Ellis & Davey Class I Fracture
(Enamel Fracture)
- Immediate Management: Smoothening of sharp enamel edges (while maintaining aesthetics).
- Restoration: When the shape or extent of fracture precludes recontouring.
Ellis & Davey Class II Fracture
(Enamel and Dentin Fracture)
- Reattachment of the tooth fragment: When the fragment remains intact and is recovered safely.
- Restoration: GIC or Composite restoration with suitable liner and dentin bonding agent.
Ellis & Davey Class III Fracture
(Enamel and Dentin Fracture with Pulp Exposure)
Stage of tooth development
- Immature tooth (Open apex) - Apexogenesis (Pulp capping, Pulpotomy).
- Mature tooth (Closed apex) - Pulp capping, Pulpotomy, Pulpectomy.
Size of pulp exposure
- Small (0.5 - 1 mm): Direct pulp capping (< 0.5 mm) or Cvek's partial pulpotomy.
- Large (1 -2 mm): Complete pulpotomy or Pulpectomy.
Duration between exposure and treatment
- Until 24 hours: Direct Pulp capping.
- Until 48 hours: Pulpotomy (Partial or Complete).
- More than 48 hours: Pulpectomy.
Duration of bleeding from pulp chamber
- Less than 10 min: Direct pulp capping or Cvek's partial pulpotomy.
- More than 10 min: Complete pulpotomy or Pulpectomy.
Ellis & Davey Class IV Fracture
(Non-vital fractured tooth)
- Tooth with open apex: Apexification.
- Tooth with closed apex: Pulpectomy, followed by conventional RCT.
Ellis & Davey Class V Fracture
(Avulsion)
- Clean the area with saline or chlorhexidine.
- Re-implant the tooth and verify normal position of the replanted tooth.
- Apply a flexible splint for 2-4 weeks.
- Administer systemic antibiotics (Doxycycline/Amoxicillin).
- If the avulsed tooth has been in contact with soil, tetanus booster should be considered.
- Tooth with closed apex: Initiate RCT 7-10 days after replantation and before splint removal.
- Tooth with open apex: Goal is to allow for possible re-vascularization. If that does not occur, RCT is recommended.
- In case the extraoral dry time in more than 60 min: Treatment of the root surface with fluoride (2% sodium fluoride solution for 20 minutes) prior to replantation has been suggested to slow osseous replacement.
Ellis & Davey Class VI Fracture
(Root Fracture)
- The coronal fragment to be repositioned and splinted.
Fracture in the apical 1/3rd of the root
- RCT of the coronal fragment - when there are no periapical pathologic changes.
- RCT of both fragments - when the entire pulp is necrotic.
- Surgical removal of the apical fragment.
Fracture in the middle 1/3rd of the root
- RCT of the coronal fragment alone or both fragments
- Extraction, if RCT fails.
Fracture in the cervical 1/3rd of the root
- Very poor prognosis.
- Removal of coronal segment, followed by RCT, post and crown - When the cervical fracture line is above the alveolar crest and the fragment is vey mobile.
- Orthodontic or surgical extrusion may be required, if the fracture line is deep below the alveolar crest.
Vertical root fracture
- Single-rooted teeth: Extraction.
- Multi-rooted teeth: Hemi-section and restoration of the remaining segment with endodontic treatment and crown.
Ellis & Davey Class VII Fracture
(Displacement of tooth, without crown or root fracture)
Intrusion
- Intrusion less than 3 mm - Allow the tooth to erupt on its own.
- Intrusion of 7 mm or more - Surgical repositioning and splinting.
- Permanent tooth with incomplete root formation - Allow the tooth to erupt spontaneously.
- Surgical or orthodontic repositioning is indicated when no movement is evident for 2-4 weeks.
- Most cases requires RCT as there is pulp necrosis.
Extrusion
- Repositioning and splinting.
- If tooth does not respond to pulp vitality test within 2-3 weeks RCT needs to be done.
Lateral Luxation
- Repositioning by applying digital pressure and splinting.
- If tooth does not respond to pulp vitality test within 2-3 weeks RCT needs to be done.
Ellis & Davey Class VIII Fracture (Fracture of the crown en masse)
- If sufficient tooth is present above the alveolar crest: RCT, post and crown.
- If the fracture is below the alveolar crest: Orthodontic or surgical extrusion, followed RCT, post and crown.
Points to Note
Apexification
- It refers to induction of a calcific barrier across an open apex of a non-vital tooth with incomplete root formation.
- The procedure involves pulpectomy followed by placement of Calcium hydroxide or MTA.
Apexogenesis
- It refers to preservation of the vital pulp tissue so that continued root development with apical closure may occur.
- The procedure includes direct pulp capping or pulpotomy, in order to allow continued root growth and closure of the open apex.
References
- Andreasen J., Andreasen F., Andersson L. (Editors) - Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th Editon) - Blackwell Munksgaard.
- McDonald and Avery's Dentistry for the Child and Adolescent (11th Edition) -Mosby (2021).
- Arathi Rao - Principles and Practice of Pedodontics (3rd Edition) - Jaypee Brothers Medical Publishers (P) Ltd.
- Nikhil Marwah - Textbook of Pediatric Dentistry (4th Editon)-Jaypee Brothers Medical Publishers Pvt. Ltd. (2018).
- Grossman's Endodontic Practice (14th Edition) - V. Gopikrishna (editor) - Wolters Kluwer (India) Pvt. Ltd.
*This article is an excerpt from the above mentioned books and Medical Sutras does not make any ownership or affiliation claims.