contents are concussion, horizontal and vertical displacements

1. Prepared by: Dr Krishna Meghana. E
Guided by - Dr Jacob G daniel
National institute of clinical endodontics

2.  Introduction to displaced tooth
 History and examination
 Types of displacement injuries
 Concussion – diagnosis, management
 Horizontal displacements- a.minor b.major
 diagnosis & management.
 Vertical displacement – intrusion and extrusion,
 diagnosis & management
 Importance of Follow up in Management
 Sequelae of displaced tooth

3.  Biologically two features are common for
all displaced teeth, irrespective of
direction of displacement
 1.The main vascular and neural bundle
entering into the pulp cavity through the
apical foramen is either stretched or
snapped during the displacement.
 2.The PDL attachment either damaged or
completely torn all around the tooth.

4.  Knowledge of these two features are
important for proper management and
follow up of prognosis
 The physiology of both internal and
external structures of the tooth being
deranged, biologic reaction following
treatment becomes unpredictable

5.  Case History
 Chief complaint
 History of present illness
 Medical History

6.  Clinical Examination
 External Examination
 Soft Tissues
 Facial Skeleton
 Teeth and Supporting Structures
 Occlusion

7.  Periapical
 Occlusal
 Panoramic

8.  Injuries which do not cause clinically
discernible displacements are categorized as
concussion injuries
 Based on the direction of dislocation
 A. Horizontal displacements – buccal,
lingual, mesial & distal
 B. Vertical displacements
 1. Intrusion
 2. Extrusion

9.  An injury to the tooth-supporting
structures with slight mobility or
without increased mobility of the tooth,
but with pain to percussion.

10.  tooth is slight mobile
but not displaced
 periodontal ligament (PDL)
absorbs injury and becomes
inflamed
 leaves tooth tender to biting
pressure and percussion
CONCUSSION

11.  Visual sign:
not displaced
 Percussion test:
tender to touch or tapping
 Mobility test:
no increased mobility
CONCUSSION

12.  Pulp Test:
 are unreliable
 the future vitality of the pulp will depend on
the severity of the injury to the vascular
bundle at the apical foramen
 lack of response to the test indicates an
increased risk of later pulp necrosis
CONCUSSION

13.  Radiographic findings:
no radiographic abnormalities
 Radiographs:
occlusal, periapical, lateral view from mesial ,
distal aspect of suspected tooth should be taken
CONCUSSION

14.  Treatment Objectives:
 usually there is no immediate treatment
except relieving the tooth from occlusion
 Treatment:
 frequent follow up at 1,3,6,12 month intervals
is mandatory
 monitor pulpal condition for at least 1 year
CONCUSSION

15.  Patient Instructions:
soft food for 1 week
brush with soft bristle
rinse with chlorhexidine
0.1% to prevent plaque
accumulation
CONCUSSION

16. Horizontal displacements may be in
buccal, lingual ,mesial or Distal direction
For the management purpose horizontal
displacement divided into
A. Minor displacement
B. Major displacement

17. Clinically and radiographically the
tooth should be checked for any
accompanying root or alveolar
fracture

18. It requires only repositioning and splinting of tooth
during the emergency treatment
Splint can be removed after week or two
 Root canal treatment need not be initiated immediately.

19. Follow up is mandatory
As up to half of all such teeth may lose
vitality of the pulp.
Tooth be carefully observed for either
signs of non vital tooth or external root
resorption

20. At the first evidence of either of the two, the
pulp canal be cleaned and temporarily filled with
calcium hydroxide paste or powder
 This chemical which has a PH of around 11.4 is
believed to prevent external resorption by
diffusing through the dentinal tubule and
reaching the external surface of the root

21. Major displacements in which the clinician believes that
the blood supply to the tooth must have got cut off
•root canal treatment should be instituted
 It is recommended that the tooth be repositioned and
splinted in the emergency appointments and after a week
RCT can be done
This 1 week delay is in order to allow for the healing of the
PDL
Instituting RCT immediately could apply more stress on
the already torn PDL Increasing the chance for the external
resorption

22. Special care should be shown if patient reports
for treatment after blood clot is fully formed In that
part of socket left by the displaced tooth
Although it may be tempting, clinician must
desist from repositioning the tooth by applying
pressure against the clot

23. Application of such a pressure can adversely
affect the status of the torn PDL on the surface of
the root and increase the chance for external
resorption
The tooth either be allowed to heal in the
displaced position and subsequently brought to
the desired (original) position using orthodontic
means or the tooth be extracted and the socket
cleansed off of the clot using saline & treatment
proceeded as that for an avulsed tooth

24. Vertical displacements may be either
A.INTRUSION
B.EXTRUSION
(with reference to
Alveolar crest)

25. The behavior of extruded tooth is similar
to that of horizontally displaced tooth
except for the higher chance of necrosis
of the pulp and requirement for two
month splinting

27. Intruded tooth behave in a more complicated manner &
are managed as follows
Intruded tooth should always be decided for root canal
treatment as almost always the pulp of an intruded tooth
dies
One week after the repositioning and splinting
procedure root canal may be opened and filled with
calcium hydroxide to reduce the possibility of occurrence
of external resorption

28. Ankylosis is known to occur subsequent to
intrusion
Turley et al have demonstrated in animal studies
that Ankylosis might get initiated within a week time
following Intrusive injuries

29. It has been recommended that the tooth should
be preferred ,to be moved to its original position
using orthodontic means rather than forceps in a
single attempt as complications are less
following such relatively slow repositioning

30. In cases of teeth with incompletely formed apex there
is no need for immediate iatrogenic intervention for
repositioning of tooth
The tooth can be kept under close observation as
there is chance for the re-eruption of the tooth and also
it has better chance for survival of the pulp
However frequent & careful monitoring of immature
permanent tooth is important as it has been reported
that resorption once sets in, progresses rapidly in these
teeth

31.  Soft food for 1 week.
 Good healing following an injury to the teeth and
oral tissues depends, in part, on good oral
hygiene.
 Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to prevent
accumulation of plaque and debris.
 FOLLOW-UP
after 2 weeks.
Splint removal and follow-up after 4 weeks,
6-8 weeks, 6 months, 1 year and yearly for 5 years

32. Follow up of the tooth for knowing
1.Signs of necrosis of the pulp forms
2.External root resorption
3.Healing of PDL & BONE
4.Ankylosis

33.  Yellow discoloration
 Grey discoloration
 Resorption – 5 to 15%
 Incomplete root formation
 Primary teeth – pulp space obliteration
by calcification

34. Thank you