Traumatic injuries of teeth /certified fixed orthodontic courses by Indian dental academy

Traumatic injuries of teeth

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com


•Etiology
•Mechanism of action
•Introduction
•Classification
•Examination and diagnosis
•Crown infraction
•Uncomplicated crown fracture
•Complicated crown fracture
•Crown and root fracture
•Root fracture luxation injuries
•Avulsion
•Alveolar fracture
•Prevention of dental injuries
• Conclusion
• References www.indiandentalacademy.com

Incidence

Most dental injuries occur during first tow decades of life [8 to
2yrs]

Boys tend to injure their teeth more than girls in ratio of 1:2.

The tooth more vulnerable to injury is maxillary central incisors
follow by maxillary lateral and mandibular incisors.

The most commonly observed dental trauma involves fracture of
enamel or enamel and dentin but without pulp.


Etiology
  Sudden impct involving the face or head may result in
trauma to the  teeth and supporting structure. the frequent
cause.
•Dental abnormalities
Falling while running
•  Traffic accidents[20 to 60 per]
•  Acts of violence
Sports child abuse
•  Medical causes

Predisposing factors

Increase overjet with protrusion of upper incisors and insufficient
lip closure.

Mechanism of dental injuries

Direct trauma                                                                                                   indirect trauma

Anterior region                        favours crown and crown- root
fracture
                                                Premolar and molar region
                                                jaw frcturein condylar and
                                                symphysis  region.


Direct trauma

Indirect trauma


The following factors characterize the impact and
determine the extent of injuries.

•Energy of impact

•Resiliency of the impact object

•Shape of the impact object

•Direction of the impaction force


Classification
WHO Classification
873.60enamel fracture

873.61crown fracture without pulp involvement
873.62 crown fracture with pulp involvement
873.63 root fracture
873.64 crown root fracture
873.66 tooth luxation
873.67 itrusion or extrusion
873.68 avulsion
873.69 other injuries

802.20;802.40 fracture or comminution of the alveolar
process.this may or may not involve the tooth
802.21;802.41 fracture of the bodey of mandible or maxilla

Ellis classification
Class 1;simple crown fracture with little or no dentin affected
Class 2; extensive crown fracture with considerable loss of the
dentin with pulp not affected
Class 3 ;extensive crown fracture with considerable loss of dentin
and pulp exposure.
Class 4; a tooth devitalized by trauma with or without loos of
tooth structure.
Class 5;tooth loss as a result of trauma.

Class 6; root fracture with or without the loss of crown fracture.
Class7;displacement of the tooth with neither crown or root
fracture
Class8;complete crown fracture and its replacement.
Class9; traumatic injuries of primary teeth.
Andreasens classification;
a.injury of the hard tissue and the pulp
b.injury of the periodontal tissue
c.injury of gums and oral mucosa
d.injury of the supporting bone

Who classification modified by Andreasen and
Andreasen used by international association of dental
traumatology.
Dentofacial injuries.
Soft tissue
    laceration
    contusion
    abrasion
Tooth fracture
    Enamel fracture crown fracture[uncomplicated]
   Crown fracture [complicated]
   Crown root fracture
   Root fracture www.indiandentalacademy.com

Luxation injuries
   tooth concussion
   Subluxation
   Extrusive luxation
   Intrusive luxation and avulsion

Facial skeletal injuries
   alveolar process
   body of maxilla
tempromandibular  joint

Other classifications
Ulfohn
Ellis and Davis
Heithersay and morile
Basrani www.indiandentalacademy.com

Examination and diagnosis
History

Chief complaint

History of present illness

• When and where did the injury happen?
• How did the injury happen?
• Have you had treatment elsewhere before coming here?
• Have you had similar injuries before?
• Have you noticed any other symptoms since the injury?
• What specific problem you have with the traumatic teeth/tooth?

Medical history
•Allergic reaction
•Discords
•Current medications
•Tetanus immunization status

Examination
A.EXTRA- ORAL
B.INTRA-ORAL
Hard tissue
facial bone

Teeth

fracture

Mobility and
displacement

Injury to the PL
and alveolar tissue

Enamel fracture
Include chips and cracks confined to the enamel and not crossing
the enamel dentin border.

Biological consequences;
Theoretically these fractures are week points through which
bacteria and their byproducts can travel to challenge the pulp.

Diagnosis and clinical presentation;
Crack or craze lines can occasionally be observed during
routine examination.[fiber-optic]
Treatment

Establish baseline pulp status
Selective grinding
Composite restoration

Prognosis and follow up;
Prognosis is good


Uncomplicated crown fracture;
Description;crown fracture involving enamel and dentin without
pulp exposure and called uncomplicated fracture by andreasen and
Ellis class 2 by Ellis.

Biologic consequences;
                                           dentin
                                            pulp

          chronic pulpal infection        reparative dentin

The reaction of pulp depends on;

1.Time of treatment
2.Distance of fracture from the teeth
3.Size of the dentinal tubules
4.Age of the patient
5.Concomitant injury to the pulps blood supply
6.Possibly the time of initial treatment

Classification
   Horizontal
   Oblique
   Vertical


Diagnosis and clinical presentation
Rough edge of the tooth
Sensitivity to air,hot and coold substance
Lip bruise or laceration is seen commonly

Treatment
Objectives;
Elimination of pain
Preservation of vital pulp
Restoration of fractured crown

Immediate treatment;
Protection of dentin from physical ,chemical and bacterial
irritation www.indiandentalacademy.com

1.hard setting calcium hydroxide

2.reattachment


TREATMENT OF UN-COMPLICATED
FRACTURE WITH COMPOSITE
AND ACID –ETCH TECHNIQUE

SHADE SELECTION AFTER
POLISHING

Rubber dam application


Chamfer preparation

Etching enamel

Polymerization of composites

Finished restoration


Treatment of Un-complicated crown fracture
by reattachment

Testing pulpal sensitivity


Testing for the fit of the
fragment and etching the enamel

Removal of the etchant
and drying


Application of bonding agent

Polymerization and finishing


Reinforcing the fraccture site

Restored with composite

Reinforcing the palatal aspect of
the fracture

Final restoration


Complicated crown root fracture;
Involves the enamel ,dentin and pulp.the degree of pulpal
involvement varies from pin point exposure to a total unroofing
of the coronal pulp.


Biological consequences;
hemorrhage

Superficial inflammatory response

Necrosis proliferation

Diagnosis
Clinical observation


Treatment
Two options
1.vital pulp therapy                             2. pulpectomy

•  pulp capping
•  partial pulpotomy
•  cervical pulpotomy

Choice of treatment depends on;

•  stage of development of tooth
•  time elapsed between injury and arrival of patient at the operator
•  extent of  pulp injury
•  presence or absence of hemorrhage
•  size of remaining crown
•  root fracture www.indiandentalacademy.com

Pulp capping
pulp capping implies placing the dressing directly onto the pulp
exposure

Indication
•Immature permanent pulp,on a very recent exposure
[less than 24hrs]
•Mature permanent with a simple restoration plan


Technique

Tooth isolated

Calcium hydroxide placed

Prognosis
In range of 80%


Treatment of complicated crow fracture by pulpotomy
and subsequent bonding of crown fracture

Pulp exposure and fracture
fragment

pulpotomy

Testing of fit of the fragment

Bonding the fragment

2.pulpotomy
a.partial
b.full

Partial pulpoyomy;
Implies the removal of the coronal pulp tissue to the level of
healthy pulp.[Cvek pulpotomy]
Indication
Immature and young mature teeth,irrespective of the time
interval in immature teeth and up to one week in mature teeth in
which the fracture segment can be restored with composite resin.


Full pulpotomy
Polpotomy is defined as surgical removal of the entire
coronal pulp,leaving intact the vital tissue in the canal.
Indications
1.young permanent teeth with exposed pulps and
incompletely formed apices.
2.pulpaly exposed primary teeth when their retention is more
advantageous than their extraction
Prognosis
Up to 76%


Technique

Large pulp exposure

Isolation with rubber dam

Pulpotomy to depth of 2mm


Preparing the cavity Hemostasis and calcium
hydroxide

Compressing and placing hard restoration
setting calcium hydroxide

Prognosis
Up to 96% to 94%www.indiandentalacademy.com

Treatment of the non-vital pulp;
b.Pulpectomy
Implies removal of the entire pulp to the level of apical foramen
1.Teeth with complete apex formation
[Total biopulpectomy
This is total extirpation of the pulp under anesthesia .According to
Basrani,the tissue beyond the limits of CDJ must not be removed
because it facilitates the repair process.]


Indication
1.All cases that have extensive coronal fracture.
2.Use of post in root canal
Technique
Root canal treatment
Prognosis;90%
Treatment of nonvital pulp


TREATMENT OF IMMATYRE FORMED APEX
Apexification
Apexification is a method to induce development of the root apex
of an immature ,pulpless tooth by formation of osteocementum or
other bone like tissue.
Objectives;
Aim is to induce either closure of the open apical third of the root
canal or the formation of an apical ‘calcific barrier’ against which
obturation can be achieved
Technique;


Crown root fracture

Defined as a fracture involving enamel, dentin and Cementum.

Classification
Uncomplicated
Complicated

Mechanism ;
The horizontal impact produces zones at the point
of impact cervically on the palatal aspect and
apically on the labial aspect of the root .the
shearing stress zone s which extend between the
compression zones determine the course of the
fracture

Incidence
5% of injury affecting permanent and 2% of primary teeth.

Etiology;the most common are injury caused by falls,bicycle and
automobile accident and foreign bodies striking the teeth
Pathology

Communication from the oral cavity to the pulp and periodontal
ligament in these fractures causes inflammation in these structure
Treatment

Emergency treatment

This includes stabilization of the coronal fragment
with an acid etch/resin splint to adjacent teeth and
later RCT is done and post is given

Uncomplicated fractures

1. Suferficial crown root fracture;

Reattachment of new periodontal fibers and deposition of new cementum

upon exposed dentin can occur once coronal fragment has been removed

2.deep crown root fracture;

Gingivectomy and dentin covering procedure


Procedure
Uncomplicated
Superficial crown root fracture
Removal of coronal fragment , Dentin covering and
smoothed with bur and gingivectomy composite restoration

4yrs after treatment


Complicated fracture

1.surgical exposure of fracture surface

removal of the coronal fragment supplemented by gigivectomy and
osteotomy and subsequent restoration with a post retained restoration

.
Treatment principal;
To convert subgingival fracture to supra gingival fracture.

Indication;
When surgical technique does not compromise the esthetic results i.e.
only palatal aspects of the fracture must be exposed in this manner.


Complicated crown root fracture
1.Surgical exposure of the fracture site

Removal of fracture fragment Exposure of fracture site

Post retained crown Finished restoration


2.removal of coronal fragment and surgical extrusion of the root;

treatment

Treatment principal
To surgically move the fracture to a supragingival position.

Indication

Should be only be used where the root portion is long to
accommodate a post retained crown.


2.Removal of coronal fragment and surgical extrusion of the root
Loose fragment stabilized LA and incision of PLD

Luxation of the root Extraction of the root


Reimplantation of
apical segment

Stabilization of apical
fragment during healing


Root filling

Completion of the restoration


3.removal of coronal fragment and subsequent orthodontic
extrusion of teeth.

Treatment principle ;to orthodontically move the fracture to a
supragingival position.

Indication;
The same as for surgical extrusion,but is more time consuming.


Removal of coronal fragment
pulpotomy and orthodontic
extrusion

Removal of loosened fragment


pulpotomy

Orthodontic extrusion


Extrusion completed

Restoration completed


Removal of coronal fragment ,pulp extirpation and orthodontic
extrusion
Procedure;

RCT

Applying extrusion appliance


Orthodontic extrusion

1yr after extrusion

Follow up procedures;
2 months after complete treatment and 1yr after injury

Root fracture
This type of injury is limited to fracture involving the root only.
( cementum dentin and pulp)
Incidence;
1-7 % of the cases of trauma to the dentition and occur most often between
11 to 21 yrs
Etiology
1.Iatrogenic
2. Traumatic
Classification
a.According to the line of fracture with respect to the long axis of the
teeth.
Horizontal.
Oblique.
Vertical
b.According to location;
1.The cervical third.
2.the middle third
3.apical third www.indiandentalacademy.com

b.According to location;
1.The cervical third.
2.the middle third
3.apical third

C.According to number of fracture lines.
1.Simple
2.multiple
3.comminuted

d.according to the extension of the line of fracture
1.partial
2.total

e.position of root fragment.
1.Without displacemen
2.with displacement

Mechanism

A frontal impact displaces the

tooth palatally and results in a

root fracture and displacement

of the coronal fragment.this

leads to both pulp and PLD

damage in coronal fragment.

Treatment of horizontal fractures

Principle;

Reduction of displaced fragment and firm immobilization

Immediate TREATMENT; The type of treatment depends on whether
the pulp remains vital .If there are doubt to the state of the pulp,it is treated
as a fracture

WITH PULPAL VITALITY;
Under anestesia the fracture fragments are reduced,moving the portion
apically with pingef pressure.followed by radiographs to confirm .the tooth
stabilized.occlusion checked.


Horizontal fracture teeth

Clinical examination


Repositioning the fragment

Verifying the repositioning


Fixation procedure

Applying splinting material


Removing the splint

1year after treatment


WITHOUT PULPAL VITALITY
a.root fragment communicating with oral cavity
fracture of any part of the root coronal to the periodontal attachment have
a poor prognosis for healing.

The treatment choice are

1.Periodontal gingival and osseous surgery to expose an adequate amount of
tooth structure for a crown margin
.
2.extrusion of the root until all the fracture site is supragingival sufficient for
restoring the tooth

3.combine orthodontic extrusion and periodontal gingival and osseous
recontouring for adequate margination

4.removing the clinical crown segment and retaining the submerged root with
its vital pulp followed by placement of fixed bridge across the space.if the root
pulp is necrotic, endodontic treatment must be accomplished.

b.treatment of fracture teeth not communicating with the oral
cavity(middle and apical third )

Treatment of horizontal root fracture due to necrotic pulp can consist of;

• Endodontically treating the coronal segment only.

• Endodontically treating both coronal and apical segment.

• Endodontically treating the coronal segment and surgically removing the
apical segment.


vertical root fractures;
Described as longitudinally oriented fracture of the root ,extending from the
root canal to the periodontium.they usually occur in endodonticaly treated
teeth.

Radiographic changes seen in vertical root fractures are summarized;

1.separation of the root fragments 2.space along the root or root fillings


3.space beside a root filling or post 4.Double image

5..radioopaque signs


6.widening of periodontal 7.radiolucent halos
ligament space

8.steep like bone defect


9.Isolated horizontal bone 10.Unexplained boon loss in posterior
loss in posterior teeth teeth

11 .V-shaped bone loss on roots
of posterior teeth


12.resorption along the fracture line. 13.displacement of retrograde filling
material

14.endodontic failure after healing has occurred
.


Direct visualization of the fracture


Treatment alternatives

Repair of fractures
According to Andreasen there are four types of repair:
1. healing with calcified
tissue the pulp is ruptured at the level of the fracture.fracture
healing with in growth of cells cells originating from the apical
half of the pulp ensures hard tissue union of the fracture


2. healing with interposition of connective tissue
The pulp is ruptured or severely stretched at the
level of the level of fracture.healing is dominated
by in growth of cells originating from the periodontal
ligament and results in interposition of connective tissue
between the two fragments


3.Interposition of tissue between the segments
infection occurs in avascular coronal pulp.granulation
tissue is soon formed which originates from the
periodontal ligament.accumulation of the cell between
two fragments causes separation of the fragments and
loosening of coronal fragments.

.4.Healing with interposition of bone and connective tissue

PROGNOSIS :
Prognosis of root fracture depends on
• how soon the patient receive treatment
• adaptation of the fragment
• location of the fragment
• stabilization of the fragment
• horizontal or vertical fracture
• absence of infection
• health status of patient

COMPLICATIONS:
1) root resorption
2) internal resorption
3) periodontal complications

luxation injuries
Terminology;

1.concussion
an injury to the tooth-supporting structure without abnormal loosening
or displacement but with marked reaction to percussion.

2.subluxation
an injury to the supporting structure with abnormal loosening but
without clinically or radigraphically demonstrable displacement of teeth.

3.intrusive luxation
displacement of the tooth deeper into the alveolar bone.the injury is
accompanied by communication or fracture of the alveolar socket


4.extrusive luxation
partial displacement of the tooth out of its socket .
5.lateral luxation ,displacement of the tooth in a direction other than axially .this
is accompanied by comminution or fracture of the alveolar socket.

FREQUENCY

Luxation injuries compromises 15 to 40 % of dental injuries.
62 to69 % in primary teeth

.Etiology.

Fights,fall are the major factors.
Luxation of teeth primarily involves max central incisor
and seldom seen in mandibular teeth

MECHANISM OF

CONCUSSION INJURY

A frontal impact leads

to hemorrhage

and edema in the PDL


MECHANISM OF
SUBLUXATION INJURY

IF THE IMPACT HAS GREATER
FORCE, FIBERS MAY BE TORN
,RESULTING IN LOOSENING OF
THE INJURED TOOTH


Mechanism of
extrusive luxation
Oblique forces
displaces the tooth out
of socket.only the
gingival fibers
palatally prevents the
tooth from being
avulsed


Mechanism of lateral
luxation

Horizontal forces displace the
crown palatally and the apex
labially.apart from severance
of the PDL and the
neurovascular supply to the
pulp,compression of the PDL
is found on the palatal aspect
of the root

Mechanism of intrusive

luxation

Axial impact leads to extensive

injury to the pulp and

peridontium


1,Concussion; minor injuries have been sustained by periodontal structure so

that no loosening is present. The patient complains that the tooth feels sore.

clinical examination reveals a marked reaction to percussion in horizontal

and or vertical direction.

2.Subluxation;

Abnormally mobile
Sensitive to percussion and occlusal forces.
Bleeding from gingival sulcus


3.Extrusion luxation;

Tooth appears elongated

Bleeding from PL

Percussion is dull.

Radiographic findings

Width of periodontal space increased
in extrusive luxation


4.Intrusive luxation
Marked displacement
Sensitive to percussion
Firm
Metallic sound similar to ankylosed tooth

Radiographic findings
Periodontal space disappears totally or partially in intrusive luxation


5.Lateral luxation.

Usually crown is displaced lingually

Associated with fracture of
vestibular part of socket wall.


Treatment

Concussion;
Adjusting the occlusion
Pulp test is repeated at 1,3,6,12 month


Subluxation;
Adjusting the occlusion
Teeth repositioning and splinting
Half of this will undergo pulpal necrosis and requires RCT

Splinting
Object of splinting
Stabilization of the injured tooth and prevention of further
damage to the pulp and periodontal structure during healing
period. In luxation injuries, the value and influence of splinting
upon periodontal and pulpal healing has not been classified.


Extrusive luxation
Repositioning and stabilization for
4 to 8 weeks.
RCT except in young immature
teeth

Mobility and
percussion test


Sensitivity testing and
radiographic diagnosis

repositioning


splinting

Polishing the splint


Finished splint

Gingival wound is sutured


Lateral luxation
Repositioning and stabilization
RCT if pulp necrosis


Laterally luxated teeth

Percussion test


Mobility and sensitivity test

Radiographic examination


Anesthesia

Repositioning the teeth


splinting

After etching


Splinting material

3 weeks after splinting


Splinting removed

6 months after injury


Intrusive luxation
Immature teeth will re-erupt within 3-4 weeks.

Spontaneous eruptions of
intruded teeth

7yrs old 6weeks 1year
girl


Mature teeth

Orthodontic reposition
and stabilization 3-4 weeks
Gingivectomy and RCT

Dentin protection


Orthodontic traction

Placing the brackets


Orthodontic traction

Extrusion initiated


Complete extrusion after 4
weeks

Crown restoration


Complication following luxation injuries:
These include pulpal necrosis, pulp canal obliteration, root
resorption( external or internal)

Pulp canal obliteration:
1) Partial obliteration
2) Total canal obliteration

Root resorption
a) External root resorption:
3 types
1) Surface resorption
2) Replacement resorption
3) Inflammatory resorption

b) Internal root resorption
2 types
1) Internal replacement resorption
Internal inflammatory resorption

Avulsion:

An avulsed tooth is completely displaced out of its socket
and may be referred as exarticulation or complete avulsion.

Incidence:

1-16% of all traumatic injuries of permanent teeth.
7-13% of primary dentition
male: female ratio 3:1
age group 7-11 yrs
maxillary central incisors are commonly avulsed
Examination:


Factors affecting success of replantation
1.1.extra oral time
Shorter the extra oral period,the better the prognosis for
retention of the replanted tooth.
2.storage media and transportation of avulsed teeth.
a. milk
b. Saliva
c. hanks balance salt solution
d. physiologic saline


Replantation;
Replantation is sometimes referred to as reimplantation
is the insertion of a tooth in its socket after its complete
avulsion resulting from traumatic injury.

Intentional replantation ;

Transplantation;

Auto-transplantation;

Allotransplantation;


Management of the socket;

Management of the surface ;

Adjunctive drug therapy
Antibiotics
Steroids and other drugs
Tetanus prophylaxis
Calcium hydroxide root canal filling
Permanent filling with GP
Splinting
Duration of splinting

Treatment

Endodontic treatment of replanted tooth

1.Teeth with incomplete root formation

2.Teeth with complete root formation

3.Replation of tooth with avital periodontal ligament


Replantation of teeth with
complete root formation

Examination and
Rinsing the tooth


Replanting the tooth

splinting


Follow up after 1 week

Extirpation of the pulp


Access preparation

Preparing the canal


Placing calcium
hydroxide dressing

Condensing calcium
hydroxide


Access cavity closed

Splint removed


Replanting the tooth with incomplete root formation

8yrs old avulsed teeth

Rinsing the root surface



Monitoring the healing


Replanting the tooth with avital periodontal
ligament

Tooth kept dry for 24hrs

Treatment of root surface


Fluoride treatment of
cementum and dentin

Endodontic treatment


Condition of the
socket after 3 weeks



Splinting

Follow-up


Healing after replantation

1.healing with normal PDL;
most of the intra alveolar periodontalfibers have healed. Pulpal
revascularization has reached mid-root level


2.healing with ankylosis or replacement resorption

1 week 2months 4months 1yr 2 yrs 10yrs


3.inflammatory resorption

0day 1week 3weeks 4weeks 2months 3months


Fracture of the alveolar process
Classified
1.Comminution of alveolar socket
2. Fracture of alveolar socket wall
3.fracture of alveolar process
4.fracture of maxilla or mandible
Etiology;
Fights,automobile accidents resulting from direct impact
Frequency
Permanent-16%
Primary dentition-7%

Clinical findings;

.Tenderness on palpation and percussion

•.Comminution of alveolar socket

•.Abnormal mobility of the involved teeth

•.dull percussion sound

•.disturbed occlusion


Treatment
Principle;
Repositioning splinting


Fracture of maxillary alveolar process

Anesthetizing the area


Repositioning

splinting


Fracture of mandibular alveolar process


Conclusion;


References;
1.Essential of traumatic injuries of teeth
2nd edition ,J.O .Andreasen and F.M. Andreasen
2.Pathways of pulp
6 th edition Stephen Cohen,Richard C Burns
3.Endodontics
5th edition Ingle,Bakland
4.principles and practice of endodontics
2nd edition Walton,Torabinajad
5.dental clinics of North America 1999
6.journals
IEJ,JOE,Endodontics and Dental Traumatology,
Australian Dental Journals

Traumatic injuries of teeth /certified fixed orthodontic courses by Indian dental academy

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