Traumatic injuries of teeth         INDIAN DENTAL ACADEMY      Leader in Continuing Dental Education         www.indianden...
•Etiology•Mechanism of action•Introduction•Classification•Examination and diagnosis•Crown infraction•Uncomplicated crown f...
Incidence Most dental injuries occur during first tow decades of life [8 to 2yrs] Boys tend to injure their teeth more tha...
Etiology  Sudden impct involving the face or head may result in trauma to the  teeth and supporting structure. the frequen...
         Predisposing factors                   Increase overjet with protrusion of upper incisors and insufficient       ...
Direct traumaIndirect trauma                  www.indiandentalacademy.com
 The following factors characterize the impact anddetermine the extent of injuries.    •Energy of impact    •Resiliency of...
Classification    WHO Classification    873.60enamel fracture     873.61crown fracture without pulp involvement    873.62 ...
802.20;802.40 fracture or comminution of the alveolar process.this may or may not involve the tooth802.21;802.41 fracture ...
Class 6; root fracture with or without the loss of crown fracture.Class7;displacement of the tooth with neither crown or r...
Who classification modified by Andreasen andAndreasen used by international association of dentaltraumatology.Dentofacial ...
Luxation injuries   tooth concussion   Subluxation   Extrusive luxation   Intrusive luxation and avulsionFacial skeletal i...
Examination and diagnosisHistory    Chief complaint    History of present illness•     When and where did the injury happe...
Medical history•Allergic reaction•Discords•Current medications•Tetanus immunization statusExaminationA.EXTRA- ORALB.INTRA-...
Teeth             fracture                   Mobility and    displacement      Injury to the PL     and alveolar tissue   ...
Enamel fractureInclude chips and cracks confined to the enamel and not crossing the enamel dentin border.Biological conseq...
Diagnosis and clinical presentation;Crack or craze lines can occasionally be observed during routine examination.[fiber-op...
Uncomplicated crown fracture;Description;crown fracture involving enamel and dentin without pulp exposure and called uncom...
The reaction of pulp depends on;1.Time of treatment2.Distance of fracture from the teeth3.Size of the dentinal tubules4.Ag...
Diagnosis and clinical presentationRough edge of the toothSensitivity to air,hot and coold substanceLip bruise or lacerati...
1.hard setting calcium hydroxide2.reattachment                 www.indiandentalacademy.com
TREATMENT OF UN-COMPLICATED FRACTURE           WITH COMPOSITE AND ACID –ETCH TECHNIQUESHADE SELECTION AFTER POLISHINGRubbe...
Chamfer preparationEtching enamelPolymerization of compositesFinished restoration                 www.indiandentalacademy....
Treatment of Un-complicated crown fractureby reattachmentTesting pulpal sensitivity                 www.indiandentalacadem...
Testing for the fit of the fragment and etching the enamel                                  Removal of the etchant        ...
Application of bonding agent                               Polymerization and finishing                 www.indiandentalac...
Reinforcing the fraccture site                                      Restored with compositeReinforcing the palatal aspect ...
Complicated crown root fracture;Involves the enamel ,dentin and pulp.the degree of pulpal involvement varies from pin poin...
Biological consequences;                            hemorrhage              Superficial inflammatory response             ...
TreatmentTwo options1.vital pulp therapy                             2. pulpectomy•  pulp capping•  partial pulpotomy•  ce...
Pulp capping pulp capping implies placing the dressing directly onto the pulp exposureIndication•Immature permanent pulp,o...
TechniqueTooth isolatedCalcium hydroxide placedPrognosis    In range of 80%                 www.indiandentalacademy.com
Treatment of complicated crow fracture by pulpotomy     and subsequent bonding of crown fracturePulp exposure and fracture...
2.pulpotomya.partial b.fullPartial pulpoyomy;Implies the removal of the coronal pulp tissue to the level of healthy pulp.[...
Full pulpotomyPolpotomy is defined as surgical removal of the entire coronal pulp,leaving intact the vital tissue in the c...
TechniqueLarge pulp exposure Isolation with rubber dam Pulpotomy to depth of 2mm                www.indiandentalacademy.com
Preparing the cavity          Hemostasis and calcium                               hydroxideCompressing and placing hard  ...
Treatment of the non-vital pulp;b.PulpectomyImplies removal of the entire pulp to the level of apical foramen1.Teeth with ...
Indication1.All cases that have extensive coronal fracture.2.Use of post in root canalTechniqueRoot canal treatmentPrognos...
TREATMENT OF IMMATYRE FORMED APEXApexificationApexification is a method to induce development of the root apexof an immatu...
Crown root fractureDefined as a fracture involving enamel, dentin and Cementum.ClassificationUncomplicatedComplicated Mech...
Incidence5% of injury affecting permanent and 2% of primary teeth.Etiology;the most common are injury caused by falls,bicy...
Uncomplicated fractures1. Suferficial crown root fracture;Reattachment of new periodontal fibers and deposition of new cem...
Procedure Uncomplicated Superficial crown root fractureRemoval of coronal fragment ,               Dentin covering andsmoo...
Complicated fracture1.surgical exposure of fracture surfaceremoval of the coronal fragment supplemented by gigivectomy and...
Complicated crown root fracture1.Surgical exposure of the fracture site    Removal of fracture fragment                Exp...
2.removal of coronal fragment and surgical extrusion of the root;treatmentTreatment principalTo surgically move the fractu...
2.Removal of coronal fragment and surgical extrusion of the root Loose fragment stabilized       LA and incision of PLD Lu...
Reimplantation ofapical segment Stabilization of apical fragment during healing                    www.indiandentalacademy...
Root fillingCompletion of the restoration                  www.indiandentalacademy.com
3.removal of coronal fragment and subsequent orthodonticextrusion of teeth.Treatment principle ;to orthodontically move th...
Removal of coronal fragmentpulpotomy and orthodonticextrusionRemoval of loosened fragment               www.indiandentalac...
pulpotomyOrthodontic extrusion            www.indiandentalacademy.com
Extrusion completedRestoration completed               www.indiandentalacademy.com
Removal of coronal fragment ,pulp extirpation and orthodonticextrusion  Procedure;  RCTApplying extrusion appliance       ...
Orthodontic extrusion1yr after extrusionFollow up procedures;2 months after complete treatment and 1yr after injury       ...
Root fractureThis type of injury is limited to fracture involving the root only.  ( cementum dentin and pulp)Incidence;1-7...
b.According to location;1.The cervical third.2.the middle third3.apical thirdC.According to number of fracture lines.1.Sim...
MechanismA frontal impact displaces thetooth palatally and results in aroot fracture and displacementof the coronal fragme...
Treatment of horizontal fracturesPrinciple;Reduction of displaced fragment and firm immobilizationImmediate TREATMENT; The...
Horizontal fracture teethClinical examination                    www.indiandentalacademy.com
Repositioning the fragmentVerifying the repositioning                    www.indiandentalacademy.com
Fixation procedureApplying splinting material                  www.indiandentalacademy.com
Removing the splint1year after treatment                   www.indiandentalacademy.com
WITHOUT PULPAL VITALITYa.root fragment communicating with oral cavity     fracture of any part of the root coronal to the ...
b.treatment of fracture teeth not communicating with the oral    cavity(middle and apical third )    Treatment of horizont...
www.indiandentalacademy.com
vertical root fractures;  Described as longitudinally oriented fracture of the root ,extending from the  root canal to the...
3.space beside a root filling or post   4.Double image 5..radioopaque signs                       www.indiandentalacademy....
6.widening of periodontal          7.radiolucent halosligament space                     8.steep like bone defect         ...
9.Isolated horizontal bone         10.Unexplained boon loss in posteriorloss in posterior teeth            teeth 11 .V-sha...
12.resorption along the fracture line.     13.displacement of retrograde filling                                          ...
Direct visualization of the fracture                 www.indiandentalacademy.com
Treatment alternativesRepair of fracturesAccording to Andreasen there are four types of repair: 1. healing with calcified ...
2. healing with interposition of connective tissue The pulp is ruptured or severely stretched at the level of the level of...
3.Interposition of tissue between the segments    infection occurs in avascular coronal pulp.granulation   tissue is soon ...
PROGNOSIS :       Prognosis of root fracture depends on• how soon the patient receive treatment• adaptation of the fragmen...
luxation injuriesTerminology;1.concussionan injury to the tooth-supporting structure without abnormal looseningor displace...
4.extrusive luxationpartial displacement of the tooth out of its socket .5.lateral luxation ,displacement of the tooth in ...
MECHANISM OFCONCUSSION INJURYA frontal impact leadsto hemorrhageand edema in the PDL                 www.indiandentalacade...
MECHANISM OFSUBLUXATION INJURYIF THE IMPACT HAS GREATERFORCE, FIBERS MAY BE TORN,RESULTING IN LOOSENING OFTHE INJURED TOOT...
Mechanism ofextrusive luxationOblique forcesdisplaces the tooth outof socket.only thegingival fiberspalatally prevents the...
Mechanism of lateralluxationHorizontal forces displace thecrown palatally and the apexlabially.apart from severanceof the ...
Mechanism of intrusiveluxationAxial impact leads to extensiveinjury to the pulp andperidontium                 www.indiand...
1,Concussion;   minor injuries have been sustained by periodontal structure sothat no loosening is present. The patient co...
3.Extrusion luxation;Tooth appears elongatedBleeding from PLPercussion is dull.Radiographic findingsWidth of periodontal s...
4.Intrusive luxation Marked displacement Sensitive to percussion Firm Metallic sound similar to ankylosed toothRadiographi...
5.Lateral luxation.Usually crown is displaced linguallyAssociated with fracture ofvestibular part of socket wall.         ...
TreatmentConcussion;Adjusting the occlusionPulp test is repeated at 1,3,6,12 month                   www.indiandentalacade...
Subluxation;Adjusting the occlusionTeeth repositioning and splintingHalf of this will undergo pulpal necrosis and requires...
Extrusive luxationRepositioning and stabilization for4 to 8 weeks.RCT except in young immatureteethMobility andpercussion ...
Sensitivity testing andradiographic diagnosis  repositioning                  www.indiandentalacademy.com
splintingPolishing the splint                www.indiandentalacademy.com
Finished splintGingival wound is sutured                   www.indiandentalacademy.com
Lateral luxationRepositioning and stabilizationRCT if pulp necrosis                    www.indiandentalacademy.com
Laterally luxated teethPercussion test                  www.indiandentalacademy.com
Mobility and sensitivity test Radiographic examination                  www.indiandentalacademy.com
AnesthesiaRepositioning the teeth                 www.indiandentalacademy.com
splintingAfter etching                www.indiandentalacademy.com
Splinting material3 weeks after splinting                www.indiandentalacademy.com
Splinting removed6 months after injury                 www.indiandentalacademy.com
Intrusive luxationImmature teeth will re-erupt within 3-4 weeks.   Spontaneous eruptions of   intruded teeth     7yrs old ...
Mature teethOrthodontic repositionand stabilization 3-4 weeksGingivectomy and RCTDentin protection                    www....
Orthodontic tractionPlacing the brackets                  www.indiandentalacademy.com
Orthodontic tractionExtrusion initiated                 www.indiandentalacademy.com
Complete extrusion after 4  weeksCrown restoration                    www.indiandentalacademy.com
Complication following luxation injuries:  These include pulpal necrosis, pulp canal obliteration, rootresorption( externa...
Avulsion:  An avulsed tooth is completely displaced out of its socketand may be referred as exarticulation or complete avu...
Factors affecting success of replantation 1.1.extra oral time Shorter the extra oral period,the better the prognosis for r...
Replantation; Replantation is sometimes referred to as reimplantationis the insertion of a tooth in its socket after its c...
Management of the socket;Management of the surface ;Adjunctive drug therapy  Antibiotics  Steroids and other drugs  Tetanu...
TreatmentEndodontic treatment of replanted tooth    1.Teeth with incomplete root formation    2.Teeth with complete root f...
Replantation of teeth withcomplete root formationExamination andRinsing the tooth                www.indiandentalacademy.com
Replanting the tooth splinting                www.indiandentalacademy.com
Follow up after 1 weekExtirpation of the pulp                 www.indiandentalacademy.com
Access preparationPreparing the canal               www.indiandentalacademy.com
Placing calciumhydroxide dressingCondensing calciumhydroxide               www.indiandentalacademy.com
Access cavity closedSplint removed             www.indiandentalacademy.com
Replanting the tooth with incomplete root formation8yrs old avulsed teethRinsing the root surface                  www.ind...
Replanting the tooth Monitoring the healing                 www.indiandentalacademy.com
Replanting the tooth with avital periodontalligamentTooth kept dry for 24hrsTreatment of root surface                 www....
Fluoride treatment ofcementum and dentin Endodontic treatment                  www.indiandentalacademy.com
Condition of the   socket after 3 weeksReplanting the tooth               www.indiandentalacademy.com
SplintingFollow-up             www.indiandentalacademy.com
Healing after replantation1.healing with normal PDL; most of the intra alveolar periodontalfibers have healed. Pulpal reva...
2.healing with ankylosis or replacement resorption 1 week      2months      4months     1yr      2 yrs   10yrs            ...
3.inflammatory resorption0day    1week     3weeks    4weeks   2months   3months             www.indiandentalacademy.com
Fracture of the alveolar process  Classified  1.Comminution of alveolar socket  2. Fracture of alveolar socket wall  3.fra...
Clinical findings;.Tenderness on palpation and percussion•.Comminution of alveolar socket•.Abnormal mobility of the involv...
TreatmentPrinciple;Repositioning                       splinting             www.indiandentalacademy.com
Fracture of maxillary alveolar process Anesthetizing the area                www.indiandentalacademy.com
Repositioningsplinting                www.indiandentalacademy.com
Fracture of mandibular alveolar process       www.indiandentalacademy.com
www.indiandentalacademy.com
Conclusion;              www.indiandentalacademy.com
References;1.Essential of traumatic injuries of teeth             2nd edition ,J.O .Andreasen and F.M. Andreasen2.Pathways...
www.indiandentalacademy.com
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Traumatic injuries of teeth /certified fixed orthodontic courses by Indian dental academy

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

  1. 1. Traumatic injuries of teeth INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 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 www.indiandentalacademy.com
  3. 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.  www.indiandentalacademy.com
  4. 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  www.indiandentalacademy.com
  5. 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.   www.indiandentalacademy.com
  6. 6. Direct traumaIndirect trauma www.indiandentalacademy.com
  7. 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  www.indiandentalacademy.com
  8. 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 www.indiandentalacademy.com
  9. 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. 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 www.indiandentalacademy.com
  11. 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 www.indiandentalacademy.com
  12. 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 www.indiandentalacademy.com
  13. 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? www.indiandentalacademy.com
  14. 14. Medical history•Allergic reaction•Discords•Current medications•Tetanus immunization statusExaminationA.EXTRA- ORALB.INTRA-ORAL Hard tissue        facial bone www.indiandentalacademy.com
  15. 15. Teeth             fracture                Mobility and displacement Injury to the PL and alveolar tissue www.indiandentalacademy.com
  16. 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. www.indiandentalacademy.com
  17. 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 www.indiandentalacademy.com
  18. 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 www.indiandentalacademy.com          chronic pulpal infection        reparative dentin 
  19. 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 www.indiandentalacademy.com
  20. 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 www.indiandentalacademy.com
  21. 21. 1.hard setting calcium hydroxide2.reattachment www.indiandentalacademy.com
  22. 22. TREATMENT OF UN-COMPLICATED FRACTURE           WITH COMPOSITE AND ACID –ETCH TECHNIQUESHADE SELECTION AFTER POLISHINGRubber dam  application www.indiandentalacademy.com
  23. 23. Chamfer preparationEtching enamelPolymerization of compositesFinished restoration www.indiandentalacademy.com
  24. 24. Treatment of Un-complicated crown fractureby reattachmentTesting pulpal sensitivity www.indiandentalacademy.com
  25. 25. Testing for the fit of the fragment and etching the enamel Removal of the etchant  and drying www.indiandentalacademy.com
  26. 26. Application of bonding agent Polymerization and finishing  www.indiandentalacademy.com
  27. 27. Reinforcing the fraccture site  Restored with compositeReinforcing the palatal aspect of the fractureFinal restoration www.indiandentalacademy.com
  28. 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. www.indiandentalacademy.com
  29. 29. Biological consequences;   hemorrhage Superficial inflammatory response Necrosis                     proliferationDiagnosisClinical observation www.indiandentalacademy.com
  30. 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 www.indiandentalacademy.com
  31. 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 www.indiandentalacademy.com
  32. 32. TechniqueTooth isolatedCalcium hydroxide placedPrognosis    In range of 80% www.indiandentalacademy.com
  33. 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 www.indiandentalacademy.com
  34. 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. www.indiandentalacademy.com
  35. 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% www.indiandentalacademy.com
  36. 36. TechniqueLarge pulp exposure Isolation with rubber dam Pulpotomy to depth of 2mm www.indiandentalacademy.com
  37. 37. Preparing the cavity Hemostasis and calcium hydroxideCompressing and placing hard restorationsetting calcium hydroxidePrognosisUp to 96% to 94%www.indiandentalacademy.com
  38. 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.] www.indiandentalacademy.com
  39. 39. Indication1.All cases that have extensive coronal fracture.2.Use of post in root canalTechniqueRoot canal treatmentPrognosis;90%Treatment of nonvital pulp www.indiandentalacademy.com
  40. 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; www.indiandentalacademy.com
  41. 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 www.indiandentalacademy.com
  42. 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 www.indiandentalacademy.com
  43. 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 www.indiandentalacademy.com
  44. 44. Procedure Uncomplicated Superficial crown root fractureRemoval of coronal fragment , Dentin covering andsmoothed with bur and gingivectomy composite restoration 4yrs after treatment www.indiandentalacademy.com
  45. 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. www.indiandentalacademy.com
  46. 46. Complicated crown root fracture1.Surgical exposure of the fracture site Removal of fracture fragment Exposure of fracture site Post retained crown Finished restoration www.indiandentalacademy.com
  47. 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. www.indiandentalacademy.com
  48. 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 www.indiandentalacademy.com
  49. 49. Reimplantation ofapical segment Stabilization of apical fragment during healing www.indiandentalacademy.com
  50. 50. Root fillingCompletion of the restoration www.indiandentalacademy.com
  51. 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. www.indiandentalacademy.com
  52. 52. Removal of coronal fragmentpulpotomy and orthodonticextrusionRemoval of loosened fragment www.indiandentalacademy.com
  53. 53. pulpotomyOrthodontic extrusion www.indiandentalacademy.com
  54. 54. Extrusion completedRestoration completed www.indiandentalacademy.com
  55. 55. Removal of coronal fragment ,pulp extirpation and orthodonticextrusion Procedure; RCTApplying extrusion appliance www.indiandentalacademy.com
  56. 56. Orthodontic extrusion1yr after extrusionFollow up procedures;2 months after complete treatment and 1yr after injury www.indiandentalacademy.com
  57. 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 www.indiandentalacademy.com
  58. 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 www.indiandentalacademy.com
  59. 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. www.indiandentalacademy.com
  60. 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. www.indiandentalacademy.com
  61. 61. Horizontal fracture teethClinical examination www.indiandentalacademy.com
  62. 62. Repositioning the fragmentVerifying the repositioning www.indiandentalacademy.com
  63. 63. Fixation procedureApplying splinting material www.indiandentalacademy.com
  64. 64. Removing the splint1year after treatment www.indiandentalacademy.com
  65. 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. www.indiandentalacademy.com
  66. 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. www.indiandentalacademy.com
  67. 67. www.indiandentalacademy.com
  68. 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 2.space along the root or root fillings www.indiandentalacademy.com
  69. 69. 3.space beside a root filling or post 4.Double image 5..radioopaque signs www.indiandentalacademy.com
  70. 70. 6.widening of periodontal 7.radiolucent halosligament space 8.steep like bone defect www.indiandentalacademy.com
  71. 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 www.indiandentalacademy.com
  72. 72. 12.resorption along the fracture line. 13.displacement of retrograde filling material 14.endodontic failure after healing has occurred . www.indiandentalacademy.com
  73. 73. Direct visualization of the fracture www.indiandentalacademy.com
  74. 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 www.indiandentalacademy.com
  75. 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 www.indiandentalacademy.com
  76. 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 www.indiandentalacademy.com
  77. 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 www.indiandentalacademy.com
  78. 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 www.indiandentalacademy.com
  79. 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 www.indiandentalacademy.com
  80. 80. MECHANISM OFCONCUSSION INJURYA frontal impact leadsto hemorrhageand edema in the PDL www.indiandentalacademy.com
  81. 81. MECHANISM OFSUBLUXATION INJURYIF THE IMPACT HAS GREATERFORCE, FIBERS MAY BE TORN,RESULTING IN LOOSENING OFTHE INJURED TOOTH www.indiandentalacademy.com
  82. 82. Mechanism ofextrusive luxationOblique forcesdisplaces the tooth outof socket.only thegingival fiberspalatally prevents thetooth from beingavulsed www.indiandentalacademy.com
  83. 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 www.indiandentalacademy.com
  84. 84. Mechanism of intrusiveluxationAxial impact leads to extensiveinjury to the pulp andperidontium www.indiandentalacademy.com
  85. 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 www.indiandentalacademy.com
  86. 86. 3.Extrusion luxation;Tooth appears elongatedBleeding from PLPercussion is dull.Radiographic findingsWidth of periodontal space increasedin extrusive luxation www.indiandentalacademy.com
  87. 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 www.indiandentalacademy.com
  88. 88. 5.Lateral luxation.Usually crown is displaced linguallyAssociated with fracture ofvestibular part of socket wall. www.indiandentalacademy.com
  89. 89. TreatmentConcussion;Adjusting the occlusionPulp test is repeated at 1,3,6,12 month www.indiandentalacademy.com
  90. 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. www.indiandentalacademy.com
  91. 91. Extrusive luxationRepositioning and stabilization for4 to 8 weeks.RCT except in young immatureteethMobility andpercussion test www.indiandentalacademy.com
  92. 92. Sensitivity testing andradiographic diagnosis repositioning www.indiandentalacademy.com
  93. 93. splintingPolishing the splint www.indiandentalacademy.com
  94. 94. Finished splintGingival wound is sutured www.indiandentalacademy.com
  95. 95. Lateral luxationRepositioning and stabilizationRCT if pulp necrosis www.indiandentalacademy.com
  96. 96. Laterally luxated teethPercussion test www.indiandentalacademy.com
  97. 97. Mobility and sensitivity test Radiographic examination www.indiandentalacademy.com
  98. 98. AnesthesiaRepositioning the teeth www.indiandentalacademy.com
  99. 99. splintingAfter etching www.indiandentalacademy.com
  100. 100. Splinting material3 weeks after splinting www.indiandentalacademy.com
  101. 101. Splinting removed6 months after injury www.indiandentalacademy.com
  102. 102. Intrusive luxationImmature teeth will re-erupt within 3-4 weeks. Spontaneous eruptions of intruded teeth 7yrs old 6weeks 1year girl www.indiandentalacademy.com
  103. 103. Mature teethOrthodontic repositionand stabilization 3-4 weeksGingivectomy and RCTDentin protection www.indiandentalacademy.com
  104. 104. Orthodontic tractionPlacing the brackets www.indiandentalacademy.com
  105. 105. Orthodontic tractionExtrusion initiated www.indiandentalacademy.com
  106. 106. Complete extrusion after 4 weeksCrown restoration www.indiandentalacademy.com
  107. 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 www.indiandentalacademy.com Internal inflammatory resorption
  108. 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: www.indiandentalacademy.com
  109. 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. 2.storage media and transportation of avulsed teeth. a. milk b. Saliva c. hanks balance salt solutiond. physiologic saline www.indiandentalacademy.com
  110. 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; www.indiandentalacademy.com
  111. 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 www.indiandentalacademy.com
  112. 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 www.indiandentalacademy.com
  113. 113. Replantation of teeth withcomplete root formationExamination andRinsing the tooth www.indiandentalacademy.com
  114. 114. Replanting the tooth splinting www.indiandentalacademy.com
  115. 115. Follow up after 1 weekExtirpation of the pulp www.indiandentalacademy.com
  116. 116. Access preparationPreparing the canal www.indiandentalacademy.com
  117. 117. Placing calciumhydroxide dressingCondensing calciumhydroxide www.indiandentalacademy.com
  118. 118. Access cavity closedSplint removed www.indiandentalacademy.com
  119. 119. Replanting the tooth with incomplete root formation8yrs old avulsed teethRinsing the root surface www.indiandentalacademy.com
  120. 120. Replanting the tooth Monitoring the healing www.indiandentalacademy.com
  121. 121. Replanting the tooth with avital periodontalligamentTooth kept dry for 24hrsTreatment of root surface www.indiandentalacademy.com
  122. 122. Fluoride treatment ofcementum and dentin Endodontic treatment www.indiandentalacademy.com
  123. 123. Condition of the socket after 3 weeksReplanting the tooth www.indiandentalacademy.com
  124. 124. SplintingFollow-up www.indiandentalacademy.com
  125. 125. Healing after replantation1.healing with normal PDL; most of the intra alveolar periodontalfibers have healed. Pulpal revascularization has reached mid-root level www.indiandentalacademy.com
  126. 126. 2.healing with ankylosis or replacement resorption 1 week 2months 4months 1yr 2 yrs 10yrs www.indiandentalacademy.com
  127. 127. 3.inflammatory resorption0day 1week 3weeks 4weeks 2months 3months www.indiandentalacademy.com
  128. 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% www.indiandentalacademy.com Primary dentition-7%
  129. 129. Clinical findings;.Tenderness on palpation and percussion•.Comminution of alveolar socket•.Abnormal mobility of the involved teeth•.dull percussion sound•.disturbed occlusion www.indiandentalacademy.com
  130. 130. TreatmentPrinciple;Repositioning splinting www.indiandentalacademy.com
  131. 131. Fracture of maxillary alveolar process Anesthetizing the area www.indiandentalacademy.com
  132. 132. Repositioningsplinting www.indiandentalacademy.com
  133. 133. Fracture of mandibular alveolar process www.indiandentalacademy.com
  134. 134. www.indiandentalacademy.com
  135. 135. Conclusion; www.indiandentalacademy.com
  136. 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,Torabinajad5.dental clinics of North America 19996.journals IEJ,JOE,Endodontics and Dental Traumatology, www.indiandentalacademy.comAustralian Dental Journals
  137. 137. www.indiandentalacademy.com

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