- Email: [email protected]
Emergency Covering for a Fractured Anterior Tooth in Children
original articles Jam es L . D an n en b erg , D D S , P hiladelphia
E m e r g e n c y c o v e r i n g f o r a f r a c t u r e d a n t e r i o r t o o t h in c h i l d r e n
A p refo rm ed stainless steel orthodontic band cem en ted over a bland dressing is effective as an em ergency trea tm en t of Class I I incisal fractures. T h e band is used for so short a tim e (6 w eeks to 2 m o n th s) th a t its lack of esthetic appeal is not a serious disadvantage.
Im m ed iate p ro tectio n of th e exposed d e n tin in th e Class II fractu re of th e in cisor m ay m ean th e difference betw een preservatio n o r loss of vitality of the pulp. T his p ro tectio n should consist of a bland dressing, such as zinc oxide an d eugenol paste or one of th e calcium hydroxide p rep aratio n s, held in place over th e d e n tin by a rigid, leakproof covering. T h e choice an d ap plicatio n of th e tem porary crow n often is th e difficult p a rt of the tre a tm e n t a n d frequen tly is m ishandled. T h is re p o rt describes a sim ple a n d effec tive m e th o d fo r h a n d lin g th e problem in ch ildren, using p refo rm ed stainless steel o rth o d o n tic bands. P reform ed a n terio r stainless steel bands are o b tain ab le in a n assortm ent of w idths a n d sizes fro m m any m anufactu rers. T h ey are preco n to u red so th a t fu rth er a d a p ta tio n rarely is necessary. W hen
properly fitted a n d cem ented over a dressing, such bonds provide m axim um p ro tectio n fo r an ex tended tim e. INDICATIONS AND CONTRAINDICATIONS
T h e use of p refo rm ed bands simplifies the em ergency treatm en t. T h ey are effective in m ost cases of Class II fra ctu re; th a t is, fractu re involving the loss of enam el an d d en tin b u t n o t involving the incisal th ird or h alf of th e tooth. T h is is th e p a rt of th e to o th fo r w hich th e bands w ere d e signed. I n cases of vertical fractures th a t ex tend apically beyond th e m iddle of the tooth , th e b an d is co ntraindicated. T hese teeth require full coverage, w hich is best achieved w ith a stainless steel crow n. P R E LIM IN AR Y DIAGNOSTIC PROCEDURES
A fter o b tain in g th e history of the injury, th e to o th should be exam ined for vi tality. Sim ply scratch ing th e exposed d en tin w ith a n explorer w ill elicit a re sponse if th e p u lp is vital. W hen there is no response to such a test, ice, h e a t o r th e electric p u lp tester should be used. T h e responses w ill v ary w ith th e condition of th e pulp. If th e fra ctu red tooth is seen w ith in 24 hou rs a fte r th e accident, it is unlikely th a t th e p u lp has becom e non-
Fig. I • Preform ed incisal stainless steel o rth o d on tic b and
T h e occlusion should be ex am ined to determ ine if there is sufficient space for the tem porary as well as the p e rm a n en t restoration an d to p la n fo r space if it is n o t sufficient. M alocclusion is a predis posing facto r in fractures of an terio r teeth, an d orthod ontic correction m ay be indicated. TECH N IC
A fter the diagnostic p rocedure is com pleted, th e in ju red to o th is w ashed free of debris w ith w arm w ater, an d blood a n d m a teria alb a are rem oved w ith p e r oxide on a co tton pledget. If o ral hygiene has been poor, the tooth should be cleaned w ith a ru b b e r cup an d p roph y laxis paste. T h e to o th is then isolated w ith co tton rolls, the exposed dentin w iped w ith co tton to dry it (a ir should vital. T h e injury, how ever, m ay occasion ally pro du ce p u lp al shock th a t results in a negative test response. T his condition m ay be reversible an d , afte r a period of u p to six weeks, th e vitality m ay becom e norm al. Im m a tu re teeth w ith incom pletely developed roots m ay o r m ay not respond to p u lp testing. S uch young teeth deserve ad eq u ate an d p ro m p t protective care so th a t the roots co ntinue to d e velop. Also, d e n tin of young teeth is highly tu b u lar, w hich adds urgency to th e need for em ergency treatm en t. A ll an terio r teeth should be exam ined radiog rap hically to d eterm ine w h eth er th ere are fractu res of th e roots. T h e ra d i ographs w ill also provid e a record of the progress of p u lp al reaction to th e injury an d tre atm en t an d provide a basis of com parison for determ in in g continued root developm ent of im m atu re teeth. Fig. 2 • Preform ed b a n d with s p ot-w eld ed strip p ro tectin g incisal e d g e of to oth
D a nnenbe rg: FRACTURED TO O TH C O V E R IN G • 855
never be used) and the dressing applied. As soon as the dressing has set, the proper size of stainless steel band is selected. The band should fit snugly when seated with a band pusher or serrated amalgam plugger and should not interfere with centric occlusion. Occasionally, it is necessary to adapt the band by pushing it against the lingual side of the tooth incisally to the cingulum. Judicious grinding of the edge of the band may be required. If the fracture is sharply angular, the cemented band alone is sufficient protec tion (Fig. 1). Little incisal cement is ex posed, and it seldom washes away in the six weeks to two months that the covering is to remain in place. If, however, the entire incisal edge is exposed, it may be protected by spot-welding a strip of band or matrix material to the preformed band, from the labial to the lingual side, for added protection to this surface (Fig. 2)‘When the fit, retention, amount of cov ering and occlusion are satisfactory, the band is cemented with zinc phosphate cement. Enough protection is afforded so that the tooth can be used normally. The emergency covering should remain in place a minimum of six weeks, but it is wise to allow two months or longer for an adequate layer of secondary dentin to form. Periodic reexamination to deter mine the vitality of the tooth is indicated. The covering may be removed by slitting the temporary band with a scaler or bur. A more esthetic permanent restoration may then be planned.
ADVANTAGES
The preformed orthodontic band has the advantages of comfort to the patient, ease of construction and adequate protection of the tooth. One disadvantage is the band’s lack of esthetic qualities; this is a minor consideration, however, because the band is used for so short a time. Parents of children with fractured an terior teeth readily accept the explana tion that the band is analogous to a bandage on a cut finger and is an aid in protecting future health of the tooth. Celluloid crown forms or stainless steel crowns are alternative protective cover ings. Celluloid crowns have esthetic qual ities when used with silicate cement or plastic, but their resistance to abrasives and their retentive ability is deficient when compared with metal. The anterior stainless steel crown, when properly fit ted, is an excellent temporary restoration. It is superior to the band in many re spects, but has the disadvantage that, in close bite occlusions, the thickness of metal over the cingulum makes grinding of the opposing tooth necessary to estab lish a noninterfering occlusion. SUM M ARY
The technic utilizing a preformed stain less steel orthodontic band has been pre sented as a simple, but effective, method for temporary protection in the emer gency treatment of the Class II incisal fracture. 1913 Walnut Street
E m e r g e n c y c o v e r i n g f o r a f r a c t u r e d a n t e r i o r t o o t h in c h i l d r e n
A p refo rm ed stainless steel orthodontic band cem en ted over a bland dressing is effective as an em ergency trea tm en t of Class I I incisal fractures. T h e band is used for so short a tim e (6 w eeks to 2 m o n th s) th a t its lack of esthetic appeal is not a serious disadvantage.
Im m ed iate p ro tectio n of th e exposed d e n tin in th e Class II fractu re of th e in cisor m ay m ean th e difference betw een preservatio n o r loss of vitality of the pulp. T his p ro tectio n should consist of a bland dressing, such as zinc oxide an d eugenol paste or one of th e calcium hydroxide p rep aratio n s, held in place over th e d e n tin by a rigid, leakproof covering. T h e choice an d ap plicatio n of th e tem porary crow n often is th e difficult p a rt of the tre a tm e n t a n d frequen tly is m ishandled. T h is re p o rt describes a sim ple a n d effec tive m e th o d fo r h a n d lin g th e problem in ch ildren, using p refo rm ed stainless steel o rth o d o n tic bands. P reform ed a n terio r stainless steel bands are o b tain ab le in a n assortm ent of w idths a n d sizes fro m m any m anufactu rers. T h ey are preco n to u red so th a t fu rth er a d a p ta tio n rarely is necessary. W hen
properly fitted a n d cem ented over a dressing, such bonds provide m axim um p ro tectio n fo r an ex tended tim e. INDICATIONS AND CONTRAINDICATIONS
T h e use of p refo rm ed bands simplifies the em ergency treatm en t. T h ey are effective in m ost cases of Class II fra ctu re; th a t is, fractu re involving the loss of enam el an d d en tin b u t n o t involving the incisal th ird or h alf of th e tooth. T h is is th e p a rt of th e to o th fo r w hich th e bands w ere d e signed. I n cases of vertical fractures th a t ex tend apically beyond th e m iddle of the tooth , th e b an d is co ntraindicated. T hese teeth require full coverage, w hich is best achieved w ith a stainless steel crow n. P R E LIM IN AR Y DIAGNOSTIC PROCEDURES
A fter o b tain in g th e history of the injury, th e to o th should be exam ined for vi tality. Sim ply scratch ing th e exposed d en tin w ith a n explorer w ill elicit a re sponse if th e p u lp is vital. W hen there is no response to such a test, ice, h e a t o r th e electric p u lp tester should be used. T h e responses w ill v ary w ith th e condition of th e pulp. If th e fra ctu red tooth is seen w ith in 24 hou rs a fte r th e accident, it is unlikely th a t th e p u lp has becom e non-
Fig. I • Preform ed incisal stainless steel o rth o d on tic b and
T h e occlusion should be ex am ined to determ ine if there is sufficient space for the tem porary as well as the p e rm a n en t restoration an d to p la n fo r space if it is n o t sufficient. M alocclusion is a predis posing facto r in fractures of an terio r teeth, an d orthod ontic correction m ay be indicated. TECH N IC
A fter the diagnostic p rocedure is com pleted, th e in ju red to o th is w ashed free of debris w ith w arm w ater, an d blood a n d m a teria alb a are rem oved w ith p e r oxide on a co tton pledget. If o ral hygiene has been poor, the tooth should be cleaned w ith a ru b b e r cup an d p roph y laxis paste. T h e to o th is then isolated w ith co tton rolls, the exposed dentin w iped w ith co tton to dry it (a ir should vital. T h e injury, how ever, m ay occasion ally pro du ce p u lp al shock th a t results in a negative test response. T his condition m ay be reversible an d , afte r a period of u p to six weeks, th e vitality m ay becom e norm al. Im m a tu re teeth w ith incom pletely developed roots m ay o r m ay not respond to p u lp testing. S uch young teeth deserve ad eq u ate an d p ro m p t protective care so th a t the roots co ntinue to d e velop. Also, d e n tin of young teeth is highly tu b u lar, w hich adds urgency to th e need for em ergency treatm en t. A ll an terio r teeth should be exam ined radiog rap hically to d eterm ine w h eth er th ere are fractu res of th e roots. T h e ra d i ographs w ill also provid e a record of the progress of p u lp al reaction to th e injury an d tre atm en t an d provide a basis of com parison for determ in in g continued root developm ent of im m atu re teeth. Fig. 2 • Preform ed b a n d with s p ot-w eld ed strip p ro tectin g incisal e d g e of to oth
D a nnenbe rg: FRACTURED TO O TH C O V E R IN G • 855
never be used) and the dressing applied. As soon as the dressing has set, the proper size of stainless steel band is selected. The band should fit snugly when seated with a band pusher or serrated amalgam plugger and should not interfere with centric occlusion. Occasionally, it is necessary to adapt the band by pushing it against the lingual side of the tooth incisally to the cingulum. Judicious grinding of the edge of the band may be required. If the fracture is sharply angular, the cemented band alone is sufficient protec tion (Fig. 1). Little incisal cement is ex posed, and it seldom washes away in the six weeks to two months that the covering is to remain in place. If, however, the entire incisal edge is exposed, it may be protected by spot-welding a strip of band or matrix material to the preformed band, from the labial to the lingual side, for added protection to this surface (Fig. 2)‘When the fit, retention, amount of cov ering and occlusion are satisfactory, the band is cemented with zinc phosphate cement. Enough protection is afforded so that the tooth can be used normally. The emergency covering should remain in place a minimum of six weeks, but it is wise to allow two months or longer for an adequate layer of secondary dentin to form. Periodic reexamination to deter mine the vitality of the tooth is indicated. The covering may be removed by slitting the temporary band with a scaler or bur. A more esthetic permanent restoration may then be planned.
ADVANTAGES
The preformed orthodontic band has the advantages of comfort to the patient, ease of construction and adequate protection of the tooth. One disadvantage is the band’s lack of esthetic qualities; this is a minor consideration, however, because the band is used for so short a time. Parents of children with fractured an terior teeth readily accept the explana tion that the band is analogous to a bandage on a cut finger and is an aid in protecting future health of the tooth. Celluloid crown forms or stainless steel crowns are alternative protective cover ings. Celluloid crowns have esthetic qual ities when used with silicate cement or plastic, but their resistance to abrasives and their retentive ability is deficient when compared with metal. The anterior stainless steel crown, when properly fit ted, is an excellent temporary restoration. It is superior to the band in many re spects, but has the disadvantage that, in close bite occlusions, the thickness of metal over the cingulum makes grinding of the opposing tooth necessary to estab lish a noninterfering occlusion. SUM M ARY
The technic utilizing a preformed stain less steel orthodontic band has been pre sented as a simple, but effective, method for temporary protection in the emer gency treatment of the Class II incisal fracture. 1913 Walnut Street