What is the treatment for a patient with a fractured tooth and no significant medical history or allergies?

Treatment of Fractured Tooth

The treatment of a fractured tooth depends entirely on the depth of the fracture: enamel-only fractures require only smoothing of sharp edges or no treatment, enamel-dentin fractures need dental referral within a few days for restoration, and fractures with visible pulp exposure require immediate same-day dental referral to preserve tooth vitality. 1

Initial Assessment: Determine Fracture Depth

The first critical step is identifying which layer of the tooth is involved, as this dictates urgency and treatment 1:

• Enamel-only (infraction): Superficial crack or chip, white surface only, no sensitivity 1
• Enamel-dentin fracture: Yellowish dentin visible beneath white enamel, temperature sensitivity present 1
• Complicated crown fracture: Red pulp tissue visible in center of fracture, typically painful 2, 1
• Root fracture: Excessive tooth mobility suggests root involvement, requires radiographic confirmation 2

Treatment Algorithm by Fracture Type

Enamel-Only Fractures (Infractions)

Smooth sharp edges with a dental handpiece and polishing bur, or leave untreated if the fracture site is smooth to touch. 2, 1

• This does not require immediate attention unless a sharp edge is causing soft tissue injury 2
• Monitor the tooth for signs of pulpal necrosis (gray discoloration, gum swelling, parulis formation) 1, 3
• Placing a resin sealant over the crack line may prevent staining 2

Enamel-Dentin Fractures (Uncomplicated Crown Fractures)

Refer to a dentist within a few days for restoration with tooth-colored dental material to cover exposed dentin and prevent bacterial contamination. 2, 1

• If the patient's behavior precludes restorative care, smooth the fracture area or leave untreated if smooth 2
• The exposed dentin creates a pathway for bacterial invasion, making timely restoration important 1
• Continue monitoring for pulpal necrosis until the tooth is definitively restored 2

Complicated Crown Fractures (Pulp Exposure)

Immediate same-day dental referral is mandatory for pulp therapy (pulpotomy or pulpectomy) followed by restoration. 2, 1, 3

• The exposed pulp tissue introduces high risk of infection from oral flora 2
• If the patient cannot cooperate with pulp therapy and restorative care, extraction is indicated 2, 3
• These fractures are frequently sensitive and require prompt intervention to preserve tooth vitality 2, 1

Root Fractures

Refer to a dentist for radiographic examination to determine fracture location, which dictates prognosis and treatment. 2

• Fracture near root apex: Excellent prognosis, rarely requires treatment 2, 3
• Fracture near crown: Poor prognosis, crown segment usually removed 2, 3
• If there is concern for aspiration of the mobile crown portion, immediate referral is indicated 2
• If removing the root risks damaging the underlying permanent tooth bud (in primary teeth), leave the residual root and monitor for natural resorption 2

Alveolar Fractures

Immediate dental referral for repositioning of the segment and stabilization with a splint. 2

• This is identified when several teeth move together as a unit upon palpation 2
• Requires rigid splinting for 4 to 8 weeks 4

Pain Management and Supportive Care

Prescribe ibuprofen (NSAIDs) as first-line for pain control, with acetaminophen as an alternative. 1, 3

• Apply cold compresses to reduce swelling 1
• Maintain a soft diet for 10 days after any dental procedure to minimize mechanical stress 1, 3
• Avoid temperature extremes with food and beverages 3
• Systemic antibiotics are not routinely indicated for uncomplicated fractures in healthy patients 2, 5

Critical Red Flags Requiring Immediate Referral

Immediate same-day dental referral is mandatory for 1:

• Visible pulp exposure (red tissue in fracture center)
• Multiple teeth moving together as a segment (alveolar fracture)
• Severe tooth mobility with aspiration risk
• Inability to close jaw properly or interference with occlusion
• Extensive gingival or facial swelling suggesting abscess

Follow-Up Monitoring

All fractured teeth must be monitored for signs of pulpal necrosis, regardless of initial fracture depth. 1, 3

Watch for 2, 1:

• Gray discoloration of the tooth
• Gingival swelling with increased mobility
• Parulis formation (gum boil adjacent to the tooth root)

Children may not report painful symptoms from a necrotic tooth, making vigilant observation essential 2

Special Considerations

If the fractured fragment is recovered and brought to the dental office, reattachment with bonding system and composite resin cement is a viable conservative option that preserves tooth structure and provides excellent esthetics. 6, 7

• This technique is reasonably simple and provides long-lasting results with positive psychological response 7
• The fragment should be handled carefully and stored in saline or milk if immediate reattachment is not possible 4