Eric G. comments:Very difficult decision. Multiple options may be applicable to this case and patient tolerance to treatment may have an impact in your decision making however implant is definitely out at this age/stage. Surprisingly enough the pulp at young age will tolerate a lot so the most conservative approach IMO, would be CVEK pulpotomy with Biodentine and direct composite restoration. Review at 3/6 and 12 months. If any symptoms or evidence of pulp necrosis , conventional RCT will be appropriate. In terms of restorability the palatal fracture will be of a great challenge and ortho extrusion may be necessary. In terms of surgical option you may consider autotransplantation. Hope you find some guidance and patient recovers well. Take care , E
Lyubomir Danev comments:Thanks!
Tim comments:While there is a good amount of remaining tooth structure to support a conservative composite build up I would suggest just that after endo but no post yet. Rather than sculpting composite multiple times over the years to come you could restore with a lab processed provisional to be replaced periodically until an appropriate definitive crown can be made. If all goes well there should be enough passive eruption over time to allow adequate ferrule and avoid the need for a post (possible). I know I am going against my training here, I am a periodontist, but I would suggest compromise for now and not rush to crown lengthening yet as that palatial fracture can be managed through good restorative.
Matt Helm DDS comments:It's much too early and destructive of hard dental structure to even contemplate a crown at this time, or talk about ferrule. Ultra-conservative is the only way to treat this at the patient's age of 11! You're right about avoiding crown lengthening, it may not even be necessary in time, as well as about the palatal fracture being sufficiently minimal to be easily manageable now and in the future, when the time for a crown does come. And that may be a longer way off than anyone thinks right now. I've seen and done hundreds like this in my half-trauma practice.
Matt Helm DDS comments:An implant is out of the question at this time. Injuries like this are very common. The very first thing you must do is to immobilize the tooth and eliminate the 2nd degree mobility! This is PARAMOUNT! I would use the classical cervical thin wire tying the tooth to the adjacent teeth cervicaly, as opposed to any removable appliance, because compliance will be a problem and the kid will be tempted to remove it. Then you may attempt a vital pulpotomy if you wish, but don't expect it to work. Treatment of choice here is immobilization and RCT, no post yet, and composite core with crown build-up. Do NOT prepare the tooth for a crown at this time! Being conservative right now is key! As per the CT scan the lingual fracture is not a concern because it stops just below the lingual bony alveolar crest. LEAVE IT ALONE, and only smooth out rough edges with a fine, then ultra-fine diamond burr. Things are still shifting in this kid's mouth and the tooth will most likely continue to erupt enough to make any crown lengthening unnecessary in the future. DO NOT do any crown lengthening now! It is not necessary, and is overkill! Remember: CONSERVATIVE is the key word here. Remove immobilization wire only when mobility has disappeared completely. While prognosis is guarded right now, treated properly and managed properly and conservatively, in time this tooth has every chance to last even decades and surprise both you and the patient. Keep under observation preferably twice yearly, or at least once yearly. Be on the lookout for apical resorption which can sometimes occur, but is the exception, not the rule. If it does occur and is asymptomatic, as is most often the case, leave it alone. This can happen on these traumatized teeth, but it often happens very slowly. Additionally: 1) provide serious OHI (oral hygiene instruction). You must improve his hygiene, as his gingivitis is too exacerbated for his age. 2) Very seriously recommend ortho. If his occlusion is balanced -- which right now it does not appear to be -- that will also go a very long way to lengthening the useful life of this tooth also. In my more than 36 years of treating trauma (one of my "sub-specialties") I've seen dozens of this type of injury. It is the most common in kids his age. You can take what I said verbatim and run with it. I am particularly surprised that none of the other commenters even mentioned immobilizing the tooth to address the mobility. Again, this is KEY to greatly improving the long-term prognosis. Good luck! And don't sweat it: it's an easy case.
Matt Helm DDS comments:One last word: do not overcomplicate this case at this stage! Keep it just as simple as I've described. Stay away from laser gingivectomy, provisional crown, or anything invasive or destructive of hard or soft tissue. Anything that exceeds what I've told you is overkill, unnecessary, and it's way to early for exceeding my guidelines. Stay within those and you and your patient will be fine! You'll see.
Matt Helm DDS comments:One more small detail: when you rebuild the tooth in composite in the final phase, use the lingual half an ion crown or of a polycarbonate clear template to rebuild the whole palatal anatomy properly, i.e. rebuild the basic cingulum area contour, AND extend the composite all the way cervically AND subgingivlally to rebuild the fractured lingual. You will want to do all of this in order to preserve the whole palatal anatomy and gingival contour to prevent the gingiva from growing into the void created by the lingual fracture, as well as to avoid his speech being affected by too flat a lingual anatomy. Yes, it can be done and, bleeding can be easily controlled intra-operatively, with a little patience.
Lyubomir Danev comments:Thanks for the guidance! I have already covered the pulp chamber with CaOH and composite.
Matt Helm DDS comments:Excellent. Hopefully it works. But if it becomes symptomatic you will have to do an RCT. If symptomatic, just be careful that you don't confuse soreness that may still exist while the tooth is still mobile with pulpal pathology. Don't rush! If it passes this critical period and remains asymptomatic, and if it firms up and is no longer mobile, chances are 95% it will be ok. You will have to keep it under radiological observation at 3 months for the first year, then at 6 months for two years, then once year. Be on the lookout for periapical changes and apical resorption in time. If all goes well (it usually does even when RCT has to be done), you should be able to proceed with conservative restoration as I outlined. When building the final restoration make sure that is is not in occlusion as much as possible. If anterior guidance contact on it cannot be avoided make the contact as light as possible, at least in the initial period of 1 year. The key is to not overwork the tooth and give it plenty of time to heal at this age. Best of luck!
Matt Helm DDS comments:Trust me on everything I have told you! I must have treated hundreds of cases just like this one in my 36 years of trauma practice. Until the kid reaches the age of 18-20 do NOT do ANY of the things that the others advise below (post, crown, crown lengthening) unless of course some of it becomes absolutely necessary due to premature coronal structure breakdown caused by caries or, by another trauma. Additionally, very strongly advise the parents he should wear a soft sports mouthguard. With this kid's active demeanor it will go a very long way towards preventing further injury to this tooth as well as to the other teeth. He may not be so lucky the next time. :)
Lyubomir Danev comments:Thanks, Dr. Helm. I absolutely trust your words and I will follow your instructions. For the first time I have such a case with a small child and I was not sure of the right approach. Thank you very much!
Matt Helm DDS comments:You're very welcome. Always glad to impart knowledge that is harder to come by than the average conventional wisdom. Trauma isn't easy and it requires experience as well as flair. Those who don't or didn't do it on a steady basis have much to learn, like I did when I first started treating trauma. It has many "secrets", and a very demanding logic tree. Best of luck!
Matt Helm DDS comments:By the way, did you notice that I took the time to strongly critique every comment here that was wrong? Why do you think I did that? Because everything everyone was saying was so wrong it could result in actually doing more harm than good, and on an 11-year old kid, no less, and I feel very strongly about such things. And the absolute worst part was that no one even addressed the Class 2 mobility, which is the biggest mistake by far. That should ALWAYS be the FIRST thing you address! Not addressing it timely and promptly can make the difference between saving or not saving the tooth in question. If one doesn't know, or isn't sure, one must not speak out of turn and give wrong advice that could harm the patient. One needs to remain quiet and learn from those who know better. That is how we ALL learn in this profession. NO ONE knows absolutely everything absolutely. That's why we have CE, after all! Periodontists don't know restorative, and restoratives don't know periodontics. Periodontists should stay very tightly within their "lane" on anything regarding restorative. I've seen many of them commit outright blunders, in both restorative and implantology. Anyone even talking about an implant on an 11-year old is out of their mind, pure and simple! I particularly detest tunnel vision. As professionals we have an obligation to the patient to see the whole picture, not just one tooth or one implant. Yet there are too many to make that grave mistake. Don't become one of them.
Tim Carter comments:Matt I have no doubt that you are likely a very good dental provider but you should go back and read some of your past comments on this forum. Aside from you, the overwhelming majority of those that post do so in a manner in which they suggest alternatives rather than matter of fact solutions. I find it interesting that you mention "staying in a lane" which is something that I agree with and as a periodontist I can only make suggestions regarding restorative options. What exactly is your lane? You boast expertise in trauma, you claim to be the greatest restorative dentist and implant surgeon on the planet and you insult any suggestion or thought that does not line up perfectly with your opinion. Yes, I am critical of you, and regardless of whatever exceptional dental knowledge you might have you sir are a perfect example of an arrogant ass of epic proportion!!
Ken Heath comments:Id echo @matt's comments ... trying very hard to keep the tooth if only to preserve bone and allow normal bone formation as the face continues to develop ; but i may surprise you and remain insitu for many years. BUT .... i agree with another comment, he needs to clean those pegs or it will be a waste of time ;)
Claudio comments:My good.!! Go to the school again
Lloyd S. Drucker comments:If #11 well out of occlusion why splint? What if the composite does not hold up?
Richard Waghalter, DDS comments:First consideration: are there any other fractures in the root that can account for the extreme mobility besides the traumatic insult. If not a root canal, can you do a pulp cap or a pulpectomy and preserve the vitality of the remaining dental pulp? If the root is in one piece, A-ok. If not, extract and place a external splint around all this teeth like a hard plastic fluoride tray to wear. All maxillary occlusal surfaces must be covered to support the dentition and any repositioning of the upper and lower teeth. This will serve as a splinting device 24 hrs a day. Alternating splinting: A temporary composite cap can be held in place with final cementation approach. This will allow the temp to stay in place as long as you want and do crown lengthening if still a needed procedure. You can splint the teeth with a wire with composite on the lingual 7-8-9 and into the temporary as long as there is room for the wire on the palatal of 7 and 9 and non-traumatic occlusion if not using the tray aforementioned. A wire placed at and under the gumline produces loss of supporting alveolar bone in animal experiments. Subgingival rubber bands have inadvertently caused bone loss and the extraction of that tooth without the dentist's having to remove it with forceps. No crown lengthening necessary. After the tooth is determined not to be infected anymore and the occlusal contact are no longer traumatic, you can remove the wire. If you then take the injured central out of occlusion, it will supererupt and bring the supporting bone with it. You can avoid having to do a crown lengthening procedure afterward by detaching the gingival tissue attachment from the bone before extrusion is induced. The bone will not come with the tooth. This young patient at his present age assumes no responsibility for his homecare. Keep cleaning his teeth while you teach him effective oral hygiene habits. With time and in a few years, he will finally get the idea.
Richard Waghalter, DDS comments:For clarity: Use the stiff fluoride tray only until the tooth is no longer movable to prevent retarding his jaw development and teeth moving into correct position during his adolescent years with or without orthodontics.
Abirra Nartel comments:Most fractured teeth can be repaired either by reattaching the broken tooth enamel or by bonding a tooth-colored filling or crown in place. My brother had a broken tooth, and our dentist from https://diamonddentalassociates.com/dental-implant/ was contacted immediately after the injury to keep the damage from worsening.