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Traumatic injuries of teeth

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Traumatic injuries of teeth

  1. 1. TRAUMATICINJURIES OF TEETH Prepared by: Dr. Rea Corpuz
  2. 2. Traumatic Injuries ofTeeth Case History  Chief complaint  History of present illness  Medical History
  3. 3. Traumatic Injuries ofTeeth Clinical Examination  External Examination  Soft Tissues  Facial Skeleton  Teeth and Supporting Structures
  4. 4. Traumatic Injuries ofTeeth Radiographic Examination  Periapical  Occlusal  Panoramic
  5. 5. Traumatic Injuries ofTeeth (1) Concussion (2) Luxation (3) Fracture
  6. 6. Concussion tooth is not mobile not displaced periodontal ligament (PDL) absorbs injury + inflammed  leaves tooth tender to biting pressure + percussion
  7. 7. Concussion Visual sign:  not displaced Percussion test:  tender to touch or tapping Mobility test:  no increased mobility
  8. 8. Concussion Pulp Sensibility Test:  positive result  it is important in assessing future risk of healing complications  lack of response to the test indicates an increased risk of later pulp necrosis
  9. 9. Concussion Radiographic findings:  no radiographic abnormalities Radiographs:  occlusal  periapical  lateral view from mesial + distal aspect of tooth in question
  10. 10. Concussion Treatment Objectives:  usually there is no treatment Treatment:  monitor pulpal condition for at least 1 year
  11. 11. Concussion Patient Instructions:  soft food for 1 week  brush with soft bristle  rinse with chlorhexidine 0.1% to prevent plaque accumulation
  12. 12. Luxation tooth is displaced in a labial, lingual or lateral direction PDL is usually torn fractures of supporting alveolus may occur
  13. 13. Luxation similar to extrusion injuries  partial or total separation of periodontal ligament
  14. 14. Luxation Visual sign:  displaced, usually in a palatal/lingual or labial direction Percussion test:  usually gives a metallic (ankylotic) sound Mobility test: 
  15. 15. Luxation Pulp Sensibility Test:  likely give a lack of response except for teeth with minor displacement  test is important in assessing risk of healing complications  positive result at the initial examination indicates a reduced risk of future pulp necrosis
  16. 16. Luxation Radiographic findings:  widened periapical ligament space best seen on occlusal or eccentric exposures Radiographs:  occlusal  periapical  lateral view from mesial + distal aspect of tooth in
  17. 17. Luxation Treatment Objective:  reposition + splint a displaced tooth to facilitate pulp + periodontal ligament healing
  18. 18. Luxation Treatment:  rinse the exposed part of root surface with saline before repositioning  apply local anesthesia  reposition tooth with forceps or with digital pressure to disengage it from its bony socket
  19. 19. Luxation Treatment:  gently reposition it into its original position  stabilize the tooth for 4 weeks using a flexible splint  4 weeks is indicated due to associated bone fracture
  20. 20. Luxation Patient Instructions:  soft food for 1 week  brush with soft bristle  rinse with chlorhexidine 0.1% to prevent plaque accumulation
  21. 21. Fracture Ellis and Davey classification of crown fracture is useful in recording extent of damage to crown  Class I – simple fracture of crown involving little or no dentin  Class II – extensive fracture of crown involving considerable dentin but not dental pulp
  22. 22. Fracture  Class III – extensive fracture of crown with an exposure of dental pulp  Class IV – loss of entire crown
  23. 23. Fracture Enamel Fracture Enamel-Dentin Fracture Enamel-Dentin-Pulp Fracture Root Fracture
  24. 24. Enamel Fracture fracture confined to the enamel with loss of tooth structure
  25. 25. Enamel Fracture Visual sign:  visible loss of enamel  no visible sign of exposed dentin Percussion test:  not tender  if tenderness is observed evaluate tooth for a possible luxation or root fracture injury
  26. 26. Enamel Fracture Mobility test:  normal mobility Sensibility test:  usually positive  test may be negative initially indicating transient pulpal damage
  27. 27. Enamel Fracture Sensibility test:  monitor pulpal response until definitive pulpal diagnosis can be made  test is important in assessing risk of future healing complications  lack of response at initial examination indicates an increased risk of later pulpal necrosis
  28. 28. Enamel Fracture Radiographic findings:  enamel lost is visible Radiographs:  occlusal  periapical  recommended to rule out possible presence of root fracture or a luxation injury
  29. 29. Enamel Fracture Treatment:  if tooth fragment is available, it can be bonded to the tooth  grinding or restoration with composite resin depending on extent + location of fracture
  30. 30. Enamel-Dentin Fracture fracture confined to enamel + dentin with loss of tooth structure, but not involving pulp
  31. 31. Enamel-Dentin Fracture Visual sign:  visible loss of enamel + dentin  no visible sign of exposed pulp tissue Percussion test:  not tender  if tenderness is observed evaluate tooth for a possible luxation or root fracture injury
  32. 32. Enamel-Dentin Fracture Mobility test:  normal mobility Sensibility test:  usually positive  test may be negative initially indicating transient pulpal damage
  33. 33. Enamel-Dentin Fracture Sensibility test:  monitor pulpal response until definitive pulpal diagnosis can be made  test is important in assessing risk of future healing complications  lack of response at initial examination indicates an increased risk of later pulpal necrosis
  34. 34. Enamel-Dentin Fracture Radiographic findings:  enamel-dentin lost is visible Radiographs:  occlusal  periapical  recommended to rule out displacement or possible presence of root fracture
  35. 35. Enamel-Dentin Fracture Treatment:  if tooth fragment is available, it can be bonded to the tooth  otherwise perform provisional treatment by covering exposed dentin with glass ionomer or a permanent restoration using a bonding agent + composite resin
  36. 36. Enamel-Dentin-PulpFracture (Complicated Crown Fracture) a fracture involving enamel + dentin with loss of tooth structure + exposure of pulp
  37. 37. Enamel-Dentin-PulpFracture Visual sign:  visible loss of enamel + dentin  exposed pulp tissue Percussion test:  not tender  if tenderness is observed evaluate tooth for a possible luxation or root fracture injury
  38. 38. Enamel-Dentin-PulpFracture Mobility test:  normal mobility Sensibility test:  usually positive
  39. 39. Enamel-Dentin-PulpFracture Sensibility test:  test is important in assessing risk of future healing complications  lack of response at initial examination indicates an increased risk of later pulpal necrosis
  40. 40. Enamel-Dentin-PulpFracture Radiographic findings:  lost of tooth substance is visible Radiographs:  occlusal  periapical  recommended to rule out displacement or possible presence of luxation or root fracture
  41. 41. Enamel-Dentin-PulpFracture Treatment:  if young patients with open apices, it is very important to preserve pulp vitality by pulp capping or partial pulpotomy in order to secure further root development  this treatment is also treatment of choice in patients with closed apices
  42. 42. Enamel-Dentin-PulpFracture Treatment:  Calcium hydroxide compunds + MTA are suitable materials for such procedures  in older patients with closed apices + luxation injury with displacement, root canal treatment is usually treatment of choice
  43. 43. Crown-Root Fracturewithout pulp involvement fracture involving:  enamel  dentin  cementum  with loss of tooth structure  but not exposing pulp
  44. 44. Crown-Root Fracturewithout pulp involvement Visual sign:  crown fracture extending below gingival margin Percussion test:  tender
  45. 45. Crown-Root Fracturewithout pulp involvement Mobility test:  coronal fragment mobile Sensibility test:  usually positive for apical fragment
  46. 46. Crown-Root Fracturewithout pulp involvement Radiographic findings:  apical extension of fracture usually not visible Radiographs:  occlusal  periapical  recommended to detect fracture lines in root  cone beam exposure can reveal whole fracture extension
  47. 47. Crown-Root Fracturewithout pulp involvement Treatment:  Fragment removal only • removal of superficial coronal crown-root fragment • subsequent restoration of exposed dentin above gingival level
  48. 48. Crown-Root Fracturewithout pulp involvement Treatment:  Fragment removal + gingivectomy (sometimes ostectomy) • removal of coronal segment with subsequent endodontic treatment + restoration with a post-retained crown
  49. 49. Crown-Root Fracturewithout pulp involvement Treatment:  Orthodontic extrusion of apical fragment • removal of coronal segment with subsequent endodontic treatment + orthodontic extrusion of remaining root with sufficient length after extrusion to support a post- retained crown
  50. 50. Crown-Root Fracturewithout pulp involvement Treatment:  Surgical extrusion • removal of mobile fractured fragment • subsequent surgical repositioning of root in a more coronal position
  51. 51. Crown-Root Fracturewithout pulp involvement Treatment:  Decoronation (root submergence) • implant solution is planned, root fragment may be left in situ after in order to avoid alveolar bone resorption • thereby maintaining volume of alveolar process for later implant installation
  52. 52. Crown-Root Fracturewithout pulp involvement Treatment:  Extraction • with immediate or delayed implant-retained crown restoration or a coventional bridge • fractures with severe apical extension, the extreme being a vertical fracture
  53. 53. Crown-Root Fracturewith pulp involvement fracture involving:  enamel  dentin  cementum  with loss of tooth structure  exposure of pulp
  54. 54. Crown-Root Fracturewith pulp involvement Visual sign:  crown fracture extending below gingival margin Percussion test:  tender
  55. 55. Crown-Root Fracturewith pulp involvement Mobility test:  coronal fragment mobile Sensibility test:  usually positive for apical fragment
  56. 56. Crown-Root Fracturewithout pulp involvement Radiographic findings:  apical extension of fracture usually not visible Radiographs:  occlusal  periapical  cone beam exposure can reveal whole fracture extension
  57. 57. Crown-Root Fracturewith pulp involvement Treatment:  Fragment removal + gingivectomy (sometimes ostectomy) • removal of coronal segment with subsequent endodontic treatment + restoration with a post-retained crown
  58. 58. Crown-Root Fracturewith pulp involvement Treatment:  Orthodontic extrusion of apical fragment • removal of coronal segment with subsequent endodontic treatment + orthodontic extrusion of remaining root with sufficient length after extrusion to support a post- retained crown
  59. 59. Crown-Root Fracturewith pulp involvement Treatment:  Surgical extrusion • removal of mobile fractured fragment • subsequent surgical repositioning of root in a more coronal position
  60. 60. Crown-Root Fracturewith pulp involvement Treatment:  Decoronation (root submergence) • implant solution is planned, root fragment may be left in situ after in order to avoid alveolar bone resorption • thereby maintaining volume of alveolar process for later implant installation
  61. 61. Crown-Root Fracturewith pulp involvement Treatment:  Extraction • with immediate or delayed implant-retained crown restoration or a coventional bridge • fractures with severe apical extension, the extreme being a vertical fracture
  62. 62. Root Fracture fracture confined to the root of tooth involving:  cementum  dentin  pulp
  63. 63. Root Fracture Visual sign:  coronal segment may be mobile  some cases displaced  transient crown discoloration (red or gray) may occur  bleeding from gingival sulcus may be noted
  64. 64. Root Fracture Percussion test:  tooth may be tender Mobility test:  coronal segment may be mobile
  65. 65. Root Fracture Sensibility test:  the test is important in assessing risk of healing complications  a positive sensibility test at the initial examination indicates a significantly reduced risk of later pulpal necrosis
  66. 66. Root Fracture Sensibility test:  may give negative results initially  indicating transient or permanent neural damage  pulp sensibility test is usually negative for root fractures except for teeth with minor displacements
  67. 67. Root Fracture Radiographic findings:  root fracture line is usually visible  fracture involves root of the tooth in a horizontal or diagonal plane
  68. 68. Root Fracture Treatment:  rinse exposed root surface with saline before repositioning  if displaced, reposition the coronal segment of the tooth as soon as possible  check that correct position has been reached radiographically
  69. 69. Root Fracture Treatment:  stabilize the tooth with flexible splint for 4 weeks  if the root fracture is near cervical area of the tooth stabilization is beneficial for a longer period of time (upto 4 months)
  70. 70. Root Fracture Treatment:  monitor healing for at least 1 year to determine pulpal status  if pulp necrosis develops, then root canal treatment of the coronal tooth segment to the fracture is indicated
  71. 71. References: Books McDonald, Avery et al: Dentistry for the Child and Adolescent • (pages 458-459) Internet http://www.dentaltraumaguide.org

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