Traumatic injuries srikanth

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Traumatic injuries srikanth

  1. 1. CONTENTS  Introduction  Classification  Etiology and causes  Clinical examination  Enamel fractures  Uncomplicated crown fracture  complicated crown fracture  Crown root fracture  Root fracture  Luxation injuries  Avulsion  conclusion
  2. 2. Introduction Traumatic dental injuries are everyday occurrences and their prevalence has been continuously rising. Trauma has been one of the main etiological factor for numerous restorative and endodontic procedures. A thorough knowledge of various types of traumatic injuries is mandatory to treat these cases successfully.
  3. 3. • Ellis classification class 1 class 2 class 3 class 4 class 5 Class 6
  4. 4. Ellis And Daveys Classification • Class I – simple crown fracture with plain enamel involvement • Class II – extended crown fracture with noticeable dentinal involvement, without pulp exposure • Class III - extended crown fracture with noticeable dentinal involvement, with pulp exposure • Class IV – teeth that lost vitality, with or without loss of crown • Class V – traumatically avulsed teeth • Class VI – crown fracture with or without loss of crown • Class VII - tooth luxation without crown or root fracture • Class VIII – cervical crown fracture • Class IX - traumatic injuries on primary teeth
  5. 5. • WHO classification (1978) 873.60 – crown fracture involving only enamel 873.61 – crown fracture involving enamel and dentin without pulp exposure 873.62 – crown fracture involving enamel and dentin with pulp exposure 873.63 – root fracture 873.64 – crown root fracture 873.66 – tooth luxation 873.67 – tooth intrusion or extrusion 873.68 – tooth avulsion 873.69 – other injuries ( soft tissue injuries )
  6. 6. • Andreasen modification of WHO classification 873.64 – complicated and uncomplicated crown root fracture 873.66 – concussion Subluxation Luxation injuries with alveolar fractures
  7. 7. • WHO classification (1995) S.02.5 - Fracture Of Tooth S.02.50 - Fracture of enamel only + enamel infraction S.02.51 - Fracture of crown of tooth without pulpal involvement S.02.52 - Fracture of crown of tooth with pulpal involvement S.02.53 - fracture of root of tooth S.02.54 - Fracture of crown with root of tooth, with or without pulpal involvement S.02.57 - multiple fractures of tooth
  8. 8. • Andreasen classification Injuries to teeth Crown infraction and uncomplicated fracture without involvement of dentin Uncomplicated crown fracture with involvement of dentin Complicated crown fracture Uncomplicated crown root fracture Complicated crown root fracture Root fracture
  9. 9. • Injuries to periodontal tissues Concussion Subluxation Intrusive luxation Extrusive luxation lateral luxation Exarticulation
  10. 10. • Garcia Godoys classification Class 0 – enamel crack Class 1 – enamel fracture Class 2 – enamel- dentin fracture without pulp exposure Class 3 – enamel-dentin fracture with pulp exposure Class 4 – enamel-dentin-cementum fracture without pulp exposure Class 5 – enamel-dentin-cementum fracture with pulp exposure Class 6 – root fracture Class 7 – concussion Class 8 – luxation ( loosening ) Class 9 – lateral displacement Class 10 – intrusion Class 11 – extrusion Class 12 – avulsion
  11. 11. • Pulver classification Class I Division I – no external fracture, no displacement Division II – displacement but no fracture Division III – fracture of enamel only, no displacement Division IV – displacement and fracture of enamel only Class II Division I – fracture of enamel and dentin only, no displacement Division II - displacement and fracture of enamel and dentin only
  12. 12. Class III Division I – fracture (with exposure of pulp), no displacement Division II – displacement and fracture (with exposure of pulp) Class IV Division I – fracture of root Class V Division I – intrusion Division II – partial avulsion Division III –complete avulsion
  13. 13. Heithersay and Morile classification (sub gingival fractures) Class 1 – fracture line does not extend below the level of attached gingiva Class 2 – fracture line extends below the level of attached gingiva but above the crest of alveolar bone Class 3 – fracture line extend below the level of crest of alveolar bone Class 4 – fracture line is within the coronal third of root but below the level of crest of alveolar bone
  14. 14. Ingle classification Soft tissues Lacerations Contusions Abrasions Tooth fractures Enamel fracture Crown fracture – uncomplicated Crown fracture – complicated Crown root fracture Root fracture Luxation injuries Tooth concussion Subluxation Intrusive luxation Lateral luxation Extrusive luxation Avulsion Facial skeletal injuries Alveolar process Body of mandible TMJ
  15. 15. Causes and incidence 1. Accidental falls 2. Traffic accidents 3. Acts of violence 4. Sports  7 to 10 years – most accident prone  Maxillary cental incisors, lateral incisors and then mandibular incisors  Most common dental trauma – enamel fracture or uncomplicated crown fracture
  16. 16. Clinical examination  Soft tissues - adjacent to fractured teeth should be carefully examined and palpated  Facial bones  Teeth 1. Fracture 2. Mobility 3. Displacement 4. Injury to periodontal tissues
  17. 17. 5. PULPAL TRAUMA evaluated both initially and at various times following the trauma Pulp stunning Pulp test unpredictable in trauma – why??? (Pillegi et al,EDT’96)
  18. 18. LDF – promising practical problems PULSE OXIMETRY measuring vascular health by evaluating oxygen saturation highly effective – recently traumatised teeth (Velayutham et al’07)
  19. 19. Prognosis of pulp after different levels of fracture LEVEL OF FRACTURE PROGNOSIS OF PULP Enamel infractionEnamel infraction 97 – 100% survival97 – 100% survival Enamel fractureEnamel fracture 99-100% survival99-100% survival Enamel – dentin fractureEnamel – dentin fracture uncomplicateduncomplicated 75-98% survival75-98% survival 0.2%-0.5% obliteration0.2%-0.5% obliteration Enamel – dentin fractureEnamel – dentin fracture complicatedcomplicated Direct pulp capping:72-81%Direct pulp capping:72-81% Vital amputation 94 -100%Vital amputation 94 -100% All crown root fracturesAll crown root fractures Worse than crown fractures, noWorse than crown fractures, no reports availablereports available (Olsburg et al’01)
  20. 20. Prognosis of pulp after luxation injuries Type of luxation injuryType of luxation injury Pulp deathPulp death concussionconcussion 4%4% sub-luxationsub-luxation 12%12% lateral luxationlateral luxation 77%77% extrusive luxationextrusive luxation 55 – 98%55 – 98% intrusive luxationintrusive luxation 100%100% Barnett et al ‘02
  21. 21. Radiographic examination - embedded fragments in soft tissues - dislocations - root and jaw fractures - resorptive and calcific changes
  22. 22. Soft tissue injuries control bleeding, repositioning displaced tissues and suturing LacerationLaceration ContusionContusion AbrasionAbrasion
  23. 23. Enamel fracture • Chips and cracks confined to enamel • Enamel infractions – transillumination, indirect light or disclosing dyes • Cracks – no treatment • Follow up
  24. 24. Crown fractures (uncomplicated) • Outcome – formation of irritation dentin or pulp necrosis
  25. 25.  Composite Build Up Restores About 100% Strength Recovery  Reattachment of fractured fragment – restores around 50% to 60% of original strength (worthington et al ’99) GO IN FOR REATTACHMENT WHENEVER POSSIBLE !!!
  26. 26.  Methods of reattachment A. using circumferential bevel before reattaching B. using a V shaped notch C. placing a internal groove
  27. 27. D. placing a chamfer at the fracture line after reattaching E. superficial over contour over the fracture line F. simple reattachment
  28. 28.  Fracture strength of different reattachment techniques Superficial over contour, placing a internal groove provided fracture strength as high as sound teeth (Reis & others ‘01)  Influence of materials used in reattachment onInfluence of materials used in reattachment on fracture strengthfracture strength Different material combinations used to bond tooth fragments to remaining crown were found to have no influence on fracture strength after bonding (Reis, Kraul et al ’02)
  29. 29. Crown fracture (complicated)  0.9 to 13% - all dental injuries  Consequence  First 24 hrs – proliferative response with inflammation not extending more than 2mm into pulp Treatment 1. Vital pulp therapy 2. Pulpectomy
  30. 30. Factors affecting treatment selectionFactors affecting treatment selection a.a. TimeTime b.b. Attachment damageAttachment damage c.c. Restorative treatment planRestorative treatment plan d.d. Level of developmentLevel of development VITAL PULP THERAPYVITAL PULP THERAPY  PULP CAPPINGPULP CAPPING - no absolute indications- no absolute indications - a bacteria tight coronal seal more difficult- a bacteria tight coronal seal more difficult - 80% success rate- 80% success rate
  31. 31. PARTIAL PULPOTOMY  Shallow or CVEK pulpotomy  Advantage over deep pulpotomy  Procedure  Prognosis – 94 to 96%
  32. 32.  Material of choiceMaterial of choice CaOH or MTACaOH or MTA The reparative dentin is consistently more uniform and thicker under MTA compared with CaOH Heide And Cvek – Safe to proceed with shallow pulpotomies upto 1 week post fracture
  33. 33. FULL PULPOTOMY  Traumatic exposures after 72 hours  Technique  Prognosis – 75%  Contraindicated – mature teeth pulpectomy has a success rate 95%, whereas if apical periodontitis develops, the prognosis of RCT drops to 80%.
  34. 34.  Other treatmentsOther treatments a.a. PulpectomyPulpectomy b.b. Apexification proceduresApexification procedures CaOH apexificationCaOH apexification MTA apexificationMTA apexification
  35. 35. CROWN – ROOT FRACTURE  Complicated and uncomplicatedComplicated and uncomplicated  Treatment modalitiesTreatment modalities ReattachmentReattachment Restorative TreatmentRestorative Treatment
  36. 36. Crown root fracture and biological width  Biological width –Biological width – connective tissue attachment +connective tissue attachment + junctional epitheliumjunctional epithelium Andersean et al – 4mm tooth structure above crest of alveolar bone  MethodsMethods a.a. Periodontal surgeryPeriodontal surgery b.b. Surgical extrusionSurgical extrusion c.c. Orthodontic extrusionOrthodontic extrusion
  37. 37. Periodontal surgery Apically repositioned flap surgeryApically repositioned flap surgery  esthetics??esthetics?? When to go for gingivectomy???When to go for gingivectomy???
  38. 38. Surgical extrusion (intra-alveolar transplantation) ProcedureProcedure
  39. 39.  AdvantagesAdvantages  DisadvantagesDisadvantages surgical extrusion of average 4.25mm ( 3 – 7mm) can be performed without any complication and good long term success (caliskan et al ’99 )
  40. 40. Healing after surgical extrusion
  41. 41. Orthodontic extrusion  Slow or forced extrusionSlow or forced extrusion  ProcedureProcedure
  42. 42.  Time of treatment – 2 to 3 weeksTime of treatment – 2 to 3 weeks  Stabilisation – 2-3 monthsStabilisation – 2-3 months
  43. 43.  Orthodontic extrusion with supracrestal fibrotomy ( Ami Smidt et ’05 )  Force required – 25 to 30 g ( Reitan and Vanarsdall ’94 ) 50 to 75 g ( Profitt and Fields ’93 )
  44. 44. Root fracture • Types –Types – transverse or obliquetransverse or oblique single or multiplesingle or multiple complete or incompletecomplete or incomplete • Radiographs – angled within 4 degrees of fractureRadiographs – angled within 4 degrees of fracture lineline • Additional radiograph at 45 degrees ( INGLE )Additional radiograph at 45 degrees ( INGLE ) • At least 3 angled radiographs – 45, 90 , 110 degreesAt least 3 angled radiographs – 45, 90 , 110 degrees ( COHEN( COHEN ))
  45. 45. • Displacement - none to severeDisplacement - none to severe • Biological consequenceBiological consequence pulp necrosis of coronal part – 25%pulp necrosis of coronal part – 25% pulp necrosis of apical part – rare Emergency treatmentEmergency treatment a. Repositioning – finger pressure or orthodontica. Repositioning – finger pressure or orthodontic interventionintervention b. Splinting - 2 to 4 weeksb. Splinting - 2 to 4 weeks
  46. 46. • Healing pattern of root fracturesHealing pattern of root fractures (Andresean and Hjorting-Hansen) 1. Healing With Calcified Tissue 2. Healing with interproximal connective tissue 3. Healing with interproximal bone and connective tissue 4. Interproximal inflammatory tissue without healing First 3 types - success
  47. 47. • TREATMENT OPTIONSTREATMENT OPTIONS a.a. Root canal therapy of both segmentsRoot canal therapy of both segments b.b. Root canal treatment of coronal segment aloneRoot canal treatment of coronal segment alone c.c. Use of intraradicular splintUse of intraradicular splint d.d. Root extrusionRoot extrusion Cvek modification of root canal therapy of coronal segment alone
  48. 48. • PrognosisPrognosis - amount of dislocation, stage of root development and- amount of dislocation, stage of root development and quality of treatment.quality of treatment. • Fracture location on prognosisFracture location on prognosis More apical the fracture, better the prognosisMore apical the fracture, better the prognosis MISCONCEPTIONMISCONCEPTION - location did not influence outcome ( Zachrisson and Jacobsen ) - fracture location matters less as long as it is not too close to the alveolar crest ( Jacobsen )
  49. 49. • ComplicationsComplications a.a. Pulp necrosisPulp necrosis b.b. Pulp canal obliterationPulp canal obliteration
  50. 50. Deep root fracture without pulp necrosis
  51. 51. Deep root fracture with pulp necrosis
  52. 52. Autotransplantation for shallow root fracture
  53. 53. Deep root fracture with coronal and apical pulp necrosis
  54. 54. Luxation injuries  Largest group – 30 to 44%  Includes 1. Concussion 2. Subluxation 3. Extrusive luxation 4. Lateral luxation 5. Intrusive luxation 6. Avulsion
  55. 55. concussion  No displacement  Normal mobility  Sensitivity to percussion  Management symptomatic D. Diagnosis root fracture, subluxation
  56. 56. subluxation  Sensitivity to percussion  Increased mobility  No displacement  Mangement optional splinting for 2 to 3 weeks D. Diagnosis root fracture Pulp death in 12 to 20%
  57. 57. Lateral luxation  Displacement labially, mesially, distally or palataly  Management repositioning splinting (2 – 3 months)
  58. 58. Extrusive luxation  Displacement in coronal direction  Differential Diagnosis root fracture Management 1. Repositioning 2. Splint – 1 - 3 weeks
  59. 59. Intrusive luxation  Displacement in apical direction into alveolus  Poorprognosis  Management 1. No treatment in immature teeth 2. Repositioned – surgical or orthodontic or combination
  60. 60. Sequalae to luxation injury  Yellow discoloration  Grey discoloration  Resorption – 5 to 15%  Incomplete root formation  Primary teeth – pulp space obliteration by calcification
  61. 61. Healing events 2 weeks after replantation Most
  62. 62. Healing with minor injury to the periodontal ligament
  63. 63. Healing with moderate injury to theperiodontal ligament and associated infection in the pulp and /or dentinal tubules
  64. 64. Healing after extensive injury to the periodontal ligament
  65. 65. Hank’s Balanced Salt Solution (HBSS), Viaspan® ,Euro-Collins® , Custodiol Minimum Essential Medium (MEM) Saline , Water, Saliva, Milk, Propolis , Red mulberry, Egg white, Coconut water, Gatorade ,Ricetral,,Green tea , Conditioned medium Contact lens solution , Salvia extract, Tooth rescue box (Dentosafe)
  66. 66. Storage medium Desired – PDL viability Saliva, saline and tap water Hanks balanced salt solution (HBSS) standard saline solution non toxic, pH balanced and contains essential nutrients ‘Save-A-Tooth’ – no longer recommended
  67. 67. Milk PDL cell viability – physiological osmolality Milk with a lower fat content more useful at maintaining cell viability than milk with higher fat content (Sigalas et al ’04) longer shelf life milk with lower fat content – tested (Ozan et al’07)
  68. 68. Propolis Multifunctional material anti inflammatory, antibacterial, antioxidant, antifungal, antiviral and tissue regenerative properties 10% Propolis better than milk, HBSS (Ozan et al’07)
  69. 69. Order of preference By literature PropolisPropolis HBSSHBSS Long shelf life Milk with lowLong shelf life Milk with low fat contentfat content Milk with high fat contentMilk with high fat content SalineSaline SalivaSaliva By availability Long shelf life milk with lowLong shelf life milk with low fat contentfat content Milk with high fat contentMilk with high fat content SalineSaline SalivaSaliva Contact lens solution – alternative (Sigalas et al’04)
  70. 70. Treatment objectives Avoid or minimize – inflammation 1. attachment damage 2. pulpal infection
  71. 71. PREPARARTION OF SOCKET Left undisturbedLeft undisturbed Light aspiration – remove blood clotLight aspiration – remove blood clot Alveolar bone collapse – reposition using bluntAlveolar bone collapse – reposition using blunt instrumentsinstruments Rinse of emdogainRinse of emdogain
  72. 72. Clinical Management of avulsed teeth Preparation of rootPreparation of root Extra oral time Less than 60 minutesLess than 60 minutes Greater than 60 minutesGreater than 60 minutes Closed apexClosed apex Open apexOpen apex Root development
  73. 73. Replantation of a tooth with completed root formation
  74. 74. Replanting a tooth with incomplete root formation
  75. 75. Extra oral time more than 60 minutes
  76. 76.  ‘EXARTICULATION’  Attachment damage and pulp necrosis  Why osseous replacement or replacement resorption occurs???  External inflammatory resorption after avulsion??
  77. 77. Development of inflammatory root resorption and pulp necrosis
  78. 78. Development of ankylosis
  79. 79. EMDOGAINEMDOGAIN - Increase resistance to root resorption - Stimulate PDL regeneration (Fillipi et al’01) - inhibits epithelial cell growthinhibits epithelial cell growth How does it act ??How does it act ?? Emdogain – does not prevent progressive root resorption. (Schjott at al’05)
  80. 80. Splinting  Splinting – technique and durationSplinting – technique and duration  Splinting technique – physiological toothSplinting technique – physiological tooth movementmovement  Duration – minimalDuration – minimal
  81. 81. Splinting techniques a. Rigid b. Semi rigid Types Bracket splint Composite Resin splint Acrylic or gold cap splints Orthodontic bands + arch bar splints Composite – wire splint / bonded metal wire splint Titanium trauma splint (TTS)
  82. 82. TTS required reduced chair side time – application and removal (VonArx et al’01) TTS and composite wire splint – less gingival irritation, well tolerated (Fillipi et al’02) TTS and composite wire splint – allowed physiological mobility
  83. 83.  Duration of splinting Root fracture – 2 to 4 weeks (2 – 4 months) Avulsion – 7 to 10 days Avulsion with alveolar fracture – 4 to 8 weeks Lateral luxation – 3 to 4 weeks Extrusive luxation – 4 to 8 weeks Sub luxation – 2 to 3 weeks (optional) concussion – 1 to 2 weeks (optional)
  84. 84. Adjunctive therapy  Systemic and topical antibiotic application  Tetracycline – affects osteoclast motility + reduction of collagenase effectiveness (Sae-Lim et al’98)  Systemic pencillin  Chlorhexidine rinses  Tetanus booster – within 48 hours
  85. 85. Various factors influence the outcome of teeth that had undergone trauma. Correct diagnosis, quality and timeliness of initial and long term treatment can improve the prognosis of the traumatized teeth. Conclusion
  86. 86. REFERENCES - Essentials of traumatic injuries to the teeth J.O.Anderasen and F.M. Anderasen -Treatment planning for traumatized teeth - Mitsuhiro tsukiboshi -cohen’s pathways of the pulp tenth edition
  87. 87. - Ingle’s –Endodontics 6th edition - Storage Media For Avulsed Teeth: A Literature Review Brazilian Dental Journal (2013) 24(5): 437-445 - Transport media for avulsed teeth: A review Aust Endod J 2012; 38: 129–136
  88. 88. - A proposal for classification of tooth fractures based on treatment need Journal of Oral Science, Vol. 52, No. 4, 517-529, 2010 Assessment of pulp vitality: a review International Journal of Paediatric Dentistry 2009; 19: 3–15 STUDY OF STORAGE MEDIA FOR AVULSED TEETH Brazilian Journal of Dental Traumatology (2009) 1(2): 69-76
  89. 89. Fracture resistance of tooth fragment reattachment: effects of different preparation techniques and adhesive materials Dental Traumatology 2010; 26: 9–15;

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