Chipped Tooth – Now What?

A chipped tooth refers to the complete fracture of part of the tooth structure. In the anterior (front) region of the mouth, it is most often caused by physical trauma. A fractured tooth raises several causes for concern beyond the aesthetic realm. The condition of the supporting tissues of the tooth including the periodontal ligament and the state of the vital tissue inside the tooth are but two examples. This article intends to explore the various types of tooth chips and how they are each treated.

Types of Tooth Chips

Tooth chips can be broadly classified according to the extent of tooth structure involved. Any fracture that does not involve the vital, innermost tissue of the tooth known as the pulp is considered an uncomplicated fracture. Uncomplicated fractures may be isolated to the outer protective covering of the tooth known as the enamel, or may extend into the second layer known as the dentin. If a crown root fracture occurs, the cementum layer can also be affected. Complicated tooth fractures result in pulpal exposure. The pulp contains the nerves of the tooth and therefore you can expect a tooth to become symptomatic when a complicated fracture has occurred. They can originate from the crown or exposed area of the tooth or from the roots.

The primary intent of treatment in complicated fractures is to preserve the pulpal tissue, especially if tooth development is incomplete. The pulp can be medicated to aid regrowth of the dentin layer at the fracture site. Ongoing monitoring of the pulp post-treatment is necessary to watch for signs of necrosis (death), at which point root canal therapy is indicated.

Posterior tooth chips (premolars and molars) warrant a dedicated explanation as their primary causes differ. Existing restorations are most frequently blamed for cracks and complete fractures in these teeth. These restorations can leak, prompting decay to reemerge inside the tooth. This weakens the tooth structure allowing for complete fracture to occur. Hasty placement of composite fillings without successive layering of the material can impart stress on the tooth due to considerable shrinkage of the material. Other contributing factors include over-preparation of decayed tooth structure and poor restoration design.

Complications

Treatment of a tooth chip can be rendered increasingly difficult if other complications are present.

• Luxation – movement or displacement of the tooth structure. Requires that the tooth be repositioned and braced to allow for the periodontal ligament, jawbone and other supporting tooth structures to heal. Intrusive luxation injuries (tooth is pushed vertically into the socket) may require orthodontic or surgical intervention. Luxation injuries can result in pulpal necrosis and thus must be monitored closely. Root canal treatment may be recommended depending on outcome of follow-up.

• Untreated fractures – Tooth chips can arise from untreated, incomplete tooth fractures. These fractures can expose the interior of the tooth to bacteria, leading to decay and subsequent pulpitis. This can significantly diminish the prognosis for the tooth.

Cosmetic Management of Tooth Chips

Cosmetic treatment for fractures can involve dental bonding, indirect restorations like porcelain veneers or crowns or even reattachment of the broken tooth segment. The severity of the fracture in terms of degree of overall tooth structure loss, location of fracture and pulpal involvement and prognosis will all factor into the decision. Additional considerations like the patient’s aesthetic goals and budget will also factor into this choice.

Composite bonding presents the most inexpensive option for managing uncomplicated fractures in the absence of a suitable tooth fragment. The tooth is etched, composite material applied then shaped and cured. The restoration is then finalized. Composite bonding is not as durable or aesthetic as porcelain veneers or crowns, but is many times cheaper.

Porcelain veneers are bonded to the labial (front) surface of the tooth after slight enamel reduction is undertaken. They boast excellent aesthetics, durability, and resilience against staining. Porcelain veneers can last upwards of 20 years with diligent care, but have a high upfront cost of over $1,000 per tooth.

Crowns are reserved for teeth that have sustained considerable tooth structure loss or undergone root canal therapy. They are a good option for replacing fractured posterior teeth. Since aesthetics may not be an overriding concern in restoring posterior teeth, expensive all-ceramic crowns are not necessary. Re-attaching the broken tooth segment(s) can be an attractive option in terms of aesthetics, durability and cost. A test fitting is conducted to ensure the fragments fits the fracture site, both the tooth and fragment are etched and then bonded into place, and the restoration finalized.

Closing Thoughts Seeking immediate treatment for a tooth fracture is of paramount importance. A fracture represents much more than an aesthetic nuisance and can severely compromise the health of the affected tooth. Schedule an appointment today for a conclusive diagnosis and appropriate treatment.

References:

International Association of Dental Traumatology. Dental Trauma Guidelines. https://www.iadt-dentaltrauma.org/1-9%20%20iadt%20guidelines%20combined%20-%20lr%20-%2011-5-2013.pdf. Accessed April 14, 2018.

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