Universitas Padjadjaran

DSP9
FKG 2012/2013

Dentoalveolar Fracture
Adlin Illani 160110123010
Evelyn Ho Yen Chiew 160110123011
Tan Zhi Xin 160110123012
Ng Kar Mun 160110123013
Faqiha Nadirah 160110123014
Amreeta Kaur Xavier 160110123015
Law Sui Yng 160110123016
Aisyah Sufian 16011012301

Chapter 1: Introduction

Chapter 2
Literature Review
2.1 Tooth Fracture
2.1.1 Definition
A tooth fracture is a break or crack in the hard shell of the tooth. The outer shell of the tooth is
called the enamel. It protects the softer inner pulp of the tooth that contains nerves and blood
vessels. Depending on the type of fracture, the tooth may not cause any problems or it may cause
pain.
Teeth can crack in several different ways:
Cracked tooth: This type of crack extends from the chewing surface of the tooth vertically
towards the root and sometimes below the gum line. A cracked tooth is not completely split into
two distinct movable segments. If caught early enough, the tooth is usually crowned but
endodontic therapy may be needed at a later date (typically in the first 6 months). Nonsurgical
endodontic therapy (root canal) will be needed when the pulp becomes substantially injured or
exposed. During endodontic therapy the inside crown portion of the tooth is stained with a
temporary dye and viewed microscopically for the extent of the fracture. Prognosis depends on
the severity of the crack. A full crown is needed to hold the tooth together.

Craze lines: Craze lines are tiny cracks that affect only the outer enamel of the tooth. They are
common in all adult teeth and cause no pain. Craze lines need no treatment. They do NOT extend
into dentin. Hence, these cracks are observed in most teeth and are considered normal. They are
the result of "wear and tear" on teeth.Hence, the answer is no, not all cracks seen on the outside
of teeth are bad.

Cuspal fracture: When a cusp or the pointed part of the chewing surface of your tooth becomes
weakened, the cusp will fracture. Part of the cusp may break off or may need to be removed by
your dentist. Depending upon the extent of the fracture, the pulp may also become damaged.

Endodontic therapy is needed when the pulp is damaged beyond repair and a crown will be
placed to help protect the tooth and replace the fractured tooth structure.

Split tooth: A split tooth is a cracked tooth in which the crack has progressed so there are 2
distinct segments that can be separated from one another. Unfortunately, with todays
technology, a split tooth can never be saved intact. The extent and position of the crack will
determine if any portion can be maintained but most of these teeth will be extracted. In rare
instances, endodontic treatment, possibly some gum surgery, and a crown may be used to retain a
portion of the tooth.

2.1.2 Etiology
Teeth are remarkably strong, but they can chip, crack (fracture) or break. This can happen in
several ways:
i) Biting down on something hard
ii) Being hit in the face or mouth
iii) Falling
iv) Having cavities that weaken the tooth
v) Having large, old amalgam fillings that don't support the remaining enamel of the tooth

2.1.3 Classification
Ellis classification (Tooth fractures)
Ellis Class I
Enamel fracture: This level of injury includes crown fractures that extend through the enamel
only. These teeth are usually nontender and without visible color change but have rough edges.
Ellis Class II

Enamel and dentin fracture without pulp exposure: Injuries in this category are fractures that
involve the enamel as well as the dentin layer. These teeth are typically tender to the touch and to
air exposure. A yellow layer of dentin may be visible on examination.

Ellis Class III

Crown fracture with pulp exposure: These fractures involve the enamel, dentin, and pulp layers.
These teeth are tender (similar to those in the Ellis II category) and have a visible area of pink,
red, or even blood at the center of the tooth.

Ellis Class IV
Traumatized tooth that has become non-vital with or without loss of tooth structure.
Ellis Class V
Luxation: The effect on the tooth that tends to dislocate the tooth from the alveolus.
Teeth loss due to trauma.

Ellis Class VI
Avulsion: The complete separation of a tooth from its alveolus by traumatic injury.
Fracture of root with or without loss of crown structure.

Ellis Class VII

Displacement of a tooth without the fracture of crown or root.

Ellis Class VIII

Fracture of the crown en masse and its replacement.
Ellis Class IX
Fracture of deciduous teeth.
2.1.4 Examination, Diagnosis and Treatment
a) Enamel Fracture

(a)

(b)
Figure : Enamel fracture (a), (b)
Source : https://www.rickwilsondmd.typepad.com (a)
https://www.aofoundation.org (b)

Description

A fracture confined to the enamel with loss of tooth

structure.

Visual signs

Visible loss of enamel. No visible sign of exposed dentin.

Percussion test

Not tender. If tenderness is observed evaluate the tooth for

a possible luxation or root fracture injury.

Mobility test

Normal mobility.

Sensibility pulp test

Usually positive. The test may be negative initially

indicating transient pulpal damage. Monitor pulpal
response until a definitive pulpal diagnosis can be made.
The test is important in assessing risk of future healing
complications. A lack of response at the initial examination
indicates an increased risk of later pulp necrosis.

Radiographic findings

The enamel loss is visible.

Radiographs
recommended

Periapical, occlusal and eccentric exposures. They are

recommended in order to rule out the possible presence of a
root fracture or a luxation injury.

Treatment :
If a tooth fragment is available, it can be bonded to the tooth. Grinding or restoration with
composite resin depending on the extent and location of the fracture. Follow up by clinical and
radiographic control at 6-8 weeks and 1 year.

b) Enamel-Dentin Fracture

(a)

Description

(b)
Figure : Enamel-dentin fracture (a), (b)
Source : https://www.intelligentdental.com (a)
https://www.aofoundation.org (b)

A fracture confined to enamel and dentin with loss of tooth

structure, but not involving the pulp.

Visual signs

Visible loss of enamel and dentin. No visible sign of

exposed pulp tissue.

Percussion test

Not tender. If tenderness is observed evaluate the tooth for

possible luxation or root fracture injury.

Mobility test

Normal mobility.

Sensibility pulp test

Usually positive. The test may be negative initially

indicating transient pulpal damage. Monitor pulpal
response until a definitive pulpal diagnosis can be made.
The test is important in assessing future risk of healing
complications. A lack of response at the initial examination
indicates an increased risk of later pulp necrosis.

Radiographic findings

The enamel-dentin loss is visible.

Radiographs
recommended

Periapical, occlusal and eccentric exposure. They are

recommended in order to rule out displacement or the
possible presence of a root fracture.
Radiograph of lip or cheek lacerations to search for tooth
fragments or foreign material.

Treatment :
If a tooth fragment is available, it can be bonded to the tooth. Otherwise perform a provisional
treatment by covering the exposed dentin with glass-ionomer or a permanent restoration using a

bonding agent and composite resin. The definitive treatment for the fractured crown is
restoration with accepted dental restorative materials. Radiograph of lip or cheek lacerations to
search for tooth fragments or foreign material. Follow up by clinical and radiographic control at
6-8 weeks and 1 year.

c) Enamel-Dentin-Pulp Fracture

(a)

(b)
Figure : Enamel-dentin-pulp fracture (a), (b)
Source : https://www.michelle.sisnetusa.com (a)
https://www.aofoundation.org (b)

Description

A fracture involving enamel and dentin with loss of tooth

structure and exposure of the pulp.

Visual signs

Visible loss of enamel and dentin and exposed pulp tissue.

Percussion test

Not tender. If tenderness is observed evaluate the tooth for

luxation or root fracture injury.

Mobility test

Normal mobility.

Sensibility test

Usually positive. The test is important in assessing risk of

future healing complications. A lack of response at the
initial examination indicates an increased risk of later pulp
necrosis.

Radiographic findings

The loss of tooth substance is visible.

Radiographs
recommended

Periapical, occlusal and eccentric exposure. They are

recommended in order to rule out displacement or the
possible presence of a luxation or a root fracture.
Radiograph of lip or cheek lacerations to search for tooth
fragments or foreign material.

Treatment :
In young patients with open apices, it is very important to preserve pulp vitality by pulp capping
or partial pulpotomy in order to secure further root development. This treatment is also the
treatment of choice in patients with closed apices. Calcium hydroxide compounds and MTA
(white) are suitable materials for such procedures. In older patients with closed apices and an
associated luxation injury with displacement, root canal treatment is usually the treatment of
choice. Follow up by clinical and radiographic control at 6-8 weeks and 1 year.

d) Crown-Root Fracture without Pulp Involvement (Uncomplicated)

Figure : Uncomplicated crown-root fracture

Source : https://www.avdc.org

Description

A fracture involving enamel, dentin and cementum with

loss of tooth structure, but not exposing the pulp.

Visual signs

Crown fracture extending below gingival margin.

Percussion test

Tender.

Mobility test

Coronal fragment mobile.

Sensibility pulp test

Usually positive for apical fragment.

Radiographic findings

Apical extension of fracture usually not visible.

Radiographs
recommended

Periapical, occlusal and eccentric exposures. They are

recommended in order to detect fracture lines in the root. A
cone beam exposure can reveal the whole fracture
extension.

Treatment :
Depending on the clinical findings, six treatment scenarios may be considered. Most of these
may be deferred to later treatment.

Fragment removal only

Removal of a superficial coronal crown-root fragment and subsequent restoration of
exposed dentin above the gingival level.

Fragment removal and gingivectomy (sometimes ostectomy)

Removal of coronal segment with subsequent endodontic treatment and restoration with a
post-retained crown. This procedure should be preceded by
a gingivectomy, ostectomy with osteoplasty. This treatment option is indicated in crownroot fractures with palatal subgingival extension.

Orthodontic extrusion of apical fragment

Removal of the coronal segment with subsequent endodontic treatment and orthodontic
extrusion of the remaining root with sufficient length after extrusion to support a postretained crown.

Surgical extrusion
Removal of the mobile fractured fragment with subsequent surgical repositioning of the
root in a more coronal position. A rotation of the root (90 or 180) may offter a better
position for periodontal ligament healing. Because the fracture site becomes exposed
labially and thereby more periodontal ligament can be saved.

Decoronation (Root submergence)

Implant solution is planned, the root fragment may be left in situ after in order to avoid
alveolar bone resorption and thereby maintaining the volume of the alveolar process for
later optimal implant installation.

Extraction
Extraction with immediate or delayed implant-retained crown restoration or a
conventional bridge. Extraction is inevitable crown-root fractures with a severe apical
extension, the extreme being a vertical fracture.

Patient is instructed to only have soft food for 1 week. Good healing following an injury to the
teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and
rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.
Follow up is necessary after 6-8 weeks and 1 year.

e) Crown-Root Fracture with Pulp Involvement (Complicated)

Figure : Complicated crown-root fracture

Source : https://www.dentaltraumaguide.org

Description

A fracture involving enamel, dentin, and cementum with

loss of tooth structure, and exposure of the pulp.

Visual signs

Crown fracture extending below gingival margin.

Percussion test

Tender.

Mobility test

Coronal fragment mobile.

Sensibility test

Usually positive for apical fragment.

Radiographic findings

Apical extension of fracture usually not visible.

Radiographs
recommended

Periapical and occlusal exposure. A cone beam exposure

can reveal the whole fracture extension.

Treatment :

Fragment removal and gingivectomy (sometimes ostectomy)

Orthodontic extrusion of apical fragment

Surgical extrusion

Decoronation (Root submergence)

Extraction

Patient instructions and follow up are similar as for crown-root fracture without pulp
involvement.
f) Root Fracture

Figure : Root fracture

Source : https://www.aofoundation.org

Description

A fracture confined to the root of the tooth involving

cementum, dentin, and the pulp. Root fractures can be
further classified by whether the coronal fragment is
displaced.

Visual signs

The coronal segment may be mobile and in some cases

displaced. Transient crown discoloration (red or grey) may
occur. Bleeding from the gingival sulcus may be noted.

Percussion test

The tooth may be tender.

Mobility test

The coronal segment may be mobile.

Sensibility pulp test

Sensibility testing may give negative results initially,

indicating transient or permanent neural damage.

Monitoring the status of the pulp is recommended.

The pulp sensibility test is usually negative for root

fractures except for teeth with minor displacements. The
test is important in assessing risk of healing complications.
A positive sensibility test at the initial examination
indicates a significantly reduced risk of later pulp necrosis.
Radiographic findings

The root fracture line is usually visible. The fracture

involves the root of the tooth and is in a horizontal or
diagonal plane.

Radiographs

Periapical, occlusal and eccentric exposures.

recommended
An occlusal exposure is optimal for locating root fractures
in the apical and middle third. Bisecting angle exposure or
90o degree angulation exposure is needed to locate the
fractures in the cervical third of the root.
Treatment :

Rinse exposed root surface with saline before repositioning. If displaced, reposition the
coronal segment of the tooth as soon as possible.

Check that correct position has been reached radiographically.

Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the
cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4
months).

Monitor healing for at least 1 year to determine pulpal status. If pulp necrosis develops,
then root canal treatment of the coronal tooth segment to the fracture line is indicated.

Patient instructed to have soft food for 1 week. Good healing following an injury to the teeth and
oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.
Follow up :

Splint removal and clinical and radiographic control after 4 weeks in apical third and
mid-root fractures. However, if the root fracture is near the cervical area the splint should
be kept on for up to 4 months.

Clinical and radiographic control after 6-8 weeks.

Clinical and radiographic control after 4 months. If the root fracture is near the cervical
area the splint should be removed at this session.

Clinical and radiographic control after 6 months, 1 year and yearly for 5 years.

Follow-up may include endodontic treatment of the coronal fragment if pulp necrosis
develops. The decision for endodontic treatment may be taken after three months of

follow-up if the tooth still does not respond to electrometric or thermal pulp testing and if
radiographs show a radiolucency next to the fracture line.
2.2Tooth Discoloration
2.2.1 Definition

Ingle defines tooth discoloration as any changes in the hue, colour or translucency of a
tooth due to any cause such as restorative filling materials, drugs (both topical &
systemic), pulpal necrosis or hemorrhage may be responsible. Tooth discoloration also
known as Darkening of Teeth. Teeth become discoloured by stains on the tooth surface.
A stain is a discoloured spot or area.Tooth discoloration can occur on the outer layer of

2.2.2

the tooth, enamel or on the inner layer of the tooth, dentin.

Etiology
Tooth discoloration can be caused by certain foods and drinks, poor dental hygiene,
smoking or chewing tobacco, caries means cavities, certain infectious in pregnant
mothers, several disease that can affect enamel and dentin, dental product used in

2.2.3

dentistry, certain medications, excessive fluoride, trauma and normal aging

Types

There are three types of tooth discoloration. Firstly, extrinsic stains. This occurs when the outer
layer of the tooth meant the enamel is stained. Coffee, wine, cola or other drinks or foods can
stain teeth. Smoking also causes extrinsic stains.
Next is intrinsic stains. This is when the inner structure of the tooth (the dentin) darkens or gets a
yellow tint. You can get this type of discoloration if, patient had too much exposure to fluoride
during early childhood. Pregnant women used tetracycline antibiotics during the second half of
pregnancy. Patient used tetracycline antibiotics when you were 8 years old or younger. Patient

had trauma that affected a tooth when you were a young child. A fall, for example, may damage
the developing permanent tooth. Patient had trauma in a permanent tooth, and internal bleeding
discolored the tooth. Lastly,patient were born with a rare condition called dentinogenesis
imperfecta. This causes gray, amber or purple discolorations.
Last but not least is age-related. This is a combination of extrinsic and intrinsic factors. Dentin
naturally yellows over time. The enamel that covers the teeth gets thinner with age, which allows
the dentin to show through. Foods and smoking also can stain teeth as people get older. Finally,
chips or other injuries can discolor a tooth, especially when the pulp has been damaged
2.2.4

Treatment

A healthy smile improves self images and confidence and indicates good overall health. Today
dentists have many treatment modalities to improve the appearance of smile.
Superficial stains or extrinsic stains are removed by simple professional scale and polish done by
the dentist. An ultrasonic scaler is used to remove the stains and polishing is done with pumice.
Deep embedded stains or intrinsic stains cannot be removed by scale and polish techniques and
require tooth whitening treatment.
Tooth whitening. This procedure is done only in cases of mild fluorosis. It is also known as
Tooth Bleaching. This is common procedure in the field of cosmetic dentistry. Bleaching is
done by bleaching strips, bleaching pen, bleaching gel, laser bleaching and natural bleaching.
First the dentist, applies gel on the gums to protect the soft tissue from irritation. Ten the
whitening product is applied to the tooth. This product contains hydrogen peroxide or carbamide
peroxide. As this product is broken down oxygen gets into the enamel on the teeth and the tooth

color is made lighter. As a result of bleaching there may be temporary tooth sensitivity to heat
and cold and gum irritation may be present.
In the case of inherited or developmental stains, these types of stains cannot be removed by teeth
whitening. In such cases veneers and composite bonding may be the only option. Composite
bonding, in this procedure, plastic material or resin material which matches the color of the tooth
is applied. It is then bonded onto the tooth using a special kind of light. Other treatment is
veneers. In this treatment a thin wafer like tooth colored material known as porcelain veneer or
porcelain laminate is designed to cover the front portion of the teeth.
Prognosis for extrinsic stains is good. Intrinsic stains however may be more difficult or take
longer to remove.
2.3 Crown
2.3.1 Definition
A crown is an artificial restoration that fits over the remaining part of a prepared tooth, - to cover
the tooth to restore its shape and size, strength, and improve its appearance. The crowns, when
cemented into place, fully encase the entire visible portion of a tooth that lies at and above the
gum line. For anterior teeth, they are sometimes termed as jacket while for posterior teeth, they
are termed as crown.

Figure 1. Posterior Crown. (Source : www.doctoradrian.com)

2.3.2 Indication
1. To protect a weak tooth from breaking or to hold together parts of a cracked tooth.
2. To restore an already broken tooth or a tooth that has been severely worn down.
3. To cover and support a tooth with a large filling when there isn't a lot of tooth left.
4. To hold a dental bridge in place.
5. To cover misshapened or severely discolored teeth.
6. To cover a dental implant or endodontic treatment.
7. To make a cosmetic modification.

Figure 2. Before and after anterior teeth restoration using porcelain jackets. (Source: Dr. Mark
Bilelo www.houmacomprehensivedentistry.com)

Figure 3. 3-unit Dental Bridge. (Source:www.wawaseefamilydentistry.com)

Figure 4. Before and after cosmetic restoration using jackets and crowns on the whole lower jaw.
(Source: www.hubertydental.com)

Figure 5. Before and after cosmetic restoration using jackets on anterior maxillary teeth.
(Source: www.drsellinger.com)

2.3.3 Types

In Terms of Support
Tooth Support
Teeth with enough tooth support will be prepared to receive the crowns. The Support for the
crown is provided by the tooth itself.

Figure 6. Preparation for posterior crown on premolar. (Source: teethgeek.com)

Figure 7. Preparation of posterior teeth. (Source: Aqeel Reshamvala)

Post/ Core Support

In root-filled teeth it may be necessary to insert a post into the tooth root before placing a crown.
A post gives support and helps the crown to stay in place. The surface of the tooth may be
removed down to the level of the gum. A post can be made of prefabricated stainless steel which
the dentist can fit directly into the root canal. Or a custom-made post can be constructed by a
dental technician to accurately fit the shape of the prepared root canal. The post is placed into the
root canal and cemented in position, ready for the crown to be attached.

Figure 8. Prepared and cemented core in an endodontically treated tooth. (Source:

www.schweitzerdental.com)

In Terms of Material
Permanent crowns can be made from stainless steel, all metal (such as gold or another alloy),
porcelain-fused-to-metal, all resin, or all ceramic.

Stainless steel crowns are prefabricated crowns that are used on permanent teeth
primarily as a temporary measure. The crown protects the tooth or filling while a
permanent crown is made from another material. For children, a stainless steel crown is
commonly used to fit over a primary tooth that's been prepared to fit it. The crown covers
the entire tooth and protects it from further decay. When the primary tooth comes out to
make room for the permanent tooth, the crown comes out naturally with it. In general,
stainless steel crowns are used for children's teeth because they don't require multiple
dental visits to put in place and so are more cost- effective than custom-made crowns and
prophylactic dental care needed to protect a tooth without a crown.

Figure 9. Stainless steel crown. (Source: www.brantavenuedental.com)

Metals used in crowns include gold alloy, other alloys (for example, palladium), or a
base-metal alloy (for example, nickel or chromium). Compared with other crown types,
less tooth structure needs to be removed with metal crowns, and tooth wear to opposing

teeth is kept to a minimum. Metal crowns withstand biting and chewing forces well and
probably last the longest in terms of wear down. Also, metal crowns rarely chip or break.
The metallic color is the main drawback. Metal crowns are a good choice for out-of-sight
molars.

Figure 10. Full gold crown. (Source: drmartharich.com)

Porcelain-fused-to-metal dental crowns can be color matched to your adjacent teeth

(unlike the metallic crowns). However, more wearing to the opposing teeth occurs with
this crown type compared with metal or resin crowns. The crown's porcelain portion can
also chip or break off. Next to all-ceramic crowns, porcelain-fused-to-metal crowns look
most like normal teeth. However, sometimes the metal underlying the crown's porcelain
can show through as a dark line, especially at the gum line and even more so if your
gums recede. These crowns can be a good choice for front or back teeth.

Figure 11. Porcelain-fued-to-metal crown. (Source: www.a-1dentallab.com)

All-resin dental crowns are less expensive than other crown types. However, they wear
down over time and are more prone to fractures than porcelain-fused-to-metal crowns.

Figure 12. All-resin crown. (Source: www.bloubergdental.co.za)

All-ceramic or all-porcelain dental crowns provide better natural color match than any
other crown type and may be more suitable for people with metal allergies. However,
they are not as strong as porcelain-fused-to-metal crowns and they wear down opposing
teeth a little more than metal or resin crowns. All-ceramic crowns are a good choice for
front teeth.

Figure 13. All-porcelain bridge. (Source: www.drchetan.com)

Temporary versus permanent. Temporary crowns can be made in your dentist's office,
whereas permanent crowns are made in a dental laboratory. Temporary crowns are made
of acrylic or stainless steel and can be used as a temporary restoration until a permanent
crown is constructed by a lab.

Figure 14. Temporary crowns. (Source: www.smartpractice.com)

Zirconia or milled crown which are digitally constructed either in an office that has the
software and hardware to produce them or in a dental lab. Dental offices that have the
software and hardware have the ability to produce a crown in one visit with no need for a
temporary. These crowns require no impression.

Figure 15. Zirconia crown and bridge. (Source: www.glidewelldental.com)

2.3.4

Cotraindication

1. General conditions that make anesthesia or tooth preparation inadvisable

These include: serious heart diseases, recent strokes and others. These situations require a
medical examination performed by the appropriate specialist.

2. When the tooth can be restored with fillings or other restorations

When a tooth can be restored with other types of restorations that do not involve such an
extensive preparation (such as composite fillings, inlays, onlays or veneers). Crowning will
destroy a significant amount of dental tissues.

2.3.5 Procedure
The crowning process usually includes two separate appointments (two visits).
The first appointment involves: 1) Preparing (shaping) the tooth, 2) Taking its impression
and 3) Placing a temporary crown. Time needed to perform these steps range from 30 minutes to
an hour. During the time period (about two weeks) between the two appointments, a dental

laboratory will fabricate the crown. When the patient returns for their second visit, dentist will
cement finished crown into place. This usually completed in about 20 minutes or so.

Initial Appointment
1. Numbing the tooth
Anesthetize both tooth and gum tissue that surrounds it. Numbing is not needed if there is
root canal treatment.

2. Preparing (Shaping) the tooth

(a) A specific amount of tooth structure must be trimmed away
All crowns need to have a certain minimal thickness to insure adequate strength. For
porcelain crowns, enough ceramic thickness is needed to create a life-like translucency. Most
cowns need a minimal thickness of two millimetres.Trimming process must remove any decay
(or filling material) that present along with tooth structure.
(b) The prepared tooth must have a specific shape
The tooth must has a slightly tapered form, so the crown (a hard object that can't flex) can
be slipped over it.

(c) The tooth's shape helps to insure the crown's retention and stability
The shape of the tooth on which it sits plays a significant role in providing stability and
retention. The larger the nub of tooth that extends up into the interior of a crown and the more
parallel the opposite sides of the nub are, the better it will stay in place.

3. Taking impression of prepared tooth - Conventional dental impressions

Most dentists will take an impression of your tooth using a paste or putty-like compound
that referred as "impression material."
a. The prepared tooth is washed and dried
b. Retraction cord is tucked around the tooth in the space between it and its
surrounding gum tissue
c. A small amount of runny impression material is squirted around the tooth
d. A tray that's been filled with a thick impression putty is then squished over the
tooth and its neighboring teeth and allowed to sit for some minutes
e. As impression materials set, they fuse together into a single unit.
f. When removed from the mouth, the impression contains a copy of both the prepared tooth and
the teeth on that jaw
An impression of the opposing teeth will need to be taken too. Completed impression is
sent to a dental laboratory where plaster cast is created for fabrication of crown. Amount of time
needed to fabricate a crown is usually two weeks.

4. Placing a temporary crown

Temporary crown protect your tooth and keep it from shifting position.
They are usually made out of plastic or possibly metal. A temporary crown is cemented using
"temporary" cement, so it can be removed easily and predictably at your next appointment.

5.

Choosing shade for your crown

Source: Animate-Teeth.com
Dentist will judge what shade of ceramic most closely matches your tooth's neighboring
teeth using shade guide (a series of small, tooth-shaped pieces of dental porcelain, each one
having a different color).

Crown Placement Appoinment

1. Remove temporary crown
Temporary crown is removed and remnants of temporary cement that remain on your
tooth is cleaned.

2. Evaluate the fit and appearance of the crown

(a) Checking the fit
Dentist will seat the crown on tooth and inspect that it fits (possibly by using dental floss,
feeling it with a dental tool, or asking patient to bite down gently).

(b) Checking the appearance

Dentist will likely hand patient a mirror and ask to evaluate the crown's overall shape and
color.

3. Cementing the crown

Source: Animate-Teeth.com
Dental cement is first placed inside the crown and then seat it over the tooth. Dental tool
is used to scrape away any excess that extruded from underneath the edges of the crown.

2.4 ADLIN
2.5 Clinical tests (for more information)
2.5.1 Periradicular Tests
1. Palpation
Palpation test is done with finger tip using light pressure to examine tissue consistency and pain
response. One can identify the presence, intensity and location of pain, presence of location of
adenopathy, presence of bone crepitus or tissue fluctuation or enlargement. However, when
infection confined to pulp palpation is not diagnostic.
2. Percussion
The tooth is struck with a quick, moderate blow initially with low intensity by the finger, then
with increasing intensity by using handle of instruments. A positive response indicates presence
of inflammation of the periodontal ligament and the degree of its inflammation
2.5.2 Pulp vitality test

Pulp testing is often referred to as vitality testing. Pulp vitality tests play an important role in
diagnosis because these tests not only determine the vitality of tooth but also the pathological
status of pulp. The dentist should include control teeth of similar type for the first application of
any test, to establish a baseline for response. The patient should not be told beforehand.
Some pulp testing techniques include:

gutta percha stick

Ice sticks and CO2 snow
Dicholoro-difloromethane
Ethyl chloride spray
Electric pulp tester
Radiographs
Tooth sloth

1. Cold test
Can be done with air blast, cold water bath, ethylchloride sticks of ice, carbon dioxide ice
stick. The cold test is kept in contact with tooth for 5 seconds or until pain is elicited. Carbon
dioxide snow causes infarction lines in enamel. Hence, aerosol of dichloro-difluoro-methane
was introduced to substitute carbon dioxide snow
2. Heat test
Types of heat test include hot air, Hot water, Hot burnisher, Hot gutta percha, Hot compound
Responses to the thermal tests
No response
Mild to moderate degree of pain that subsides within 1-2 sec after stimulus
has been removed
Strong, momentary painful response that subsides within 1-2 secs after
stimulus is removed
Moderate to strong painful response that lingers for several seconds or
longer after stimulus has been removed

Non-vital pulp
Normal
Reversible
pulpitis
Irreversible
pulpitis

3. Electric pulp tests (EPT)

EPT is designed to stimulate a response of sensory fibers within the pulp by electric excitation.
The disadvantages are that it cannot be used on patients with cardiac pace maker. It also does not
suggest the health or integrity of the pulp, simply indicates the presence of vital sensory fibers

within the pulp or provide any information about the vascular supply of the pulp which is the
true determinant of pulp vitality.
False positive response with EPT, whereby the pulp is necrotic but the patient has positive
sensation could be due to:

Electrode or conductor in contact with metal restoration or gingiva

Liquefaction necrosis may conduct current to attachment apparatus
Failure to isolate and dry the tooth ( saliva)

False Negative Response with EPT whereby the pulp is vital, but patient gives no response
couldb e due to:
Patients heavily medicated with analgesics, alcohol or tranquilizers
Inadequate contact with electrode or conductor and enamel
Recently traumatized tooth
Excessive canal calcification
Recently erupted tooth with immature apex
4. Anesthetic Test
It is performed when usual tests have failed to enable one the identify the tooth. The objective is
to anaesthetize a single tooth at a time until the pain disappears and is localized to specific tooth
5. Test cavity
Only performed when other methods have failed. Test cavity is made by drilling through enamel
dentin junction of un-anaesthetized tooth. Sensitivity or pain felt is an indication of pulp vitality
6. Sloth test
This test helps if patient complains of pain on mastication. Tooth is sensitive to biting if pulpal
necrosis has extended to the periodontal ligament space of if a crack is present in a tooth. In this,
patient is asked to bite on a hard objects such as as cotton swab, tooth pic, tooth sloth or orange
wood stick with suspected tooth and the contralateral tooth
2.5.3 Mobility test
1. Horizontal mobility
Rationale of mobility test is the evaluate the integrity of the attachment apparatus surrounding
the tooth. Test consist of moving the involved tooth facio-lingually using handles or two
instruments or using the two index fingers
2. Depressibility test
Test for depresssiblity is performed by applying pressure in an apical direction on the occlusal/
incisal aspect of tooth and observing vertical movement if any.

2.5.4 Radiographic examination

Radiographic examination allows identification of:

Presence of caries that may involve or threat to involve pulp

May show the number ,curve, length and width of root canals
Presence of calcified materials in the pulp chamber or root canals
Resorption of dentin
Thickening of PDL
Maturity and extent of periapical and alveolar bone destruction

http://www.slideshare.net/dr_mzs/diagnostic-procedures-11925025?related=1

Chapter 3: Case Report

3.1Anamnesis
3.2 Examination

Chapter 4:Discussion
4.1Treatment
4.2 Conclusion