Complicated crown fracture of an upper central incisor in a schoolboy

§Chief complaint

Broken front tooth with a bleeding pink spot after falling in the playground

§Medical & dental history

• 01Healthy, immunisations up to date including tetanus
• 02No previous trauma; 11 immature with an open apex

§Clinical examination

• 01Oblique crown fracture of 11 involving enamel, dentine and a 1.5 mm pinpoint pulp exposure
• 02Tooth not mobile or displaced; percussion mildly tender
• 03Lower lip abrasion, no embedded fragments on soft tissue radiograph
• 04No other dental injuries; alveolus intact

§Figures

§Differential diagnosis

§Final diagnosis

Complicated crown fracture of 11 with an immature open apex

Pulp exposure in an immature permanent incisor within hours of injury is best managed by vital pulp therapy rather than pulpectomy, to allow continued root development (apexogenesis).

§Investigations

• 01Pulp sensibility testing of 11, 12, 21 — baseline recorded (unreliable early after trauma)
• 02Soft tissue radiograph of the lip to exclude retained fragments
• 03Photographs for records and possible medico-legal use

§Radiology

• 01IOPA 11 — open apex, wide root canal, no root fracture, intact periapical tissues
• 02Occlusal view — no alveolar fracture

§Treatment plan

• 01Partial (Cvek) pulpotomy with calcium silicate cement within 24 hours
• 02Composite restoration or reattachment of the fragment
• 03Regular vitality and radiographic review for 5 years

§Surgical procedure

• 01Rubber dam isolation, 2 mm of inflamed pulp removed with a high-speed diamond under saline irrigation
• 02Haemostasis with sterile saline-moistened cotton, calcium silicate cement placed, sealed with glass ionomer and composite

§Follow-up & outcome

• 016-8 weeks — asymptomatic, responds to cold
• 026 months — continued root development on radiograph
• 0312 and 24 months — apex closing, no periapical change; annual review to 5 years

Outcome: Pulp vitality maintained with complete root development and a stable composite restoration.

§Discussion

• 01Cvek pulpotomy has success rates above 90% when performed early in a clean exposure with healthy remaining pulp.
• 02Maintaining vitality in an immature tooth preserves dentine thickness and greatly reduces future root fracture risk.
• 03Follow-up must be long term — pulp necrosis and resorption can appear years later.

§Clinical pearls / learning points

• 01Immature tooth + pulp exposure = preserve vitality, do not pulpectomise reflexively.
• 02Always radiograph the lip when a fragment is unaccounted for.

§Viva questions

§MCQs

§Related diseases

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