Crown Fracture: Enamel-Dentine-Pulp
Adult Teeth and Dental Trauma
In this section, we will cover:
- What is an enamel-dentine-pulp (crown) fracture?
- What should I do after the injury?
- Will I need treatment?
- What can I do to help the area heal at home?
- Will I need any follow up appointments?
- What should I look out for?
- What are the long term complications?
What is an enamel-dentine-pulp (crown) fracture?
This is an injury in which the crown of the tooth has fractured, exposing the nerve. The tooth will usually be very sensitive to temperature and touch.
It is sometimes referred to as a "complicated crown fracture".
What should I do after the injury?
It can be very distressing if you/your child has suffered trauma to the teeth. The first thing to do is not panic.
Dental trauma is very common and there are a few steps you can follow to get the best outcome after the injury.
You should:
- Take a second to collect yourself and check you/your child hasn't blacked out.
If you/your child has hit their head and you think they may have lost consciousness (even for a few seconds) or they feel nauseous or dizzy, you should get this checked out by your doctor or local A&E department to rule out a concussion (head injury). - Call your dentist as soon as possible so they can arrange to check the teeth and provide any necessary treatment.
- Pick up any broken fragments of the tooth if you can find them. You should take these to your dentist's appointment so they can check the fragment hasn't been accidentally swallowed and no tooth fragments are in any cuts in the soft tissues.
- If there are any cuts in or around the mouth, clean them with warm salty water. If there is any bleeding, dampen a clean handkerchief in salt water and press it firmly on the bleeding area.
- If the injury happened in a place thought to be unclean, and there has been a cut to the skin/lip/gum, you should check all tetanus vaccinations are up to date with your GP. You may need a tetanus booster vaccination.
Will I need treatment?
Your dentist will take an xray of the teeth to check for any other injuries and to compare any future xrays against. If the broken fragment of tooth was not found and there is a cut in the soft tissue (e.g. lip), your dentist will take an xray of this area to make sure the missing fragment is not in the soft tissue.
Teeth with a fracture which has exposed the nerve need treatment as soon as possible. Treatment depends on how long it has been since the tooth fractured and how much of the tooth is left above the gum. Options include:
1. Lining the nerve
- Local anaesthetic
- Placing a soothing medicine over the nerve
- Sealing the nerve with a glass ionomer (dental filling material)
- Restoring the tooth with a dental composite
2. Pulpotomy
- Local anaesthetic
- Removing a very small amount of inflamed nerve tissue
- Placing a soothing medicine over the remaining nerve
- Sealing the nerve with a glass ionomer (dental filling material)
- Restoring the tooth with a dental composite
- This is the preferred option if a post will be needed to restore the tooth with a post-crown
- If a pulpotomy fails because the nerve is inflamed/infected, your dentist will need to carry out root canal treatment
If there are any deep cuts on the gum/lip/tongue which your dentist thinks will not heal by themselves, they will place a few stitches to help them heal. You may need to be seen in an A&E department with a specialist team of "oral and maxillofacial surgeons" for this.
If you/your child are unable to tolerate treatment under local anaesthetic, they will be able to offer the treatment under sedation and/or general anaesthetic in hospital. If you think your child will need a general anaesthetic for treatment, they will need to be fasted for 8 hours prior to the procedure.
What can I do to help the area heal at home?
To help the area heal at home, you should:
- Brush the teeth after every meal with a soft toothbrush
- Gently brush the injured area to prevent build up of plaque
- Carry out salt water or alcohol-free chlorhexidine mouthwash (corsodyl) twice a day.
For a young child who isn't able to use a mouthwash, use a cotton swab/handkerchief moistened in salt water or alcohol-free chlorhexidine mouthwash (Corsodyl) to clean the gum twice a day - Have a soft diet
- Take medicine to help manage any discomfort (ibuprofen or paracetamol)
- Avoid contact sports
- Don't smoke
Will I need any follow up appointments?
Your dentist will want to see you/your child again for a clinical examination and xray after:
- 6-8 weeks
- 3 months
- 6 months
- 1 year
X-rays are taken to assess how the root of the tooth is developing and to identify any complications with healing.
What should I look out for?
The long term consequences of dental trauma are unpredictable. You should monitor your/your child's teeth for any signs of infection.
Favourable outcome
- No pain
- Normal colour of the tooth
- Good quality, aesthetic restoration (bonded fragment or composite)
Unfavourable outcome
- Pain
- Abscess on the gum
- Permanent grey discolouration of the tooth, along with one of the above signs/symptoms
- Loss of restoration (bonded fragment or composite)
What are the long term complications?
The long term consequences of dental trauma are unpredictable. You should monitor your/your child's teeth for any signs of infection (see "unfavourable outcome" above).
Possible complications include:
1) Nerve damage
- A) Nerve dies causing pain and infection.
The tooth may look grey/brown and be tender to bite on. This can be managed with root canal treatment. Once the tooth has been treated, it can be whitened to improve the appearance. You can find about more about tooth whitening here. - B) Root canal constricts as more dentine is formed (find out more about tooth anatomy here).
This is called "pulp canal obliteration". The tooth may look more yellow or brown but you won't have any pain from the tooth. This doesn't need any treatment unless the nerve dies. If the nerve dies, you may need to see a specialist endodontist for root canal treatment. If you are unhappy with the colour of the tooth, you can consider a course of tooth whitening. - C) Tooth starts to "dissolve" from the inside out.
This is called "internal inflammatory resorption". The tooth may have a pink-ish tinge to it. In most cases, you won't have any pain from the tooth unless the resorption has extended to the outer surface of the root. If detected very early, this condition can usually be managed with root canal treatment. Sometimes, the tooth will have to be removed (see dental extraction).
2) Abnormal root development
- This is more relevant if the injured tooth has erupted in the last 3 years, as the root is still growing.
- If the nerve dies, the root stops growing.
This means the tip of the root is left wide open. It can be managed with root canal treatment and a special material called "MTA", which is a bit like a cement. MTA is used to "plug" the hole at the tip of the root during root canal treatment. This is a treatment which is usually only carried out by a specialist children's dentist (paediatric dentist) or endodontist (root canal specialist).
3) Failure of restoration
- Restoration falls off
A new restoration will need to be replaced - this will most commonly be through composite bonding - Restoration picks up staining
Sometimes the composite restoration material can be polished to remove the staining, but occasionally the whole restoration will need to be replaced