traumatic injury to teeth in Dentistry.ppt

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Traumatic
Injuries to Teeth

2. Epidemiology
-Dental trauma in childhood and
adolescent is common.
-Boys are more affected than girls.
-Teeth most affected by injuries are the
anterior teeth, especially the maxillary
central incisor. This is followed by the
maxillary lateral and the mandibular
central and lateral incisor.

3. -Concussion, subluxation and luxation
are the commonest in the primary
dentition, while uncomplicated crown
fractures are the commonest in the
permanent dentition.
-Most dental injuries occur at 2 – 4
years of age for primary teeth, and at
7 – 10 years for permanent teeth.

4. Aetiology
-Most injuries to primary dentition occur
due to falls at home because of
incompletely developed coordination and
judgment.
-For permanent teeth, trauma occurs due
to falls and collisions (in the school yard),
sport injuries (usually for teenagers), road
traffic accidents and assaults (usually in
late teenage years and adult hood).
-One form of injury is child physical abuse
or non accidental injury (NAI).

5. Mechanism of injuries:
-direct trauma: - implies injuries to the
anterior region.
-indirect trauma: - favours injuries to
the posterior teeth and jaw fractures in
the condylar regions and symphysis.

6. Factors which influence the
outcome of injury:-
-energy impact
-resilience of the impacting object
-shape of the impacting object
-angle of direction of the impacting
force.

7. Some predisposing factors:-
-Increased overjet.
-Children with increased seizure
disorders e.g. epilepsy.
-Mentally and physically handicapped.

8. Classification
(WHO classification of dento-
alveolar injuries (based on
Andereason classification)

9. -Injuries to the hard dental tissues
and pulp.
-Injuries to the periodontal tissues.
-Injuries to supporting bone.
-Injuries to gingival or oral mucosa.

10. Injuries to the hard dental
tissues and pulp:
-Enamel infraction: -incomplete
fracture (crack) of enamel without loss
of tooth substance.
-Enamel fracture: -loss of tooth
substance confined to enamel.
-Enamel-dentine fracture : -loss of
tooth substance confined to enamel and
dentine and not involving the pulp.

11. -Complicated crown fracture : -
fracture of enamel and dentine
exposing the pulp.
-Uncomplicated crown-root
fracture: -fracture of enamel, dentine
and cementum but not involving the
pulp.
-Complicated crown-root fracture : -
fracture of enamel, dentine and
cementum and exposing the pulp.

12. Enamel Fracture

13. Complicated Crown Fracture

15. -Root fracture: -fracture involving
dentine, cementum, and pulp. Can be
classified into:
- apical third
- middle third
- coronal third .

16. Root Fractures

17. Injuries to the periodontal
tissues:-
-Concussion: -no abnormal loosening
or displacement but marked reaction to
percussion.
-Subluxation: -abnormal loosening
but no displacement.
-Extrusive luxation: -partial
displacement of tooth from socket.

18. -Lateral luxation: -displacement
other than axially with comminution or
fracture of alveolar socket.
-Intrusive luxation: -displacement
into alveolar bone with comminution or
fracture of alveolar socket.
-Avulsion: -complete displacement of
tooth from socket.

19. Lateral Luxation

20. Intrusion

21. Injuries to supporting bone:
-Comminution of mandibular or
maxillary alveolar socket wall: -
crushing or compression of alveolar
socket, found in intrusive and lateral
luxation injuries.
-Fracture of mandibular or
maxillary alveolar socket wall: -
fracture confined to facial or
lingual/palatal socket wall.

22. -Fracture of mandibular or maxillary
alveolar process: -fracture of the
alveolar process which may or may not
involve the tooth sockets.
-Fracture of mandible or maxilla : -
may or may not involve the alveolar
socket.

23. Injuries to gingival or oral
mucosa:
-Laceration of gingiva or oral
mucosa: -wound in the mucosa resulting
from a tear.
-Contusion of gingival or oral
mucosa: -bruise not accompanied by a
break in the mucosa, usually causing a
submucosal haemorrhage.
-Abrasion of gingival or oral mucosa :
-superficial wound produced by rubbing or
scrapping the mucosal surface.

24. History
-When did the injury occur? The time
elapsed since the injury plays a major role
in determining the type of treatment to be
provided.
-Where did the injury occur? May help to
determine the need for tetanus
prophylaxis.
-How did the injury occur? May provide
information about nature and severity of
injury; and to consider the possibility of
non accidental injuries.

25. -Any treatment been provided for the
injury before.
-Previous dental trauma.
-Lost teeth or fragments should be
accounted for.
-Any change of occlusion.

26. -Any symptom of head injury such as
drowsiness, headache, loss of
consciousness, vomiting, amnesia….
-Medical history e.g. congenital heart
disease, bleeding disorders, allergies,
tetanus immunization state….

27. Examination
Neurologic examination:

-If there is any doubt about this, the
patient should be referred immediately
for appropriate medical treatment.

28. Extra oral examination:
-Signs of shock
-Facial swelling, bruises, laceration.
-TMJ: limitation of movement,
deviation
-Palpation of bony borders

29. Intra oral examination:
-Laceration, haemorrhage, and
swelling.
N.B. Any laceration must be felt and
radiographed for embedded foreign
objects.
-Palpation for bony fractures.
-Abnormalities of occlusion.
-Tooth displacement.

30. -Fractures or cracks of crown (pulpal
exposures should be noted).
-Mobility: - tooth mobility, crown
mobility, degree of mobility, enblock
movement.
-Reaction to percussion.
-Colour of tooth.
-Sensitivity tests: - not always reliable.

32. -Radiography: -
•periapicals: -best for accurate
diagnosis; thee radiographs at different
angles may be essential to detect root
fractures.
•occlusal: -to detect root fractures and
foreign bodies within soft tissues.
•orthopantomograms.
•others.

33. -Laser Doppler flowmetry: - to determine
vascular vitality.
-Test cavity.
Photography.

34. Management of Trauma to
Primary Dentition

36. General considerations:
-risk of damage to the underlying
permanent successor.
-difficulty of treatment due to young
age of patient.

38. Enamel Infraction:
-Follow up.
Enamel Fractures:
-Rough enamel margins can be
smoothed.
-The tooth can be restored with an
acid-etch composite resin technique.

39. Enamel and Dentin Fractures:
-Exposed dentin should be covered
with calcium hydroxide paste or with
glass ionomer cement to prevent insult
to the pulp.
-The tooth is then restored with an
acid-etch composite resin technique.

40. Complicated Crown Fractures:
-The treatment depends on the vitality
of the pulpal tissue.
-Formocresol pulpotomy is done for a
vital tooth.
-If the tooth is non vital, pulpectomy or
extraction is indicated.

41. -Final restoration of the tooth depends
on the amount of tooth structure
remaining. A composite resin crown
using a celluloid crown matrix or a
stainless steel crown with a composite
veneer may be used.

42. Crown Root Fractures:
-The pulp is usually exposed and any
restorative treatment is very difficult.
The tooth is best extracted.

44. Root Fractures:
-Management of root fractures in
primary teeth depends on the level of
the fracture.
-The best prognosis is for fractures in
the apical one third of the root. Most of
these teeth retain their vitality and are
minimally mobile. The tooth, including
the apical fragment, should resorb
normally and should be monitored
periodically with radiographs.

45. -Fractures of the middle or cervical third
of the root indicate extraction. A gentle
attempt should be made to dislodge the
apical root fragment. If it can not be
easily extracted, it should be left and
monitored with radiographs.

46. Concussion:
-Follow up.
Subluxation:
-If slight mobility: -soft diet for 1 -2 weeks.
-mouthwash.
-follow up.
-If marked mobility: -extraction.

47. Extrusive Luxation:
-Some clinicians recommend splinting
for two weeks.
-Some recommend extraction especially
if mobility is marked.

48. Lateral Luxation:
-If the crown is displaced palatally, the
apex moves buccally (i.e. away from the
permanent tooth germ. If there is no
occlusion interference, then
conservative treatment to await for
spontaneous realignment is possible.
-If the crown is displaced buccally then
the apex will be displaced towards the
permanent tooth bud and extraction ix
indicated to minimize further damage to
the permanent tooth bud.

50. Intrusive Luxation:
-This is the most dangerous to the
permanent tooth bud.
-Positioning X-rays are needed to
establish the direction of displacement.
-If the root is displaced, the primary
tooth should be extracted to minimize
the damage to the permanent tooth
bud.

52. -If the root is displaced labially, then
periodic follow up to allow for
spontaneous re-eruption should be
done. If re-eruption did not occur within
6 months, then ankylosis is likely and
extraction should be done to prevent
ectopic eruption of the permanent
successor.

54. Avulsion:
-Avulsed primary teeth should not be
replanted due to the risk of damage to
the permanent tooth germ.

55. Sequelae of Injuries to the
Primary Dentition
•Pulpal necrosis.
•Pulpal obliteration
•Root resorption.
•Injuries to the developing permanent
tooth.

57. •Injuries to the developing
permanent tooth:
-White or brown discoloration of
enamel.
-White or brown discoloration of enamel
with circular enamel hypoplasia.
-Crown dilaceration.
-Odontoma-like malformation.

60. -Root duplication.
-Vestibular or lateral root angulation or
dilaceration.
-Partial or complete arrest of root
formation.
-Sequestration of permanent tooth
germs.
-Disturbance of eruption.

61. Management of Trauma to
Permanent Dentition

62. Crown Infraction:
-This can be easily overlooked; proper
illumination e.g. fiber optic or resin
curing light is useful for diagnosis.
-Cracks are weak points through which
bacteria and their by- products can
challenge the pulp.

63. -Energy of the blow may be transmitted
to the periodontal ligaments and pulp.
-Treatment involves establishing a base
line pulp status with routine vitality
testing and follow up examination at 3,
6 and 12 months and then annually.
-Some recommend protective covering
of the crack by composite veneering.
-Pulp complications are extremely rare.

64. Uncomplicated Crown Fractures:
-These are very common, accounting to 1/3
of all dental injuries.
-Prognosis is extremely good; pulpal
complications are rare.
-These include:-

65. Enamel fractures:
-Consequences and complications are
minimal.
-Treatment involves smoothing of
sharp edges or placing bonded
composite resins if necessary for
aesthetics.
-Follow up at 3, 6 and 12 months and
annually thereafter.

66. Enamel and Dentin Fractures:
-Exposure of dentin provides a direct
pathway for noxious stimuli (thermal,
bacterial) to pass through the dentinal
tubules to the pulp.
-Emergency treatment requires the
placing of fast setting calcium hydroxide
over the dentin.
-This is followed by composite
restoration.

67. -At a later age, composite can be
reduced to form the core of a porcelain
jacket crown.
-Glass ionomer within an orthodontic
band or incisal end of a stainless steel
crown may serve as temporary
treatment if there is insufficient enamel
for acid-etch technique.
-Controversy exists to as to whether
dentin bonding can be carried out
without an intermediate calcium
hydroxide base.

68. Reattachment of crown fragment:
-This is another alternative of treatment
which provides excellent aesthetics and
acceptable strength.
-This technique depends on dentin
bonding agents.
-If the fracture line is not very close to
the pulp, then the fragment may be
reattached immediately.

69. -If it is close to the pulp:
•put a protected calcium hydroxide
dressing over the exposed dentin for
at least 1 month while storing the
fragment in saline which should be
renewed weekly.
•or do the reattachment immediately.
•or cover the exposed dentin with
glass ionomer cement and making a
corresponding gutter at the fragment
to fit the tooth and the fragment
together before the reattachment.

70. Technique of the reattachment:
-check the fit of the fragment
-clean the fragment and the tooth.
-isolate the tooth with rubber dam.
-etch enamel 2 mm from fracture line on
tooth and fragment (on both fracture
sides); wash and dry.

71. -apply dentine primer to both surfaces
and then dry.
-apply enamel-dentine bonding agent to
both surfaces, then light cure.
-place appropriate shade of composite
resin over both surfaces and position
fragment, remove excess and cure
(labially and palatally).

72. -remove a 1 mm gutter of enamel on
each side of fracture line both labially
and palatally to a depth of 0.5 mm.
-etch, wash, dry, apply composite,
cure and finish.
-Follow up at 3, 6, 12 months and
then annually.

79. Complicated Crown Fracture:
-In the first 24 hours (to few days),
pulpal inflammation will extend no more
than 2 mm.
-If left untreated, pulpal necrosis will
occur.

80. Choices of treatment depend on:
-Stage of development of the tooth.
-Time between the accident and
treatment.
-Concomitant attachment damage.
-Restorative treatment plan.

81. Vital Pulp Therapy:
-Bacteria tight seal protecting the healing
pulp is the most critical factor.
-Calcium hydroxide is the most common
dressing used for vital pulp therapy.
Other materials include zinc oxide
eugenol, tricalcium phosphate, composite
resins, mineral trioxide aggregate (MTA,
a new promising material).

82. Pulp capping:
-This technique is used on immature
permanent teeth; on a very recent
exposure (< 24 hours); and possibly on
a mature permanent tooth with a simple
restorative plan.

83. Partial (Cvek) pulpotomy:
-Partial pulpotomy implies the removal of
coronal pulp tissue to the level of healthy
pulp.
-As with pulp capping, the zone of
inflammation in the pulp has extended no
more than 2 mm in an apical direction but
has not reached the root pulp. Therefore
only 2 mm of pulpal tissue beyond the
exposure site is removed.
-This treatment is superior to pulp capping
and affords better prognosis.

87. Full (cervical) pulpotomy:
-This technique involves removal of the
entire coronal pulp to the level of the
root orifices.
-It is indicated when the prediction is
that the pulp is inflamed to the deeper
levels of the coronal pulp in carious and
traumatic exposure (after 72 hours) in
immature teeth.
-It is contraindicated in mature teeth.

88. Root canal treatment:
-Removal of the entire pulp to the level
of the apical foramen (pulpectomy) is
indicated for mature teeth when
conditions are not ideal for vital
treatment.

89. Treatment of the non vital pulp:
Root canal treatment:
-For mature teeth.
Apexification:
-This technique is indicated for non vital
immature (with open apices) teeth.
-It depends on the stimulation of the
formation of a hard tissue barrier at the
open apex so that obturation of the canal
is possible.

90. Crown Root Fracture:
-After removal of the fractured piece, the
fracture margin has to be brought
supragingival either by gingivoplasty or
extrusion (orthodontically or surgically) of
the root portion.
-Then the tooth is then treated in the
same manner as uncomplicated or
complicated crown fracture according to
whether the pulp is involved or not.
-If this could not be done, the tooth
should be extracted.

91. Root extrusion, a practical solution in complicated crown-root
incisor fractures
Appearance of the root face after removal of coronal tissue. The
fracture line labially is just subgingival, and palatally it extends
below the alveolar crest

92. Position after extrusion. Note: 3 mm of labial tooth
tissue is now visible

93. Post, core, and diaphragm cemented in
position
 
  

94. Final coronal restoration
 
                                                   

95. Root Fracture:
-When a root fractures horizontally, the
coronal segment is displaced to a
varying degree. Generally the apical
segment is not displaced.
-Because the apical pulpal circulation is
not disrupted, pulpal necrosis in the
apical segment is extremely rare. Pulp
necrosis of the coronal segment results
because of its displacement (20% -
25%).

96. -Because a root fracture is usually
oblique, one periapical radiograph may
easily miss its presence. At least three
radiographs at different angles (45, 90
and 110 degrees) are needed for
diagnosis of root fractures.

97. Treatment:
-Prognosis is better in case of apical third
fracture, followed by middle third fracture
and then coronal third fracture.
-If displacement has occurred, the coronal
fragment should be repositioned as soon
as possible by gentle digital manipulation
and the position checked radiographically.
-Mobile root fractures need to be rigidly
splinted to encourage repair of the
fracture.

98. -Apical third fractures, in the absence
of periodontal injury are often firm and
do not require splinting but need to be
regularly reviewed to check pulpal
status and treated endodontically if
necessary
-Middle and coronal third fractures
need rigid splinting.

99. -A rigid splint is one that includes two
abutment teeth on either side of the
fracture tooth.

-The splint should remain in place for 2 –
4 months. It should allow for colour
observation, sensitivity testing an access
to the root canal (if needed).

100. Healing Patterns:
1- Healing with calcified tissue: -
radiographically the fracture line is
hardly visible; the fragments are in close
contact.
2- Healing with interproximal connective
tissue: -in X-rays the fragments appear
separated by a narrow radiolucent line,
and the fractured edges appear rounded.

101. 3- Healing with interproximal bone and
connective tissue: -a distinct bony ridge
separating the fragments appears in X-
rays.
N.B. These three patterns are considered
successful.
4- Interproximal inflammatory tissue
without healing: -radiographically there
is a widening of the fracture line, a
developing radiolucency corresponding
to the fracture line or both.

102. FIGURE 1: Different forms of healing: A, Calcific callus;
B, Connective tissue; C, Combination of bone and
connective tissue; D, Nonunion and granulation tissue
formation

105. Treatment of complications:
Coronal root fracture:
-Healing may occur as long as no
communication exists between the
fracture line and the gingival crevice;
otherwise chances of healing are
extremely poor.

106. -It is better to extract the coronal
fragment and retain the remaining root
and treat it endodontically, then either:
•post, core and crown.
•extrusion of the root surgically or
orthodontically.
•cover with a mucoperiosteal flap (to
maintain the height and width of the
arch and will facilitate later placement
of tooth implant).

107. -Other alternatives:
•extract the two fragments.
•internal splint (poor prognosis).

108. Middle or apical root fracture:
-Pulp necrosis occurs in 25% of root
fractures and this usually occurs in the
coronal fragment.
-Endodontic treatment must be done in
the coronal root segment only, unless
periapical pathology is seen in the
apical segment.

110. -Apexification with calcium hydroxide is
done at the level of the fracture, then
obturation of the coronal segment is done
after a hard tissue barrier is formed
apically in the coronal segment.
-Rarely both coronal and apical pulp are
necrotic:
•endodontic treatment may be done
through the fracture line (poor
prognosis).
•in more apical root fractures, necrotic
apical segment may be surgically
removed.

111. -Follow up.
-Common complications:
• pulp necrosis.
• root canal obliteration.

112. Luxation Injuries
-Luxation injuries result in damage to
the attachment apparatus.
-The apical neurovascular supply to the
pulp is also affected to varying degrees,
resulting in unreliable response to
electric pulp testing, and thus an altered
or complete loss of vitality of the tooth.

114. Concussion:
-The impact force causes oedema and
haemorrhage in the periodontal ligaments
and the tooth is tender to percussion.
There is no rupture of periodontal
ligament fibers and the tooth is firm in
the socket.
-Treatment includes base line vitality
tests, occlusal relief, soft diet for 7 days,
0.2% chlorohexidine mouthwash and
follow up.
-There is minimum risk of pulp necrosis.

115. Subluxation:
-Clinical presentation is similar to
concussion in addition to slight mobility
of the tooth.
-Management is similar to concussion in
addition to immobilization by non rigid
functional splint if needed.
-Follow up

116. Extrusive Luxation:
-There is rupture of periodontal
ligaments and pulp.
Lateral luxation:
-There is rupture of periodontal
ligaments, pulp and alveolar plate.

117. Treatment of both these injuries:
-Repositioning of the tooth with firm
gentle digital pressure.
-Non-rigid functional splint for 2 – 3
weeks(this type of splint should allow
some functional movement).
-Antibiotics, mouthwash and soft diet.
-Follow up.

118. -In case of a mature tooth, pulp survival
is possible in a small number of cases. If
vitality testing indicates pulp necrosis,
endodontic treatment should be
performed.
-In case of an immature tooth chances
of pulp vitality are fairly good. However,
careful follow up is very important. At
the first sign of apical or periradicular
resorption, endodontic treatment should
be initiated.
-There is an increased of root resorption.

120. Intrusive Luxation:
-This is probably the most damaging
injury that a tooth can sustain.
-There is an extensive damage of
periodontal ligaments, pulp and alveolar
plate.

121. -Dento-alveolar ankylosis and replacement
resorption result very frequently.
-Pulp necrosis is extremely common
especially in the closed apex, so that
inflammatory root resorption will result if
timely and adequate endodontic treatment
is not performed.

122. Immature tooth:
-Spontaneous re-eruption may occur within
few weeks or months. If re-eruption is not
complete in 2 – 4 months, orthodontic
movement should be initiated quickly before
the tooth is ankylosed in position.
-Alternatively, the tooth is surgically
repositioned. Functional splint is put for 7 –
10 days.
-Follow up for pulp status.
-Endodontic treatment (apexification) is done
if needed.

123. Mature tooth:
-Orthodontic or surgical extrusion.
-Functional splint for 7 – 10 days after
surgical extrusion.
-Start endodontic treatment at 10 days.
Calcium hydroxide is maintained in the root
canal during orthodontic movement before
obturation.

125. Avulsion:
-There is damage to periodontal ligaments
and pulp, in addition to the drying damage
that occurs to the periodontal ligaments.
-Replantation of the avulsed tooth should
always be attempted.
-Pulpal necrosis always occurs after an
avulsion injury, but revascularization is
possible in teeth with immature apices.

126. -Replacement resorption is a very
common complication.
-Successful healing after replantation can
only occur if there is minimal damage to
the pulp and the periodontal ligaments;
and this depends on some critical
factors:

127. -The extra-alveolar time i.e. the time the
tooth has been out of the mouth: the
tooth is best replanted within 10 – 15
minutes.
-The type of extra-alveolar storage media:
the tooth is best stored in its own alveolar
socket; otherwise milk is the best
medium, followed by the patient's saliva
and physiological saline, water is the least
desirable. Other types of media include
Hank's Balanced Salt Solution (HBSS) and
cell culture media.

128. Advice to the person at the accident
place:
-Don't touch the root; hold the tooth by the
crown.
-Wash gently by cold tap water.
-Replace the tooth in its socket and let the
patient bite gently on a piece of cotton or
handkerchief or transport the tooth in a
suitable media.

129. In the dental office:
N.B. Emergency treatment is directed
towards the attachment apparatus.
-Do not handle the root; remove the
replant tooth from the socket.
-Rinse the tooth with saline and store it in
saline.
-Local anaesthesia.
-Irrigate socket with saline to remove clot
and foreign material.

130. -Push the tooth gently but firmly into
the socket.
-Non-rigid functional splint for 7 – 10
days.
-Check occlusion and make base-line
radiograph.
-Antibiotics, mouthwash and soft diet.
-Follow up.

131. Immature tooth:
-Storage time less than 45 minutes: -keep
the patient under follow since
revascularization of the pulp is possible.
-Storage time more than 45 minutes: -
endodontic treatment (apexification).

132. Mature tooth:
-There is no chance of pulp
revascularization thus endodontic
treatment must be done.
-Long term therapy with calcium hydroxide
is recommended for treatment of root
resorption.

133. Dry storage more than 1 hour:
-Extra-oral pulp extirpation is done.
-The tooth is put in a concentrated solution
of sodium fluoride for 20 minutes. Sodium
fluoride may slow the resorptive process.
-the root canal is then obturated, the tooth
replanted and rigidly splinted.
-Nevertheless, the tooth has poor
prognosis. Ankylosis will occur and the
tooth may be kept temporarily as a space
maintainer.

134. Complications of periodontal tissue
injuries:
-pulp necrosis.
-periapical infection.
-tooth discoloration.
-arrest of root development.
-external inflammatory root resorption.
-internal inflammatory root resorption.
-replacement resorption (ankylosis).
-pulp canal obliteration.

136. Methods of splinting:
-composite resin / acrylic and wire splint.
-orthodontic brackets and wire.
-interdental wiring.
-foil/cement splint.
-laboratory splint (acrylic or thermoplastic).