Diagnostic Assessment — Teeth - Traumatic Crown Fracture
Example 1 of 1 · fictitious patient (Veteran DG)
Diagnostic Assessment
Teeth - Traumatic Crown Fracture
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran DG, date of birth 21 January 1990, Australian Army, Rifleman (Infantry, later Lance Corporal), enlisted 03 February 2008, medically discharged 14 June 2017. Operational service: Afghanistan, 20 February 2012 to 25 September 2012 (warlike); Iraq, 12 May 2015 to 20 November 2015 (warlike).
Occupational History
Infantry soldiers conduct dismounted patrols, live-fire training, close combat and combatives, carrying rifles, body armour and loads of 30 to 40 kilograms over rough ground. Facial and dental injuries are common from falls, blows from weapons and equipment, combatives and contact sport, vehicle movement and blast, and soldiers routinely train without mouthguards outside organised sport.
On operations and long field exercises soldiers rely on high-sugar and acidic drinks for energy and hydration, have limited opportunity for oral hygiene, and experience the stress and sleep disruption associated with clenching and grinding of the teeth. Access to dental officers is limited at forward patrol bases, and routine dental treatment is often deferred to meet deployment timelines.
History
Veteran DG, an infantry rifleman in the Australian Army, sustained a complicated crown fracture of the upper left central incisor (tooth 21) on 03 July 2012 on warlike service in Afghanistan, when his rifle struck his mouth as he dived for cover under fire. The tooth had been weakened by a 2010 combatives injury, a large restoration, untreated decay, erosion, bruxism and a large overjet, and the fracture worsened in Iraq in 2015 after further trauma, pulp necrosis and delayed dental care.
Timeline
- 11 Feb 2008 — At his enlistment dental examination the veteran was recorded as having a Class II division 1 malocclusion with an incisal overjet of 8 mm and incompetent lips, leaving the upper incisors proclined and exposed. Orthodontic treatment was not offered. The upper left central incisor (tooth 21) was intact and free of decay. "overjet 8 mm, lips incompetent"
- 22 Apr 2010 — During unit combatives training, conducted without mouthguards, the veteran was struck in the mouth by an opponent's elbow. A dental officer found an enamel-dentine fracture of the incisal edge of tooth 21 with enamel cracks extending across the crown, and placed a large Class IV composite restoration covering about 40 per cent of the crown. The pulp was not exposed and remained vital. "combatives blow, Class IV composite"
- 19 Oct 2011 — At a pre-deployment dental examination the dental officer recorded generalised wear facets and masseter hypertrophy consistent with bruxism, palatal erosion of the upper incisors, and early secondary decay at the palatal margin of the restoration on tooth 21. An occlusal splint was made, but the replacement of the restoration was deferred because of the deployment timeline. He was taking omeprazole for gastro-oesophageal reflux disease diagnosed in 2011. "bruxism, erosion, marginal caries"
- 03 Jul 2012 — On warlike service in Afghanistan, during a contact on a dismounted patrol, the veteran dived for cover and the rear sight of his rifle struck his upper front teeth. Tooth 21 fractured across the crown with bleeding from an exposed pulp. The patrol medic covered the tooth and gave analgesia. There was no dental officer at the patrol base and he remained on operations for four days. He had been drinking four to six cans of energy drink a day since arriving in theatre and grinding his teeth at night without his splint, which had been lost in transit. "rifle struck incisors, pulp exposed"
- 07 Jul 2012 — A deployed dental officer confirmed a complicated crown fracture of tooth 21 through enamel and dentine with a 1.5 mm pulp exposure, contaminated after four days, and recurrent decay at the old restoration margin. A partial pulpotomy was performed and the crown was rebuilt with composite. Periapical radiograph showed a fracture line 2 mm above the gingival margin with no root fracture. "complicated crown fracture, pulpotomy"
- 14 Aug 2015 — On warlike service in Iraq his helmeted head was thrown forward against the vehicle's gun mount when his vehicle hit a crater, striking tooth 21. The composite build-up was dislodged and the tooth became painful and mobile. The deployed dental facility could provide only a temporary dressing, and definitive treatment was deferred until his return. "blow to tooth 21, build-up lost"
- 19 Aug 2015 — A dental officer recorded a palatal extension of the fracture 3 mm below the gingival margin, a non-vital tooth with a sinus tract, and a 4 mm periapical radiolucency on radiograph, indicating pulp necrosis with chronic apical periodontitis. Recurrent decay was present at the fracture margin and the wear facets had progressed. Antibiotics and a temporary dressing were provided. "subgingival extension, apical abscess"
- 08 Dec 2015 — After his return to Australia, root canal treatment and surgical crown lengthening of tooth 21 were attempted, but cone beam CT showed the subgingival fracture extending to the alveolar crest with insufficient sound tooth to retain a crown. The tooth was extracted on 23 February 2016 and replaced with an implant-retained crown in September 2016. "unrestorable, extraction and implant"
Symptoms
At onset the veteran had sudden severe pain and bleeding from the upper left central incisor, with a visibly fractured crown, exposed pink pulp, sensitivity to air and cold, and difficulty biting and eating. After the pulpotomy and build-up the tooth was comfortable but discoloured.
After the worsening in 2015 he had a painful, mobile tooth with a discharging gum sinus and swelling, followed by extraction and an implant. He now has an implant-retained crown with a visible gum recession defect, avoids biting hard food with his front teeth, and is self-conscious about his smile. Night grinding continues and he wears an occlusal splint.
Imaging
- 22 Apr 2010 — Periapical radiograph tooth 21: "Enamel-dentine fracture of the incisal third with no pulp involvement. Normal periapical tissues and intact root."
- 07 Jul 2012 — Periapical radiograph tooth 21: "Oblique crown fracture with pulp exposure, fracture line 2 mm above the cemento-enamel junction. Secondary caries at the palatal restoration margin. No root fracture."
- 19 Aug 2015 — Periapical radiograph tooth 21: "4 mm periapical radiolucency at the apex of tooth 21 consistent with chronic apical periodontitis. Loss of coronal restoration."
- 08 Dec 2015 — Cone beam CT anterior maxilla: "Palatal fracture of tooth 21 extending subgingivally to the level of the alveolar crest. Periapical radiolucency 5 mm. Root otherwise intact."
Onset Date
The most likely date of onset of this condition is 03 Jul 2012.
At that date the veteran was serving full time as an infantry rifleman on warlike service in Afghanistan, operating from a patrol base without a dental officer. During a contact on a dismounted patrol he dived for cover and the rear sight of his rifle struck his upper front teeth, fracturing tooth 21 and exposing the pulp.
This date is appropriate because his pre-deployment dental examination of 19 October 2011 recorded tooth 21 as restored and intact, and the fracture occurred in a witnessed incident on 03 July 2012, recorded by the patrol medic the same day and confirmed by a dental officer on 07 July 2012. It falls within uninterrupted full-time service.
For the bruxism and erosion causes, the 6 months before onset run from 03 Jan 2012 to 03 Jul 2012. Bruxism was documented from October 2011 and continued throughout this period, unprotected after his splint was lost in transit in February 2012. He had gastro-oesophageal reflux throughout the period and drank four to six cans of energy drink a day on warlike service from 20 February 2012. The overjet was present from before enlistment, the 2010 combatives fracture and the large restoration preceded onset, and the marginal decay recorded in October 2011 was present on 03 July 2012.
For the worsening causes, the period after onset runs from 03 Jul 2012 to the documented worsening on 19 Aug 2015, which followed the blow to the tooth on warlike service in Iraq on 14 August 2015. Pulp necrosis with apical periodontitis, progressing decay and continuing bruxism were each present at the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Traumatic Crown Fracture of the upper left central incisor, tooth 21, complicated by pulp exposure (ICD-10-AM S02.5, fracture of tooth). No Statement of Principles has been determined for traumatic fracture of a tooth.
A traumatic crown fracture is a break in the visible part of a tooth caused by an external force. An uncomplicated fracture involves enamel and dentine; a complicated fracture also exposes the pulp, which becomes contaminated by oral bacteria and, unless sealed promptly, may become inflamed and necrotic, leading to apical infection. The upper central incisors are most often affected, especially when they protrude with a large overjet. Teeth weakened by previous fracture, large restorations, decay, erosion and grinding fracture more easily, and further trauma, pulp necrosis and delayed definitive restoration can extend a fracture below the gum and make the tooth unrestorable.
The diagnosis followed an incisal fracture in combatives training in 2010 restored with a large composite, untreated marginal decay, erosion and bruxism, and a pre-existing 8 mm overjet. It occurred on 03 July 2012 on warlike service in Afghanistan, was confirmed by a dental officer on 07 July 2012 and worsened on warlike service in Iraq in 2015, leading to extraction.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
03 July 2012.
When did the veteran first present to a health / medical provider for this condition?
03 July 2012.
When was the condition confirmed / formally diagnosed?
07 July 2012.
When did the veteran first present to you (or your practice) for this condition?
21 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made by a deployed dental officer on 07 July 2012 on clinical examination, which showed a fracture of the crown of tooth 21 through enamel and dentine with a 1.5 mm pulp exposure, and on periapical radiography showing an oblique crown fracture 2 mm above the cemento-enamel junction with no root fracture. The patrol medic's record of 03 July 2012 documents the mechanism of injury and the exposed, bleeding pulp.
The worsening was confirmed by a dental officer on 19 August 2015, with a subgingival palatal extension of the fracture, a non-vital tooth with a sinus tract and a 4 mm periapical radiolucency, and by cone beam CT on 08 December 2015, which showed the fracture extending to the alveolar crest. The tooth was assessed as unrestorable and extracted on 23 February 2016.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for traumatic fracture of a tooth, so the Statements of Principles do not limit the factors that can be considered. The claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, applied to the veteran's service. The recognised causes below are drawn from the dental traumatology literature and are set out in Statement of Principles style.
Legislation: the clinical onset of this condition was on 03 July 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The fracture occurred on warlike service in Afghanistan and worsened on warlike service in Iraq in 2015; the earlier combatives injury, restoration and dental conditions arose during peacetime service. For conditions with Statements of Principles, the Reasonable Hypothesis standard applies to operational service and the Balance of Probabilities standard to peacetime service, and the same beneficial approach is applied here.
Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: sustaining a direct blow to the affected tooth, mouth or face at the time of the clinical onset of traumatic crown fracture; — MET
- On 03 July 2012, on warlike service in Afghanistan, the rear sight of the veteran's rifle struck his upper front teeth as he dived for cover during a contact, fracturing the crown of tooth 21 and exposing the pulp. The blow was recorded by the patrol medic the same day.
Cause 2: having a previous fracture or crack of the affected tooth before the clinical onset of traumatic crown fracture; — MET
- On 22 April 2010, during unit combatives training conducted without mouthguards, an elbow strike fractured the incisal edge of tooth 21, and the dental officer recorded enamel cracks extending across the crown. This previous fracture weakened the crown more than two years before onset.
Cause 3: having a large restoration or endodontic treatment of the affected tooth before the clinical onset of traumatic crown fracture; — MET
- A Class IV composite restoration covering about 40 per cent of the crown of tooth 21 was placed by a Defence dental officer on 22 April 2010 to repair the combatives fracture. Large restorations reduce the fracture resistance of incisors, and the 2012 fracture line ran through the margin of this restoration.
Cause 4: having sleep bruxism or habitual clenching for at least the 6 months before the clinical onset of traumatic crown fracture; — MET
- Bruxism with generalised wear facets and masseter hypertrophy was recorded on 19 October 2011 and continued throughout the 6 months before onset, from 03 January to 03 July 2012. On warlike service he ground his teeth nightly without his occlusal splint, which was lost in transit, and his section commander reported audible grinding in shared accommodation.
Cause 5: having dental caries involving the affected tooth at the time of the clinical onset of traumatic crown fracture; — MET
- Secondary decay at the palatal margin of the restoration on tooth 21 was recorded on 19 October 2011, and its replacement was deferred to meet the deployment timeline. The decay was still present on 07 July 2012, undermining the crown at the site of the fracture.
Cause 6: having erosion of the affected tooth from frequent consumption of acidic drinks or from gastro-oesophageal reflux for at least the 6 months before the clinical onset of traumatic crown fracture; — MET
- Palatal erosion of the upper incisors was recorded on 19 October 2011. He had gastro-oesophageal reflux disease, treated with omeprazole, throughout the 6 months before onset, and on warlike service from 20 February 2012 he drank four to six cans of acidic energy drink a day, supplied through the base canteen, to sustain long patrols in heat.
Cause 7: having an increased incisal overjet of at least 6 millimetres, with incompetent lips, at the time of the clinical onset of traumatic crown fracture; — MET
- An incisal overjet of 8 mm with incompetent lips was recorded at his enlistment dental examination on 11 February 2008 and was never treated, so his proclined upper incisors took the full force of the rifle sight on 03 July 2012. A large overjet is the strongest recognised predictor of incisor trauma.
Worsening factors
Worsening 1: sustaining a further blow to the affected tooth after the clinical onset of traumatic crown fracture; — MET
- On 14 August 2015, on warlike service in Iraq, his head was thrown forward against the gun mount when his vehicle hit a crater, striking tooth 21. The build-up was dislodged, and by 19 August 2015 the fracture had extended 3 mm below the gingival margin.
Worsening 2: developing pulp necrosis or apical periodontitis in the affected tooth after the clinical onset of traumatic crown fracture; — MET
- The pulp of tooth 21 was exposed for four days before treatment in July 2012 and became necrotic. On 19 August 2015 the tooth was non-vital with a sinus tract and a 4 mm periapical radiolucency, enlarging to 5 mm on cone beam CT on 08 December 2015, which weakened the tooth further.
Worsening 3: having sleep bruxism or habitual clenching after the clinical onset of traumatic crown fracture; — MET
- Bruxism continued after onset, with progression of the wear facets recorded on 19 August 2015, during his warlike service in Iraq, where he again had no replacement splint.
Worsening 4: having dental caries involving the affected tooth after the clinical onset of traumatic crown fracture; — MET
- Recurrent decay at the fracture margin of tooth 21 was recorded on 19 August 2015, undermining the remaining tooth structure and contributing to the subgingival extension of the fracture.
Worsening 5: inability to obtain appropriate clinical management for traumatic crown fracture. — MET
- On warlike service in Afghanistan in July 2012 there was no dental officer at his patrol base, so the exposed pulp was not treated for four days and became contaminated. In Iraq in August 2015 the deployed dental facility could provide only a temporary dressing, and definitive endodontic and restorative treatment was deferred until December 2015, by which time the tooth was unrestorable. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The traumatic crown fracture is a sequela of the combatives injury of 2010 to the same tooth and the Defence-placed restoration that followed it. In turn, the fracture led to pulp necrosis, apical periodontitis, extraction of tooth 21 and its replacement with an implant-retained crown, with a residual gum recession defect and ongoing maintenance needs.
Unintended Consequence
Met. The deferral by Defence dental services of the replacement of the decayed restoration on tooth 21 to meet the deployment timeline, and the large restoration placed in 2010, contributed to the fracture, and the treatment of the fracture led to extraction and an implant (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On 03 July 2012, on warlike service in Afghanistan, the veteran's exposed pulp could not be treated for four days because there was no dental officer at his patrol base, so the pulp became contaminated and later necrotic. In August 2015, on warlike service in Iraq, the deployed dental facility could provide only a temporary dressing after the further blow, and definitive treatment was delayed until December 2015, by which time the fracture had extended to the alveolar crest and the tooth could not be saved. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent timely pulp treatment and definitive restoration amount to an inability to obtain appropriate clinical management. The deferral of treatment of the decayed restoration before deployment is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 11 Feb 2008, Enlistment dental examination, Dental Officer
- 22 Apr 2010, Dental treatment record and periapical radiograph, Dental Officer, Garrison dental centre
- 19 Oct 2011, Pre-deployment dental examination, Dental Officer, Garrison dental centre
- 03 Jul 2012, Patrol medic casualty record, Afghanistan
- 07 Jul 2012, Deployed dental treatment record and periapical radiograph, Dental Officer, Afghanistan
- 14 Aug 2015, Deployed health record, Medical Officer, Iraq
- 19 Aug 2015, Deployed dental treatment record and periapical radiograph, Dental Officer, Iraq
- 08 Dec 2015, Cone beam CT and endodontic consultation, Endodontist
- 23 Feb 2016, Oral surgery operation record, Oral surgeon
- 15 Sep 2016, Implant restoration record, Prosthodontist
