Traumatic Dental injuries in endodontology .pdf

traumatic dental injuries and how to cross them

1. TRAUMATIC DENTAL INJURIES

2. Introduction
Classification
Diagnosis &
Examination
Case management
OUTLINE
0102
0304

4. ●Traumatic dental injuries (TDIs) à
5% of all injuries.
●Most common TDIs:
ØIn permanent teeth àCrown
fractures.
ØIn deciduous teethàLuxation
injuries.

5. EPIDEMIOLOGY
MORE COMMON IN
Age
Deciduous (2-5)
Permanent 7-12 years
Arch
Maxilla
Sex
Males
Position
Anteriors

6. Causes:
a)Sport accidents
b)Road accidents
c)Domestic violence
d)Falls in infancy
INCIDENCE OF TRAUMATIC INJURY

7. MECHANISM OF DENTAL INJURIES
•Direct trauma
•(playground equipment)
•Indirect trauma
•(blow to chin)

8. RISK FACTORS
Increased
overjet
Inadequate lip
coverage
Class II division
1 occlusal
relationship

10. 1) Examination & diagnosis
2) Medical History
3) Clinical Examination
4) Teeth & supporting structure

11. 1) DIAGNOSIS & EXAMINATION
A)INITIAL MENTAL STATE
1.Thefirststeptoexamineapatientwhosuffered
headinjuryistoassesshis/hermentalstatus.
2.Thiscanbedonebyaskingthepatientfewbasic
questionsabouthis/hername,age,currentdate
andlocation.
3.Ifthepatientcananswerwithoutconfusionor
hesitation,thenassumptioncanbemadethat
mentalstatusisnotaffectedandtheexamination
procedurescanbeproceeded.

12. 1) DIAGNOSIS & EXAMINATIONB)CHIEF COMPLAIN:
-Patient history is initiated by patient chief complain and recorded in the patient’s own
words
-Next, History of present illness should be explored as follows:

13. 1) DIAGNOSIS & EXAMINATION
B)CHIEF COMPLAIN:
Case History
When
WhereHow
1.Roadtrafficaccidents
2.Falls
3.Sportsinjuries
(mechanism & force delivered
implies type of injury to expect)
Time between injury and
presentation
(influence the prognosis)
Outdoor or indoor
dirty injuries may need
(anti-tetanus)

14. 2) MEDICAL HISTORY
-
•Medicalhistoryisessentialforprovidinginformationaboutthecurrentmedical
state,medicationtaken&numberofdisorderssuchasallergicreactionsor
bleedingdisorders,suchashemophilia.
•Thepatient’stetanusimmunizationstatusshouldalsobedeterminedbecausea
boostermightbenecessaryinthepresenceofinjuriesthatcarrythepotentialfor
contamination.
An 8-year-old boy with known hemophilia experiencing
prolonged bleeding from the periodontal ligament around
the left central incisor. The patient had suffered a
subluxation injury 22 hours earlier.

15. Extra oral
Intra Oral
Hard tissue
Soft tissue
Hard tissue
Soft tissue
3) CLINICAL EXAMINATION

16. •Extraoral:
A-Softtissueexamination:
Øsofttissuesshouldbeassessedforlaceration
&ecchymosis.
B-Hardtissueexamination(FacialSkeleton):
ØItshouldbeassessedforpotentialfracture.
ThisislargelydonebyInspection&palpation.
3) CLINICAL EXAMINATION

17. 3) CLINICAL EXAMINATION
•Intra-Oral:
A-Softtissueexamination:
ØLipandtonguelaceration,swellingor
bruisingandentrapmentofforeign
body.
ØAnti-Tetanusbooster.(contaminated)
ØSofttissueRadiographbefore
suturingàtobesurethatthereisno
foreignobjects.
ØTechnique:Bynormal-sizedfilm/
exposedatreducedkilovoltage.

18. Extensive hemorrhage lingually associated with a dentoalveolar
fracture

19. B-Hardtissueexamination:
ØAmarkedchangeinalignmentordisplacementoftheteethasablockmay
indicateafractureofthemaxillaormandible.
3) CLINICAL EXAMINATION

20. §Inspection: Clean the area with gauze soaked in water or saline.
§Mobility.
§Displacement (LUXATION).
§Periodontal Damage.
§Pulpal Injury.
§Radiographic Evaluation.
4)Teeth & Supporting Structure:

21. 4)TEETH & SUPPORTING STRUCTURE:
Theidealpulpalresponseaftertraumaticinjuryiscompleterecovery.However,twopotential
outcomesmayoccur:
CalcificmetamorphosisorPulpnecrosisduetoapicaldisplacementoftoothwhichdisruptsapical
bloodvessels.
Pulpnecrosismaycauseexternalinflammatoryrootresorptionwhichoccurssilentlysofollowup
isamust.
Pulpstatusshouldbeassessed:
initially&duringfollowupvisits.
• Pulpal Injury:

22. NeuralVascular
1) Thermal (Hot & Cold)1) Pulse oximetry
2) Electrical2) Laser doppler flowmetry
• Pulpal Injury:
4)Teeth & Supporting Structure:

23. 1.Sensitivityisnotreliableintraumatizedteeth,becausethetoothisinastateof
shock(theinflammatoryedemaispressingonthenervefiberspreventing
transmissionofimpulses).
2.Teeththatgivepositiveresponseattheinitialexamcannotbeassumedtobe
healthyandcontinuetogiveapositiveresponse.
3.Teeththatgiveanegativeresponsecannotbeassumedtohaveanecrotic
pulps,becausetheymaygiveapositiveresponselater.
• Pulpal Injury:
4)Teeth & Supporting Structure:

24. 4.Itmaytakeupto9monthsaftertraumafornormalbloodflowtoreturnto
coronalpulp.
5.Thepurposeofthetestistoestablishabaselinereferenceforthephysiologic
statusofthepulpsoftheseteeth.
• Pulpal Injury:
4)Teeth & Supporting Structure:

25. TheIADT(InternationalAssociation
ofDentalTraumatology–British
DentalJournal)advisesthat:
PulpSensitivityTesting,shouldbe
performedinitiallyandateachfollow
upvisittofirstestablishbaseline,and
furtherdetermineifchangesoccurred
overtime.
• Pulpal Injury:
4)Teeth & Supporting Structure:

26. •AllAnteriorTeethshouldbetested(Canineto
Canine)forbothmaxillaryandmandibular
arches(Notonlythetoothofthepatient’schief
complain).
•Timing:
üatthetimeofinitialexamination(toestablisha
baselineforcomparisoninthefollowupvisits)
üateachfollowupvisit.
üfollowup(2to4and6to8weeks,3,6,12
months&yearlyfor5years)
•Placedonthethefacialsurfaceofthe
tooth.
1-Thermaltesting:
Pulp Sensitivity Testing:

27. 2-Electricaltesting:
§Limitedvalueinyoungteeth.Young&immature
teethàAbsenceofA-deltafibers.
Pulp Sensitivity Testing:

28. vTransitionfrom
ü–veto+veresponseofpulptestingèhealingpulp.
ü+veto–veresponseèdegeneratingpulp.
üPersistentlossofresponseèirreversiblydamagedpulp.
• Pulpal Injury:
4)Teeth & Supporting Structure:

29. IADTrecommended at least 4 different
radiographsfor almost every injury
90°to the long axis
2 different vertical angulation
Occlusal film
•Radiographic Evaluation:
4)Teeth & Supporting Structure:

30. •2Dimagingmethodhasitslimitationsandlackof3Dinformationmayleadto
improperdiagnosisandinverselyaffectlongtermoutcome.
•3DimagingisrecommendedsuchasCBCTtoenhanceclinicianabilityto
properlydiagnoseluxationinjuries,alveolarfracture,rootfracture,rootresorption
•Radiographic Evaluation:

31. Extraoral
radiographs

32. THE ROLE OF ENDODONTICS AFTER TRAUMATIC DENTAL INJURIES

33. CLASSIFICATION

34. Pagadala S, Tadikonda DC. An overview of


Review Article

An overview of classification of dental
trauma

Sasikala Pagadala
1*
, Deepti Chaitanya Tadikonda

1
Assistant Professor, Department of Periodontics,
Nanded, Maharashtra, India
2
Assistant Professor, Department of Pedodontics,
Nanded, Maharashtra, India
*
Corresponding author email: [email protected]


International Archives of Inte
Received on:
Source of support:

Abstract
Minor falls, local accidents, while participating in sports or childish pranks that are not intended to
harm produce greatest number of
seemingly benign accidents, child’s facial appearance be
child appear unattractive. Dental injuries are considered emergency situation that require immediate
care. The purpose of this article is aimed to overview the classification of the traumatized teeth.

Key words
Fracture, Dental trauma, Luxation, Concussion.

Classification of the dental trauma
In the 1950, Pediatric dentist G.E. Ellis was the
first person to promote a universal classification
of dental injuries. Dental injuries have been
classified according to a variety of factors, such
as etiology, anatomy, pathology or therapeutic
considerations.

Classification of anterior teeth trauma by
Sweets (1955) [1]
It is mainly based on the anatomy and
morphology of the tooth structure. The
disadvantages of this classification are that no
An overview of classification of dental trauma. IAIM, 2015; 2(9): 157-1
An overview of classification of dental
, Deepti Chaitanya Tadikonda
2

t of Periodontics, Nanded Rural Dental College and Research C
t of Pedodontics, Nanded Rural Dental College and Research C
[email protected]
International Archives of Integrated Medicine, Vol. 2, Issue 9
Copy right © 2015, IAIM, All Rights Reserved.
Available online at http://iaimjournal.com/
ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)
Received on: 07-08-2015 Accepted on: 13
Source of support: Nil Conflict of interest:

Minor falls, local accidents, while participating in sports or childish pranks that are not intended to
harm produce greatest number of teeth fractures and teeth displacements in children. From these
seemingly benign accidents, child’s facial appearance becomes so altered as to make an attractive
child appear unattractive. Dental injuries are considered emergency situation that require immediate
care. The purpose of this article is aimed to overview the classification of the traumatized teeth.
Fracture, Dental trauma, Luxation, Concussion.
Classification of the dental trauma
In the 1950, Pediatric dentist G.E. Ellis was the
first person to promote a universal classification
injuries have been
classified according to a variety of factors, such
as etiology, anatomy, pathology or therapeutic
Classification of anterior teeth trauma by
It is mainly based on the anatomy and
h structure. The
disadvantages of this classification are that no
stress has been laid on injuries to supporting
structures soft tissue and bone. It indicates more
towards the permanent teeth than primary teeth
as injury to periodontium is more common in
primary teeth as compared to permanent.

Class I – A simple of crown exposing no
dentition.
Class II – A parallel of crown involving little
dentin.
Class III – Extensive fracture of crown
involving more dentin bur no pulp exposure.
Class IV – Extensive fracture of crown exposing
pulp.
164.
Page 157
An overview of classification of dental
Rural Dental College and Research Center,
Rural Dental College and Research Center,
Medicine, Vol. 2, Issue 9, September, 2015.
Copy right © 2015, IAIM, All Rights Reserved.
http://iaimjournal.com/
0034 (O)
13-08-2015
Conflict of interest: None declared.
Minor falls, local accidents, while participating in sports or childish pranks that are not intended to
displacements in children. From these
comes so altered as to make an attractive
child appear unattractive. Dental injuries are considered emergency situation that require immediate
care. The purpose of this article is aimed to overview the classification of the traumatized teeth.
stress has been laid on injuries to supporting
structures soft tissue and bone. It indicates more
towards the permanent teeth than primary teeth
as injury to periodontium is more common in
primary teeth as compared to permanent.
A simple of crown exposing no
A parallel of crown involving little
Extensive fracture of crown
involving more dentin bur no pulp exposure.
acture of crown exposing

35. Classification of Traumatic Injuries
Ellis
classification
WHO
classification

36. CLASSIFICATION –WHO INTERNATIONAL CLASSIFICATION OF DISEASES TO DENTISTRY & STOMATOLOGY
I-Injuries to Hard Dental Tissues &
Pulp:
II-Injuries to the Periodontium:
A-Enamel Infraction A-Concussion
B-Enamel Fracture B-Subluxation
C-Enamel-Dentin Fracture
(Uncomplicated Crown Fracture)
C-Extrusive Luxation
D-Complicated Crown FractureD-Intrusive Luxation
E-Uncomplicated Crown Root FractureE-Lateral Luxation
F-Complicated Crown Root FractureF-Avulsion
G-Root Fracture

37. INJURIES TO THE SUPPORTING BONE
Crushing the alveolar socket
Alveolar socket fractures
Alveolar process fractures
Mandible and maxilla fractures

38. INJURIES TO GINGIVA OR ORAL MUCOSA
Laceration
Contusion
Abrasion

40. CROWN FRACTURE
ØEnamel infraction
ØEnamel fracture
ØUncomplicated crown fracture
ØComplicated crown fracture

41. CASE MANAGEMENT
-Diagnosis
-Management
-Prognosis(Biologic Consequences)
-Follow Up

42. CROWN (ENAMEL) INFRACTION
Enamel Chipping, Enamel Cracks, incomplete fracture.

43. 1) CROWN (ENAMEL) INFRACTION
ØDefinition:
-Incompletefractureorcrackinenamelwithoutlossoftoothstructure.
ØDiagnosis:
-SameProcessasdiscussedbefore+Transillumination.
ØTreatment:
-Simply smoothing any rough edges may be all that is necessary to
address the chips or cracks noted.
FOLLOW UP

44. 2) ENAMEL FRACTURE
1.Treatment objects to restore aesthetics.:
2.Small fragment➡smooth & refine.
3.Large fragments➡restored fragment may adhered or restored by GI
or composite restoration
4.Check PDL status

45. ØPrognosis:
•Crowninfractions/fracturesareinjuriesthatcarrylittledangerofresultinginpulp
necrosis.
•follow-upovera6-8weeks,1yearandover5-yearperiodisthemostimportant
endodonticpreventivemeasureinthesecases(clinicalandradiographic).
•If,atanyfollow-upexamination,thereactiontosensitivitytestschanges,orif,on
radiographicassessment,signsofapicalorperi-radicularperiodontitisdevelopor
therootappearstohavestoppeddevelopmentorisobliterating,endodontic
interventionshouldbeconsidered.
2) ENAMEL FRACTURE

46. 3) UNCOMPLICATED CROWN FRACTURE
ØDefinition:
•Involves fracture enamel only or enamel & dentin withoutpulp involvement.
•Majority of dental injuries {1/3-1/2}.
•Dentin is exposed; open DT (direct pathway for bacteria)

47. ØDiagnosis:
Same Process as discussed before:
1.Examination & Diagnosis
2.Medical History
3.Clinical Examination
4.Teeth & Supporting Structure
3) UNCOMPLICATED CROWN FRACTURE

48. The main aim is to preserve pulp vitality
Concerns :
üSealing all exposed dentin (open dentinal
tubules).
üRemaining dentin thickness (< / > 0.5 mm)
ØManagement:
3) UNCOMPLICATED CROWN FRACTURE

49. • Sealing Exposed Dentin:
Emergency appointment,
-Ifthebroken-offpieceisavailable➡reattachusingadhesivebonding.
-Ifthebroken-offpieceisnotavailableandthereisnotimetodoafullcomposite
restorationatthetimeoftheemergencyappointment,➡atemporarycoverageshouldbe
placedonallexposeddentin.Thispreventsanyingressofbacteriaintothetubulesand
reducesthepatient’sdiscomfort.
ØManagement:
3) UNCOMPLICATED CROWN FRACTURE

50. 3) UNCOMPLICATED CROWN FRACTURE

51. •RemainingDentinThickness:
-iftheremainingdentinismorethan0.5mmthick,thetoothcanbe
restoredwiththerestorationofchoice,includingetchingandbonding,and
nospecialattentionneedstobegiventothepulp.
-However,iftheremainingdentinislessthan0.5mm,aprotective
layer,(Ca(OH)),inthedeepestpartofthedentinexposuremustbeadded.
ØManagement:
3) UNCOMPLICATED CROWN FRACTURE

52. •Uncomplicatedcrownfracturescarrylittledangeronthepulpstatus.
•Infact,thebiggestdangertothehealthofthepulpisiatrogenic,causedduring
estheticrestorationoftheseteeth.
•follow-upovera6-8weeks,1yearandover5-yearperiodisthemostimportant
endodonticpreventivemeasureinthesecases(clinicalandradiographic).
•If,atanyfollow-upexamination,thereactiontosensitivitytestschanges,orif,on
radiographicassessment,signsofapicalorperi-radicularperiodontitisdeveloportheroot
appearstohavestoppeddevelopmentorisobliterating,endodonticinterventionshouldbe
considered.
ØPrognosis:
3) UNCOMPLICATED CROWN FRACTURE

53. •No tooth fragment ----composite build-up
•Tooth fragment saved ----reattached the fragment
•More than 0.5mm ----no alterations
•Less than 0.5mm ----add capping material
•Follow up to 6-8 weeks, 1 year