Department ofendodonticsTraumatic injuriesseminar done byGuddu kumarCRI,BDS(2008-2009)BATCH
introduction-• Dentoalveolar injuries are those injuriesinvolving the teeth, the alveolar portion ofthe maxilla and mandible, and the adjacentsoft tissues. They are among the mostserious dental conditions.Examples of such injuries include the avulsionof teeth, fractures of the teeth, fractures of thealveolar process, and lacerations of the softtissue.
HISTORYHippocrates of Cos , was the first todocumenttreatment regiemes for dentoalveolartraumas inhis writings . He was the one who alludedvarioussplinting techniques as well as to expedithealingprocess.
ETIOLOGY AND INCIDENCE :Common inPediatric-Falls during 1st years of lifeTeenage-contact sports ,background activity ,Adults - motor vehicle accidents, contact sports, altercations,assaults,industrial accidents and iatrogenic medical and dental misadventuresChild abuse is one of the significant etiology causing dentoalveolartrauma.PREVALANCE:Primary dentition – 11 – 30 %Permanent dentition – 5 to 20 %SEX RATIO:Mem :women – 2:1
Other groups at increased risk :• Seizure disorders• Mental disorders•Congenital abnormalitiesTrauma can be•Direct – most commonly affected teeth is Maxillary centrals(class II division 1 is more prone for such trauma)Primary dentition – Luxation occurs morecommonly(75%)Permanent dentiton – Crown/crown-root fracture(39%)•Indirect –Forceful impact in the chin may trasmit the forcestothe posterior teeth
HISTORY :•Preinjury data – biographic-demographic•Past Medical History•Time of incident•Occlusion•Location of incident•Loss of consiousness•Nature of incidentPHYSICAL EXAMINATION:Check for- potential for aspiration-Airway compromise-Neurosensory deficit
CLASSIFICATIONS:Two commonly used classifications are-Ellis and Davey’s classification-Andersons classification- Adopted by WHOEllis and Davey’s classification(1960):Class I - Simple fracture of the crown involving only enamel with littleor nodentin.Class II - Extensive Fracture of crown involving considerable dentin butnotexposing dental pulp.ClassIII - Extensive fracture of crown involving considerable dentin andexposing dental pulp.Class IV - Traumatized tooth that becomes non-vital.Class V - Total tooth loss-Avulsion.Class VI - Fracture of the root with or with out loss of crown structure.Class VII - Displacement of tooth with neither crown or root fracture.ClassVIII - Fracture of crown en masse and its displacement.Class IX - Traumatic injuries of primary teeth.
Anderson’s classification:• Injuries to hard dental tissues and Pulp:1. Enamel infarction2. Enamel fracture3. Enamel-Dentin fracture(uncomplicated crown fracture4. Complicated crown fracture5. Uncomplicated crown root fracture6. Complicated crown root fracture7. Root fracture• Injuries to periodontal tissues:1. Concussion2. Subluxation3. Extrusive luxation(peripheral dislocation,partial avulsion)4. Lateral luxation5. Intrusive luxation(central dislocation)6. Avulsion (exarticulation)• Injuries to supporting bone:1. Comminution of mandibular or maxillary alveolar socket2. Fracture of maxillary or mandibular socket wall3. Fracture of maxillary or mandibular alveolar process• Injuries to gingiva or oral mucosa:1. Laceration of gingiva or oral mucosa2. Contusion of gingiva or oral mucosa3. Abrasion of gingiva or oral mucosa
MANAGEMENT OF DENTOALVEOLARINJURIESENAMEL INFARCTIONS:• Very common• Appear as crazing within the enamel which do notcross the dentino-enamel junction and appear withor without loss of tooth substance.• Caused by direct impact• Patterns of infarction lines depends on direction andlocation of trauma• Seen by – visualizing along the long axis of the tooth fromthe incisal edge- Fiberoptic light sources- Transillumination
ENAMEL FRACTURE:Clinical feature:•More common in both primary and permanentdentitionthen the complicated fracture•Confined to a single tooth•Common in maxillary regionTreatment:•Restoration with composite resin after corrective grinding andremoval of sharp edges
UNCOMPLICATED CROWN FRACTURE:Clinical feature:•Dentin exposed after crown fracture often gives riseto sensitivity to thermal changes and mastication•Careful search for any minute pulp exposure to bedone during examination .Treatment:•Immediate provisional treatment :Placement of calcium hydroxide paste on the exposeddentin and restore•Permanent treatment:Restoration with composite resin or full coverage crown
COMPLICATED CROWN FRACTURE:Clinical fracture:•Occurs when there is a fracture of enamel ,dentinalong with exposure of pulp .•Usuallypresents as a fractured segment of the toothwith frank bleeding from exposed pulp.Treatment:Treatment depends upon the extent and time of pulp exposure• When the exposure is small , which is not exposed for more than4-5 minutes then it is advisable to do pulp capping .• When the exposure is large , and is exposed formore than 5 minutes – pulpotomy(pulp is vital)Apexification(pulp is necrotic)Endodontic treatment(pulpectomy)
CROWN –ROOT FRACTURE:It is defined as the fracture involving enamel,dentinand cementum .Can be either complicated oruncomplicated fracture.Anterior crown fracture – direct traumaPosterior crown fracture- indirect traumaClinical feature:•Fracture lines begins few millimeters incisal to marginalgingiva or to the facial aspect of the crown (in an obliquecourse below the gingival crevice )Treatment :Emergency treatment- acid etch splitDefinitive treatment-( Before deciding the treatment the fractured fragmentto be removed to evaluate the apical extent of thefracture)Uncomplicated with out pulp exposure – restorableComplicated fracture – may require RCT or extraction of root fragment
ROOT FRACTUREIt is the fractures involving dentin,cementum and pulp.Mechanism of Root fracture – Frontal impact.Clinical feature:• Commonly seen in maxillary central incisor regionin age group of 11 to 20 years• Coronal fragments are displaced lingually or slightly extruded• Temporary loss of sensitivity.Radiographically:1. Radiolucent oblique line which is most often visible only if thecentral beam is directed with in maximum range of 15-20°CLASSIFICATION:1.CORONAL THIRD ROOT FRACTURE2.MIDROOT FRACTURE3.APICAL THIRD ROOT FRACTURE
Coronal root fractureFracture in thecervical segmentwere considered tohave poor prognosis .Treatment –extraction of tooth
Mid root fracturePrognosis and treatment plan depends on following factors1.Position of the tooth after root fracture2.Mobility of the coronal segment3.Ststus of the pulp4.Position of the fracture line.Treatment options-1.root canal therapy of bothsegments,when the segments are not separated2.Root canal therapy of coronal segment andremoval of apical segment,when the segments areseparated.3.Use of intra-radicular splint,eg-rigid type post tostabilize the two root segments.4.Root canal treatment of the coronal segment andno treatment of apical one,when the apical segmentis vital
Apical third root fracturePrognosis is favorable becouse pulpin apical segment usually remainsvital.If pulp of coronal segment is nonvital –rct can be done.If tooth fails to recover,apical,segment can be removedsurgically.
VERTICAL ROOT FRACTURE( Cracked tooth syndrome )It runs lengthvise from crown towards the apex .Etiology – mostly iatrogenic.Clinical Features:•Persistant dull pain of long standing origin .•Pain is elicited by applying pressureRadiographic Feature:•If the central beam lies in the line of fracture it is visibleas a radiolucent line•Widening of PDLTreatment:•Single rooted teeth- extraction•Multiple rooted teeth- Hemisection and remaining tooth isendodontically treated and restored with crown.
Healing patterns 1.Healing with calcified tissue-fracture line is discernible onradiograph. 2.Healing with interproximal connective tissue-fracturefragments appear Separated but fracture edges appear rounded 3.Healing with interproximal connective tissue and bone-fragments are separated by a distinct ridge. 4.Interproximal inflmmatory tissue without healing(granulomatous tissue) -widening of fracture line
CONCUSSION (Sensitivity)An injury to the tooth supporting structure,when thereis some crushing injury to apical vasculatureperiodontal ligament with resultant inflammatory edemawith marked reaction to percussion but no abnormalloosening or displacement.Clinical feature:•Traumatized tooth has pain on percussion•Sensitivity during masitication.Radiographically :•Widening of periodontal ligamen space apically.•Reduction in size of pulp after a few monthsTreatment:•Sensitivity – symtomatic relief- relieving the tooth from occlusal contact.
SUBLUXATION (MOBILITY, LOOSENESS)An injury to tooth supporting structures with abnormalloosening but with out clinically or radiographicallydemonstrable displacement of the teeth.Clinical feature:• Tooth is tender on palpation• Mobility• Evidence of hemorrhage at gingival marginRadiographically:• Widening of PDL space• Reduction in the size of the pulp after few monthsTreatment:• Adjustment of occlusion• Splinting for 10 days
INTRUSIVE LUXATIONDisplacement of the tooth into alveolar bone.Clinical feature:•Displacement with fracture or crushing of alveolar bone.•Mobile tooth•Gingival bleeding•Metallic sound with pain on percussion•Pain on mastication•Clinically crown appeas shorter.Radiographic feature:•Obliteration of apical portion of PDL space•Crushiong of lamina duraTreatment:• Mostly involves orthodontic or surgical repositioning of thetooth• Stabilization using splits for 2-3 weeks aftertooth has come to normal or original position
EXTRUSIVE LUXATION:It is also called peripheral displacement or partial avulsion.It is partial dispacement of tooth out of its socket.Clinical feature:•Crown appears longer•Mobile tooth•Gingival bleeding•Pain on percussion.Radiographically:•Widwning of PDLTreatment :•Repositioning of tooth in normal position using digitalpressure.•Splint the tooth for 2-3 weeks
LATERAL LUXATIONDisplacement of the tooth in any direction other than axial.Clinical features:•Tooth is mobile and displaced•Gingival bleeding•Pain on percussion and masticationRadiographically:•Widening of the PDL space on one side and crushing of lamina dura onother sideTreatment:1. Repositioning of tooth followed by splinting for 2-3 weeks
AVULSION: (Exarticulation)Complete displacement of tooth from its alveolus .Clinical features:•Bleeding socket with missing toothRadiographic features:•Empty socket•Associated bone fractures•If the wound is recent then lamina dura is visibleTreatment:The factors most important for determining the prognosis of the treatment ar- the length of time the tooth has been out of the socket(sooner the better)-Periodontal tissues-The manner in which the tooth is preserved
REIMPLANTATIONThe following conditions should be considered before reimplanting apermanent tooth:•The alveolar socket should be reasonably intact in order to provideseat for the avulsed tooth .•The extra alveolar period-Short- LongStorage medium:•Hank’s balanced salt solution(HBSS)•Milk•Saliva•SalineFollow up: Minimum of 1 yearComplication : Root resorptionPrognosis:1. Tooth survival -51 to 89 %2. PDL healing - 9 to 50 %3. Pulp healing - 4 to 15 %
PROCEDURE:The tooth is placed in salineIf contaminated ,the root surface is cleansed with stream of salineThe socket is examined for evidence of fracture.The alveolus is also cleansedwith a flow of saline to remove contaminated coagulumTooth to be reimplanted using slight digital pressure with light pressure. Thereimplanted tooth should fit loosely in the alveolusSuture gingival lacerationApply splint for 1 week only as prolonged splinting of replanted toothcauses root resorptionProper repositioning can now be evaluvated by the occlusion of toothVerify position radiographicallyTetanus prophylaxis is importantand tetracycline twice a day for2 weekIf apical foramen is closed then perform endodontic therapy after one weekprior to removal of splint
STABILIZATION PERIODS FOR DENTOALVEOLARINJURIESDENTOALVEOLARINJURYDURATION OFIMMOBILIZATIONMobile toothTooth displacementRoot fractureReplanted tooth (mature)Replanted tooth(immature)7-10 days2-3 weeks2-4 months7-10days3-4 weeks
METHODS OF IMMOBILISATIONSPLINTING:It is the method of fixation is the best for treating bothdentoalveolar fracture and subluxed teeth .Splints provide excellent immobilization and have additionaladvantage that when teeth have had their crown fractured , thesplint is able to retain sedative dressing in place and provide goodprotection for the traumatized tooth.Types splinting:•Foil /cement splint:It is an emergency procedure , it is possible to mould a splintusing either protective lead foil from an xray pack or thin tinfoil.It can be gently manipulated over both the subluxed toothand adjuscent firm tooth.Rigidity can be gained using double thickness foil andcemented using cold cure resin.
Cold-cure acrylic splint:The material is moulded in situ with fingers to providetemporary splinting of the subluxed tooth .Enamel bound composite resin splint:Hall in 1983 recommends for fixation of dentoalveolarfracture of maxilla or mandible following repositioningor reimplatation of the teeth.Composite resin/acrylic resin and wire splint:This technique is used as a rigid splint by incorporating twoadjuscent healthy teech on either side of injured teeth.Orthodontic brackets and wires:Used for displacement injuries and exarticulation .They have an advantage of allowing more accuratereduction of injury ny gentle forces .
Interdental Wiring:Interdental wiring on a arch wire ligated to the teethwith ligature wire should not be used except astemporary measure , as it compromises gingival health.Wiring techniques that can be followed are:•Arch bars•Loop wiring•Figure of eight wiringThermoplastic splint:Constructed from polyvinylacetate-poly ethylene in thesame way like a mouth caurd
Conclusion:Dentoalveolar trauma being very common in dental practicerequires prompt treatment which aids in saving a tooth.Treatment modalites in this modern world are very simple and veryeffective provided the management is done on time .After all “We can make a difference when it comes to teeth as well”
Reference:.• Contemporary Oral and maxillo facial surgery- James.R.Hupp, Edward Ellis III, Myron R.Tucker.• Text book of oral and Maxillo facial surgery-Neelima Anil Malik• Grossman’s endodontic practice(12th edition)