Complicated crown fractures are those in which
fracture of the crown involves the pulp. Where
exposure of the pulp occurs, some urgent form of
treatment is necessary if the health of the pulp is to be
maintained. Except in immature teeth,
mosttraumatically exposed pulps in anterior teeth will
become necrotic and infected if left untreated for one
month.
A number of procedures have been
recommended for the treatment of exposed pulps.
These include pulp capping, partial pulpotomy,
pulpotomy and pulpectomy procedures.
In the absence of luxation injury, necrosis of an
exposed pulp does not usually occur immediately,
although this is the inevitable response if an exposed
pulp is left untreated. Inflammatory responses and
bacterial contamination, which are responsible for
necrosis in exposed pulps, are confined to the site of the
exposure for some time.
Accordingly, in traumatically exposed teeth, both pulp capping
procedures and partial pulpotomy procedures have
been shown to be successful, particularly in younger
patients. Pulpotomy procedures appear to be superior
to pulp capping
and involve removal of the “injured”
coronal pulp usually at the level of, or near to, the
coronal opening of the root canal and the placing of
medicament (usually calcium hydroxide) against the
remaining vital tissue. Treatment seems to be more
successful if the medicament is placed directly onto the
exposed pulp without an intervening layer of
haemorrhage.
Cvek has reported that 96 per cent of
exposed pulps, which were amputated about 2mm
below the exposure site with a high speed diamond bur
and then covered with calcium hydroxide after removal
of the blood clot, survived and developed calcific
bridges at the fracture site.
The success rate did not
appear to be related to the size of the exposure, the
location of the exposure, or to the time interval
between trauma and treatment. Recent studies have
confirmed the success of Cvek’s original procedure and
suggested the criteria for the use of this technique be
expanded to include all traumatically fractured teeth
regardless of the patient’s age and degree of apical
closure of the teeth, and that the restoration placed at
this time could be considered a definitive one rather
than a temporary measure.
The advantage of both
pulp capping and partial pulpotomy procedures in
young teeth, if they prove successful, is that a healthy
pulp is maintained throughout the root canal system.
This is an especially important consideration in the
treatment of young and immature teeth as, in these
teeth, measures should be taken to maintain a healthy
pulp, not only to ensure apical maturation, but also to
promote the development of lateral root dentine to
improve root strength. These procedures should only
be carried out on vascular pulps. Recently, partial
pulpotomy procedures involving the use of mineral
trioxide aggregate (MTA) have been described and have
been shown to be effective. Proponents of the use of
MTA suggest that it helps to protect the pulps from the
effects of bacterial penetration and that its use
precludes the need to re-enter the exposure site to place
a more definitive restorative material over the exposure
at later date.