Management of crown-related fractures in children: an update review

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.

Endodontic management of submerged roots following complicated traumatic dental injury (TDI) in children and adolescents: A systematic review

INTRODUCTION

The International Association of Dental Traumatology (IADT) guidelines include the use of decoronation for the management of complex crown-root fractures but do not outline how this technique is best employed. The aim of this review is to reach a consensus in the management of the root canal system in decoronated permanent teeth undergoing root submergence and to determine whether this has an impact on the success and survival of the retained root.

MATERIALS AND METHODS

Search included databases MEDLINE via Ebsco, EMBASE via Ovid, Web of Science via Clarivate, PubMed via PubMed.gov, the Cochrane Library via Wiley, cited reference searching and hand searching of relevant journals. Two independent reviewers performed study selection, data extraction and risk of bias assessment using Joanna Briggs Institute (JBI) Critical Appraisal Checklist.

RESULTS AND DISCUSSION

In total, 18 articles were included in qualitative analysis: 17 of these were case reports and one case series. A total of 37 teeth were treated with decoronation either using the Malmgren or an alternative protocol (root submergence following endodontic treatment with gutta-percha [GP] or a calcium silicate cement and vital root submergence). Limited evidence from this review suggests that immediate decoronation and vital root submergence are successful in apexogenesis and preserving alveolar bone. This systematic review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO: registration number CRD42022316266).

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.

Crown Fracture of an Unerupted Incisor in a Young Child: Case Report and Restorative Protocol

Aim

This case report describes a protocol for restoring a crown fracture of an unerupted permanent incisor in a child.

Background

Crown fractures are an important concern in pediatric dentistry due to the negative impact on oral health-related quality of life (OHRQoL) in children and adolescents resulting from functional limitations as well as consequences related to social and emotional well-being.

Case description

An enamel and dentin fracture of the crown of unerupted tooth 11 due to direct trauma is being presented in a 7-year-old girl. The restorative treatment involved minimally invasive dentistry, including computer-aided design (CAD)/computer-aided manufacturing (CAM) technology and direct resin restoration.

Conclusion

The treatment decision was essential for maintaining pulp vitality and continued root development, as well as ensuring esthetic and functional results.

Clinical significance

Crown fracture of an unerupted incisor may occur in childhood, requiring a long-term clinical and radiographic follow-up. Predictable, positive, and reliable esthetic outcomes can be achieved using CAD/CAM technology combined with adhesive protocols.

How to cite this article

Kamanski D, Tavares JG, Weber JBB, et al. Crown Fracture of an Unerupted Incisor in a Young Child: Case Report and Restorative Protocol. Int J Clin Pediatr Dent 2022;15(5):636-641.

Novel trends, challenges and new perspectives for enamel repair and regeneration to treat dental defects

Dental enamel is the hardest tissue in the human body, providing external protection for the tooth against masticatory forces, temperature changes and chemical stimuli. Once enamel is damaged/altered by genetic defects, dental caries, trauma, and/or dental wear, it cannot repair itself due to the loss of enamel producing cells following the tooth eruption. The current restorative dental materials are unable to replicate physico-mechanical, esthetic features and crystal structures of the native enamel. Thus, development of alternative approaches to repair and regenerate enamel defects is much needed but remains challenging due to the structural and functional complexities involved. This review paper summarizes the clinical aspects to be taken into consideration for the development of optimal therapeutic approaches to tackle dental enamel defects. It also provides a comprehensive overview of the emerging acellular and cellular approaches proposed for enamel remineralization and regeneration. Acellular approaches aim to artificially synthesize or re-mineralize enamel, whereas cell-based strategies aim to mimic the natural process of enamel development given that epithelial cells can be stimulated to produce enamel postnatally during the adult life. The key issues and current challenges are also discussed here, along with new perspectives for future research to advance the field of regenerative dentistry.

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.

Intentional replantation and Biodentine root reconstruction. A case report with 10-year follow-up

AIM

To describe the innovative use of intentional replantation for Biodentine root reconstruction of a previously treated immature maxillary central incisor with vertically extended crown root fracture and root detachment.

SUMMARY

In the present case, the intentional replantation of a failing, previously treated maxillary central incisor with a vertical crown/root fracture in a 12-year-old male patient is reported. The gross extrusion of gutta-percha points beyond the apex and the pre-existing extensive, trauma related, distal cervical dentinal detachment justified the intentional replantation treatment plan as an option for tooth retention. After controlling the infection by oral administration of antibiotics, the immature tooth was extracted atraumatically and kept in gauze embedded with tooth replantation medium. The apical third of the immature fractured tooth was treated with ultrasonics and an MTA plug (MTA Angelus White, Londrina, Brazil). The distal cervical dentinal root defect was reconstructed with Biodentine (Septodont, St. Maur-des-Fosses, France). The tooth was reinserted and stabilized to the adjacent teeth for 2 weeks. The total extraoral time before replantation was 25 min. In the 10 years since the initial trauma (9 years after the intervention) radiographic and clinical evaluation revealed uneventful healing of the periapical lesion, normal mobility and no detectable signs of external replacement resorption.

KEY LEARNING POINTS

Intentional replantation may provide a viable treatment alternative in cases of severe complicated crown/ root fractures Biodentine may be useful in the reconstruction of external root defects in crown root fractured traumatic dental injuries.

Treatment outcomes after uncomplicated and complicated crown fractures in permanent teeth

OBJECTIVES

The objectives of this retrospective clinical study were to describe characteristics of crown fractures in permanent teeth and to investigate the survival of pulp vitality and restorations in uncomplicated and complicated crown fractures.

MATERIALS AND METHODS

This retrospective study collected information from patients suffering from dental trauma who were treated between January 2004 and June 2017. The study population consisted of 434 patients (253 males/181 females; mean age 20.7 years) with 489 uncomplicated and 127 complicated crown fractures. The Kaplan-Meier survival curves and Cox proportional hazard regression analyses were performed to explore the data statistically.

RESULTS

The mean observation time was 522 days. Uncomplicated crown fractures without luxation showed a higher success rate of 82.3% (345/419) than complicated crown fractures without luxation (72.3%, 73/101). An additional luxation in uncomplicated crown fractures resulted in significantly reduced success rates in terms of survival of the pulp and restoration. Direct restorations survived significantly better independent of the fracture mode than did adhesively reattached crown fragments. No superiority of mineral trioxide aggregate or calcium hydroxide as pulp capping agent in complicated crown fractures was documented. Approximately 85.5% of all complications occurred within 2 years after the accident.

CONCLUSION

The treatment of crown fractures resulted mostly in successful outcomes and only a moderate number of complications were observed.

CLINICAL RELEVANCE

Primary dental management of crown fractures should follow recently published clinical guidelines, and close monitoring over at least 2 years seems to be justified.

Teeth: Small but Mighty and Mighty Important. A Comprehensive Review of Children's Dental Health for Primary Care Clinicians

Healthy teeth allow us to eat and stay well-nourished. Although primary care clinicians receive limited training about teeth, given the common nature of dental problems, it is important that they understand and recognize normal and abnormal dental conditions and can implement primary and secondary prevention of dental conditions in their practice. PubMed has been used to search the scientific literature for evidence on the following topics: normal dental development, dental abnormalities, malocclusion, teething, dental caries and related epidemiology and prevention, fluoride, dental injury and its management and prevention; and identification, prevention and treatment of gingivitis and periodontal disease. Literature review relied on randomized controlled trials, meta-analyses, systematic reviews, and Cochrane reviews when relevant and available. Other sources of evidence included cohort and case-control studies. Consensus statements and expert opinion were used when there was a paucity of high-quality research studies. The literature has been synthesized on these topics to make them relevant to pediatric primary care clinicians, and as available, the strength of evidence has been characterized when making clinical recommendations.

Italian guidelines for the prevention and management of dental trauma in children

Dental trauma is a frequent occurrence in children and adolescent and a correct diagnosis and treatment are essential for a favourable long-term prognosis. The present Guidelines aim to formulate evidence-based recommendations to assist dentists, paediatricians, surgeons, teachers, school and sport staff, parents in the prevention and first aid of dental trauma in children and to provide a careful assessment of the medico-legal implications, reviewing the first draft of the guidelines published in 2012. A multidisciplinary panel on the behalf of the Italian Ministry of Health and in collaboration with the WHO Collaborating Centre for Epidemiology and Community Dentistry of Milan, developed this document. The following four queries were postulated: 1) Which kind of precautions the health personnel, parents, sports and educational personnel must activate in order to prevent the dental trauma damage? 2) How an orofacial trauma in paediatric patients should be managed either in the Emergency Care Unit and/or in private dental office? 3) What criteria should be adopted by a dentist private practitioner to fill in a certificate in cases of dental and/or tempomandibular joint trauma occurring in children and adolescents? 4) What are the elements that should lead clinicians to suspect a non-accidental dental trauma? A systematic review and analysis of the scientific literature published in English, Italian and French from 2007 to 2017 regarding dental trauma in children and adolescents aged 0-18 years was performed, and about 100 papers were analysed and included. The following four domains were analysed and discussed: Dental Trauma Prevention Strategies and Health Education, First aid in orofacial and dental trauma, Certificate of the dental trauma, Oral and dental signs of child abuse and neglect. Twenty-eight recommendations were draw up and codified by the panel according to the Methodological handbook, produced by the Istituto Superiore di Sanità, in order to guide physicians in the prevention and first aid of dental trauma in children and adolescents. In addition, a careful assessment of the medico-legal implications is reported in this document.

The effect of enamel fractures on oral health-related quality of life in adolescents

BACKGROUND/AIM

Enamel fractures are the most common type of traumatic dental injury (TDI) in children and adolescents. Recognizing the impact of these fractures on oral health-related quality of life (OHRQoL) could contribute to the establishment of treatment protocols. The aim of this study was to assess and quantify the impact of enamel fractures on overall OHRQoL and domain scores in adolescents.

MATERIALS AND METHODS

A cross-sectional study was conducted with 775 adolescents aged 11 to 14 years in the city of Santo Ângelo in southern Brazil. Sociodemographic variables were collected from parents/caregivers using a structured questionnaire. The adolescents answered the Child Perceptions Questionnaire (CPQ_11-14 ). Physical examinations were performed by an examiner who had undergone training and calibration exercises for the investigation of TDI (Andreasen criteria), dental caries (WHO criteria), and malocclusion (Dental Aesthetic Index). Data analysis involved Poisson regression with robust variance.

RESULTS

The prevalence of TDI was 11.9% and enamel fractures accounted for 79.3% of all injuries. In the multivariate analysis, adolescents with enamel fractures had 29% higher CPQ_11-14 scores (worse OHRQoL) than those without TDI, even after adjustment for sociodemographic and clinical variables (mean ratio = 1.29; 95% CI: 1.09-1.53; P = .003). Enamel fractures exerted a negative impact on the functional limitation, emotional well-being, and social well-being domains.

CONCLUSIONS

Enamel fractures exert a negative impact on the OHRQoL of adolescents, suggesting that subjective measures should be incorporated in the evaluation of patients with this traumatic injury.

Long-term results of crown fragment reattachment techniques for fractured anterior teeth: A retrospective case-control study

OBJECTIVE

Among the techniques used by pediatric dentists for the crown fracture is the fragment reattachment. The aim of this study was to evaluate the long-term survival of the tooth reattachment in comparison to the composite restoration technique.

METHODS

The study included 67 patients aged 7-9 years (males 38/56.7%; females 29/43.3%), with noncomplicated fractures of permanent teeth. The patients were divided into two groups; group A included 32 patients (males 18/56.2%; females 14/43.8%; total number of affected tooth 36), and group B comprised 35 patients (males 20/57.1%; females 15/42.9%; 36 affected tooth). In group A patients the reattachment was conducted after the trauma, and the direct composite restoration technique was used for patients in group B. All patients were evaluated for complications and pulp status for 5 years.

RESULTS

There were no significant differences (P > 0.05) in terms of the occurrence of complications observed between groups throughout the 5-year observation period.

CONCLUSION

Both methods provide similar results over the 60 months of observation.

CLINICAL SIGNIFICANCE

Reattachment technique has shown to be a reliable treatment option that might be considered as a primary technique when the fragment is saved after the trauma.

Prevalence of Anterior Dental Trauma and Its Associated Factors among Preschool Children Aged 3-5 Years in Khartoum City, Sudan

Background

Traumatic dental injury (TDI) is a challenging public health problem. Its incidence and prevalence vary within countries, states, and different social groups.

Aim

The purpose of this study was to determine the prevalence of traumatic dental injuries in primary incisors among 3–5-year-old Sudanese preschool children and associated factors such as age, sex, and size of overjet and anterior open bite.

Materials and Methods

Descriptive cross-sectional study was carried out among 600 preschool children (3–5 years old) selected by multistage cluster technique from preschools located in Khartoum city, Sudan. The data regarding age, sex, causes, and treatment of TDI were collected from the mothers through structured interview questionnaire. Children were examined in an upright position, using mouth mirror and torch. A single examiner assessed the type of trauma, the tooth involved, and overbite/overjet. The data were analyzed statistically through descriptive analysis, and the chi-square test was used to compare between different variables with P < 0.05.

Results

The prevalence of traumatic dental injuries (TDIs) was 18.5%. Enamel fractures were the most common type (74.8%), followed by enamel and dentin (11.7%). The maxillary central incisors were the most commonly affected teeth, and the home was most common place for TDI. The prevalence rate was 45% in boys and 55% in girls with a statistically significant difference (P=0.02).

Conclusions

The prevalence of traumatic dental injuries to the primary anterior teeth among the Sudanese preschool children was relatively high (18.5%). Factors such as overjet size, overbite size, and lip competency were not significantly correlated with dental trauma among the studied population.

Treatment of subluxation injury concomitant with coronal fracture: A case report

Traumatic dental injuries are not only a serious public health problem, but they are also the most common injuries among children according to the epidemiological data. Subluxation is defined as the loosening of a tooth without displacement. Coronal fractures are the most common injuries. Considering the treatment options, which are suitable for the concomitant occurrence of these two traumatic injuries, there are only limited number of studies in the literature. In the concomitant occurrence of these two trauma types, like in other traumatic injuries, if the treatment is not implemented timely, long-term problems may develop. The objective of this case report was to describe the therapeutic approach to the subluxation concomitant with a coronal fracture.

The Emergency Treatment of Traumatised Permanent Anterior Teeth in Children and Adolescents

This article aims to provide a practical clinician's guide to assessing and diagnosing dental trauma involving permanent teeth in children and young people, and for carrying out appropriate, guideline supported acute management. Timely referral to specialist paediatric dental services is crucial in more complex trauma presentations and will lead to improved outcomes for the dentition. Appropriate acute management by the primary clinician optimises the prognosis of any traumatised tooth and this article will focus on the emergency treatment of the traumatised permanent tooth.

Pulp prognosis following conservative pulp treatment in teeth with complicated crown fractures-A retrospective study

BACKGROUND/AIM

Complicated crown fractures are relatively common in children where the maintenance of the pulp is especially important in young permanent teeth. The aim of this study was to analyze the pulp prognosis of permanent teeth with complicated crown fractures treated with conservative pulp treatment in adolescents.

MATERIAL AND METHODS

Complete dental records of teeth with complicated crown fractures treated with conservative pulp treatment were obtained. The risk of pulp necrosis and infection was evaluated by the Kaplan-Meier method and Cox regression (P<.05). Risk factors included gender, age, time interval between dental injury and treatment, stage of root development, type of pulp treatment, and coronal restoration.

RESULTS

The study involved 375 teeth treated with direct pulp capping, partial or coronal pulpotomy, and direct pulp capping retreated by pulpotomy (partial or coronal). The frequency of pulp necrosis and infection was 10.1% (11/109) for partial pulpotomy and 9.8% (22/205) for coronal pulpotomy. There was no difference between partial and coronal pulpotomy (P=.673). The risk of pulp necrosis and infection was not significantly different between pulpotomy (partial and coronal; 33/314, 10.5%) and retreatment by pulpotomy (partial or coronal) after direct pulp capping (2/33, 6.1%; P=.436). However, the frequency of pulp necrosis and infection after direct pulp capping (16/28, 57.1%) was significantly higher than that with pulpotomy (partial or coronal; odds ratio=8.216, P<.001). The time interval between dental injury and treatment did not significantly influence pulp survival after pulpotomy (partial or coronal; P=.312), but the stage of root development had a significant impact (P<.001).

CONCLUSIONS

Partial or coronal pulpotomy, employed either as a primary pulp treatment or secondary to emergency pulp capping, had similarly satisfactory pulp survival rates.

Signs of attention deficit/hyperactivity disorder as a risk factor for traumatic dental injury among schoolchildren: a case-control study

BACKGROUND

The determination of risk factors for traumatic dental injury (TDI) is important to the implementation of preventive measures.

AIM

The aim of this study was to evaluate the association between signs of attention deficit/hyperactivity disorder (ADHD) and TDI.

MATERIAL AND METHODS

A case-control (1 : 1) study involved a population-based sample of 230 schoolchildren aged seven to 12 years. The case and control groups were composed of children with (n = 115) and without (n = 115) TDI, respectively. The groups were matched for age and sex. The outcome variable (TDI) was detected using the O'Brien criteria. The main independent variable (signs of ADHD) was evaluated using the Swanson, Nolan and Pelham scale (version IV) administered to parents and teachers. Socio-demographic characteristics and accentuated overjet were analyzed as confounding factors. Statistical analysis involved the McNemar's test as well as the bivariate and multivariate conditional logistic regression.

RESULTS

The multivariate regression demonstrated that schoolchildren with the signs of hyperactivity (parental reports) had a 2.33-fold greater chance of exhibiting TDI (95% CI: 1.10-4.94) than those without this condition, as well as those with accentuated overjet (OR = 3.13, 95% CI: 1.70-5.77).

CONCLUSION

Schoolchildren whose parents reported signs suggestive of hyperactivity had a greater chance of exhibiting TDI than those without such signs.

Enamel fracture in the primary dentition has no impact on children's quality of life: implications for clinicians and researchers

AIM

The aim of this study was to quantify the impact of traumatic dental injuries (TDI) on oral-health-related quality of life (OHRQoL) of preschool children, when enamel fractures were either included or excluded within the category of TDI.

MATERIAL AND METHODS

An oral health survey was undertaken of preschool children, age 1-5 years attending public nurseries in Canoas, Brazil. Children were examined for TDI, dental caries, and malocclusion. Parents were interviewed on their perception of their child's OHRQoL (Early Childhood Oral Health Impact Scale-ECOHIS) and their sociodemographic background. Multivariable Poisson regression models with robust variance were fitted to assess the impacts of TDI (including and excluding enamel fractures) on OHRQoL.

RESULTS

A full dataset was collected from 76% of the eligible population. The prevalence of TDI was 13.4% (171/1275). The prevalence of any impact (ECOHIS ≥ 1) was significantly higher in children with crown discoloration (29.7%), enamel/dentin fracture (29.2%), and avulsion (73.3%), compared to children with enamel fracture (16.2%) or without a TDI (15.8%) (P < 0.001). Enamel fractures were the most prevalent TDI (40%) but halved the proportion of children with a reported impact from their TDI. The mean increase in OHRQoL impact for those children with a TDI was 1.59 (95%CI 1.20-2.10) when enamel fracture was included, and 1.86 (95%CI 1.39-2.50) when it was excluded.

CONCLUSION

Enamel fractures have no significant impact on young children's quality of life. Including enamel fractures within the diagnosis of TDI increases the prevalence of TDI while reducing the OHRQoL impact of TDI for the primary dentition.

Unusual transalveolar and transmuco-gingival root avulsion of a fractured primary central incisor: a case with an 8-year follow-up

The purpose of this unique case report is to describe a very unusual dentoalveolar fracture associated with avulsion of the near-complete root. A 3-year-old male patient came for consultation after a dentoalveolar trauma with a “fragment that looks like canine” found in his mouth by his mother. This boy suffered root fracture of the upper primary central right incisor, accompanied by transalveolar and transmuco-gingival avulsion of the tooth root fragment, leaving the crown in its position in the dental arch. Clinical and radiological examinations were performed in order to follow up the case: 15 days, one month, and three months after trauma, the crown had a slight mobility without other clinical or radiological signs. After six months, the upper primary central right incisor's crown was exfoliated. Open bite due to the persistence of the pacifier habit favored the crown retention in the mouth. This case emphasizes the importance of primary diagnosis and follow-up of trauma cases. To the best of our knowledge, this kind of dental injury has not been previously described in the literature nor in the current Dental Trauma guidelines for the management of traumatic dental injuries in the primary dentition.