DENTAL TRAUMATIC INJURIES

CONTENTS
‡ INTRODUCTION
‡ EPIDEMIOLOGY
‡ ETIOLOGY
‡ PREDISPOSING FACTORS
‡ INCIDENCE OF TRAUMATIC INJURIES
‡ MECHANISM OF DENTAL TRAUMATIC INJURIES
‡ DIAGNOSIS
‡ CLINICAL AND RADIOGRAPHIC EXAMINATION
‡ CLASSIFICATION

‡ DENTAL TRAUMATIC INJURIES
 CROWN INFARCTION
 CROWN FRACTURES
 CROWN – ROOT FRACTURES
 ROOT FRACTURES
 LUXATION INJURIES
 AVULSION
 ALVEOLAR FRACTURE
‡ CONCLUSION
‡ REFERENCES

INTRODUCTION
Trauma to the anterior teeth with the underlying esthetic, psychosocial, functional and therapeutic problems
adversely affect an individuals quality of life
Most traumatic injuries to the teeth and the supporting structures constitute a true dental emergency. In
comparison to other bodily injuries, dental trauma may not be seen serious. However teeth have the lowest
potential of any tissue for returning to the normal healthy state after injury - rational therapy based on accurate
diagnosis must be instituted
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.

 Trauma of the oral and maxillofacial region comprises 5% of all body injuries.
 In oral injuries, dental injuries are most common (92%).
Eilert-Petersson E, Andersson L, Sorensen S. Traumatic oral vs. non-oral injuries.An
epidemiological study during one year in a Swedish county. Swed Dent J 1997

Epidemiology of traumatic injuries to teeth
 49% -falls
 18% - sports relatedinjuries
 13% - bicycle and scooteraccidents
 7% - assaults
 1.5% - other road trafficaccidents
Husam Elias DCNA (2009) 675-689
(ANDREASEN JO. Traumatic injuries of the teeth. 5th ed. )

ETIOLOGY
Multiple causes contribute to tooth trauma.
Each trauma factor presents with unique circumstances and combined with age of the individual, a mosaic of
traumatic injuries can occur.
Causes can be intentional /unintentional
Traffic accidents and “at risk” athletic activities are most common cause of dental trauma
(Dietschi et al 2000)

The various causes listed are
Domestic violence
• Child abuse and neglect is an international problem having victims of all ages, race, religion and
socioeconomic background.
• Formerly called Battered Child Syndrome, over 50% all physical trauma from child
• Violence against spouse and elderly people- is another area of domestic abuse that contributes to oral
trauma.
.
In Battered child syndrome
• Of all the soft tissue trauma, the head and neck areas were among the most
frequently observed areas with traumatic injuries
• Of the 386 injuries recorded, 33% were to the head, 61% to the face (contusions,
ecchymoses, abrasions, lacerations, fractures, burns, and bites) and 6% to intraoral
structures.
Becker DB et al: Child abuse and dentistry: orofacial trauma and its recognition by
dentists. J Am Dent Assoc 1978

Iatrogenic injuries in newborn
o Prolonged intubations in neonates are used in case of prematurely born infants. The
prolonged pressure of the tubes against the maxillary arch - may lead to
developmental enamel defects in the primary dentition as well as injuries to the
tooth germs of the first and second dentition and deformation of the maxillary
skeleton
Falls in infancy
Injury increases when child starts to move
Falls and collision
Frequently occur in school children commonly with normal play activities.

Sporting activities
Injuries to the teeth during sporting activities are prevalent during teenage
years however with the expansion of sports to younger individual and
plethora of sporting activities in adults, a wide range of the population is
exposed to factors that relate in sports related injury.
Assaults and altercation
• Tooth trauma during an assault or altercation can be classified as
intentional injury.
• Commonly occur in older individual and closely related to alcohol
abuse.
Oliveira Filho et al (2013)Dent Traumatol.

Automobile, bicycle and motorcycle accidents
Commonly occur in late teenage years. The injury sustained by this
type of trauma often encompasses the entire oral cavity.
Mental retardation
Phenomena probably related to various factors such as lack of motor
coordination.
Epilepsy
Injuries directly related to falls during the epileptic episodes.

Drug related injuries
It has been reported that many drug addicts suffer from crown fractures of molars and premolars apparently
resulting from violent tooth clenching 3-4hrs after drug intake.
Dentinogenesis imperfecta
Easily prone to fractures due to decrease in microhardness of dentin and abnormal tapering of roots.
Patient undergoing General anaesthesia
Occasionally incur broken teeth during the intubation process and contribute to
26% of all general anaesthetic complications.
Fonseca, Walker,Betts& Barber. Oral and maxillofacial trauma. 2nd edition
Perianesthetic dental injury varies from 0.04% to 12% and is considered to be the most frequent
anesthesia-related cause for claims in the UK

PREDISPOSING FACTORS
Forsberg & Tedestam identified the following factors that significantly increase the susceptibility to dental
injury.
-post normal occlusion
-overjet exceeding 4mm
-short upper lip
-incompetent lips
-mouth breathing
CM Forsberg et al. Etiological and predisposing factors related to traumatic
injuries to permanent teeth. Swed Dent J. 1993

Predisposing factors were divided into 2 groups by Baldava et al
Anatomic factors
• Increased maxillary incisors overjet
• Inadequate lip coverage of anterior teeth
Sociobehavioural factors
• Gender
• Age
• Psychosocial environment
• Problem behaviour
• Increased participation in sports and recreational activities
Baldava P, Anup N. Risk factors for traumatic dental injuries in adolescent male
population. The journal of contemporary dental practice, 2007

• A major predisposing factor in dental injuries is incisal overjet of the maxillary
incisors.
• As the dimension of incisal overjet increases from a normal 0 to 3 mm to a distinct 3
to 6 mm range, the incidence of injury to the maxillary incisors doubles.
• A possible reason for this increase in severity of injury is the lack of lip closure over
the overjet incisors, thereby reducing the impact of absorbing protection of the lips
Cohens Pathway Of Pulp -7th Ed
• The most vulnerable tooth is the maxillary central incisor, which sustains approximately 80% of dental
injuries, followed by the maxillary lateral and the mandibular central and lateral incisors.

 Increased overjet with protrusion of upper incisors and insufficient lip closure are significant predisposing factors
to TDI
 Some studies have shown that overweight and obese children run a higher risk of sustaining TDIs
 The fraction of global Traumatic Dental Injuries attributable to large overjet is
21.8% .
 Large overjet is co-responsible for 235,008,000 cases
Petti S. Over two hundred million injuries to anterior teeth attributable to
large overjet:a meta-analysis. Dental Traumatology 2015

AGE DISTRIBUTION
• Traumatic injuries can occur at any age
• Common in childhood & adolescent
World TDI prevalence in primary dentition (at 5 years of age) – age when children learns to walk
• Mean age 3.4 years; prevalence 23% (17.3–29%)
World TDI prevalence in permanent dentition (at 12 years of age) – increased sports activity,
learning bicycle etc
• Mean age 14.0 years; prevalence 15.5% (13.2–17.9%)
• Prevalence of dental injuries decreases significantly after 30 years of age
INCIDENCE

According to Cohen (6th ed)
• Although dental injuries occur at any age, one of the more likely times is ages 2 to 5 years. During this
developmental period children are learning to walk and then to run. Because their coordination and
judgment are not keenly developed, falls are common.
• As children gain confidence and coordination, the incidence of dental injuries decreases; it then rises again
during the very active 8- to 12-year age range, as a result of bicycle, skateboard,
playground, or sports accidents

SEX
• Prior to 1960s, boys to girls ratio in traumatic injuries was 3:1 but the ratio has reduced to 1:1/2 nowadays due
to more involvement of girls in sports – Cohen, 7th ed
• Incidence of dental trauma is 31-40% of boys & 16-30% of girls at 5 years of age
• Incidence of dental trauma is 12-33% of boys & 4-19% of girls at 12 years of age
• Boys are affected almost twice as often as girls in both the dentitions
Traebert et al. Dent Traumatol 2003

BIRTH ORDER
 Relative risk of second dental trauma was 2.1 times higher in lastborns than in firstborns.
 Behaviour of last borns: curious and aggressive
Käch, M., Krastl, G., Zitzmann, N. U., Kühl, S. and Filippi, A. Birth order – a risk
factor for dental trauma?. Dent Traumatol, 2014

 Most frequent injuries were crown fractures without pulp exposure (34.9%),
 Concussions (24.2%) and subluxations (22.2%).
Lauridsen et al (2012), Dental Traumatology.
TYPE OF INJURY
o The dental injuries are predominantly enamel only or enamel and dentin fractures of
the maxillary incisors.
o Approximated 90% of dental injuries are chipped teeth, and the remainder being
severe crown fractures involving the pulp, tooth displacement, or avulsion
- Cohen 7th ed

Primary dentition: most often luxations
Permanent dentition: most often uncomplicated crown fractures
Maxillary central incisors are most commonly involved
Trauma to primary dentition confined to supporting structure
Trauma to permanent dentition represented by crown fractures

SOCIOECONOMIC STATUS
Socioeconomic factors are important health determinants.
 Socioeconomic indicators are not associated with Traumatic Dental Injury
 The association between a low income and TDI is weak.
Absence of an association between socioeconomic indicators and traumatic
dental injury: a systematic review and meta-analysis.
Dental Traumatology 2015

MECHANISM OF TRAUMATIC DENTAL INJURIES
DIRECT TRAUMA
Exact mechanism is unknown.
Injuries can be the result of
 Direct or Indirect trauma
Direct trauma - occurs when the tooth itself is struck, e.g. against playground equipment, a table or chair

Indirect trauma - seen when the lower dental arch is forcefully closed against the upper, as by a blow to
the chin in a fight or a fall
 While direct trauma usually implies injuries to the anterior region, indirect
trauma favors crown or crown-root fractures in the premolar and molar
regions as well as the possibility of jaw fractures in the condylar regions and
symphysis.

Extent of trauma depends on 4 factors :(Hallet 1954)
 Impact force- low velocity blows cause the greatest damage to the supporting structures, whereas tooth
fractures are less pronounced. High velocity impacts the resulting crown fractures are usually not
associated with damage to the supporting structures.
 Shape of object - Impact with a sharp object cause clean crown fractures with a
minimum of displacement of the tooth, as the energy is spread rapidly over a limited area.
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.

 Resilience of object – If a tooth is struck with a resilient or cushioned object, the chance of crown
fracture is reduced while the risk of luxation and alveolar fracture is increased
• If the bone is resilient, the tooth will be displaced. But if the bone is thick and rigid, the tooth will
fracture because of its being more brittle than the bone – Cohen, 7th ed
 Direction of force - the fractures fall easily into four categories
(1) Horizontal crown fractures.
(2) Horizontal fractures at the neck of the tooth.
(3) Oblique crown-root fractures.
(4) Oblique root fractures.

DIAGNOSIS OF TRAUMATIC INJURIES Case History
Clinical examination
Pulp Vitality Tests
Radiographic
examination

CHIEF
COMPLAINT
MEDICAL
HISTORY
DENTAL
HISTORY
Case History

CHIEF COMPLAINT
 Patients should be asked for pain and other symptoms such as bleeding
 This should be noted as per the order of importance to the patient in “PATIENT OWN WORDS”
MEDICAL CONSIDERATIONS
 A complete medical evaluation is usually performed by the physician.
 Vital signs should be recorded.
 Traumatic injuries may also result in a partial or complete airway obstruction due to the
aspiration of avulsed teeth, tooth fragments, or removable prosthesis
Subramaniam & Chogle. DCNA- Medical and Orofacial Considerations in Traumatic
Dental Injuries- 2009

MEDICAL HISTORY
 Cardiac disease
 Systemic disorders like bleeding disorders, diabetes, epilepsy etc
 Allergies to medications - As antibiotics and analgesics are frequently prescribed for
trauma patients, it is necessary to know if the patient can tolerate the prescribed
medication
 Any current medications, patient is taking - To avoid unwanted drug interactions, the
dentist must know which drug the patient is currently taking, including over the counter
medications
 Status of tetanus vaccination – in case of contaminated wound, booster dose should
be given if more than 5 years have elapsed since last dose. But for clean wounds, no
booster dose is required if time elapsed between last dose is less than 10 years

Neurological assessment
Clinician should check for
 Difficulty in neck movement
 Paresthesia of lips or tongue
 Persistent headaches
 signs of dizziness or nausea and vomiting (may indicate brain concussion)
If there is any question about this, the patient should be referred for to appropriate
medical treatment

Use of vasoconstrictors in local anesthetic
 Local anesthetics: These are generally safe and effective for most patients. The use of epinephrine in
patients with suspected hyperthyroidism is generally contraindicated.
 With recreational drug use on the rise, epinephrine should not be used if a patient has used
cocaine recently.
 Dysfunction in the eyes and ears can indicate intracranial disease or conditions which
might cause a decision to limit the use of a vasoconstrictor in a local anesthetic for instance

 For patients diagnosed with cardiovascular disease, we should aim to limit the amount of epinephrine
administered to 0.04mg. Epinephrine may also induce a cardiac arrhythmia in patients taking cardiac
glycosides such as digitalis.
 Ideally, vasoconstrictors should be minimized during the first 3 months after bypass surgery to avoid the
possibility of precipitating arrhythmias.

 Obvious respiratory challenges could preclude the use of a rubber dam for treatment or the decision to avoid
nitrous oxide use
 Skin diseases such as those related to autoimmune disorders (lupus, lichen planus, erythema multiforme, etc.)
can be found on oral mucosa and may indicate an inability to tolerate oral surgical procedures in the usual
manner..
 Gingival overgrowth in seizure patient from drug therapy or appropriate management of anxiety
and seizure inducing situations should be assessed.

 The white blood cell (WBC) count and platelet status of a patient undergoing chemotherapy should also
be reviewed before endodontic treatment.
 In general, routine dental procedures can be performed if the granulocyte count is greater than 2000/mm3
and the platelet count is greater than 50,000/mm3.
 Any appearance of anemia with pale tissues or history of anemia can lead to suspicion of leukemias or the
patient’s inability to heal from surgical procedures or tolerate a significant blood loss.
 Know the laboratory tests used to assess anticoagulation levels
(i.e., International Normalized Ratio [INR] values for patients receiving anticoagulants).
A typical INR score ranges between 2 to 3. The “ideal” INR score can vary from patient to patient

 Acetaminophen-containing drugs are generally considered the safest option for patients taking anticoagulants
and for patients with end-stage-renal-disease. All of these drugs are metabolized by the liver but are considered
safe for patients with mild to moderate liver disease if administered in minimal amounts for short duration.
 In patients with chronic renal disease, it is best to avoid drugs that are eliminated and metabolized by the
kidneys. Clindamycin should be considered in the management of endodontic infections in a patient with
advanced renal disease.
 The use of steroid drugs with the associated adrenal insufficiency could lead to hypotensive
crises during stressful dental appointments

Preoperative Care
ANTIBIOTIC PROPHYLAXIS
“Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue,
manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:
1. Prosthetic cardiac valves, including transcatheter implanted prostheses and homografts.
2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
3. Previous IE.
4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease
5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve
AAE Guidance on Antibiotic Prophylaxis for Patients at Risk of Systemic Disease, 2017
AHA guidelines 2017

DENTAL HISTORY
Past dental history
 To reveal any special dental procedures
 To access the level of cooperation, attitude of the patient towards dental treatment
 To explore the incidence of previous traumatic injuries
History of presenting illness
 When
 How
 Where for the trauma occurred is significant

WHEN
• This influence the decision that need to be made concerning the
sequence of treatment
• Signifies the “condition of the pulp”
• Shorter the time elapsed between trauma and treatment, better the
prognosis
HOW
• To assess direct or indirect trauma
• Will assist the clinician in locating specific injuries
• e.g: A blow to the lips could possibly cause crown, root or bone fractures
to the anterior region.
• A blow under the chin or jaw may fracture any tooth in the mouth
WHERE
• Significant for treatment plan and prognosis.
• Influences the necessity for prophylaxis tetanus toxoid
• Where the trauma occurred may also be significant because of
insurance and possible litigation

Another important question to ask is
whether treatment, of any kind, has been given for this injury by a parent, coach, physician, school nurse,
teacher, or ambulance attendant.
A normal-appearing tooth may have been replanted or repositioned 2 days
previously by any of these or by the patient himself, and this will influence
the prognosis for treatment and the sequence of treatment

EXTRAORAL
EXAMINATION
• Head and neck findings
– neck pain, nasal
hemorrhage, etc
• Lacerations or
hemorrhage in head &
neck regions
• TMJ deviations
• Bilateral palpation -
zygomatic arch, angle,
and lower border of the
mandible – tenderness,
swelling
INTRAORAL
EXAMINATION
• Soft tissue
examination
• Hard tissue
examination
Clinical examination - Cohen, 7th ed

INTRAORAL EXAMINATION
SOFT TISSUE EXAMINATION
• Inspection of the tongue, oral mucosa, palate, floor of the mouth & gingiva for lacerations
• Presence of any hematomas –hematoma in the floor of the mouth indicate mandibular fractures
• Penetrating or cut wounds
• Palpation of the oral mucosa, facial & lingual gingivae, anterior border of the ramus of
the mandible for areas of tenderness, swelling or bruises.
• Radiographic examination for presence of any tooth fragments, or foreign bodies
DCNA- Medical and Orofacial Considerations in Traumatic Dental Injuries- 2009
Subramaniam & Chogle, 617-626.

HARD TISSUE EXAMINATION
• Teeth alignment – several teeth in out of alignment may indicate fracture of maxillary or mandibular basal
bone
• Occlusion – abnormalities in occlusion can indicate fracture of jaws or alveolar process
• Bone fractures
• Mobility – check mobility in all directions
o Looseness of individual tooth – displacement from socket (avulsion, luxation,
extrusion, intrusion)
o Crown mobile but tooth intact – crown fracture
o Adjacent tooth move along with the tooth being tested – alveolar fracture

• Tooth discoloration
• Hemorrhage in the gingival sulcus may indicate a displaced tooth or tooth segment
• Infarction lines in the enamel can be visualized by directing a light beam parallel to
the long axis of the tooth or by shadowing the light beam with a finger or mouth mirror
• Root fracture
Can be felt by placing finger on mucosa over the tooth and moving the crown

• Crown fracture
• Mobility of crown
• Each cusp and incisal edge must be percussed with mirror handle to check incomplete fracture
(Tender on percussion)
• Pulp involvement - Crown fractures with minute pulp exposures can be detected
with a cotton pellet soaked in saline and pressed against the area of the suspected
exposure. The mechanical pressure of the cotton against an exposure elicits a response

PERCUSSION TEST
 Reaction to percussion is indicative of damage to the periodontal ligament (periradicular inflammation)
 Injuries to the periodontal ligament will result in pain
 It is done by tapping the tooth lightly with the handle of a mouth mirror, in a vertical as well as horizontal
direction
 Should begun on a non‐injured tooth to assure a reliable patient response
Metallic percussion tone in a horizontal direction  the tooth is locked into bone or ankylosis;
Dull sound  subluxation or extrusive luxation.
However, it should be noted that teeth with apical and marginal periodontal lesions
can also give a dull percussion sound

PULP CONDITION
Pulpal diagnosis of traumatized teeth is a challenge in dental practice
The main factors that interfere with the effectiveness of sensibility tests in newly traumatized
teeth are
• Subjectivity of the patients response
• Alteration of pain threshold
• Changes in supporting dental tissues
• Transient paresthesia may persist upto 6 months after the traumatic accident provoking a
negative result in the teeth that still present pulp vitality
Vitality tests for pulp diagnosis of Traumatized teeth : A systematic review. Journal Of
Endodontics, 2019

Pulp vitality tests are non-invasive methods that evaluate the vascular conditions of the tooth, and the literature
suggests that these tests provide a more accurate indicator of normality or abnormality.
 Pulpal sensibility testing at the time of injury is important for establishing a point of reference for evaluating
pulpal status at later follow‐up examinations
 After acute trauma, the dental pulp blood supply might be torn or severed/ruptured. This
could lead to pulpal edema, which could result in a negative pulpal ‘response’ just after injury.
Pulp Vitality Tests
It has been demonstrated that it may take as long as 9 months for normal blood flow to
return to the coronal pulp of a traumatized fully formed tooth

Thermal and Electrical tests
• They are, in reality, sensitivity tests for nerve function and do not indicate the presence or absence of blood
circulation within the pulp.
• It is assumed that subsequent to traumatic injury the conduction capability of the
nerve endings or sensory receptors is sufficiently deranged to inhibit the nerve impulse
from an electrical or thermal stimulus.
• This makes the traumatized tooth vulnerable to false-negative readings from these tests
Ingles Endodontics, 6th ed
Cohens Pathway of Pulp, 11th ed

Thermal/ cold test
• Dry ice pencil or CO2 stick or dichlorofluoromethane can be placed at the incisal third of traumatized tooth
for testing the tooth in response to cold. These tests should be repeated at 3 weeks, 3 months 6 months, 12
months, and yearly intervals
• Dry ice gives more accurate responses than does a water ice pencil and seems to
penetrate the tooth and covering splints or restorations and reach the deeper areas
of the tooth
• Whereas water ice may disperse over the adjacent teeth and gingiva giving false
positive result

Electrical tests
 Relies on electrical impulses directly stimulating pulpal responses
 Limited value in young teeth
 Useful in elderly patients or traumatized teeth undergoing premature sclerosis – as Dentinal tubules
are closed and do not allow dentinal fluid in them

 Neural regeneration in a traumatized pulp is slower than vascular regeneration and
sometimes is even lacking
 Vascular detecting systems (e.g. Laser Doppler Flowmetry and Pulse Oximeter) are more
sensitive than EPT and thermal testing devices, which are specifically related to
nerve regeneration

LASER DOPPLER FLOWMETRY
This is a non invasive, objective, painless, semi-quantitative method, which is more
reliable in measuring the blood flow to the pulp
Mechanism
• Laser light is transmitted to the pulp by means of a fiber optic probe placed against
the tooth surface
• Two equal-intensity beams (split from a single beam) intersect across the target
area.
• The scattered light beams from moving red blood cells will be frequency-shifted
whilst those from the static tissue remain unshifted in frequency
Jafarzadeh. Laser Doppler flowmetry in endodontics : A review. International
Endodontic Journal, 2009

• Ultrasound Doppler flowmetry seems to be more accurate than electric pulp testing in
assessing pulp vitality of traumatized teeth.
• Hasty decisions to perform root canal treatment could be reduced by applying ultrasound
Doppler flowmetry.
J ENDODON 2018; 44(3):379-383
• The reflected light, composed of Doppler-shifted (light reflected
by a moving object is Doppler-shifted) and unshifted light, is
returned by an afferent fibre within the same probe to
photodetectors
• Photodetectors convert these patterns into flux signals

PULSE OXIMETRY
• The term ‘oximetry’ is defined as the determination of the percentage of oxygen saturation of the
circulating arterial blood
• Studies have shown that vital teeth constantly provided oxygen saturation values that were lower than
the values recorded on the patients’ fingers
Patient's finger - 97.17%,
Maxillary central & lateral incisors - 86.77% and 83 %, respectively.
Mean oxygen values in teeth with open apex were significantly higher than
the teeth with closed apex. (P < 0.001).
(Bargrizan et al Dent Traumatol – 2016)
• Better sensitivity and specificity than electrical and thermal tests
• Gives a constant positive vitality reading with time in cases of recently traumatized
teeth

Mechanism
• Oxygenated haemoglobin and deoxygenated haemoglobin are different in colour and therefore absorb
different amounts of red and infrared light.
• The pulse oximeter therefore utilizes probes which emit red and infrared light to transilluminate the targeted
vascular area, which allows the photo detectors to identify the absorbance peak due to a pulsatile blood
circulation, and thereby calculate the pulse rate and oxygen saturation levels
Baiju Gopalan Nair et al. A Review of Laser Doppler Flowmetry and Pulse Oximetry in Dental Pulp
Vitality. Journal of Clinical and Diagnostic Research. 2011

Radiographic
examination
 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.
 Most root fractures are disclosed by radiographic examination, as the fracture
line usually runs parallel to the central beam

Recent textbook of Dental Traumatology recommends
One occlusal exposure
(gives an excellent view of lateral luxation, alveolar fracture, apical and mid root fracture)
+
Three periapical bisecting angle exposures
(horizontal fracture & displacement of the tooth)
Extra oral radiography- for detecting the fracture of the middle third of the face,
zygomatic maxillary complex, mandibular fractures.

IADT 2020 Guidelines
Injured teeth and surrounding structures
• One parallel periapical radiograph aimed through the midline to show the two maxillary
central incisors.
• One parallel periapical radiograph aimed at the maxillary right lateral incisors (should also
show the right canine and central incisor).
• One parallel periapical radiograph aimed at the maxillary left lateral incisor (should also
show the left canine and central incisor).
• One maxillary occlusal radiograph.
• At least one parallel periapical radiograph of the lower incisors centered on the two
mandibular centrals.
• One mandibular occlusal radiograph

CONE BEAM COMPUTED TOMOGRAPHY (CBCT)
 CBCT has significantly improved the ability to accurately diagnose traumatic injuries, along with the
capability of providing a 3D representation of the maxillofacial tissues in a cost‐ and dose‐efficient manner
 Since no film and/or material are introduced inside the patient’s mouth, the technique might be suitable
even for patients presenting with different levels of fear and anxiety or behavioral problems
 studies concluded that CBCT is most useful in cases in which conventional
radiography yields inconclusive results or shows a fracture in the middle third of a root
Patel S, Durack C, Abella F, Shemesh H, Roig M,Lemberg K.
Cone beam computed tomography in Endodontics – a review. International Endodontic Journal, 2015.

In evaluating the value of CT in diagnosing VRF, Youssefzadeh et al showed that the average
sensitivity of CT approximated 70% while conventional radiography averaged 23%
(Youssefzadeh et al. Dental vertical root fractures: value of CT in detection. Radiology 1992
Flat panel detector–volume computed tomography (FD-VCT) has also made the observation and
assessment of cracks possible
Hanning C, Dullin C, Hu¨lsmann M, Heidrich G. Int Endod J 2005

(AAOMR/AAE) joint position statement
‘Limited FOV CBCT should be considered the imaging modality of choice for diagnosis and management
of limited dento-alveolar trauma, root fractures, luxation, and/or displacement of teeth and localized
alveolar fractures, in the absence of other maxillofacial or soft tissue injury that may require other advanced
imaging modalities

MAGNETIC RESONANCE IMAGING (MRI)
MRI may be an alternative diagnostic imaging method for determining the presence and extent of root cracks
and fractures because of better contrast, acquisition of a 3D data set, inclusion of usable information about the
soft tissues, and avoidance of ionizing radiation
Recently, magnetic resonance scanning with administration of a contrast medium was found
to be able to demonstrate signs of revascularization of transplanted teeth.
Schuurmans et al. Accuracy and Reliability of Root Crack and Fracture Detection in Teeth
Using Magnetic Resonance Imaging. JOE 2019

PHOTOGRAPHIC DOCUMENTATION
o Photographic documentation is not specifically included in the current IADT guidelines
o 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
o Note that patient consent would be required

CLASSIFICATION
Rabinowitch in 1956
Ellis and Davey in 1970
Hargreaves and Craig in 1970
WHO in 1978
Andreason in 1981
Garcia and Godoi in 1981
Heithersay and Morile in 1982
Ellis classification modified by
McDonald , Avery, Lynch in 1983
Spinas and Atlanta in 2002
Pagadala S, Tadikonda DC. An overview of classification of dental trauma. IAIM, 2015

Classification by Rabinowitch -1956
Injuries to primary teeth
- Fracture of enamel, or slightly into dentine
- - Fractures into dentine
- - Fractures into the pulp
- - Fractures of the root
- - Comminuted fractures
- - Displaced teeth

Classification by Ellis and Davey - 1970
Class I – simple fracture of crown involving only enamel
Class II- extensive fracture of crown with considerable amount of dentine, with no pulp exposure
Class III- extensive fracture of crown, with dentinal involvement and pulp exposure

Class IV- traumatized tooth becomes non vital with or without loss of crown structure
Class V – tooth lost due to trauma
Class VI- fracture of root with or without crown fracture
Class VII – displacement of the tooth without crown or root fracture
Class VIII – fracture of the crown en masse
Class IX- fracture of deciduous teeth

Classification by Hargreaves and Craig (1970)
Class I - No fracture or fracture of enamel only, with or without loosening or displacement of the tooth
Class II - Fracture of the crown involving both enamel and dentin without exposure of the pulp and with or
without loosening or displacement of the tooth
Class III - Fracture of the crown exposing the pulp, with or without loosening or displacement of the tooth
Class IV - Fracture of the root with or without coronal fracture, with or without loosening or displacement of the
tooth
Class V - Total displacement of the tooth.

WHO Classification 1978
873.60- enamel fracture
873.61- crown fracture involving enamel, dentine without pulpal involvement
873.62- crown fracture with pulpal involvement
873.63- root fracture
873.64- crown root fracture
873.66- luxation
873.67- intrusion or extrusion
873.68- avulsion
873.69- other injuries like soft tissue lacerations

Classification by Andreasen – 1981
A. Injuries to the hard dental tissues and pulp.
1. Crown infarction N873.60. An incomplete fracture (crack) of the enamel without loss of the tooth
substance.
2. Uncomplicated crown fracture. A fracture contained to the enamel or involving enamel and dentin,
but not exposing the pulp (N 873.61)
3. Complicated crown fracture N873.62. A fracture involving enamel and dentin and exposing the
pulp.
4. Uncomplicated crown root fracture. N873.64. A fracture involving enamel, dentin and cementum
but not involving the pulp.
5. Complicated crown root fracture N873.64. A fracture involving enamel, dentin and cementum and
exposing pulp.
6. Root fracture N873.65 A fracture involving dentin, cementum and the pulp.

B. Injuries to the periodontal tissues
1. Concussion N873.66. An injury to the tooth supporting structures without abnormal loosening or
displacement of the tooth, but with marked reaction to percussion.
2. Subluxation N873.66. An injury to the tooth supporting structures with abnormal loosening but
without displacement of the teeth.
3. Intrusive Luxation (central dislocation) N873.66. Displacement of the tooth into the alveolar bone.
This injury is accompanied by comminution or fracture of the alveolar socket.
4. Extrusive luxation (peripheral dislocation partial avulsion) N873.66. Partial displacement of the
tooth out of its socket.
5. Lateral Luxation N873.66. Displacement of the tooth in a direction other than axially. This is
accompanied by comminution or fracture of the alveolar socket.
6. Exarticulation (complete avulsion) N873.68 Complete displacement of the tooth out of its
socket.

C. Injuries of the supporting bone
1. Comminution of alveolar socket (Mandible N802.20, Maxilla 802.40) Crushing and compression of
the alveolar socket. This condition is found together with intrusive and lateral luxation.
2. Fracture of the alveolar socket wall (Mandible N802.20, Maxilla N802.40). A fracture contained to
the facial or lingual socket wall.
3. Fracture of the alveolar process (Mandible N802.20, Maxilla N802.40). A fracture of the alveolar
process, which may or may not involve the alveolar socket.
4. Fracture of the Mandible and Maxilla (Mandible N802.21). Maxilla N802.42).
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.

D. Injuries to gingiva or oral mucosa.
1. Laceration of gingiva or oral mucosa N873.69. A shallow or deep wound in the mucosa resulting
from a tear and usually produced by a sharp object.
2. Contusion of gingiva or oral mucosa N 902.00: A bruise usually produced by an impact from a
blunt object and not accompanied by a break of the continuity in the mucosa, causing submucosal
hemorrhage.
3. Abrasion of gingiva or oral mucosa N 910.00: A superficial wound produced by rubbing or
scrapping of the mucosa leaving a raw bleeding surface.

Classification by Garcia and Godoy(1981)
Class I- enamel fracture
Class II- enamel and dentine fracture
Class III- enamel and dentine fracture with pulp exposure
Class IV- enamel, dentine and cementum fracture
Class V- root fracture
Class VI – concussion
Class VII- luxation
Class VIII- extrusion
Class IX- avulsion – total displacement

Heithersay and Morile Classification of Subgingival Fractures (1982)
Class I - Fracture line does not extend below the level of the attached gingiva
Class II - Fracture line extends below the level of the attached gingiva, but not below the
level of the alveolar crest
Class III - Fracture line extends below the level of the alveolar crest
Class IV - Fracture line is within the coronal third of the root, but below the level of the
alveolar crest

Modification of Ellis classification by Mc Donald, Avery,Lynch (1983)
Class 1: simple fracture of crown involving little or no dentine
Class 2: extensive fracture of crown involving considerable dentine but not dental pulp
Class 3: extensive fracture of crown with pulp exposure
Class 4: loss of entire crown

Modified Andreason Classification (1995)
Code number is according to the international classification of diseases
INJURIES TO HARD DENTALTISSUES AND PULP
 Root fracture (N 502.53) -A fracture involving dentin, cementum and the pulp.
 Uncomplicated Crown root fracture (N 502.54) - A fracture involving enamel, dentin and cementum, but not
exposing the pulp
 Complicated crown root fracture (N 502.54)- A # with loss of enamel and dentin, but not involving the pulp.

INJURIES TO SUPPORTING TISSUES
 Concussion (503.20) - An injury to the tooth-supporting structures without abnormal loosening or displacement of
the tooth, but with marked reaction to percussion
 Subluxation (503.20) - An injury to the tooth-supporting structures with abnormal loosening, but without
displacement of the toot
 Extrusive luxation (503.20) - Partial displacement of the tooth out of its socket

 Lateral luxation (503.20) - Displacement of the tooth in a direction other than axially.
 Intrusive luxation (503.21) - Displacement of the tooth into the alveolar bone.
 Avulsion (503.22)- Complete displacement of the tooth out of its socket

Spinas and Atlanta’s classification (2002)
It consist of 4 classes (A-B-C-D) and 3 subclasses (b1-c1-d1)
Class A: All the simple enamel lesions, which involve a mesial or distal crown angle, or only the incisal
edge.
Class B: All the enamel dentin lesions, which involve a mesial or distal angle and the incisal edge. When a
pulp exposition exists defined as a subclass b1.
Class C: All the enamel dentin lesions, which involve the incisal edge and at least a third of the crown
surface. In case of pulp exposure defined as subclass c1
Class D: All the enamel dentin lesions, which involve a mesial or distal crown angle and
the incisal or palatal surface, with root cement involvement (crown root fracture) in case
of pulpal exposure exists defined as subclass d1.

Laser Doppler Flowmetry (LDF) and Ultrasound Doppler Flowmetry (UDF)
• Ultrasound doppler assess blood flow by transmitting ultrasound through the tissues whereas Laser
Doppler Flowmetry examines frequency shifts when the laser beam is reflected by red blood cells
• The laser beam in LDF can be easily altered by obstructions such as discolorations, cracks, and light
absorbing pigments, resulting in alterations to the signal.
• This disadvantage is overcome by Ultrasound Doppler.
• Therefore, UDF appeared to be more sensitive in assessing pulp vitality in traumatized teeth
Efficacy of Ultrasound Doppler Flowmetry in Assessing Pulp Vitality of Traumatized Teeth: A Propensity Score
Matching Analysis. J Endod, 2017

Results:
• Male: female = 4.1:1 (1596:354)
• The highest numbers of patients were in the 20–30 years age group
• Most of the trauma cases were due to road traffic accidents (66.46%). The next cause was fall
(18.41%). The remainder was caused by violence (9.12%), occupational accidents (4.56%), sports
(1.38) and others (1.38%).
• Maxillofacial trauma – 32.2% cases
• Mandibular fractures >> Maxilla

CROWN FRACTURES
Enamel Infraction
Enamel Fracture
Enamel and Dentin
fracture
Complicated Crown
Fracture
Comprise 26–76% of dental injuries in permanent dentition
4-38% in primary dentition – Cohen, 7th ed
Andreasen JO, Andreasen FM: Textbook and color alias of traumatic injuries to the teeth, ed 3, Copenhagen and St Louis, 1994.

ENAMEL INFRACTION
 Incomplete fracture of the enamel without loss of tooth structure.
Clinical Findings & Diagnosis
 Visual signs- A visible fracture line on the surface of the tooth (through dyes or
transillumination)
 Percussion test -Not tender. If tender evaluate for luxation or root #.
 Mobility test- Normal mobility.
 Pulp sensibility tests -Usually positive.
 Intra Oral Periapical Radiography – no abnormalities

 Infractions are often overlooked if direct illumination is used, but are easily
visualized when the light beam is directed perpendicular to the long axis of the
tooth from the incisal edge
 Indirect illumination reveals the infraction lines although they are barely visible
by direct illumination
 By modifying the intensity of the light beam, many infractions become readily visible

Treatment
 enamel infractions generally do not require treatment.
 Smoothening
 Fluoride treatment
 in case of multiple infraction lines - seal the enamel surface with an unfilled resin with acid‐etch
technique to prevent discolouration (Love et al, 1996)
Follow-up
 No follow-up unless associated with a luxation injury
 If symptomatic or negative to pulp test follow up required for further therapy
 Endodontic intervention may be required
(If reaction to sensitivity tests changes, or signs of apical periodontitis develops or the
root appears to have stopped development or is obliterating)

A fracture confined to the enamel with loss of tooth structure.
Pulpal complications rarely occur in teeth with enamel fractures only (0–
1%), unless there is an associated luxation injury (8.5%)
ENAMEL FRACTURE
Clinical findings and Diagnosis
• Visual signs : loss of enamel. Dentin not exposed
• Percussion test : Not tender. If tenderness is observed evaluate the tooth for a possible luxation or root fracture injury.
• Mobility test : Normal

Sensibility pulp test :
• Usually positive.
• The test may be negative initially indicating transient pulpal damage.
• Monitor pulpal response until a definitive pulpal diagnosis can be made.
The test is important in assessing risk of future healing complications. A lack of response at the initial examination may
indicate an increased risk of later pulp necrosis.
Radiographic findings
• The enamel loss is visible.
• Radiographs recommended : Periapical, occlusal and eccentric exposures to rule
out the possible presence of a root fracture or a luxation injury.
DiAngelis et al. International Association of Dental Traumatology guidelines for the management of traumatic dental
injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012

Treatment
 Smoothening, Recontouring of rough edges
 If a tooth fragment is available, it can be bonded to the tooth.
 If not Restoration with composite resin
Follow-up - Clinical and radiographic evaluation at 6-8 weeks, and 1 year.
Prognosis - Prevalence of pulp survival ranges from 99 –100%

A fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp.
UNCOMPLICATED CROWN FRACTURE
• More common -1/3-1/4 of dental injuries – Cohen, 11th ed. Ingle 6th ed
• Often confined to a single tooth
• Usually - the mesial or distal corners.
• Also, horizontal, extending mesio-distally.
- Andreason, 1994

Clinical findings and diagnosis
• Visual signs : loss of enamel and dentin. No pulp exposure.
• Percussion test : Not tender. If tenderness is observed evaluate for possible luxation or
root fracture injury.
• Sensibility pulp test : Usually positive. The test may be negative initially indicating
transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can
be made.

• The enamel-dentin loss is visible.
• Radiographs recommended : Periapical, occlusal and eccentric exposure to rule out displacement or the possible
presence of a root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material (Exposure reduced to 25%
of normal)

Treatment
Enamel fracture only
• Smooth the sharp edges and leave if aesthetically acceptable.
• Use bonded composite resin if necessary for aesthetic
Enamel and Dentin fracture
• If a tooth fragment is available, it can be bonded to the tooth.
• Otherwise, perform a provisional treatment by covering the exposed dentin with glass
ionomer or a more permanent restoration using a bonding agent and composite resin,
or other accepted dental restorative materials.
AAE Guidelines for the management of Traumatic Dental injuries, 2013

2 key issues in the restoration of enamel – dentin fracture –Cohen 11th ed
1. All exposed dentinal tubules should be closed as soon as possible
 if broken fragment is not available or not possible to attach or there is no time to do full
composite at the time of emergency appointment – A Glass ionomer bandage should be placed
on the exposed dentin.
 Glass ionomer be an ideal material for temporary coverage (bandage) or as a liner for deep
fractures before restoration with composite restoration.
 This reduces ingress of bacteria into the tubules
2. Remaining dentin thickness
 >0.5mm- Restoration without pulp protection
 RD <0.5mm – hard setting Ca(OH)2 followed by composite restoration

Restoration with re-attachment of coronal fragment
( Reis et al 2004.Reattachment of fractured teeth : a review of literature regarding techniques and materials. Oper Dent.)
Advantages
• Improved aesthetics since enamel's original shape, color, brightness and surface texture are maintained
• Reduced chair-side time
• Use of tissue that abrades the same as the antagonist tooth and provides more predictable long term wear
• Psychological benefit to patient or parent
Technique
A. Use of circumferential bevel on enamel before re-attaching
(Simonson 1979 ,Walker 1996)

B. V shaped internal enamel groove (Simonson 1982 )
C. Internal dentin groove (Walker 1996, Reis 2001 )
D. External chamfer (Franco 1985 )
E. Overcontour (Reis 2001 )
F. Simple re-attachment (Pagliarini 2000)

 Presence of bevel increased the resistance to fracture in all restorative material used for re-attachment.
 Overcontour and Internal dentin groove technique provided highest fracture strength recovery.
( Reis et al 2004)

Prognosis
o Enamel and dentine fracture –(3.2% necrosis)
o Enamel & Dentin Fracture & Concussion –(5.8% necrosis)
Ravnn J J ,Scand J; 1981
Follow up
 Clinical and radiographic evaluation at 3wks, 3, 6, 12months and every year upto 5 years
 Endodontic intervention is required when reaction to sensitivity test changes or apical
periodontitis develops or root development appears to have stopped Ingle (6th ed)

A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.
0.9 to 13% of all dental injuries
COMPLICATED CROWN FRACTURE
Clinical findings and diagnosis
• Visual signs : loss of enamel and dentin with exposed pulp tissue.
• Percussion test : Not tender. If tenderness is observed evaluate the tooth for luxation or
root fracture injury.

Sensibility test :
• Usually positive.
• The test is important in assessing risk of future healing complications.
• A lack of response at the initial examination indicates an increased risk of later pulp
necrosis.

Traumatic exposure of pulp
Immediate hemorrhage - clot
Superficial inflammatory response
Proliferative response in first 24hrs
Superficial necrosis with healthy pulp
several mm deep

Stage of development of root.
The time between trauma and treatment.
Concomitant luxation injury.
Age of the patient.
Diameter of Pulp exposure
Extent of fracture
Choice of treatment depends on the:
Martin Trope. Cohen 11th ed. Ingle 6th ed

Stage of Development of the Tooth
• Every effort must be made to keep the tooth vital, at least until the apex and cervical root have completed
their development.
• In an immature tooth, vital pulp therapy should always be attempted if at all feasible because of the
tremendous advantages of maintaining the vital pulp.
• Pulpectomy in a mature tooth has an extremely high success rate. However, it has been shown that under
optimal conditions, vital pulp therapy can be carried out successfully on a mature tooth.
Concomitant Attachment Damage
• A periodontal injury compromises the nutritional supply of the pulp.
• This fact is particularly important in mature teeth, in which the chance of pulp
survival is not as good as for immature teeth.

Time Between Trauma and Treatment
• For 48 hours after a traumatic injury, the initial reaction of the pulp is proliferative,
with no more than a 2-mm depth of pulpal inflammation
• After 48 hours, chances of direct bacterial contamination of the pulp increase, with
the zone of inflammation progressing apically; as time passes, the likelihood of
successfully maintaining a healthy pulp decreases.

TREATMENTMETHODS
VITAL PULP THERAPY:
Open apex
 PULP CAPPING
 PARTIAL PULPOTOMY
 FULL PULPOTOMY
Closed apex
 PARTIAL PULPOTOMY if crown not needed,
 PULPECTOMY if crown required
NON VITAL PULP THERAPY:
 Open apex – APEXIFICATION, REVASCULARISATION
 Closed apex -PULPECTOMY
Cohen’s Pathways of the Pulp, 10th edition 2011.

VITAL PULP THERAPY
Vital pulp therapy has an extremely high success rate if the following requirements can be met
Treatment of a noninflamed pulp
• Vital pulp therapy of the inflamed pulp yields an inferior success rate, so the optimal time
for treatment is in the first 24 hours when pulp inflammation is superficial.
• As time between the injury and therapy increases, pulp removal must be extended apically to
ensure that noninflamed pulp has been reached.
Bacteria-tight seal
• This requirement is the most critical factor for successful treatment.
• If the exposed pulp is effectively sealed from bacterial leakage, successful healing of
the pulp with a hard tissue barrier will occur independent of the dressing placed on the
pulp and after more extended time periods between accident and treatment.

Pulp dressing
Calcium hydroxide
 It is antibacterial and disinfects the superficial pulp.
 Pure calcium hydroxide causes necrosis of about 1.5 mm of pulp tissue, which removes superficial
layers of inflamed pulp if present
 The high pH (12.5) of calcium hydroxide causes a liquefaction necrosis in the most superficial layers.

 The toxicity of calcium hydroxide appears to be neutralized as the deeper layers of pulp are affected,
causing a coagulative necrosis at the junction of the necrotic and vital pulp, resulting in only mild
irritation.
 This mild irritation initiates an inflammatory response, and in the absence of bacteria the pulp will heal
with a hard tissue barrier
 Hard-setting calcium hydroxide does not cause necrosis of the superficial layers of pulp
The major disadvantage of calcium hydroxide is that it does not seal the fractured surface.
Therefore, an additional material must be used to ensure that bacteria do not challenge the pulp,
particularly during the critical healing phase

Bioceramic materials such as Mineral trioxide aggregate (MTA)
 It is also hard enough to act as a base for a final restoration.
 MTA have very good antibacterial properties because of their high pH values.
 Moreover, MTA has a very high degree of biocompatibility and has very low solubility compared with calcium
hydroxide pastes.
 In addition, bridging takes place more quickly in the presence of MTA, and the dentine bridge that forms is
thicker and more homogeneous
 Excellent bacteria-tight seal- (Torabinejad et al J Endod 1995).
 Mineral trioxide aggregate does not appear to deteriorate and disintegrate with time; thus, space for
microleakage does not develop as it does with calcium hydroxide
- Ingle, 5th ed
Mente J et al. Mineral trioxide aggregate or calcium hydroxide direct pulp
capping: an analysis of the clinical treatment outcome. J Endod 2010;

Yet MTA does not enjoy the same popularity as calcium hydroxide as a pulp capping agent in the treatment of
traumatic exposures. It may because of following reasons
 MTA needs a moist environment for at least 6 hours to set properly (two-step procedure, compared with a
one-step for other medicaments). Therefore, a wet cotton pellet be placed over it until it is set, and then the
permanent restoration can be fabricated at a later time.
 MTA was gray in color and reported to cause discoloration in the tooth crown. To counter
this problem, white MTA was introduced. Unfortunately, it has been found to discolor in a
similar fashion to the gray, presumably because of the bismuth oxide filler
-- Cohens pathway of pulp, 11th ed
-- Ingles Endodontics, 6th ed

PULP CAPPING
Pulp capping implies placing the dressing directly onto the pulp exposure.
Indications.
• Immature permanent tooth, a very recent exposure (<24hrs) or a mature permanent teeth with simple restorative
plan
• Partially inflamed pulp can be capped if remaining healthy tissue can be conserved
to generate a hard tissue seal
Materials most commonly used for pulp capping of :
• Calcium hydroxide
• MTA

Technique:-
Surrounding enamel acid etched and bonded with composite resin
Ca(OH)2 mixed with saline and placed over the exposed pulp and dentinal
surface
Disinfected with 0.12% CHX or betadine
Crown and exposed dentinal surface rinsed with saline
Adequate anesthesia + Rubber dam placement

Preoperative condition: Punctiform exposure of the
pulp in the occlusal view.
Capping of the pulp with a hard-setting calcium
hydroxide cement
Post operative view

Prognosis
 80% success rate
 Less prognosis when compared to partial pulpotomy (95%)
 Superficial inflammation develops soon after traumatic exposure
 Bacterial tight seal is difficult to attain in pulp capping because there is no depth to cavity to aid in
creating seal – Ingle, 6th Ed
 Follow up-Sensibility testing after vital pulp treatment should be tested regularly, after
3, 6, and 12 months and annually thereafter.
 A radiographic examination is only recommended in the case of a negative sensibility test

CVEK PULPOTOMY (Partial pulpotomy)
Removal of coronal pulp tissue to the level of healthy pulp (2mm)
Indications:
 Small exposure reported within 24-48 hrs.
A review of the literature revealed that that early treatment (within 24 h) is crucial for the success of a cervical
pulpotomy. Other authors have claimed success at 48 hrs of exposure
The above-mentioned findings indicate that a general statement claiming that the time period
between the accident and Cvek pulpotomy is not critical if the inflamed superficial pulp tissue is
amputated to a healthy pulp
 Cvek pulpotomy may be successful in teeth with pulp exposures sized 0.5– 4.0 mm not
more than 4mm
(Bimstein & Rotstein, Dental Traumatology, 2016)

Capping materials used for Cvek Pulpotomy:
 Calcium hydroxide (Ca(OH)2) or bioceramic materials such as mineral trioxide aggregate (MTA)
 They should be placed gently and directly in contact with non - inflamed pulp tissue with only passive contact
with the pulp
 The key factor in determining the prognosis of a partial pulpotomy is not the specific
form of material, but its presence, along with the ability to seal it well in the root canal
system thus minimizing microbial invasion to the remaining pulp
(Bimstein & Rotstein, Dental Traumatology, 2016)

The remaining cavity filled with GIC or composite resin
Ca(OH)2 mix placed carefully on the pulp stumps or MTA followed by moist cotton pellet
over it
5% NaOCl recommended to rinse the pulpal floor
Excess blood carefully removed by rinsing with sterile saline and then dried with sterile
cotton pellet
1-2mm deep cavity prepared into the pulp using high speed handpiece with sterile
diamond bur
Administration of LA, rubber dam placement and superficial disinfection
Technique:-

Crown fracture
exposes pulp
Pulp tissue removed
with a round
diamond bur to a
depth of about 2
mm
After bleeding has
stopped, wash with
saline and apply a
calcium hydroxide
liner
A GIC base followed
by replacing the lost
tooth structure with
composite resin

Isabel Gomes. Case Reports in Dentistry, 2020

Crown fracture with small
pulp exposure in tooth no. 21
Partial Pulpotomy of tooth no. 21
MTA placed.
The crown was restored with
GIC. 2 weeks later, GIC removed
and composite placed

Advantages of Cvek Pulpotomy
 The cell-rich coronal pulp tissue is preserved, providing a better healing potential.
 Physiologic apposition of dentin is maintained in the cervical region.
 The natural color and translucency of the tooth are preserved.
 Since coronal pulp tissue is retained , it is possible to perform future sensitivity testing.
Güngör, H. C,Dent Traumatol - 2014
• Antibacterial effect of the pulp capping agents disinfects and removes additional
inflammation if present
• Space is provided for material that can achieve better bacterial tight seal
- Cohen , 11th ed

FULLPULPOTOMY
Removal of the entire coronal pulp to a level of root orifice.
INDICATIONS:
 Inflammation of the pulp to the deeper levels of the coronal pulp.
 Traumatic exposure after 72 hrs .
 Carious exposure of young permanent tooth (vital tooth) with partially developed root
apex (atleast 2/3rd of root formed)
 Hemorrhage from amputation site is pale red and easy to control

Prognosis
 Success rate of 75 %
 Lesser when compared to other vital pulp therapy treatment because
• Site of amputation is arbitrary
• Treatment is performed in pulp with deeper inflammation - since the inflamed pulp sometimes extends
past the canal orifices into the root pulp, many "mistakes" are made, resulting in treatment of an
inflamed rather than noninflamed pulp
Follow up
• Follow up at 3, 6, and 12 months
• Radiographic follow up - to ensure root apex formation and to assess for signs of apical
periodontitis
Current recommendations for vital pulp treatment Scientific Communication
Status: German Society of Endodontology and Dental Traumatology 01.01.2019

PULPECTOMY
Removal of entire pulp to the level of apical foramen
Indications:-
 Complicated crown fracture of mature teeth after 72 hrs if conditions are not ideal for vital pulp therapy
 Extensive tooth damage with need for crown, post
 Irreversible pulpitis with periapical changes
Prognosis
o High success rate of 95 % whereas in the presence of apical periodontitis, it drops to 80 %

APEXIFICATION
Method of inducing the development of root apex in an immature pulpless tooth by formation of osteocementum
or other bone like tissues - Cohen
Technique:-
Disinfection of
the canal
Hard tissue
barrier
Filling of the
root canal

Disinfection of the Canal
The first phase of treatment is to disinfect the root canal system to ensure periapical healing.
Working length estimated
Very light filing is performed with copious irrigation with 0.5% NaOCl
Canal dried with paper points
A creamy mix of Ca(OH)2 spun into the canal with a Lentulo spiral
instrument

Hard tissue barrier formation
Traditional Method
Bioceramic Method
Traditional method of Apexification with Ca(OH)2
 Ca(OH)2 is mixed to thick consistency and placed in canal.
 This thick mix is packed against the apical soft tissue with a plugger
or thick point to initiate hard-tissue formation.
 This step is followed by backfilling with calcium hydroxide to
completely fill the canal.
 The calcium hydroxide is meticulously removed from the access cavity
to the level of the root orifices and a well-sealing temporary filling
placed in the access cavity.

Root canal completely filled with Calcium Hydroxide
A radiograph is taken, and the canal should appear to have
become calcified, indicating that the entire canal has been filled
with the calcium hydroxide
 At 3-month intervals, a radiograph is exposed to
evaluate whether a hard-tissue barrier has formed and if
the calcium hydroxide has washed out of the canal.
 If no washout is evident, it can be left intact for another 3 months.
 When completion of a hard-tissue barrier is suspected, the calcium hydroxide
should be washed out of the canal with NaOCl.

When a hard-tissue barrier is indicated radiographically and can be probed with an instrument, the canal is
ready for filling
 Follow up after 3 months showing no washout of Ca(OH)2 and in 6 months,
Ca(OH)2 removed ad hard tissue barrier has been formed
 The remaining canal is filled with gutta percha

Disadvantages:
 Long term treatment with Ca(OH)2 can weaken the roots and make them more
susceptible for fracture.
(Andreasen J et al Dent Traumatol, 2002 ).
 Long term Ca(OH)2 may also lead to internal resorption of tooth
 Formation of hard tissue barrier with Ca(OH)2 may take 3 to 18 months. Long term
follow up is difficult as patient has to make multiple visits
 Also the tooth may fracture during the treatment before thin dentinal walls are
strengthened
(Cohen 11th ed)

Bioceramic method of Apexification (MTA/Biodentine)
 Calcium sulphate is pushed through the apex to provide a resorbable extraradicular barrier against which
MTA is packed.
 MTA is mixed and placed into the apical 3 to 4 mm of the canal
 A wet cotton pellet should be placed against the MTA and left for at least 6 hours.
 After the MTA is fully set, the entire canal is then filled with a root filling
material.
 The cervical canal is then reinforced with composite resin to below the
marginal bone level

A, The canal is disinfected with light
instrumentation, copious irrigation, and a
creamy mix of calcium hydroxide for 1 month.
B, Calcium sulfate is placed through the apex as a
barrier against which the MTA is placed.
C, A 4-mm MTA plug is placed at the apex
D, The body of the canal is filled with the Resilon obturation
system.
E, A bonded resin is placed below the cementoenamel junction
(CEJ) to strengthen the root.

PULP REVASCULARIZATION
Advantages:
 Further root development.
 Reinforcement of dentinal walls by deposition of hard –tissue, strengthening the
root against fracture.
Revascularization/ Revitalization may be defined as invagination of undifferentiated periodontal cells from the
apical region in immature teeth
Pulp revitalization has also been used to define the formation of vital tissue inside the root canal

AAE Clinical Considerations for a Regenerative Procedure
First Appointment
 Local anesthesia, dental dam isolation and access.
 Copious, gentle irrigation with 20ml NaOCl using an irrigation system that minimizes the possibility
of extrusion of irrigants into the periapical space
 Lower concentrations of NaOCl are advised [1.5% NaOCl (20mL/canal, 5 min) and then irrigated with
saline or EDTA (20 mL/canal, 5 min), with irrigating needle positioned about 1 mm from root end, to
minimize cytotoxicity to stem cells in the apical tissues.
 Dry canals with paper points.

 Place calcium hydroxide or low concentration of triple antibiotic paste (1:1:1
ciprofloxacin: metronidazole: minocycline to a final concentration of 0.1-1.0
mg/ml)
 Triple antibiotic paste has been associated with tooth discoloration ( should remain
below CEJ)
 Double antibiotic paste without minocycline paste or substitution of minocycline
for other antibiotic (e.g., clindamycin; amoxicillin; cefaclor) is another possible
alternative
 Seal with 3-4mm of a temporary restorative material such as Cavit™, IRM™,etc
 Dismiss patient for 1-4 weeks.
Triple antibiotic
paste consistency

Second Appointment (1-4 weeks after 1st visit)
 Copious, gentle irrigation.
 Dry with paper points.
 Create bleeding into canal system by over-instrumenting (endo file,
endo explorer) (induce by rotating a pre-curved K-file at 2 mm past the
apical foramen with the goal of having the entire canal filled with
blood to the level of the cemento–enamel junction).
 An alternative to creating of a blood clot is the use of platelet-rich
plasma (PRP), platelet rich fibrin (PRF) or autologous fibrin matrix
(AFM).
Blood clot stimulation with a
manual endodontic file

 Stop bleeding at a level that allows for 3-4 mm of restorative material.
 Place a resorbable matrix such as CollaPlug™, Collacote™,
CollaTape™ over the blood clot if necessary and white MTA as
capping material.
 MTA has been associated with discoloration. Alternatives to MTA
(such as bioceramics or tricalcium silicate cements should be
considered in teeth where there is an esthetic concern
 This is followed by restoring with RMGIC or resin bonded composite

CROWN AND ROOT FRACTURES
With Pulp Involvement
Without Pulp Involvement
5% of all dental injuries – Cohen 7th ed

A fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp.
Fracture extending below gingival margin.
• Visual signs : Crown fracture extending below gingival margin.
• Percussion test : Tender.
• Mobility test : Coronal fragment mobile.
CROWN ROOT FRACTURE WITHOUT PULP INVOLVEMENT

Sensibility pulp test : Usually positive for apical fragment
• Apical extension of fracture usually not visible.
• Radiographs recommended : Periapical, occlusal and eccentric exposures to
detect fracture lines in the root. A cone beam exposure can reveal the whole
fracture extension

CROWN ROOT FRACTURE WITH PULP INVOLVEMENT
A fracture involving enamel, dentin, and cementum with loss of tooth structure, and exposure of the pulp.
Visual signs : Apical extent of the fracture extending below gingival margin
(chisel type fracture)
Percussion test : Tender.
Mobility test : Coronal fragment mobile.

Sensibility test : Usually positive for apical fragment
• Apical extension of fracture usually not visible.
• Radiographs recommended : Periapical and occlusal exposure.
• A cone beam exposure can reveal the whole fracture extension.

 Crown root fractures are in most instances due to direct trauma
 The fragments may be firm, loose, and attached only by the periodontal ligament or lost.
 Pain on pressure and biting is evident because of the periodontal injury, as is pain to air and hoi or cold
liquids because of dentin or pulp exposure.
 Indirect light and transillumination is an effective way of diagnosis

TREATMENT OF CROWN ROOT FRACTURES
EMERGENCY TREATMENT
Anterior region
• Stabilization of the coronal fragment with an acid etch/resin splint to adjacent teeth
Posterior region
• Removal of loose fragments and coverage of exposed supragingival dentin with GIC.
• Vertical crown root fractures must generally be extracted.
AAE Recommended Guidelines for Treatment of Traumatic Dental Injuries.2013

NON-EMERGENCY TREATMENT ALTERNATIVES
1. Fragment removal only
Removal of the coronal crown–root fragment and subsequent restoration
2. Fragment removal and gingivectomy
Removal of the coronal crown–root segment with subsequent endodontic treatment, gingivectomy and
restoration with a post-retained crown
3. Orthodontic extrusion of apical fragment
Removal of the coronal segment with subsequent endodontic treatment and orthodontic
extrusion of the remaining root with sufficient length after extrusion to support a
post-retained crown

4. Surgical extrusion
Removal of the mobile fractured fragment with subsequent surgical repositioning of the
root in a more coronal position
5. Extraction

TREATMENT OPTIONS ACCORDING TO HEITHERSAY& MOULE CLASSIFICATION
 Type I – Gingivectomy
 Type II – Gingival & osseous surgery
 Type III – Orthodontic or surgical repositioning with Gingival &
osseous surgery
 Type IV - splinting
Heithersay, G. S. and Moule, A. J. Australian Dental Journal - 1982.

 Crown root fractures are treated in the same manner as uncomplicated or complicated crown fractures with
additional treatment for the attachment injury
 After administration of adequate anesthesia, all loose fragments are removed.
 A periodontal assessment is made as to whether the tooth can be treated periodontally to allow it to be adequately
restored.
 Periodontal therapy could involve a simple removal of tissue with a scalpel, electrosurgical or laser procedure to
allow for adequate sealing of the restoration, or forced eruption to extrude the fractured area above the attachment
level to allow for adequate restoration
 If a crown root fracture cannot be made into uncomplicated crown fracture by periodontal therapy (crown
lengthening) or by orthodontic extrusion, the tooth is extracted as it is not properly restored
Cohen Pathway of Pulp. 7th ed

SURGICAL EXPOSURE
Textbook and color atlas of traumatic
injuries to the teeth, 5th edn.
Treatment principle:
Convert the sub gingival fracture to a supragingival fracture with
the help of gingivectomy and osteotomy
Procedure:
A combined gingivectomy and osteotomy expose the fracture
surface - used if the esthetics would not be compromised (i.e. only
on the palatal aspect of the fracture) .

ORTHODONTIC EXTRUSION
Treatment Principle:
• Move the fracture to a supra-gingival position
orthodontically. –Heithersay (1973)
Indication:
• Only method for uncomplicated crown-root fractures if pulp
vitality is to be preserved.
• Also for complicated Crown-Root fractures
• More time consuming than surgical extrusion.

Cementation of a
post-hook after root
canal treatment
Horizontal wire is bent to cross midline of the
tooth to be extruded. Wire is embedded with
acid-etched composite on adjacent teeth.
Elastic is attached to activate extrusion.
Tooth extruded - stabilized
until periodontal and bony
repair are complete

SURGICAL REPOSITIONING
Treatment principle:
• Surgically move the fracture to a supra-gingival position -
Tegsjo et al (1978)
• Further developed by Buhler and Kahnberg.
Indication:
• Only if - completed root development
• apical fragment is long enough to accommodate a post-
retained crown.

 These methods are done to improve restorative prognosis in Crown/root fractures, cervical fractures.
 Ankylosis not reported.
 Self limiting Surface resorption seen.
 Maximum extrusion of 8mm reported.
Elkhadem et al, Dent Traumatol - 2014
Das, B. and Muthu, M. S.Dent Traumatol - 2013

‡ INTRODUCTION
‡ EPIDEMIOLOGY
‡ ETIOLOGY
‡ PREDISPOSING FACTORS
‡ INCIDENCE OF TRAUMATIC INJURIES
‡ MECHANISM OF DENTAL TRAUMATIC INJURIES
‡ DIAGNOSIS
‡ CLINICAL AND RADIOGRAPHIC EXAMINATION
‡ CLASSIFICATION

‡ DENTAL TRAUMATIC INJURIES AND ITS MANAGEMENT
 CROWN INFARCTION
 CROWN FRACTURES
 CROWN – ROOT FRACTURES

Lentulospirals
• They are used for the placement of sealer, cement and intracanal medicament
• They can be used as hand or rotary instruments
• They are available as Handy lentulospirals and Lentulospiral drills
• Twirling them in the fingers is safer, and Lentulo spirals are now being made with
regular instrument handles (Dentsply/Maillefer)
• The file, set 1 mm short of the working length.
• Handy lentulospirals are rotated clockwise by finger action and rotated
counterclockwise as it is withdrawn, spinning the sealer into the canal

• Lentulo spiral drills(spiral filler or a paste carrier) are twisted wire
instruments with latch key grip used in the slow-speed handpiece
• It must be operated clockwise in the handpiece, inserted not rotating to
working length, then retracted 1 to 2 mm to make sure it is free to rotate
without engaging the canal walls.
• It should be started and rotated at a slow speed while being gradually
withdrawn from the root canal.
• This instrument effectively drives the paste into the root canal.
• However, for optimal effect, the spiral must be as large as possible so
that the paste is forced forward as the material is squeezed between the
canal walls and the spiral.

Lentulo spiral fractured
in distal canal of lower
molar
Disadvantages:
• If powered by a handpiece, they can be easily locked in the canal and snapped off
• Powered Lentulo spiral was seen to cause sealer extrusion
• Another problem encountered in using rotary-powered Lentulo spirals comes from “whipping up” the
cement in the canal and causing it to set prematurely

ROOT FRACTURE
• A fracture confined to the root of the tooth involving cementum, dentin, and the pulp.
• Less than 3% of all dental injuries -Cohen
Can be of following types:-
- Neurovascular supply intact at root apex.
- Rupture of neurovascular supply at fracture line.
- Separation of PDL and exposure of root surface.
A Review of Root Fractures: Diagnosis, Treatment and Prognosis. Journal of
restorative dentistry, 2011

CLASSIFICATION OF VERTICALAND HORIZONTAL ROOT FRACTURES

Depending on the position of the fracture line, transverse (horizontal) root fractures can also be classified into
three zones
Zone 1 – extends from the occlusal/incisal edge to the alveolar bone crest.
Zone 2 – extends from the alveolar bone crest to 5 mm below.
Zone 3 – extends from 5 mm below the alveolar bone crest to the apex of the root.
These zones are analogues to crown fracture, cervical-root fracture, and middle/apical root fracture, respectively

Clinical findings
 Middle-third root fractures occur with greater frequency than apical- and cervical-thirds
fractures
 Fractures in the apical-third of the root do not show signs of displacement or mobility.
 Teeth with middle third fractures are usually slightly extruded with displacement in the
lingual direction and lateral luxation of the coronal segment.

 In cervical-third fractures extending below crestal bone, the crown is usually present with minor mobility
owing to attachment of the periodontal fibers to the portion of root that has fractured off with the crown
 In anteriors, with fracture line above the crestal bone, the crown is usually extremely mobile or dislodged.
 The tooth may be tender to percussion and/or palpation and show transient crown discoloration.
 Bleeding from the gingival sulcus.
Pulp sensibility tests
• Initially, sensibility testing may give negative results due to transient or
permanent pulpal damage inflicted by trauma.
• A routine follow-up is required to monitor the pulpal status continuously.

Radiographic findings:
 Horizontal # - regular periapical 90 deg.
 Oblique # - occlusal view or radiographs with three angled radiographs –
45,90 and 110) - so that at least at one angulation, the x-ray beam will pass
directly through the fracture line to make it visible on the radiograph
 An occlusal exposure is optimal for locating root fractures in the apical
and middle third.
 Bisecting angle exposure or 90o degree angulation exposure is needed to
locate the fractures in the cervical third of the root.

Radiographs showing the importance of different vertical angulations for
diagnosis of root fracture.
(All three radiographs were taken within minutes of each other)

TREATMENT FOR ROOT FRACTURE
• Emergency treatment - Reposition, the segment of the tooth in close proximity as much as possible
• In case of severe displacement of the coronal segment, its apical extension is frequently lodged in the
cortical bone facial to the tooth.
• Forcing the crown facially will not be possible, and the two segments will not be properly aligned.
• The only way to accomplish reapproximation of the two segments is to release the coronal
segment from the bone by gently pulling it slightly downward with finger pressure or
extraction forceps, and then once it is loose, rotate it back to its original position

The traditionally recommended splinting protocol has been changed from 2 to 4 months with rigid
splinting to a semirigid splint to adjacent teeth for 2 to 4 weeks – Cohen, 11th ed
According to IADT and AAE guidelines
Flexible splint for 4 weeks.
Cervical root # – stabilization for a longer period of time (upto 4 months).

Follow- up
• Monitor healing for at least 1 year to determine pulpal status
• If pulp necrosis develops, root canal treatment of the coronal tooth segment
to the fracture line is indicated to preserve the tooth
• If a long time has elapsed between the injury and treatment, it will likely not be possible to reposition
the segments close to their original position, compromising the long-term prognosis for the tooth.
• Immature teeth with incomplete root fractures require no fixation and will heal by hard tissue union

ROOT CANAL THERAPY OF FRACTURED SEGMENTS
Root canal therapy of both segments
Fracture segments not
separated
Filling materials can be
placed in both coronal and
apical segments similar to
normal teeth
In separated fragments
Following RC filling, a post
space is prepared extending
from coronal segment into
the apical one, allowing
placement of a rigid-type
post to stabilize the two root
segments
Root canal treatment of the
coronal segment only
This is the current
recommendation,
particularly with the view
that the apical segment may
contain vital, healthy pulp
tissue.
Apexification is done at the
exit of the coronal segment

A. Radiograph shows a central incisor with an
apical root fracture
B. Radiograph taken 4 months after initial
treatment: root canal cleaning and calcium
hydroxide medications.
C. The tooth immediately after root canal filling.
D. Twelve months after filling the root canal, the
radiograph shows good repair; the apical root
fragment can be left in place.

 Poor prognosis, especially if the fracture line is at the level or coronal to alveolar crest
 If adequately splinted, chances of healing is similar to midroot or apical root fractures
 If the fracture is located at the cervical third of the root and below the alveolar crest - treatment can be permanent
fixation of the coronal fragment to adjacent non‐injured teeth with a lingual orthodontic retention wire
 If cervical fracture line is close to or communicating with the gingival crevice - removal of
the coronal fragment and subsequent orthodontic or surgical extrusion of the remaining
apical fragment for restoration purpose
 If re-approximation is not possible, extract coronal fragment, and evaluate root length
for restorability
 If it is not possible to treat the fractured tooth conservatively - the tooth must be extracted
Coronal Root fracture

 Revascularization is possible if segments are well re-approximated
 In more apical root fracture, necrotic segments can be surgically removed, if remaining coronal
segment is long enough
 In most cases, permanent necrosis occurs in the coronal segment with apical segment remaining
vital. Endodontic treatment is initiated in the coronal segment after MTA plug formation at the
apical end.
 Coronal segment with compromised attachment -Endodontic implants can be used to
provide additional support to tooth
Middle & Apical Root Fracture

Root resorption
Occurs in approximately 60% of root‐fractured permanent incisors and can usually be detected within 1 year
after injury
Root resorption appears in the following types.
1. External repair‐related resorption
2. External infection‐related resorption
3. External ankylosis‐related resorption.
4. Internal repair‐related resorption
5. Internal tunneling resorption, going behind the pre‐ dentin layer and burrowing along
the root canal walls of the coronal fragment

HEALING AFTER
ROOT FRACTURE
CALCIFIED
TISSUE
CONNECTIVE
TISSUE
BONE AND
CONNECTIVE
TISSUE
NON-HEALING
GRANULATION
TISSUE

Healing with Calcified tissue
 Seen primarily in cases with little or no dislocation of the coronal
fragment and most often in teeth with immature root formation.
 Odontoblast progenitor cells will be recruited and create a small, hard
tissue dentin bridge
 This bridge forms the initial callus and could stabilize the fracture.
 Callus formation is followed by deposition of cementum

Healing with Connective tissue
 When pulp is severely stretched at the level of the fracture
 Periodontally derived cells dominate root fracture healing, resulting
in ‘union’ of the coronal and apical root fragments by interposition of
connective tissue
 The fracture surfaces are covered by cementum, often deposited after
initial resorption, with connective tissue fibers running parallel to the
fracture surface
 A new ‘apical foramen’ is created at the level of the fracture
 R/G - peripheral rounding of the fracture edges and a radiolucent line
separating the fragments

Healing with Interposition of bone and connective tissue
• Trauma prior to completed growth of the alveolar process
• There is interposition of a bony bridge and connective tissue
between the apical and coronal fragments, with a normal
periodontal ligament surrounding both fragments
• Radiographically, a bony bridge is seen separating the
fragments, with a periodontal space around both fragments
.

Healing with Interposition Of Granulation tissue
• if bacteria gain access- pulp necrosis results, with
accumulation of inflamed granulation tissue between the
two root fragments
• The coronal portion of the pulp is necrotic and infected,
while the apical fragment usually contains vital pulp tissue
• The necrotic and infected pulp tissue is responsible for the
inflammatory changes along the fracture line
• Radiographically, widening of the fracture line, loss
of lamina dura and rarefaction of the alveolar bone
corresponding to the fracture line

Prognosis
The location of the root fracture had a significant effect on tooth survival.
The 10-year tooth survival of
 apical root fractures - 89%
 mid-root fractures - 78%
 cervical-mid-root fractures - 67%
 cervical fractures - 33%.
Andreasen et al, Dental Traumatol - 2012.
• Pulp necrosis in the apical segment is extremely rare.
• Permanent pulpal necrosis of the coronal segment, requiring endodontic treatment,
occurs in about 25% of cases
Cohen Pathway of Pulp, 11th ed

LUXATION INJURIES
Concussion
Subluxation
Intrusive luxation
Lateral luxation
Extrusive luxation
30-44% of dental injuries

CONCUSSION
• An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain
to percussion.
• Neurovascular supply not damaged
• Gingival bleeding not present
Clinical findings:-
Visual signs : tooth not displaced.
Percussion test : Tender to touch or tapping.

Mobility test : No increased mobility.
Pulp sensibility test : Usually a positive result.
The test is important in assessing future risk of healing complications. A lack of response to the test
indicates an increased risk of later pulp necrosis.
Radiographic Findings
 No radiographic abnormalities, the tooth is in-situ in its socket.

Treatment :
• No treatment is needed
• Monitor pulpal condition for at least 1 year
• Only 3% of these teeth undergo pulp necrosis or pulp canal calcification (2–7%).
• Root resorption is not a feature of concussed teeth.

SUBLUXATION
• An injury to the tooth supporting structures resulting in increased mobility, but without displacement of the
tooth.
• Bleeding from the gingival sulcus confirms the diagnosis
• Neurovascular supply may get damaged

Clinical Findings:-
Visual signs : Not displaced.
Percussion test : Tender
Mobility test : Increased
Pulp sensibility test : Sensibility testing may be negative initially indicating
transient pulpal damage. Monitor pulpal response until a definitive pulpal
diagnosis can be made.
• Usually no radiographic abnormalities.
• As a routine: Occlusal, periapical exposure and lateral view from the
mesial or distal aspect of the tooth.

Treatment :
• Usually no treatment is needed; however, a flexible splint to stabilize the tooth for patient comfort can be
used for up to 2 weeks. (Traumatic Occlusion can increase PDL damage and delay healing)
DiAngelis AJ et al. International Association of Dental Traumatology guidelines
for the management of traumatic dental injuries: 1. Fractures and luxations of
permanent teeth. Dent Traumatol 2012.
• Clinical and radiographic follow up : 2 , 4, 6-8 weeks,6 months,1 year

LATERAL LUXATION
• Displacement of the tooth other than axially. Displacement is accompanied by comminution or fracture of either
the labial or the palatal/lingual alveolar bone.
• Severance of neurovascular supply

Clinical findings:-
• Visual signs : Displaced, usually in a palatal/lingual or labial direction.
• Percussion test : Usually gives a high metallic (ankylotic) sound.
• Mobility test : Usually immobile.
• Sensibility test : Sensibility tests will likely give a lack of response except for teeth
with minor displacements.

• Widened periapical ligament space best seen on occlusal or eccentric exposures.
• Radiographs recommended. As a routine: Occlusal, periapical exposure and lateral
view from the mesial or distal aspect of the tooth in question.
• In primary teeth,
No collision with tooth bud Collision with tooth bud

TREATMENT:
IN PERMANENT TEETH
 Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it
into its original location
 Stabilize the tooth for 4 weeks using a flexible splint – IADT Guidelines
 Monitor the pulpal condition
 If the tooth has a fully formed apex and was diagnosed to have moved into the cortical
plate (apical translocation), there is a good likelihood of the pulp being devitalized,
endodontic treatment should be initiated as early as 2 weeks after the injury.
 If the apex is still not fully formed, waiting for signs of revascularization is strongly
recommended.

IN PRIMARY TEETH
 If there is no occlusal interference, as is often the case in anterior open bite, the tooth is allowed to reposition
spontaneously
 In case of minor occlusal interference, slight grinding is indicated
 When there is more severe occlusal interference, the tooth can be gently repositioned by combined labial and
palatal pressure after the use of local anesthesia
 In severe displacement, when the crown is dislocated in a labial direction, extraction
is the treatment of choice

EXTRUSIVE LUXATION
• Partial displacement of the tooth out of its socket
• The alveolar socket bone is intact in an extrusion injury.
• Severance of neurovascular supply
• Separation of PDL and exposure of root surface
Clinical Findings:-
Visual signs : Appears elongated.
Percussion test : Tender.
Mobility test : Excessively mobile.
Sensibility test : Usually lack of response except for teeth with minor displacements.
The test is important in assessing risk of healing complications.

Radiographic findings:-
• Widening of periodontal ligament space.
• As a routine: Occlusal, periapical exposure and view from the mesial or distal aspect
of the tooth.

Treatment :
• Reposition the tooth by gently re-inserting it into the tooth socket
• Stabilize the tooth for 2 weeks using a flexible splint - – IADT Guidelines
• In cases where pulp necrosis is anticipated, root canal treatment is indicated
• In primary teeth, treatment decisions are based on the degree of displacement, mobility,
root formation, and the ability of the child to cope with the emergency situation
• For minor extrusion (<3 mm) in an immature developing tooth, careful repositioning or
leaving the tooth for spontaneous alignment can be treatment options
• Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth

INTRUSIVE LUXATION
• Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the
alveolar socket.
• Disruption of neurovascular supply
• Contusion of PDL and alveolar bone
• Disruption of marginal gingival seal
• Damage to permanent tooth bud in primary teeth

Clinical findings:-
Visual signs : The tooth is displaced axially into the alveolar bone.
Percussion test : Usually gives a high metallic (ankylotic) sound
Mobility test : tooth is immobile.
Sensibility test : likely give negative response.
In immature, not fully developed teeth, pulpal revascularization may occur.

Radiographs recommended
• As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal
aspect of the tooth in question.
• If the tooth is totally intruded a lateral exposure is indicated to make sure the tooth
has not penetrated the nasal cavity.
Radiographic findings:-
• The periodontal ligament space may be absent from all or part of the root.
• The cemento-enamel junction is located more apically in the intruded tooth than in
adjacent non-injured teeth, at times even apical to the marginal bone level.

INCOMPLETE ROOT FORMATION COMPLETE ROOT FORMATION
• Up to 7mm – allow for re-eruption
without intervention.
• If no movement, initiate orthodontic
repositioning within 3 weeks.
• >7mm, reposition surgically or
orthodontically within 3
weeks.
• Up to 3mm and <17 years -allow
for re eruption
• If no movement after 2-3 weeks,
reposition surgically or
orthodontically before ankylosis
develops.
• Between 3-7mm - reposition
surgically or orthodontically
within 3 weeks.
• In cases of >7mm, reposition
surgically.
Treatment:
AAE Guidelines for management of Traumatic Dental Injuries, 2013

In primary teeth (immature teeth)
• if the apex is displaced toward or through the labial bone plate, the
tooth is left for spontaneous repositioning.
• If the apex is displaced into the developing tooth germ, extract

In mature teeth,
The pulp will likely become necrotic in teeth with complete root formation.
Root canal therapy using a temporary filling with calcium hydroxide is recommended and
treatment should begin 2–3 weeks after surgery
 Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with
a flexible splint for 4 weeks

Biologic Consequences
 Luxation injuries result in damage to the attachment apparatus - the severity of which is dependent on the type of
injury sustained (concussion least, intrusion most).
 The apical neurovascular supply to the pulp is also affected to varying degrees,
resulting in an altered or total loss of vitality to the tooth.

Consequences of apical neurovascular supply
Pulp Canal Obliteration (Calcification)
 Common after luxation injuries
 The exact mechanism of pulp canal obliteration is unknown.
 It has been theorized that the sympathetic/parasympathetic control
of blood flow to the odontoblasts is altered, resulting in
uncontrolled reparative dentin.
 Another theory is that hemorrhage and blood clot formation in the
pulp form a nidus for subsequent calcification if the pulp remains
vital.
Cohen Pathways Of Pulp, 11th edition

Pulp Necrosis
The factors most important for the development of pulp necrosis are
 Type of injury (concussion least, intrusion most) and
 The stage of root development (mature apex more than an immature apex).
Pulp necrosis most likely lead to infection of the root canal system, with problematic
consequences.
Pulp Space Infection
 Pulp space infection in conjunction with damage to the external root surface
results in periradicular root and bone resorption and continues in its active
state as long as the pulpal stimulus (infection) remains.
 When the root loses its cemental protection, lateral periodontitis with root
resorption can result
Inflammatory root
resorption caused by a pulp
space infection.
Note the radiolucency's in
the root and surrounding
bone

AVULSION
 Tooth avulsion (exarticulation, total luxation) implies total displacement of the tooth out of its socket.
 0.5 to 16% of traumatic injuries in the permanent dentition
 The maxillary central incisors are the most frequently avulsed teeth, while the lower jaw is seldom affected
 Other injuries - fractures of the alveolar socket wall and injuries to the lips are the most common

Consequences of tooth avulsion
• If PDL remains hydrated and cell viability is maintained :
- it will repair after reimplantation
- Inflammation stimulated by damaged tissues will be minimal
- Favourable healing with new replacement cementum likely to occur
• If excessive drying occurs :
- Severe inflammatory response over damaged PDL
- Slow moving cementoblasts will not cover the entire root surface
- It is likely that in certain areas bone will attach directly to root
- Via physiologic contouring of bone, entire root will be replaced by bone in time
(replacement resorption)

 Replantation is in most situations the treatment of choice, but cannot always be carried out immediately.
 There are also individual situations when replantation is not indicated (e.g., severe caries or periodontal
disease, non-cooperating patient, severe medical conditions (e.g., immunosuppression
and severe cardiac conditions) which must be dealt with individually.

The prognosis of a replanted tooth depends on
the viability of the periodontal ligament (PDL) cells remaining on root surface,
integrity of root cementum and
minimal bacterial contamination
Directly related to –
-the extra-alveolar time,
-type of storage after avulsion and
-root surface alterations.
AAE GUIDELINES 2013

Fouad AF, Abbott PV, Tsilingaridis G, et al.
Dent Traumatol 2020

DENTAL TRAUMATIC INJURIES

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to DENTAL TRAUMATIC INJURIES

Similar to DENTAL TRAUMATIC INJURIES (20)

More from REVATHY M NAIR

More from REVATHY M NAIR (9)

Recently uploaded

Recently uploaded (20)

DENTAL TRAUMATIC INJURIES

Editor's Notes