1. The Traumatic
Dental Injuries
The Role of Endodontics After
Dental Traumatic Injuries
Dr. Hadil Abdallah Altilbani
BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine .
%50 of facial
trauma occurs in
mouth and teeth
2. I- Causes of traumatic injuries
❑ • Automobile injury
❑ • Battered child
❑ • Child abuse
❑ • Drug abuse
❑ • Epilepsy
❑ • Fall from height
❑ • Sports related injuries
3. • Age distribution
• Traumatic injuries can occur at any age.
• Most commonly at the age of 2 to 5 years ” children are learning to walk”.
• Another age is 7 to 12 years “ increased sports activity, and learning bicycle,
etc
II- Incidence of traumatic
injuries.
• Sex
• Prior to 1960s boys to girls ratio in traumatic injuries used to be 3:1 but
• becauseof more involvement of females in sports, it has reduced to 2:1.
4. • Site
• Maxillary central incisor is most commonly affected
(80%) tooth followed by maxillary lateral incisor and mandibular
incisors
IV -Predisposing factures .
• Mentally handicapped patients and those with neurological disorders.
• Class II div 1 malocclusion.
• Destructive defects of teeth ..Enamel hypoplasia.
• Contact of sports ..act of violence.
5. ❑ The outcome of dental injury is influenced by patient age, severity, and treatment offered.
❑ In most of the cases,
Immature permanent teeth
with injuries have better prognosis than mature teeth with same injuries.
❑ Follow-up evaluation is also important, e.g. if root resorption is detected early, it can be arrested.
III- Prognosis of traumatic injuries.
6. 1- Soft Tissue Injuries:
A. Lacerations
B. Contusion
C. Abrasions
2- Tooth Fractures:
A. Enamel fracture
I. Complete..chipping
II. Incomplete.. cracks
B- Crown-fractures-uncomplicated
(no pulp exposure)
c. Crown-fractures-complicated
(with pulp exposure)
d. Crown-root fractures
I. Uncomplicated crown—root fracture
II. Complicated crown—root fracture without pulp exposure
e. Root fractures
3- Luxation Injuries
A. concussion
B. Subluxation
C. Extrusive luxation
D. Lateral luxation
E. Intrusive luxation
F. Avulsion
4- Facial Skeletal Injuries
A. Fracture of alveolar process of mandible
B. Fracture of alveolar process of maxilla
C. Fracture of body of mandible
D. Fracture of body of maxilla
The currently recommended classification is one based on the WHO and modified by JO Andreasen and FM Andreasen.
This classification is used by International Association of Dental Traumatology.
IV- Classification of traumatic injuries.
7. I- CASE HISTORY
1.Chief Complaint
2.Medical History
3.Dental history
V- diagnosis
Of
Traumatic injuries.
8. Chief Complaint
Patient should be asked for pain and other symptoms (bleeding) .
These should be listed in order of importance to the patient .
”PATIENTS OWN WORDS”
Medical History
✓ • Allergies, as reaction to medication
✓ • Systemic disorders like bleeding problems, diabetes, epilepsy, etc.
✓ • Any current medication patient is taking
✓ • Condition of tetanus immunization— In case of contaminated wound, booster dose should be given if more than 5
years have elapsed since last dose.
✓ But for clean wounds, no booster dose needed, if time elapsed between last dose is less than 10 years.
✓ Neurological assessment : signs of dizziness or nausea and vomiting
May indicate brain concussion ………..further investigations
9. Chief Complaint
Patient should be asked for pain and other symptoms (bleeding) .
These should be listed in order of importance to the patient .
”PATIENTS OWN WORDS”
Medical History
✓ • Allergies, as reaction to medication
✓ • Systemic disorders like bleeding problems, diabetes, epilepsy, etc......antibiotic prophylaxis.
✓ • Any current medication patient is taking
✓ • Condition of tetanus immunization— In case of contaminated wound, booster dose should be given if more than 5
years have elapsed since last dose.
✓ But for clean wounds, no booster dose needed, if time elapsed between last dose is less than 10 years.
✓ Neurological assessment : signs of dizziness or nausea and vomiting
May indicate brain concussion ………..further investigations
10.
11. ❖Past dental history
• To reveal any special dental procedures
• To determine the pts cooperation level, attitude.
• To explore the incidence of any previous traumatic injury.
❖History of Present Illness
(When, How, Where)
of the trauma are significant..
Dental history
12. How
• Direct trauma
• Indirect trauma
When
• The Shorter the time between trauma and the trea
tment the better the
Prognosis
“predict the condition of the pulp”
Where
• Location of the Accident is important for
prognosis and ttt plan.
• ‘Street accident ‘
Vaccine
13. II- clinical examination:
✓Extraoral Examination
✓Intraoral Examination
V- diagnosis
Of
Traumatic injuries.
Extraoral Examination
✓ Mental status, orientation, consciousness level and vital signs.
✓ General condition
✓ Head and neck findings “nasal hemorrhage, neck pain”
✓ Facial fractures, facial asymmetries.
✓ Hemorrhage.
✓ Impacted foreign body.
✓ TMJ deviations.
✓ Soft tissue examination.
Intraoral Examination
A. Soft Tissue examination:
➢ Lacerations of lips and intraoral soft tissues must be radiographically examined
for presence of any tooth fragments and/or other foreign bodies.
➢ Hematomas“ hematoma of the floor of the mouth indicate mandibular fracture”
➢ Penetrating wounds ..cut wounds.
14.
15.
16.
17. B- Hard Tissue examination:
” Teeth and its supporting structures”
• Check the occlusion:
Abnormalities in occlusion can indicate fracture of jaws or alveolar process.
• Several teeth out of alignment:
indicate fracture of mandible or maxillary basal bone.
• Check mobility in all the directions.
If adjacent teeth move along with the tooth being tested, suspect the alveolar fracture.
In crown fracture, the crown is mobile but tooth will remain in position
18. • Looseness of individual teeth , displacement from the socket.
• Tooth displacement:
➢Extrusion & Intrusion.
➢Lateral luxation.
➢Avulsion.
• Tooth discoloration
• Crowns fracture
o Mobility of crown &mobility of tooth
o Each cusp and incisal edge must be percussed with mirror handle to check incomplete fracture.
o pulp involvement
• Root fracture can be felt by placing finger on mucosa over the tooth and moving the crown.
19.
20. III- Condition of Pulp
• The sensitivity is not reliable in traumatized teeth, because THE TOOTH is in
state of shock
“THE EDEMA IS PRESSING ON THE NERVE FIBERS PREVENTING THE TRANSMISSION OF IMPULSES “.
• Teeth which give a +ve response at initial exam cant be assumed to
be healthy and will continue to give +ve response.
• Teeth which give a -ve response at initial exam cant be assumed to
be necrotic and will continue to give - ve response.
Various studies have shown that pulp may take as long
as Nine months for normal blood flow to return to the coronal pulp of the traumatic tooth.
V- Diagnosis of traumatic injuries.
21. They are performed at the time of initial examination and recorded to
establish a baseline reference for comparison with subsequent repeated tests in future
If the sensitivity are not reliable , then why we use it ??????????
More recently, the use of a pulse-oximeter was recommended to
evaluate the pulpal status of a recently traumatized tooth.
22. 1. Occlusal view
2. Lateral view from mesial or distal aspect of the tooth
3. 90° horizontal angle with central beam through the tooth
It should be done in the area of suspected injury and in soft tissue injury before suturing.
An occlusal exposure of anterior region may show lateral luxations, root fractures or alveolar region.
Periapical radiographs can assess the crown as well as cervical root.
IV- Radiographic Examination
Three angulations recommended by International Association of Dental
Traumatology (IADT) are:
23. V- Clinical Photographs
➢ Clinical photographs are helpful for establishing clinical record for monitoring the patient
and treatment progress.
➢ They also help in being as additional means of documenting injuries for
➢ Legal purposes and insurance.
24.
25. The role of endodontics after
Traumatic dental injuries.
Theraputic aim is: to Maintain
the Pulp Vitality
26. 1- Soft Tissue Injuries:
A. Lacerations
B. Contusion
C. Abrasions
2- Tooth Fractures:
A. Enamel fracture
I. Complete..chipping
II. Incomplete.. cracks
B- Crown-fractures-uncomplicated
(no pulp exposure)
c. Crown-fractures-complicated
(with pulp exposure)
d. Crown-root fractures
I. Uncomplicated crown—root fracture
II. Complicated crown—root fracture without pulp exposure
e. Root fractures
3- Luxation Injuries
A. concussion
B. Subluxation
C. Extrusive luxation
D. Lateral luxation
E. Intrusive luxation
F. Avulsion
4- Facial Skeletal Injuries
A. Fracture of alveolar process of mandible
B. Fracture of alveolar process of maxilla
C. Fracture of body of mandible
D. Fracture of body of maxilla
The currently recommended classification is one based on the WHO and modified by JO Andreasen and FM
Andreasen.
This classification is used by International Association of Dental Traumatology.
27. 1- CROWN INFRACTION
(Craze lines)
Def: is an incomplete fracture or crack of
enamel without loss of tooth structure.
Biological Consequences
• Fracture lines ……weak points ……
.bacteria & their products can travel to pulp
…..little possibility of necrosis.
• A 5 years Follow up period is the important endodontic prevention measure
❑ Diagnosis
✓ fiberoptic light source, resin curing light, indirect light or by transillumination
✓ dyes.
❑ Treatment
Just follow up:
• Regular pulp testing should be done and recorded for future reference.
• Follow-up of patient at 3, 6 and 12 months
interval is done, but if rough edges are present:
• Smoothening of rough edges .
• Repairing by composite if needed.
Crown-fractures
28. ❑ Prognosis
Prognosis is good for infraction cases
❑ Sequel:
1. Pulp resolution.
2. Pulp necrosis
3. Internal resorption.
4. Calcific metamorphosis.
29. Def:
fracture involving enamel or enamel and dentin but pulp is not involved.
➢ Incidence:
Most frequent dental injury.( 1/3 to ½ of dental trauma.)
➢ Biological Consequences
• if dentin is exposed, a direct pathway for irritants through dentinal tubules to the pulp .
• Pulp may remain normal or may get chronically inflamed depending upon proximity of fracture to the pulp, size of dentinal tubul
es and time of the treatment provided.
➢ Diagnosis
sensitivity to air, heat and cold liquids .
➢ Treatment
• In case of enamel fractures, selective grinding of incisal edge.
• For esthetic reasons, composite restorations can be placed.
• Calcium hydroxide placed over exposed dentin closure of dentinal tubules.
If the fracture fragment of crown is available, reattach it It requires acid etching and application of bonding agent.
After removal of any soft tissue remnants, fractured site is disinfected.
➢ Prognosis
Patient should be recalled and sensitivity testing is done at the regular interval of 3, 6 and 12 months.
Prognosis is good.
2- Uncomplicated Crown Fracture
32. ❖ Def :Crown fracture involving enamel, dentin and pulp
❖ Incidence
It occurs in 0.9 to 13 % of all the dental injuries.
❖ Biological Consequences
• the first reaction after the injury (first 24hrs) is
hemorrhage and local inflammation
which doesn’t extend beyond 2mm into the pulp.
• After 48 hrs, there's greater chances of :
✓ Direct bacterial contamination.
✓ Progression of inflammation apically.
✓ Pulp necrosis.
3- COMPLICATED CROWN FRACTURE
33. ✓ Diagnosis
It is made by clinically evaluating the fracture and by pulp testing and taking radiographs
✓ Treatment plan and prognosis:
It depends on :
1. Stage of root maturation Maintaining the pulp vitality is main
concern at least until the root continue to develop.
1. The time between the trauma and the treatment
2. Concomitant periodontal injury
3. The restorative treatment plane: Pulpotomy rather than pulp
capping in case of complex restorations
35. ▣ Def. : fracture involves
enamel, dentin and cementum with or without the involveme
nt of pulp.
• It is considered as
more complex type of injury
because of its greater severity and involvement of the pulp.
• It’s a Periodontal rather than
an endodontic challenge.
Most of these fractures occur as the result of a
Horizontal impact.
4- CROWN ROOT FRACTURE
36. ▣Biological Consequences
• Identical to complicated or uncomplicated fracture depending upon the pulp involvement.
• In addition to these, periodontal complications are also present because of
encroachment of the attachment apparatus.
▣Diagnosis
➢ Coronal fragment is usually mobile.
➢ Patient may complain of pain on mastication due to
movement of the coronal portion.
➢ plaque accumulation in the line of fracture.
➢ Patient may complain of sensitivity to hot and cold.
➢ Radiographs are taken at different angles
➢ Indirect light and transillumination.
37. ▣ Treatment
Objectives of treating crown root fracture :
• Restoration of the coronal portion as complicated or uncomplicated crown fracture.
• Allow subgingival portion of the fracture to heal.
Depending upon extent of fracture following should be considered while management of
crown root fracture:
Supragingival
Treatment with
restoration Subgingival
o Crown lengthening
1. Gingivectomy
2. Alveloplasty
3. Osteoplasty
o Orhodontic extrusion
Infracrestal
extraction
38. Crown-root fracture without pulp
involvement
can be treated by
removing the coronal segment
and
restoring it with composite
39.
40.
41.
42. When root portion is long enough to Accommodate post
supported crown,
remove the coronal segment, extrude root fragment and
perform endodontic therapy
