Traumatic Injuries

Traumatic Injuries
Dr. Ashraf Refai
BDS MSc DD HMD
Al-Azhar University (Boys Branch)
Cairo, Egypt
www.arefai.edublogs.org

Ouch… ‫...واوا‬
• Most common age to get
traumatic injuries
7-12 years!!!
Good news or Bad news?
– Blood Supply
– Root Formation

Elis Classification
• Class I: Crown fracture (Root intact)
• Class II: Crown fracture without pulp exposure
• Class III: Crown fracture with pulp exposure
• Class IV: Coronal fracture extending subgingival
• Class V: Root fracture
• Class VI: Tooth displacement
• Class VII: Injuries to deciduous teeth

Who Classification
• 873.60: Enamel fracture
• 873.61: Crown fracture without pulp
exposure
• 873.62: Crown fracture with pulp
exposure
• 873.63: Root fracture
• 873.64: Crown/Root fracture
• 873.66: Tooth luxation
• 873.67: Intrusion & extrusion
• 873.68: Avulsion
• 873.69: Other injuries (Soft tissue)
• 802.20: Fracture of the alveolar
process of the mandible
• 802.40: Fracture of the alveolar
process of the maxilla
• 802.21: Fracture of the body of the
mandible
• 802.41: Fracture of the body of the
maxilla

Enamel Fracture
Crown Fracture
without pulp
involvement
Crown Fracture
with pulp
involvement
Crown-Root
Fracture
Root Fracture
Luxation
Avulsion
Classification of Dental Injuries
Modification of WHO Classification (By Andreasen)

1st things first...
• A patient presents to the
clinic with a traumatic injury
i.e.
Fractured upper anterior tooth
Question
What should be done first?

Examination & Diagnosis
History
Chief
complaint
History of
present illness
Medical history
Clinical
Examination
Soft tissues Facial skeleton Teeth &
supporting
tissues

History
1. Chief complaint
– Statement of what happened
– In the patients own words
– Sometimes it is obvious!!!

History
2. History of present illness
– When & how did this injury
occur?
• Missing teeth
• Contamination
• Time elapsed affects treatment
options

History
– Have you had any previous
injuries to your mouth or teeth
in the past?
• Battered wife or child
• Accident prone
• Contact sports
Previously undiagnosed injuries

History
– What symptoms are you now
having with the affected teeth
or tooth?
• Mobility
• Pain
• Bleeding
This will help with diagnosis

History
3. Medical History
– Allergies
– Medical conditions
– Tetanus status

Clinical Examination
1. Soft tissues
– Extent of damage
(Suturing maybe required)
– Foreign body
(Removal of foreign body)
Examination is done visually &
radiographically

Soft Tissue Injury with Foreign Body

2. Facial Skeleton
– Teeth involved in fracture line
may become necrotic
– When should I worry?
• Several teeth are displaced
• Tooth displacement is extensive
• Occlusal malalignment

3. Teeth & Supporting tissue
What should we look for???
Mobility
Displacement
Periradicular Damage
Pulpal Injury
Radiographic Examination

– Mobility
Degree of horizontal mobility
• 0 = No mobility
(Maybe locked in bone)
• 1 = < 1mm mobility
• 2 = 1 to 3 mm mobility
• 3 = > 3mm mobility

– Displacement
If a tooth is displaced from its
original position this maybe a
luxation injury

– Periradicular Damage
• Injury to the apical vessels may result in
pulp necrosis
• Gentle Percussion the tooth will be
sensitive to even mild touch
• The affected & adjacent teeth should be
examined
You may identify other teeth that are
injured
Start with the adjacent teeth

– Pulpal Injury
• May cause
– Internal resorption
– External resorption
– Calcific metamorphosis
• Pulp testing
– Thermal (Ice)
– EPT

– Radiographic Examination
• Search for bone & tooth fracture
• Used for medico legal purposes
Multiple exposures
Multiple angulations
No distortion
Using film holder

Enamel
Fracture
Crown Fracture
without pulp
involvement
Crown Fracture
with pulp
involvement
Crown-Root
Fracture
Root Fracture
Luxation
Avulsion

Enamel Fractures
• Description: Cracks & chips
of enamel
• Treatment:
– Grinding & polishing
– Restoration
• Prognosis: It is good, no
threat unless compounded
with a luxation injury

• Description:
– Fracture of Enamel & Dentin
– Not usually associated with severe
pain
– Usually doesn’t require urgent care
• Treatment:
– Bonded composite restoration
– Bonding of fractured segment
– Indirect Veneer
Crown Fracture without pulp involvement

Enamel Fracture Crown
Fracture
without
pulp
involvement
Crown Fracture
with pulp
involvement
Crown-Root
Fracture
Root Fracture
Luxation
Avulsion

• Prognosis: It is good, no
threat unless compounded
with a luxation injury
• Primary teeth:
– Not common
– Patient handling is more difficult
– Can be left alone (Grinding)
Crown Fracture without pulp involvement

Crown Fracture Without Pulp Exposure

Traumatic Injuries
(Last Weeks Lecture Revision)
• Most Common Age for
traumatic injuries (Good vs
Bad)
• Classifications
– Ellis
– WHO
– Modification of WHO
• What to do first???

Traumatic Injuries
• Diagnostic Process
– History
• Chief Complaint
• History of present illnes
• Medical History
– Examination
• Soft tissue
• Hard Tissue
• Teeth & supporting structure
• Enamel Fracture
• Crown Fracture without pulp
exposure

Enamel Fracture
Crown Fracture
without pulp
involvement
Crown
Fracture
with pulp
involvementCrown-Root
Fracture
Root Fracture
Luxation
Avulsion

• Description:
– Complicated Fracture involving
enamel, dentin & pulp
– Treatment option varies:
• Level of root maturity (Pulpotomy or
else)
• Extent of damage restorability (Vital
pulp therapy or RCT)
• Time elapsed after fracture
Crown Fracture with pulp involvement

• Treatment:
1. Shallow Pulpotomy (Cvek
Technique)
– Indication: Immature Teeth
– Immature teeth are weak
– Allows the pulp to deposit hard
tissue reinforcing the tooth
structure and allowing for root
completion
Shallow vs. Deep pulpotomy

• Technique of Pulpotomy:
– Anesthesia & rubber dam
– Washed exposed dentin with
saline or NaoCl
– Excavation: Removal of
granulation tissue and pulp
tissue to a level 2mm below
exposure
– Do pulpotomy using round bur in
high speed with coolant

– Create dentin shelf
– Wash with saline to achieve
Hemostasis
– Remove clot and apply either
CaOH or MTA
• CaOH:
– Apply liner
– IRM
– Bonded composite
– Re-entry after 6 -12 months

• MTA:
– Apply the material in increments
– Wait 6 to 12 hrs for setting
– Bonded composite
– Re-entry after 6 -12 months is not
needed
– Evaluation is done after 6
months & yearly after that

• Treatment
2. Root Canal Treatment
For teeth that cant be
restored with bonded
composite

Criteria for Successful Pulpotomy
• Tooth is asymptomatic
• No radiographic evidence of
apical periodontitis
• No root resorption
• Tooth responds to pulp
testing
• Continued root development
if no (Apexification)

• Prognosis:
– Depends on time elapsed from
injury
< Than 1 wk good prognosis
> Than 1 wk prognosis gets worse

Shallow Pulpotomy

• Primary Teeth:
– Occurs less often
– Treatment options:
• Pulpotomy
• RCT
• Extraction
Depending on degree of
root resorption more
More than ½ then extract

Crown
Fracture
with Pulp
Exposure

• Description:
– Usually oblique
– Involves both crown & root
– Chisel type fracture (Anterior
teeth)
– Shattered tooth usually with pulp
exposure
– Rarely affects posterior teeth but
it can happen usually doesn’t
happen with pulp exposure
Crown-Root Fracture

• Examination:
– Check for loose fragments
– Old school: Remove all
fragments
– New school: Bond fragments
especially when immature
(Temporarily)
Crown-Root Fracture

• Emergency Care:
– It can be painful so removal of
loose tooth fragments maybe
necessary
– If root immature and pulp is
exposed then pulpotomy or vital
pulp therapy maybe indicated as
well
Crown-Root Fracture

• Treatment Planning:
– Which is better for the tooth
pulpotomy or pulpectomy?
– Is the remaining tooth structure
enough to support a restoration?
– How subgingival is the fracture?
– Should it be extracted and restored
with bridge or implant?
– Or should the space be closed
orthodontically?
Crown-Root Fracture

• Primary Teeth:
– Usually means an extraction
– Sometimes there maybe enough
remaining tooth structure for a
restoration
Crown-Root Fracture

Crown-Root Fracture

Traumatic Injuries
• Fracture involving Enamel,
Dentin & Pulp
• Treament options depend
on:
– Level of root maturity
– Restorability
– Time Elapsed

Traumatic Injuries
• Treatment options
– Pulpotomy
• Ca(OH)
• MTA
• Criteria of Success
• Crown Root Fracture
– Oblique fracture
– Shattered tooth
– Old School
– New School

Enamel Fracture
Crown Fracture
without pulp
involvement
Crown Fracture
with pulp
involvement
Crown-Root
Fracture
Root
Fracture
Luxation
Avulsion

• Description:
It has many names that help
describe it!!
Intraalveolar Root Fracture
Horizontal Root Fracture
Transverse Root Fracture
Root Fracture

• Description:
– Difficult to detect
– Easily missed
Click on the
Picture
Root Fracture

Angulated Radiographs Are Essential
• Additional
Angulations
• Severe Angulations
• Central beam must
pass through space

• Description:
– Usually mild symptoms
– Tooth maybe
• Mobile
• Displaced
• Painful on biting
• Symptomless
The more coronal the fracture the
more the symptoms
Root Fracture

• Emergency Care
– Repositioning
– Stabilization
• Using composite & orthodontic wire
• 12 weeks for calcification
– Follow up (Vitality)
Root Fracture
Application of
finger pressure
Orthodontic
Repositioning

• Sequelae of Root Fracture:
– Most cases heal by calcific
metamorphosis
– Calcification may occur in either
or both segments
– Most commonly in the coronal
segment
What if it doesn’t happen?
Root Fracture

Sequelae of Root Fracture
No healing
presence of
interproximal
inflammatory
tissue
Healing with
interproximal
connective
tissue & bone
Healing with
interproximal
connective
tissue
Healing by
Calcification

Sequelae of Root Fracture: Calcification
12 Weeks
1 Year
1 Day

Sequelae of Root Fracture
Healing with
interproximal
Connective
Tissue
No Healing
with
presence of
interproximal
inflammatory
Tissue
Healing with interproximal
Connective Tissue & Bone

(Necrotic Pulp)
1. RCT for both segments
2. RCT for coronal segment
3. Surgical removal of apical segment
& RCT
4. Hard tissue Induction & RCT
5. Intraradicular Splint
6. Endodontic Implant
7. RCT followed by root Extrusion
Root Fracture (7)
R2I2S2

The Recommended Method of Treatment
Hard Tissue Induction & RCT

Case Report: Root Extrusion
• Crown Root Fracture
• Root Canals Treatment
• Fracture is Sub-Osseous
• Orthodontic wire in the
canal

• Placement of orthodontic wire
• Application of orthodontic force

• Note: The periapical space
• Coronal positioning of fracture
line
• Placement of post
• May need further crown
lengthening or gingivectomy

• Primary Teeth
– Not common
– If not mobile (no symptoms)
• No treatment necessary
– If mobile
• Removal of coronal portion
• Leave apical portion
(not to damage successor)
Root Fracture

• Description
– Usually involves sudden impact
– Damage to supporting structures
and neurovascular supply
– Severity is proportional to
displacement
Luxation Injury

Types of Luxation injuries
1.Concussion
2.Subluxation
3.Extrusive Luxation
4.Lateral Luxation
5.Intrusive Luxation
3
4
5

Description of the Different Luxation Injuries
Clinical
Findings
Concussion Subluxation
Extrusive
Luxation
Intrusive
Luxation
Lateral
Luxation
Abnormal
Mobility
- + + - (+) - (+)
Tenderness to
Percussion
+ + (-) ± - (+) - (+)
Percussion
Sound
Normal Dull Dull Metallic Metallic
Response to
pulp testing
± ± - (+) - (+) - (+)
Clinical
Dislocation
- - + + +
Radiographic
Dislocation
- - + + +
• Subluxation injuries may exhibit bleeding
• Intrusive injuries may result in complete burial
• Lateral luxation may also be accompanied with alveolar fracture

• Examination & Diagnosis
– Pulp status monitoring for
weeks, months or years
– Concussion:
• Most likely to recover
– Subluxation:
• Also likely to recover
• Les predictable than concussion
injuries
Luxation Injury

– Extrusive, Intrusive & Lateral
Luxation:
• More aggressive injuries
• Pulp responds less often
• Pulp usually doesn’t recover
In general Immature teeth
have a better chance of
recovery
Luxation Injury

– Pulp status must be regularly
monitored
• Pulp testing
• Radiographic evaluation
• Color changes
Luxation Injury

– Pulp testing:
• Carbon ice or EPT
• Initial lack of response not
uncommon
• Testing in 4 to 6 weeks
• Testing again in 3 to 4 months
• If pulp recovers it will usually
respond to testing (Exception?)
3 possibilities to testing
procedure
Luxation Injury

– Radiographic Evaluation:
• Done same time as pulp testing
• Periapical lesion (Necrosis)
• Look for resorption (I & E)
• In case of resorption, process must
be stopped to prevent root damage
• Calcific metamorphosis may occur
(No intervention)
Luxation Injury

– Crown color changes:
• Initial discoloration
(Pink)
• If necrotic
(Grey & loss of translucency)
• Calcific metamorphosis
(Yellow or Brown)
• Rarely discoloration maybe reversed
Luxation Injury

Color Change

• Treatment
– Concussion
• No immediate action
• ‘rest’ the tooth & follow up
– Subluxation
• Same as concussion
• Mobility Splinting
Luxation Injury

• Treatment
– Extrusive & Lateral Luxation
• Requires repositioning & splinting
– 3 weeks on average
– 8 weeks (Bony fracture)
• RCT (Incase of Necrosis)
Displacement Necrosis
Luxation Injury

• Treatment
– Intrusive Luxation
• Immature open apex may
re-erupt
• Mature teeth
– Active extrusion (Orthodontic)
– Surgical & Orthodontic extrusion
• RCT (incase of necrosis or
irreversible pulpits) CaOH
Luxation Injury

Intrusive
Luxation
Extrusive
Luxation

Re-Eruption of Intruded Central

• Primary Teeth
– Concussion & Subluxation
• Require no treatment
• If Necrotic RCT or Extraction
– Lateral & Extrusive Luxation
• Depending on severity
– Left alone
– Extracted
Luxation Injury

• Primary Teeth
– Intrusive luxation
• Radiographic evaluation
• Position in relation to successor
– Elongated (Danger)
– Shortened (OK)
• Shape of successors
• If impinging on successor
EXTRACT
Luxation Injury

• Description
– A tooth which has been totally
displaced out of the socket
– Keep tooth moist:
Preserve the periodontal
ligaments
– Minimize time out of the socket
– Minimize handling
Avulsion

• Treatment
– 3 patient situations can occur
– When the tooth has been:
• Immediately avulsed
• Out of the socket for < an hour (kept
in storage media)
• Out of the socket for > an hour (Not
kept in storage media)
Avulsion

• Treatment
– Immediate Replantation:
First Aid for the Avulsed
Tooth
Avulsion

First Aid for Avulsed teeth
Rinse tooth
with cold
running tap
water (10
sec)
Do not scrub
tooth
Replace
tooth in
socket using
gentle finger
pressure
Hold tooth in
place
Seek dental
care
immediately

• Treatment (Immediate)
– Clinical & Radiographic examination
– Look for other injuries
– Check position & stability
Do what is done with
replantation within 1 hour
Avulsion

• Treatment
– Replantation within 1 hour
• Tooth should be placed in transport
media
– Saline
– Milk
– Saliva
NOT WATER
Avulsion

• Treatment (Within in Hour)
– Place tooth in cup of saline
– Check for alveolar fracture
– Remove loose fragments and
open collapsed socket
– Irrigate socket with saline
– Hold tooth from crown with
forceps
– Remove debris with moist gauze
Avulsion

– Replace tooth in socket mild
finger pressure
– Adjust alignment
– Suture soft tissue lacerations
around tooth
– Stabilization with composite
splint 1 to 2 weeks
– Tetanus shot & Antibiotics
– Supportive care (Diet &
Analgesic
Avulsion
Immediate
Replantation

– Mature teeth
RCT after 1 week
– Immature teeth
Evaluate 2,6, & 12 months
• Vital: Root completion
• Necrotic: RCT or Apexification
Avulsion

• Treatment
– Replantation after 1 hour
• Periodontal fibers will not survive
• This will result in replacement
resorption
• Procedure involves root surface
treatment (Slow resorptive process)
Avulsion

• Treatment (After 1 hour)
– Similar steps
– Cleaning root surface
– Soak tooth in 2.4% NaF
(Acidulated to ph 5.5)
5 to 20 minutes
– RCT is performed outside the
patients mouth
Hold tooth in gauze soaked
with NaF
Avulsion

• Treatment (After 1 hour)
– Remove clot from socket &
irrigate
– Gently replace tooth and adjust
position & alignment
– Splinting for 3 to 6 weeks
Avulsion

• Sequelae to Replantation
– Three types of resorption occur
– Surface resorption
• Lacunae of resorption on cementum
surface
• Healed by deposition of cementum
Avulsion

– Inflammatory resorption
• Occurs with infected necrotic pulp
and injury to periodontal ligaments
• Loss of tooth structure & adjacent
alveolar bone
• Resorption subsides after RCT
Avulsion

– Replacement resorption
• Tooth is resorbed and replaced by
bone
• Ankylosis occurs
– Lack of any mobility
– No eruption
– Metallic sound when percussed
• Primary teeth
– Replantation not indicated
Avulsion

Case Presentation: Replantation Resorption

Thank You…
‫جزاكم‬‫هللا‬‫كل‬‫خير‬ ...

Traumatic Injuries

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