Treatment outcomes after uncomplicated and complicated crown fractures in permanent teeth

Treatment Modalities of Uncomplicated Crown Fracture in Anterior Maxillary Permanent Teeth: A Systematic Review

AIM

Several treatment modalities have been used to restore crown fractures in case of uncomplicated crown fractures. Although many treatment modalities have been reported, there is no consensus on which one has the best results in terms of success and durability. This systematic review of treatment modalities in uncomplicated crown fractures aims to provide the most common and successful treatment modality for each patient's unique needs, balancing conservation, aesthetics, and long-term durability.

MATERIALS AND METHODS

Three electronic databases (PubMed, Scopus, and Google Scholar) were searched for articles regarding treatment modalities in uncomplicated crown fractures in anterior maxillary teeth.

RESULTS

Following the application of the inclusion and exclusion criteria, 10 case reports, four case series, and two retrospective studies were selected for the review. These studies reported on fragment reattachment, direct composite resin, and veneers for the management of uncomplicated crown fractures. Fragment reattachment was the most preferred treatment modality, with milk, water, or sterile saline used as storage mediums. Direct composite restoration was preferred for missing or bad-shaped fragments or longevity. Veneers were given for aesthetic consideration and fracture resistance when the crown structure was majorly affected by the fracture. Fragment reattachment was favored in 63% of the articles included in the review followed by direct composite restoration in 26% of the articles. Venners were used in about 11% of the articles. Composites depicted a higher survival rate and a better outcome than fragment reattachment. Follow-up periods ranged from 1 week to 4 years, and all articles successfully re-established function and aesthetics, except for one tooth that required root canal treatment.

CONCLUSION

Fragment reattachment, direct composite restoration, and veneers are successful treatment modalities in uncomplicated crown fractures of anterior teeth. The choice of treatment depends on various factors like availability of fragments, age, and financial condition of the patient.

TRIAL REGISTRATION

PROSPERO Registration ID: CRD42020153091.

The risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment: a systematic review and meta-analysis

PURPOSE

To identify the factors affecting the risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment.

METHODS

The study protocol followed the best practices of evidence-based medicine and was registered in PROSPERO. A comprehensive literature search was performed electronically in six databases (PubMed, Embase, SCOPUS, Web-of-Science, Lilacs, and Cochrane) on 18-09-2023. It was saved in EndNote-online and duplicates were removed. Selection of articles was performed in two stages, followed by data-extraction, risk of bias assessment, data-analysis, and meta-analysis. The quality of evidence for the outcomes was assessed by the GRADE-approach.

RESULTS

The study included six articles that had similar selection protocols with variations in duration from trauma to treatment and the observation period. Only one study employed pre-attachment fragment preparation and three performed post-attachment reinforcements. Overall loss of fragment was 20% (95%CI-13,30%). When the risk ratio for loss of restoration or fragment was compared, it was found to be 2.21 (95%CI-1.52,3.21) in uncomplicated crown fractures, 2.54 (95%CI-1.35,4.79) in complicated crown fractures. The risk of bias was found to be low in two and moderate in four studies. Grade of evidence for all the outcomes was very low.

CONCLUSION

Fragment loss was lowest in uncomplicated crown fractures where reinforcement had been performed, and highest when bonding was done in complicated crown fractures without reinforcement. The risk of fragment loss was higher than the loss of composite restorations.

Treatment outcomes of permanent teeth with uncomplicated and complicated crown fractures and factors associated with pulp survival: A retrospective study

BACKGROUND

Crown fracture is the most common injury in permanent teeth. This study aimed to evaluate the treatment outcomes of permanent teeth with uncomplicated and complicated crown fractures and to investigate potential factors.

MATERIALS AND METHODS

This retrospective study included patients who experienced crown fractures in permanent teeth from 2018 to 2021 with at least 12 months of follow-up. All complicated crown fractured teeth were treated with pulpotomy, while for teeth with uncomplicated crown fractures, three treatments (restoration, indirect pulp capping, or pulpotomy) were employed. The chi-square test was used to compare the prognosis of teeth with uncomplicated and complicated crown fractures. Potential factors associated with pulp survival including gender, interval, root development, enamel infraction, mobility, concomitant luxation injury, treatment, and coronal restoration were identified via Cox regression analysis.

RESULTS

A total of 307 teeth from 220 children (average age = 9.3 ± 1.4 years; age range, 6-14 years) with a median follow-up of 23 months were included, and 82.1% of all teeth had immature roots. Complicated crown fractured teeth (93.6%, 102/109) had a significantly higher success rate compared with uncomplicated crown fractured teeth (85.4%, 169/198) (p < .05). Pulpotomy (96.9%) had the highest success rate of all treatments for uncomplicated crown fractures, followed by only restoration (85.0%) and indirect pulp capping (76.9%). The success rate of teeth that received pulpotomy was significantly higher than those treated by indirect pulp capping (p < .05). In uncomplicated crown fractures, teeth with Class II mobility were more vulnerable to failure than teeth without abnormal mobility (HR = 34.83; 95% CI, 9.59-126.56; p < .05); teeth that received pulpotomy were less prone to failure than teeth that received indirect pulp capping (HR = 13.53; 95% CI, 1.58-115.72; p < .05).

CONCLUSION

Crown fractures treated with conservative pulp treatments had a relatively highly favorable prognosis. The prognosis of uncomplicated crown fractured teeth was impacted by the severity of periodontal injury and treatment strategies. Accurate diagnosis and identification of micro-exposures are important. Dentists should take multiple risk factors into account and select optimal treatment strategies.

An assessment of Brazilian dentists' knowledge about tooth fragment reattachment: A cross-sectional study

BACKGROUND/AIM

Crown fractures are common traumatic dental injuries and tooth fragment reattachment is a viable option for restoring a fractured tooth. The aim of this study was to assess the knowledge and experience of dentists in the Federal District regarding the tooth fragment reattachment technique for enamel and dentin fractures.

MATERIALS AND METHODS

For the cross-sectional observational study, an electronic form was designed with objective and self-report questions for dentists. The data were analyzed using descriptive statistics, with their absolute and relative frequencies. For the analysis of categorical variables, the nonparametric chi-squared or Fisher exact association tests were used in the statistical software R (version 4.2.1).

RESULTS

A total of 416 dentists participated in the study (58.9% female and 41.1% male). Of these, 70% declared they knew about fragment reattachment, but only 42.3% reported previous experience with this procedure. The most common storage medium used for the fractured fragment was milk (78.1%), and the bonding material used for reattachment was light-cured composite resin (86.3%). A majority (66.3%) reported that for a patient with enamel and dentin fracture, with the crown fragment in good condition, they would choose to do the reattachment.

CONCLUSION

Dentists demonstrated that they had adequate knowledge about the tooth fragment technique, although many did not have previous experience with this procedure.

Epidemiological profile of luxations injuries with or without dental fractures in permanent teeth: A 10-years retrospective study

BACKGROUND/AIM

This study assessed the epidemiology of luxation injuries with or without dental fractures in patients attending the outpatient clinic of a Brazilian dental school over the past decade.

MATERIAL AND METHODS

We reviewed clinical records from a specialized center for dental trauma care in Brazil, focusing on patients who experienced at least one traumatic dental injury (TDI) in a permanent tooth between 2012 and 2022. The extracted data included sex, age, etiology, time between trauma occurrence and the search for initial care, TDI classification, and the need for endodontic treatment. The statistical analysis involved Pearson's chi-squared and Fisher's exact tests at a 5% significance level.

RESULTS

The 366 analyzed clinical records included 166 patients (350 teeth) with luxation injuries. Men (n = 102) showed a higher prevalence of luxation injuries than women (n = 64). Extrusive luxation prevailed (n = 99 patients and 208 teeth). Patients with luxation injuries sought care promptly after dental trauma incidents (p = .02) and demonstrated a higher incidence of endodontic treatment (p < .0001) than those without luxation injuries. Lateral luxation was notably associated with traffic accidents (p < .0001). The combination of luxation injuries and tooth fractures did not correlate with a higher need for endodontic treatment (p > .05).

CONCLUSIONS

Age and trauma etiology seemed to have influenced the epidemiological profile of luxation injuries. Additionally, these injuries affected the time to seek initial care and the need for endodontic treatment.

[Application of bioactive ceramics iRoot BP Plus® in pulpotomy for complicated crown fracture of immature permanent anterior teeth in children]

OBJECTIVE

To analyze the clinical and radiographic effectiveness of a calcium silicate-based bioactive ceramic iRoot BP Plus® pulpotomy of immature permanent teeth with complicated crown fracture and to evaluate the factors influencing its long-term success rate.

METHODS

The digital medical records of patients under 13 years old who had undergone iRoot BP Plus® pulpotomy in the Department of Oral Emergency or the First Clinical Division, Peking University School and Hospital of Stomatology from March 2017 to September 2022 due to complicated crown fracture of anterior teeth, and had taken at least one post-operation apical radiograph were reviewed. The clinical and radiographic information at the initial examination and follow-up period were obtained, including crown color, mobility, percussion, cold test (partial pulpotomy teeth), dental restoration, fistula, swelling or inflammation of the gingival tissue, the formation of apical foramen, pathologic radiolucency and calcification of pulp chamber or root canal obliteration. Data were tested by Fisher exact test and a multiple comparison.

RESULTS

In the study, 64 patients including 37 males (57.8%) and 27 females (42.2%) with a mean age of 9.1 years : ere finally enrolled. The total number of permanent teeth that received pulpotomy was 75, and the average follow-up time was 19.3 months. The success rate was 93.1% with the time interval between dental injury and treatment in 24 h, while the success rate dropped to 88.2% with the time intervals beyond 24 h. The time intervals did not significantly affect the pulp survival rate (P=0.61) after pulpotomy (partial or coronal). The success rate 6 months after pulpotomy was 96. 0%, and one-year success rate was 94. 7%. A total of 23 cases were reviewed for more than 2 years after pulpotomy, and 6 cases failed. The mobility had no significant effect on the success rate (P=0.28). Pulp chamber calcification and pulp canal obli-teration were not observed in all the post-operative radiographs.

CONCLUSION

The one year clinical and radiographic success rates obtained in this study indicate that iRoot BP Plus® is an appropriate pulp capping material option for pulpotomy treatment of complicated crown fracture in immature permanent teeth without displacement injuries. This technique has broad promotional value.

Survival analysis of fragment reattachments and direct composite restorations in permanent teeth after dental traumatic injuries

BACKGROUND/AIM

In case of crown fractures after traumatic dental injuries, the affected teeth can be restored either with reattachment of the fractured fragment or with a direct composite restoration. So far, longevity data for reattachments and direct composite restorations with regard to different failure types (pulp necrosis and infection, restoration loss) are scarce. Therefore, the aim of this retrospective study was to evaluate the restorative and biological survival of reattached fragments and composite restorations after crown fractures in permanent teeth.

MATERIAL AND METHODS

Dental records of patients treated between 2000 and 2018 were retrospectively analysed regarding the restoration (reattachment or direct composite restorations) of teeth with crown fractures. Survival (no further intervention) and restorative and/or biological failure of all restored teeth were recorded. Statistical analysis was performed using Kaplan-Meier statistics, and the mean annual failure rates for two and 5 years were calculated. Furthermore, the effect of potential risk factors on survival was assessed. Log-rank tests and univariate Cox regression models (likelihood ratio tests) were used to assess the univariate effect of all variables of interest. Variables with a p-value ≤.10 were included in a multivariate Cox regression model with shared frailty (p < .05).

RESULTS

Overall, 164 patients with 235 teeth (uncomplicated crown fracture: N = 201, complicated crown fracture: N = 34) were included (1.6 ± 2.5 years observation time). Of these, 59 teeth were restored with reattachment of the fragment and 176 with a composite restoration. Overall, composite restorations had a significantly higher survival rate than reattachments (p = .002). The cumulative survival after 2 years was 42.9% and 65.0% for teeth treated with a reattachment (mAFR = 34.5%) and a composite restoration (mAFR = 19.3%), respectively. When differentiating between failure types, restoration failure and pulp necrosis were significantly more frequently detected in reattached crown fractures compared to composite restorations (restorative failure: p = .001; biological failure: p = .036). In the multivariate Cox regression model, the variable jaw and luxation significantly influenced the survival when the tooth was restored with a composite restoration. The survival was not influenced by the fracture type.

CONCLUSIONS

Restorative and biological failures were more frequently detected when the tooth was restored with a reattached fragment compared to a direct composite restoration. Both, restoration failure and pulp necrosis with infection should be considered as frequent complications after restoration of crown-fractured teeth which emphasizes the necessity of regular and short follow-up intervals throughout the first 2 years.

Retrospective analysis of the outcomes of pulpotomies in traumatised permanent anterior teeth

BACKGROUND/AIM

Complicated crown fractures are frequently encountered in the paediatric population and pulpotomy procedures (either partial or coronal) are recommended to maintain the pulp. The aim of this study was to determine the pulp outcomes of permanent teeth with complicated crown fractures treated with pulpotomy in a hospital-setting and to identify potential factors which may influence the outcomes.

MATERIAL AND METHODS

Data for this retrospective study were extracted from dental records of patients with complicated crown fractures and treated with pulpotomies at a single centre between 1 January 2015 and 30 August 2019. Pulp outcomes were determined, and the associations between the outcome and independent variables were assessed using the Chi-Square test of independence and the Point-Biserial Correlation Test. Predictors of outcome were identified using the binary logistic regression model.

RESULTS

The overall success of pulpotomy in managing traumatised permanent teeth was 61%, which was lower than those previously reported. Pulp healing was seen in 54.1% and 73.7% of teeth treated with partial pulpotomies and coronal pulpotomies, respectively. The presence of a radiographically detectable dentine bridge (p < .01) and longer clinical experience of the clinician (p < .04) was significantly associated with successful outcomes. The history of pain and the stage of root development were identified as significant predictors of the outcome.

CONCLUSION

Pulpotomy is a viable treatment modality for complicated crown fractures in the paediatric population. However, appropriate case selection and further training may be required to ensure improved pulp healing outcomes. A longer follow-up period should be considered to identify late-stage complications.

Present status and future directions: Endodontic management of traumatic injuries to permanent teeth

The prognosis of traumatized teeth depends largely on the fate of the pulp and its treatment. This review aims to update the present status on the endodontic management of traumatic injuries to permanent teeth and to identify relevant research areas that could contribute to an improvement in diagnosis and treatment of traumatized permanent teeth. Future research should pay greater attention to (1) diagnostic methods to assess the perfusion of the pulp and enhance detection of tooth cracks and initial signs of root resorption; (2) improved materials for vital pulp treatment; (3) studies focusing on type and duration of splinting after root fractures; (4) antiresorptive intracanal medication in case of posttraumatic pulp necrosis and infection-related resorption and (5) long-term data on the apical barrier technique compared to revitalization.

Treatment Outcomes of Permanent Immature Teeth with Crown Fracture: A Retrospective Cohort Study

INTRODUCTION

Crown fractures are a common type of traumatic dental injury. Various factors may affect the outcome of crown fractures. This study aimed to evaluate the treatment outcomes of immature teeth with a crown fracture.

METHODS

This retrospective cohort study included patients who presented to a dental trauma center from 2008-2018 with a history of a crown fracture of immature teeth and at least 6 months of follow-up. Outcomes of primary endodontic or restorative interventions as well as reinterventions were evaluated. Kaplan-Meier curves were used to compare the unadjusted differences in survival time. Logistic and Cox regression analyses were performed to identify potential predictors for complication and survival time, respectively.

RESULTS

The success rates of the primary interventions for 99 teeth (72 patients) after a median follow-up of 22 months were as follows: cervical pulpotomy (90.4%), partial pulpotomy (85.2%), mineral trioxide aggregate apical barrier (80.0%), root canal treatment (66.6%), and only restoration (47.2%). Teeth that received vital pulp therapy were less prone to complications (adjusted hazard ratio = 0.21; 95% confidence interval, 0.09-0.53; P < .05), whereas those with concomitant luxation injuries were more susceptible to complications (adjusted odds ratio = 2.90; 95% confidence interval, 1.01-8.29; P < .05).

CONCLUSIONS

Crown fractures had a relatively high favorable prognosis. Vital pulp therapy (partial or cervical pulpotomy) had the highest success rate, whereas cases that received only restoration had the lowest success rate. Teeth with concomitant luxation injuries had more odds and hazards of complications.

Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The aim of this systematic review was to evaluate the existing randomized controlled trials (RCTs) on the safety and efficacy of vital pulp therapy (VPT) and to analyze the outcomes of VPT performed with a variety of pulp-capping materials and techniques.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and gray literature were searched (January 2000-March 2021). Study selection and data extraction were performed in duplicate. Eligible RCTs were critically appraised for risk of bias and quality of evidence and were meta-analyzed to estimate the treatment effects.

RESULTS

Fourteen studies were included. The pooled success rate of VPT using contemporary capping materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials (CSMs) was 93.2% (95% confidence interval [CI], 91.6%-94.9%). Multiple subgroup analyses by different etiologies, procedure types, developmental stages of teeth, and preoperative diagnoses were performed. Analyses presented low certainty of evidence. No significant difference was noted between MTA and CSM at 12 months or a longer follow-up (risk ratio = 0.99; 95% CI, 0.95-1.03) with low certainty of evidence. Laser-assisted VPT failed to show significantly better outcomes than conventional VPT (risk ratio = 1.19; 95% CI, 0.99-1.49) with very low certainty of evidence.

CONCLUSIONS

When MTA or CSM was used as a capping material, VPT was 93% successful. The techniques, etiologies, developmental stages of teeth, and preoperative diagnosis had no significant influence on treatment outcomes. No major adverse effects (except discoloration associated with the use of MTA) were identified. The overall quality of evidence was low.

Complex Implant-Prosthetic Rehabilitation Following Sports Trauma with 14 Years of Follow-Up: Case Report

Tooth loss after traumatic dental injuries (TDI) often requires rehabilitation with a multidisciplinary treatment plan. In growing patients, the therapeutic approach may be different than in adults; the scientific literature offers alternative solutions even if they involve long, complex and uncomfortable treatments. Among the possible therapeutic options, implant-prosthetic treatment through the use of mini-implants is presented in this complex case report with a 14-year follow-up.