Traumatic injury to tooth

1. TRAUMATIC INJURIES OF
TOOTH
Presented by:
Dr Ashwan S. Uke
IIIrd MDS

2. CONTENTS
 INTRODUCTION
 TERMINOLOGIES
 CLASSIFICATION OF INJURIES
 AIM OF THE TREATMENT
 SPECIAL CONSIDERATIONS
 DIAGNOSIS
 INFARCTION
 ENAMEL FRACTURE
 UNCOMPLICATED CROWN FRACTURE
 CROWN ROOT FRACTURE WITHOUT PULP
EXPOSURE

3.  CROWN ROOT FRACTURE WITH PULP
EXPOSURE
 ROOT FRACTURE
 ALVEOLAR FRACTURE
 CONCUSSSION
 SUBLUXATION
 EXTRUSIVE LUXATION
 INTRUSIVE LUXATION
 AVULSOIN
 VERTICL ROOT FRACTURE
 CONCLUSION
 REFERENCES

4. INTRODUCTION
 Comprise 5% of all injuries for which people seek dental
treatment.
 Traumatic dental injuries occur with great frequency in
preschool, school-age children, and young adults.
 Boys are affected twice than girls.
 Primarily in anterior region of mouth
Petersson EE, Andersson L, Sorensen S. Traumatic oral vs nonoral injuries.
Swed Dent J 1997;21:55–68.

5.  Affecting maxillary jaw more than the
mandibular.
 25% of all school children and 33% of adults
have experienced trauma to the permanent
dentition.
 Luxation injuries : most common in the primary
dentition
 Crown fractures : for the permanent dentition

6.  Common causes of traumatic injuries to the
teeth include the following-
1) Sports accident
2) Automobile accidents
3) Fights and assaults
4) Domestic violence
5) Inappropriate use of teeth
6) Biting hard items

7. The 3 key predisposing factors for these kinds of
injuries are-
• Increased overjet
• Proclination of maxillary anterior teeth
• Incomplete closure of lips
Andreasen JO, Andreasen FM, Andersson L. Textbook and
color atlas of traumatic injuries to the teeth, 4th edn. Oxford,UK: Wiley-Blackwell; 2007.

8. TERMINOLOGIES OF TOOTH FRACTURE-
 Craze lines
 Cuspal fracture
 Cracked teeth
 Split tooth
 Vertical Root Fracture

9. CLASSIFICATION OF DENTOFACIAL
INJURIES
 By International Association of Dental
Traumatology is based on the WHO classification
modified by JO Andreasen and FM Andreasen.
 Revised in the year 2012

10. A. INJURIES TO THE HARD DENTAL TISSUES
AND PULP.
1. Crown infarction
N873.60.
2. Uncomplicated crown
fracture. (N 873.61)
3. Complicated crown
fracture N873.62.
4. Uncomplicated crown
root fracture.
N873.64.
5. Complicated crown
root fracture
N873.64.
6. Root fracture
N873.63

11. B. INJURIES TO THE PERIODONTAL TISSUES.
1. Concussion N873.66.
2. Subluxation N873.66.
3. Intrusive Luxation (central dislocation)
N873.67
4. Extrusive luxation (peripheral
dislocation partial avulsion) N873.67.
5. Lateral Luxation N873.67.
6. Exarticulation (complete avulsion)
N873.68.

12. C. INJURIES OF THE SUPPORTING BONE
1.
Comminution
of alveolar
socket
(Mandible
N802.20,
Maxilla
802.40)
2. Fracture of
the alveolar
socket wall
(Mandible
N802.20,
Maxilla
N802.40).
3. Fracture of
the alveolar
process
(Mandible
N802.20,
Maxilla
N802.40).
4. Fracture of
the Mandible
and Maxilla
(Mandible
N802.21).
Maxilla
N802.42).

13. D. INJURIES TO GINGIVA OR ORAL MUCOSA.
1. Laceration
of gingiva or
oral mucosa
N873.69.
2. Contusion
of gingiva or
oral mucosa N
902.00:
3. Abrasion of
gingiva or oral
mucosa N
910.00:
Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth, 3rd
edition, Copenhagen Munksgaard, 1994.

14. CLASSIFICATION BY WORLD HEALTH
ORGANIZATION IN ITS APPLICATION OF
INTERNATIONAL DISEASES OF DENTISTRY AND
STOMATOLOGY (1994)
THE CODE NUMBER IS ACCORDING TO THE
INTERNATIONAL CLASSIFICATION OF DISEASES
TO DENTISTRY (1992)

15. A) INJURIES TO THE DENTAL HARD TISSUES AND PULP
1) Enamel infraction
(N 502.50)
.
2) Enamel fracture
(uncomplicated crown
fracture) (N 502.50)
.
3) Enamel- Dentin Fracture
(Uncomplicated
Crown fracture)
(N 502.51)
4) Complicated crown fracture
(N 502.52)

16. 5) Uncomplicated Crown-
Root Fracture
(N502.54)
6) Complicated Crown-Root
fracture (N 502.54)
7) Root Fracture (N 502.53)

17. B) INJURIES TO PERIODONTAL TISSUES
1) Concussion
(N 503.20)
2) Subluxation (Loosening)
(N 503.20)
3) Extrusive Luxation(Peripheral Dislocation,
Peripheral Avulsion)
(N 503.20)
4) Lateral Luxation
(N 503.20)
5) Intrusive Luxation (Central dislocation)
(N 503.21)
6) Avulsion (Exarticulation)
(N 503.22)

18. C) INJURIES TO THE SUPPORTING BONE
 (N 502.60) Communution of the mandibular
 (N 502.40) Maxillary Alveolar Socket
 (N 502.60) Fracture of the Mandibular
 (N 502.40) Maxillary Alveolar Socket Wall
 (N 502.60) Fracture of the Mandibular
 (N 502.40) Maxillary Alveolar process
 (N 502.61) Fracture of Mandible
 (N 502.42) Fracture of Maxilla

19. D) INJURIES TO GINGIVA OR ORAL MUCOSA
1) Laceration of gingival or oral mucosa
(S01.50)
2) Contusion of gingiva or oral mucosa
(S00.50)
3) Abrasion of gingival or oral mucosa
(S 00.50)
Pagadala S, Tadikonda DC. An overview of classification of dental trauma. IAIM, 2015; 2(9): 157-
164.

20. INGLE’S CLASSIFICATION
Soft tissue injury
 Laceration
 Abrasion
 Contusion
Luxation injury
 Concussion
 Intrusive luxation
 Lateral luxation
 Extrusive luxation
 Avulsion
Tooth fractures
 Enamel fractures
 Uncomplicated crown
fractures
 Complicated crown
fractures
 Crown root fractures
 Root fractures
Facial skeletal injury
 Alveolar process
 Body of mandible
 TMJ

21. ELLIS AND DAVEY’S
CLASSIFICATION (1960)
 Class I : simple fracture of the crown involving enamel
 Class II : extensive fracture of the crown, with considerable
amount of dentin involved but no pulp exposure
 Class III : extensive fracture of the crown, with considerable
amount of dentin involved, with pulp exposure
 Class IV : traumatized tooth becomes non vital (with or without
loss of crown structures)
 Class V : tooth lost due to trauma
 Class VI : fracture of root with or without crown or root structure
 Class VII : displacement of the tooth without crown or root
fracture
 Class VIII : fracture of crown en masse
 Class IX : fracture of deciduous teeth

22. CLASSIFICATION BY LEE-KNIGHT, ET AL. (1989)
Tooth infraction
Chipped tooth
Fractured tooth
Lacerated lip
Traumatized TMJ

23. AIM OF TREATMENT
Pulp vitality
Esthetic
Contour
Function
and
Occlusion

24. SPECIAL CONSIDERATIONS
Special
considerations
for trauma to
primary teeth
Patient and
parent
instructions
Immature
versus Mature
Permanent
Teeth
Avulsion of
Permanent
Teeth

25. DIAGNOSIS
History, Visual and clinical
examination
Intraoral and extraoral
radiographs
Thermal and Electric pulp
test
Removal of fragments
CBCT

26.  Ultrasound Doppler flowmetry seems to be more
accurate than electric pulp testing in assessing
pulp vitality of traumatized teeth.
 Hasty decisions to perform root canal treatment
could be reduced by applying Ultrasound Doppler
flowmetry.
J ENDODON 2018; 44(3):379-383

27. INFARCTION
 An incomplete fracture (crack) of the enamel
without loss of tooth structure.
 Pulpal complications are considered to be rare
(0–3.5%) unless there is an associated luxation
injury.

28. CLINICAL FINDINGS :
 Visual signs : fracture line on tooth surface
(using dyes and transillumination)
 Percussion test : Non-tender. If tenderness is
observed evaluate the tooth for a possible
luxation injury or a root fracture
 Mobility test : Normal
 Sensibility pulp test : Usually positive. It is
important in assessing future risk of healing
complications. A lack of response to the test
at the initial examination indicates an
increased risk of later pulp necrosis.

29. RADIOGRAPHIC FINDINGS :
 No radiographic abnormalities.
 Radiographs recommended : A periapical view.
Additional radiographs are indicated if other signs
and symptoms are present.

30. TREATMENT :
 Etching and sealing with resin to prevent
discoloration of infarction lines
 Otherwise, no treatment is necessary.
Follow-up-
 Meticulous follow-up for 5 years
 Endodontic intervention may be required
(If reaction to sensitivity tests changes, or signs of apical
periodontitis develops or the root appears to have
stopped development or is obliterating)

31. ENAMEL FRACTURE
 A fracture confined to the enamel with loss of tooth
structure.
 Pulpal complications rarely occur in teeth with
enamel fractures only (0–1%), unless there is an
associated luxation injury (8.5%)

32. CLINICAL FINDINGS :
 Visual signs : loss of enamel. Dentin
not exposed
 Percussion test : Not tender. If
tenderness is observed evaluate the
tooth for a possible luxation or root
fracture injury.
 Mobility test : Normal

33. Sensibility pulp test :
o Usually positive.
o The test may be negative initially indicating transient pulpal
damage.
o Monitor pulpal response until a definitive pulpal diagnosis can
be made.
The test is important in assessing risk of future healing complications.
A lack of response at the initial examination indicates an increased
risk of later pulp necrosis.

34. RADIOGRAPHIC FINDINGS :
 The enamel loss is visible.
 Radiographs recommended :
Periapical, occlusal and
eccentric exposures to rule out
the possible presence of a root
fracture or a luxation injury.

35. TREATMENT :
Contouring or restoration with composite resin
 In case of primary teeth, smoothen the sharp edges
of the tooth
 Follow up : Clinical and radiographic control at 6-8
weeks and 1 year.

36. UNCOMPLICATED CROWN FRACTURE
 A fracture confined to enamel and dentin with loss of
tooth structure, but not involving the pulp.

37. CLINICAL FINDINGS :
 Visual signs : loss of enamel and dentin. No
pulp exposure.
 Percussion test : Not tender. If tenderness is
observed evaluate for possible luxation or root
fracture injury.
 Mobility test : Normal
 Sensibility pulp test : Usually positive. The test
may be negative initially indicating transient
pulpal damage. Monitor pulpal response until a
definitive pulpal diagnosis can be made.

38. RADIOGRAPHIC FINDINGS :
 The enamel-dentin loss is visible.
 Radiographs recommended :
Periapical, occlusal and eccentric
exposure to rule out displacement or
the possible presence of a root
fracture.
 Radiograph of lip or cheek lacerations
to search for tooth fragments or
foreign material.

39. TREATMENT :
 If a tooth fragment is available, it can be bonded to the
tooth.
 Otherwise, perform a provisional treatment by
covering the exposed dentin with glass ionomer or a
more permanent restoration using a bonding agent and
composite resin, or other accepted dental restorative
materials.

40.  If the exposed dentin is within 0.5 mm of the pulp (pink,
no bleeding), place calcium hydroxide base and cover with
a material such as a glass ionomer
Follow up : Clinical and radiographic control at 6-8 weeks
and 1 year
Prognosis-good

41. COMPLICATED CROWN FRACTURE
 A fracture involving enamel and dentin with loss of
tooth structure and exposure of the pulp.
 0.9 to 13% of all dental injuries

42. CLINICAL FINDINGS :
 Visual signs : loss of enamel and dentin
and exposed pulp tissue.
 Percussion test : Not tender. If
tenderness is observed evaluate the
tooth for luxation or root fracture injury.
 Mobility test : Normal
 Sensibility test : Usually positive. The
test is important in assessing risk of
future healing complications. A lack of
response at the initial examination
indicates an increased risk of later pulp
necrosis.

43. RADIOGRAPHIC FINDINGS :
 The loss of tooth substance is visible.
 Radiographs recommended :
Periapical, occlusal and eccentric
exposure to rule out displacement or
the possible presence of a luxation or
a root fracture.
Radiograph of lip or cheek lacerations
to search for tooth fragments or
foreign material.

44. TREATMENT METHODS
 VITAL PULP THERAPY:
 PULP CAPPING(fresh exposure <24 hr)
 PARTIAL PULPOTOMY
 FULL PULPOTOMY
 NON VITAL PULP THERAPY:
 APEXIFICATION (for immmature root)
 PULPECTOMY (for mature root)

45. CROWN-ROOT FRACTURE WITHOUT PULP
EXPOSURE
 A fracture involving enamel, dentin and cementum with
loss of tooth structure, but not exposing the pulp.

46. CLINICAL FINDINGS :
 Visual signs : Crown fracture extending
below gingival margin.
 Percussion test : Tender.
 Mobility test : Coronal fragment mobile.
 Sensibility pulp test : Usually positive for
apical fragment; not reliable in case of
primary teeth

47. RADIOGRAPHIC FINDINGS :
 Apical extension of fracture
usually not visible.
 Radiographs recommended :
Periapical, occlusal and eccentric
exposures to detect fracture lines
in the root. A cone beam
exposure can reveal the whole
fracture extension.

48. TREATMENT : PERMANENT TEETH
Emergency treatment
temporary stabilization of the loose segment to adjacent teeth
Non-emergency treatment alternatives
1. Fragment removal only
Removal of the coronal crown–root fragment and subsequent
restoration

49. 2. Fragment removal and gingivectomy
Removal of the coronal crown–root segment with
subsequent endodontic treatment, gingivectomy and
restoration with a post-retained crown
3. Orthodontic extrusion of apical fragment
Removal of the coronal segment with subsequent
endodontic treatment and orthodontic extrusion of the
remaining root with sufficient length after extrusion to support a
post-retained crown

50. 4. Surgical extrusion
Removal of the mobile fractured fragment with
subsequent surgical repositioning of the root in a more
coronal position
5. Extraction

51. CROWN-ROOT FRACTURE WITH PULP
EXPOSURE
 A fracture involving enamel, dentin, and cementum
with loss of tooth structure, and exposure of the pulp.

52. CLINICAL FINDINGS :
 Visual signs : Crown fracture
extending below gingival margin.
 Percussion test : Tender.
 Mobility test : Coronal fragment
mobile.
 Sensibility test : Usually positive for
apical fragment; not reliable in
primary teeth

53. RADIOGRAPHIC FINDINGS :
 Apical extension of fracture
usually not visible.
 Radiographs recommended :
Periapical and occlusal
exposure. A cone beam
exposure can reveal the whole
fracture extension.

54. TREATMENT : PERMANENT TEETH
Emergency treatment
 Temporary stabilization of the loose segment to adjacent
teeth
 In patients with open apices, preserve pulp vitality by a
partial pulpotomy.
 In patients with mature apical development - Root canal
treatment

55. Non-Emergency Treatment Alternatives
1. Fragment removal only
2. Fragment removal and
gingivectomy
3. Orthodontic extrusion of apical
fragment
4. Surgical extrusion
5. Extraction

56. ROOT FRACTURE
 A fracture confined to the root of the tooth
involving cementum, dentin, and the pulp.
 Approx. 5% of all dental injuries
- Neurovascular supply is intact at root apex.
- Rupture of neurovascular supply at fracture line.
- Separation of PDL and exposure of root surface.

58. CLINICAL FINDINGS :
 Visual signs : coronal segment may be mobile
and in some cases displaced. Transient crown
discoloration (red or grey) may occur. Bleeding
from the gingival sulcus may be noted.
 Percussion test : tooth may be tender.
 Mobility test : coronal segment may be mobile.
 Sensibility pulp test : Sensibility testing may give
negative results initially, indicating transient or
permanent neural damage. Monitoring the
status of the pulp is recommended.
The pulp sensibility test is usually negative for
root fractures except for teeth with minor
displacements.

59. RADIOGRAPHIC FINDINGS :
 The root fracture line is usually visible. The
fracture involves the root of the tooth and is in
a horizontal or diagonal plane.
 Radiographs recommended : Periapical,
occlusal and eccentric exposures.
 An occlusal exposure is optimal for locating
root fractures in the apical and middle third.
Bisecting angle exposure or 90o degree
angulation exposure is needed to locate the
fractures in the cervical third of the root.

60. TREATMENT : PERMANENT TEETH
 Reposition, if displaced, the coronal segment of the
tooth as soon as possible
 Check position radiographically
 Stabilize the tooth with a flexible splint for 4-6 weeks.
 Monitor healing for at least 1 year to determine pulpal
status
 If pulp necrosis develops, root canal treatment of the
coronal tooth segment to the fracture line is indicated
to preserve the tooth

61. CORONAL ROOT FRACTURES
 Poor prognosis
 If adequately splinted, chances of healing similar to
midroot or apical fractures
 If fracture is at level or coronal to alveolar crest ,
extremely poor prognosis
 If reapproximation is not possible, extract coronal
fragment, and evaluate root length for restorability
 Orthodontic or surgical extrusion can be done for
restoration purpose.

62. MIDROOT AND APICAL ROOT FRACTURES
 When coronal fragment gets necrosed and apical
segment is vital
 Endodontic treatment in the coronal fragment only
unless periapical pathology is seen in apical fragment
 Long term calcium hydroxide treatment or MTA plug
is indicated.
 When hard tissue barrier forms at the apical end of
coronal fragment and periradicular healing is evident,
canal is filled.

63. When both coronal and apical fragments necrosed.
 Endodontic treatment done through fracture line
 Extremely difficult as endodontic manipulations,
medicaments and filling materials have detrimental
effect on the fracture healing.
 In more apical root fractures, necrotic apical segments
can be surgically removed if the remaining coronal
root fragment is long enough to provide adequate
support.

64. DEAN’S CLASSIFICATION OF TRAUMATIC
INJURIES TO TOOTH
Dean JA, Avery DR, Swartz ML (1986) Attachment of anterior tooth fragments. Pediatr Dent
8, 139-143.

65. CONCUSSION
 An injury to the tooth-supporting structures without
increased mobility or displacement of the tooth, but
with pain to percussion.
 Neurovascular supply is intact
 Bleeding edema in few areas
 In most areas, PDL is without damage

66. CLINICAL FINDINGS :
 Visual signs : Not displaced.
 Percussion test : Tender to touch or
tapping.
 Mobility test : No increased mobility.
 Pulp sensibility test : Usually a positive
result.
The test is important in assessing future
risk of healing complications. A lack of
response to the test indicates an
increased risk of later pulp necrosis.

67. RADIOGRAPHIC FINDINGS :
 No radiographic abnormalities, the tooth is
in-situ in its socket.
 Radiographs recommended
As a routine: Occlusal, periapical exposure
and lateral view from mesial or distal
aspect of the tooth in question. This should
be done in order to exclude displacement.

68. Treatment :
No treatment is needed
 Monitor pulpal condition for at least 1 year
 Only 3% of these teeth undergo pulp necrosis or
pulp canal calcification (2–7%). Root resorption is
not a feature of concussed teeth.

69. SUBLUXATION
 An injury to the tooth supporting structures resulting
in increased mobility, but without displacement of the
tooth. Bleeding from the gingival sulcus confirms the
diagnosis
 Neurovascular supply may get damaged
 In many areas, separation of PDL with interstitial
bleeding and edema
 Loosening of tooth

70. CLINICAL FINDINGS :
 Visual signs : Not displaced.
 Percussion test : Tender
 Mobility test : Increased
 Pulp sensibility test : Sensibility testing
may be negative initially indicating
transient pulpal damage. Monitor pulpal
response until a definitive pulpal
diagnosis can be made.

71. RADIOGRAPHIC FINDINGS :
 Usually no radiographic abnormalities.
 Radiographs recommended
As a routine: Occlusal, periapical
exposure and lateral view from the
mesial or distal aspect of the tooth.

72. Treatment :
Usually no treatment is needed; however, a
flexible splint to stabilize the tooth for
patient comfort can be used for up to 2
weeks.

73. EXTRUSIVE LUXATION
 Partial displacement of the tooth out of its socket
 The alveolar socket bone is intact in an extrusion injury.
 Severance of neurovascular supply
 Separation of PDL and exposure of root surface

74. CLINICAL FINDINGS :
 Visual signs : Appears elongated.
 Percussion test : Tender.
 Mobility test : Excessively mobile.
 Sensibility test : Usually lack of response
except for teeth with minor displacements. The
test is important in assessing risk of healing
complications. A positive result to the initial
test indicates a reduced risk of later pulp
necrosis.
In immature, not fully developed teeth, pulpal
revascularization usually occurs. In mature
teeth pulp revascularization sometimes
occurs.

75. RADIOGRAPHIC FINDINGS :
 Increased periapical ligament
space.
 Radiographs recommended
As a routine: Occlusal, periapical
exposure and view from the mesial
or distal aspect of the tooth.

76. TREATMENT :
• Reposition the tooth by gently re-inserting it into the
tooth socket
• Stabilize the tooth for 2 weeks using a flexible splint
• In mature teeth where pulp necrosis is anticipated or if
several signs and symptoms indicate that the pulp of
mature or immature teeth became necrotic, root canal
treatment is indicated

77. In primary teeth, treatment decisions are based on the
degree of displacement, mobility, root formation, and the
ability of the child to cope with the emergency situation
For minor extrusion (<3 mm) in an immature developing
tooth, careful repositioning or leaving the tooth for
spontaneous alignment can be treatment options
Extraction is the treatment of choice for severe extrusion
in a fully formed primary tooth

78. LATERAL LUXATION
 Displacement of the tooth other than axially.
Displacement is accompanied by comminution or
fracture of either the labial or the palatal/lingual alveolar
bone.
 Severance of neurovascular supply

79. CLINICAL FINDINGS:
 Visual signs : Displaced, usually in a
palatal/lingual or labial direction.
 Percussion test : Usually gives a high
metallic (ankylotic) sound.
 Mobility test : Usually immobile.
 Sensibility test : Sensibility tests will
likely give a lack of response except
for teeth with minor displacements.

80. RADIOGRAPHIC FINDINGS :
 Widened periapical ligament space
best seen on occlusal or eccentric
exposures.
 Radiographs recommended
As a routine: Occlusal, periapical
exposure and lateral view from the
mesial or distal aspect of the tooth in
question.

81. No collision with tooth bud Collision with tooth bud

82. TREATMENT : PERMANENT TEETH
o Reposition the tooth digitally or with forceps to
disengage it from its bony lock and gently reposition
it into its original location
o Stabilize the tooth for 4 weeks using a flexible
splint
o Monitor the pulpal condition
o If the pulp becomes necrotic, root canal treatment is
indicated to prevent root resorption

83. TREATMENT : PRIMARY TEETH
o If there is no occlusal interference, as is often the case in
anterior open bite, the tooth is allowed to reposition
spontaneously
o In case of minor occlusal interference, slight grinding is
indicated
o When there is more severe occlusal interference, the
tooth can be gently repositioned by combined labial and
palatal pressure after the use of local anesthesia
o In severe displacement, when the crown is dislocated in a
labial direction, extraction is the treatment of choice

84. INTRUSIVE LUXATION
 Displacement of the tooth into the
alveolar bone. This injury is
accompanied by comminution or
fracture of the alveolar socket.
 Disruption of neurovascular
supply
 Contusion of PDL and alveolar
bone
 Laceration of PDL
 Disruption of marginal gingival
seal
 Damage to permanent tooth bud

85. CLINICAL FINDINGS :
 Visual signs : The tooth is displaced
axially into the alveolar bone.
 Percussion test : Usually gives a high
metallic (ankylotic) sound.
 Mobility test : tooth is immobile.
 Sensibility test : likely give negative
response.
In immature, not fully developed teeth,
pulpal revascularization may occur.

86. RADIOGRAPHIC FINDINGS :
 The periodontal ligament space may be absent
from all or part of the root.
 The cemento-enamel junction is located more
apically in the intruded tooth than in adjacent
non-injured teeth, at times even apical to the
marginal bone level.
 Radiographs recommended
As a routine: Occlusal, periapical exposure and
lateral view from the mesial or distal aspect of the
tooth in question.
If the tooth is totally intruded a lateral exposure is
indicated to make sure the tooth has not
penetrated the nasal cavity.

87. TREATMENT :
 Teeth with complete root formation
 Allow eruption without intervention if tooth intruded
less than 3 mm. If no movement after 2–4 weeks,
reposition surgically or orthodontically before
ankylosis can develop.
 If tooth is intruded beyond 7 mm, reposition surgically

88.  The pulp will likely become necrotic in teeth
with complete root formation. Root canal therapy
using a temporary filling with calcium hydroxide is
recommended and treatment should begin 2–3
weeks after surgery
 Once an intruded tooth has been repositioned
surgically or orthodontically, stabilize with a
flexible splint.

89.  Teeth with incomplete root formation
• Allow eruption without intervention
• If no movement within 2 weeks, initiate orthodontic
repositioning
• If tooth is intruded more than 7 mm, reposition
surgically or orthodontically
 In primary teeth, if the apex is displaced toward or
through the labial bone plate, the tooth is left for
spontaneous repositioning. If the apex is displaced
into the developing tooth germ, extract.

90. AVULSION (EXARTICULATON)
 Avulsion of permanent teeth is seen in 0.5–3% of all
dental injuries.

91.  The prognosis is very much dependent on the actions taken
at the place of accident and promptly after the avulsion.
 Replantation is in most situations the treatment of choice,
but cannot always be carried out immediately.
 There are also individual situations when replantation is not
indicated (e.g., severe caries or periodontal disease, non-
cooperating patient, severe medical conditions (e.g.,
immunosuppression and severe cardiac conditions) which
must be dealt with individually.

92.  The prognosis of a replanted tooth depends on
 the viability of the periodontal ligament (PDL)
cells remaining on root surface,
 integrity of root cementum and
 minimal bacterial contamination
Directly related to –
- the extra-alveolar time,
- type of storage after avulsion and
- root surface alterations.

93. CONSEQUENCES OF TOOTH AVULSION
 If PDL remains hydrated and cell viability is maintained :
- it will repair after reimplantation
- Inflammation stimulated by damaged tissues will be
minimal
- Favourable healing with new replacement cementum
likely to occur

94. If excessive drying occurs :
-Severe inflammatory response over damaged PDL
-Slow moving cementoblasts will not cover the entire
root surface
-It is likely that in certain areas bone will attach directly
to root
-Via physiologic contouring of bone, entire root will be
replaced by bone in time (osseous replacement or
replacement resorption)

95. Pulpal necrosis :
- Always occur after avulsion
- Necrotic tissue extremely susceptible to
bacterial contamination
- If revascularization does not occur or
endodontic therapy is not carried out,
external inflammatory root resorption will
occur

96. TREATMENT GUIDELINES FOR AVULSED
PERMANENT TEETH
 Choice of treatment is related to the maturity of the
root (open or closed apex) and the condition of the
periodontal ligament cells.
 The condition of the cells is depending on the storage
medium and the time out of the mouth, especially the
dry time is critical for survival of the cells.
 After a dry time of 60 min or more, all periodontal
ligament (PDL) cells are nonviable.
 Every effort must be made to replant teeth within first
15 to 20 min

97. FIRST AID FOR AVULSED TEETH AT THE PLACE OF
ACCIDENT :
 If a tooth is avulsed, make sure it is a permanent tooth
(primary teeth should not be replanted).
 Keep the patient calm.
 Find the tooth and pick it up by the crown (the white
part). Avoid touching the root.
 If the tooth is dirty, wash it briefly (max 10 s) under cold
running water and reposition it.
 Try to encourage the patient/guardian to replant the
tooth.
 Once the tooth is back in place, bite on a handkerchief to
hold it in position.

98.  If this is not possible, or for other reasons when
replantation of the avulsed tooth is not possible
(e.g., an unconscious patient), place the tooth in a
glass of milk or another suitable storage medium
and bring with the patient to the emergency clinic.
 The tooth can also be transported in the mouth,
keeping it inside the lip or cheek if the patient is
conscious.
 If the patient is very young, he/she could swallow
the tooth – therefore it is advisable to get the
patient to spit in a container and place the tooth in
it.

99.  Avoid storage in water.
 If there is access at the place of accident to special
storage or transport media (e.g., tissue
culture/transport medium, Hanks balanced storage
medium (HBSS or saline) such media can preferably
be used.
 Seek emergency dental treatment immediately.

100. MANAGEMENT IN DENTAL OFFICE
 Emergency visit :
- Prepare root
- Prepare socket
- Replant
- Construct a functional splint
- Administer adjunctive antibiotics
 Second visit :
- Root canal therapy
 Follow up visits

101. CLOSED APEX : EXTRAORAL DRY TIME < 60 MIN
Rinse off debris with saline
Examine the alveolar socket. If there
is a fracture of the socket wall,
reposition it with a blunt instrument.
Lightly aspirate if a blood clot is
present
Replant the tooth slowly with slight
digital pressure

102. OPEN APEX : EXTRAORAL DRY TIME < 60 MIN
Gently rinse off debris
Soak in doxycycline (1mg in approx
20 ml saline) for 5 min or cover with
minocycline
Prepare the socket
Replant with slight digital pressure

103. CLOSED APEX : EXTRAORAL TIME > 60 MIN
Rinse off debris
Soak in 3% citric acid for 3 min
to remove all necrotic tissue
Soak in 2% stannous flouride
for 5 min
Prepare socket
Replant with slight digital
pressure

104. OPEN APEX : EXTRAORAL DRY TIME > 60 MIN
Treat as closed apex
Perform endodontic treatment
extraorally
Prognosis poor and complications
of an ankylosed tooth is severe :
not to be replanted
Will inevitably be lost to osseous
replacement

105. SPLINTING
 Verify normal position of the replanted tooth clinically
and radiographically.
 Semi rigid physiologic splinting for 1-2 weeks
 Adjust the bite

107.  A new protocol using a resin activated glass
ionomer cement has been proposed that offers
ease of application and removal with minimal or no
iatrogenic damage to enamel.
Marriot-Smith C, Marino V, Heithersay GS. A preclinical dental trauma
teaching module. Dent Traumatol 2015 Dec 15.

108. SOFT TISSUE MANAGEMENT
 Suture laceration
 Make sure no foreign body is embedded in the soft
tissue
Adjunctive therapy
o Adult: Doxycycline 100mg b.i.d. x 7 days or
o Penicillin V 1-2g stat, then 500mg q.i.d. x 7days.
o Analgesics, as needed.

109. INSTRUCTIONS
 Soft diet.
 Brush after every meal with soft toothbrush.
 0.12% chlorhexidine mouth rinse b.i.d. x 7 days.
 Tetanus booster within 48 hrs.

110. ORTHODONTIC MOVEMENT OF TRAUMATIZED
TEETH
 Even with more simple crown/root fractures without
pulpal involvement, a 3 month wait is
recommended before tooth movement should
begin.
 Other minor trauma to the tooth and periodontium
(eg, minor concussions, subluxations, and
extrusions) also require a 3 month wait.

111. o When there has been moderate to severe
trauma/damage to the periodontium, a minimum of
6 months wait is recommended.
o Teeth that have sustained root fractures cannot be
moved for at least 1 year.
o Where there is radiographic evidence of healing,
these teeth can be moved successfully.
o In teeth that require endodontics, movement can
begin once healing is evident.

112.  Because teeth that have sustained severe
periodontal injury have been found to undergo pulp
necrosis when orthodontic movement was initiated
even after a rest period, light intermittent forces are
recommended along with avoidance of prolonged
tipping forces and contact with the buccal or lingual
cortical plates.

113. VERTICAL ROOT FRACTURE

114. INTRODUCTION
A VRF is a longitudinally oriented fracture of the
root that originates from the apex and propagates
to the coronal part

115. PREVALENCE
o It occurs about 2 to 5 % of TDI with greatest
incidence in teeth after endodontic therapy
about 11 to 20 %
o Maxilla is most affected than mandible
o More in males
o Premolars are affected more than molars

116. PREDISPOSING FACTORS
Excessive Biomechanical preparation
Over widening for post placement
Excessive occlusal force
Moisture loss in pulpless teeth
Previous cracks in dentin
Loss of tooth structure due to caries and
restoration

117. ETIOLOGY
Endodontic treatment
Placement of pins
and posts
Parafunctional habits
Restorative treatment
Pathologic resorption
induced fracture

118. CLASSIFICATION
On the basis of
fragment seperation
Complete
Incomplete
On the basis of
relative position of
fracture of alveolar
crest
Supraosseous
Intraosseous

119. DIAGNOSIS
Illumination
Radiographs
Periodontal
probing
Staining
Surgical
exploration
Bite test
Direct visual
examination
Dental
microscope

120. CLINICAL PRESENTATION
 History of variable discomfort or soreness, mild to
moderate pain especially on biting
 VRF must be suspected if a root filled tooth
presents with pain on biting
 A sinus tract sometimes presence of multiple sinus
tract is a feature

121. MANIFESTATIONS
EARLY
• Pain or discomfort on
the affected side.
• Sensitive upon
chewing
• Pain is often a dull
nature
LATE
• Major destruction of
alveolar bone
adjacent to the root
• J shaped
radiolucency
• Periodontal pocket
along the fracture

122. RADIOGRAPHIC SIGNS
Separation of root fragments
Fracture line along the root
Space beside the filling
Double image
Radioopaque signs
Step like bone defects
Unexplained bifurcation bone loss
Radiolucent halos

123. CBCT – ACCURATE DIAGNOSIS ?
Definitely yes
Difficult
when
<0.15mm
Increased
resolution
in
detection
Smaller
radiation

124. TREATMENT
Bonding using
GIC,
Composite
resin
Bonding using
bands, wires
Bonding using
adhesive resin
cement
Replanation
technique
Fusing the
fragments
using co2 and
Nd: YAG laser
Hemisection
and amputation
Extraction

125. CONCLUSION
 Dental traumatology has progressed in recent years to
improve the understanding of the biological considerations
involved in both diagnosis and treatment principles.
 Identifying the etiologic factors makes it possible to establish
preventive measures, aimed at avoiding future injuries.
 The outcome of treatment depends on the extent of injury, the
stage of root formation and correct execution of treatment.

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129. THANK YOU