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Treatment and restoration of fractured permanent incisors
TREATMENT
AND
RESTORATION
PERMANENT R.
M.
WAY,
OF
FRACTURED
INCISORS”
D.D.S.,
GALESBURG,
ILL.
0
NE of the many distressing situations which occur in a dental office is to The praMem is have a child come in with a fractured permanent ineimr. what to do and how t’o restore the lost contour wit,h some type of restorat*ion which will also appeal from the esthetic standpoint. The many cases we see may be divided for means of discussion into three groups: first, fractured incisors with the pulp not exposed; second, frac.. tured incisors with the pulp exposed and vital; third, fractured incisors with pulps exposed, nonvital, and fully developed a,pices. For example, a patient at the age of nine years has the maxillary permanent incisor fractured. The incisal angle and in&al one-third are lost. The fraetured surface is very sensitive to touch and to cold air. X-ray pictures are t&m, and the rest of the tooth is found to be in a normal condition. It is necessary in such a case to place some protection over the fracture for a period of six months or a year, until the pulp begins to respond by depositing secondax dentin. This condition is taken care af by the following method: The edges of the fracture are smoothed. With a dentimeter gauge the circumference is measured, and a band is constructed of 24K 36 gauge gold. The band is festooned, contoured, and allowed to extend just beneath the free margin of the gum, also to extend incisally, so that when completed it will be just out of occlusion. The lingual part of the band is cut to the desired length (slightly below the fracture), leaving the labial part extended. The lingual surf’nee is burnished and contoured. This part of the extended labial surface is bent over and brought in contact with the lingual, and is soldered. The ineisal edge is burnished to contour before soldering. The incisal edge is filled with solder for strength and the gold cap is then finished and polished. This cap can be cornpletrd in a short time in one appointment. The tooth is isolated and the band cemented to place with copper cement by first placing a layer of zinc oxide and eugenol over the fractured surface. It is important that the cap be short of occlusion. The tooth should be carefully watched, x-ray pictures taken periodically, and the vitality tested frequently. Another method of restoring a tooth of this crown slightly modified, which has a minimum the preparation. If the fracture is not great protection over it, or if the tooth has had a gold is suggested. *Presented
before
the
Knox
County
Dnntal 483
Societ3-,
type is t,o plaoe a three-yuartel amount of tooth destruction in and the pulp has some normal cap for some time, the following Dec.
17, 1934.
484
K. A!. wcrj/
If the child js too young to have any permanent have an!- extensive preparation, the mesial and distal Since it is necessary only to with a saaldpapcr disc. more and no proximal grooves are made. The in&al completing the preparation.
restorat,ion made or to surfaces are paralleled remove the contact, no edge is smoothed, thus
A copper band is fitted and festooned, and an impression is taken with compound in the band. This impression is poured with inlay investment, allowing The model is separated and inlay the investment to extend above the band. investment is added to bring out the lost contour. Kerr wax is ada.pted, 29 gauge over the lingual, in&al, and around the proximal surfaces and extending over the labial margin onto the labial surface. The wax can be easily adapted by first heating the model slightly and using art gum rubber to adapt the wax. This will give a more perfect adaptation. The wax is trimmed and cut to t,he contour of a three-quarter crown on the labial, and sealed to the model around the gingival, on the lingual and proximal surfaces of the tooth. The wax is smoot,hed and polished. VaseIine used on a pellet of cotton will give a high gloss to the wax. The sprue is attached on the incisal edge. The model is soaked in wa.ter, and the whole is invested for casting. Regular casting procedure is followed, allowing for expansion. The crown is cast, and polished, and tried on the tooth. The margins on the labial surface should extend just over the marginal ridge onto the labial surface, so that a minimum amount of gold will show and at the same time offer enough for retention. The margins are trimmed down; however they will not be flush with the tooth surface. The crown is cemented to place using a light colored cement. When the cement is set, the part in the fractured area is cut, out, leaving a thin layer of the cement a.round the inside of the crown, so that when the enamodent or synthetic porcelain is filled in it will not show a discqlored filling. This makes a very neat restorat,ion with a minimum amount of gold showing, and with little tooth destruction. This can be worn by the patient unt,il time for a more permanent restoration. In cases in which the pulp is involved and the patient arrives a short time after the accident, one of two things can be done : first, amputation of the bulbous The latter is done portion of the pulp; or, second, removal of t,he entire pulp. only in cases in which the pulp has died or the x-ray picture shows a completely developed apex. In all other cases a pulp amputation may be done. The tooth will remain vital, and proper normal development of the end of the root will continue. Later a permanent restoration can be placed on a vital tooth. After obtaining an x-ray picture, and being sure that the apical end of the tooth is open and the tooth is vital, the procedure for the pulp amputation is as follows : Isolate the tooth with a rubber dam and use pressure anesthesia. To get the best result,s, a copper band is fitted tightly around the tooth extending above the fracture. A pellet of cotton saturated in phenolated water and then placed in the powder of a crushed E novocaine tablet is placed into the band on the exposure. With a strip of unvulcanized rubber, pressure is applied by packing it into the band, thus forcing the solution into the pulp tissue. The patient should be previously informed that pain will be noted for a second. Test t,hc
pulp with an explorer, and be certain of the anesthesia ; talie a rou11d bn~, slightly smaller than the pulp chamber, and remove about 3 mm. of pulp tissue. -\fter the chamber is cleaned of all debris, it is ready to be tilled. If hcrno~~~~hw,vc occurs, nlil(ac a small pellet, of cotton saturated with formocresol or phenol wmpound in the pulp canal for one minute. The chamhrr is filled with il thicl< mix of zinc oxide and eugcnol. The zinc oxide must bc chemically pure. When packitlg inlo the pulp chamber, be careful not to trap al1~7air under the zinc ositlv, The pulp end must also bc free of blood clot. Fith the zinc oxidc iis il IMSP, I IN cauit)- is scaled with enamodent or cement. The tooth should bc carefully watched and x-ray pictures talron ever>- six months; also the T-itality should be tested frequently. If cvctryt hing goes along all right for six months or a year, then a restoration similar t,o the one dew~iiwtl could be placed. Secondary dentin is slowly deposited in t hc canal! and when the I)aticnt is older a more permanent r&oration can ltc made. ‘t’ht: tooth will still remain vital.
AND
RESTORATION
PERMANENT R.
M.
WAY,
OF
FRACTURED
INCISORS”
D.D.S.,
GALESBURG,
ILL.
0
NE of the many distressing situations which occur in a dental office is to The praMem is have a child come in with a fractured permanent ineimr. what to do and how t’o restore the lost contour wit,h some type of restorat*ion which will also appeal from the esthetic standpoint. The many cases we see may be divided for means of discussion into three groups: first, fractured incisors with the pulp not exposed; second, frac.. tured incisors with the pulp exposed and vital; third, fractured incisors with pulps exposed, nonvital, and fully developed a,pices. For example, a patient at the age of nine years has the maxillary permanent incisor fractured. The incisal angle and in&al one-third are lost. The fraetured surface is very sensitive to touch and to cold air. X-ray pictures are t&m, and the rest of the tooth is found to be in a normal condition. It is necessary in such a case to place some protection over the fracture for a period of six months or a year, until the pulp begins to respond by depositing secondax dentin. This condition is taken care af by the following method: The edges of the fracture are smoothed. With a dentimeter gauge the circumference is measured, and a band is constructed of 24K 36 gauge gold. The band is festooned, contoured, and allowed to extend just beneath the free margin of the gum, also to extend incisally, so that when completed it will be just out of occlusion. The lingual part of the band is cut to the desired length (slightly below the fracture), leaving the labial part extended. The lingual surf’nee is burnished and contoured. This part of the extended labial surface is bent over and brought in contact with the lingual, and is soldered. The ineisal edge is burnished to contour before soldering. The incisal edge is filled with solder for strength and the gold cap is then finished and polished. This cap can be cornpletrd in a short time in one appointment. The tooth is isolated and the band cemented to place with copper cement by first placing a layer of zinc oxide and eugenol over the fractured surface. It is important that the cap be short of occlusion. The tooth should be carefully watched, x-ray pictures taken periodically, and the vitality tested frequently. Another method of restoring a tooth of this crown slightly modified, which has a minimum the preparation. If the fracture is not great protection over it, or if the tooth has had a gold is suggested. *Presented
before
the
Knox
County
Dnntal 483
Societ3-,
type is t,o plaoe a three-yuartel amount of tooth destruction in and the pulp has some normal cap for some time, the following Dec.
17, 1934.
484
K. A!. wcrj/
If the child js too young to have any permanent have an!- extensive preparation, the mesial and distal Since it is necessary only to with a saaldpapcr disc. more and no proximal grooves are made. The in&al completing the preparation.
restorat,ion made or to surfaces are paralleled remove the contact, no edge is smoothed, thus
A copper band is fitted and festooned, and an impression is taken with compound in the band. This impression is poured with inlay investment, allowing The model is separated and inlay the investment to extend above the band. investment is added to bring out the lost contour. Kerr wax is ada.pted, 29 gauge over the lingual, in&al, and around the proximal surfaces and extending over the labial margin onto the labial surface. The wax can be easily adapted by first heating the model slightly and using art gum rubber to adapt the wax. This will give a more perfect adaptation. The wax is trimmed and cut to t,he contour of a three-quarter crown on the labial, and sealed to the model around the gingival, on the lingual and proximal surfaces of the tooth. The wax is smoot,hed and polished. VaseIine used on a pellet of cotton will give a high gloss to the wax. The sprue is attached on the incisal edge. The model is soaked in wa.ter, and the whole is invested for casting. Regular casting procedure is followed, allowing for expansion. The crown is cast, and polished, and tried on the tooth. The margins on the labial surface should extend just over the marginal ridge onto the labial surface, so that a minimum amount of gold will show and at the same time offer enough for retention. The margins are trimmed down; however they will not be flush with the tooth surface. The crown is cemented to place using a light colored cement. When the cement is set, the part in the fractured area is cut, out, leaving a thin layer of the cement a.round the inside of the crown, so that when the enamodent or synthetic porcelain is filled in it will not show a discqlored filling. This makes a very neat restorat,ion with a minimum amount of gold showing, and with little tooth destruction. This can be worn by the patient unt,il time for a more permanent restoration. In cases in which the pulp is involved and the patient arrives a short time after the accident, one of two things can be done : first, amputation of the bulbous The latter is done portion of the pulp; or, second, removal of t,he entire pulp. only in cases in which the pulp has died or the x-ray picture shows a completely developed apex. In all other cases a pulp amputation may be done. The tooth will remain vital, and proper normal development of the end of the root will continue. Later a permanent restoration can be placed on a vital tooth. After obtaining an x-ray picture, and being sure that the apical end of the tooth is open and the tooth is vital, the procedure for the pulp amputation is as follows : Isolate the tooth with a rubber dam and use pressure anesthesia. To get the best result,s, a copper band is fitted tightly around the tooth extending above the fracture. A pellet of cotton saturated in phenolated water and then placed in the powder of a crushed E novocaine tablet is placed into the band on the exposure. With a strip of unvulcanized rubber, pressure is applied by packing it into the band, thus forcing the solution into the pulp tissue. The patient should be previously informed that pain will be noted for a second. Test t,hc
pulp with an explorer, and be certain of the anesthesia ; talie a rou11d bn~, slightly smaller than the pulp chamber, and remove about 3 mm. of pulp tissue. -\fter the chamber is cleaned of all debris, it is ready to be tilled. If hcrno~~~~hw,vc occurs, nlil(ac a small pellet, of cotton saturated with formocresol or phenol wmpound in the pulp canal for one minute. The chamhrr is filled with il thicl< mix of zinc oxide and eugcnol. The zinc oxide must bc chemically pure. When packitlg inlo the pulp chamber, be careful not to trap al1~7air under the zinc ositlv, The pulp end must also bc free of blood clot. Fith the zinc oxidc iis il IMSP, I IN cauit)- is scaled with enamodent or cement. The tooth should bc carefully watched and x-ray pictures talron ever>- six months; also the T-itality should be tested frequently. If cvctryt hing goes along all right for six months or a year, then a restoration similar t,o the one dew~iiwtl could be placed. Secondary dentin is slowly deposited in t hc canal! and when the I)aticnt is older a more permanent r&oration can ltc made. ‘t’ht: tooth will still remain vital.