dental trauma

1. TRAUMATIC
INJURIES OF TEETH
Presented by:
DRISHYA DINESH

2. CONTENT
 INTRODUCTION
 CAUSE AND INCIDENCE
 CLASSIFICATION
 EXAMINATION OF THE PATIENT
 DIAGNOSTIC METHODS
 GARCIA& GODOY CLASSIFICATION
 Enamel fracture
 Crown fracture without pulpal exposure
 Crown fracture with pulpal exposure
 Crown- root fracture
 Root fracture
 Vertical fracture
 Luxated teeth
 Avulsion
 RESPONSE OF PULP TO TRAUMA
 CONCLUSION
 SUMMARY
 REFERENCE

3. INTRODUCTION
 Trauma of the oral and maxillofacial region occur frequently
 Dental injuries are common among facial injury
 Can occur at any age
 Child groups – while learning to walk, falling from chair, child
abuse
 Teenagers & young adult – sports accident
 Other age groups –automobile accident

4. CAUSE & INCIDENCE
The common causes are
 Direct/indirect trauma
 Sports accident
 Automobile accident
 Fight & assault
 Biting hard items
INCIDENCE
 About 5%
 Boys have 2/3 times as many fracture teeth as girls

5. Bakland reported that 8-12years of age are
most prone for dental accident.
3 key predisposing factors for # are:
1. Increased overjet of tooth
2. Protrusion of maxillary anterior

6. CLASSIFICATIONS
ELLIS & DAVEY
(1970)
GARCIA & GODOY
(1981)
ANDREAESEN
(1981)
BENNET
(1963)

7. 1.ELLIS & DAVEY (1970)

8. 2.GARCIAAND GODOY (1981)
 Enamel crack
 Enamel fracture
 Enamel Dentin fracture without pulp exposures
 Enamel Dentin fracture with pulp exposure
 Enamel-Dentin-Cementum fracture without pulp exposure
 Enamel-Dentin-Cementum fracture with pulp exposure
 Root fracture
 Concussion
 Luxation
 Lateral displacement
 Intrusion
 Extrusion
 Avulsion.

9. EXAMINATION
OF
PATIENT

10. 1. INFORMATION ABOUT THE INJURY:
The following questions are intended to elicit
essential information about the traumatic event.
 When did the injury occur?
 Where did the injury occur?
 How did the injury occur?
 Are there previous injuries to the teeth?
 Is there a change in the bite?
 Past medical history.

11. 2. CLINICAL EXAMINATION:
SOFT TISSUE WOUNDS
[ presence of impacted foreign bodies]
TEETH
(for fractures or infractions)
(displacement of teeth )
PULP
[the extent of exposure]
BONE

12. 3.DIAGNOSTIC METHODS
 Pulp vitality:
 by electric pulp vitality tester
 When negative- injured nerve bundle
,paralyzed.
o Radiographic examination:
3 recommended angulations are-
 90 degree horizontal angle with
central beam through root
 Occlusal view
 Lateral view from mesial/distal aspect
of tooth

13. ENAMEL INFARCTION
 CLINICAL FINDINGS:
Visual examination- by DYES (Methylene Blue)
Tooth is not tender on percussion. If tender on
percussion check for luxation injury/root
fracture
 RADIOGRAPHIC FINDINGS:-
No radiographic abnormality
Periapical view radiograph is used.
(additional added if any other signs and symptoms
present)
 TREATMENT:
Etching and sealing with resin to prevent
discoloration of infarction line

14. ENAMEL FRACTURE
 CLINICAL FINDINGS:-
Visual signs- loss of enamel without
dentin exposure
No tenderness on percussion
Pulp sensitivity test is recommended
 RADIOGRAPHIC FINDINGS:-
Visible enamel loss
Radiograph of lip ,cheek to find out root
fragments or foreign material

15. TREATMENT
Smoothening the margins to prevent
laceration of soft tissue
 In extensive cases:-
recontouring of the roughened
margins followed by esthetic
composite restoration
 If fractured segment is available -
re positioned and bonded to
the tooth

16. CROWN FRACTURE WITHOUT PULPAL
EXPOSURE (E+D)
OBJECTIVES
 Elimination of discomfort
 Preservation of vital pulp
 Restoration of fractured crown
CLINICAL FINDINGS:-
 No tender on percussion
 Pulp test is positive
RADIOGRAPH:-
 E+D loss is visible

17. TREATMENT
 Remaining dentinal thickness of
2mm is sufficient for pulpal
protection
 Composite is prefferd-
reapproximation and bonding the
segments with DBA & composite
 Another approach is use of indirect
veneering
 Tooth is periodically tested with
pulp tester
 If more current is necessary to
elicit pulpal response for vitality,
the prognosis is unfavorable

18. CROWN FRACTURE WITH PULP EXPOSURE
(E+D+P)
CLINICAL FINDINGS:
 Tooth is not tender on percussion
RADIOGRAPHIC:
 Loss of tooth structure is visible

19. 4 kinds of treatment
 Direct Pulp Capping
 Pulpotomy (pulp is vital)
 Apexification (pulp is necrotic)
 Pulpectomy (endodontic treatment)
Mechanical exposure of pulp due to trauma has better prognosis than carious exposure

20. E+D+C with no pulpal
involvement
E+D+C with pulpal
involvement
CROWN
ROOT
FRACTURE

21. CROWN-ROOT FRACTURE WITH NO PULPAL
INVOLVEMENT
 Oblique line # ,begins incisal to marginal gingiva and
extend beyond the gingival crevice
 # segments are held by the PDL
 Tooth is tender on percussion
 Coronal fragment is mobile
 Sensibility pulp test is positive for apical fragment
RADIOGRAPH
Radiograph recommended are Periapical, Occlusal, &
Eccentric exposures to detect fracture lines of root

22.  Localization of fracture line-
CBCT reveals whole fracture extension
 Emergency treatment-
Temporary stabilization of loose segment to adjacent teeth
 Definitive treatment-
Removal/reattachment of fractured segment
Removal is indicated in superficial /chisel fractures
Subgingival extension is converted into supra gingival
fracture by gingivectomy / ostectomy
TREATMENT

23. CROWN-ROOT FRACTURE WITH PULPAL
INVOLVEMENT
 # line is single
 Symptoms are mild and pain is due to mobility of
fractured segment
 Tooth is tender on percussion
 Coronal fragment is mobile
RADIOGRAPH
 Recommended are periapical and occlusal

24. TREATMENT
 With pulpal exposure and immature roots-
Partial Pulpotomy to preserve pulp
 Pulp exposure with mature roots-
Perform Endodontic Treatment
Use Fiber-Reinforced Composite Post for retention of the
fractured segment if reapproximation is proper

25. ORTHODONTIC EXTRUSION OF APICAL FRAGMENT
 This was first advocated by HEITHERSAY in 1973
 The coronal fragment is unrestorable & remaining
radicular portion is partly below the gingiva
 This procedure is indicated in case where C:R ratio is
compromised
 Subgingival portion is made to supra gingival position

26. SURGICAL EXTRUSION OF APICAL FRAGMENT
 Surgical movement of apical fragment to supra
gingival position
 Indicated where tooth is long enough to
accommodate a post retained crown after surgical
extrusion
 This method is faster than orthodontic extrusion

27. • Forms about 3% of
dental injuries
• Results from
horizontal impact
• Usually transverse to
oblique in nature
• Clinically coronal is
mobile and
displaced with
tender on percussion
ROOT
FRACTURE

28. RADIOGRAPHIC ASSESMENT
 HORIZONTAL FRACTURE
90 degree placement of film with central beam through
tooth
 DIAGONAL FRACTURE
Occlusal view radiograph

29. CORONAL
MIDDLE
APICAL

30. CORONAL THIRD FRACTURE
 Prognosis is LESS FAVOURABLE
(because of difficulty in immobilizing the
root)
 Repair does not occur due to movement
of tooth & exposure of pulp to oral
environment
 Tooth become loose or exfoliated due to
resorption
 Apical fragment is retained
NOTE: In case of coronal third root fracture, its
beneficial to have splints for stabilization up to
4months of time

31. MIDDLE THIRD ROOT FRACTURE
Prognosis depend on :
1. Position of the tooth
after root fracture
2. Mobility of the coronal
segment
3. Status of pulp
4. Position of fracture line

32. TREATMENT OPTIONS AVAILABLE ARE:-
 RCT of both segments
1. Indicated where the segment are not separated
2. Allow passage of instruments from coronal to apex
 RCT of coronal segment and removal of apical segment
1. Apex has separated from coronal
 Use of intra radicular splint
1. After endodontic, a post space is prepared in canal to extend
from coronal segment to apical one, allowing placement of
rigid-type post to stabilize root segments
 RCT of coronal segment and no treatment of apical one
1. The apical segment is vital healthy pulp tissue. Apexification
of the coronal segment.
2. Most effective is to employ MTA to form apical barrier in
coronal segment and backfill the canal with
thermoplasticized GP

33. APICAL THIRD ROOT FRACTURE
 Prognosis is favourable,provided that the tooth is
immobilized and not placed under pressure of mastication

34. •Opposing teeth should be grinded to minimize incisal –
occlusal stress
•Tooth with its root fracture at apical segment has excellent
prognosis because pulp at the apex is vital & firm in the
socket. Mobile tooth should be ligated
•If pulp in coronal fragment is vital and tooth is stable
with/without ligation, no additional treatment is indicated
•If pulp is dead in coronal fragment, endodontic treatment can
be done
•If tooth fails to recover the apical part, then it is surgically
removed
TREATMENT

36. HEALING DEPENDS ON 3 CRITERIA
 Distance between fragments
 Degree & Duration of immobilization
 Presence or absence of infection
ANDREASEN & HJORTING-HANSEN DESCRIBED 4 TYPES
OF REPAIR FOLLOWING ROOT FRACTURE
 Calcified tissue
 Connective tissue
 Connective tissue and bone
 Granulomatous tissue

37. Tissue replaced with
cementum by
cementoblast & cover
the # root surface
Following # complete
union does not occur
Healing depends on
PDL
Pulp is vital, blood clot
forms & macrophages
dispose damaged tissue
Meshwork of
granulation tissue
develops
Fibroblast appear and
lay down fibrous tissue

38. Pulp is vital
Odontoblast covers the
medial # root surface
with dentin like tissue
Cementum extends into
the canal, & covers the
irregular dentinal
surface for short
distance
CT fills the space
between cementum
covered fragments
Fibrous tissue replaced
by bone
If treatment fails,
granulation tissue
replaces bone between #
segments

40.  Diagnosis is often difficult to establish by radiograph
 Patient c/o sensitivity ,may/ may not able to locate the
affected tooth
 Tooth react normally to EPT or may be hypertensive
 Chew on tooth slooth,cotton applicator helps in identifying
the tooth
 Common causes are:-
• Traumatic occlusion
• Excessive load on endodontically treated tooth
• Bruxism

41. VERTICAL
FRACTURE
CROWN
FRACTURE
ROOT
FRACTURE

42. VERTICAL CROWN FRACTURE
 Prognosis depends on
location
 Favorable prognosis-
# passes through clinical
crown of multirooted tooth
& through its
furcation(provided tooth can
be hemisected)

43.  If vertical fracture occurs through the crown furcation of
maxillary molars in M-D plane, endodontic treatment is
done following :
1. Section the crown into two segments- buccal & palatal
and extract the less strategic of the two
2. Restore the remaining segment with full coverage
restoration that has narrower contoured occlusal table
to limit the occlusal forces to long axis of the root of
retained segment
3. Segment the crown into two and move the segment
with ortho appliance & splinted by full coverage
restoration

44. VERTICAL ROOT FRACTURE
 Longitudinal fracture of the root,
the prognosis is hopeless
 Fracture segments are extracted,
and recememted with
cyanoacrylate
 Endodontic treatment is completed
extra orally within 30min and tooth
is replanted into the socket
 First the tooth recovered but later
failure happened by pocket
formation, root resorption and
finally extraction is recommended

46. LUXATED TOOTH
INTRUSIVE
LUXATION
LATERAL
LUXATION
EXTRUSIVE
LUXATIONSUBLUXATIONCONCUSSION

47. CONCUSSION
 Injury to supporting structure of tooth, without abnormal
loosening/displacement of tooth but significant reaction
to percussion
 Tooth may feel numb shortly after blow.
 No bleeding & no radiographic changes
 Tooth respond normal to sensitivity
 Treatment confines to occlusal adjustment of opposing
teeth and repeated periodic vitality testing

48. SUBLUXATION
 Injury to supporting tissue with abnormal loosening
of tooth without displacement
 Tooth is in normal position in arch, but exhibit
horizontal mobility and have pain on percussion
 Bleeding from the gingival crevice indicating
damage to periodontal tissue
 Teeth respond normally to sensitivity test
 Treatment similar to concussion. Splinting might be
required for multiple tooth injuries

49. EXTRUSIVE LUXATION
 Partial displacement of tooth from its alveolar socket
 Teeth appear elongated with lingual deviation of crown
 Dull sound on percussion and bleeding from PDL

50.  Extruded tooth is forced back into
socket done after anaesthetizing the
region and by means of gentle finger
pressure or pressure exerted on a
wooden tongue blade against the
incisal surface of adjacent teeth to
force them back in their socket
 Affected tooth is splinted for 2-3
week
 Vitality is tested once in month
 If more current is required for pulp
testing and response to cold test
become weaker “dying pulp” is
expected
 If pulp is dead RCT is indicated
TREATMENT

51. LATERAL LUXATION
 Eccentric displacement of tooth other than axial direction
 Associated with comminution or fracture of alveolar
socket
 Crown is displaced in lingual direction along with # of
alveolar socket wall

52. TREATMENT
1
• Reposition of tooth back into its normal
position
2
• Difficult and painful and has to be done
with forceps under infra-orbital regional
anesthesia
3
• Teeth is stabilized with splint for 3 weeks
(longer fixation for marginal bone break
down)

53. INTRUSIVE LUXATION
 Intrusion into the alveolar socket
along the long axis of tooth &
accompanied by fracture of
socket
 Only small amount of tooth
visible due to swelling of soft
tissue
 Occur greater in primary teeth
than in permanent
 Diagnosed by history and
radiographic examination
 Not sensitive to percussion

54. TREATMENT
 Immediate treatment is not needed unless its not primary
teeth(because permanent tooth bud present at apex)
 Apply cold to alleviate swelling, pain & stop bleeding
 Spontaneous re-eruption is treatment of choice & varies from
2-14 months
 Surgical extrusion is done in case of multiple teeth intrusion

55. AVULSION
 Complete and total displacement
of tooth from socket
 Incidence varies from .5 to 3% in
permanent teeth and 7 to 13% in
primary teeth
 ETIOLOGY
Sports & fight injuries
 Maxillary central is most
affected

56. O R

58. TRANSPORT MEDIA

60. (b)Administer systemic antibiotics. Tetracycline is the
first choice( doxycycline 1-0-1 x7days)
Tetracycline is not recommended for patient under age of
12yrs
Penicillin v is given to children under age 12 as an alternative to
tetracycline
1.Tooth has been replanted at the site of
avulsion
(a)Clean the area with water spray, saline or chlorhexine.verify
the normal position clinically and radiographically .apply
flexible splint for a period of 2 weeks

61. IF AVULSED TOOTH CONTACTED SOIL
Patient recommended on soft diet for 2 weeks and brush with soft
tooth brush
Use chlorhexidine (0.1%) for 1 week
(ii)Tooth with open apex
The goal of replanting in still developing teeth in children is to allow for possible
revascularization of the tooth pulp.
If that does not occur RCT may be recommended
(i)Tooth with a closed apex
Root canal treatment done after 7-10 days of replantation and before splint removal.
Calcium is placed as intra canal medicament until filling of the root canal

62. 2.TOOTH KEPT IN SPECIAL STORAGE MEDIA WITH
EXTRA ORAL DRY TIME LESS THAN 60MIN
Tooth with
closed apex
• If contaminated, clean the root surface and apical foramen
with stream of saline and place the tooth in saline. Remove
the coagulum in stream of saline
• If fracture occurs in alv.socket,reposition with suitable
instrument and replant tooth with digital pressure and
continue the previous treatment for replantation
Tooth with
open apex
• Clean tooth with saline and remove the coagulum.
• Cover the root surface with minocycline hydrochloride
microsphere before replanting
• Continue same procedure as replanting

63. 3. EXTRA ORAL DRY TIME LONGER THAN 60 MIN
• Remove attached necrotic soft tissue with gauze
• .RCT done prior to replantation
• .Remove coagulum with saline stream
• Examine the alveolar socket and reposition with
suitable instrument
• Immerse tooth in 2% sodium fluoride for 20min
• Replant tooth slowly with digital pressure .suture
gingival laceration
• Verify the position clinically and radiographically
• Stabilize the tooth for 4 weeks using flexible splint
• Administer systemic antibiotics
Tooth with a
closed apex
(delayed
replantation- poor
long term
prognosis.
The PDL will be
necrotic and not
expected to heal)
•Treatment is similar like
the one with closed apex
Tooth with open
apex

64. FOLLOW- UP PROCEDURES
 ROOT CANAL TREATMENT:
Teeth with closed apex: RCT to be done 7-10days after
replantation
Teeth with open apex : replanted immediately , chances of
vascularization is possible. RCT should be avoided
unless there is clinical and radiographic evidence of
pulpal necrosis
RCT should be done prior to replantation in a tooth that has
been dry for >60min
FOLLOW UP- 1,3,6, and 12

65. RESPONSE OF PULP TO TRAUMA
TRAUMA
PULP HEALING
PULPAL
NECROSIS
PULP CANAL
OBLITERATION
AFFECTED TOOTH

66. SUMMARY
Because of wide variety of different types of cracks and fractures of the
teeth, there may be a number of symptoms and presentation that may
appear at different stages of fracture development making prognosis often
difficult.
 Management of traumatic injuries include, after examination and diagnosis
 Immediate care may be initiated with the emergency treatment provided,
such as pulp protection for continued root formation in developing teeth
with complicated crown fractures.
 In cases of luxation and avulsion injuries, the immediate concern is to
stabilize the tooth in its normal position to allow re-attachment and re-
organization of the periodontal ligament support

67.  Uncomplicated crown fractures: esthetic and functional restoration will provide
good prognosis.
 Complicated crown fractures: the patient may wisely choose to have root canal
treatment followed by prosthetic crown
 Crown-root fractures: These complicated fractures often involve pulpal exposure,
and in developing teeth, pulpal protection is essential
 Luxation injuries: Minor involvement such as concussion and subluxation,
requires mostly symptomatic treatment- soft diet and possibly occlusal adjustment
to minimize discomfort . All traumatized teeth must be monitored for pulpal
necrosis; endodontic intervention is indicated in such cases.
 Extrusive and lateral luxation , need immediate care repositioning and
stabilization for 2–4 weeks
 The most serious type of luxation injury is Intrusion. Damage occurs to the
cementum and the PDL, and the neurovascular pulp supply is crushed .Current
treatment approaches include surgical repositioning, orthodontic extrusion, and a
combination of both
 Avulsions: All current evidence indicates that immediate replantation favors a
successful outcome . If an avulsed tooth must be transported or stored prior to
replantation, specially developed storage media can sustain the vitality of the PDL
for several hours . Availability of such storage media is a problem, but is has been
demonstrated that milk can be a very suitable storage solution for up to several
hours. Plain water or dry storage will result in a quick death of the PDL and its
cells. Failure to replant the avulsed tooth before PDL death will likely lead to
ankylosis related
resorption.

68. CONCLUSION
Prompt, accurate diagnosis and
appropriate initial management would
improve the prognosis for many dento-
alveolar injuries

69. REFERENCE
Textbook of Endodontics- GROSSMAN
Pathway of the pulp – COHEN’S
Textbook of Pedodontics – SHOBHA
TANDON
GOOGLE SEARCH