Traumatic Dental Injuries to Permanent Teeth

Traumatic Injuries to
Permanent Teeth
Presented by:
Dr Susmita Shah
II MDS
1
09-05-2020

Content:
• Introduction
• Mechanism of Dental Injuries
• Classifications
• Incidence & prevalence
• Etiology
• Examination
– History of trauma
– Clinical Examination
– Investigations
• Treatment guidelines for fractures of teeth and
alveolar bone
• Conclusion
• Bibliography
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INTRODUCTION
• Injury: Interruption in the continuity of tissues.
• Dental trauma has been and continues to be the
common occurrence that every dental professional must
be prepared to assess and treat when necessary
• It is important to establish diagnosis descriptive of
specific traumatic entities, and to delineate
recommended treatment approaches for these injuries
based on available evidence.
• If not managed appropriately can have serious
consequences for the patient.
3
Pagadala S, Tadikonda C. An overview of classification of dental trauma.
IAIM, 2015; 2(9): 157-164.
09-05-2020

MECHANISM OF DENTAL INJURIES
• Direct Trauma:
• Indirect Trauma:
• Extent of trauma:
– Energy of impact
– Resilience of impacting object
– Shape of impacting object
– Direction of impacting force
4
J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries
to the teeth. Munksgaard. 3rd edition.2007
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CLASSIFICATION OF DENTAL TRAUMA
1. Classification of anterior teeth trauma by Sweets (1955)
– Class I – A simple of crown exposing no dentition.
– Class II – A parallel of crown involving little dentin.
– Class III – Extensive fracture of crown involving more dentin bur no pulp
exposure.
– Class IV – Extensive fracture of crown exposing pulp.
– Class V – Complete fracture of crown exposing pulp.
– Class VI – Fracture of root with or without loss of crown structure.
– Class VII – Tooth loss as a result of trauma.
5
Pagadala S, Tadikonda C. An overview of classification of
dental trauma. IAIM, 2015; 2(9): 157-164.
09-05-2020

2. Classification by
Rabinowitch (1956)
1. Fractures of the enamel
or slightly into the dentin
2. Fractures into the dentin
3. Fractures into the pulp
4. Fractures of the
periodontium
5. Comminuted fractures
6. Displaced teeth.
6
Pagadala S, Tadikonda C. An overview of classification of dental
trauma. IAIM, 2015; 2(9): 157-164.
3. Benetts Classification (1963)
Class I – Traumatized tooth
without coronal or
root fracture.
a) Tooth from in alveolus.
b) Tooth subluxated in alveolus.
Class II – Coronal fracture
a) Involving enamel
b) Involving enamel + dentin.
Class III – Coronal fracture with
pulp exposure.
Class IV – Root fracture
a) Without coronal fracture.
b) With coronal fracture.
Class V – Avulsion of tooth.
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4. Classification by Ulfohn (1969)
1) The possibility of identifying the clinical state of
the pulp.
2) The absolute conviction that it is impossible to
view the dentin and the pulp as separate organs and
that they constitute one organ. Considering this, any
attack on the dentin represents indirect damage to
the pulp.
3) Determination of treatment
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trauma. IAIM, 2015; 2(9): 157-164.
09-05-2020

5. Classification by Ellis (1960)
• Class I - Simple crown fracture with little or no dentin affected
• Class II - Extensive crown fracture with considerable loss of
dentin, but with the pulp not affected.
• Class III - Extensive crown fracture with considerable loss of
dentin and pulp exposure.
• Class IV - A tooth devitalized by trauma with or without loss of
tooth structure.
• Class V - Teeth lost as a result of trauma.
• Class VI - Root fracture with or without the loss of crown
structure.
• Class VII - Displacement of the tooth with neither root nor
crown fracture
• Class VIII - Complete crown fracture and its replacement.
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trauma. IAIM, 2015; 2(9): 157-164.
09-05-2020

6. Classification by Ellis and Davey (1970)
• Class 1 - Simple fracture of the crown-involving little or no
dentin
• Class 2 - Extensive fracture of the crown – involving
considerable dentin, but not the pulp
• Class 3 - Extensive fracture of the crown – involving
considerable dentin, and exposing the dental pulp
• Class 4 - The traumatized tooth which becomes nonvital-with or
without loss of crown structure
• Class 5 - Teeth lost as a trauma
• Class 6 - Fracture of the root - with or without loss of crown
structure
• Class 7 - Displacement of the tooth-without fracture of crown or
root
• Class 8 - Fracture of the crown en masse and its replacement.
• Class 9 - Traumatic injuries of primary teeth.
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7. 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
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8. Application of international classification
of diseases to dentistry and stomatology
(WHO, 1978)
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Pagadala S, Tadikonda C. An overview of classification of dental trauma. IAIM,
2015; 2(9): 157-164.
09-05-2020

9. Classification by Garcia – Godoy (1981)
0. Enamel crack
1.Enamel fracture
2.Enamel dentin fracture without pulp exposure
3.Enamel dentin fracture with pulp exposure
4.Enamel dentin cementum fracture without pulp exposure
5.Enamel dentin cementum fracture with pulp exposure
6.Root fracture
7.Concussion
8.Luxation
9.Lateral displacement
10.Intrusion
11.Extrusion
12.Avulsion
12
Pagadala S, Tadikonda C. An overview of classification of dental trauma. IAIM, 2015;
2(9): 157-164.
09-05-2020

10. 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 (N 873) 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. A fracture involving dentin, cementum and the pulp.
trauma. IAIM, 2015; 2(9): 157-164.
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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.
Pagadala S, Tadikonda C. An overview of classification
of dental trauma. IAIM, 2015; 2(9): 157-164.
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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
Pagadala S, Tadikonda C. An overview of classification of dental trauma. IAIM,
2015; 2(9): 157-164.
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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.
trauma. IAIM, 2015; 2(9): 157-164.
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Textbook of Pediatric Dentistry by Nikhil Marwah. 3rd edition 17
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11. Classification by Basrani
(1982)
Based on the anatomy of the teeth
a) Crown fracture
i) Fracture of the enamel
ii) Fracture of the enamel and
dentin.
Without pulp exposure
With pulp exposure
b) Root fractures
c) Crown-root fractures
trauma. IAIM, 2015; 2(9): 157-164.
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12. Classification by Galea (1984)
• Crown facture without pulp
exposure
• Crown facture with pulp exposure
• Crown –Root fractures
• Root fractures
• Subluxation
• Subluxation with intrusion
• Subluxation with extrusion
• Luxation
• Fracture of the alveolar socket
• Dento- alveolar fracture
• Fractures to the maxilla and
mandible
• Injuries to the soft tissues
• Other injuries.
13. Classification by Burton, et
al. (1985)
• Fracture involving dentin and/or
pulp
• Devitalization
• Avulsion
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14. Classification by Stockwell
(1988)
• Fracture of enamel only
• Fracture of crown involving enamel
and dentin, but not the pulp
• Fracture of the crown with
exposure of the pulp Fracture of
the root
• Luxation of the tooth without
fracture
• Avulsion of the tooth
• Concussion without fracture,
displacement or avulsion, but loss
of vitality during survey period
• Trauma to a previously traumatized
tooth resulting in either
dislodgement of the restoration, or
further fracture, dislodgement or
avulsion of the tooth
19
15. Classification by Lee-Knight, et
al. (1989)
• Tooth infraction
• Chipped tooth
• Fractured tooth
• Lacerated lip
• Traumatized TMJ
16. Classification by Hunter, et al.
(1990)
• Fracture
• Discolouration
• Absence of any maxillary incisor
teeth
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17. Classification by Bijella, et al.
(1990)
• Crown fracture
• Concussion
• Subluxation
• Subluxation with enamel fracture
• Subluxation with lingual or labial
displacement
• Intrusion
• Extrusion
• Full displacement
• Root fracture
• Crown-root fracture
• Alveolar bone fracture
Pagadala S, Tadikonda C. An overview of
classification of dental trauma. IAIM, 2015;
2(9): 157-164.
20
18. Classification by
Forsberg and Tedestam
(1990)
• Enamel fracture
• Enamel dentin fracture
• Fracture involving pulp
• Root fracture
• Luxation,Subluxtation
• Exarticulation
• Discolouration
19. Classification by Perez, et al.
(1991)
• Intra-oral and / or extra-oral soft
tissue injury
• Presence or absence of
fracture/displacement to teeth
• Alveolar fracture
• Crown fracture were analyzed
according to Ellis classification
system
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20. Classification by Zerman and Cavellari (1993)
• Fracture of enamel including enamel chipping
• Fracture of enamel- dentine without pulpal involvement
• Fracture of enamel- dentine with pulpal involvement
• Fracture of root
• Crown-root fracture with pulpal involvement
• Concussion
• Subluxation
• Intrusive luxation
• Extrusive luxation
• Latetral luxation
• Avulsion
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21. Classification by World Health Organization in its application
of International Diseases of Dentistry and Stomatology (1994)
A. Injuries to the hard dental tissues and the pulp
1) Enamel infraction (N 502.50) An incomplete fracture (crack) of the enamel without loss of
tooth substance.
2) Enamel fracture (uncomplicated crown fracture) (N 502.50) A fracture with loss of tooth
substance confined to the enamel.
3) Enamel- Dentin Fracture (Uncomplicated Crown fracture) (N 502.51) A fracture with loss of
tooth substance confined to enamel and dentin, but not involving the pulp.
4) Complicated crown fracture (N 502.52) A fracture involving enamel and dentin, and exposing
the pulp.
5) Uncomplicated Crown- Root Fracture (N 502.54) A fracture involving enamel, dentin and
cementum, but not exposing the pulp.
6) Complicated Crown-Root fracture (N 502.54) A fracture involving enamel, dentin and
cementum, and exposing the pulp.
7) Root Fracture (N 502.53) A fracture involving dentin, cementum, and the pulp. Root fracture
can be further classified according to displacement of the coronal fragment, as Horizontal,
Oblique, and Vertical.
trauma. IAIM, 2015; 2(9): 157-164.
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B. Injuries to the periodontal tissues.
1) Concussion (N 503.20) An injury to the tooth-supporting structures with abnormal
loosening or displacement of the tooth, but with marked reaction to percussion.
2) Subluxation (Loosening) (N 503.20) An injury to the tooth-supporting structures with
abnormal loosening, but without displacement of the tooth.
3) Extrusive Luxation(Peripheral Dislocation, Peripheral Avulsion) (N 503.20) Partial
displacement of the tooth out of its socket.
4) Lateral Luxation (N 503.20) Displacement of the tooth in a direction other than
axially. This is accompanied by communition or fracture of the alveolar socket.
5) Intrusive Luxation (Central dislocation) (N 503.21) Displacement of the tooth into the
alveolar bone. This injury is accompanied by communition or fracture of the alveolar
socket.
7) Avulsion (Exarticulation) (N 503.22) Complete displacement of the tooth out of its
socket.
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C. Injuries to the supporting bone
1) Communution of the mandibular (N 502.60) or Maxillary (N
502.40) Alveolar Socket Crushing and compression of the alveolar
socket.
2) Fracture of the Mandibular (N 502.60) or Maxillary (N 502.40)
Alveolar Socket Wall A fracture confined to the facial or oral socket
wall.
3) Fracture of the Mandibular (N 502.60) or Maxillary (N 502.40)
Alveolar process A fracture of the alveolar process which may or
may not involve the alveolar socket.
4) A fracture involving the base of the mandible or maxilla and often
the alveolar process(jaw fracture).The fracture may or may not
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D. Injuries to gingiva or oral mucosa
1) Laceration of gingival or oral mucosa (S01.50) A shallow or
deep wound in the mucosa resulting from a tear, and usually
produced by a harp object
2) Contusion of gingiva or oral mucosa (S00.50) A bruise usually
produced by impact with a blunt object and not accompanied by a
break in the mucosa, usually causing sub mucosal hemorrhage.
3) Abrasion of gingival or oral mucosa (S00.50) A superficial wound
produced by rubbing or scraping of the mucosa leaving a raw,
bleeding
mucosa.
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22. Classification by Hamilton,
et al. (1997)
• Fracture confined to enamel
• Fracture involving dentin
• Fracture with pulp exposed
• Intrinsic discoloration
• Abnormal mobility
• Infraocclusion
26
23. Classification by Spinas (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
24. Classification by McDonald
(2004)
Class 1 - Simple fracture of the
crown involving little or no dentin
Class 2 - Extensive fracture of the
crown involving considerable dentin
but not the dental Pulp
Class 3 - Extensive fracture of the
crown with an exposure of the
dental pulp
Class 4 - Loss of the entire crown.
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Incidence & Prevalence
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Patel MC, Sujan SG. The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with
predisposing risk factors among 8–13 years school children of Vadodara city:an epidemiological study. Journal of
Indian society of pedodontics and preventive dentistry. Apr - Jun 2012;Issue 2;Vol 30.

28
Title Author
Journal
L
O
E
Aim Materials and methodology Results
PREVALEN
CE OF
TRAUMATI
C DENTAL
INJURIES
AND THEIR
RELATION
WITH
PREDISPO
SING
FACTORS
AMONG 8-
15
YEARS
OLD
SCHOOL
CHILDREN
OF INDORE
CITY, INDIA
JUNEJA
P,
SADAN
KULKAR
NI, RAJE
S.
Clujul
Medical
Vol.91,
No. 3,
2018:
328-335
5 To assess the
prevalence of
traumatic dental
injuries (TDI) and
their relation with
predisposing
factors among 8-
15 years old
school children in
Indore city,
India.
A cross sectional study was
carried out among 4000
children of 60
schools in Indore using
multistage random sampling
method. Examination of
permanent
incisor teeth was done in
accordance with the
modified Elli’s and Davey
Classification using a
standard mouth mirror and
probe. Subjects who had
clinical evidence of trauma
were interviewed for details
of the injury event by using
structured questionnaire.
Chi square test was used to
analyze the distribution of
all the measurement in this
study at the statistical
significance of 0.05.
Among the 4000 children of
60 schools examined, 10.2%
experienced TDI. 68.38%
boys experienced TDI, which
was approximately twice as
higher in females being
31.62%. The most commonly
affected teeth were maxillary
central incisors. A higher
number of children with
incisal overjet greater than 3
mm had TDI than those with
less than 3mm, although this
difference was not statistically
significant. Lip closure
incompetence was found to
be more common in subjects
having a TDI. Fall was the
most common cause for TDI
and place of occurrence was
home. Most common type of
fracture was class I and most
of them were untreated.
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Etiology
• Unintentional
– Falls & collisions
– Accidents
– Sports
– Inappropriate use of
teeth
– Biting hard items
– Presence of illness,
physical limitations or
learning difficulties
J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to
the teeth. Munksgaard. 3rd edition.2007
29
• Intentional
– Battered child syndrome
– Oral Piercing
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Examination & Diagnosis
• History:
– When did the injury occur?
– Where did the injury occur?
– How did the injury occur?
– Treatment elsewhere?
– Previous dental injuries?
– General health
– Did the trauma caused
drowsiness, vomiting, headache?
– Is there spontaneous pain from
teeth?
– Are the teeth tender to touch or
during eating?
– Is there any disturbance in the
bite?
J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to
30
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• Clinical Examination:
– Recording of extraoral wounds &
palpation of facial skeleton
– Recording of injuries to oral mucosa or
gingiva
– Examination of crowns of teeth
– Recording of displacement of teeth
– Disturbances in occlusion
– Tenderness of teeth to percussion
– Reaction of teeth pulpal testing
• Radiographic Examination:
– Intraoral and Extraoral radiographs
J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to the
teeth. Munksgaard. 3rd edition.2007
31
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AAPD. Assessment of Acute Traumatic Injuries. REFERENCE MANUAL V 3 9 / N O 6 1 7 / 18.
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AAPD. Assessment of Acute Traumatic Injuries. REFERENCE MANUAL V 3 9 / N O 6 1 7 / 18.
33
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J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to the
teeth. Munksgaard. 3rd edition.2007
34
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IADT treatment Guidelines
35
International Association of Dental Trauma Treatment
Guidelines 2012.
09-05-2020

a. Infraction
• Clinical findings
– An incomplete fracture (crack) of the enamel without loss of tooth
structure.
– Not tender. If tenderness is observed, evaluate the tooth for a
possible luxation injury or a root fracture.
• Radiographic findings
– No radiographic abnormalities.
– Radiographs recommended: a periapical view.
• Treatment
– In case of marked infractions, etching and sealing with resin to
prevent discoloration of the infraction lines. Otherwise, no treatment
is necessary.
• Follow-up
– No follow-up is generally needed for infraction injuries unless they
are associated with a luxation injury or other types of fracture
International Association of Dental Trauma Treatment Guidelines
2012.
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b. Enamel fracture
– A complete fracture of the enamel.
– Loss of enamel. No visible sign of exposed dentin.
– Not tender. If tenderness is observed, evaluate the tooth for a possible luxation or
root fracture injury.
– Normal mobility.
– Sensibility pulp test usually positive.
– Enamel loss is visible.
– Radiographs recommended: periapical, occlusal and eccentric exposures. They
are recommended in order to rule out the possible presence of a root fracture or a
luxation injury.
– Radiograph of lip or cheek to search for tooth fragments or foreign materials.
• Treatment
– If the tooth fragment is available, it can be bonded to the tooth.
– Contouring or restoration with composite resin depending on the extent and
location of the fracture.
• Follow-up
– 6-8 weeks – Clinical and radiographic examination.
– 1 year – Clinical and radiographic examination.
2012.
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c. Enamel-dentin fracture
– A fracture confined to enamel and dentin with loss of tooth structure, but not exposing the
pulp.
– Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation
or root fracture injury.
– Sensibility pulp test usually positive.
– Enamel-dentin loss is visible.
– Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth
displacement or possible presence of root fracture.
– Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.
• Treatment
– If a tooth fragment is available, it can be bonded to the tooth. Otherwise, perform
a provisional treatment by covering the exposed dentin with glassIonomer or a more
permanent restoration using a bonding agent and composite resin or other accepted dental
restorative materials.
– If the exposed dentin is within 0.5 mm of the pulp (pink, no bleeding), place calcium
hydroxide base and cover with a material such as a glass ionomer.
• Follow-up
International Association of Dental Trauma Treatment Guidelines 2012.
38
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J. O Andreasen, F M Andreasen. Essentials of
Traumatic Injuries to the teeth. Munksgaard.
3rd edition.2007
39
Direct Composite
Restoration
Fragment Reattachment
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d. Enamel-dentin-pulp fracture
– A fracture involving enamel and dentin with loss of tooth
structure and exposure of the pulp.
– Percussion test: not tender. If tenderness is observed,
evaluate for possible luxation or root fracture injury.
– Exposed pulp sensitive to stimuli.
– Enamel-dentin loss visible.
– Radiographs recommended: periapical, occlusal and
eccentric exposures, to rule out tooth displacement or
possible presence of root fracture.
– Radiograph of lip or cheek lacerations to search for tooth
fragments or foreign materials.
International Association of Dental Trauma Treatment
Guidelines 2012.
40
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• Treatment
• In young patients with immature, still developing teeth, it is
advantageous to preserve pulp vitality by pulp capping or partial
pulpotomy. Also, this treatment is the choice in young patients with
completely formed teeth.
• Calcium hydroxide is a suitable material to be placed on the pulp
wound in such procedures.
• In patients with mature apical development, root canal treatment is
usually the treatment of choice, although pulp capping or partial
pulpotomy also may be selected.
• If tooth fragment is available, it can be bonded to the tooth.
• Future treatment for the fractured crown may be restoration with
other accepted dental restorative materials.
• Follow-up
• 6-8 weeks – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.
2012.
41
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J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries
to the teeth. Munksgaard. 3rd edition.2007
42
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e. Crown-root fracture without
pulp involvement
– A fracture involving enamel, dentin and cementum with loss of tooth structure,
but not exposing the pulp.
– Crown fracture extending below gingival margin.
– Percussion test: Tender.
– Coronal fragment mobile.
– Sensibility pulp test usually positive for apical fragment.
– Apical extension of fracture usually not visible.
– Radiographs recommended: periapical, occlusal and eccentric exposures. They
are recommended in order to detect fracture lines in the root.
• Treatment
• Emergency treatment
– temporary stabilization of the loose segment to adjacent teeth can be performed
until a definitive treatment plan is made.
International Association of Dental Trauma Treatment Guidelines 2012. 43
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• Non-emergency treatment alternatives
– Fragment removal only.
– Removal of the coronal crown-root fragment and subsequent restoration
of the apical fragment exposed above the gingival level.
– Fragment removal and gingivectomy (sometimes ostectomy)
– Removal of the coronal crown-root segment with subsequent
endodontic treatment and restoration with a post-retained crown. This
procedure should be preceded by a gingivectomy, and sometimes
ostectomy with osteoplasty.
• 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
• Surgical extrusion
• Removal of the mobile fractured fragment with subsequent
surgical repositioning of the root in a more coronal position.
• Root submergence
• Implant solution is planned.
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• Extraction
• Extraction with immediate or delayed implant-retained
crown restoration or a conventional bridge. Extraction
is inevitable in crown-root fractures with a severe
apical extension, the extreme being a vertical fracture.
• Follow-up
J. O Andreasen, F M Andreasen. Essentials of Traumatic
Injuries to the teeth. Munksgaard. 3rd edition.2007
45
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f. Crown-root fracture with pulp
involvement
46
– A fracture involving enamel, dentin and cementum and exposing the pulp.
– Percussion test: tender.
– Coronal fragment mobile.
– Apical extension of fracture usually not visible.
– Radiographs recommended: periapical and occlusal exposure.
• Treatment
• Emergency treatment
– As an emergency treatment a temporary stabilization of the loose segment to
adjacent teeth.
– In patients with open apices,
– to preserve pulp vitality by a partial pulpotomy.
– in young patients with completely formed teeth.
– Calcium hydroxide compounds are suitable pulp capping materials..
09-05-2020

• Non-emergency treatment alternatives
– Fragment removal and gingivectomy (sometimes ostectomy)
– 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.
• Surgical extrusion
– Removal of the mobile fractured fragment with subsequent surgical
repositioning of the root in a more coronal position.
– Root submergence
• An implant solution is planned, the root fragment may be left in
situ.
• Extraction
– Extraction with immediate or delayed implant-retained crown restoration or a
conventional bridge.
• Follow-up
– 1 year – Clinical and radiographic examination
09-05-2020

g. Root Fracture
– The coronal segment may be mobile and may be displaced.
– The tooth may be tender to percussion.
– Bleeding from the gingival sulcus may be noted.
– Sensibility testing may give negative results initially, indicating
transient or permanent neural damage.
– Monitoring the status of the pulp is recommended.
– Transient crown discoloration (red or grey) may occur.
– The fracture involves the root of the tooth and is in a horizontal
or oblique plane.
– Fractures that are in the horizontal plane can usually be
detected in the regular periapical 90o angle film with the central
beam through the tooth. This is usually the case with fractures in
the cervical third of the root.
– If the plane of fracture is more oblique which is common with
apical third fractures, an occlusal view or radiographs with
varying horizontal angles are more likely to demonstrate the
fracture including those located in the middle third.
J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to the teeth.
Munksgaard. 3rd edition.2007
48
09-05-2020

Malhotra N, Kundabala M, Acharya S. A
Review of Root Fractures: Diagnosis,
Treatment and Prognosis. Dental update ·
November 2011.
49
09-05-2020

• Treatment
– Reposition any displaced segment and then splint.
– Suture gingival laceration, if present.
– Stabilize the segment for 4 weeks.
• Follow-up
– 4 weeks – Splint removal, clinical and radiographic
examination.
– 4 months – Clinical and radiographic examination.
– 5 years – Clinical and radiographic examination
•International Association of Dental Trauma Treatment Guidelines 2012.
51
09-05-2020

Andreasen and Hjorting-Hansen classified transverse root fractures
into four categories
1) Coronal and apical segment may have union by hard tissue
2) Union by fibrous tissue
3) Union by bony ingrowth across the fracture line
4) Ingrowth of chronic granulation tissue
52
Four types of healing in transverse root fractures: (a) healing by hard tissue
(calcified tissue); (b) healing by interposition of connective tissue; (c) healing by
interposition of bone and connective tissue; and (d) healing by interposition of
granulation tissue.
09-05-2020

• Union by hard tissue:
– is most desirable
– but occurs relatively infrequently.
• Can occur in
– 2 fractured tooth segments are brought together and remain
without mobility
– when there is small amount of luxation of coronal segment
– Small amount of separation of segments
Union by way of fibrous tissue:
- is more common
-where slight mobility exists during healing process.
Union by in growth of bone:
- Occurs principally during growth spurts of child.
- Coronal segment of fractured tooth moves with the growing bone
and leaves a bony interface b/w the two fractured segments.
09-05-2020

J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to the teeth. Munksgaard.
3rd edition.2007
54
09-05-2020

h. Alveolar Fracture
– The fracture involves the alveolar bone and may extend to the
adjacent bone.
– Segment mobility and dislocation with several teeth moving
together are common findings.
– An occlusal change due to misalignment of the fractured alveolar
segment is often noted.
– Sensibility testing may or may not be positive.
– Fracture lines may be located at any level, from the marginal
bone to the root apex and above the apex.
– In addition to the 3 angulations and occlusal film, additional views
such as a panoramic radiograph can be helpful in determining the
course and position of the fracture lines
09-05-2020

• Treatment
– Reposition any displaced segment and then splint.
– Suture gingival laceration, if present.
– Stabilize the segment for 4 weeks.
• Follow-up
– 4 weeks – Splint removal, clinical and radiographic examination.
– 5 years – Clinical and radiographic examination.
09-05-2020

i. Concussion
– The tooth is tender to touch or tapping; it
has not been displaced and does not have
increased mobility.
– No radiographic abnormalities.
• Treatment
– No treatment is needed.
– Monitor pulpal condition for at least one
year.
• Follow-up
– 4 weeks – Clinical and radiographic
examination.
– 6-8 weeks – Clinical and radiographic
examination.
– 1 year – Clinical and radiographic
examination.
International Association of Dental
Trauma Treatment Guidelines 2012.
62
09-05-2020

j. Subluxation
– The tooth is tender to touch or tapping and has increased mobility; it has not been
displaced.
– Bleeding from gingival crevice may be noted.
– Sensibility testing may be negative initially indicating transient pulpal damage.
– Monitor pulpal response until a definitive pulpal diagnosis can be made.
– Radiographic abnormalities are usually not found.
• Treatment
– Normally no treatment is needed, however, a flexible splint to stabilize the tooth for
patient comfort can be used for up to 2 weeks.
• Follow-up
– 4 weeks – Clinical and radiographic examination.
09-05-2020

k. Extrusion
– The tooth appears elongated and is excessively mobile.
– Sensibility tests will likely give negative results.
– Increased periodontal ligament space apically.
• Treatment
– Reposition the tooth by gently reinserting It into the tooth socket.
– Stabilize the tooth for 2 weeks using a flexible splint.
– In mature teeth where pulp necrosis is anticipated, or if several signs and
symptoms indicate that the pulp of mature or immature teeth is becoming
necrotic, root canal treatment is indicated.
• Follow-up
– 1 year – Clinical and radiographic examination yearly.
– 5 years – Clinical and radiographic examination.
09-05-2020

l. Lateral luxation
– The tooth is displaced, usually in a palatal/lingual or labial direction.
– It will be immobile and percussion usually gives a high, metallic (ankylotic) sound.
– Fracture of the alveolar process present.
– The widened periodontal ligament space is best seen on eccentric or occlusal exposures.
• Treatment
– 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.
– Monitor the pulpal condition.
– If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption.
• Follow-up
– Yearly for 5 years – Clinical and radiographic examination.
67
09-05-2020

J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to the teeth.
Munksgaard. 3rd edition.2007
69
Oblique forces displace the tooth out
of socket. Only the gingival fibers
palatally prevent the tooth from being
avulsed. Both the PDL and the
neurovascular supply to the pulp are
severed.
09-05-2020

m. Intrusion
– The tooth is displaced axially into the alveolar bone.
– It is immobile and percussion may give a high, metallic
(ankylotic) sound.
– 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.
• Treatment
• Teeth with incomplete root formation:
– Allow eruption without intervention.
– If no movement within few weeks, initiate orthodontic
repositioning.
– If the tooth is intruded more than 7 mm, reposition surgically
or orthodontically.
71
09-05-2020

• Teeth with complete root formation:
– Allow eruption without intervention if the tooth is intruded less than 3 mm.
If no movement after 2-4 weeks, reposition surgically or orthodontically
before ankylosis can develop.
– If the tooth is intruded 3-7 mm, reposition surgically or orthodontically.
– If the tooth is intruded beyond 7 mm, reposition surgically.
– 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 repositioning.
– Once an intruded tooth has been repositioned surgically or
orthodontically, stabilize with a flexible splint for 4 weeks.
• Follow-up
– Yearly for 5 years – Clinical and radiographic examination
09-05-2020

74
Concussio
n
Subluxatio
n
Extrusion Intrusion Lateral
luxation
Abnormal
mobility
- + + -/+ -/+
Tenderness
to
percussion
+ +/- +/- - -
Percussion
sound
Normal Dull Dull Metallic Metallic
Positive
response to
sensibility
tests
+/- +/- - - -
Radiographi
c dislocation
- -/+ + + +
09-05-2020

n. Avulsion
First aid for avulsed teeth
• Give appropriate advice to the public about first aid.
• An avulsed permanent tooth is one of the few real emergency.
• Also, instructions may be given by telephone to parents at the
emergency site.
• If a tooth is avulsed, make sure it is a permanent tooth (primary
teeth should not be replanted).
• Keep the patient calm.
• Find the tooth and pick it up by the crown (the white part). Avoid
touching the root.
• If the tooth is dirty, wash it briefly (10 seconds) under cold running
water and reposition it. Try to encourage the patient / parent to
replant the tooth. Bite on a handkerchief to hold it in position.
• If this is not possible, place the tooth in a suitable storage medium.
Avoid storage in water!
2012.
75
09-05-2020

Closed Apex
Tooth replanted
prior to the patient’s
arrival at the dental
office or clinic
Extraoral dry time
less than 60 min
Extraoral dry time
exceeding 60 min
• Clean the area: water spray, saline, or chlorhexidine.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both
• Apply a flexible splint for up to 2 weeks.
• Antibiotics: Tetracycline is the first choice (Doxycycline 2x per day
for 7 days
• Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate
dose for If the avulsed tooth has been in contact with soil, and if
tetanus coverage is uncertain, refer to physician for a tetanus
booster.
• Initiate root canal treatment 7-10 days after replantation and before
splint removal.
09-05-2020

Patients Instructions & Follow Up
• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1
week.
• Follow-up
• Root canal treatment 7-10 days after replantation. Place
calcium hydroxide as an intra-canal medicament for up to 1
month followed by root canal filling with an acceptable
material. Splint removal and clinical and radiographic control
after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6
months, 1 year and then yearly thereafter
09-05-2020

2012.
79
Open Apex
Tooth replanted
prior to the patient’s
arrival at the dental
office or clinic
Extraoral dry time
less than 60 min
Extraoral dry time
exceeding 60 min
• The most frequent causes of tooth
avulsion in teeth with open apex are
related to falls and accidents in sports
practice.
• The immediate replantation is considered
the best treatment choice
09-05-2020

• Remove attached non-viable soft tissue with gauze.
• Root canal treatment can be carried out prior to replantation or
later.
• Administer local anesthesia.
• Irrigate the socket with saline.
• Examine the alveolar socket.
• Replant the tooth slowly with slight digital pressure.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth clinically and
radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Administer systemic antibiotics.
• If the avulsed tooth has been in contact with soil or if tetanus
coverage is uncertain, refer to physician for evaluation of the
need for a tetanus booster.
2012.
81
09-05-2020

Patients Instructions & Follow Up
• Avoide participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
• Follow up:
• For immature teeth, root canal treatment should be avoided unless
there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months,
1 year and then yearly thereafter.
2012.
82
09-05-2020

Leelavathi L, R. Karthick, Sankari L, N. Aravindha Babu. Avulsed Tooth - A Review
Biomedical & Pharmacology Journal. Vol. 9(2), 847-850 (2016) 83
09-05-2020

STORAGE MEDIA
Laboratory prepared Natural source
Hank’s Balanced Salt Solution Milk
Normal saline Saliva
ViaSpan Propolis
Eagle’s medium Coconut water
Custodiol Egg white
Dubelco’s storage Emdogain
Tooth rescue box Morusrubra
Conditioned medium Salvia officinalis extract
Gatorade Honey milk
Contact lens solution Tap water
Growth factors
Ascorbic acid
L-DOPA
Cryoprotective agents
Catalase supplementation
Leelavathi L, R. Karthick, Sankari L, N. Aravindha Babu. Avulsed Tooth - A Review
Biomedical & Pharmacology Journal. Vol. 9(2), 847-850 (2016)
09-05-2020 84

Leelavathi L, R. Karthick, Sankari L, N. Aravindha Babu. Avulsed Tooth - A
Review Biomedical & Pharmacology Journal. Vol. 9(2), 847-850 (2016)
85
09-05-2020

09-05-2020 Savas S,kyilmaz K, Akcay M, Koseoglu S. Delayed Replantation of Avulsed Teeth: Two
Case Reports. Hindawi Publishing Corporation Case Reports in Dentistry
Volume 2015, Article ID 197202, 5 pages
86
Figure 1: Avulsion of the
left upper incisor.
Figure 2: Splinting of
the avulsed tooth with
orthodontic wire and
composite resin. Figure 2: Splinting of
the avulsed tooth with
composite resin.
Figure 4: Frontal view,
18 months after trauma,
slight infraposition
of avulsed tooth.
Figure 5: 18-months follow-up
of replanted tooth.

09-05-2020 Savas S,kyilmaz K, Akcay M, Koseoglu S. Delayed Replantation of Avulsed
Teeth: Two Case Reports. Hindawi Publishing Corporation Case Reports in
Dentistry Volume 2015, Article ID 197202, 5 pages
87
Figure 6: Avulsion of the
right upper incisor.
Figure 10: No pathology
and resorption, 12-month
radiographic examination.
Figure 9: Frontal view, 12
months after trauma.
Figure 7: Splinting of the
avulsed tooth with
composite resin.
Figure 8: Periapical
radiograph after
replantation of avulsed
tooth.

09-05-2020 D.Sardanan, A.Goyal,K.Gauba. Delayed replantation of avulsed tooth with15-hours
extra-oral time:3-yearfollow-up. Singapore Dental Journal35(2014)71–76.
88
Fig. 1: Pre- treatment
photograph showing
avulsed 11.
Fig. 2 – Pre-treatment
photograph showing
avulsed11. Fig. 3 – Pre-
treatment radiograph.
Fig. 4 – Acid-etch
composite splint from
canine-to-canine.
Fig. 5 – Radiograph post-splinting to
verify position of re- implanted tooth.
Fig. 6 – 1-year
follow-up
radiograph.

09-05-2020 D.Sardanan, A.Goyal,K.Gauba. Delayed replantation of avulsed tooth with15-hours
extra-oral time:3-yearfollow-up. Singapore Dental Journal35(2014)71–76.
89
Fig. 7 – 2-year follow-
up radiograph.
Fig. 8 – 3-year
follow-up radiograph.
Fig. 9 – Post-treatment photograph.
Fig. 10 – Post-treatment photograph.

09-05-2020 90
Title Author
Journal
L
O
E
Aim Materials and methodology Results
Prognosi
s of
Replante
d
Avulsed
Permane
nt
Incisors:
A
Systemat
ic Review
Priya
K,
Nene
S,
Bendg
ude V.
Internat
ional
Journal
of
Pedodo
ntic
Rehabil
itation ¦
Volume
3 ¦
Issue 2
¦ July-
Decem
ber
2018
2
a
the principles of
evidence based
dentistry to
evaluate
clinically and
radiographically
the
prognosis of
replanted
avulsed
permanent
incisors in the
pediatric age
group with an
immature or
mature apex
having an
extraoral dry
time up
to 60 min and a
follow-up period
of 24 months or
more.
The study inclusion
criteria included case
reports and case series
published in English.
Databases used for the
search were PubMed,
EBSCOhost, Google
Scholar, and Cochrane
from January 1, 2000 to
September 30, 2017. In
addition, hand search of
dissertations and journals
on pediatric dentistry
related to the topic of
interest was performed in
the institutional library.
Contact to authors and
colleagues working on
similar subjects in the
field was made through
e-mails
Based on the moderate
level of evidence
available to assess the
prognosis of replanted
avulsed permanent
incisors by clinical and
radiographic
evaluation, it is fair to
conclude that
the prognosis of the
replanted teeth was
best when the extraoral
dry time was <15 min
and the tooth was
stored in osmolality
balanced media
such as Hank’s
balanced salt solution,
saline, and milk. The
immature teeth showed
better prognosis than
mature teeth.

09-05-2020 Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion
of Permanent Teeth REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19
92

IADT Recommendation for Splinting
09-05-2020 International Association of Dental Trauma Treatment
Guidelines 2012.
93
Types of Injuries Splinting Time Splinting Type
Subluxation 2 weeks Flexible splint
Extrusive Luxation 2 weeks Flexible splint
Lateral Luxation 4 weeks Flexible splint
Intrusive Luxation 4 weeks Flexible splint
Root Fracture 4 weeks Flexible splint
Root Fracture
Cervical 1/3rd
4 weeks Flexible splint
Avulsion 2 weeks Flexible splint
Avulsion
Dry time more than 60 min
4 weeks Flexible splint
Alveolar fracture 4 weeks No Recommendation

Conclusion
• The clinician should have a thorough knowledge of
etiological cause of fracture, classic signs and
symptoms of fracture, availability and applicability of
diagnostic methods, differential diagnosis, and
factors determining the prognosis, so as to arrive at
an appropriate diagnosis and design a suitable
treatment protocol.
• A regular follow-up of teeth is required to evaluate
the success of treatment and to do the necessary
alterations in the suggested treatment protocol, if
indicated.
94
09-05-2020

BIBLIOGRAPHY
• McDonald and Avery’s Dentistry for the Child and Adolescent. Tenth
edtion. Chapter 27, Management of trauma to teeth and supporting
tissues;563-600. Elsevier.
• J. O Andreasen, F M Andreasen. Essentials of Traumatic Injuries to
• International Association of Dental Trauma Treatment Guidelines
2012.
• Patel MC, Sujan SG. The prevalence of traumatic dental injuries to
permanent anterior teeth and its relation with predisposing risk
factors among 8–13 years school children of Vadodara city:an
epidemiological study. Journal of Indian society of pedodontics and
preventive dentistry. Apr - Jun 2012;Issue 2;Vol 30.
• Textbook of Pediatric Dentistry by Nikhil Marwah. 3rd edition.
• AAPD. Assessment of Acute Traumatic Injuries. REFERENCE
MANUAL V 3 9 / N O 6 1 7 / 18.
95
09-05-2020

• Juneja p, sadan kulkarni, raje s. prevalence of traumatic dental
injuries and their relation with predisposing factors among 8-15
years old school children of indore city, India. Clujul Medical
Vol.91, No. 3, 2018: 328-335.
• Pagadala S, Tadikonda C. An overview of classification of dental
trauma. IAIM, 2015; 2(9): 157-164.
• Malhotra N, Kundabala M, Acharya S. A Review of Root
Fractures: Diagnosis, Treatment and Prognosis. Dental update ·
November 2011.
• Leelavathi L, R. Karthick, Sankari L, N. Aravindha Babu.
Avulsed Tooth - A Review Biomedical & Pharmacology Journal.
Vol. 9(2), 847-850 (2016)
• Belladonna F G, Ane Poly, Teixeira J, Nascimento V, Fidel S,
Fidel R. Avulsion of permanent teeth with open apex: a
systematic review of the literature. RSBO. 2012 Jul-
Sep;9(3):309-15.
• Tandon S,Textbook of pedodontics,3rd edition,2009
96
09-05-2020

• Savas S,kyilmaz K, Akcay M, Koseoglu S. Delayed Replantation of Avulsed
Teeth: Two Case Reports. Hindawi Publishing Corporation Case Reports in
Dentistry Volume 2015, Article ID 197202, 5 pages.
• D.Sardanan, A.Goyal,K.Gauba. Delayed replantationofavulsedtoothwith15-
hours extra-oral time:3-yearfollow-up. SingaporeDentalJournal35(2014)71–
76.
• Hanasuddin A. Sequelae of delayed replantation of maxillary permanent
incisors after avulsion: A case series with 24-month follow-up and clinical
review. Journal of Indian Society of Pedodontics and Preventive Dentistry |
Volume 36 | Issue 4 | October-December 2018.
• Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of
Permanent Teeth REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19
09-05-2020 97

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