Traumatic injuries

TRAUMATIC INJURIES OF THE
TEETH AND IT’S MANAGEMENT
1
Presented by-Dr Divya Popli
PG student (Pediatric dentistry)

CONTENTS
• Introduction
• Etiology
• Incidence
• Predisposing factors
• Mechanism of dental injury
• Classification
• History and clinical examination
• Management of traumatic injuries
o Crown fractures (diagnosis, treatment, prognosis )
o Crown root fractures (diagnosis, treatment, prognosis)
o Root fractures (diagnosis, treatment, prognosis)
o Luxation injuries (diagnosis, treatment, prognosis )
2

•Avulsion
•Soft tissue injuries (diagnosis, treatment, prognosis)
•Traumatic injuries of the primary dentition
•Prevention of dental injuries
•Summary and conclusion
•References
3

Introduction
 Incidence of dental trauma due to automobile accidents and violent sports
has increased significantly during the last decade causing fractures to anterior
teeth of children and teenagers to be commonly affected.
 Mean prevalence of dental and oral injuries is between 14% and 27%.
 Quality and timeliness of initial care contribute to a desirable outcome by
promoting healing.
 Long term outcome of success is related to the response of tooth pulp-thus
the importance of endodontic consideration in dental trauma.
 Incidence of dental trauma will overtake the incidence of caries and
periodontal disease in children and teenagers. (Andreasen 1993)
4

EPIDEMIOLOGY OF DENTAL TRAUMA
Prevalence
• The prevalence of TDI in the literature is high worldwide and varies
considerably.
• Prevalence in primary dentition is 11 to 30 percent and permanent
is 5 to 29 percent
Teeth involved
Primary dentition-60% injuries involve maxillary central incisors
15-20% involve maxillary lateral incisors
4.1% mandibular incisors
Permanent dentition-70% injuries involve maxillary incisors
18% mandibular central incisor
6% mandibular lateral incisor
5

WORLD TRAUMATIC DENTAL INJURY PREVALENCE AND
INCIDENCE, A META‐ANALYSIS—ONE BILLION LIVING
PEOPLE HAVE HAD TRAUMATIC DENTAL INJURIES
• DI prevalence to permanent dentition.
• TDI prevalence to primary dentition.
• TDI prevalence among12‐year‐old subjects.
• TDI incidence rate to any tooth and for any age.
• World TDI frequency resulted as follows:
• permanent dentition prevalence 15.2% (3.0%‐17.4%)
• primary dentition prevalence 22.7% (17.3%‐28.7%)
• 12‐year‐olds prevalence 18.1% (15.3%‐21.0%);
Stefano Petti ,Ulf Glendor, Lars Andersson,18 February 2018
6

THE FIFTH MOST PREVALENT DISEASE IS BEING
NEGLECTED BY PUBLIC HEALTH ORGANISATIONS
• Traumatic dental injuries would be the fifth most prevalent
disease or injury after permanent caries, tension-type headache,
iron-deficiency anaemia, and age-related and other hearing
loss, preceding migraine and genital herpes.
• The use of the conditional tense is due to the fact that,
paradoxically, the GBD Study did not consider traumatic dental
injuries among the 300 most prevalent diseases and injuries.
Tefano Petti,Jens Ove Andreasen,Ulf Glendor,Lars Andersson
Oct 2018
8

Type of injury
Most frequent injury in primary teeth is luxation and permanent
teeth is uncomplicated crown fracture
Background factors
Gender
• Boys sustain TDIs more often than girls in most studies. The
general finding that boys have almost twice the number of
in the permanent dentition than girls seems to be related to
their more active participation in contact games and sports but
recent studies have shown a reduction in this difference, which
may reflect a change in girls’ behavior in playing sports.
Age
• It is estimated that 71–92% of all TDIs sustained in a lifetime
occur before the age of 19 years
• Holland et al. reported a decrease of traumatic tooth injuries
after the age of 24 and Shulman and Peterson after the age of
30 years. 9

• Peak incidence in boys is 2 to 4 year and 9 to 10 year and in
girls is 2 to 3 years
• It can be seen that the first peak appears at 2–4 years of age. By
the age of 7 years, 28% of the girls and 32% of the boys have
suffered a TDI to the primary dentition.
• In the permanent dentition, a marked increase in the incidence
of TDIs is seen in boys aged 8–10 years; while the incidence is
rather stable for girls
• Facial injuries are more common in boys of 6 to 12 year of age,
mandible is most affected
• Arikan V et al(2010) reviewd that the majority of trauma
occurred between the 2-4 age.the most common is luxation
injuries.(33.3%)
Most injuries (33.3%) presented during May.The most common
form of treatment was follow up(39.4%),followed by
extraction(29.3%) and RCT(12.1%)
10

PREVALENCE OF PERMANENT ANTERIOR TEETH TRAUMA IN
CHILDREN BETWEEN 8-12 YEARS IN URBAN AND RURAL DISTRICTS
IN ROHTAK, HARYANA, INDIA
• 2000 school children, 323 children had suffered injury to
permanent anterior teeth.
• The overall prevalence of traumatic dental injuries of permanent
anterior teeth in Rohtak was observed to be 16.1%.
• A significant gender influence on the occurrence of trauma
was observed with more boys (18.4%) than girls (13.6%).
• Prevalence of Anterior Teeth Trauma According to Age
• 74.6% of the children who suffered dental injuries were eleven
and twelve years (11-12 years) of age, while the younger age
group of eight to ten years (8-10 years) suffered far less injuries
(25.4%)
• Prevalence of Anterior Teeth Trauma according to teeth
affected
• The most commonly affected tooth in this study was the
Suganthi Saraswathi and R. Pradeep
Kumar
11

• Prevalence of Anterior Teeth Trauma According to Cause of
Trauma
• fall was the most frequent cause of dental trauma, occurring in
192 (59.4%),followed by collision, sports activities (8.9%) and
road accidents (2.5%)
• Prevalence of Anterior Teeth Trauma According to Type of
Trauma
• class I fracture ie fractures involving enamel (78.6%) were the
most frequent type of traumatic dental injuries
observed,followed by calss 2
• Prevalence of Anterior Teeth Trauma According to lip Coverage
and Locality
• In this study, 52.7% of traumatized children had incompetent
lips
• Prevalence of Anterior Teeth Trauma According to Treatment
done
• This study showed that 97.3% of children with dental trauma
remained untreated
12

EPIDEMIOLOGY OF TRAUMATIC DENTAL INJURIES
TO PRIMARY AND PERMANENT TEETH IN A DANISH
POPULATION SAMPLE
• Danish population sample consisting of 487 children.
• 30 % of the children had sustained injuries to primary teeth
• 22 % had injured permanent teeth.
• 46 % of the children had a history of traumatic injuries to
primary and/or permanent teeth.
• The annual incidence of traumatic injuries was determined for
the examined population. Among boys, peak incidences
occurred in the following age-groups: 2-4 years, and 9-10 years.
• In girls only one peak incidence was found, in the age-group 2-
3 years.
J. 0. ANDREASEN AND J. J. RAVN
Int. J. oral Surg. 1972: 1:235-239
13

• Socio-economic status
• The higher risk of dental injuries among children from higher
socio-economic backgrounds may be related to greater
ownership of bicycles, access to skiing, skateboards, roller-
skating, horse-riding and swimming pools than those from low
socio-economic groups
• Hamilton et al 1997 observed that significantly more children in
lower socioeconomic groups receive TDI compared to higher
socio economic groups
• Further research is needed to elucidate this relationship.
• Glendor(2008) in a review stated that activities of person and
environment are probably more important determining factor
TDI than age and gender
14

ETIOLOGY
• Multiple cause
• Intentional /unintentional
• Traffic accidents and “at risk” athletic activities
are most common cause of dental trauma
(Dietschi et al 2000).
15

• Fall
• Sports,Horseback riding
• Automobile, bicycle and
motorcycle accidents
16

• Domestic violence
child abuse
violence against spouse
and elderly people
• Assaults and altercation
• Mental retardation
• Dentinogenesis imperfecta
(decrease in micro hardness of
dentin, tapered roots)
• Patient undergoing anesthesia
17

PREVALENCE AND ETIOLOGY OF TRAUMATIC INJURIES TO
THE ANTERIOR TEETH AMONG 5 TO 8 YEARS OLD
SCHOOL CHILDREN IN MATHURA CITY, INDIA: AN
EPIDEMIOLOGICAL STUDY
• 1657 children of the age groups: 5, 6, 7 and 8 years from 20
schools situated in various parts of Mathura city were included
• The prevalence of traumatic injuries to the anterior teeth in 5 to
8 years old age group was found to be 2.7%.
• Males accounted for 3.1% whereas females accounted for 2.3%.
Overall, males experienced more traumatic injuries than the
females with male to female ratio of 1.8:1.
• The etiology of traumatic injuries was mostly due to falls,
followed by bicycle accidents, collisions, violence and bike
accidents in that order.
Gojanur S, Yeluri R, Munshi AK.
Int J Clin Pediatr Dent 2015;8(3):172-175
18

PREDISPOSING FACTORS
Increased overjet with protrusion
• Increased overjet with protrusion of upper incisors and insufficient
lip closure are significant predisposing factors to TDI
• The Swedish council on technology assessment in health care in a
systematic review of literature (2005) concluded that there is
increased risk of TDI to upper front teeth in children with
pronounced overjet
• Burden(1995) observed overjet greater than normal range(0-3.5mm)
were significantly more likely to injury maxillary incisors.
19

Human behaviour
• Risk-taking children, children being bullied, emotionally stressful conditions,
obesity and attention-deficit hyperactivity disorder have been pointed out
Glendor
Presence of illness,learning difficulties and physical limitations
Epilepsy
• Dentofacial trauma occurring during seizure has been reported to include
injuries to tongue,buccal mucosa,facial fractures,avulsion,subluxation of TMJ.
• Generalized tonic-clonic seizure often causes minor oral injuries.
• Gurbuz et al(2010) found 68.8% of children with epilepsy suffer from TDI
Cerebral palsy
Hearing or visual impairment
• Meyer et al(1980) found 13.2% children have fractured teeth in visually
impaired child.
• Greeley et al(1976) in their Baltimore study found 27.2% of visually impaired
children to have fracture of anterior teeth.
• Prevalence of trauma in hearing impaired children is 24% have suffered20

AETIOLOGY AND RISK FACTORS RELATED TO
TRAUMATIC DENTAL INJURIES--A REVIEW OF THE
LITERATURE
• Oral factors (increased overjet with protrusion), environmental
determinants (material deprivation) and human behaviour (risk-
taking children, children being bullied, emotionally stressful
conditions, obesity and attention-deficit hyperactivity disorder)
were found to increase the risk for TDIs.
• A new cause of TDIs that is of particular interest is oral piercing.
In traffic facial injury was similar in unrestrained occupants (no
seat belts) and occupants restrained only with an air bag.
• Amateur athletes have been found to suffer from TDIs more
often than professional athletes. Falls and collisions mask
intentional TDIs, such as physical abuse, assaults and torture.
Ulf Glendor
•
•. 2009 Feb;25(1):19-31
21

CLARIFYING THE EFFECT OF BEHAVIORAL AND
CLINICAL FACTORS ON TRAUMATIC DENTAL
INJURIES IN CHILDHOOD: A HIERARCHICAL
APPROACH
• To explore associations between traumatic dental injuries (TDI )
in Brazilian preschool children and clinical, behavioral, and
socio‐demographic factors using a hierarchical approach.
• Pacifier use is strongly associated with the occurrence of TDI in
the primary dentition, and accentuated overjet represents a
pathway to this association.
Paulo Floriani Kramer, Eliane Gerson Feldens Cristina Montini Bruch
Simone Helena Ferreira Carlos Alberto Feldens, 25 March 2015
22

MECHANISM OF DENTAL INJURIES
• Direct trauma (eg: play
ground equipment)
• Indirect trauma (blow to
chin)
23

• Direct trauma usually implies injuries to the anterior region
• Indirect trauma favors crown or crown-root fractures in the
premolar and molar region
24

EXTENT OF TRAUMA CAN BE ASSESSED BY 4 FACTORS GIVEN BY
HALLET IN 1954
• Energy of impact.
• This factor includes both mass and
velocity. Examples of these
combinations are a force of high
velocity and low mass (gunshot) or of
high mass and minimal velocity
(striking the tooth against the ground).
• Resilience of the impacting object.
If a tooth is struck with a resilient or
cushioned object, such as an elbow
during play, or if the lip absorbs and
distributes the impact, the chance of
crown fracture is reduced while the risk
of luxation and alveolar fracture is
increased
25

• Shape of the impacting object.
• Impact with a sharp object favors clean crown fractures with a
minimum of displacement of the tooth, as the energy is spread
rapidly over a limited area.
• On the other hand, with a blunt object, impact increases the
area of resistance to the force in the crown region and allows
the energy to be transmitted to the apical region, causing
luxation or root fracture.
• Direction of the impacting force.
• The impact can meet the tooth at different angles, most often
hitting the tooth facially and perpendicular to the long axis of
the root.
• When considering the direction and position of fracture lines
caused by frontal impacts, the fractures fall easily into four
categories
• (1) Horizontal crown fractures.
• (2) Horizontal fractures at the neck of the tooth. 26

• Frontal impacts to anterior teeth generate forces that tend to
displace the coronal portion orally.
• Under certain conditions, such as blunt impacts and high
resilience of tooth-supporting structures in young individuals, a
tooth is more likely to be displaced orally without fracturing, as
the energy of the impact is absorbed by the supporting
structures during displacement.
27

• A different situation arises if the bone and periodontal ligament resist
displacement
• The root surface is forced against the bone marginally and apically
(a and b), creating high compressive forces. As the tensile and shearing
strength of the brittle dental tissues are much lower than the
compressive strength, shearing strains develop between the two zones
of the opposing forces, and the root is fractured along the plane joining
the two compression areas
28

• The tooth is firmly locked in its socket so that stresses in the
shearing zone will not be as high as those shown in Fig. The
impact will, therefore, induce a pure bending fracture at the site
of maximum bending stress, i.e. where the tooth emerges from
its supporting structures
• Tensile strains on the facial surface of the crown usually result in
horizontal infraction lines in the cervical enamel
• Horizontal fractures at the cervical area usually affect the
maxillary lateral incisors, probably due to their firm, deep
anchorage in alveolar bone.
29

• The stresses possibly causing oblique crownroot fractures are
illustrated. The oblique fracture line follows a course along the
inclined tensile stress lines developed between the compressive
areas a and c.
. This line of fracture is supported by experiments
using brittle materials, such as concrete
30

• In this same compressive forces and tensile strains as in Fig. are
present, but are not great enough to cause an oblique fracture,
so that the cleavage line follows the shortest possible route,
resulting in a horizontal fracture of the crown. The area of
contact between the impacting object and the enamel may
show a shallow notch surrounded by radiating infraction lines
The orientation of the enamel prisms determines the course of the fracture
line in enamel, while the direction of the fracture in dentin is primarily
perpendicular to the dentinal tubules
It has been found that enamel is weakest parallel to the enamel rods and
that dentin is most easily fractured perpendicularly to the dentinal tubules
31

• Penetrating lip lesions occur when the direction of impact is
parallel to the axis of the mandibular or maxillary incisors
32

HISTORY OF DENTAL TRAUMATIC INJURIES
• 1936- Brauer classified fractures of anterior teeth
• 1946- Hogeborn classified fracture of incisors according to the
degree of the break
• 1955- Sweet classified anterior teeth
• 1960- Ellis classified anterior teeth fracture into six groups. (1)
Enamel fracture; (2) Dentin fracture; (3) Crown fracture with pulp
exposure; (4) Root fracture; (5) Tooth luxation; (6) Tooth intrusion
• 1970- Ellis and Davey modified Ellis classification and classified
anterior teeth fracture
33

• 1978- WHO classified oral structures injuries using code
numbers while considering both primary and permanent teeth
• 1981- Andreasen modified WHO classification by including
terms uncomplicated complicated crown-root fracture and
concussion/subluxation/lateral luxation
• 1983-McDonald, Avery and Lynch modified Ellis and Davey
classification
• 2001 Dentofacial injuries classification adopted by International
Association of Dental Traumatology
• 2002 Spinas and Altana classified crown fractures of teeth
34

Laceration of gingiva-tear produced by sharp
object
39

Classification by Basrani 1985
Crown fracture
1. Fracture of enamel
2. Fracture of enamel and dentin
-without pulp exposure
-with pulp exposure
Root fracture
Crown root fracture
40

Type of injuries Code
Enamel infarction N 502.50
Enamel fracture N 502.50
Enamel- dentin fracture
(uncomplicated)
N 502.51
Enamel – dentin fracture
(complicated)
N 502.52
Root fracture N 502.53
Crown- root fracture
(uncomplicated)
N 502.54
Crown- root fracture
(complicated)
N 502.54
Multiple fracture N 502.57
Fracture of tooth unspecified N 502.59
WHO classification and modified by Andreasen & Andreasen ( 1995 )
Used by the International Association of Dental Traumatology
41

INJURIES TO THE PERIODONTIUM
• Concussion
• Subluxation
• Extrusive luxation
• Lateral luxation
• Intrusive luxation
• Avulsion
• N 503.20
• N 503.20
• N 503.20
• N 503.20
• N 503.21
• N 503.22
42

INJURIES TO THE SUPPORTING BONE
• Communition of mandibular
alveolar socket
• Communition of maxillary
alveolar socket
• Fracture of mandibular alveolar
socket wall
• Fracture of maxillary alveolar
socket wall
• Fractue of mandible
• Fractue of maxilla
• N 502.60
• N 502.40
• N 502.60
• N 502.40
• N 502.61
• N 502.42
43

INJURIES TO GINGIVA OR ORAL MUCOSA
• Laceration
• Contusion
• Abrasion
• N 801.50
• N 800.50
• N 800.50
44

SPINAS AND ATLANTA’S CLASSIFICATION(2002)
• A Class
• B Class
• Simple enamel lesions involving one proximal
angle or only incisal edge
• Enamel- dentin lesions involving one proximal
angle or only an incisal edge
subclass b1-with pulp exposition
A Class B Class in 11 & C Class in 21 45

•C Class •Enamel- dentin lesions involving the incisal edge and
at least a third of the crown
subclass c1-with pulp exposition
•Enamel- dentin lesion involving the mesial or distal
angle and and the incisal or palatal surface and root
involvement
subclass d1-with pulp exposition
•D Class
Subclass c1 Subclass d1
46

HISTORY AND CLINICAL EXAMINATION
• Patient name,age,sex ,address and telephone
number
• History of the accident
- when?
- how?
- where?
• Clinical examination
-neurologic examination
• Chief complaint
47

The trauma triad
• WHEN the accident happened. This gives an indication of
whether the treatment was sought immediately or not. Time
interval between injury and treatment may significantly affect
prognosis in case of pulp exposure, displacement and avulsion
type of injuries. Delay in seeking advice also may give an
indication of neglect on the child by the caretaker.
• WHERE it happened. The place of injury, whether a play ground
which is not clean, classroom or home where the surroundings
may be clean. This is done to consider tetanus protection and
also medicolegal implications, if it is involving any other places
because of accidents, assaults, etc. and also to retrieve the teeth
or their fragments form the site of injury.
• HOW the accident happened. This may give an indication of
other injuries, like soft tissue injuries, etc. Consideration to be
given for non-accidental injury and also for medicolegal 48

Treatment elsewhere:
• Previous treatment, such as immobilization, reduction or
reimplantation of teeth should be considered before further
treatment is instituted. It is also important to ascertain how the
avulsed tooth was stored, e.g. tap water, sterilizing solutions or
dry.
History of previous dental injuries:
• A number of patients may have sustained repeated injuries to
their teeth. This can influence pulpal sensibility test and the
recuperative capacity of the pulp and periodontium.
• If there is spontaneous pain from any teeth: Positive findings
here may indicate pulp inflammation that is due to a fractured
crown or injuries to the supporting structures such as
extravasation of blood into the PDL.
• Does the child experience a thermal change with sweet or sour
foods? If so, dentin or pulp may be exposed.
• Does the child note a change in occlusion? These findings may
indicate a luxation injury or an alveolar fracture. 49

MEDICAL HISTORY
• Bleeding disorders
• Cardiac disease, rheumatic fever
• Epilepsy
• Allergies—specifically to penicillin
• Anti-tetanus protection—date of booster
• Did trauma cause loss of consciousness, amnesia,
drowsiness, vomiting or headache?
• History of taking any medication, to avoid overdosage of
some medicines being already taken.
50

OUT LINE OF INITIAL NEUROLOGIC ASSESMENT
(CROLL TP ET AL )
1. Notice unusual communication or motor functions
2. Look for normal respiration without obstruction of the airway or
danger of aspiration
3. Replant avulsed teeth as indicated
4. Obtain a medical history and information on the accident
5. Determine blood-pressure and pulse
6. Examine for rhinorrhea or otorrhea
7. Evaluate function of the eyes- Is diplopia or nystagmus apparent?
Are pupillary activity and movement of the eyes normal?
51

6. Evaluate movement of the neck for pain or limitation.
7. Examine the sensitivity of the facial skin for paraesthesia or
anesthesia
8. Confirm normal vocal functions
9. Confirm patient’s ability to protrude the tongue
10. Confirm hearing (tinnitus or vertigo)
11. Evaluate sense of smell
12. Ensure follow up evaluation
52

EXTERNAL EXAMINATION
• Assessment of any asymmetry of the face due to injuries to
facial skeleton or due to any swelling.
• Palpation of facial skeleton for any noticeable fractures,
deviations, etc.
• Observation of symptoms and signs that gives an idea of
fractures of facial bones.
• Recording of any extraoral wounds/bruising like lacerations,
contusions, and abrasions.
• Recording of paresthesia of any part of the face in case of 53

INTRA ORAL EXAMINATION
Recording of injuries to oral mucosa or gingival injuries:
Wounds penetrating the entire thickness ofthe lip can frequently be
observed, often demarcated by two parallel wounds on the inner
and outer labial surfaces. If present, the possibility of tooth
fragments buried between the lacerations should be considered.
54

• Submucosal hematomas sublingually, in the vestibular region or
in the palate can be indicative of a jaw fracture.
• Thorough radiographic examination, including examination of
the border of the mandible and mobility of jaw segments en
bloc, must accompany this finding, as a jaw fracture could
otherwise be overlooked
55

• Examination of crowns of teeth:
• For the presence and extent of fractures, pulp exposures or
changes in color. Before examining traumatized teeth, the
crowns should be cleaned of bloodand debris.
• When examining crownfractures, it is important to note
whether the fracture is confined to enamel or includes dentin.
The fracture surface should be carefully examined for pulp
exposures, if present, the size and location should be recorded
• Recording of displacement of teeth:
• Displacement of teeth is usually evident by visual examination;
however minor abnormalities can often be difficult to detect.
• Although inhalation of foreign bodies in connection with
traumatic injuries is normally associated with a loss of protective
reflexes in an unconscious patient, it may also occur in a
conscious patient without producing symptoms. Consequently,
if there is reason to suspect inhalation or swallowing of a tooth
or dental appliance, it is important that radiographs of the chest
and the abdomen be taken as soon as possible
56

Disturbances in occlusion:
Abnormalities in occlusion can indicate fractures of the jaw or alveolar process.
In the case of jaw fractures, abnormal mobility of the jaw fragments can be
demonstrated.
Tenderness of teeth to percussion and change in percussion tone: Reaction to
percussion is indicative of damage to the periodontal ligament. The test may be
performed by tapping the tooth lightly with the handle of a mouth mirror, in
vertical as well as horizontal direction. Injuries to the periodontal ligament will
result in pain. As with all examination techniques used at the time of injury, the
percussion test should begin on a noninjured tooth to assure a reliable patient
response. A calibrated percussion instrument has been introduced, a Periotest.
However, the force imparted by such an instrument might contribute to a new
trauma, as in the case of root fractures. The sound elicited by percussion is
also of diagnostic value. Thus, a hard, metallic sound elicited by percussion in57

VITALITY TEST
• In the evaluation of various pulp testing procedures, it should be considered
that most procedures e.g. thermal tests, electrometric pulp testing assess the
nerve supply to the pulp whereas laser Doppler flowmetry (LDF) and pulse
oximetry (PO) assess the presence of a functioning vascular supply.
• After acute trauma, the dental pulp blood supply might be torn (e.g.
subluxation) or severed/ruptured (extrusive or lateral luxation). This could lead
to pulpal edema, which could result in a negative pulpal ‘response’ just after
injury.
• In this situation, a period of approximately 10–14 days could elapse before a
positive pulpal response returns.
• In the case of tooth dislocation and subsequent rupture of the neurovascular
supply at the apical foramen, it might take up to 3 months in immature tooth.58

THERMAL TESTS
• Most frequently used are heated
gutta‐percha, ethyl chloride, ice, carbon
dioxide snow and dichlor‐difluormethane.
• Heated gutta‐percha
• A stick of gutta‐percha is heated by holding
about 5 mm of its length in a flame for 2
seconds, whereupon it is applied to the
tooth on the middle third of the facial
surface
• Ice
• This method involves the application of a
cone of ice to the facial surface of the
tooth. Reaction depends on the duration of
application; a period of 5–8 seconds
increases the sensitivity of this test.
• The reliability of this procedure has also
been questioned as non‐injured teeth may
59

• Ethyl chloride
• Ethyl chloride can be applied by
soaking a cotton pledget and then
placing it on the facial surface of the
tooth to be tested
• Carbon dioxide snow
• Because of its low temperature (–78
°C, –108 °F), carbon dioxide snow
gives very consistent and reliable
results, even in immature teeth. This
method also allows pulp testing in
cases where an injured tooth is
completely covered with a temporary
crown or splint
• However, a serious drawback to this
procedure is that the very low
temperature of the carbon dioxide
snow can result in new infraction 60

• Dichlor‐difluormethane
• This is another cold test in which an aerosol is released at a
temperature of –28 °C (–18 °F) onto the enamel surface
• . Like carbon dioxide snow, it elicits a very reliable and consistent
response from both mature and immature teeth .
• However, the same drawback has been recorded with this test as
with carbon dioxide snow, although to a lesser degree; namely,
infraction lines in the enamel caused by the thermal shock
• Responses To Thermal Tests
• • No response - Non-vital pulp
• • Mild to moderate degree of pain that subsides within 1-2 sec
after stimulus has been removed-Normal
• • Strong, momentary painful response that subsides within 1-2
secs after stimulus is removed- Reversible pulpitis
• • Moderate to strong painful response that lingers for several
seconds or longer after stimulus has been removed- Irreversible
pulpitis
61

ELECTROMETRIC PULP TESTING
• EPT should employ a current measurement instrument that allows
control of the mode, duration, frequency and direction of the
stimulus
• Stimulus duration of 10 milliseconds or more has been advocated
• Such tests are conducted by applying a conducting medium (e.g.
toothpaste) on a dried tooth and placing the probe tip of an electric
pulp tester on the surface of the tooth closest to the pulp horn(s).
The patient is then directed to hold the end of the conducting probe
to complete the circuit and asked to let go of the probe when a
‘tingling’ sensation is felt.
• Disadvantages Cannot be used on patients having cardiac pace
maker.
• Does not suggest the health or integrity of the pulp, simply indicates
the presence of vital sensory fibers with in the pulp. 62

CLINICAL INTERPRETATIONS OF PULPAL
RESPONSE TO EPT
• Normal response: positive response occurs at same neural
• excitation threshold as the control teeth
• Negative response:nonvital tooth
• Early response:A diseased pulp- responds to threshold less tha
control teeth
• Delayed response: A diseased pulp- responds to threshold
greater than control teeth
• False positive-gangrenous necrotic pulp present
-multirooted teeth in which pulp is partially
negative
False negative-recently traumatized teeth
-Fibrotic pulp,sedative medications taken by patien63

LASER DOPPLER FLOWMETRY
• A method has been developed whereby a laser beam can be
directed at the coronal aspect of the pulp.
• First described by Gazelius et al in 1986
• The reflected light scattered by moving blood cells undergoes a
Doppler frequency shift. The fraction of light scattered back
from the pulp is detected and processed to yield a signal
• Signal is recorded as conc and velocity of cells using an arbitrary
units
PU,where 2.5 volts of blood flow is equivalent to 250 PU.
64

PULSE OXIMETRY
• Pulse oximetry measures actual blood
flow rather than the neural response,
and has been shown to be a reliable
and accurate way of assessing the
vitality of the pulp
• Pulse oximetry is a non‐invasive means
of assessing the vitality of a dental
pulp by measuring the percentage of
hemoglobin in the arterial blood that is
saturated with oxygen.
• Oxygenated blood is bright red while
deoxygenated blood is of a darker,
red‐blue shade
• The pulse oximeter, which uses a
light‐emitting diode (LED) to transmit
light through the vascular bed,
measures the color difference to 65

• In 2007, Gopikrishna et al compared the efficacy of a
custom‐made pulse oximeter dental probe with electric
pulp testing and thermal testing for measuring the pulp
vitality status of 17 recently traumatized permanent
teeth.
• The results demonstrated that pulp oximetry was
a reliable and accurate test.
• Bargrizan et al. conducted a clinical study on 329
maxillary central and lateral incisors in children . Mean
oxygen values recorded in the patient’s finger were
97%, and mean oxygen values in the maxillary central
and lateral incisors were 87% and 84%, respectively. The
authors reported no significant correlation between
blood oxygen levels in the finger and in the teeth.
• There was a significant negative correlation between
the stage of root development and the blood oxygen
levels in the patients’ teeth. Mean oxygen values in
teeth with an open apex were significantly higher than
in the teeth with a closed apex.
66

RADIOGRAPHIC EXAMINATION
Intraoral techniques
• All injured teeth should be examined radiographically. This
examination serves two purposes:
• (1) it reveals the stage of root formation; and
• (2) it discloses injuries affecting the root portion of the tooth and
the periodontal structures.
• Current recommendations of the International Association of
Dental Traumatology (IADT)
• The ideal method is the use of three different angulations for each
traumatized tooth, using a standardized projection technique
• Thus, a traumatized anterior region is covered by one occlusal film
and three periapical exposures, where the central beam is directed
between the lateral and central incisors and the two central
incisors. This procedure ensures diagnosis of even minor
dislocations in cases of luxations as well as root fractures 67

• Children under 2 years of age are often difficult to examine
radiographically because of fear or lack of cooperation. With the
parents’ help and the use of film holders, it is usually possible to
obtain a radiograph of the traumatized area
69

EXTRAORAL TECHNIQUES
• Panoramic technique
• This procedure is always indicated in cases where a jaw fracture
is suspected or a temporomandibular joint (TMJ) problem is
found.
• Cone beam computed tomography
• Enhanced visualization of TDI,particularly root fractures and
lateral luxations,monitoring of healing and complications
• The usefulness of CBCT may be questioned in cases in which a
single periapical film has definitively shown a fracture in the
apical or coronal third of a root. However, clinical outcomes
depend on the exact location of the fracture, extent of
displacement and potential connection of the fracture to the
oral cavity
• May et al. concluded that CBCT is most useful in cases in which
conventional radiography yields inconclusive results or shows a70

• In such cases CBCT may rule out false
negatives, for example, a suspected
root fracture not visualized with
conventional radiography.
• For a root fracture in the middle
third, CBCT may rule out or confirm
an oblique course of fracture
involving the cervical third in the
labio‐lingual dimension.
• When intraoral radiography shows a
fracture in the middle third or the
absence of fracture in a case when
root fracture is suspected, CBCT is
also indicated
• CBCT is useful because it can reveal
the course of the fracture in the
sagittal plane
71

• Current therapeutic guidelines published by the IADT and the
American Association of Endodontists (AAE) recommend
considering the use of CBCT in cases with uncertain diagnosis.
• In the case of an alveolar fracture, CBCT may give valuable
information of the labio‐lingual course of the fracture
72

• Photographic registration of trauma
Exact documentation
The Dental Trauma Guide states ‘photographic
registration of the trauma is recommended, as it offers an
exact documentation of the extent of injury and can be
used later in treatment planning, legal claims, or clinical
research’ Note that patient consent can be required
73

Enamel infraction
- Incomplete fracture of the
enamel without loss of tooth
structure.
- Microcracks in the thickness
of enamel
- Rarely occurs alone and can
be sign of attachment injury
•Diagnosis
• - observed during routine
examination
• - detected using indirect light
or transillumination
• -use of dyes 76

The International Association of Dental Traumatology (IADT). Dental
Traumatology 2012;28:2-12
77

ENAMEL FRACTURES
Diagnosis
- generally involves the anterior
teeth(incisal edge or proximal angle)
- tooth is not sensitive to
temperature,dehydration and
pressure
- vitality testing may be negative
initially
- concomitant luxation injury can
result in discoloration of the tooth
78

Treatment
Extent and location of the fracture dictates the choice of
treatment
- selective grinding of the incisal edge
- composite restoration
Prognosis
Prevalence of pulp survival ranges from 99 –100%
Preoperative view After selective grinding 79

ENAMEL-DENTIN FRACTURE
Diagnosis
- clinical examination of the fractured
crown
- tooth is sensitive to variation in
temperature,dehydration and pressure
- vitality test may be negative
- concomitant luxation injury can result in
discoloration of the tooth
Incidence
- one-third of all dental injuries
80

• Biological consequences
• Enamel‐dentin crown fractures expose a large number of dentinal tubules.
• It has been estimated that the exposure of 1 mm of dentin exposes 20,000 to
45,000 dentinal tubules. Dentinal tubules constitute a pathway for bacteria
and thermal and chemical irritants which can provoke pulpal inflammation,
for which reason dentin covering procedures
• The speed of bacterial penetration into prepared dentin left exposed to saliva
and plaque formation in vivo was found by Landy and Stanley to be 0.03–
0.36 mm 6–11 days after preparation and 0.52 mm after approximately 84
days.
Defense mechanism can combat this reaction
-passive mechanism- outward flow of dentinal fluid
-active mechanism- immediate inflammatory response
Factors that affect these protective mechanism
-concomitant luxation injury
-age of the tooth
-time of treatment
-distance of the fracture from the pulp
Affect the prognosis of the tooth
81

TREATMENT
-Always require restoration in order to seal dentinal
tubules or restore aesthetics
-Achieved by- composite resin build-up
- re-attachment of the crown fragment
Prognosis
-Prevalence of pulp survival equals to 94-98%
82

RESTORATION BY COMPOSITE BUILD-UP
Preoperative view After composite build-up
83

Chamfer preparation
A chamfer preparation is made labially and
ligually, extending 2 mm from the fracture
surface
Application of a rubber dam
A rubber dam is applied. Adjacent
teeth should he included.
Shade selection
Shade selection should be made after
polishing with pure pumice and water and
before application of the rubber dam, as
the dehydrated enamel will change color.
Treatment of un-complicated crown
fracture with composite resin and acid-
etch technique
Uncomplicated crown fracture in a 19-year-
old girl.
84

Finished restoration
Clinical appearance of the
restoration.
Covering EXPOSED dentin exposed
dentin is covered with hard setting
calcium hydroxide cement.
Etching enamel
The enamel is etched and a
temporary crown form adapted.
Polymerization of composite
85

RESTORATION WITH RE-ATTACHMENT OF
CORONAL FRAGMENT
Advantages
-Improved aesthetics since enamel's original shape,color,
brightness and surface texture are maintained
-Reduced chair-side time
-Psychological benefit to patient or parent
( Reis et al 2004 )
86

Use of circumferential
bevel on enamel
before re-attaching
(Simonson 1979
,Walker 1996)
V shaped internal enamel
groove (Simonson 1982 )
Internal dentin groove
(Walker 1996, Reis 2001 )
External chamfer
(Franco 1985 )
Overcontour (Reis 2001 ) Simple re-attachment
(Pagliarini 2000 )
Techniques
87

 Overcontour and Internal dentin groove technique
provided highest fracture strength recovery. ( Reis et al
2004 )
 Presence of bevel increased the resistance to
fracture in all restorative material used for re-attachment.
Best fracture resistance was obtained with chemically cured
composite in the beveled specimens and worst fracture
resistance was in bonded specimens with adhesive
specimen alone.( Flavio 2004 )
88

Clinical steps in fracture reattatchment
89

Macedo GV, Diaz PI, DE O. FERNANDES CA, Ritter
AV. Reattachment of anterior teeth fragments: a
conservative approach. Journal of Esthetic and
Restorative Dentistry. 2008 Feb;20(1):5-18.
90

ENAMEL-DENTIN FRACTURE WITH PULPAL
INVOLVEMENT (COMPLICATED CROWN FRACTURE)
-Involves enamel, dentin &
pulp
-Diagnosis
- clinical examination of the
tooth
- pulp exposure
- tooth is sensitive to
variation in temperature,dehydration
and pressure
vitality test is positive unless
there is concomitant luxation injury
-Incidence
-2-13% of all dental injury
95

• Diagnostic signs
• Visual signs Crown fracture extending below gingival margin.
• Percussion test Tenderness to percussion.
• Mobility test Coronal fragment is mobile.
• Sensibility test Primary teeth -Inconsistent results. Permanent teeth -
Positive for apical fragment.
• Radiographs recommended An occlusal exposure.
Fracture at tooth 21
involving enamel dentine
and pulp.
96

Choice of treatment
-time spent with the exposed pulp
-health of the pulp before trauma
-diameter of the pulp exposure
-age of the tooth
-concomitant luxation injury
-stage of root development
•Treatment Objective:
• To maintain pulp vitality
• In immature teeth - to continue root development.
• To restore normal esthetics and function.
•Vital pulp therapy-pulp capping and pulpotomy
•Non vital pulp therapy-
-Immature apices-revascularization/Apexification
-Mature apices-pulpectomy 97

1.Direct Pulp Capping
Aim:
Preserve vital pulp tissue by physiologically
walled off with calcific
barrier.
1)Direct Pulp Capping
Indications: Exposure < 1mm
: Time elapsed since injury- within a few
hours
: Vital pulp
: Complete root development
: Absence of root fracture
98

2 )Partial Pulpotomy/Cvek
Pulpotomy
Aim:Remove only inflamed tissue , leaving healthy pulp
tissue for physiologic maturation of the root.
Partial Pulpotomy/Cvek Pulpotomy
Indications : Exposure > 1mm
: Time elapsed since injury >24 hours
: Vital pulp
: Fractured primary teeth
: Young permanent teeth
with incomplete root development
99

In 1978, Cvek noted that in most cases of pulps exposed for
more than a few hours, the initial biological response is pulpal
hyperplasia.
Inflammation in these cases rarely extends beyond 2 mm.
In his study involving 60 teeth with pulps exposed from 1 hour to
90 days, Cvek removed only 2 mm of the pulp and the
surrounding dentin. He covered the pulp stumps with calcium
hydroxide and reported a success rate of 96%.
100

3)Root Canal Treatment
Aims:
To remove all the infected material from the pulp chamber and
root canal system and filling the root canal with inert filling material.
:Large contaminated exposure
: Exposure >24 hours since the injury
: Necrotic pulp
: Permanent teeth with mature and closed
apex
: Absence of root fracture 101

4)Apexification
Aims:to induce either closure of the open apical third of the root canal or the
formation of an apical “calcific barrier” against which obturation can be achieved.
:Large contaminated exposure
: Exposure >24 hours
: Necrotic pulp
: Immature permanent teeth with open apex
Frank's criteria for apexification
• Apex is closed, through minimum
recession of the canal.
• Apex is closed with no change in root
space.
• Radiographically apparent calcific bridge
at the apex.
• There is no radiographic evidence of
apical closure but upon clinical
instrumentation there is definite stop at the
apex, indicating calcific repair.
102

CROWN AND ROOT FRACTURE
-Involves enamel, dentin,and cementum
-Pulp may or may not be involved
-Fracture extends below the cemento-enamel junction
Diagnosis and clinical presentation
- chisel type of fracture with a fragment or
fragments below the lingual gingiva
- fragment may be firm, loose and attatched
only to the periodontal ligament or may be lost
- periodontal injury causes pain on pressure or
biting
- exposed dentin or pulp causes sensitivity to
variation in temperature, dehydration and
pressure
Incidence
- 5% of all dental injuries
103

• A crown-root fracture left untreated usually results in pain from
mastication due to movement of the coronal fragment but is
otherwise without symptoms,
• The pathological events in case of no treatment comprise
inflammatory changes in the pulp, periodontal ligament and the
gingiva due to plaque accumulation in the line of fracture
• The clinical diagnosis of a crown-root fracture is apparent when the
coronal fragment is mobile
• The radiographic diagnosis is more difficult, at least with respect to
its lingual extent as the fracture line is usually perpendicular to the
central radiographic beam
104

TREATMENT
-Crown-root fracture have immediate implications for
endodontic, restorative and periodontal prognosis due to its
line of fracture which is subgingival
Objective
Exposing the fracture margins juxtragingivally so that all
clinical procedures can be managed with strict moist and
bleeding control.
Treatment is a multidisciplinary approach with an
an orthodontist, a periodontist and a prosthodontist.
105

1.REMOVAL OF CORONAL FRAGMENT AND
SUPRAGINGIVAL RESTORATION
-More conservative treatment as long as the lesion extends superficially under
the cemento-enamel junction.
•Indications-This procedure should be limited to superficial fractures that do not
involve the pulp.
•The loose fragment is removed as soon as possible after injury. Rough edges
along the fracture surface below the gingiva may be smoothed with a chisel-
The remaining Crown is covered with a temporary crown whose margin ends
supragingivally. Once gingival healing is seen (after 2-3 weeks), the crown can
be restored.
- It is followed by restoration at the juxtra gingival level.
- Gingiva reattach to the exposed dentin by forming long junctional epithelium
- Prognosis of the pulp and of the restoration is poorer 106

This is to convert the subgingival fracture to a supragingival fracture with
the help of gingivectomy and osteotomy
Indication -This should only be used where the surgical technique does
not compromise the esthetic result, i.e. only the palatal aspect of the
fracture must be exposed by this procedure.
• 2.Surgical exposure of # surface
Complications:
- pathologic lingual pocket
- inflammation of surrounding gingiva
-facial migration of restored tooth
107

Exposing the fracture site
The coronal fragment is removed. A
combined gingivectomy and osteotomy
expose the fracture surface.
Removal of the coronal
fragment and surgical exposure
of the fracture
Clinical and radiographic appearance
of a complicated crown‐root fracture.
Constructing a post‐retained crown
After taking an impression, a postretained
full crown is fabricated
The finished restoration
The clinical and radiographic condition
2 months after insertion of the crown.
108

3.FORCED ORTHODONTIC EXTRUSION
(WITH OR WITHOUT GINGIVOPLASTY)
Principle : To orthodontically move the fracture to a supragingival position
introduced by Heithersay 1973.
Indication : This is the only method that can be used for uncomplicated
crown‐root fractures if pulp vitality is to be preserved. It can also be used for
complicated crown‐root fractures but is more time‐consuming than surgical
extrusion.
In cases where it is desirable to reconstruct osseous and/or gingival defects,
slow orthodontic extrusion can be used to guide downgrowth of these tissues
How much tooth is extruded ?
Goal of extrusion - crown: root =1:1
109

• Treatment :
- after pulp capping ,pulpotomy or endodontic therapy
- orthodontic traction is applied to the labial surface of
the fragment or to a hook cemented into the root canal
- root is extruded over a period of 2-3 weeks
- gingiva follows the path of extruding root thus
gingivectomy performed
- prevention of re-intrusion by incising the
circumferential PDL fibers and
- fixation of the tooth for 14 days
- tooth is later restored with composite build up or
post-retained crown
110

A complicated crown root fracture in a 13-
year-old boy.
Endodontic treatment
The pulp has been extirpated.
After a period with a calcium hydroxide
interim dressing, the canal is filled with
gutta percha and a sealer.
Applying extrusion Appliances
Two premolars and the canine are used as
anchorage for the orthodontic appliances.
Orthodontic extrusion
The tooth is extruded quickly over a period
of 2-3 weeks in order to prevent coronal
migration of marginal bone.
Condition 1 year after extrusion
The root has been extruded
111

Removing the loose fragment
The coronal fragment is removed,
revealing a large pulp exposure. However,
pulpal vascularity appears intact.
Removal of the coronal fragment,
pulpotomy And orthodontic extrusion A
complicated crown-root fracture of a
mandibular central incisor in a 14-year-old
girl.
Pulpotomy
A pulpotomy is performed. The level of
amputation is placed at the cervical area,
and the tooth temporarily restored with
glass ionomer cement.
After verification of a hard tissue closure at
the amputation site, the tooth is extruded
using an orthodontic appliance
112

Extrusion complete
After extrusion ,the tooth is retained using
an acid- etch retainer employing glass fiber
and composite resin.
Restoration completed
The tooth has been restored using
combination of glass ionomer cement and
composite and resin
113

Malmgren et al 1991 report an average of five weeks of
active treatment is needed for 2-3 mm of extrusion
followed by retention period of 8-10 weeks
Bondemark et al 1997 described a new way for extruding
teeth orthodontically with the use of magnets, total of 9-11
weeks were needed for 2-3 mm extrusion
114

FORCED SURGICAL EXTRUSION
Tegsjo et al-1978
Buhler -1984
Kahnberg-1982
Principle : To surgically move the fracture to a
supra gingival position
•Indication : This approach should only be used
where there is completed root development and
the apical fragment is long enough to
accommodate a post‐retained crown.
•Surgical extrusion results in loss of pulp vitality
if performed in uncomplicated crown‐root
fractures. In such cases orthodontic extrusion
may be a better alternative if there is adesire to 115

• Treatment : - removal of the coronal fragment
- followed by luxation and removal of the
apical fragment.
- root is moved into a more coronal position
and secured in that position with sutures
and / or splint
In case of palatally inclined fractures ,
disarticulation of the radicular fragment
followed by intentional replantation with 180 degree
rotation.
After 3-4 weeks,tooth can be treated endodontically.
after another 1-2 months,tooth can be restored with post
retained crown
116

Vital root submergence
Johnson and Jensen (1997)
The root fragment is retained in situ and left vital.
Gingival tissue is sutured over the exposed root stump
to achieve primary closure. Later the root is replaced by
an implant.
117

CLINICAL MANAGEMENT OF A COMPLICATED
CROWN-ROOT FRACTURE OF MAXILLARY CENTRAL
INCISOR IN A 12-YEAR-OLD PATIENT
Ashveeta J. Shetty, Farhin Katge1 , Manohar
Poojari, Chirag International Journal of Pedodontic
Rehabilitation, 2018
The patient had a history of trauma to the
anterior teeth 5 days ago due to fall while
playing.
The medical history was not significant and
the findings of the extraoral examination
were unremarkable.
Intraoral examination revealed a
complicated crown-root fracture in the
maxillary right central incisor with a mobile
tooth fragment that extended subgingivally
in the palatal region.
118

• Radiographic examination using
intraoral periapical radiograph
confirmed the findings of the
clinical examination; the fracture
line on the palatal side could be
traced 2 mm below the alveolar
crest
• Closed apex was present with
maxillary right central incisor.
The periodontal space around
the tooth appeared to be normal,
and there were no pathologic
findings in adjacent teeth
• On the basis of clinical and
radiographic findings, a
diagnosis of complicated crown-
root oblique fracture
119

• A definitive treatment plan was made as follows: removal of
fractured fragment under local anesthesia followed by
endodontic therapy of residual tooth. Following this,
orthodontic extrusion to move the fracture line 3 mm above the
alveolar crest was planned to regain the lost biologic width
• After removal of the loose fragment, the tooth margin was
clinically visible on the labial side but not on the palatal side.
Probing with a periodontal probe revealed that the tooth
margin on the palatal side was located subgingivally and below
the alveolar crest level
• Root canal treatment was initiated. After preparing an
endodontic access cavity, the root canal working length was
determined
• The canal was prepared using ProTaper® rotary instruments till
F2.
• the root canal treatment was completed
120

Post space was prepared with the help of
Peeso reamer size 3
A “J” shaped post hook was prepared
using 19-gauge stainless steel wire and
cemented with glass ionomer cement.
Brackets were placed on maxillary right
lateral incisor and left central incisor.
Extrusion was activated by elastic which
was attached to the brackets and “J” hook.
Within a span of 2 weeks, 1 mm extrusion
was observed
121

However, 1 mm mesial tipping of maxillary
right lateral incisor was also observed.
Hence, brackets were also placed on both
right maxillary premolars, and E chain was
placed to reposition the right lateral incisor
Within 4 weeks, the desirable 3 mm
extrusion was observed along with
repositioning of the right lateral incisor. The
brackets and J hook were then debonded
Glass fiber post was placed into the root
canal for supporting the coronal fragment.
Size 2 glass fiber post with a 1.4mm
diameter was placed at the length of 12mm
and was luted. After cutting the excessive
post, core buildup was done using
composite resin . Tooth preparation was
done to receive polycarbonate crown.
Following tooth preparation and necessary
adjustments in the crown, the
polycarbonate crown was cemented using
luting glass ionomer cement and 122

• At 6-month follow-up,
patient was asymptomatic.
Clinical evaluation revealed
0.5 mm apical migration of
gingival margin and incisal
edge of 11. However, there
was no tooth mobility or
periodontal pocket
formation. Radiographic
evaluation at 6 months
revealed no abnormality
123

Type of
treatment
Advantage Disadvantage
1. Fragment
removal and
status quo
Very conservative
Restoration soon after injury
Poor prognosis of
pulp and restoration
due to difficult moist
control
2. Gingivectomy
(osteotomy if
needed)
Easy to perform.
Restoration soon after injury
Not in an esthetic
sensitive region
3. Forced
orthodontic
extrusion
Aesthetic sensitive region
Bone and gingiva follow the
tooth
Time consuming
Restoration much
later after injury
124

Type of
treatment
Advantage Disadvantage
4. Forced surgical
extrusion
Esthetic sensitive region
Rapid procedure
Diagnosis of additional fractures
/ fissures
RCT must be
performed
More traumatising
Restoration only
after contention
period
Risk of external
resorption
5. Vital root
submergence
Preservation of bone support Not in an esthetic
sensitive region
Cost of temporary
tooth replacement
6. Extraction Losses bone support
for future implant
Cost for temporary
tooth replacement
125

Level of fracture Prognosis of pulp
Enamel infraction Pulp survival 97-100%
Enamel fracture Pulp survival 99-100%
Enamel-dentin fracture Pulp survival 95-98%
Uncomplicated crown fracture Pulp canal obliteration 0.2-0.5%
Complicated crown fracture Pulp survival after direct pulp
capping 72-81%
Vital amputation 94-100%
All crown root fracture Worse than crown fractures
No reports available
Prognosis of the pulp for different levels of fracture
126

ROOT FRACTURE
Fracture of cementum and dentin involving the pulp
Mechanism- Frontal impact creates a compression zones labially and
lingually and the resulting shearing stress zone dictates the plane of fracture.
127

Incidence : relatively infrequent
occurs in less than 3% of all dental injuries
Frequency • Primary dentition: 2–4% of dental injuries
• Permanent dentition: 0.5–7% of dental injuries
The extent of displacement of the coronal segment is usually
indicative of the location of the fracture and can vary from simulating a
concussion injury (apical fracture ) to simulating an extrusive luxation (cervical
fracture)
Radiographic examination
Imperative to take 3 angled radiographs
Central beam is directed with a maximum range of 15-20o
of the fractured plane
128

Classification
direction location number extension position of root fragments
horizontal cervical third simple partial without displacement
oblique middle third multiple total with displacement
vertical apical third communited
129

Horizontal fractures
Case history and clinical examination
- patient feels discomfort on the buccal portion of the tooth
- sensitive to vertical and horizontal percussion
- slight or moderate mobility depending on the height of the line
of #
- tooth may appear elongated due to separation of fragments
- tooth may or may not respond to vitality testing
131

Radiographic examination
• Radicular fracture follows an oblique direction and if
they happen to coincide with the angulation of x-ray
beam , the radiograph image will be sharper.
• If the x-ray beam do not coincide - an elliptical line
giving the image of a multiple fracture.
• It is necessary to take several radiographs using
different angulations to confirm the diagnosis.+15,0,-15
• The lateral or anterior –posterior displacement of the
segments - step like appearance on the radiograph.
132

Radiographic demonstration of root fracture
133

HEALING PATTERNS
Andreasen and Hjorting-Hansen have described four types of healing of
root fractures
1. Healing with calcified tissue : Radiographically fracture line is
discernible but the fragments are in close contact
134

2. Healing with interposition of connective tissue :
Radiographically:
fragments appear separated by narrow radiolucent line and the
fractured edges appear rounded
135

3.Healing with interposition of bone and connective tissue :
Radiographically a distinct bony ridge separates the fragments
136

4.Lack of healing with interposition of
granulation tissue :
- Radio graphically a widening of the
fractured line radiolucency corresponding to
fracture line or both become apparent
137

138
Andreasen et al observed
 30% of the cases with root fractures healed by hard tissue
fusion of the fragments
 43% by interposition of connective tissue (PDL)
 5% by interposition of connective tissue (PDL) and bone and
 22% showed signs of inflammation and pulp necrosis

TREATMENT
• If treatment is instituted immediately
after injury, repositioning of the
fragment by digital manipulation is
easily achieved
• If resistance is felt upon
repositioning, it is most likely due to
fracture of the labial socket wall.
• In this case, repositioning of the
fractured bone is necessary before
further attempts are made to reduce
the root fracture After reduction, the
position should be checked
radiographically.
• Principles : Complete repositioning
and firm, immobile splinting ,with
passive splint for 3 months usually 139

APICAL THIRD FRACTURE
• In the case of apical-third fractures of the root, there is usually
no mobility and the tooth may be asymptomatic.
• It has been observed that the apical segment of a transversely
fractured tooth remains vital in most of the cases.
• Thus no treatment is required and a watch and observe policy
is advocated.
• If the pulp undergoes necrosis in the apical fragment, surgical
removal of the apical fragment is indicated
• When a root fractures horizontally, the coronal segment is
displaced to a varying degree, but, generally, the apical segment
is not displaced. Because the apical pulpal circulation is not
disrupted, pulp necrosis in the apical segment is extremely rare.
• Pulp necrosis develops in the coronal segment owing to its
displacement but occurs in only about 25% of cases.
140

• Saroglu et al have described treatment for horizontal root
fractures located in the apical third of the roots of the teeth 11
and 21.
• After administration of local anesthesia, the teeth were gently
repositioned by finger pressure and splinted.
• After 4 months, the splint was removed.
• There was no abnormal mobility in the root fractured teeth and
all of the teeth gave positive response to the vitality tests and
there was no sign of periapical pathology in the radiograph.
• After 6 years, the teeth were of normal color and mobility
Saroğlu I, Sönmez H. Horizontal root fracture followed for
6 years. Dent Traumatol 2008 Feb;24:117-9
141

• Middle third fracture
• Middle third root fractures has been repositioning of the coronal
fragment and immobilization through fixation to the neighbouring
teeth by means of a semi-rigid or rigid splint (e.g. orthodontic
wire/composite resin splint, acid-etch/ resin splint)
• Maintaining the splint for 2–3 months.
• Titanium trauma splints have also been advocated which are 0.2 mm
thick rhomboid mesh that can be easily adapted and stabilized on the
teeth.
142

• The treatment options may be categorized as follows:
• 1) Repositioning the fractured segment and splinting
• Marco et al reported a case of horizontal fracture in the middle third
of the left upper central incisor with a diastasis of 0.1 mm.
clinical aspects showing pulp with cold-induced sensibility, absence
of dental mobility or periapical changes and non-discolored crown
• A rigid splinting was performed with an orthodontic wire bonded to
the labial surfaces of the maxillary anterior teeth using composite
resin.
• After 45 days of observation, the clinical findings remained unaltered
and the rigid fixation was removed.
• The Clinical–radiographic control to assess loss of vitality must
continue for 1 month to 1 year because in this period, there is greater
possibility for the occurrence of pulp necrosis
Prithviraj DR, Balla HK, Vashisht R, Regish KM, Suresh P.
An overview of management of root fractures. Kathmandu
University Medical Journal. 2014;12(3):222-30.
143

• 2) Disinfection and obturation of the coronal segment only
If pulp necrosis develops, the apical fragment remains vital in
approximately 99% of cases, while the pulp tissue on the cervical
fragment can develop necrosis with consequent formation of
granulation tissue between the fragments,
Endodontic treatment is performed only in the coronal segment. An
apexification procedure of this segment should be performed before
obturation of the root canal.
This technique involves the repeated placement of calcium hydroxide
over a period of 6–24 months until a calcific barrier is formed at the
fracture line. Disinfection of coronal segment with calcium hydroxide
followed by obturation with gutta-percha
144

• Kusgoz et al have presented case reports describing the treatment
and follow-up of 3 maxillary central incisors with horizontal root
fractures treated with MTA as apical plug.
• All of the three cases had horizontal root fracture at the mid root
level with a diastasis of approximately 1 mm.
• The coronal fragment was filled with MTA as an apical plug.
Radiographs showed healing between the root fragments in each
case.
• Periapical radiolucency had decreased in the fracture areas
145

• 3)The third category of cases may be - of complete pulp necrosis,
• when endodontic treatment should be performed in both the apical
and the coronal fragments.
• 4) In addition to both the coronal and apical fragments being non-
vital and misaligned too, fourth treatment option should be
considered that is the-surgical removal of the apical portion
• Pulp space therapy of the coronal fragment and surgical removal of
the apical fragment is an arduous procedure but has reasonable
prognosis provided the remaining coronal fragment can support the
crown
146

• 5) Intraradicular splinting(Weine et al)
• The technique involves connecting the tooth fragments through
the root canal using a metal pin together with a root canal sealer
• It corrects the mobility of the coronal segment and the periodontal
tissue around the fracture site may heal
• Steel pins, titanium endodontic implants, prefabricated titanium
• dowels, posts, and ceramic, silver, or alloy cast dowels and posts have
been used for intraradicular splinting
147

• local infiltrative anesthetics,
• The coronal fragment is repositioned.
Both the coronal and the apical root fragments were endodontically
• treated and obturated at single visit
 The fragments were stabilized internally through insertion of a
stainless-steel endodontic file into the root canal.
• Just before completion of the root canal filling, a size 40 Hedstrom
file
• is inserted into the root canal with clockwise winding motion to
further
• reduce the fracture (achieve anchorage from the apical fragment for
• the coronal fragment).
• The file was separated intentionally, approximately at the cervical
• level.
• Four-year follow-up examination revealed satisfactory clinical and
• radiographic findings with hard tissue repair of the fracture line 148

• 6)Removal of the apical segment and stabilization of the coronal
segment with
• endodontic implants. (Feldman)
• The coronal segment is stabilized with the use of chrome cobalt pin
as the implant material.
• This alloy is composed of 65% cobalt, 30% chromium, and 5%
molybdenum.
• An endodontic stabilizer was used in conjunction with surgical
intervention and bone grafting
• Indication
• Both the fragments were displaced wide apart
• Mittal et al have described this treatment option for mid root fracture
of 11 that had greater amount of external root resorption.
• As both the fragments were displaced wide apart, it was decided to
extract the apical fragment surgically and place the endodontic
implant.
• An endodontic stabilizer was used in conjunction with surgical 149

Treatment plan for deep root fracture without pulp necrosis
150

Treatment plan of deep root fracture with pulp necrosis
151

Treatment plan for deep root fractures with pulp
necrosis of the coronal and apical segments
152

Treatment of severely extruded root
fracture
Treatment of a severely
extruded root fracture
This 20‐year‐old woman has suffered a frontal blow to
the left central incisor, resulting in extreme
displacement of
the coronal fragment.
Examining the displaced coronal
fragment
After cleansing the exposed root surface with saline, it
can be seen that thE coronal fragment has been forced
past the cervical margin of the labial bone
plate. The stretched and displaced pulp is seen within
the socket area.
Repositioning
After local anesthetic infiltration, the coronal fragment is
repositioned. To guide the root fragment into place, an
amalgam carver is inserted beneath the cervical bone
margin.
Splinting
The acid‐etch technique is employed once optimal
repositioning has been verified radiographically. The
labial surfaces are etched and a flexible splinting
material is applied.
153

• CERVICAL THIRD ROOT FRACTURES
• Cervical root fracture has poor prognosis; because of
• 1. Exposure of pulp to oral environment
• 2. Constant movement of tooth therefore difficult to
Treatment options are decided upon by
• 1. the position of the fracture line,
• 2. length of the remaining root segment and
• 3. the presence or absence of a coronal segment.
• Chances of healing with calcified tissue is poorest in
third fractures
154

Cervical third root
fracture
Fracture line above
the
level alveolar crest
Coronal segment
intact
Coronal segment
lost
Fracture line below
level of alveolar crest
155

FRACTURE LINE ABOVE THE LEVEL
ALVEOLAR CREST
• If the fracture line is coronal.
• Healing does not take place if an interaction between the
fracture line and the oral environment exists, because of
bacterial contamination from bacteria in the sulcus .
• The pulp tissue becomes necrotic
• In such cases, endodontic treatment is necessary
156

CORONAL SEGMENT INTACT
• Reattachment
• In cases where the coronal segment is available and fracture
occurs at or coronal to the level of alveolar bone crest,
• reattachment of the fractured segments can be done by light
transmitting or fibre-reinforced posts and resin-based composite
material.
157

CORONAL SEGMENT LOST
• Post crowns
• Post crowns with subgingival margins are indicated in cases
where the coronal segment is absent (lost)
• the fracture line is above the alveolar bone crest and the
apical root segment has sufficient length.
• In cases where exposure of crown margins is required, a
simple gingivoplasty or an apical positioned flap surgery is
performed.
158

FRACTURE LINE BELOW LEVEL
OF ALVEOLAR CREST
• If the fracture line extends below the level of the alveolar
bone crest and the remaining root structure is long enough to
support the subsequently applied restoration
• only the fractured portion is extracted and root canal therapy
is
performed.
• In the above case, gingivectomy, surgical or orthodontic
extrusion of the apical fragment is necessary to convert the
subgingival fracture to a supragingival
• restore the fracture either with the original fragment or
composite resins.
159

• Crown lengthening (periodontal surgery)
• Crown lengthening is performed if the fracture line is not
more than 1–2 mm below the alveolar bone crest.
• Removal of 1–2 mm of crestal bone adjacent to the deepest
part of the fracture and restoring the normal sulcus depth of 2
mm.
• It usually leads to apical shifting of gingival margin which
compromise aesthetics.
• Periodontal and osseous recontouring allows exposure of
fracture margin and sufficient root surface to give an
restorative finish line.
160

• Orthodontic extrusion
• This is also known as forced eruption, orthodontic eruption,
vertical extrusion or assisted eruption.
• It is carried out in cases where the fracture line extends
in the interproximal or labial surface (up to 6 mm below the
alveolar crest) and when crown lengthening would be
unaesthetic
• For a successful extrusion and post-treatment restoration,
distance from the fracture line to the apex should not be less
than 12 mm and a crown root ratio of approximately 50:50
be obtained
• This technique involves application of traction forces to the
tooth, causing vertical extrusion of the root and marginal
apposition of crestal bone
• The gingiva, epithelial attachment, and newly formed crestal
bone are also extruded, along with the tooth, leading to a
coronal shift of the marginal gingiva. 161

• Coronal shift of gingiva has the following disadvantages:
• 1. It partially masks the extent of root extrusion
• 2. Disparity in levels of epithelial attachment and bone between the
adjacent teeth
• 3. Relapse of the extruded fragment.
• Therefore, at the end of the procedure, a conservative periodontal
surgery is necessary to correct any discrepancy followed by a
stabilization period of 7–14 weeks before the orthodontic appliance
is removed.
• Follow-up
• Clinical and radiographic examination should be done at 3, 6, 12
months and yearly thereafter
• Patients should be advised Use of a soft brush and 0.2%
chlorhexidine rinse prevents accumulation of plaque and debris and
helps in maintaining good oral hygiene.
162

COMPLICATIONS
• 3-complications
1.Pulp necrosis- 20-44%- can be Rx ed
successfully.
2.Root canal obliteration -69%-73%.
3. Root resorption: 60% – Surface resorption
(internal and/or external) is considered to be
a link in fracture healing and requires no
treatment – External inflammatory resorption
and ankylosis (replacement resorption) are
very rare 163

Vertical fractures
•The line of fracture is parallel to the long axis of the tooth and can extend from
the crown to the apex or is localized in the apical, middle or cervical third of the
root
• May or may not involve the pulp chamber
• Seen most often in teeth that have had endodontic treatment
164

Incidence
 Vertical root fracture represents 2 to 5% of crown/root fractures
 They usually occur in older patients in posterior teeth due to
iatrogenic causes
 They also commonly occur in endodontically treated teeth
 In molar teeth, the fracture is most commonly bucco-lingual in
orientation in individual roots. Mesio-distal fractures are less common.
 The incidence of root fracture increases as the mesio-distal
diameter of the root decreases (maxillary second premolar,
mesiobuccal roots of maxillary molars, mesial roots of mandibular
molars).
.
Rosen H, Partida-Rivera M. Iatrogenic fracture of roots
reinforced with a cervical collar. Oper
Dent 1986; 11: 46–50
165

•Radiographic examination
Fracture line perpendicular to the line of x-ray beam-
Presence of radio-opaque obturating material or posts-
Periapical radiolucency or a “halo” appearance on the proximal aspect
of root surface, angular resorption of the crestal bone
Difficulty in
diagnosing the
fracture
Case history and clinical examination
Spontaneous pain or pain on mastication, swelling, presence of sinus tract
Presence of deep, narrow periodontal pocket on the buccal or lingual root
surface or on both surface.
Use of fiber optic illumination
Bite test, Staining, Vitality test
Surgical exploration
166

A variety of approaches have been attempted and used to
treat the VRF, including:
 The use of cyanoacrylates
 Glass-ionomer cement with guided tissue regeneration
therapy
 Adhesive resin cement (4-META)
 Repositioning and Fixation with wire and mineral trioxide
aggregate.
An in vitro study assessing the resistance to fracture of root
segments
bonded with glass ionomer cement, composite resin and
Cyanoacrylate concluded that the bond strengths of composite
resin and cyanoacrylate were superior to GIC.
Firedman S, Moshonov J, Trope M. Resistance to vertical fracture of roots, previously
fractured and bonded with glass ionomer cement, composite resin and
cyanoacrylate cement. Endod Dent Traumatol 1993 Jun;9:101-5.
167

Treatment of vertical fractures
-Single rooted tooth
-complete fracture- extraction
- coronal fracture–removal of fractured fragment- reposition
the root coronally
-apical fracture- surgical removal
-Multi rooted tooth
-fracture involves one root-hemisection / radisectomy
Sealing of the fracture
- MTA,Glass ionomer, cyanoacrylates, composite resins
-Gortex membrane (polytetra fluoroethylene to establish new
periodotal attatchment)
-CO2 laser
168

Class I fracture Class II fracture Class III fracture
No periodontal defect Minor periodontal defect Major periodontal
defect
Viable pulp
Temporary
crown
nonviable pulp
(3 months) Ca(OH)2
(3-9 months)
obturation
Permanent restoration
Intraosseous
Nonviable
pulp
Exploratory/corrective surgery
Non viable
pulp
Hemisection,
Root amputation,
or extraction
Permanent
restoration
169

Takatsu et al have described a method to treat vertical root fractures.
 the treatment of a maxillary second molar exhibiting a complete
vertical crown-root fracture.
 The buccal and palatal segments were widely separated by as much as
2 mm and were immobile.
 They used orthodontic elastics to join the buccal and palatal
segments of vertical fractured root, which were then sealed with a
photo-cured resin liner so as to allow the tooth for root canal treatment
and laterrestoration with a cast crown.
Funato et al have described the treatment of an incomplete vertical
root fracture by cementation with adhesive resin intentionally after
endodontic treatment.
Takatsu T, Sano H, Burrow MF. Treatment and prognosis of a vertically fractured
maxillary molar with widely separated segments: a case report.
Quintessence Int 1995;26:479-84.
170

• Trope et al have described the treatment of a vertically fractured
• upper left second molar.
• The two fragments were extracted separately. The periodontal
• ligament was protected from damage extraorally by soaking it with
• Hanks balanced salt solution.
• The two segments were bonded with the use of biocompatible
glass
• ionomer bone cement and replanted in conjunction with an
expanded
• polytetrafluoroethylene (gore-tex) membrane.
• After 1 year follow-up, the tooth was functioning normally and was
• clinically and radiographically within normal limits
171

LUXATION INJURIES
Involves trauma to the supporting tissues of the tooth
Incidence : 30 - 44% of all dental injuries
permanent dentition - 15-40%
primary dentition - 62-69%
Luxaton injuries in the increasing order of severity are
Concussion
Subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation 172

CONCUSSION
A minor injury to the periodontal tissue without malposition or
mobility of the teeth
Mechanism : a frontal impact leads to hemorrhage and edema
in the periodontal ligament 173
Frequency-
32% of all traumatic dental injuries,

- no displacement or mobility of the tooth
- tender to touch
- pain to percussion ( only feature )
- history of recent trauma
- no bleeding from the gingival sulcus
- radio graphically no signs of pathology
- responds normally to vitality test in most of the cases
Treatment
- relief of occlusal interferences
- ordination of soft diet for two weeks
- monitor pulp response periodically
Follow up
- schedule follow up at 3 weeks,3,6,12 months & yearly
thereafter
174

SUBLUXATION
Results from slight injury to the periodontal tissue with a
slight increase in mobility
Mechanism : if the impact has greater force the periodontal ligament fibres
may be torn resulting in loosening of the injured teeth
175
frequency-
17% of the injuries

-tooth is slightly mobile
-signs of sulcular bleeding
-sensitive to percussion
Treatment
- relief of occlusal interferences
- ordination of soft diet for two weeks
- monitor pulp response periodically
- immobilization of 2 weeks for patient comfort
Follow up
- schedule follow up at 3weeks,3,6,12 months & yearly
thereafter
Prognosis of concussion and subluxation
- minimal risk of pulp necrosis and even less risk of root
resorption
176

EXTRUSIVE LUXATION
Extrusive luxation is partial displacement of the tooth out
of its socket
Frequency-7%
Pathogenesis :
• Oblique forces displace the tooth out of its socket. Only the
palatal gingival fibers prevent the tooth from being avulsed.
Both the periodontal ligament and the neurovascular supply
to the pulp are ruptured.
177

Clinical and radiographic features
The bisecting angle radiographic
technique Is more useful than an occlusal exposure in revealing
displacement
178

TREATMENT
•Treatment consists of atraumatic repositioning and fixation which
prevents excessive movement during the healing period. The value of
antibiotic therapy is thus far unknown.
•Repositioning of extruded incisors is achieved by a slow and steady
apical pressure which gradually displaces the coagulum formed
between the root apex and floor of the socket as the tooth is moved
apically. Thereafter, an acid-etch splint is applied and maintained for
2 - 3 weeks
179

LATERAL LUXATION
An injury involving displacement labially,
lingually, distally,or incisally
Frequency-11%
Represents rupture of the periodontal
ligament, pulp as well as injury to the labial
and/ or palatal alveolar bone plate
Pathogenesis -
Horizontal forces displace the crown palatally and apex labially. Apart from
severance of the p. ligament and neurovascular supply to the pulp,
compression of the p.ligament is found on the palatal aspect of the root.
180

CLINICAL AND RADIOGRAPHIC FEATURES
Clinical features- lateral displacement of tooth, sulcular bleeding,
sensitivity to percussion, high metallic sound to percussion due to
locking of the tooth in the new position.
Radiograph -Occlusal radiographic exposure
181

Treatment
Local anesthetic administered
Tooth repositioned by placing coronal and palatal pressure on the
apical root with index finger and labial pressure on the palatal aspect of
the crown with the thumb.
Splinting with an acid etch technique for three weeks.
182

Follow up
-radiograph taken at the end of three weeks to ascertain
healing
- Splint removed
-in case of rarefaction of marginal periodontium (due to extent
of trauma osteoclastic activity
-Splint is maintained for two months
183

• Prognosis for extruded and laterally luxated teeth
- pulpal and periodontal healing depends upon the
stage of root development at the time of injury
- risk of pulp necrosis present in both luxation
categories, especially in teeth with mature root formation
In a tooth with immature root formation, arrested root
development can be expected due to irreversible damage
to the Hertwig's epithelial root sheath.
-Progressive root resorption is rare after extrusion but
can occur after lateral luxation
184

INTRUSIVE LUXATION
An injury involving displacement in an apical direction into the alveolus
An axial impact leads to extensive injury to the pulp and periodontium
185

-tooth pushed into the socket
-gives metallic sound to percussion test
-infra occlusion
Radiographic evaluation
Treatment
Depends entirely upon the stage of root development
Immature root formation
- spontaneous re eruption can be anticipated
- During this process, the crushed cervical bone is usually repaired.
- Await spontaneous re-eruption, which usually takes 2-4 months
- pulpal healing is monitered during the period of re-eruption at 3, 4, 6 weeks
after injury
- in case of negative response of the pulp or periapical radiolucency
endodontic therapy with Ca(OH)2 dressing is done
186

Completed root development
-spontaneous re-eruption is unpredictable
-orthodontic extrusion is indicated over a period of 2-3 weeks
-prophylactic endodontic therapy is indicated as frequency
of pulp necrosis is found in 100% of cases.
Prognosis
-high risk of pulp necrosis and progressive root resorption especially in teeth
with mature root formation
187

With respect to pulp survival, only teeth with immature root
formation have been shown to demonstrate pulp survival
following intrusion.
With respect to periodontal healing, there is a high risk of root
resorption (58% for teeth with immature root formation and 70%
for teeth with mature root formation.
Moreover some teeth have been found to demonstrate ankylosis
as late as 5 years following injury, therefore requiring extended
follow-up periods.
Andreasen & Vestergaard Pedersen 1955.
188

189
of an intruded incisor
Clinical and radiographic condition in a
22‐year‐old woman after an axial
impact. Before application of orthodontic
appliances the tooth may be slightly
loosened with forceps.
The exposed dentin of both central
Incisors is covered with a hard‐setting
calcium hydroxide cement and glass ionomer cement.
Applying orthodontic traction
A 0.5 mm thick semi‐rigid orthodontic wire is adapted to
follow the curvature of the dental arch, including two
adjacent teeth on either side of the intruded
incisor. The orthodontic wire is bonded to the adjacent
teeth using an acid‐etch technique. In the area where
elastic
traction is exerted, a wire coil is placed in
order to prevent slippage of the elastic
Placing the bracket
A bracket is placed on the
labial surface.

190
Orthodontic traction Elastic traction of 70–100 g is
activated. The direction of traction should extrude the
tooth out of its socket in a purely axial direction. Elastic
traction should wait for 4–6 days if surgical loosening
has been performed.
Extrusion initiated After approximately 10 days,
osteoclastic activity around the intruded tooth has
usually resulted in loosening; and extrusion can then
take place. If extrusion has not yet begun after 10 days,
a local anesthetic is administered and the tooth is
luxated slightly with a forceps.
Extrusion complete After 4 weeks, the intruded tooth is
extruded to its original position and retained in this
position for 2–4 weeks. Thereafter, the orthodontic
appliance can be removed
Crown restoration The fractured crowns are restored
with composite resin.

Surgical extrusion
This procedure implies immediate
repositioning of the tooth into its normal
position. After administration of local
anesthesia, the tooth is grasped with a
forceps (preferably proximally) and brought
down into its normal position. Thereafter, the
displaced labial and palatal bone is
repositioned by finger pressure and the
gingival lacerations sutured.
A splint is applied and maintained for 6–8
weeks. This procedure is primarily indicated
in teeth with severe intrusion and mature
root formation
With multiple intrusions that have been
surgically repositioned, there may be
difficulty in reaching stability after
repositioning. This must be taken into
consideration when fabricating a splint,
which has to be extended bilaterally to
involve stable teeth.
191

Treatment related to trauma scenario
192

The International Association for Dental Traumatology (IADT) has
developed guidelines for the treatment of intruded permanent teeth
Teeth with immature root development with an intrusion depth <7
mm are recommended to left to spontaneously re‐erupt.
In teeth with immature root development with an intrusion depth >7
mm the guidelines recommend surgical or orthodontic repositioning.
Furthermore, the guidelines recommend spontaneous re‐eruption
for mature teeth with an intrusion depth <3 mm.
For mature teeth intruded >7 mm, orthodontic or surgical
repositioning is recommended.
For teeth intruded 3–7 mm no treatment recommendations are
given in the guidelines
193

AVULSION
Avulsion or exarticulation implies complete displacement of the tooth
from the alveolus
Incidence -0.5-16% in permanent dentition
-7-13% in primary dentition
Avulsion of teeth occurs most often in children from 7 to 9 years of
age, when the permanent incisors are erupting.
At this age, the loosely structured periodontal ligament and low
mineralized bone surrounding erupting teeth provide only minimal
resistance to an extrusive force.
Other types of injuries are often associated with avulsions; among
these, fractures of the alveolar socket wall and injuries to the lips are
the most common
Mechanism of avulsion
Frontal impact leads to avulsion with subsequent injury to both pulp
and periodontal ligament
-Drying of the periodontal ligament has detrimental effect on healing
-Pulp necrosis occurs with avulsion
-Revascularization possible in immature apices
194

STORAGE MEDIUM
• A storage medium may be defined as a physiological solution
that closely replicates the oral environment to help preserve the
viability of PDL cells following avulsion.
• The ideal requirements for a storage medium are
• It should have antimicrobial characteristics
• It should maintain the viability of periodontal fibres for an
acceptable period of time
• It should favour proliferative capacity of the cells (clonogenic
and mitogenic capacity)
• It should have the same osmolarity as that of body fluids (290-
300 mosmol/ kg) and pH balanced (7.2 – 7.4)
• It should be unreactive with body fluids
• It should not produce any antigen-antibody reactions
195

STORAGE MEDIUM
• It should reduce the risk of post-replantation root resorption or
ankylosis
• It should have a good shelf life
• It should be effective in different climates and under different
conditions
• It should wash off extraneous materials and toxic waste
products
• Use of such a storage media has been associated with
favourable healing outcomes.
• The storage media can be classified as Laboratory prepared and
Natural source.
196

Laboratory sources Natural sources
Hank’s Balanced Salt Solution Milk
Normal saline Saliva
ViaSpan Propolis
Eagle’s medium Coconut water
Custodiol Egg white
Dubelco’s storage Emdogain
Tooth rescue box Morusrubra
Conditioned medium Salvia officinalis extract
Gatorade Honey milk
Contact lens solution Tap water
Growth factors
L-DOPA
Cryoprotective agents
197

TYPES OF STORAGE MEDIA
Saline solution: –
The saline solution provides osmolality
of 280 mOsm/kg and despite
being compatible to the cells of the
periodontal ligament, it lacks essential
nutrients necessary to the normal
metabolic needs of the cells of the
periodontal ligament.
Blomlöf (1981), Courts 1983 and Krasner
1992 have stated that saline solution was
harmful to the cells of the periodontal
ligament in avulsed teeth if it is used for
longer than two hours.
199

• Tap water:
• It is an unacceptable storage media for
avulsed teeth.
• Blomlöf 1981, found that storing
cultured human PDL cells in tap water
for 1 hour caused more PDL cell
damage than the other physiological
and nonphysiological storage media
tested.
• They attributed the increased cell
damage to the cells lysis caused by the
very low osmolarity of tap water.
• Thus, tap water is not suitable interim
storage medium for retaining the
viability of PDL cells.
200

• Saliva:
• It can be used as a storing medium for a short period of time, for
it can damage the cells of the periodontal ligament if used for
longer than an hour.
• Its osmolality is much lower than the physiologic saline (60–70
mOsm/kg), thus it boosts the harming effects of bacterial
contamination.
• Its only advantage is it availability.
• Milk
• The American Association of Endodontics indicate milk as a
solution for avulsed teeth, for keeping the viability of the human
cellular periodontal ligament.
• Milk is significantly better than other solutions for its
physiological properties, including pH and osmolality compatible
to those of the cells from the periodontal ligament; the easy way
of obtaining it and for being free of bacteria
201

• It is used in the first 20 minutes after
avulsion.
• The favorable results of milk probably
occur due to the presence of nutritional
substances, such as amino acids,
carbohydrates and vitamins.
• The pasteurization of milk is
responsible for diminishing the number
of bacteria and bacteriostatic
substances, also for the inactive
presence of enzymes, which could be
potentially harmful to the fibroblasts of
the periodontal ligament.
• – Blomlöf (1983), and Trope and
Friedman (1992) recommended milk as
an excellent storing solution for 6
hours, however, milk cannot revive the
degenerated cells. 202

Hank’s balanced salt solution (AAE recommendation )
Composition
Glucose
Sodium chloride
Potassium chloride
Calcium chloride
Magnesium chloride
Sodium bi- carbonate
Sodium phosphate
Magnesium sulfate
pH – 7.2, Osmolarity 320m Osm / litre appropriate for cell
growth, non toxic and contain essential nutrients
Shelf life – 2 years 203

Viaspan
( Dupont Pharmaceuticials, Wilmington, U.S.A.)
Cold storage medium – Organ transplantation
pH – 7.4, Osmolarity – 320 m Osm / Litre
Superior long term storage medium
- 76.7% of PDL cells after 24 hrs
Reduces the incidence of root resorption
Disadvantages
Short shelf life
204

Contact Lens Solution (Huang et al)
 Sodium Chloride
 Copolymer of Polyoxyethylene and Polyoxypropylene
 Sodium phosphate monobasic
 Sodium phosphate dibasic
 Edetate disodium dihydrate (0.025%)
 Preserved with polyhexamide (0.0001%)
Preserve more viable cells than tap water and
Gatorade but are not as effective as HBSS &
Milk.
Buffered isotonic solution with preservatives
205

Egg albumin (Rozenfarb 1997)
Egg albumin is considered as a good
choice because of its high protein
content, vitamins, water, lack of
microbial contamination and easy
accessibility.
It has shown better cell viability and
significantly higher incident of PDL
healing as compared to milk and
equivalent cell viability as HBSS.
•Khademi (2008), had compared milk and egg
white as solutions for storing avulsed teeth, and
the results have shown that teeth stored in egg
white for 6 to 10 hours had a better incidence of
repair than those stored in milk for the same
amount of time.
206

Propolis (Margaret &Roberta 2004)
It is a sticky resin that seeps from the buds or bark of trees, chiefly
conifers.
It consists of flavonoids (45-55%), waxes and fatty acids (23-35%),
essential oils (10%), pollen-proteins (>1%), vitamins and sugars (5%),
other organics (ketones, lactones, quinones, steroids) and trace
minerals (iron and zinc).
The main active ingredients of propolis are flavonoids.
– It has antiseptic, antibiotic, antibacterial, antifungal,
antiviral, antioxidant, anticarcinogenic, antithrombotic
and immunomodulatory properties.
– Margaret and Pileggi (2004), reported that teeth
stored in propolis demonstrated the highest viability
for PDL cells, when compared with HBSS, milk and
saline.
– Shaher (2004), observed that with propolis, the
viability of PDL fibroblasts can be maintained for as
long as 20 hours. Hence propolis can act as a good
alternative natural storage medium for avulsed
207

Gatorade (Quaker Oats Company, USA):
– It is a transport medium commonly found at sporting
events.
– It is a noncarbonated sports drink often consumed
by nonathletes as a snack beverage.
It contains water, sucrose and glucose, fructose
syrups, citric acid, sodium chloride, sodium citrate,
monopotassium phosphate and flavoring/coloring
agent.
– It has a pH 3 and osmolarity ranging from 280 to
360
mOsm/L.
– Gatorade preserves more viable cells than tap
water but fewer than all other media, both at room
temperature and on ice. Therefore, Gatorade can only
serve as a storage medium if other more acceptable
media are not available, rather than allowing the
208

Emdogain:
Emdogain (Biora, Malmo, Sweden) is a commercial Enamel Matrix
Derivative (EMD) extracted from developing embryonic enamel of porcine
origin and contains several matrix proteins.
Studies have shown that it can influence the migration, attachment,
proliferative capacity and biosynthetic activity of PDL cells.
It has also been used in antiresorptive-regenerative therapy along with
topical glucocorticoids and systemic doxycycline.
Thus, it is a recommended therapeutic agent for the management of
avulsed permanent teeth. However, no firm conclusion regarding the
efficacy of EMD application on healing of replanted and autotransplanted
permanent teeth can be drawn because of a lack of randomised controlled
trials and clinical controlled trials
209

• Coconut water
• Coconut water is a biologically pure, sterile and natural
isotonic fluid that is mainly available in tropical countries. It
is rich in amino acids, proteins, vitamins and minerals and
thus is readily consumed to replenish lost body fluids,
electrolytes and sugars.
• Recent investigation by Gopikrishna et al.(2008) has
proposed coconut water as a promising medium for
avulsed teeth and has shown it to be superior to HBSS and
milk in maintaining the viability of PDL cells.
• Eagle’s medium:
• – It contains 4 mL of L-glutamine; 105 IU/L of penicillin; 100
μg/mL of streptomycin, 10 μg/mL of nystatin and calf
serum
• – It has high viability, mitogenic and clonogenic capacity up
to 8 hours of storage at 4°C.
• When the storage time was up to 24 hours, Eagle’s medium
was less effective than milk or Hank’s balanced salt
solution, which could be attributed to the low temperature
210

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