What is the recommended treatment for a pediatric patient with a complicated fracture of a matured permanent tooth according to International Association of Paediatric Dentistry (IAPD) guidelines?

Treatment of Complicated Fracture of Matured Permanent Tooth

For a complicated crown fracture (pulp exposure) of a mature permanent tooth, root canal therapy is the definitive treatment of choice, regardless of timing, and requires immediate same-day dental referral. 1

Treatment Algorithm

Immediate Assessment

• Confirm the fracture is complicated by identifying visible red pulp tissue in the center of the fracture site 2
• Verify tooth maturity (typically >3 years post-eruption with complete root formation) 1
• Arrange immediate same-day dental referral—do not delay treatment 2, 3

Definitive Treatment Approach

Root canal therapy (pulpectomy) is the standard treatment for mature permanent teeth with pulp exposure, as the priority shifts to definitive treatment rather than pulp preservation once root formation is complete. 1

• For mature teeth with closed apex, pulpectomy followed by restoration is indicated in approximately 36% of cases 4
• Alternative pulp preservation approaches (pulpotomy or pulp capping) are not appropriate for mature teeth with complete root formation 1
• The tooth requires restoration with tooth-colored dental material after endodontic treatment 3

Critical Timing Considerations

• Bacterial contamination risk increases significantly with time when pulp is exposed to oral flora 3, 1
• Appropriate pulp therapy should be rendered immediately to preserve tooth vitality and prevent infection 1
• Delayed treatment beyond 48 hours substantially reduces success rates and increases risk of pulpal necrosis 4

Pain Management and Supportive Care

• Prescribe ibuprofen (NSAIDs) as first-line for pain control, with acetaminophen as alternative 2, 3
• Apply cold compresses to reduce swelling 2
• Maintain soft diet for 10 days after dental procedure 2, 3
• Avoid temperature extremes with food and beverages 3
• Systemic antibiotics are not indicated for uncomplicated fractures in healthy patients 3

Common Pitfalls to Avoid

Inadequate Emergency Management

• Do not use conventional glass ionomer cement alone as an emergency bandage—67% of pulp caps and 47% of pulpotomies fail due to inadequate coronal seal when this approach is used 4
• Use etched or bonded materials at initial presentation, which extends median survival time for vitality from 15 to 64 days in closed apex teeth 4
• Ensure hermetic coronal seal to prevent bacterial contamination 4

Inappropriate Treatment Selection

• Do not attempt pulp capping or pulpotomy as definitive treatment for mature teeth—these are reserved for immature teeth with open apex 1
• Do not delay referral hoping for spontaneous resolution—immediate treatment is essential 2, 1

Follow-Up Monitoring

• Monitor all treated teeth for signs of pulpal necrosis, including: 2, 3
  • Gray discoloration of the tooth
  • Gingival swelling with increased mobility
  • Parulis formation (gum boil adjacent to tooth root)
• Continue monitoring until the tooth demonstrates long-term stability 3

Additional Red Flags Requiring Immediate Attention

• Multiple teeth moving together as a segment (alveolar fracture) 2, 3
• Severe tooth mobility with aspiration risk 2, 3
• Inability to close jaw properly or interference with occlusion 3
• Extensive gingival or facial swelling suggesting abscess 2, 3