Dental Trauma in children and adolescents is sadly far too common; with 1 in 4 adolescents and 1 in 3 adults experiencing a dental trauma.(1) Proper and early management of the trauma is crucial in achieving the best long-term outcome, particularly for an immature permanent tooth.(2, 3) In this post, we will discuss management of a complicated crown fracture (pulp exposed) without a luxation injury.

A complicated crown fracture results in exposure of the pulpal tissue to the oral environment. The aim of care is to ensure the ongoing vitality of the tooth and in a younger child, to ensure that the tooth continues to develop. The Cvek Pulpotomy is a well know procedure for managing an exposed pulp and we will take you through the steps.(2, 4)

What Material Should I Place On The Pulp?

The material you place directly onto the pulpal tissue may depend upon what you have access to. The material you use should stimulate a reparative process in the pulpal tissue resulting in the creation of a dentine barrier. Vital pulpal tissue will then remain under this and allow ongoing root development.(3, 5)

Historically, Calcium Hydroxide has been successfully used with a 88 - 100% success rate.(3, 4) However it is a porous material, is penetrated by blood vessels (vascular inclusions), can wash out, and does not tend to form a firm dentine barrier. As such, mineral trioxide aggregate (MTA) was attempted due to its biocompatible properties, however, the discolouration left was terrible and it is no longer recommended for use in an anterior Cvek pulpotomy (unless it is placed well below the gingival margin of the tooth; this also includes ‘white MTA’).

A newer material, Biodentine, is now available on the market. It is a bioceramic which does not result in discolouration as significant as MTA. It has been suggested to be the most ‘ideal’ material to place, however it is quite expensive and may not be available in all practices. If this was the case, we would recommend you stick to CaOH.

Does It Matter If Treatment Has Been Delayed

On some occasions, patients can present to you several days after the injury. This can affect the prognosis, however what is more important here is the pulpal response as opposed to the exact amount of time that has passed. Cvek Pulpotomies have successfully been completed up to 9 days later,(3) so we would encourage you to give it a go before you pick up the barbed broach.

How To Do A Cvek Pulpotomy

1. Initially ensure you have a complete trauma history and have the correct diagnosis with your clinical and radiological examinations (we will address this in another post) and do baseline vitality testing.

2. Ensure you have excellent anaesthesia and isolation with rubber dam

3. Use a brand new diamond high speed bur (to avoid tearing the tissue) with copious irrigation to remove 1 – 3mm of the exposed pulp, until you are on non-inflamed pulpal tissue. The aim here is to get to visually ‘healthy’ pulp. This is pulpal tissue that ceases bleeding in under 5 minutes. If this doesn’t occur, remove an additional 1-2mm and attempt to get haemostasis again. Sometimes, if the tooth has been left for several days, you may find that you have to remove more pulpal tissue as the inflammation extends deeper. However, any tissue left apically will still be vital and help avoid the requirement for a root canal treatment.

4. Use a wet sterile cotton pellet to achieve haemostasis

5. You can then use a cotton pellet with NaOCl (3 – 5%) over the pulp to hopefully address any residual bacteria

6. Ensure that you have COMPLETE haemostasis. If you do not, the prognosis can be significantly affected and the next step will be very hard for you

7. Place your pulpal medicament

a. If using CaOH use a non-setting material, followed by a setting material

b. If using Biodentine, place around 2-3mm of the material over the pulp

8. Seal the medicament with a RMGIC, such as Fuji II LC (it is not absolutely necessary for Biodentine, however its setting time is quite long and sealing it can allow you to proceed with the following steps)

9. Restore, or rebond, the tooth fragment on to the tooth (see below for steps for rebonding the fragment)

10. Review the patient in 6-8 weeks with pulp vitality testing and a radiograph, followed by reviews 6-monthly.

How To Rebond The Tooth Fragment

On most occasions, the patient will present with the fractured section of tooth with them. This is generally the best material to use to restore the tooth. However, depending how long it has been out of the mouth it may have dehydrated. So get the patient to put it in some water as soon as they can. The tooth will rehydrate over time in the mouth, but it can take a long time.

Excess resin composite can easily be removed

Clean the fragment well and remove some dentine from within the fragment to increase the amount of resin for bonding. Etch the tooth and the fragment, prime and bond and then place a resin material in between. We like using a non-flowable resin composite instead of a flowable one as it helps stabilise the fragment whilst you reposition it and the excess is quite easy to remove. Once you have removed the excess and cured it, make a bevel in the enamel overlying the fracture line, so you can overlay resin composite to mask the fracture. It may also help with retention of the fragment. Over several days/weeks the fragment will rehydrate to blend back in nicely. We always warn the patient that this is now a smiling tooth and not a chewing tooth and that it can still fracture again.

All the best,

Sarah and Tim