Crown-Root Fracture (Uncomplicated): Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Crown-Root Fracture (Uncomplicated) Example

Chief Complaint: ______________________________

‍History of Trauma

• Date and Time: ______________________________
• Location of Injury: ___________________________
• Mechanism of Injury: (e.g., fall, sports, accident): ____________________________
• Initial Care Provided: ________________________

Medical History

• Allergies: _________________________________
• Medications: ______________________________
• Tetanus Status: ___________________________
• Relevant Medical History: ______________________

Dental History

• Previous Dental Injuries: ___________________________

Intraoral Findings

Soft Tissues:

• Lacerations: Minor gingival lacerations noted around tooth #8.
• Bleeding: Localized gingival bleeding near the fracture site.
• Swelling: No significant swelling observed.

Tooth Findings:

• Tooth #8:
  • Fracture: Crown-root fracture involving enamel, dentin, and cementum without pulp exposure.
  • Mobility: Coronal fragment showed slight mobility.
  • Displacement: No significant displacement of the coronal fragment.
  • Percussion: Tender to percussion.
  • Sensitivity Testing (cold, electric pulp test): Normal response, indicating pulp vitality.

Radiograph

• Periapical Radiograph:
  • Fracture line extending obliquely from the crown into the coronal portion of the root.
  • No signs of pulp exposure or root fracture beyond the coronal segment.
  • Periodontal ligament space appeared intact apically.

Plan

Immediate Management:

1. Fragment Management:
   • The mobile coronal fragment was carefully removed to prevent irritation or further trauma.
2. Temporary Restoration:
   • Applied a glass ionomer dressing to cover the exposed dentin and protect it from thermal and bacterial irritation.
3. Definitive Restoration Plan:
   • Planned for crown lengthening or orthodontic extrusion to expose sufficient tooth structure for a permanent restoration.
   • Definitive restoration (composite crown or porcelain crown) to be placed after sufficient healing and adjustment.
4. Oral Hygiene:
   • Advised meticulous oral hygiene with gentle brushing to prevent bacterial contamination.
   • Recommended chlorhexidine rinse (0.12%) twice daily for 1 week to promote gingival healing.
5. Medications:
   • Recommended ibuprofen 400-600 mg every 6-8 hours as needed for pain management.

Follow-Up Schedule:

• 2 Weeks: Evaluate healing of soft tissues and stability of temporary restoration.
• 4-6 Weeks: Reassess the tooth for definitive restoration planning (e.g., crown placement or orthodontic extrusion).
• 3-6 Months: Periodic radiographic monitoring for signs of root resorption or other complications.
• 1 Year: Ensure long-term stability of the definitive restoration and evaluate for periodontal health.

Warning About Risks Associated with Dental Trauma

Crown-root fractures, even without pulp exposure, carry risks such as root resorption, periodontal complications, and delayed healing. Regular follow-ups and reporting of symptoms like increased mobility, pain, or discoloration are essential to ensure successful treatment outcomes.

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