Traumatic injuries of teeth /certified fixed orthodontic courses by Indian dental academy

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  • 1. Traumatic injuries of teeth INDIAN DENTAL ACADEMY Leader in Continuing Dental Education
  • 2. •Etiology•Mechanism of action•Introduction•Classification•Examination and diagnosis•Crown infraction•Uncomplicated crown fracture•Complicated crown fracture•Crown and root fracture•Root fracture luxation injuries•Avulsion•Alveolar fracture•Prevention of dental injuries• Conclusion• References
  • 3. Incidence Most dental injuries occur during first tow decades of life [8 to 2yrs] Boys tend to injure their teeth more than girls in ratio of 1:2. The tooth more vulnerable to injury is maxillary central incisors follow by maxillary lateral and mandibular incisors.The most commonly observed dental trauma involves fracture of enamel or enamel and dentin but without pulp.
  • 4. Etiology  Sudden impct involving the face or head may result in trauma to the  teeth and supporting structure. the frequent cause. •Dental abnormalitiesFalling while running•  Traffic accidents[20 to 60 per]•  Acts of violenceSports child abuse•  Medical causes
  • 5.   Predisposing factors   Increase overjet with protrusion of upper incisors and insufficient   lip closure.   Mechanism of dental injuries  Direct trauma                                                                                                   indirect trauma    Anterior region                        favours crown and crown- root  fracture                                                  Premolar and molar region                                                 jaw frcturein condylar and                                                   symphysis  region.
  • 6. Direct traumaIndirect trauma
  • 7.  The following factors characterize the impact anddetermine the extent of injuries. •Energy of impact •Resiliency of the impact object •Shape of the impact object •Direction of the impaction force
  • 8. Classification WHO Classification 873.60enamel fracture  873.61crown fracture without pulp involvement 873.62 crown fracture with pulp involvement 873.63 root fracture 873.64 crown root fracture 873.66 tooth luxation 873.67 itrusion or extrusion  873.68 avulsion 873.69 other injuries
  • 9. 802.20;802.40 fracture or comminution of the alveolar process.this may or may not involve the tooth802.21;802.41 fracture of the bodey of mandible or maxillaEllis classificationClass 1;simple crown fracture with little or no dentin affectedClass 2; extensive crown fracture with considerable loss of the dentin with pulp not affectedClass 3 ;extensive crown fracture with considerable loss of dentin and pulp exposure.Class 4; a tooth devitalized by trauma with or without loos of tooth structure. www.indiandentalacademy.comClass 5;tooth loss as a result of trauma.
  • 10. Class 6; root fracture with or without the loss of crown fracture.Class7;displacement of the tooth with neither crown or root fracture Class8;complete crown fracture and its replacement.Class9; traumatic injuries of primary teeth.Andreasens classification;a.injury of the hard tissue and the pulpb.injury of the periodontal tissuec.injury of gums and oral mucosad.injury of the supporting bone
  • 11. Who classification modified by Andreasen andAndreasen used by international association of dentaltraumatology.Dentofacial injuries.Soft tissue    laceration                                          contusion       abrasionTooth fracture    Enamel fracture crown fracture[uncomplicated]   Crown fracture [complicated]   Crown root fracture   Root fracture
  • 12. Luxation injuries   tooth concussion   Subluxation   Extrusive luxation   Intrusive luxation and avulsionFacial skeletal injuries   alveolar process   body of maxilla tempromandibular  jointOther classificationsUlfohnEllis and DavisHeithersay and morileBasrani
  • 13. Examination and diagnosisHistory Chief complaint History of present illness• When and where did the injury happen?• How did the injury happen?• Have you had treatment elsewhere before coming here?• Have you had similar injuries before?    • Have you noticed any other symptoms since the injury?• What specific problem you have with  the traumatic teeth/tooth?
  • 14. Medical history•Allergic reaction•Discords•Current medications•Tetanus immunization statusExaminationA.EXTRA- ORALB.INTRA-ORAL Hard tissue        facial bone
  • 15. Teeth             fracture                Mobility and displacement Injury to the PL and alveolar tissue
  • 16. Enamel fractureInclude chips and cracks confined to the enamel and not crossing the enamel dentin border.Biological consequences;Theoretically these  fractures are week points through which bacteria and their byproducts can travel to challenge the pulp.
  • 17. Diagnosis and clinical presentation;Crack or craze lines can occasionally be observed during routine examination.[fiber-optic] TreatmentEstablish baseline pulp statusSelective grindingComposite restorationPrognosis and follow up;Prognosis is good
  • 18. Uncomplicated crown fracture;Description;crown fracture involving enamel and dentin without pulp exposure and called uncomplicated fracture by andreasen and Ellis class 2 by Ellis.Biologic consequences;                                           dentin                                            pulp          chronic pulpal infection        reparative dentin 
  • 19. The reaction of pulp depends on;1.Time of treatment2.Distance of fracture from the teeth3.Size of the dentinal tubules4.Age of the patient5.Concomitant injury to the pulps blood supply6.Possibly the time of initial treatmentClassification   Horizontal   Oblique   Vertical
  • 20. Diagnosis and clinical presentationRough edge of the toothSensitivity to air,hot and coold substanceLip bruise or laceration is seen commonlyTreatmentObjectives;Elimination of painPreservation of vital pulpRestoration of fractured crownImmediate treatment; Protection of dentin from physical ,chemical and bacterial  irritation
  • 21. 1.hard setting calcium hydroxide2.reattachment
  • 23. Chamfer preparationEtching enamelPolymerization of compositesFinished restoration
  • 24. Treatment of Un-complicated crown fractureby reattachmentTesting pulpal sensitivity
  • 25. Testing for the fit of the fragment and etching the enamel Removal of the etchant  and drying
  • 26. Application of bonding agent Polymerization and finishing
  • 27. Reinforcing the fraccture site  Restored with compositeReinforcing the palatal aspect of the fractureFinal restoration
  • 28. Complicated crown root fracture;Involves the enamel ,dentin and pulp.the degree of pulpal involvement varies from pin point exposure to a total unroofing of the coronal pulp.
  • 29. Biological consequences;   hemorrhage Superficial inflammatory response Necrosis                     proliferationDiagnosisClinical observation
  • 30. TreatmentTwo options1.vital pulp therapy                             2. pulpectomy•  pulp capping•  partial pulpotomy•  cervical pulpotomyChoice of treatment depends on;•  stage of development of tooth•  time elapsed between injury and arrival of patient at the operator•  extent of  pulp injury•  presence or absence of hemorrhage•  size of remaining crown•  root fracture
  • 31. Pulp capping pulp capping implies placing the dressing directly onto the pulp exposureIndication•Immature permanent pulp,on a very recent exposure    [less than  24hrs]•Mature permanent with a simple restoration plan
  • 32. TechniqueTooth isolatedCalcium hydroxide placedPrognosis    In range of 80%
  • 33. Treatment of complicated crow fracture by pulpotomy and subsequent bonding of crown fracturePulp exposure and fracture fragmentpulpotomy Testing of fit of the fragment Bonding the fragment
  • 34. 2.pulpotomya.partial b.fullPartial pulpoyomy;Implies the removal of the coronal pulp tissue to the level of healthy pulp.[Cvek pulpotomy]IndicationImmature and young mature teeth,irrespective of the time interval in immature teeth and up to one week in mature teeth in which the fracture segment can be restored with composite resin.
  • 35. Full pulpotomyPolpotomy is defined as surgical removal of the entire coronal pulp,leaving intact the vital tissue in the canal.Indications1.young permanent teeth with exposed pulps and incompletely formed apices.2.pulpaly exposed primary teeth when their retention is more advantageous than their extractionPrognosisUp to 76%
  • 36. TechniqueLarge pulp exposure Isolation with rubber dam Pulpotomy to depth of 2mm
  • 37. Preparing the cavity Hemostasis and calcium hydroxideCompressing and placing hard restorationsetting calcium hydroxidePrognosisUp to 96% to
  • 38. Treatment of the non-vital pulp;b.PulpectomyImplies removal of the entire pulp to the level of apical foramen1.Teeth with complete apex formation[Total biopulpectomyThis is total extirpation of the pulp under anesthesia .According toBasrani,the tissue beyond the limits of CDJ must not be removedbecause it facilitates the repair process.]
  • 39. Indication1.All cases that have extensive coronal fracture.2.Use of post in root canalTechniqueRoot canal treatmentPrognosis;90%Treatment of nonvital pulp
  • 40. TREATMENT OF IMMATYRE FORMED APEXApexificationApexification is a method to induce development of the root apexof an immature ,pulpless tooth by formation of osteocementum orother bone like tissue.Objectives;Aim is to induce either closure of the open apical third of the rootcanal or the formation of an apical ‘calcific barrier’ against whichobturation can be achievedTechnique;
  • 41. Crown root fractureDefined as a fracture involving enamel, dentin and Cementum.ClassificationUncomplicatedComplicated Mechanism ; The horizontal impact produces zones at the point of impact cervically on the palatal aspect and apically on the labial aspect of the root .the shearing stress zone s which extend between the compression zones determine the course of the fracture
  • 42. Incidence5% of injury affecting permanent and 2% of primary teeth.Etiology;the most common are injury caused by falls,bicycle andautomobile accident and foreign bodies striking the teethPathologyCommunication from the oral cavity to the pulp and periodontalligament in these fractures causes inflammation in these structure Treatment Emergency treatment This includes stabilization of the coronal fragment with an acid etch/resin splint to adjacent teeth and later RCT is done and post is given
  • 43. Uncomplicated fractures1. Suferficial crown root fracture;Reattachment of new periodontal fibers and deposition of new cementumupon exposed dentin can occur once coronal fragment has been removed2.deep crown root fracture;Gingivectomy and dentin covering procedure
  • 44. Procedure Uncomplicated Superficial crown root fractureRemoval of coronal fragment , Dentin covering andsmoothed with bur and gingivectomy composite restoration 4yrs after treatment
  • 45. Complicated fracture1.surgical exposure of fracture surfaceremoval of the coronal fragment supplemented by gigivectomy andosteotomy and subsequent restoration with a post retained restoration.Treatment principal;To convert subgingival fracture to supra gingival fracture.Indication;When surgical technique does not compromise the esthetic results i.e. only palatal aspects of the fracture must be exposed in this manner.
  • 46. Complicated crown root fracture1.Surgical exposure of the fracture site Removal of fracture fragment Exposure of fracture site Post retained crown Finished restoration
  • 47. 2.removal of coronal fragment and surgical extrusion of the root;treatmentTreatment principalTo surgically move the fracture to a supragingival position.IndicationShould be only be used where the root portion is long toaccommodate a post retained crown.
  • 48. 2.Removal of coronal fragment and surgical extrusion of the root Loose fragment stabilized LA and incision of PLD Luxation of the root Extraction of the root
  • 49. Reimplantation ofapical segment Stabilization of apical fragment during healing
  • 50. Root fillingCompletion of the restoration
  • 51. 3.removal of coronal fragment and subsequent orthodonticextrusion of teeth.Treatment principle ;to orthodontically move the fracture to asupragingival position.Indication;The same as for surgical extrusion,but is more time consuming.
  • 52. Removal of coronal fragmentpulpotomy and orthodonticextrusionRemoval of loosened fragment
  • 53. pulpotomyOrthodontic extrusion
  • 54. Extrusion completedRestoration completed
  • 55. Removal of coronal fragment ,pulp extirpation and orthodonticextrusion Procedure; RCTApplying extrusion appliance
  • 56. Orthodontic extrusion1yr after extrusionFollow up procedures;2 months after complete treatment and 1yr after injury
  • 57. Root fractureThis type of injury is limited to fracture involving the root only. ( cementum dentin and pulp)Incidence;1-7 % of the cases of trauma to the dentition and occur most often between11 to 21 yrsEtiology1.Iatrogenic2. TraumaticClassificationa.According to the line of fracture with respect to the long axis of theteeth.Horizontal.Oblique.Vertical b.According to location;1.The cervical third.2.the middle third3.apical third
  • 58. b.According to location;1.The cervical third.2.the middle third3.apical thirdC.According to number of fracture lines.1.Simple2.multiple3.comminutedd.according to the extension of the line of fracture1.partial2.totale.position of root fragment.1.Without displacemen2.with displacement
  • 59. MechanismA frontal impact displaces thetooth palatally and results in aroot fracture and displacementof the coronal fragment.thisleads to both pulp and PLDdamage in coronal fragment.
  • 60. Treatment of horizontal fracturesPrinciple;Reduction of displaced fragment and firm immobilizationImmediate TREATMENT; The type of treatment depends on whether the pulp remains vital .If there are doubt to the state of the pulp,it is treated as a fractureWITH PULPAL VITALITY;Under anestesia the fracture fragments are reduced,moving the portionapically with pingef pressure.followed by radiographs to confirm .the toothstabilized.occlusion checked.
  • 61. Horizontal fracture teethClinical examination
  • 62. Repositioning the fragmentVerifying the repositioning
  • 63. Fixation procedureApplying splinting material
  • 64. Removing the splint1year after treatment
  • 65. WITHOUT PULPAL VITALITYa.root fragment communicating with oral cavity fracture of any part of the root coronal to the periodontal attachment havea poor prognosis for healing.The treatment choice are1.Periodontal gingival and osseous surgery to expose an adequate amount oftooth structure for a crown margin.2.extrusion of the root until all the fracture site is supragingival sufficient forrestoring the tooth3.combine orthodontic extrusion and periodontal gingival and osseousrecontouring for adequate margination4.removing the clinical crown segment and retaining the submerged root withits vital pulp followed by placement of fixed bridge across the space.if the rootpulp is necrotic, endodontic treatment must be accomplished.
  • 66. b.treatment of fracture teeth not communicating with the oral cavity(middle and apical third ) Treatment of horizontal root fracture due to necrotic pulp can consist of;• Endodontically treating the coronal segment only.• Endodontically treating both coronal and apical segment.• Endodontically treating the coronal segment and surgically removing the apical segment.
  • 67.
  • 68. vertical root fractures; Described as longitudinally oriented fracture of the root ,extending from the root canal to the periodontium.they usually occur in endodonticaly treatedteeth. Radiographic changes seen in vertical root fractures are summarized;1.separation of the root fragments along the root or root fillings
  • 69. beside a root filling or post 4.Double image 5..radioopaque signs
  • 70. 6.widening of periodontal 7.radiolucent halosligament space 8.steep like bone defect
  • 71. 9.Isolated horizontal bone 10.Unexplained boon loss in posteriorloss in posterior teeth teeth 11 .V-shaped bone loss on roots of posterior teeth
  • 72. 12.resorption along the fracture line. 13.displacement of retrograde filling material 14.endodontic failure after healing has occurred .
  • 73. Direct visualization of the fracture
  • 74. Treatment alternativesRepair of fracturesAccording to Andreasen there are four types of repair: 1. healing with calcified tissue the pulp is ruptured at the level of the fracture.fracture healing with in growth of cells cells originating from the apical half of the pulp ensures hard tissue union of the fracture
  • 75. 2. healing with interposition of connective tissue The pulp is ruptured or severely stretched at the level of the level of fracture.healing is dominated by in growth of cells originating from the periodontal ligament and results in interposition of connective tissue between the two fragments
  • 76. 3.Interposition of tissue between the segments infection occurs in avascular coronal pulp.granulation tissue is soon formed which originates from the periodontal ligament.accumulation of the cell between two fragments causes separation of the fragments and loosening of coronal fragments..4.Healing with interposition of bone and connective tissue
  • 77. PROGNOSIS : Prognosis of root fracture depends on• how soon the patient receive treatment• adaptation of the fragment• location of the fragment• stabilization of the fragment• horizontal or vertical fracture• absence of infection• health status of patientCOMPLICATIONS:1) root resorption2) internal resorption3) periodontal complications
  • 78. luxation injuriesTerminology;1.concussionan injury to the tooth-supporting structure without abnormal looseningor displacement but with marked reaction to percussion.2.subluxationan injury to the supporting structure with abnormal loosening butwithout clinically or radigraphically demonstrable displacement of teeth.3.intrusive luxationdisplacement of the tooth deeper into the alveolar bone.the injury isaccompanied by communication or fracture of the alveolar socket
  • 79. 4.extrusive luxationpartial displacement of the tooth out of its socket .5.lateral luxation ,displacement of the tooth in a direction other than axially .thisis accompanied by comminution or fracture of the alveolar socket. FREQUENCYLuxation injuries compromises 15 to 40 % of dental injuries.62 to69 % in primary teeth.Etiology.Fights,fall are the major factors.Luxation of teeth primarily involves max central incisorand seldom seen in mandibular teeth
  • 80. MECHANISM OFCONCUSSION INJURYA frontal impact leadsto hemorrhageand edema in the PDL
  • 82. Mechanism ofextrusive luxationOblique forcesdisplaces the tooth outof socket.only thegingival fiberspalatally prevents thetooth from beingavulsed
  • 83. Mechanism of lateralluxationHorizontal forces displace thecrown palatally and the apexlabially.apart from severanceof the PDL and theneurovascular supply to thepulp,compression of the PDLis found on the palatal aspectof the root
  • 84. Mechanism of intrusiveluxationAxial impact leads to extensiveinjury to the pulp andperidontium
  • 85. 1,Concussion; minor injuries have been sustained by periodontal structure sothat no loosening is present. The patient complains that the tooth feels sore.clinical examination reveals a marked reaction to percussion in horizontal and or vertical direction.2.Subluxation;Abnormally mobileSensitive to percussion and occlusal forces.Bleeding from gingival sulcus
  • 86. 3.Extrusion luxation;Tooth appears elongatedBleeding from PLPercussion is dull.Radiographic findingsWidth of periodontal space increasedin extrusive luxation
  • 87. 4.Intrusive luxation Marked displacement Sensitive to percussion Firm Metallic sound similar to ankylosed toothRadiographic findingsPeriodontal space disappears totally or partially in intrusive luxation
  • 88. 5.Lateral luxation.Usually crown is displaced linguallyAssociated with fracture ofvestibular part of socket wall.
  • 89. TreatmentConcussion;Adjusting the occlusionPulp test is repeated at 1,3,6,12 month
  • 90. Subluxation;Adjusting the occlusionTeeth repositioning and splintingHalf of this will undergo pulpal necrosis and requires RCTSplintingObject of splintingStabilization of the injured tooth and prevention of furtherdamage to the pulp and periodontal structure during healingperiod. In luxation injuries, the value and influence of splintingupon periodontal and pulpal healing has not been classified.
  • 91. Extrusive luxationRepositioning and stabilization for4 to 8 weeks.RCT except in young immatureteethMobility andpercussion test
  • 92. Sensitivity testing andradiographic diagnosis repositioning
  • 93. splintingPolishing the splint
  • 94. Finished splintGingival wound is sutured
  • 95. Lateral luxationRepositioning and stabilizationRCT if pulp necrosis
  • 96. Laterally luxated teethPercussion test
  • 97. Mobility and sensitivity test Radiographic examination
  • 98. AnesthesiaRepositioning the teeth
  • 99. splintingAfter etching
  • 100. Splinting material3 weeks after splinting
  • 101. Splinting removed6 months after injury
  • 102. Intrusive luxationImmature teeth will re-erupt within 3-4 weeks. Spontaneous eruptions of intruded teeth 7yrs old 6weeks 1year girl
  • 103. Mature teethOrthodontic repositionand stabilization 3-4 weeksGingivectomy and RCTDentin protection
  • 104. Orthodontic tractionPlacing the brackets
  • 105. Orthodontic tractionExtrusion initiated
  • 106. Complete extrusion after 4 weeksCrown restoration
  • 107. Complication following luxation injuries: These include pulpal necrosis, pulp canal obliteration, rootresorption( external or internal)Pulp canal obliteration:1) Partial obliteration2) Total canal obliteration Root resorption a) External root resorption: 3 types 1) Surface resorption 2) Replacement resorption 3) Inflammatory resorption b) Internal root resorption 2 types 1) Internal replacement resorption Internal inflammatory resorption
  • 108. Avulsion: An avulsed tooth is completely displaced out of its socketand may be referred as exarticulation or complete avulsion. Incidence: 1-16% of all traumatic injuries of permanent teeth. 7-13% of primary dentition male: female ratio 3:1 age group 7-11 yrs maxillary central incisors are commonly avulsed Examination:
  • 109. Factors affecting success of replantation 1.1.extra oral time Shorter the extra oral period,the better the prognosis for retention of the replanted tooth. media and transportation of avulsed teeth. a. milk b. Saliva c. hanks balance salt solutiond. physiologic saline
  • 110. Replantation; Replantation is sometimes referred to as reimplantationis the insertion of a tooth in its socket after its completeavulsion resulting from traumatic injury.Intentional replantation ;Transplantation;Auto-transplantation;Allotransplantation;
  • 111. Management of the socket;Management of the surface ;Adjunctive drug therapy Antibiotics Steroids and other drugs Tetanus prophylaxis Calcium hydroxide root canal filling Permanent filling with GPSplinting Duration of splinting
  • 112. TreatmentEndodontic treatment of replanted tooth 1.Teeth with incomplete root formation 2.Teeth with complete root formation 3.Replation of tooth with avital periodontal ligament
  • 113. Replantation of teeth withcomplete root formationExamination andRinsing the tooth
  • 114. Replanting the tooth splinting
  • 115. Follow up after 1 weekExtirpation of the pulp
  • 116. Access preparationPreparing the canal
  • 117. Placing calciumhydroxide dressingCondensing calciumhydroxide
  • 118. Access cavity closedSplint removed
  • 119. Replanting the tooth with incomplete root formation8yrs old avulsed teethRinsing the root surface
  • 120. Replanting the tooth Monitoring the healing
  • 121. Replanting the tooth with avital periodontalligamentTooth kept dry for 24hrsTreatment of root surface
  • 122. Fluoride treatment ofcementum and dentin Endodontic treatment
  • 123. Condition of the socket after 3 weeksReplanting the tooth
  • 124. SplintingFollow-up
  • 125. Healing after replantation1.healing with normal PDL; most of the intra alveolar periodontalfibers have healed. Pulpal revascularization has reached mid-root level
  • 126. 2.healing with ankylosis or replacement resorption 1 week 2months 4months 1yr 2 yrs 10yrs
  • 127. 3.inflammatory resorption0day 1week 3weeks 4weeks 2months 3months
  • 128. Fracture of the alveolar process Classified 1.Comminution of alveolar socket 2. Fracture of alveolar socket wall 3.fracture of alveolar process 4.fracture of maxilla or mandible Etiology; Fights,automobile accidents resulting from direct impact Frequency Permanent-16% Primary dentition-7%
  • 129. Clinical findings;.Tenderness on palpation and percussion•.Comminution of alveolar socket•.Abnormal mobility of the involved teeth•.dull percussion sound•.disturbed occlusion
  • 130. TreatmentPrinciple;Repositioning splinting
  • 131. Fracture of maxillary alveolar process Anesthetizing the area
  • 132. Repositioningsplinting
  • 133. Fracture of mandibular alveolar process
  • 134.
  • 135. Conclusion;
  • 136. References;1.Essential of traumatic injuries of teeth 2nd edition ,J.O .Andreasen and F.M. Andreasen2.Pathways of pulp 6 th edition Stephen Cohen,Richard C Burns3.Endodontics 5th edition Ingle,Bakland4.principles and practice of endodontics 2nd edition Walton, clinics of North America 19996.journals IEJ,JOE,Endodontics and Dental Traumatology, www.indiandentalacademy.comAustralian Dental Journals
  • 137.