Enamel-dentine fracture

Last updated February 05, 2025

Enamel-dentine fracture is a complete fracture of the tooth enamel and dentine without the exposure of the pulp. Pulp sensibility testing is recommended to confirm pulpal health. Treatment depends on how close the fracture is in relation to the pulp. If a tooth fragment is available, it can be bonded to the tooth. Otherwise, provisional treatment can be done, which the exposed dentine can be covered using glass ionomer cement or a more permanent treatment restoration using dental composite resin or other accepted restorative dental materials. If the exposed dentine is within 0.5mm of the pulp, clinically a pink appearance can be seen. This shows close proximity to the pulp. In this case, calcium hydroxide is used to place at the base and then covered with a material such as ionomer.^[1]

Enamel-dentin fractures are classified broadly under uncomplicated crown fractures. They are represented by visible loss of enamel and dentin without exposing the dental pulp (Patnana & Kanchan, 2021). The core clinical features include feeling of sensitivity and pain in the fractured tooth. Management of these fractures includes restoration of the fractured tooth or root canal treatment in fractured teeth with periapical lesions (The Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries, 2013).

Etiology

Traumatic accidents cause injuries to teeth and oral structures, with a direct or indirect impact.

Falls, which account for 65% of cases (Saber Azami-Aghdash et al., 2015), are the most common etiology for traumatic dental injuries, especially in primary dentition. Trauma to the dentition can occur as a result of sports injuries, cycling accidents, motor vehicle accidents, and physical violence (Peng, 2023).
Dental carious lesions are a predisposing cause of tooth fractures (Lubisich et al., 2010) due to the already weakened and undermined dental hard tissues.
Patients with increased overjet or lip incompetence are also at a higher risk of suffering traumatic injuries in the upper incisors (Schatz et al., 2020).

Epidemiology

Oral traumatic injuries contribute to 5% of body injuries in all age groups. However, they are more frequent in children and also males than females. The most frequently fractured teeth are the maxillary central and lateral incisors due to their anatomic location in the oral cavity (Patnana & Kanchan, 2021). While single tooth fractures are more commonly occurring than multiple teeth fractures. (Deepa Lakshmi et al., 2020)

Classifications/ Types

The common classification for tooth fracture is the Ellis and Davey Classification of tooth fracture (1960). It differentiates tooth fractures based on the extent of damage to tooth surfaces involved. This classification system is used to determine the severity of tooth fractures and to decide the treatment plan accordingly. (Diangelis & Bakland, 1998) Class I – Simple fracture of crown involving only enamel with little or no dentine involvement.

Class II – Extensive fracture of crown involving considerable dentin but not exposing the dental pulp.

Class III – Extensive fracture of crown involving considerable dentin and exposing the dental pulp.

Class IV – The traumatized tooth that becomes nonvital with or without loss of crown structure.

Class V – Total tooth loss—avulsion.

Class VI – Fracture of the root with or without loss of crown structure.

Class VII – Displacement of a tooth with neither crown nor root fracture.

Class VIII – Fracture of crown en masse and its displacement.

Clinical features


Types of fracture	Clinical findings	Radiographic findings
Enamel fracture	Complete fracture of the enamel Loss of enamel with no visible signs of exposed dentin Not tender If tenderness is observed, evaluate the tooth for a possible luxation or root fracture injury Normal mobility Sensibility pulp test is usually positive	Enamel loss is visible Radiographs recommended: periapical and occlusal exposures (to rule out the possible presence of a root fracture or a luxation injury) Radiograph of lip or cheek to search for tooth fragments or foreign materials
Enamel-dentin fracture	A fracture is confined to enamel and dentin with loss of tooth structure, but exposing the pulp Not tender upon percussion test If tenderness is observed, evaluate the tooth for possible luxation or root fracture injury Normal mobility Sensibility pulp test is usually positive	Enamel-dentin loss is visible Radiographs recommended: periapical, occlusal exposures (to rule out tooth displacement or possible presence of root fracture) Radiograph of lip or cheek lacerations to search for tooth fragments of foreign materials

Clinical presentation

Tooth pain during biting or chewing: This discomfort may result from inflammation in the gum and surrounding tissues. The crack can expose the pulp to external stimuli leading to heightened tooth sensitivity and pain during these actions. (José F. Lázaro, 2021)
Increased sensitivity: A cracked tooth can cause heightened sensitivity to temperature and certain foods.
Infections: if a cracked tooth is left untreated, the pulp can become infected. This can result in severe pain and swelling around the affected area. Over time, the infection may spread beyond the tooth to the jawbone and nearby soft tissues, potentially leading to more severe complications. (José F. Lázaro, 2021)
Lack of visible symptoms: Unlike cavities, which can often be identified through visible signs like dark spots or enamel erosion, cracked teeth may not display obvious external indicators. (José F. Lázaro, 2021)

Differential Diagnosis

Enamel fractures (uncomplicated crown fracture) are limited to the enamel without exposing dentin or pulp. This type of fracture is usually located at a proximal angle or the incisal edge of the anterior region. (Olsburgh S, Jacoby T, Krejci I, 2002) Pulp sensibility tests and tooth mobility are usually normal. The radiographic examination will show the extension of the enamel loss. (Patnana & Kanchan, 2023)
Enamel-dentin fractures (uncomplicated crown fracture) exhibit visible loss of enamel and dentin without exposing the dental pulp. When performing a clinical examination, the dentist will usually find a vital tooth with no sensitivity to percussion and no mobility. (Tooth Fracture, Enamel Only/Dentin Exposure, 2024)

Diagnostic evaluation

The clinical diagnosis of enamel and dentin fracture typically involves integrating the patient's medical history with findings from clinical and auxiliary examinations.

1.Bite Test Patients may report severe pain when biting on a cotton roll , swab or tooth slooth with the affected tooth. A hallmark of a fractured tooth is the sharp pain experienced upon the release of occlusal pressure. The nature of occlusal pain (location, direction, and intensity) depends on the crack's depth and orientation (Yu et al., 2022).

2. Vitality Test

Sensitivity to temperature stimuli, particularly cold, often indicates the presence of proximal or near-pulp cracks. A positive response to both cold stimulation and bite tests is suggestive of a cracked tooth (Mathew S et al.,2012)

3. Dye Test Dye application, using agents such as methylene blue can enhance the visibility of cracks (Yu et al., 2022). The dye test is limited in that it can only locate cracks but not assess their progression. Additionally, bacterial infiltration of cracks can cause discoloration that is difficult to remove, affecting aesthetics and treatment outcomes.

4. Transillumination

Transillumination involves using fiber-optic light to illuminate the tooth surface, with light diffraction at the crack helping to locate it (Chanchala HP et al., 2022).

5. Microscope detection

Cracks with width less than 18 µm are difficult to detect with the naked eye, making dental microscopes an essential tool for crack identification.

6. Periodontal Probing

Narrow, deep periodontal pockets at a suspicious tooth site may indicate a subgingival crack. The depth of the pocket can indirectly reflect the crack's subgingival extension. Studies indicate that teeth with probing depths greater than 4 mm due to cracks are more prone to pulp necrosis (Bajaj et al., 2016).

7. Radiographic examination

a. Periapical Radiographs

These provide detailed 2D images of the tooth and can detect fractures extending into dentin but may miss subtle enamel-only cracks due to their limited resolution.

b. CBCT

CBCT offers 3D imaging with high spatial accuracy, ideal for locating and assessing fractures extending into dentin or adjacent structures. c. Micro CT

MicroCT has a high detection accuracy, capable of identifying cracks with widths ranging from a few tenths to tens of microns. It is widely regarded as the gold standard for detecting cracks in research on cracked teeth.

Treatments and Management

1. Apply MTA Liner (if complicated crown fracture)

If the fracture is close to the pulp, the dentist may apply a layer of MTA to protect the area and encourage healing

2. Preparation for Restoration

An acid etchant is applied to clean the exposed dentin and improve the bonding process. A bonding agent is then used to form a secure base for the restoration material.

3. Repairing the Tooth

A tooth-colored material such as composite resin or glass ionomer is applied to rebuild and protect the tooth.

4. Final Polishing and Shaping

Shape and polish the restoration material to match the natural contours of the tooth, ensuring smoothness and a natural appearance.

Tooth fractures if left untreated, can lead to complications like pulp necrosis (death of the tooth's pulp), root resorption, or periapical abscesses (infection around the tooth’s root) under rare circumstances. (Bourguignon et al., 2020) To avoid these issues, regular follow-up appointments are essential.

Complications

Pulpal Complications: a) Pulpitis: This is inflammation of the pulp tissue due to irritation from bacterial infiltration, trauma, or exposure to oral fluids through the dentin tubules. b) Pulp Necrosis: The pulp tissue dies as a result of untreated pulpitis or direct trauma.
Infection: If bacteria penetrate the dentin and reach the pulp, it can lead to abscess formation or other periapical (around the root tip) infections. This can result in swelling, pain, and possible tooth loss if left untreated. (Yu CY, Abbott PV, 2016)
Discoloration: A tooth that has undergone trauma may gradually change color. This is often due to internal bleeding or necrosis of the pulp tissue, resulting in a grey, yellow, or dark hue. (Yu CY, Abbott PV, 2016)
Secondary Caries: Exposed dentin is more prone to bacterial colonization, leading to the risk of developing caries at the fracture site, especially if oral hygiene is compromised. (Yu CY, Abbott PV, 2016)
Hypersensitivity: Dentin exposure can cause ongoing sensitivity to temperature changes, sweet or acidic foods, and even air. This occurs because the dentinal tubules are exposed, transmitting stimuli directly to the pulp. (Yu CY, Abbott PV, 2016)
Loss of Tooth Structure: If not treated, the fracture may worsen over time, leading to further breakdown of the enamel and dentin, potentially resulting in the need for more extensive restorative treatments like crowns or extractions. (Yu CY, Abbott PV, 2016)

Related Research Articles

<span class="mw-page-title-main">Human tooth</span> Calcified whitish structure in humans mouths used to break down food

Human teeth function to mechanically break down items of food by cutting and crushing them in preparation for swallowing and digesting. As such, they are considered part of the human digestive system. Humans have four types of teeth: incisors, canines, premolars, and molars, which each have a specific function. The incisors cut the food, the canines tear the food and the molars and premolars crush the food. The roots of teeth are embedded in the maxilla or the mandible and are covered by gums. Teeth are made of multiple tissues of varying density and hardness.

Dentin or dentine is a calcified tissue of the body and, along with enamel, cementum, and pulp, is one of the four major components of teeth. It is usually covered by enamel on the crown and cementum on the root and surrounds the entire pulp. By volume, 45% of dentin consists of the mineral hydroxyapatite, 33% is organic material, and 22% is water. Yellow in appearance, it greatly affects the color of a tooth due to the translucency of enamel. Dentin, which is less mineralized and less brittle than enamel, is necessary for the support of enamel. Dentin rates approximately 3 on the Mohs scale of mineral hardness. There are two main characteristics which distinguish dentin from enamel: firstly, dentin forms throughout life; secondly, dentin is sensitive and can become hypersensitive to changes in temperature due to the sensory function of odontoblasts, especially when enamel recedes and dentin channels become exposed.

Toothaches, also known as dental pain or tooth pain, is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases. When severe it may impact sleep, eating, and other daily activities.

Tooth whitening or tooth bleaching is the process of lightening the colour of human teeth. Whitening is often desirable when teeth become yellowed over time for a number of reasons, and can be achieved by changing the intrinsic or extrinsic colour of the tooth enamel. The chemical degradation of the chromogens within or on the tooth is termed as bleaching.

The pulp is the connective tissue, nerves, blood vessels, and odontoblasts that comprise the innermost layer of a tooth. The pulp's activity and signalling processes regulate its behaviour.

Pulpitis is inflammation of dental pulp tissue. The pulp contains the blood vessels, the nerves, and connective tissue inside a tooth and provides the tooth's blood and nutrients. Pulpitis is mainly caused by bacterial infection which itself is a secondary development of caries. It manifests itself in the form of a toothache.

<span class="mw-page-title-main">Dentinogenesis imperfecta</span> Genetic disorder impairing tooth development

Dentinogenesis imperfecta (DI) is a genetic disorder of tooth development. It is inherited in an autosomal dominant pattern, as a result of mutations on chromosome 4q21, in the dentine sialophosphoprotein gene (DSPP). It is one of the most frequently occurring autosomal dominant features in humans. Dentinogenesis imperfecta affects an estimated 1 in 6,000-8,000 people.

A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source. Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency.

Dentin hypersensitivity is dental pain which is sharp in character and of short duration, arising from exposed dentin surfaces in response to stimuli, typically thermal, evaporative, tactile, osmotic, chemical or electrical; and which cannot be ascribed to any other dental disease.

Dens evaginatus is a rare odontogenic developmental anomaly that is found in teeth where the outer surface appears to form an extra bump or cusp.

Dentin dysplasia (DD) is a rare genetic developmental disorder affecting dentine production of the teeth, commonly exhibiting an autosomal dominant inheritance that causes malformation of the root. It affects both primary and permanent dentitions in approximately 1 in every 100,000 patients. It is characterized by the presence of normal enamel but atypical dentin with abnormal pulpal morphology. Witkop in 1972 classified DD into two types which are Type I (DD-1) is the radicular type, and type II (DD-2) is the coronal type. DD-1 has been further divided into 4 different subtypes (DD-1a,1b,1c,1d) based on the radiographic features.

In dentistry, the hydrodynamic or fluid movement theory is one of three main theories developed to explain dentine hypersensitivity, which is a sharp, transient pain arising from stimuli exposure. It states that different types of stimuli act on exposed dentine, causing increased fluid flow through the dentinal tubules. In response to this movement, mechanoreceptors on the pulp nerves trigger the acute, temporary pain of dentine hypersensitivity.

<span class="mw-page-title-main">Pulpotomy</span> Dental procedure to clean out diseased inner tissue from a primary tooth

Pulpotomy is a minimally invasive procedure performed in children on a primary tooth with extensive caries but without evidence of root pathology. The minimally invasive, endodontic techniques of vital pulp therapy (VPT) are based on improved understanding of the capacity of pulp tissues to heal and regenerate plus the availability of advanced endodontic materials. During caries removal, this results in a carious or mechanical pulp exposure from the cavity. During pulpotomy, the inflamed/diseased pulp tissue is removed from the coronal pulp chamber of the tooth, leaving healthy pulp tissue which is dressed with a long-term clinically successful medicament that maintains the survival of the pulp and promotes repair. There are various types of medicament placed above the vital pulp such as Buckley's Solution of formocresol, ferric sulfate, calcium hydroxide or mineral trioxide aggregate (MTA). MTA is a more recent material used for pulpotomies with a high rate of success, better than formocresol or ferric sulfate. It is also recommended to be the preferred pulpotomy agent in the future. After the coronal pulp chamber is filled, the tooth is restored with a filling material that seals the tooth from microleakage, such as a stainless steel crown which is the most effective long-term restoration. However, if there is sufficient remaining supporting tooth structure, other filling materials such as amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less. The medium- to long-term treatment outcomes of pulpotomy in symptomatic permanent teeth with caries, especially in young people, indicate that pulpotomy can be a potential alternative to root canal therapy (RCT).

Cracked tooth syndrome (CTS) is where a tooth has incompletely cracked but no part of the tooth has yet broken off. Sometimes it is described as a greenstick fracture. The symptoms are very variable, making it a notoriously difficult condition to diagnose.

Vertical root fractures are a type of fracture of a tooth. They can be characterized by an incomplete or complete fracture line that extends through the long axis of the root toward the apex. Vertical root fractures represent between 2 and 5 percent of crown/root fractures. The greatest incidence occurs in endodontically treated teeth, and in patients older than 40 years of age.

Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion. It is often the result of many cases of dental trauma, caries and irreversible pulpitis.

<span class="mw-page-title-main">Dental trauma</span> Medical condition

Dental trauma refers to trauma (injury) to the teeth and/or periodontium, and nearby soft tissues such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.

Enamel infractions are microcracks seen within the dental enamel of a tooth. They are commonly the result of dental trauma to the brittle enamel, which remains adherent to the underlying dentine. They can be seen more clearly when transillumination is used.

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

$<span class="mw-page-title-main">Enamel fracture</span> Cracking the outermost layer of a tooth without exposing the inner layers$

An enamel fracture is when the outermost layer of the tooth is cracked, without damaging the inner layers including the dentine or pulp. This can happen from trauma such as a fall where the teeth are impacted by a hard object causing a chip to occur.

References

↑ "Dental Trauma Guide".

This dentistry article is a stub. You can help Wikipedia by expanding it.

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.

[1] "Dental Trauma Guide".

[1]