1.
TRAUMATIC
INJURIES OF
TEETH
Prepared by:
Dr. Rea Corpuz

2.
Traumatic Injuries of
Teeth
 Case History
 Chief complaint
 History of present illness
 Medical History

3.
Traumatic Injuries of
Teeth
 Clinical Examination
 External Examination
 Soft Tissues
 Facial Skeleton
 Teeth and Supporting Structures

4.
Traumatic Injuries of
Teeth
 Radiographic Examination
 Periapical
 Occlusal
 Panoramic

5.
Traumatic Injuries of
Teeth
 (1) Concussion
 (2) Luxation
 (3) Fracture

6.
Concussion
 tooth is not mobile
 not displaced
 periodontal ligament (PDL)
absorbs injury + inflammed
 leaves tooth tender to
biting pressure + percussion

7.
Concussion
 Visual sign:
 not displaced
 Percussion test:
 tender to touch or tapping
 Mobility test:
 no increased mobility

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.
Concussion
 Radiographic findings:
 no radiographic
abnormalities
 Radiographs:
 occlusal
 periapical
 lateral view from mesial +
distal aspect of tooth in
question

10.
Concussion
 Treatment Objectives:
 usually there is no
treatment
 Treatment:
 monitor pulpal condition
for at least 1 year

11.
Concussion
 Patient Instructions:
 soft food for 1 week
 brush with soft bristle
 rinse with chlorhexidine
0.1% to prevent plaque
accumulation

12.
Luxation
 tooth is displaced in
a labial, lingual or lateral
direction
 PDL is usually torn
 fractures of supporting
alveolus may occur

13.
Luxation
 similar to extrusion injuries
 partial or total separation
of periodontal ligament

14.
Luxation
 Visual sign:
 displaced, usually in a
palatal/lingual or labial
direction
 Percussion test:
 usually gives a metallic
(ankylotic) sound
 Mobility test:


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.
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.
Luxation
 Treatment Objective:
 reposition + splint a displaced
tooth to facilitate pulp +
periodontal ligament healing

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

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.
Fracture
 Class III – extensive fracture
of crown with an exposure
of dental pulp
 Class IV – loss of entire crown

23.
Fracture
 Enamel Fracture
 Enamel-Dentin Fracture
 Enamel-Dentin-Pulp Fracture
 Root Fracture

24.
Enamel Fracture
 fracture confined to the
enamel with loss of tooth
structure

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.
Enamel Fracture
 Mobility test:
 normal mobility
 Sensibility test:
 usually positive
 test may be negative initially
indicating transient pulpal
damage

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.
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.
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.
Enamel-Dentin Fracture
 fracture confined to enamel
+ dentin with loss of tooth
structure, but not involving
pulp

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.
Enamel-Dentin Fracture
 Mobility test:
 normal mobility
 Sensibility test:
 usually positive
 test may be negative initially
indicating transient pulpal
damage

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.
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.
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.
Enamel-Dentin-Pulp
Fracture
 (Complicated Crown Fracture)
 a fracture involving enamel +
dentin with loss of tooth
structure + exposure of pulp

37.
Enamel-Dentin-Pulp
Fracture
 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.
Enamel-Dentin-Pulp
Fracture
 Mobility test:
 normal mobility
 Sensibility test:
 usually positive

39.
Enamel-Dentin-Pulp
Fracture
 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.
Enamel-Dentin-Pulp
Fracture
 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.
Enamel-Dentin-Pulp
Fracture
 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.
Enamel-Dentin-Pulp
Fracture
 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.
Crown-Root Fracture
without pulp involvement
 fracture involving:
 enamel
 dentin
 cementum
 with loss of tooth structure
 but not exposing pulp

44.
Crown-Root Fracture
without pulp involvement
 Visual sign:
 crown fracture extending
below gingival margin
 Percussion test:
 tender

45.
Crown-Root Fracture
without pulp involvement
 Mobility test:
 coronal fragment mobile
 Sensibility test:
 usually positive for apical
fragment

46.
Crown-Root Fracture
without 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.
Crown-Root Fracture
without pulp involvement
 Treatment:
 Fragment removal only
• removal of superficial coronal
crown-root fragment
• subsequent restoration of
exposed dentin above gingival
level

48.
Crown-Root Fracture
without pulp involvement
 Treatment:
 Fragment removal + gingivectomy
(sometimes ostectomy)
• removal of coronal segment
with subsequent endodontic
treatment + restoration with
a post-retained crown

49.
Crown-Root Fracture
without 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.
Crown-Root Fracture
without pulp involvement
 Treatment:
 Surgical extrusion
• removal of mobile fractured
fragment
• subsequent surgical
repositioning of root in a more
coronal position

51.
Crown-Root Fracture
without 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.
Crown-Root Fracture
without 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.
Crown-Root Fracture
with pulp involvement
 fracture involving:
 enamel
 dentin
 cementum
 with loss of tooth structure
 exposure of pulp

54.
Crown-Root Fracture
with pulp involvement
 Visual sign:
 crown fracture extending
below gingival margin
 Percussion test:
 tender

55.
Crown-Root Fracture
with pulp involvement
 Mobility test:
 coronal fragment mobile
 Sensibility test:
 usually positive for apical
fragment

56.
Crown-Root Fracture
without pulp involvement
 Radiographic findings:
 apical extension of fracture
usually not visible
 Radiographs:
 occlusal
 periapical
 cone beam exposure can reveal
whole fracture extension

57.
Crown-Root Fracture
with pulp involvement
 Treatment:
 Fragment removal + gingivectomy
(sometimes ostectomy)
• removal of coronal segment
with subsequent endodontic
treatment + restoration with
a post-retained crown

58.
Crown-Root Fracture
with 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.
Crown-Root Fracture
with pulp involvement
 Treatment:
 Surgical extrusion
• removal of mobile fractured
fragment
• subsequent surgical
repositioning of root in a more
coronal position

60.
Crown-Root Fracture
with 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.
Crown-Root Fracture
with 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.
Root Fracture
 fracture confined to the
root of tooth involving:
 cementum
 dentin
 pulp

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.
Root Fracture
 Percussion test:
 tooth may be tender
 Mobility test:
 coronal segment may be
mobile

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.
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.
Root Fracture
 Radiographic findings:
 root fracture line is
usually visible
 fracture involves root of
the tooth in a horizontal
or diagonal plane

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.
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.
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.
References:
 Books
McDonald, Avery et al: Dentistry for the
Child and Adolescent
• (pages 458-459)
 Internet
http://www.dentaltraumaguide.org