Truamatic dental injuries / prosthodontic courses

TRAUMATIC
INJURIES •INDIAN DENTAL ACADEMY
•Leader in continuing Dental
Education
www.indiandentalacademy.com

Introduction

Trauma refers to injury; damage; impairment; or
degeneration to body tissue.

Fracture is a sudden, violent breach of
continuity of bone, which may be complete or
incomplete in character.

Avulsion is loss of tissue due to trauma.

Classification

Traumatic injuries can be classified according to,
* Etiology
* Anatomy
* Pathology
* Therapeutic consideration
* Prognosis

Classification based on tissue and site
All injuries to the face may be divided into two
basic groups,
• Injuries to soft tissues
• Injuries to bone

Rabinowitch Classification (1956)
• Fractures of the enamel
• Fractures into the dentin
• Fractures into the pulp
• Fractures of the root
• Comminuted fractures
• Displaced teeth

Ellis and Davey Classification (1960)
• Class 1 - Simple fracture of the crown involving
little or no dentin.
• Class 2 - Extensive fracture of the crown
involving considerable dentin, but not the dental
pulp.

involving considerable dentin and exposing the
dental pulp.
• Class 4 - The traumatized teeth that become
non-vital with or without a loss of crown
structure.
• Class 5 - Teeth lost as a result of trauma.www.indiandentalacademy.com

• Class 6 - Fracture of the root with or without a
loss of the crown structure.
• Class 7 - Displacement of a tooth without
fracture of the crown or root.
• Class 8 - Fracture of crown en masse and its
replacement.
• Class 9 - Traumatic injuries to primary teeth.

Modification of Ellis classification by
McDonald, Avery and Lynch (1983)
• Class 1 - Simple fracture of the crown involving
little or no dentin.
involving considerable dentin, but not the dental
pulp.

• Class 3 - Extensive fracture of the crown with an
exposure of the dental pulp.
• Class 4 - Loss of the entire crown.

BASRANI CLASSIFICATION
• Crown fractures.
– Fracture of enamel.
– Fracture of enamel and dentin.
• Without pulp exposure.
• With pulp exposure.
• Root fractures.
• Crown root fractures.

WHO Classification (1992)
• Adapted from WHO Geneva 1992.
• Based on anatomy, therapeutic and prognostic
consideration.
• It is applied to both primary and permanent
teeth.
• Code numbers used according to the
International classification of diseases 1992.www.indiandentalacademy.com

Injuries to the hard dental tissues and pulp
Enamel infraction N 502.50: An incomplete
fracture (crack) of the enamel without loss of
tooth substance.

Enamel fracture (Uncomplicated crown
fracture) N 502.50: A fracture with loss of tooth
substance confined to enamel.

Enamel - dentin fracture (Uncomplicated
crown fracture) N 502.51: A fracture with loss
of tooth substance confined to enamel and
dentin but not involving pulp.

Complicated crown fracture N 502.52
A fracture involving enamel and dentin and
exposing the pulp.

Uncomplicated crown root fracture N 502.54
A fracture involving enamel, dentin and
cementum but not involving the pulp.

Complicated crown root fracture N 502.54
A fracture involving enamel, dentin and
cementum and exposing pulp.

Root fracture N 502.53: A fracture involving
dentin, cementum and the pulp.

Injuries to the periodontal tissues
Concussion N 503.20: An injury to the tooth
supporting structures without abnormal
loosening or displacement of the tooth.

Subluxation N 503.20
An injury to the tooth supporting structures with
abnormal loosening but without displacement of
the tooth.

Extrusive luxation (peripheral dislocation,
partial avulsion) N 503.20
Partial displacement of the tooth out of its
socket.

Lateral luxation N 503.20
Displacement of the tooth in a direction other
than axially. This is accompanied by fracture of
the alveolar socket.

Intrusive luxation (central dislocation) N
503.21: Displacement of the tooth into the
alveolar bone. This injury is accompanied by
fracture of the alveolar socket.

Exarticulation (complete avulsion) N 503.22
Complete displacement of the tooth out of its
socket.

Injuries of the supporting bone
Comminution of alveolar socket (mandible N
502.60, maxilla N 502.40): Crushing and
compression of the alveolar socket. intrusion
and lateral luxation.

Fracture of the alveolar socket wall
(mandible N 502.60, Maxilla N 502.40)
A fracture contained to the facial or lingual
socket wall.

Fracture of the alveolar process
(Mandible N 502.60, Maxilla N 502.40)
A fracture of the alveolar process which may or
may not involve the alveolar socket.

Fracture of mandible and maxilla
(Mandible N 502.61, Maxilla N 502.42)
A fracture involving the base of the mandible or
maxilla and often the alveolar process (jaw
fracture). The fracture may or may not involve
the alveolar socket.

Injuries to gingival or oral mucosa
Laceration of gingival or oral mucosa N
S01.50: A shallow or deep wound in the
mucosa resulting from a tear and usually
produced by a sharp object.

Contusion of gingival or oral mucosa N S00.50
A bruise usually produced by an impact from a
blunt object and not accompanied by a break of
the continuity in the mucosa, causing sub-mucosal
hemorrhage.

Abrasion of gingiva or oral mucosa N S00.50
A superficial wound produced by rubbing or
scraping of the mucosa leaving a raw bleeding
surface.

ETIOLOGY

Iatrogenic injuries in new born
• Prematurely born infants kept under prolonged
intubations in ICU .
• Intubations rests along maxillary alveolar
process.
• Cause developmental enamel defect in primary
dentition.

Fall in infancy
• Dental and maxillo-facial injuries are common
during later half of first year of life.
• Because of child's lack of experience and motor
coordination and learning motor activity like
crawl, stand, or walk .
• Occasionally due to fall from a baby carriage.

Fall in child hood
• Another peak incidence period for dental injuries
is just before school age and is mainly the result
of falls and collision.
• In school age play ground injuries are most
case of traumatic injuries.
• High frequency of crown fracture is reported.

Child physical abuse
• Battered child syndrome
• 0.6 %of children suffer traumatic injuries due to
Child physical abuse.
• In USA 3000 children per year die due to sever
traumatic injuries caused by child physical
abuse.

• Fatal out come mainly due to intra-cranial
hemorrhage. 50% of abuse injury are found on
face around mouth.
• Facial trauma is the principle reason for
admission to hospital.

Automobile / bicycle Accidents
• In young children more common.
• High velocity impact.
• Multiple crown fracture with lip
and chin injuries are most
common results.

• In recent years, injuries secondary to automobile
accidents has been observed to be on the rise.
• Front seat passenger are more prone to trauma.
• Facial trauma due to collision of face to dash
board or steering .

• Child standing or sitting on front seat thrown
against dash board during sudden stop.

Assault / torture
• Commonly seen in adults alcoholic abuse.
• Battered wife syndrome leads to battered child
syndrome --vicious cycle.
• Substantial delay in injury and treatment period.
• Repeated injury to head and neck.
• Previous history of abuse.

Sports
• Teenagers are commonly injured.
• These injuries are often related to contact sports
(1.5%- 3.5% ) like football, baseball, basketball,
ice hockey, soccer and wrestling.
• Soccer > Hand ball > Horse back riding

Drug related / GA recovery
• Drug abusers
• 3-4 hrs after drug in take violent tooth clenching
• Fracture in premolar and molar region
Epilepsy
• Special risk category
• 52% of all patient suffer from facial injuries
• 1/3rd
of such injuries reported due to fall during
attack. www.indiandentalacademy.com

Dentinogenesis imperfecta
• Spontaneous root # is common
• Due to low micro hardness of
dentin abnormally tapered root
Mental retardation
• Lack of motor coordination

Mechanism of injury

Mechanism of dental injury
Direct trauma
• Tooth strike directly
Indirect trauma
• Lower jaw force fully closed
with upper
• Associated with Jaw #
• Cerebral involvement seen
• Posterior teeth involved in #www.indiandentalacademy.com

Type of dental injury
• Primary dentition due to resilient supporting
tissue ex-articulation luxation common
• Permanent dentition crown # is more common
Place of injury
• In Iraq, Australia and in India injury in play
ground is more than other places.

Complication of dental injury to primary teeth
• Failure to continue eruption
• Color change
• Infection and abscess
• Early exfoliation space loss
• Ankylosis
• Injury to developing bud
• Financial cost

Complication of dental injury to permanent teeth
• Color change
• Infection and abscess
• Early exfoliation space loss
• Ankylosis
• Loss of alveolar bone support
• Financial cost
• Root resorption

Examination and diagnosis

Examination and diagnosis
Consider traumatic injuries as emergency,
• To relieve pain.
• Reduce psychological stress.
• Facilitate reduction of # or avulsion.
• For good prognosis.
Complete examination correct diagnosis
success full treatmentwww.indiandentalacademy.com

Record all information's in standardized charts,
• Save time.
• Not miss any information in hurry.
• Insurance claiming.
• Medico-legal considerations.
Only acute bleeding, respiratory problem, severe
cerebral trauma and avulsion of teeth will alter
above procedure.

History
Ask for personal data: Patient’s name, age, sex,
address and telephone number ?
• Obvious necessary for record maintenance.
• Provide clue for possible cerebral involvement.
• Provide clue for general mental states.

When did injury occurred ?
• Time interval between injury and treatment
started.
• Alter possible prognosis and line of treatment
specially in cases of re-implantation, pulp
exposure, bone# and severe soft tissue injuries.
Where did injury occurred ?
• For tetanus prophylaxis.www.indiandentalacademy.com

How did injury occurred ?
• Direction of blow which tells possible structure
affected.
• Object in mouth like pacifier labial displacement
of teeth.
• Young child and women with multiple soft tissue
injury at deferent stage of healing improper
history child abuse.

Treatment else where ?
• Storage of avulsed teeth.
• Medication taken.
• Re-implantation and immobilization considered.
History of previous injury ?
• Sustained repeated injury influence pulp vitality
test.
• Affects healing capacity of pulp and PDL.www.indiandentalacademy.com

General health and medical history ?
• Allergic reaction
• Epilepsy
• Bleeding disorder
• Differs emergency and later treatment

Spontaneous pain from teeth ?
• Hyperemia
• PDL damage
• Pulp damage
• Crown root #
Teeth reacts to thermal changes ?
• Dentin or pulp exposure

Did trauma caused amnesia, unconsciousness ?
• Drowsiness, vomiting, headache unable to recall
past memory possible cerebral involvement.
• Emergency medical consultation
Teeth tender to touch eating ?
Any disturbance in bite ?
• Extrusion, lateral luxation, alveolar jaw #,
crown root # www.indiandentalacademy.com

Clinical examination
• Record extra oral wound.
• Wound penetrating entire
thickness of lip.
• Demarcated by two parallel wounds, inner and
outer which indicate possible tooth # and
fragment burreid in soft tissue.www.indiandentalacademy.com

• Irrespective of size these fragments are not
palpable.
• So care full x ray examination of soft tissue is
required.
• see for possible foreign body.
• If not treated cause chronic infection and
disfiguring fibrosis.

• Record injury of oral mucosa, gingiva.
• Bleeding from non lacerated marginal gingiva
indicate damage to PDL ligament.
• Sublingual sub-mucosal heamatoma indicate
jaw #.

• Gingival laceration usually associated with
displaced teeth.
• Check for muco-periosteal displacement by
properly cleaning alveolar process.
• Palpate facial skeleton for bone #.

• Examine crown of teeth for #, pulp exposure,
color change after proper cleaning.
• Infarction lines on enamel seen by directing light
beam II to long axis of tooth by shadowing light
beam with finger.
• Examine for extent of crown fracture, pulp
involvement, if pinkish hue visible, Not perforate.www.indiandentalacademy.com

• In case of indirect trauma suspect, posterior
teeth fracture and examine.
• Crown root # in posterior teeth one quadrant is
often accompanied by similar # on same side of
opposing jaw, so suspect and examine.

• Color change of traumatized tooth noted
occurs in post injury period.
• Prominent on oral aspect of crown in cervical
third.
• Examine with trans-illumination reveal change
in translucency.

Grey discoloration of 11 after 3 months of lateral luxation
Initial grayish discoloration becoming normal in later visit

Red discoloration of11 revert back after 5years follow up
Yellow discoloration of 21 after 10 yrs pulp canal obliteration

Follow up of subluxated primary incisor
1st
day of injury 3week reddish brown discolor
1year follow up
Yellowish discoloration
Pulp canal obliteration

Trance illumination test

• Record displacement of teeth.
• Visual, occlusal x-ray examination done
• In case of luxation note direction and extent in
mm.
• Laterally luxated or intruded teeth some times
firmly locked in bone with no tender so only x
ray, percussion tone and deranged occlusion
can give clue.

• Due to loss of protective reflexes in unconscious
patient.
• Avulsion, possibility of inhalation swallowing of
teeth or prosthesis are always considered.
• Chest abdomen x ray taken.

• In case of primary dentition diagnose
dislocation of apex of teeth as it can impinge
on permanent successors

• Deranged occlusion indicate jaw #, alveolar
process #, displacement injury
• Abnormal mobility of jaw fragment seen in
case of #
• Typical sign of alveolar # is movement of
adjacent teeth when mobility of one tooth is
checked.

• Palpation of alveolar process un even counter
indicate bony #
• Mobility of teeth and alveolar fragment check for
direction
Horizontal , axial
• Axial mobility disruption of vascular supply
• D/d erupting teeth resorbing primary teeth
excluded

• Depending on location root # exhibit mobility
confirmed by X ray
• TOP and percussion note
• TOP +ve indicate damage to PDL
• Vertical and Horizontal
• Checked with handle of mouth mirror

• Begin with non injured tooth to assure reliability
of patients response
• Smaller children finger tip used
• Percussion calibrated instrument introduced
periotest
• But force produced by this this instrument might
contribute to new trauma in root #

• Hard metallic sound Horizontal teeth locked in
bone
• Dull sound sub luxation extrusive luxation
• D/D apical lesion which also will produce dull
sound

Reaction of pulp to vitality test
• Controversial issue
• Cooperative and relaxed pt required
• Accuracy not possible in first visit
• But still noted at time of injury to establish a a
point of reference for following test

• Principle - transmission of stimuli to sensory
receptor of the dental pulp and registering the
reaction.
Mechanical stimulation
• Dentin or pulpal stimuli tested by scraping with
probe or drilling the test cavity

• In replanted teeth this is not possible as pain
sensation is not noted till dentin pulp junction
reached.
• In case of clinically visible pulp exposure
stimulus is tested by cotton socked in saline.

Thermal tests
• Not reliable completely and not reproducible
• Normal pulp may yield negative response
• Non vital teeth may yield +ve response in
case of gangrene thermal expansion of fluid
exerts pressure on inflamed PDL

Heated GP
• Memford 5mm GP stick 2 sec flamed applied to
tooth on middle third of the facial surface
Ethyl chloride
• socked cotton place on facial surface of teeth
more consistent than above two
• Highly inflammable

Ice
• Cone of ice to facial surface of tooth 5-8 sec
normal tooth may not respond.
Carbon dioxide snow -ve78 -- -108 C
• Consistent reliable results seen even in immature
teeth. Allow pulp testing in completely covered
tooth with crown splint
• But it results in new infarction lines on enamelwww.indiandentalacademy.com

Dichloro difluoromethane
• Frigen, Provotest
• Aerosole –28 -- -18 c
• Consistent reliable results seen in immature
teeth
• But it results in new infarction lines on enamel

Electrometric test
Ideal requirements
• It should allow control of the mode, duration,
frequency of the stimulus.
• Voltage measurement type is not satisfactory.
• Given voltage produces varying current
depending on varying resistance of tissue which
is altered from fissure caries and restorations

• Stimulus should be clearly defined
• Electrode area should be as large as tooth
shape will permit to allow maximum stimulation.
• Stimulus duration of 10 millisecond or more has
been advocated.
• Digital pulp tester is more reliable than other.

• Patient is informed and instructed to indicate
when sensation is first experienced.
• Isolate from saliva to prevent diversion of current
to PDL or gingiva.
• Do not desiccate tooth which increases
resistance.
• Medium such as saline and tooth paste can be
used between electrode and tooth.www.indiandentalacademy.com

• Loose teeth immobilized before pulp testing
• Pulp testing should be done before
administration of LA
• Electrode is placed as far from gingiva
preferably on fracture area or the incisal edge.

• Circuit can be completed by
• neutral electrode held by patient by grasping
the end of pulp tester.
• Examiner touching patient mouth with finger
or mouth mirror.
• Clip to the lip

• Rheostat of the tester is advanced continuously till
the patient reacts to give threshold value.
• Threshold value should be determined by a quick
increase in current rather than slow which causes
adaptation.
• Then this value is compared with abnormal tooth.

• Low reading indicate hyperemia, acute pulpitis
• High reading indicate chronic pulpitis
degeneration

• Splints or temporary crown used alter
response by increasing threshold value so
cold test is the best alternative.
• Teeth with luxated injuries may not respond
to the stimulus temporarily.
• They start reacting after few weeks or months

• In case of immature root and adult obliterated
canals electric pulp testing will gives false – ve
results
• Teeth under going orthodontic treatment shows
high excitation threshold.

Laser Doppler Flowmetry
• Laser beam directed at coronal aspect of pulp
the reflected light scattered by moving blood
cell under goes a Doppler frequency shift
• The fraction of light scattered back from pulp
is detected and formed in signal

• Non vital teeth reliability 97%
• Vital teeth reliability 100%
• Draw backs
• Blood pigment in discolored teeth inter fear with
laser light transmission
• Price of instrument

Radiographic examination
• Reveal stage of root formation.
• Show root # or PDL damage.
• Most root # are disclosed by X ray examination
as fracture line usually run parallel to central
beam.
• Luxation injury PDL wide
• Intrusion causes PDL narrow

• Dislocation injury take 3 angulations Central
beam directed between two CI, Central beam
directed between CI and LI and occlusal.
• Steep occlusal exposure used for diagnosis of
root # and Lateral luxation with oral
displacement of tooth

• Below two years patient x ray taken with parents
and special holder
• In uncooperative patients reduce exposure time
by 30% for each 10 kvp increase.
• Lip exposure ¼ - ½ normal time with decreased
kvp
• Infarction lines decease kvp.

Extra oral x ray for jaw #
• Waters view or occipito-mental view (OMV)
30/400
for midface, including the zygoma,
maxilla, maxillary sinus orbital floors and nasal
pyramid.
• Extraoral – orthopantomogram (OPG) condyles,
alveolar segments..www.indiandentalacademy.com

• Caldwell view – frontal sinuses, frontal bone,
anterior ethmoidal cells and zygomatic frontal
suture.
• Towns view Lateral oblique mandible body angle

Management

Management of patient
• Emergency management
A- Airway with cervical spine control
B- Breathing and ventilation
C- Circulation and hemorrhage control
D- Disability neurological states

• H/O loss of consciousness
• Altered mental status
• Dilated and unreactive pupil
• Blurring of vision
• Severe headache, Dizziness, Drowsiness

• Seizures
• Vomiting
• Loss of smell, taste, hearing and/or sight
• Discharge from the nose and ears.

Luxation Injuries
• Concussion, subluxation, extrusion, lateral
luxation, intrusion.
• Prevalence Pry_ -15-61%, Perm_-62-73%.
• Primary intrusion and extrusion most common
• In permanent dentition other type more.

Concussion
• Miner injury to PDL
• No tooth loosening present
• Tooth tender on touch
• TOP +ve in both vertical and horizontal direction

Subluxation
• Teeth retained in normal position in arch but
tooth is mobile in horizontal direction
• Sensitive to percussion and occlusal force
• Hemorrhage from the gingival crevices indicate
trauma to PDL.

Extrusion
• Teeth appear elongated most often with lingual
deviation of crown
• PDL bleeding seen
• Percussion test show dull sound

Lateral luxation
• Crown show lingual displacement
• Associated with # of vestibular part of the socket
wall
• Displacement is usually visible
• Check occlusion

• percussion test show high pitched metallic
sound
• Teeth are not sensitive to percussion and
completely firm

Intrusion
• Show marked displacement in primary teeth
• percussion test show high pitched metallic
sound
• Teeth are not sensitive to percussion and
completely firm
• Examine floor of nose for bleeding and
protruding apex.

• Palpation of alveolar socket reveals position of
displaced tooth.
• Note amount of displacement of teeth in mm.
And direction of displacement.
• In case of lingual displacement permanent
successor is directly involved.

Radiographic examination
• Disclose minor dislocations
• Bisecting angle technique is used to minimize
the error.
• Width of PDL space increased in case of
extrusive luxation decreased or obliterated in
case of intrusion
• In primary dentition it reveals relation between
permanent to deciduouswww.indiandentalacademy.com

Pathology
Concussion subluxation after 1 hrs
• Edema, bleeding, PDL lacerations
• Pulp neuro-vascular supply may or not intact.
• After 1 day cell free zone seen in PDL bordered
by a zone of inflammation. In bony socket
osteoclasic activity may seen. After 1 week this
reach to root surface.
• www.indiandentalacademy.com

• After 10 days resorption subsides leaving
surface resorption cavities along root surface
Lateral luxation
• Complex injury involving rupture and
compression of PDL fibers and nero- vascular
supply
• With # of alveolar socket wall

Extrusive luxation
• Complete rupture of PDL and neuro-vascular
supply to pulp
• After 3 days PDL healing starts with fibroblast
formation
• After 2 weeks newly formed collagen fibers seen
• After 3 weeks PDL becomes normal.

Intrusive luxation
• Extensive crushing injury to PDL and alveolar
socket and rupture of nero- vascular supply to
pulp.
• After 3 months some teeth may show ankylosis
• Or surface resorption normal PDL

• Treatment of luxation injuries
• Concussion and sub-luxation
• Relief occlusion of injured teeth in case of
non mobile or grade 1 mobile soft diet is
advised for 14 days in case of marked
loosening immobilization is indicated
• Follow up tooth for 1 year with Xray and pulp
vitality test.

• Extrusive and lateral luxation
• Administer LA if forceful repositioning is
anticipated
• Reposition tooth in its proper position. In case
of delayed treatment teeth some time realign
spontaneously or moved orthodontically
• After replacement tooth is splinted with acid
etch resin splint.

• Splinting period
• Extrusion 2-3 weeks
• Lateral luxation 3weeks
• In case of marginal bone break down 6-8
weeks
• Follow up tooth for 1 year with Xray and pulp
vitality test.

• Intrusion
• Repositioning is anticipated in incomplete
root formation
• In case of completely formed root
orthodontocally tooth is pulled out to normal
position over a period of 3-4 weeks
• Follow up tooth for 5 year with X ray and pulp
vitality test.

Avulsed Tooth Immature Pulp
Open apex – 2 mm
No Dry Storage Time Dry Storage Time
Category 1
Replant immediately
at site of the incident
Category 2
15 min-6hrs extraoral
time stored in
physiologic media
(HBSS or Milk)
Category 3
15-120 minutes
with wet, but
non-physiologic
media (water or
saliva)
Category 4
0-60 min
extra oral
time with
dry storage
Category 5
Greater than
60 min
extraoral
time with dry
storage
Treatment guideline for avulsed tooth with open apex
Soak in 1% Doxycycline
solution for five minutes
1mg/20 ml Doxycycline
solution or 50 mg
capsule/1000 ml saline
Change
transport media
to HBSS if
available
Soak in citric acid for three
minutes and rinse well or
debride and remove PDL
gently with scaler
1) Replant and reposition
2) Obtain PA radiographs to verify position
3) Place flexible splint
4) Place on systemic antibiotics
5) Assess tetanus vaccination
6) Provide post op instructions
7) Follow-up in 7-10 days
Place in NaF for
20 minutes
Assess need for
apexification, apexogenesis
or root canal therapy

Treatment guideline for avulsed tooth with closed apex
Avulsed Tooth
Mature Pulp
Closed apex
Category 1
Replant immediately at site
of the incident OR extraoral
storage time in physiologic
media (HBSS or milk) for
15 min-6
hours
Category 3
15-120 minutes with wet,
but non-physiologic media
(water or saliva), 0-60
minutes extraoral time and
dry storage
Category 5
Greater than 60
minutes extraoral
time with dry storage
Change transport
media to HBSS if
available
Soak in citric acid for
three minutes and rinse
well or debride and
remove PDL gently with
scaler1) Replant and reposition
2) Obtain PA radiographs to verify position
3) Place flexible splint
4) Place on systemic antibiotics
5) Assess tetanus vaccination
6) Provide post op instructions
7) Follow-up in 7-10 days
Place in NaF for 20
minutes
With the possible exception of
category 1, all these teeth will need
root canal therapy

Consider contraindication
• Advanced PDL disease
• Intactness of alveolar socket
• Dry extra-oral period more than 1hrs ( chemical
protectants)

Repositioning of avulsed tooth
with complete root formation
Tooth and socket are cleaned
with saline
Prepare socket
Reposition tooth
Splinting is done

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