level pulpotomy. So really what you’re trying to do is work out how and when can I get to some vital healthy pulp? And the way that I know that, is because when I apply a cotton wool pledget, a sort of damp cotton wool pledget, for two to three minutes, I get bleeding, then hemostasis. So it stops bleeding, and I get hemostasis. So I know there’s some healthy pulp there.
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And that point, I stop, put my calcium hydroxide into my dentine, whatever you’re going to put, and then restore. And leave the rest of that pulp a chance to heal. But you can see how important it is where time comes of essence here. Because the sooner you can deal with that exposed pulp, the less invasive your method of dealing with it is going to be. And actually the easier it is, both for you and for the patient. So that’s why I don’t want to sit on it. If a. See an exposed pulp, deal with it straight away.
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Otherwise you’re in the land of pulpectomy and root canal treatment, which with a young child, with an immature apex, not always a lot of fun. So that’s dealing with the pulp. The next thing is a composite restoration. So we feel this really is the best solution. You’re going to get a much better bond with composite than you will with GIC or else. You really want to get a polymer. And also, I don’t know about you, but if my front tooth was broken, I would definitely want it to look like a tooth again, as soon as possible. So if you’ve got a– if you look at the image on the top, here, we’ve got this horizontal fracture there.
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No pulpal involvement, but clearly you can see it’s quite significant. Now, you could do this by hand, if you’re really fantastic with you composites. But you know, it takes a bit of time. You may have an anxious wiggly child in the chair. You want to get the best solution, as soon as possible. And I think we feel the crown forms really allow that, because you can wrap it over the enamel. Make sure you’ve got a nice good bond to increase the stability the composite. Invariably, for children, it’s usually shade A1. That’s kind of will cover you for most bases. And just by using crown form, you can actually rapidly put a composite on that looks nice looks, like the tooth.
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And it’s really easy, minimal polishing, if you trimmed it properly. So definitely, if you haven’t tried those before, do have a look at some videos on YouTube, or go onto the course and have a go. Because you will find it makes life so much easier. And just to show you, here’s as example from one of my colleagues. So even a minimal amount of tooth structure, you can build up with crown forms, and make it look pretty good. And I don’t know about you, but if I was going to do this free hand, it would take me an awfully long time. Wheras with the crown forms you can get very quick results, that look good. So summary.
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When it comes to fractures of the crown, it’s all about protecting the pulp. And so you want to make sure that, as soon as possible, you have a cover the dentine tubules with composite, because that’s going to give your tooth the best chance of survival. Thank you.

The next in our short series of videos covering dental trauma in children. In this video, Dr Susan Parekh looks into the management of crown fractures. Unlike primary teeth trauma, doing nothing is rarely an option.

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Paediatric Dentistry for Non-Specialists

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