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Traumatic Injuries

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Undergraduate Lecture

Published in: Health & Medicine, Education

Traumatic Injuries

  1. 1. Traumatic Injuries Dr. Ashraf Refai BDS MSc DD HMD Al-Azhar University (Boys Branch) Cairo, Egypt www.arefai.edublogs.org
  2. 2. www.arefai.edublogs.org Ouch… ‫...واوا‬ • Most common age to get traumatic injuries 7-12 years!!! Good news or Bad news? – Blood Supply – Root Formation
  3. 3. Elis Classification • Class I: Crown fracture (Root intact) • Class II: Crown fracture without pulp exposure • Class III: Crown fracture with pulp exposure • Class IV: Coronal fracture extending subgingival • Class V: Root fracture • Class VI: Tooth displacement • Class VII: Injuries to deciduous teeth
  4. 4. Who Classification • 873.60: Enamel fracture • 873.61: Crown fracture without pulp exposure • 873.62: Crown fracture with pulp exposure • 873.63: Root fracture • 873.64: Crown/Root fracture • 873.66: Tooth luxation • 873.67: Intrusion & extrusion • 873.68: Avulsion • 873.69: Other injuries (Soft tissue) • 802.20: Fracture of the alveolar process of the mandible • 802.40: Fracture of the alveolar process of the maxilla • 802.21: Fracture of the body of the mandible • 802.41: Fracture of the body of the maxilla
  5. 5. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  6. 6. www.arefai.edublogs.org 1st things first... • A patient presents to the clinic with a traumatic injury i.e. Fractured upper anterior tooth Question What should be done first?
  7. 7. Examination & Diagnosis History Chief complaint History of present illness Medical history Clinical Examination Soft tissues Facial skeleton Teeth & supporting tissues
  8. 8. www.arefai.edublogs.org History 1. Chief complaint – Statement of what happened – In the patients own words – Sometimes it is obvious!!!
  9. 9. www.arefai.edublogs.org History 2. History of present illness – When & how did this injury occur? • Missing teeth • Contamination • Time elapsed affects treatment options
  10. 10. www.arefai.edublogs.org History 2. History of present illness – Have you had any previous injuries to your mouth or teeth in the past? • Battered wife or child • Accident prone • Contact sports Previously undiagnosed injuries
  11. 11. www.arefai.edublogs.org History 2. History of present illness – What symptoms are you now having with the affected teeth or tooth? • Mobility • Pain • Bleeding This will help with diagnosis
  12. 12. www.arefai.edublogs.org History 3. Medical History – Allergies – Medical conditions – Tetanus status
  13. 13. Examination & Diagnosis History Chief complaint History of present illness Medical history Clinical Examination Soft tissues Facial skeleton Teeth & supporting tissues
  14. 14. www.arefai.edublogs.org Clinical Examination 1. Soft tissues – Extent of damage (Suturing maybe required) – Foreign body (Removal of foreign body) Examination is done visually & radiographically
  15. 15. www.arefai.edublogs.org Soft Tissue Injury with Foreign Body
  16. 16. www.arefai.edublogs.org Clinical Examination 2. Facial Skeleton – Teeth involved in fracture line may become necrotic – When should I worry? • Several teeth are displaced • Tooth displacement is extensive • Occlusal malalignment
  17. 17. www.arefai.edublogs.org Clinical Examination 3. Teeth & Supporting tissue What should we look for??? Mobility Displacement Periradicular Damage Pulpal Injury Radiographic Examination
  18. 18. www.arefai.edublogs.org Clinical Examination 3. Teeth & Supporting tissue – Mobility Degree of horizontal mobility • 0 = No mobility (Maybe locked in bone) • 1 = < 1mm mobility • 2 = 1 to 3 mm mobility • 3 = > 3mm mobility
  19. 19. www.arefai.edublogs.org Clinical Examination 3. Teeth & Supporting tissue – Displacement If a tooth is displaced from its original position this maybe a luxation injury
  20. 20. www.arefai.edublogs.org Clinical Examination 3. Teeth & Supporting tissue – Periradicular Damage • Injury to the apical vessels may result in pulp necrosis • Gentle Percussion the tooth will be sensitive to even mild touch • The affected & adjacent teeth should be examined You may identify other teeth that are injured Start with the adjacent teeth
  21. 21. www.arefai.edublogs.org Clinical Examination 3. Teeth & Supporting tissue – Pulpal Injury • May cause – Internal resorption – External resorption – Calcific metamorphosis • Pulp testing – Thermal (Ice) – EPT
  22. 22. www.arefai.edublogs.org Clinical Examination 3. Teeth & Supporting tissue – Radiographic Examination • Search for bone & tooth fracture • Used for medico legal purposes Multiple exposures Multiple angulations No distortion Using film holder
  23. 23. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  24. 24. www.arefai.edublogs.org Enamel Fractures • Description: Cracks & chips of enamel • Treatment: – Grinding & polishing – Restoration • Prognosis: It is good, no threat unless compounded with a luxation injury
  25. 25. www.arefai.edublogs.org • Description: – Fracture of Enamel & Dentin – Not usually associated with severe pain – Usually doesn’t require urgent care • Treatment: – Bonded composite restoration – Bonding of fractured segment – Indirect Veneer Crown Fracture without pulp involvement
  26. 26. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  27. 27. www.arefai.edublogs.org • Prognosis: It is good, no threat unless compounded with a luxation injury • Primary teeth: – Not common – Patient handling is more difficult – Can be left alone (Grinding) Crown Fracture without pulp involvement
  28. 28. www.arefai.edublogs.org Crown Fracture Without Pulp Exposure
  29. 29. www.arefai.edublogs.org Traumatic Injuries (Last Weeks Lecture Revision) • Most Common Age for traumatic injuries (Good vs Bad) • Classifications – Ellis – WHO – Modification of WHO • What to do first???
  30. 30. www.arefai.edublogs.org Traumatic Injuries (Last Weeks Lecture Revision) • Diagnostic Process – History • Chief Complaint • History of present illnes • Medical History – Examination • Soft tissue • Hard Tissue • Teeth & supporting structure • Enamel Fracture • Crown Fracture without pulp exposure
  31. 31. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvementCrown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  32. 32. www.arefai.edublogs.org • Description: – Complicated Fracture involving enamel, dentin & pulp – Treatment option varies: • Level of root maturity (Pulpotomy or else) • Extent of damage restorability (Vital pulp therapy or RCT) • Time elapsed after fracture Crown Fracture with pulp involvement
  33. 33. www.arefai.edublogs.org • Treatment: 1. Shallow Pulpotomy (Cvek Technique) – Indication: Immature Teeth – Immature teeth are weak – Allows the pulp to deposit hard tissue reinforcing the tooth structure and allowing for root completion Shallow vs. Deep pulpotomy Crown Fracture with pulp involvement
  34. 34. www.arefai.edublogs.org • Technique of Pulpotomy: – Anesthesia & rubber dam – Washed exposed dentin with saline or NaoCl – Excavation: Removal of granulation tissue and pulp tissue to a level 2mm below exposure – Do pulpotomy using round bur in high speed with coolant Crown Fracture with pulp involvement
  35. 35. www.arefai.edublogs.org • Technique of Pulpotomy: – Create dentin shelf – Wash with saline to achieve Hemostasis – Remove clot and apply either CaOH or MTA • CaOH: – Apply liner – IRM – Bonded composite – Re-entry after 6 -12 months Crown Fracture with pulp involvement
  36. 36. www.arefai.edublogs.org • Technique of Pulpotomy: • MTA: – Apply the material in increments – Wait 6 to 12 hrs for setting – Bonded composite – Re-entry after 6 -12 months is not needed – Evaluation is done after 6 months & yearly after that Crown Fracture with pulp involvement
  37. 37. www.arefai.edublogs.org • Treatment 2. Root Canal Treatment For teeth that cant be restored with bonded composite Crown Fracture with pulp involvement
  38. 38. www.arefai.edublogs.org Criteria for Successful Pulpotomy • Tooth is asymptomatic • No radiographic evidence of apical periodontitis • No root resorption • Tooth responds to pulp testing • Continued root development if no (Apexification) Crown Fracture with pulp involvement
  39. 39. www.arefai.edublogs.org • Prognosis: – Depends on time elapsed from injury < Than 1 wk good prognosis > Than 1 wk prognosis gets worse Crown Fracture with pulp involvement
  40. 40. www.arefai.edublogs.org Shallow Pulpotomy
  41. 41. www.arefai.edublogs.org • Primary Teeth: – Occurs less often – Treatment options: • Pulpotomy • RCT • Extraction Depending on degree of root resorption more More than ½ then extract Crown Fracture with pulp involvement
  42. 42. www.arefai.edublogs.org Crown Fracture with Pulp Exposure
  43. 43. www.arefai.edublogs.org Crown Fracture with Pulp Exposure
  44. 44. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  45. 45. www.arefai.edublogs.org • Description: – Usually oblique – Involves both crown & root – Chisel type fracture (Anterior teeth) – Shattered tooth usually with pulp exposure – Rarely affects posterior teeth but it can happen usually doesn’t happen with pulp exposure Crown-Root Fracture
  46. 46. www.arefai.edublogs.org • Examination: – Check for loose fragments – Old school: Remove all fragments – New school: Bond fragments especially when immature (Temporarily) Crown-Root Fracture
  47. 47. www.arefai.edublogs.org • Emergency Care: – It can be painful so removal of loose tooth fragments maybe necessary – If root immature and pulp is exposed then pulpotomy or vital pulp therapy maybe indicated as well Crown-Root Fracture
  48. 48. www.arefai.edublogs.org • Treatment Planning: – Which is better for the tooth pulpotomy or pulpectomy? – Is the remaining tooth structure enough to support a restoration? – How subgingival is the fracture? – Should it be extracted and restored with bridge or implant? – Or should the space be closed orthodontically? Crown-Root Fracture
  49. 49. www.arefai.edublogs.org • Primary Teeth: – Usually means an extraction – Sometimes there maybe enough remaining tooth structure for a restoration Crown-Root Fracture
  50. 50. www.arefai.edublogs.org Crown-Root Fracture
  51. 51. www.arefai.edublogs.org Traumatic Injuries (Last Weeks Lecture Revision) • Fracture involving Enamel, Dentin & Pulp • Treament options depend on: – Level of root maturity – Restorability – Time Elapsed
  52. 52. www.arefai.edublogs.org Traumatic Injuries (Last Weeks Lecture Revision) • Treatment options – Pulpotomy • Ca(OH) • MTA • Criteria of Success • Crown Root Fracture – Oblique fracture – Shattered tooth • Treatment options – Old School – New School
  53. 53. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  54. 54. www.arefai.edublogs.org • Description: It has many names that help describe it!! Intraalveolar Root Fracture Horizontal Root Fracture Transverse Root Fracture Root Fracture
  55. 55. www.arefai.edublogs.org • Description: – Difficult to detect – Easily missed Click on the Picture Root Fracture
  56. 56. Angulated Radiographs Are Essential • Additional Angulations • Severe Angulations • Central beam must pass through space
  57. 57. www.arefai.edublogs.org • Description: – Usually mild symptoms – Tooth maybe • Mobile • Displaced • Painful on biting • Symptomless The more coronal the fracture the more the symptoms Root Fracture
  58. 58. www.arefai.edublogs.org • Emergency Care – Repositioning – Stabilization • Using composite & orthodontic wire • 12 weeks for calcification – Follow up (Vitality) Root Fracture Application of finger pressure Orthodontic Repositioning
  59. 59. www.arefai.edublogs.org • Sequelae of Root Fracture: – Most cases heal by calcific metamorphosis – Calcification may occur in either or both segments – Most commonly in the coronal segment What if it doesn’t happen? Root Fracture
  60. 60. Sequelae of Root Fracture No healing presence of interproximal inflammatory tissue Healing with interproximal connective tissue & bone Healing with interproximal connective tissue Healing by Calcification
  61. 61. Sequelae of Root Fracture: Calcification 12 Weeks 1 Year 1 Day
  62. 62. Sequelae of Root Fracture Healing with interproximal Connective Tissue No Healing with presence of interproximal inflammatory Tissue Healing with interproximal Connective Tissue & Bone
  63. 63. www.arefai.edublogs.org • Treatment options (Necrotic Pulp) 1. RCT for both segments 2. RCT for coronal segment 3. Surgical removal of apical segment & RCT 4. Hard tissue Induction & RCT 5. Intraradicular Splint 6. Endodontic Implant 7. RCT followed by root Extrusion Root Fracture (7) R2I2S2
  64. 64. www.arefai.edublogs.org The Recommended Method of Treatment Hard Tissue Induction & RCT
  65. 65. Root Extrusion
  66. 66. Case Report: Root Extrusion • Crown Root Fracture • Root Canals Treatment • Fracture is Sub-Osseous • Orthodontic wire in the canal
  67. 67. www.arefai.edublogs.org Case Report: Root Extrusion • Placement of orthodontic wire • Application of orthodontic force
  68. 68. www.arefai.edublogs.org Case Report: Root Extrusion • Note: The periapical space • Coronal positioning of fracture line • Placement of post • May need further crown lengthening or gingivectomy
  69. 69. www.arefai.edublogs.org • Primary Teeth – Not common – If not mobile (no symptoms) • No treatment necessary – If mobile • Removal of coronal portion • Leave apical portion (not to damage successor) Root Fracture
  70. 70. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  71. 71. www.arefai.edublogs.org • Description – Usually involves sudden impact – Damage to supporting structures and neurovascular supply – Severity is proportional to displacement Luxation Injury
  72. 72. www.arefai.edublogs.org Types of Luxation injuries 1.Concussion 2.Subluxation 3.Extrusive Luxation 4.Lateral Luxation 5.Intrusive Luxation 3 4 5
  73. 73. Description of the Different Luxation Injuries Clinical Findings Concussion Subluxation Extrusive Luxation Intrusive Luxation Lateral Luxation Abnormal Mobility - + + - (+) - (+) Tenderness to Percussion + + (-) ± - (+) - (+) Percussion Sound Normal Dull Dull Metallic Metallic Response to pulp testing ± ± - (+) - (+) - (+) Clinical Dislocation - - + + + Radiographic Dislocation - - + + + • Subluxation injuries may exhibit bleeding • Intrusive injuries may result in complete burial • Lateral luxation may also be accompanied with alveolar fracture
  74. 74. www.arefai.edublogs.org • Examination & Diagnosis – Pulp status monitoring for weeks, months or years – Concussion: • Most likely to recover – Subluxation: • Also likely to recover • Les predictable than concussion injuries Luxation Injury
  75. 75. www.arefai.edublogs.org • Examination & Diagnosis – Extrusive, Intrusive & Lateral Luxation: • More aggressive injuries • Pulp responds less often • Pulp usually doesn’t recover In general Immature teeth have a better chance of recovery Luxation Injury
  76. 76. www.arefai.edublogs.org • Examination & Diagnosis – Pulp status must be regularly monitored • Pulp testing • Radiographic evaluation • Color changes Luxation Injury
  77. 77. www.arefai.edublogs.org • Examination & Diagnosis – Pulp testing: • Carbon ice or EPT • Initial lack of response not uncommon • Testing in 4 to 6 weeks • Testing again in 3 to 4 months • If pulp recovers it will usually respond to testing (Exception?) 3 possibilities to testing procedure Luxation Injury
  78. 78. www.arefai.edublogs.org • Examination & Diagnosis – Radiographic Evaluation: • Done same time as pulp testing • Periapical lesion (Necrosis) • Look for resorption (I & E) • In case of resorption, process must be stopped to prevent root damage • Calcific metamorphosis may occur (No intervention) Luxation Injury
  79. 79. www.arefai.edublogs.org • Examination & Diagnosis – Crown color changes: • Initial discoloration (Pink) • If necrotic (Grey & loss of translucency) • Calcific metamorphosis (Yellow or Brown) • Rarely discoloration maybe reversed Luxation Injury
  80. 80. www.arefai.edublogs.org Color Change
  81. 81. www.arefai.edublogs.org • Treatment – Concussion • No immediate action • ‘rest’ the tooth & follow up – Subluxation • Same as concussion • Mobility Splinting Luxation Injury
  82. 82. www.arefai.edublogs.org • Treatment – Extrusive & Lateral Luxation • Requires repositioning & splinting – 3 weeks on average – 8 weeks (Bony fracture) • RCT (Incase of Necrosis) Displacement Necrosis Luxation Injury
  83. 83. www.arefai.edublogs.org • Treatment – Intrusive Luxation • Immature open apex may re-erupt • Mature teeth – Active extrusion (Orthodontic) – Surgical & Orthodontic extrusion • RCT (incase of necrosis or irreversible pulpits) CaOH Luxation Injury
  84. 84. Intrusive Luxation Extrusive Luxation
  85. 85. Re-Eruption of Intruded Central
  86. 86. www.arefai.edublogs.org • Primary Teeth – Concussion & Subluxation • Require no treatment • If Necrotic RCT or Extraction – Lateral & Extrusive Luxation • Depending on severity – Left alone – Extracted Luxation Injury
  87. 87. www.arefai.edublogs.org • Primary Teeth – Intrusive luxation • Radiographic evaluation • Position in relation to successor – Elongated (Danger) – Shortened (OK) • Shape of successors • If impinging on successor EXTRACT Luxation Injury
  88. 88. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  89. 89. www.arefai.edublogs.org • Description – A tooth which has been totally displaced out of the socket – Keep tooth moist: Preserve the periodontal ligaments – Minimize time out of the socket – Minimize handling Avulsion
  90. 90. www.arefai.edublogs.org • Treatment – 3 patient situations can occur – When the tooth has been: • Immediately avulsed • Out of the socket for < an hour (kept in storage media) • Out of the socket for > an hour (Not kept in storage media) Avulsion
  91. 91. www.arefai.edublogs.org • Treatment – Immediate Replantation: First Aid for the Avulsed Tooth Avulsion
  92. 92. First Aid for Avulsed teeth Rinse tooth with cold running tap water (10 sec) Do not scrub tooth Replace tooth in socket using gentle finger pressure Hold tooth in place Seek dental care immediately
  93. 93. www.arefai.edublogs.org • Treatment (Immediate) – Clinical & Radiographic examination – Look for other injuries – Check position & stability Do what is done with replantation within 1 hour Avulsion
  94. 94. www.arefai.edublogs.org • Treatment – Replantation within 1 hour • Tooth should be placed in transport media – Saline – Milk – Saliva NOT WATER Avulsion
  95. 95. www.arefai.edublogs.org • Treatment (Within in Hour) – Place tooth in cup of saline – Check for alveolar fracture – Remove loose fragments and open collapsed socket – Irrigate socket with saline – Hold tooth from crown with forceps – Remove debris with moist gauze Avulsion
  96. 96. www.arefai.edublogs.org • Treatment (Within in Hour) – Replace tooth in socket mild finger pressure – Adjust alignment – Suture soft tissue lacerations around tooth – Stabilization with composite splint 1 to 2 weeks – Tetanus shot & Antibiotics – Supportive care (Diet & Analgesic Avulsion Immediate Replantation
  97. 97. www.arefai.edublogs.org • Treatment (Within in Hour) – Mature teeth RCT after 1 week – Immature teeth Evaluate 2,6, & 12 months • Vital: Root completion • Necrotic: RCT or Apexification Avulsion
  98. 98. www.arefai.edublogs.org • Treatment – Replantation after 1 hour • Periodontal fibers will not survive • This will result in replacement resorption • Procedure involves root surface treatment (Slow resorptive process) Avulsion
  99. 99. www.arefai.edublogs.org • Treatment (After 1 hour) – Similar steps – Cleaning root surface – Soak tooth in 2.4% NaF (Acidulated to ph 5.5) 5 to 20 minutes – RCT is performed outside the patients mouth Hold tooth in gauze soaked with NaF Avulsion
  100. 100. www.arefai.edublogs.org • Treatment (After 1 hour) – Remove clot from socket & irrigate – Gently replace tooth and adjust position & alignment – Splinting for 3 to 6 weeks Avulsion
  101. 101. Case Presentation: Avulsion
  102. 102. Case Presentation: Avulsion
  103. 103. www.arefai.edublogs.org • Sequelae to Replantation – Three types of resorption occur – Surface resorption • Lacunae of resorption on cementum surface • Healed by deposition of cementum Avulsion
  104. 104. www.arefai.edublogs.org • Sequelae to Replantation – Inflammatory resorption • Occurs with infected necrotic pulp and injury to periodontal ligaments • Loss of tooth structure & adjacent alveolar bone • Resorption subsides after RCT Avulsion
  105. 105. www.arefai.edublogs.org • Sequelae to Replantation – Replacement resorption • Tooth is resorbed and replaced by bone • Ankylosis occurs – Lack of any mobility – No eruption – Metallic sound when percussed • Primary teeth – Replantation not indicated Avulsion
  106. 106. Case Presentation: Replantation Resorption
  107. 107. Enamel Fracture Crown Fracture without pulp involvement Crown Fracture with pulp involvement Crown-Root Fracture Root Fracture Luxation Avulsion Classification of Dental Injuries Modification of WHO Classification (By Andreasen)
  108. 108. www.arefai.edublogs.org Thank You… ‫جزاكم‬‫هللا‬‫كل‬‫خير‬ ...

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