Traumatic dental injuries.pptx

Traumatic Dental Injuries
Presented by – Dr. Parikshit S Kadam

Traumatic dental injury (TDI) represents an acute transmission of kinetic energy to
the tooth (or teeth), soft tissues and supporting structures, which results in fracture
and/or displacement of the tooth (or teeth) and/or separation or crushing of the
supporting gingival tissues and alveolar bone.
Introduction
Dental Trauma varies from enamel fracture to extensive maxillofacial injury
involving the supporting structures and displacement or avulsion of teeth.
Luxation injuries are more common in primary dentition and crown fractures are more
common in permanent dentition. - AAPD 2013,
IADT 2020

 Dental traumatology : Encompasses the epidemiology, etiology,
prevention, assessment, diagnosis and management of trauma to the jaws and
surroundings tissues.
 It also embraces post traumatic sequelae.
 Dental trauma can be simple or complex and its management may be
interdisciplinary or multidisciplinary.
Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology-E-Book. Elsevier Health Sciences; 2006 .

DEFINITIONS
INJURY: -Interruption in the continuity of tissues, and healing as the reestablishment of that
continuity.
TRAUMA: - A wound or injury; damage produced by an external force.
DENTAL TRAUMA: - Injury to the mouth, including teeth, lips, gums, tongue, and jawbones.
FRACTURE: -A fracture is understood to be the cracking or breaking of a tooth that has been
subjected to a force or impact greater than its resistance.
CRACK: -Any loss of continuity of the hard tissues of the tooth with out loss of tooth
substance.

Types of injuries
Hard tissues
• Teeth
• Alveolar bone
• Facial bones
Soft tissues
• Facial skin
• Lips
• Mucosa (cheeks and
peridontium)
• Soft tissues of the hard and soft
palate and tongue

INCIDENCE
SEX AND AGE DISTRIBUTION
■ Boys > Girls (2:1)
■ Peak incidence : 2-4 years and 8-10yrs
SUSCEPTIBLE TOOTH -
Maxillary central incisor(80%)
Maxillary lateral incisor
Mandibular central and lateral incisors
Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology-E-Book. Elsevier Health Sciences; 2006 .

Based on Etiology
■ Hedegard and Stalhane, (1973) identified falls and collisions as the dominating
cause of dental trauma in 2582 children aged from 7 to 15 years.
■ Ravn, (1974) reported that falls and collisions frequently occur in school children,
commonly with normal play activities, a greater prediction exists for occurrence
during the school year.
■ Andreasen, (1994) reported that 13% to 39% of all dental injuries are sports
related.
■ Rai and Munshi, (1998) studied the cause of dental trauma among South Kanara
school Children and found that leading cause of injury was undefined falls.

Hedegard and Stalhane, (1973) falls and collisions aredominating cause of dental trauma
aged from 7 to 15 years.
Ravn, (1974) falls and collisions frequently occur in school children, commonly
with normal play activities,
Andreasen, (1994) 13% to 39% of all dental injuries are sports related.
Rai and Munshi, (1998) leading cause of injury was undefined falls.
Hamilton et al. (1997) more children in the lower socio-economic groups received
injuries compared with the higher socio-economic status
Skaare and Jacobsen, (2003) 48% of dental injuries occurred at school. Sports and accidents
represented only 8% of the total number of injuries.
Tapias et al (2003) Falls were the most frequent cause of dental trauma (43.9%).
Boys and children with overbite were higher risk of crown
fractures.

Based on Type
■ Stock well, (1988) and Kania, (1996) reported that uncomplicated crown Fracture
without pulp exposure was the most common injury to the permanent dentition.
■ Forsberg, (1990) reported that displacement (luxation) of teeth has occurred more
frequently in the younger age groups studied and indicated that the supporting
structures (alveolar bone and periodontal ligament) in the primary dentition are
resilient, thereby favoring dislocations rather than fractures.

Stock well, (1988) and Kania, (1996) uncomplicated crown Fracture without pulp exposure
was the most common injury to the permanent dentition.
Forsberg, (1990) displacement (luxation) of teeth has occurred more
frequently in the younger age groups
Galea, (1990) dental trauma involving two teeth were more frequently
than one.
Forberg and Tedestam, (1990) maxillary central incisors were the most frequently injured
teeth in all studies for both the primary and secondary
dentitions
Gupta et al. (2002) class 1 fractures were the most common followed by class 2
and class 3
Roch and Cardoso, (2002) maxillary central incisors tend to be most affected and the
most frequent types of crown fractures are fractures of
enamel

Based on Sex
■ Galea, (1984) observed that female subjects with prominent maxillary incisors and
incompetent lip closure often had multiple injuries to the supporting structures of the
teeth.
■ Garcia-Godoy, (1984) observed that male: female ratio of 0:9:1:0 in three private
schools in the Dominican Republic and 1.1:1.0 in public and private school children, the
sex distribution was not significantly different.
■ Liew and Daly (1986) and Martin et al (1990) in their study observed a relatively higher
male: female ratio of 2.6:1.0. These two studies examined patients attending after hour
clinics, which resulted in a higher incidence of 18-23 years olds, compared with other
studies.

Garcia-Godoy, (1984) male: female ratio of 0:9:1:0 in three private schools in
the Dominican Republic and 1.1:1.0 in public and
private school children, the sex distribution was not
significantly different.
Liew and Daly (1986) and Martin et al (1990) male: female ratio of 2.6:1.0
Stockwell (1988) male: female ratio ranged from 1.3-2.3:1.
Andreasen (1994) men and boys sustaining injuries 2 to 3times as often as
women and girls
Rai and Munshi, (1998) trauma was more prevalent among the boys (72.27%) than
the girls (27.73%)
Gupta et al. (2002) male: female ratio was 2:1 for dental traumatic injuries and
for class 1-fracture male: female ratio was5: 1 among age
group 8-10 ad 11-14 years.

Based on Age
■ Stockwell (1988) determined that the incidence of trauma to the anterior
permanent teeth in 6-12 year old school children was 1.7 patients /
100children/year while involving 2.1 teeth/100 children/year.
■ Kaba and Marechaux, (1989) revealed a prevalence of trauma to permanent teeth
in children aged 6-18 years of 11 per cent.
■ Forsberg and Tedestam, (1990) in Sweden observed a relatively high prevalence
of traumatized teeth in children aged 7-15 years (30 per cent) and included
traumatized primary teeth.

Stockwell (1988) incidence of trauma to the anterior
permanent teeth in 6-12 year old
school children was 1.7 patients /
100children/year
Kaba and Marechaux, (1989) trauma to permanent teeth in children
aged 6-18 years of 11 per cent.
Forsberg and Tedestam, (1990) prevalence of traumatized teeth in
children aged 7-15 years
Bijella, (1990) prevalence rates in the primary dentition
peaked at age 10-24 months in a Brazilian
study.
Gupta et al. (2002) 39.26% of the teeth were fractured among
age group 8-10 years than compared with
60.74% among 11-14 year age group.

Based on the Location
■ Davis and Knott, (1984) found that one tooth was more frequently injured than multiple teeth in
most prospective studies conducted at school dental services and general clinics.
■ Forberg and Tedestam, (1990) found that maxillary central incisors were the most frequently
injured teeth in all studies for both the primary and secondary dentitions. The second most
frequently injured teeth were maxillary lateral incisors in all studies except that by where
mandibular central incisors were the second most frequently injured teeth.
■ Galea, (1990) studied that dental trauma involving two teeth were more frequent than one.
■ Andreasen et al, (1994) reported among 434 cases, that eighty-two percent of the teeth traumatized
were maxillary incisors, 64% central incisors, 15% lateral incisors, and 3% canines.

Galea , (1988) accidents within and around the home
have been reported as being the major
source of injury to the primary
dentition, while accidents at home and
school accounted for most injuries to
the permanent dentition.
Gupta et al. (2002) 68.76% of dental trauma occurred at
home followed by school (20.39%),
playground and road accidents (10%).
Skaare and Jacobsen (2003) 48% of dental injuries occurred at school
and Sports and accidents represented only
8% of the total number of injuries and
also by violence .

Seasonal variation
■ Etchenbaum (1963) ,Gelbier (1967) , Ravn (1974) studied that dental;
injuries increase during the winter months.
■ Garcia Godoy et al (1979) , Oniel et al (1989) , Kenrad(1991) , reported
that an increase in the dental trauma during summer months.

ETIOLOGY
■ Many factors are responsible for the traumatic injuries. Fall being the most
common cause of the injuries due to the lack of the coordination of the child.
Moreover the children are more indulged in sports activities ,hence become prone
for injuries

Iatrogenic injuries in Newborns
■ Prolonged intubation in neonates is a procedure which is used in the care of
prematurely born infants.
■ Boice 1976 and Moylan 1980 have shown that the prolonged pressure of tubes
against the maxillary alveolar process has been shown to lead to a high frequency
of developmental enamel defects in the primary dentition.

Falls in infancy
■ Dental injuries are infrequent during the first year of life; but can occur for
example, due to a fall from a baby carriage . The incidence of dental injuries
reaches its peak just before school age and consists mainly of injuries due to falls
and collisions (Anderson 1970 )

Falls and collisions
■ When the child reaches school age, accidents in the school playground
are very common. Most of the resultant injuries can be classified as fall
injuries and are characterized by a high frequency of a crown fracture
(Carter 1972, Raven 1974 Oneil, Clark, Lowe 1989).
■ Falls and hitting the teeth against hard objects are consistently the most
common causes of trauma to young children. Falls account for 31% to
90% of injuries to the primary teeth.

■ Children tend to fall when learning to walk. They have newly discovered
increased mobility and activity, yet their coordination is limited.
■ Another factor, which may affect peak incidence at younger ages, is the
heightened anxiety of parents of younger children after minor traumatic
events which causes the parent to seek treatment more often . These injuries
are classified as crown fractures by (Hedegard and Stalhane 1973).

Bicycle injuries
■ Jarvinen 1980 and Wiens in 1990 found that these injuries usually result in
severe trauma to both the hard and soft tissues due to the high velocity at the
time of impact.

Sports
■ Injuries during the teenage years are often due to sports. Johnson 1975,
Hazelwood 1970 Carter 1970 Raven 1974, Hedegard 1973, Omullane
1973 Karwan 1975, Haaiko 1976 Lee 1976)
■ This especially applies to contact sports such as skying, kabaddi, cricket,
hockey, ice-hockey, soccer, baseball, American football, basketball, rugby
and wrestling (Edward 1968, Hawke 1969).

Horseback riding
■ Horseback riding, a popular sport in many countries is a significant
source of injury (Lie and Lucht 1977).
■ In a single reason 23% of all riders sustained injuries of various types,
including dental and maxillofacial injuries. There is a little doubt that
special precautions, such as the use of sturdy helmets, can reduce the
number and severity of these accidents.

Automobile injuries
■ Facial and dental injuries resulting from automobile accidents are seen
more frequently in the late teens.
■ The front seat passenger is particularly prone to facial injuries. This
trauma group is dominated by multiple dental injuries, injuries to the
supporting bone, and soft tissue injuries to the lower lip and chin.

Assaults
■ Lindahl 1977, Gayford 1975 concluded that injuries from fights are
prominent in order age groups and are closely related to alcohol abuse.
These assaults often result in trauma to the facial region.

Torture
■ A disgraceful and increasing type of injury is marked by oral and facial injuries (
Bolling 1978, Diem 1978, Bolling et al 1978 ) , examined 34 prisoners who were
tortured , among them the most common was beating which resulted in loosing ,
avulsion or fracture of teeth . Recent investigators have showed that the majority of
these victims, apart from other atrocities inflicted upon their persons, have suffered
from torture involving the oral region.
■ The most common type of torture was beating, which resulted in loosening,
avulsion or fracture of teeth and soft tissue laceration.

PREDISPOSING FACTORS FOR
TRAUMATIC INJURIES
■ Open bite is an important predisposing factor of injuries to primary
incisors. Increased overjet with protrusion of upper incisors and
insufficient lip closure are significant predisposing factors
■ It is important to emphasize that the skeletal open bite together with the
tendency to a negative overbite may be frequently associated with
incompetency of the lips, which is an additional potential risk factor for
dental trauma.

■ Wilson in 1929 reported spontaneous root fracture affecting individual
with dentinogenesis imperfecta. The explanation for this phenomenon
could be the decreased microhardness of dentin and abnormal tapering of
the roots

■ Galea, (1984) observed that the severity of injuries appeared to increase
when there was an associated injury to the lower lip, while at third of the
accidents occurred in subjects with some form of malocclusion. Female
subjects with prominent maxillary incisors and incompetent lip closure
often had multiple injuries to the supporting structures of the teeth.

■ Forsberg and Tedestam (1993) in an extensive study of 1610 children with
286 registered traumatic dental injuries identified the following factors that
significantly increase susceptibility to dental injury.
■ Postnormal occlusion
■ An overjet exceeding 4 mm
■ Short upper lip
■ Incompetent lips
■ Mouth breathing.

■ Burden, (1995) investigated the association between overjet, size, lip
coverage, and observed that subject with an over jet greater than the
normal range (0-3.5 mm) were significantly more likely to have received
an injury to the maxillary incisor and showed that, prevalence of dental
trauma in females increased as overjet increased.

■ Al-Majed (2001)studied 354 boys aged 5-6 years and 862 boys aged 12-14
years, attending 40 schools in Riyadh. The prevalence of dental trauma in 354
Saudi boys aged 5-6 years was 33%. No relationship between the degree of
overjet and the occurrence of dental trauma in the primary dentition was
observed. The prevalence of dental trauma in 862 12-14 year old boys was
34%. The commonest dental trauma was fracture of enamel (74%).
■ A significant relationship (p=0.02) between the increased overjet (6mm) and
the occurrence of dental trauma in the permanent dentition was reported

MECHANISM OF DENTAL INJURIES
■ Direct trauma ■ Indirect trauma
•Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.
•Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology-E-Book. Elsevier Health Sciences; 2006 Oct 2.

Factors characterizing the impact and determine the extent of injury:
■ Energy of the impact
■ Resilience of the impacting object
■ Shape of the impacting object
■ Direction of the impacting force
When considering the direction and position of fracture lines caused by frontal impacts , the fractures fall into four categories
i. Horizontal crown fractures
ii. Hoizontal fractures at neck of the tooth
iii. Oblique crown –root fracture
iv. Oblique root fractures
Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

In the 1950, Pediatric dentist G.E. Ellis was the first person to
promote a universal classification of dental injuries. Dental injuries
have been classified according to a variety of factors:
■ Etiology
■ Anatomy
■ Pathology
■ Therapeutic considerations

■ There have been many attempts to classify TDI’s and these vary from
simple to more detailed.
■ Sweet proposed one of the first classification systems in 1955.
■ An overview has been summarised by Pagadala and Tadikonda (2015).
■ The most widely used classification in the literature to classify TDI’s was
first proposed by the World Health Organisation (WHO) in 1994, and is
largely based on the work by Andreasen.

 Classification of anterior teeth trauma by Sweets (1955)
 Classification by Rabinowitch (1956)
 Benetts Classification (1963)
 Classification by Ulfohn (1969)
 Classification by Ellis (1970)
 Classification by Ellis and Davey (1970)
 Classification by Hargreaves and Craig (1970)
 Classification by Garcia – Godoy (1981)
 Classification by Andreasen (1981)
 Classification by Basrani (1982)
Pagadala S, Tadikonda DC. An overview of classification of dental trauma. IAIM, 2015; 2(9): 157-164.

 Heithersay and Morile (1982)
 Classification by Burton, et al. (1985)
 Classification by Lee-Knight, et al. (1989)
 Classification by Hunter, et al. (1990)
 Clinical classification by World Health Organization in its application of
International Diseases of Dentistry and Stomatology (1994)
 Classification by Burden (1995)
 Classification by Hamilton,et al. (1997)
 Classification by Spinas (2002)

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 but 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
Djemal S, Patel K (2018) Management of Traumatic Dental Injuries Presenting to the Emergency Department. J Emerg Med Care 1(1): 104
Pagadala S, Tadikonda DC. An overview of classification of dental trauma. IAIM, 2015; 2(9): 157-164.

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.

Benetts Classification (1963)
■ Benetts classification is according to injuries to periodontium and alveolus considering the anatomy and
morphology of the teeth which can be applied partially for primary and permanent teeth.
Class I – Traumatized tooth without coronal or root fracture
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

Classification by Ulfohn (1969)
■ Ulfohn examines a classification of crown fracture from a clinical endodontic
point of view based on three fundamental aspects.
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.

This classification tends to simplification. It does not take into account large or small
amount of indirect pulp exposure, from the prevention aspect, the protection of any
amount of exposed dentin is equally important.
■ Crown fractures: -
a) of enamel
b) with indirect pulp exposure through the dentin.
c) with direct pulp exposure

Classification by Ellis (1970)
It is a simplified classification, which groups many injuries and allows for subjective interpretation by including broad terms such
as simple or extensive or extensive fractures.
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.
Class IX - Traumatic injuries of primary teeth.

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.

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.

International classification of diseases to dentistry
and stomatology (WHO, 1978)
classification Description Tissues involved
S.O.25 Fracture of tooth (primary and secondary teeth)
S.02.50 Fracture of enamel of tooth only+ Enamel infraction
Enamel
S.02.51 Fracture of crown of tooth without pulpal involvement
Enamel, Dentin
S.02.52 Fracture of crown of tooth with pulpal involvement
Enamel, Dentin, pulp
S.02.53 Fracture of root of tooth Cementum, Dentin, Pulp
S.02.54 Fracture of crown with root of tooth, with or without
pulpal involvement
Enamel, Cementum, dentin, +Pulp
S.02.57 Multiple fracture of tooth Unspecified
S.02.59 Fracture of tooth, Unspecified Unspecified

Garcia-Godoy’s classification (1984)
■ Class 0 – Enamel crack.
■ Class 1 – Enamel fracture.
■ Class 2 – Enamel-dentin fracture without pulp exposure.
■ Class 3 – Enamel-dentin fracture with pulp exposure.
■ Class 4 – Enamel-dentin-cementum fracture without pulp exposure.
■ Class 5 – Enamel-dentin-cementum fracture with pulp exposure.
■ Class 6 – Root fracture.
■ Class 7 – Concussion.
■ Class 8 – Luxation.
■ Class 9 – Lateral displacement.
■ Class 10 – Intrusion.
■ Class 11 – Extrusion.
■ Class 12 – Avulsion.

Classification by Andreasen (1981)

A. Injuries to the hard dental tissues and pulp.
classification Description Tissues involved
N873.60 Crown infarction enamel without loss of the tooth
substance
N 873 Uncomplicated crown fracture A fracture contained to the enamel
(N 873.61) Uncomplicated crown fracture involving enamel and dentin, but
not exposing the pulp
N873.62. Complicated crown fracture A fracture involving enamel and
dentin and exposing the pulp.
N873.64 Uncomplicated crown root fracture A fracture involving enamel,
dentin and cementum but not
involving the pulp.
N873.64 Complicated crown root fracture A fracture involving enamel,
dentin and cementum and
exposing pulp.
N873 Root fracture dentin, cementum and the pulp

B. Injuries to the periodontal tissues.
classification Description Type
N873.66. An injury to the tooth supporting structures without abnormal loosening
or displacement of the tooth, but with marked reaction to percussion.
Concussion
N873.66 An injury to the tooth supporting structures with abnormal loosening but
without displacement of the teeth.
Subluxation
N873.66 Displacement of the tooth into the alveolar bone. This injury is
accompanied by comminution or fracture of the alveolar socket.
Intrusive Luxation
N873.66 Partial displacement of the tooth out of its socket. Extrusive luxation
N873.66. Displacement of the tooth in a direction other than axially. This is
accompanied by comminution or fracture of the alveolar socket.
Lateral Luxation
N873.68 Complete displacement of the tooth out of its socket. Exarticulation

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

D. Injuries to 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.
Laceration 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.
Contusion of gingiva or oral
mucosa
N 910.00 A superficial wound produced by rubbing or scrapping of
the mucosa leaving a raw bleeding surface.
Abrasion of gingiva or oral
mucosa

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

Heithersay and Morile (1982)
Class I : fracture line does not extend below the level of attatched gingiva
Class II : fracture line extends below the level of attatched gingiva but not below the level
of the alveolar crest
Class III : fracture line extends below the level of alveolar crest
Class IV : fracture line is within the coronal third of the root but below the level of alveolar
crest

Classification by Burton, et al. (1985)
■ Fracture involving dentin and/or pulp
■ Devitalization
■ Avulsion
Classification by Lee-Knight, et al. (1989)
■ Tooth infraction
■ Chipped tooth
■ Fractured tooth
■ Lacerated lip
■ Traumatized TMJ

Classification by Hunter, et al. (1990)
■ Fracture
■ Discoloration
■ Absence of any maxillary incisor teeth

Type of injuries Code
Enamel infarction N 502.50
Enamel fracture N 502.50
Enamel- dentin fracture (uncomplicated) N 502.51
Enamel – dentin fracture (complicated) N 502.52
Root fracture N 502.53
Crown- root fracture (uncomplicated) N 502.54
Crown- root fracture (complicated) N 502.54
Multiple fracture N 502.57
Fracture of tooth unspecified N 502.59
Clinical classification by World Health Organization in its application of International Diseases of Dentistry
and Stomatology (1994)
Injuries to the hard dental tissues and the pulp

Type of injuries Code
Concussion
N 503.20
Subluxation N 503.20
Extrusive luxation N 503.20
Lateral luxation N 503.20
Intrusive luxation N 503.21
Avulsion N 503.22
Injuries to the Periodontium
Textbook and color atlas of Traumatic injuries to the teeth- 4th edition

Injuries to the supporting bone
■ Communition of mandibular alveolar socket
■ Communition of maxillary alveolar socket
■ Fracture of mandibular alveolar socket wall
■ Fracture of maxillary alveolar socket wall
■ Fractue of mandible
■ Fractue of maxilla
■ N 502.60
■ N 502.40
■ N 502.60
■ N 502.40
■ N 502.61
■ N 502.42

Injuries to gingiva or oral mucosa
■ Laceration
■ Contusion
■ Abrasion
■ S 01.50
■ S 00.50
■ S 00.50

Classification by Burden (1995)
• Fracture (enamel)
• Fracture (enamel and dentin)
• Fracture (involving pulp)
• Discoloration
• Acid etch resoration
• Other restoration
Classification by Hamilton,et al. (1997)
• Fracture confined to enamel
• Fracture involving dentin
• Fracture with pulp exposed
• Intrinsic discoloration
• Abnormal mobility
• Infraocclusion
• Presence of sinus or swelling in the mucosa over a tooth.

Classification by Spinas (2002)
 It consist of 4 classes (A-B-C-D)
 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.

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.
 The currently accepted system is based on the World Health Organization’s Application of
International Classification of Diseases to Dentistry and Stomatology, and modified by
Andreasen.
 The classification is applicable to injuries to the teeth and supporting structures and can be
applied to both primary and permanent dentitions

History
■ Patient’s name, age, sex, address and
telephone number
■ When did the accident occur?
■ Where and how did the accident occur?
When and where – The place of accident may
indicate a need for tetanus prophylaxis.
The time interval between the injury and
treatment significantly influences the result.

History
▬ Treatment elsewhere
▬ History of previous dental injuries and general health
▬ Did the trauma cause amnesia, unconsciousness,
drowsiness, vomiting or headache?
∞ Is there spontaneous pain from the
teeth?
∞ Are the teeth painful to touch or
during eating?
∞ Is there any disturbance in the
bite?
Spontaneous pain can indicate damage to the tooth
supporting structures or pulpal damage.
Teeth painful to touch – Reaction to thermal or other stimuli
can indicate exposed dentin or pulp. This symptom is
proportional to the area of exposure.
If tooth is painful during mastication or if the
occlusion is disturbed, injuries such as extrusive
luxation should be suspected.

CLINICAL EXAMINATION
1. Recording of extraoral wounds and palpation of the facial skeleton
2. Recording of injuries to oral mucosa or gingiva
3. Examination of the tooth crowns for the presence and extent of fractures, pulp exposures, or changes in tooth
color
4. Recording of displacement of teeth (i.e. intrusion, extrusion, lateral displacement, or avulsion)
5. Abnormalities in occlusion
6. Abnormal mobility of teeth or alveolar fragments
7. Palpation of the alveolar process
8. Reaction and sound of the teeth to percussion and pulpal sensibility

Reaction of teeth to sensibility tests
■ Thermal test-
1. Heated gutta percha
2. Ice
3. CO2 snow sticks
4. Ethyl chloride
5. Dichloro-difluoromethane
■ Electric pulp tests
• Laser Doppler flowmetry (LDF)

RADIOGRAPHIC EXAMINATION
 Intraoral radiographs
■ 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)
 Extraoral radiographs
 CT scanning
 Micro CT scanning
 MR scanning

Crown fractures
Enamel infraction Enamel fracture
Enamel-dentin
fracture
Enamel-dentin fracture
with pulpal involvement

1) Enamel Infraction
These fractures appear as crazing within the enamel
substance which do not cross the dentino-enamel junction
and may appear with or without loss of tooth substance.
Infraction lines involving the right central and lateral
incisors. The use of indirect illuminations reveals
infarction lines. A) They are barely by direct illumination
Textbook and Color Atlas of Traumatic Injuries to the
teeth. Andreasen 4th edition
∫ Due to – Direct impact to the enamel
∫ Site : Labial surface of upper incisors.

Various patterns of infraction line can be seen
depending on the direction and location of the
trauma .
Patterns of infraction line :
Horizontal Vertical Diverging

Diagnosis -
Infractions are easily overlooked if direct
illuminations is used – but easily visualized when
the light beam is perpendicular to the long axis of
tooth from the incisal edge.
Fiber-optic light sources are also very useful in detecting infractions.
Radiographic Finding –
Will not typically reveal small cracks in enamel
Textbook and Color Atlas of Traumatic
Injuries to the teeth. Andreasen 4th edition

Histopathology
Enamel infarctions: in ground section,
appear as dark lines running parallel to
the enamel rods and terminate at the
dentino‐enamel junction.
Histologic Features of a permanent central incisors showing crown infractions.
A) Gross Specimen – arrow irradiating infraction line
B) Low power view of ground section through the impact area. x8
C) Facial aspect of the crown exhibiting an infraction line. x30
D) Higher magnification reveals that line follows the direction of enamel prisms
Textbook and Color Atlas of Traumatic Injuries to the teeth. Andreasen 4th edition

Management
∞ Enamel infraction in anterior region following acute trauma do not appear
to imply the same risk to tissue integrity due to the fact that infractions are
usually limited to enamel and stop at the DEJ.
∞ However due to frequently associated injuries to periodontal structures,
sensibility tests should be carried out in order to disclose possible damage
to the pulp.
These findings lead to the suspicion that an enamel infraction can be a port of
entry for bacteria if the blood supply to the pulp is compromised due to a
concomitant luxation injury

Management
▬ Enamel infractions do not require treatment.
▬ In case, of multiple infraction line, the indication might be to seal the
enamel surface with an unfilled resin and acid-etch technique.

IADT 2020 – Enamel Infraction
Clinical Findings Radiographic assessment and
findings
Treatment
No sensitivity to percussion or
palpation
No radiographic abnormalities In case of severe infractions,
etching and sealing with
bonding resin should be
considered to prevent
discoloration and bacterial
contamination of infractions.
Evaluate the tooth for a
possible associated luxation
injury or root fracture if
tenderness observed.
Recommended radiographs –
1) Periapical radiograph
2) Additonal radiographs are
indicated if signs or
symptoms of other
potential injuries are
present
Otherwise no treatment is
necessary.
Normal mobility.
Pulp Sensibility tests usually
positive.

Follow-up Favourable outcomes Unfavourable outcomes
No-follow up is needed. If it is
certain that the tooth suffered an
infraction injury only
Asymptomatic Symptomatic
If there is an associated injury such
as luxation injury, injury specific
follow-up regimen prevails
Positive response to pulp sensibility
testing
Pulp necrosis and infection
Normal mobility Continued root development in
immature teeth
Apical periodontitis
positive
Lack of further root development in
immature teeth

2) Enamel Fracture
■ Very frequent and only involve enamel.
■ As these fractures do not involve dentin they appear to have a
different prognosis in relation to pulp necrosis.
Radiographic Finding –
Enamel loss will be visible.

Management
Immediate treatment of crown fractures confined to enamel can be limited to smoothing of sharp enamel
edges to prevent laceration of the tongue or lips.
Selective reduction can be undertaken at the same or at a later visit with good aesthetic results, especially in
imitating an accentuated rounding of a distal corner.
∫ However, due to aesthetic demand for midline symmetry, a fractured mesial corner can
usually not be corrected in the same way.
∫ When shape or extent of fracture precludes recontouring – a restoration is necessary.

■ Crowns anatomy and occlusion can be restored immediately to prevent
Over-
eruption of
opposing
incisor
Drifting or
tilting of
adjacent
teeth
Labial
protrusion
of the
fractured
tooth
3) Enamel Fracture - Management

IADT 2020 – Enamel Fracture
Clinical Findings Radiographic assessment
and findings
Treatment
Loss of enamel. No visible
signs of exposed dentin
Enamel loss is visible If tooth fragment available,
can be bonded back to the
tooth
Evaluate the tooth for a
possible associated luxation
injury or root fracture if
tenderness observed.
Missing fragments should be
accounted for :
1) If fragment is missing and
there are soft tissue injuries,
radiographs of the lip and or
cheek are indicated to search
for tooth fragments and
or/foreign materials.
Alternatively, depending on
the extent and location of
fracture, the tooth edges can
be smoothed or a composite
restoration can be placed.
Normal mobility.
positive.
1) One periapical radiograph
2) Additional radiographs
are only indicated if signs
or symptoms of other
potential injuries are
present.
Clinical and radiographic
evaluations are necessary:
- After 6-8 weeks
- After 1year.
- If there is an associated luxation
or root fracture, or the suspicion
of an associated luxation injury,
the luxation follow-up regimen
prevails and should be used.
Longer follow-ups may be
needed
Asymptomatic
Positive response to pulp
testing
Good quality restoration
Continued root
development in immature
teeth
Symptomatic
Loss of restoration
Breakdown of restoration.
If there is an associated injury such
as luxation injury, injury specific
follow-up regimen prevails
sensibility testing
Pulp necrosis and
infection
Normal mobility Apical periodontitis
positive
Lack of further root
teeth

3) Enamel-Dentin Fracture
■ They are often confined to a single tooth, usually
the maxillary central incisors, especially the
mesial or distal corners.
■ Fractures - horizontal, extending mesiodistally
■ Occasionally only the central lobe of the incisal
edge is involved. In rare cases the fracture can
involve the entire facial or oral enamel surface.
Central and lateral incisors with typical uncomplicated crown
fractures involving the mesial corners.

3) Enamel- Dentin Fracture
■ Although not frequently found in combination with extrusive or lateral
luxation injuries
■ Frequently seen in teeth with concussion, subluxation and intrusion
■ Unusual finding:
Crown fractures of nonerupted permanent teeth due to trauma
transmitted from impact to the primary dentition

3) Enamel- Dentin Fracture
Clinical Examination –
Layer of dentin covering the pulp may
be so thin that the outline of the pulp
is seen as a pinkish tinge.
Examination of fractured teeth should be preceded
by thorough cleansing of the injured teeth with a
water-spray.
Followed by assessment of the extent of exposed
dentin.
Dentin exposed gives rise to symptoms like sensitivity to
thermal changes and mastication's – which are to some
degree proportional to the area of dentin exposed and
maturity of the tooth.
In such cases its important to not perforate the dentin
with a sharp probe during the search for pulp
exposures.

3) Enamel-Dentin Fracture - Histopathology
∫ Expose large number of dentinal tubules. It has been estimated that the exposure of 1 mm2 of dentin
exposes 20 000 to 45 000 dentinal tubules.
∫ Pathway for bacteria and thermal and chemical irritants and can provoke pulpal inflammation.
Speed of bacterial penetration into prepared dentin left exposed to saliva and plaque
formation in vivo was found by Lundy and Stanley to be 0.03 – 0.36mm 6-11 days after
preparation and 0.52mm after approximately 84 days.

∫ Experimental study – Monkeys – bacteria formed in dentinal tubules after 3-months in Treated
(Composite and fragment bonding) and non-treated teeth.
∫ Presence of bacteria in tubules was related to significant hard tissue formation in the coronal part of
the pulp.
- Robertson A, Andreasen FM, Bergenholtz G. Pulp reactions to restoration of experimentally induced crown fractures. J Dent 1998; 26:409-16

Ingrowth of bacteria to a certain degree is inhibited by the outward flow of dentinal fluid in
the tubules due to positive pulpal pressure.
In contrast, bacterial penetration is rapid when impeding hydrostatic pressure from an
outward pulpal fluid flow is minimal or non‐existent Ex. Concomitant luxation injuries
This increase in fluid flow after dentin exposure might also have clinical implications
with respect to moisture control in the use of dentin bonding agents.
Experimental in-vivo studies in cat have demonstrated an increased fluid flow from exposed dentinal
tubules with an intact pulpal blood supply, presumably due to a chain of events involved in neurogenic
inflammation arising from dentinal irritation following exposure and subsequent stimulation of IAN.
This fluid flow might mechanically inhibit bacterial ingress through patent dentinal tubules and also
distribute antibodies.

Pulpal changes: inflammatory changes were seen when
artificially exposed dentin was left uncovered for 1 week.
Changes are of a transient nature if the pulpal vascular
supply remains intact and bacterial invasion is prevented

Dentin Exposed
■ Dentin coverage in order to avoid bacterial ingress, thereby permitting the
pulp to recover and elicit repair
■ Immediate reattachment of the original fragment or restoration with a
composite resin
■ Preferred over a temporary filling or temporary crown
■ Potential risk of leakage -- access of bacteria to the exposed dentin --
represents a significant threat to the recovery of the pulp.

Use of Dentin Bonding Agents – Should
exposed dentin be lined?
■ Hard‐setting calcium hydroxide‐containing liner
■ In-vivo & in-vitro studies-disintegrate beneath dental restorations with time
■ Cultivable and stainable bacteria have been found within the calcium hydroxide liners
■ No permanent barrier against microleakage
■ If deeply exposed dentin is adequately sealed, the non‐exposed pulp will form reparative
dentin even without calcium hydroxide
Except for the conditions involving a thin layer of exposed dentin (i.E. 0.5 mm or less)
with the absence of bleeding, the use of a calcium hydroxide base is not necessarily
required.
- Diangelis AJ 2012

Use of Dentin Bonding Agents – Should
exposed dentin be lined?
■ Microleakage can be counteracted in part by a strong micromechanical bond
arising between a composite resin and acid‐etched enamel
■ If dentin bonding is also employed, bonding strength of reattached crown
fragments is approximately three times greater than if acid‐etched enamel is the
only source of retention

Provisional Treatment of crown fractures
∫ Several approaches exist, depending on the trauma setting (private
practice or emergency room) and the need for an immediate aesthetic
solution.
∫ All approaches rest on the premise of creating a hermetic seal against
bacterial invasion into dentinal tubules.
1) Glass-Ionomer Cement ‘Bandage’
2) Resin or Celluloid Crowns
3) Splints as coverage

1) Glass Ionomer Cement Bandage

∫ When aesthetic demands are foremost, a temporary acrylic crown
should be considered.
∫ Various types of pre-fabricated temporary crowns are available.
∫ Resin or Celluloid crown forms have too little strength and should
only be used as a mould for the crown.

After placement of a liner or glass ionomer cement over the fracture surface, a suitable
crown form is selected and contoured to fit the fractured tooth.
A hole is made with a sharp explorer through the mesial or distal incisal corner to permit
escape of excess crown material during placement.
The fitted form is then filled with composite resin and seated and excess removed, when
polymerized, the crown is removed, finished and cemented.
The crown is finished short of the gingival margin in order to permit optimal gingival health
and prevent the restorative material from being forced into the injured periodontal ligament.

Eden E, Taviloğlu E. Restoring crown fractures by direct composite layering using transparent strip crowns. Dental Traumatology. 2016 Apr;32(2):156-60.
A medically healthy 9-year-old female patient had trauma 10 days earlier on her 11 and 21.
The 11 and 21 had uncomplicated crown fractures. The 11 was restored with free hand
layering composite while a strip crown was cut to fit 21 as a mold.
The 21was restored using enamel and dentin composite layers. The palatal surface needed
minimal finishing after removing the strip crown

3) Splints as coverage
In case of concomitant injuries to the periodontium, dentin and pulp protection must
be incorporated into the splint.
In these instances – ease of splint removal and later restoration to cover the exposed
enamel and dentin with calcium hydroxide liner or glass ionomer before application
of an acid-etch/resin splint.
∞ Enamel coverage with a liner is important in the case of later reattachment of the
fractured crown fragment to ensure an intact enamel margin to which the fragment
can be bonded.
∞ Profound- crown fracture – simultaneous need for splinting – fibre reinforced
splint can be the solution for satisfactory retention until splint removal and final
restoration.

Definitive Treatment of Crown Fracture
1) Composite
restorations
2) Reattachment of the
original crown
fragment
3) Full crown coverage

1) Composite Restoration
▬ Resin composites offer a conservative restoration of crown-fracture teeth
with minimal risk of pulpal and periodontal complications in children and
adults.
▬ A composite build-up of a fractured tooth is more conservative to the hard-
tooth structures, pulp and the surrounding soft tissue than a crown.

Oliveira, Gustavo & Ritter, Andre. (2009). Composite resin restorations of
permanent incisors with crown fractures. Pediatric dentistry. 31. 102-9.

2) Reattachment of coronal fragment
Indications
∫ An intact enamel-dentin fragment is the sole indication for re-attachment.
∫ If the fragment is in two-pieces these fragments can be bonded together
prior to bonding with final fragment.

2) Reattachment of Coronal Fragment
Advantages
∞ Improved aesthetics since enamel's original shape, color, brightness and
surface texture are maintained
∞ Reduced chair-side time
∞ Immediate hermetic seal of dentinal tubules, immediate restoration of
function and aesthetic.
∞ Provides more predictable long term wear
∞ Psychological benefit to patient or parent

Overcontour technique, the placement of an internal dentinal groove and the composite buildup technique
provided fracture strength similar to those in sound teeth. Bonding with no additional preparation and
placement of a chamfer are not indicated due to the low fracture strength obtained.
A) Bonded only Re-attachment of the fragment with no additional preparation
B) Chamfer Re-attachment of the fragment + chamfer in the buccal surface
C) Overcontour Re-attachment of the fragment + superficial preparation on the enamel
D) Internal groove Internal dentinal groove + re-attachment of the fragment
E) Composite buildup No fragment was used

Use of circumferential bevel on enamel before re-
attaching (Simonson 1979 ,Walker 1996)
V shaped internal enamel groove (Simonson
1982 )
Internal dentin groove (Walker 1996, Reis
2001 )
External chamfer (Franco 1985 ) Overcontour (Reis 2001 ) Simple re-attachment (Pagliarini 2000 )
TECHNIQUES
Reis A, Francci C, Loguercio AD, Carrilho MR, Filho LE. Re-attachment of anterior fractured teeth: fracture strength using different techniques. Operative Dentistry. 2001 May 1;26(3):28

Acharya S, Singh S, Bhatia SK. Tooth fragment re–attachment in an incompletely
formed root: A case report with literature review. Indian J Dent Sci 2020;12:163.

IADT 2020 – Uncomplicated Crown fracture
( Enamel – Dentin fracture)
Clinical Findings Radiographic assessment and
findings
Treatment
Normal mobility.
positive.
Enamel-dentin loss is visible If tooth fragment available and
intact - it can be bonded back to
the tooth. The fragment should be
rehydrated by soaking in water or
saline for 20 min before bonding.
palpation
Missing fragments should be
accounted for :
1) If fragment is missing and there
are soft tissue injuries, radiographs
of the lip and or cheek are
indicated to search for tooth
fragments and or/foreign materials.
Cover exposed dentin with glass-
ionomer cement or use a bonding
agent and composite resin.
Evaluate the tooth for a possible
associated luxation injury or root
fracture, especially if tenderness
is present.
2) Additional radiographs are
only indicated if signs or
symptoms of other potential
injuries are present.
If exposed dentin is within 0.5mm
of pulp (pink but no bleeding)
place a calcium hydroxide lining
and cover with glass-ionomer.
Clinical and radiographic evaluations are
necessary:
- After 6-8 weeks
- After 1year.
- If there is an associated luxation or
root fracture, or the suspicion of an
associated luxation injury, the luxation
follow-up regimen prevails and should
be used. Longer follow-ups may be
needed
Asymptomatic
testing
Continued root
teeth
Symptomatic
Loss of restoration
Pulp necrosis and
infection.
Apical Periodontitis.
teeth

4) Complicated Crown Fractures
■ Present with a slight haemorrhage from
the exposed part of the pulp.
■ Proliferation of pulp tissue (i.e. Pulp
polyp) can occur when treatment in
young teeth is delayed for days or weeks.
■ Pulp exposure is usually followed by
symptoms, such as sensitivity to thermal
changes.
■ 4-16% of all traumatic injuries.
■ Usually occur as a result of horizontal forces.
■ Fracture line starts from the crown and proceed to the
gingival area.
Complicated Crown Fracture of permanent incisors

CLINICAL EXAMINATION
■ The clinical examination begins with the inspection and exploration of the
tooth. The patient experience pain on exploration. Inspection will show the
size of the pulp exposure, the presence or absence of hemorrhage, and the
amount of crown structure remaining.
■ The degree of pulp involvement varies from a pinpoint exposure to a total
unroofing of the coronal pulp.

Reveals,
A. The state of apical development
B. The state of the apical and periapical zones.
C. Presence of radicular fracture.

4) Complicated Crown Fracture-
Histopathology
Immediate and histologic response to crown
fracture.
A) The inflammation is very superficial after
24 hours.
B) After 1-week the pulp shows proliferation
and still very limited inflammation
∞ Exposed pulp tissue is quickly covered by a layer of
fibrin
∞ Eventually the superficial part: shows capillary
budding, numerous leukocytes and proliferation of
histiocytes
∞ This Inflammation spreads apically with increasing
observation periods

Complicated Crown-Fracture :
Management
The principles for the restoration of crown fractures with pulpal involvement
differ from those of uncomplicated crown fractures only with respect to
treatment of exposed dental pulp.
This implies –
∫ Pulp Capping.
∫ Pulpotomy
∫ Pulpal Extirpation
∫ Partial pulpotomy (Cvek’s pulpotomy)
∫ Coronal pulpotomy

MANAGEMENT
■ The patient’s clinical history brings out factors that influence the
treatment plan.
A. Time elapsed between the time of injury and the time the patient is seen in
the operatory.
B. Size of the pulp exposure.
C. Size of the remaining crown.

■ The aim of treatment should be the preservation of vital, non-inflamed
pulp, biologically walled off by a continuous hard tissue barrier. In most
cases, pulp capping or pulpotomy can achieve this.
■ When these treatment alternatives are not possible, the pulp must be
extirpated and the root canal obturated with a filling material.

■ Maturity of the tooth, concomitant luxation injury, age of the patient as well as the
effect of surgical procedures and choice of wound dressing, should be considered.
■ The maturity of the tooth is of utmost importance in the choice of treatment. It is
generally agreed that the exposed vital pulp should be maintained in young teeth with
incomplete root formation while it can be removed in mature teeth. Removal of the
pulp in children and adolescents deprives the tooth of physiologic dentin apposition,
leaving thin dentinal walls, which increases the risk of later cervical root fractures, a
problem that should be considered in treatment planning.
■ A concomitant luxation injury compromises the nutritional supply to the pulp&
contraindicates conservative treatment. However, in immature luxated teeth the
chance of pulp survival is considerable and conservative treatment may allow further
root development. Treatment should therefore be determined according to the
severity of the periodontal injury and the maturity of the tooth.

■ The effect of age is controversial as degenerative changes in the pulp increase with
age. Thus, removal of the pulp could be a more successful procedure, although no
age limit can be set for either pulp preservation or removal. However, conservative
treatment, i.e. capping or pulpotomy, should not be performed if degenerative or
inflammatory changes are anticipated, such as in teeth with reduced pulpal lumen
due to trauma.
■ Various instruments have been recommended for pulpal amputation, such as spoon
excavators, slowly rotating round burs and high-speed abrasive diamonds. Of these,
the spoon excavator, successfully used in molars, has proven unsuitable in young
incisors. Slowly rotating instruments are known to inflict significant injury to the
remaining pulp, limiting the chance of survival. However, it has been shown that
injury to the underlying tissue is minimal when abrasive diamond is used at high
speed to remove part of the pulp, provided that the bur and tissues are adequately
cooled. If effective cooling is not possible, e.g. when the amputation site is deep in
the root canal, a round bur at low speed should be used in order to avoid overheating
the pulp.

■ Camp, (2002) asserted that almost all young, endodontically involved
teeth have a good blood supply and there is always vital tissue in the
apical third of the canal, which cannot be removed with currently, used
chemicals. For these reasons, Pulp capping and Pulpotomy remains
valuable techniques when incisors sustain injuries resulting in exposure
of coronal pulp tissue

Management
Reversible Pulpitis
Irreversible Pulpitis
Open Apex Close Apex
Apexogenesis
Direct pulp capping procedure.
Pulpotomy
Open Apex Close Apex
Apexification
Conventional
root canal
treatment
Patel, Bobby. Apexogenesis, Apexification, Revascularization and Endodontic Regeneration. Springer International Publishing. Switzerland. 2016. 205-223.

PULP CAPPING
■ Pulp capping is indicated when the exposure is small no more than 2mm
in diameter and has not been open to contamination from saliva for more
than 24 hours. The shorter the time between the accident and treatment
the better the prognosis for pulp capping( Anderson 1970, Anderson
1981)

Clinical success of Pulp capping
■ The healing frequencies after the treatment of exposed pulp in crown
fractured teeth with pulp capping have been studied by Kozlowska in 1980
on 53 teeth he found the healing frequency to be 72%.
■ A similar study by Ravn in 1982 suggested 88 % healing in the sample of
84 teeth . Fuks et al studied 38 teeth and found the healing frequency to be
81% (1982 )

■ Young patients with immature teeth, it is advantageous to preserve pulp vitality by
pulp capping or partial pulpotomy.
PULP CAPPING
Indicated in mature and immature teeth when exposure is minimal and can be treated soon after injury; i.e. within 24
hours.
Follow-up: clinical and radiographic controls after 6 months, 1 year and annually for a minimum of 3 years.
Prognosis: pulp healing in 71–88%.

PULPOTOMY
■ Malone in 1952 suggested that depending on the size of exposure and the
time elapse of injury , different level of pulpal amputation have been
recommended.
■ Cvek in 1978 has shown that neither exposure site or time interval
between injury and treatment are critical for healing when only
superficial layers of pulp are removed

Partial pulpotomy technique
■ This technique was advocated by Cvek 1978 , it involved removal of 2 mm of
injured coronal pulp followed by a calcium hydroxide dressing . Cvek in 1978
reported 96% success rate of this procedure . Fuks et al reported 94 % success rate
with Cveks shallow pulpotomy technique (1987)
■ The rationale for the Cvek pulpotomy is this: if the inflamed tissue is removed, the
healthy underlying tissue is more likely to remain healthy and to seal the exposure
with hard tissue bridging of the exposure site. Of course, the other requirements for
successful pulp capping, such as hemostasis and a bacteria-tight seal, are met.
Pulpotomies have been used routinely in treatment of primary and young permanent
teeth after traumatic pulp exposures.

■ Partial pulpotomy should be selected as an alternative to direct pulp
capping when the extent of pulpal inflammation is expected to be greater
than normals in the the case of traumatic exposures older than 24 hr.
■ Depending on the size of the exposure and time elapsed since injury;
different levels of pulpal amputation have been recommended, i.e. Partial
or cervical pulpotomy.

Advantages
■ Minor injury to the pulp
■ Undisturbed physiologic apposition of dentin, especially in the critical
cervical area of the tooth.
■ The limited loss of crown substance offers continuing opportunities for
sensitivity testing.
■ Compared with pulp capping, it implies better wound control and, by
sealing off the cavity with a material which does not allow microleakage,
provides effective protection for the pulp.

1) PARTIAL PULPOTOMY ( CVEK’S PULPOTOMY) - Miomir Cvek (1978)
Administer local anesthesia.
(2) Isolate with a rubber dam and wash with a mild disinfectant.
(3) Amputate the pulp together with surrounding dentin to a depth of about 2mm below the exposure site with a
diamond bur in high-speed contra-angle hand-piece, using a continuous water spray. Cut intermittently, for brief
periods and without unnecessary pressure.
(4) Await hemostasis.
(5) Cover the wound with calcium hydroxide and seal the cavity. If the crown is to be immediately restored with a
composite material, seal the coronal cavity with zinc sulphate If the crown is restored temporarily, seal the cavity with
zinc oxide-eugenol cement.
(6) Follow-up: clinical and radiographic controls after 6 months, 1 year and annually for at least 3 years.
Berman LH, Hargreaves KM, Cohen SR. Cohen's Pathways of the Pulp Expert Consult-E-Book. Elsevier Health Sciences; 2010 May 10.

Cvek partial pulpotomy
• The fractured teeth are cleaned and disinfected; a rubber
dam is placed.
• Cavities are prepared at high speed with a round diamond
bur 1 to 2 mm into the pulpal tissue.
• Calcium hydroxide on a plugger is placed on the soft tissue
of the pulp.
• Care is taken to avoid smearing the walls of the preparation
with the calcium hydroxide.Cavity preparations are filled
with glass ionomer cement.Exposed dentin is etched and
then covered with composite resin. Radiograph exposed 6
months later shows formation of hard-tissue barriers in both
teeth.

CERVICAL PULPOTOMY
■ A pulpotomy is indicated for a larger exposure or where there has been a
delay in presentation.(Anderson 1970, Anderson 1981, Finn 1988 ,
Mathewson 1993).

CERVICAL PULPOTOMY (Deep Pulpotomy)
Indicated for immature teeth when necrotic tissue or impaired vascularity is seen at the exposure site.
(1) Administer local anesthesia.
(3) Amputate the pulp to a level at which fresh bleeding is encountered, usually in the cervical region. Due to
problems of inadequate cooling of a diamond bur run at high speed at that level, a round bur at low speed should be
used.
(4) Await hemostasis.
(5) Cover the pulp with calcium hydroxide and seal the coronal cavity. If the crown is restored immediately with a
composite resin, seal the cavity with Prader’s sulphate cement, otherwise with zinc oxide-eugenol cement.
(6) Follow-up: clinical and radiographic controls after 6 months, 1 year and annually to completion of root
development. Consider then eventual further endodontic or prosthetic treatment.

Deep pulpotomy in an incisor with crown fracture and impaired pulpal vascularity. Vital and bleeding pulp tissue
was found in the middle of the root canal. Three and 9 months after a deep pulpotomy, formation of a hard-tissue
barrier can be seen deep in the root canal. A 5-year control of the subsequent root canal filling with gutta-percha
shows completed root development.
0 d 6 d 3 mo 9 mo 5 yr

Pulpectomy
■ If two of the following signs and symptoms of pulpal necrosis occur after
pulpotomy has been completed then full endodontic therapy should be
undertaken:
■ Swelling or symptoms of pain;
■ Apical radiolucency, widening of the periodontal membrane space and/or
loss of the lamina dura;
■ Arrested root development, demonstrated by comparing current and
previous radiographs;
■ A change in sensitivity tests from positive to negative, (Mackie,1996)

PULPECTOMY
Indicated in mature teeth when necrotic tissue or impaired pulp vascularity is seen at the exposure site, or when
extensive loss of crown substance indicates restoration with a post in the root canal.
(3) Amputate the pulp 1–2mm from the apical foramen.
(4) Clean the root canal mechanically while constantly flushing with saline or 0.5% sodium hypochlorite solution.
(5) Obturate the root canal with gutta-percha, using resin chloroform, chloropercha or another sealer.
(6) Follow-up: clinical and radiographic controls after 6 months, 1 year and annually for a minimum of 4 years.
Prognosis: periapical healing in 90%
• Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

Apexification
Problems of treating immature incisor with a necrotic pulp
■ The anatomy of the non-vital immature incisor presents several problems:
■ There is an open apex so there is no hard tissue stop against which gutta
percha can be packed.
■ The open apex of the root canal tends to be shaped like a blunderbuss,
making it difficult to obdurate the apex with root filling material.
■ Apicectomy is inadvisable because the walls of the immature are like to
fracture when sealing the root apex.

■ This procedure should be performed in teeth
with open apices and thin dentinal walls in which
standard instrumentation techniques cannot create an
apical stop to facilitate effective root canal filling.
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
■ Professor Nygaard-Østby evaluated a revascularization method for re establishing a
pulp-dentin complex in permanent teeth with pulpal necrosis
■ The advantages of pulp revascularization lie in the possibility of further root
development and reinforcement of dentinal walls by deposition of hard tissue, thus
strengthening the root against fracture
Revascularization case of a 14-year-old female patient with
a diagnosis of pulpal necrosis secondary to dens invaginatus. The
tooth was isolated, accessed, and irrigated with 2.5% sodium
hypochlorite and 2% chlorhexidine, followed by placement of a mixture
of ciprofloxacin, metronidazole, and minocycline for 96 days. Upon
recall, symptoms had subsided, the tooth was isolated, and the triple
antibiotic paste was removed by irrigation. Bleeding was established,
and the root canal system was sealed with white mineral trioxide
aggregate and a composite restoration.

IADT 2020 – Complicated Crown Fracture
Clinical Findings Radiographic assessment and findings Treatment
Normal mobility. Enamel-dentin loss is visible Immature roots and open apex – Preserve the
pulp.
Partial pulpotomy or pulp capping is
recommended in order to promote further root
development.
Mature tooth and close apex –
Post required – RCT preferred.
palpation
Missing fragments should be accounted for
:
1) If fragment is missing and there are soft
tissue injuries, radiographs of the lip and or
cheek are indicated to search for tooth
fragments and or/foreign materials.
Partial pulpotomy is even preferred in teeth
with completed root development..
Calcium hydroxide – suitable to be placed on
pulp wound.
Evaluate the tooth for a possible
associated luxation injury or root
fracture, especially if tenderness is
present.
Exposed pulp is sensitive to stimuli
2) Additional radiographs are only
indicated if signs or symptoms of other
potential injuries are present.
Tooth fragment –available – bonded back to
the tooth after rehydration.
Absence of intact crown fragment – cover
exposed dentin with GIC or use dentin
bonding agent and composite resin.

Clinical and radiographic evaluations
are necessary:
- After 6-8 weeks
- After 3months
- After 6 months
- After one year
- If there is an associated luxation or
root fracture, or the suspicion of an
associated luxation injury, the
luxation follow-up regimen prevails
and should be used. Longer follow-
ups may be needed
Asymptomatic
testing
Continued root development in
immature teeth
Symptomatic
Discoloration
Loss of restoration
Pulp necrosis and infection.
Apical Periodontitis.
teeth

Etiologic factors
• Falls
• Bicycle and automobile accidents
• Foreign bodies striking the teeth
CROWN AND ROOT FRACTURE
■ Involves enamel, dentin and cementum
■ Uncomplicated or complicated
■ Comprised 5% of injuries in permanent dentition and 2% in primary
dentition.

CLASSIFICATION
A. According to the extent of the fracture line:
1. Total: The fracture line is complete and the coronal fragment is held only by
the periodontal ligament.
2. Partial: The fracture line is incomplete.
B.According to the proximity to the pulp chamber:
1. Without pulp exposure: The fracture line does not directly affects the pulp.
2. With pulp exposure: The fracture line directly affects the pulp.

CLINICAL FINDINGS
■ Fracture line begins few millimeters incisal to marginal gingiva facially
■ Fragments - slightly displaced – coronal – kept in position by fibres
■ Displacement of coronal fragment minimal- often overlooked
■ In rare cases, may occur prior to eruption of permanent tooth-
displacement of primary teeth
■ Line may be single or multiple
■ Exposes pulp in fully erupted teeth

RADIOGRAPHIC FINDINGS
■ Vertical fractures can be seen
■ Vertical fractures mesio-distal direction difficult to seen

Healing and pathology
■ Communication with oral cavity to the pulp and PDL – bacterial
invasion- healing can not be expected
■ Acute pulpal inflammation – proliferation of marginal gingival
epithelium into pulp chember

Treatment:
■ Bevelander in 1942 suggested that a communication from the oral cavity to
the periodontal ligament and pulp may permit bacterial invasion . Clyde in
1965 and Feldman in 1966 have discussed the Surgical Exposure of
Fracture Surface as treatment modality. The treatment principle to convert
the subgingival fracture to a supragingival fracture with the help of
gingivectomy ad osteotomy .
■ It should only be used where the surgical technique does not compromise the
esthetic result, i.e. only the palatal aspect of the fracture must be exposed by
this procedure. The major disadvantage of this treatment modality was the
labial migration of the restored tooth and the health of the palatal gingival
was compromised .

■ Andersen in 1970 has suggested that the Emergency treatment can include
stabilization of the coronal fragment with an acid etch / resin splint to adjacent
teeth. Despite contamination from saliva via the fracture line to the pulp, the
tooth will generally remain symptom – free. However, it is essential that
definitive treatment is begun within a few days after injury.
■ Anderson in 1970 suggested the removal of Coronal Fragment and
Supragingival Restoration, the treatment principle to allow gingival healing
(presumably with formation of a long junctional epithelium), where after the
coronal portion can be restored treatment
■ This procedure should be limited to superficial fracture s that do not involve pulp,
the major disadvantage is that a long term prognosis has not been established.

■ fracture to a supragingival position orthodontically. It is the same as for
surgical extrusion, but is more time-consuming. It is indicated in all types of
fractures assuming that reasonable root length can be achieved.
■ Michanowitz in 1978 mentioned that the vertical fractures must generally
be extracted.
■ Tegsjo et al (1978) introduced the Surgical Extrusion of Apical
Fragment. The Treatment principle is to surgically move the fracture to a
supragingival position.

■ This treatment procedure was introduced by Tegsjo et al (1978) and the
method further developed by Buhler (1984)
■ The treatment procedure should only be used where there is completed
root development and the apical fragment is long enough to accommodate
a post-retained crown. The similar treatment modality has been reported
by Andersen in 1995

TREATMENT
Treatment options are determined by the
■ Extent of the subgingival fracture
■ The remaining coronal tooth structure
■ Length and morphology of the root.

■ Vertical crown-root fractures – extraction
■ Some cases reported that bonding of coronal fragment has led to
consolidation of the intra-alveolar part of the facture
■ Tissue not known
■ In case where conservative treatment not possible – consider keeping
apical fragment – may prevent alveolar process from resorbing

1. Removal of the coronal fragment with subsequent restoration above the gingival level.
2. Removal of the coronal fragment supplemented by gingivectomy and osteotomy and
subsequent restoration with the crown.
3. Removal of the coronal fragment, raising of the gingival flap, immediate endodontic
treatment and fragment bonding
4. Removal of the coronal fragment and immediate extrusion of the root by surgical or
orthodontic procedures.
5. Extraction when fracture is extending more than one third of the root.

Removal of coronal fragment and supragingival restoration
Indicated in superficial fractures that do not involve the pulp
(2) Remove loose fragments.
(3) Smoothen the rough subgingival fracture surface with a chisel.
(4) Cover supragingival exposed dentin.
(5) When gingival healing has occurred a supragingival restoration is made using
bonded composite or the original fragment where the subgingival portion has been
removed.

■ Advantage-
1. Very conservative
2. Uses a biologic restorative material
3. Maintenance of original occlusion
4. Immediate gratification response in a patient
5. Completed within single appointment
Disadvantage-
This procedure should not be preferred on a routine basis because of
1. Poor prognosis of the restoration because of difficulties in maintaining strict
moisture control
2. Poor plaque control.

 Removal of the coronal fragment and supragingival restoration

Reattachment of an incisal fragment of a crown
■ Reattachment of a fracture should be considered in a clinical crown
involving minimal invasion of the biologic width and a viable alternative to
conventional resin bonding or fixed prosthodontics due to the subgingival
placement of the fracture margin palatally.
■ The subgingival aspect of the incisal fragment should be reduced to a sharp,
smooth margin ending at the free gingival margin and then bonded to the
remaining tooth.

■ Advantage-
■ Very conservative
■ Restores original dental anatomy
■ Maintenance of original occlusion
■ Immediate gratification response in a patient
■ Completed within single appointment
■ Disadvantage
■ Difficulties in maintaining strict moisture control
■ If the fracture is too wide at the root, gingival tissue support is reduced
and an unpleasing space a “black triangle”- might appear.

 Indicated in teeth where the coronal fragment comprises 1/3 or
less of the clinical root
- Administer local anesthesia.
- Remove loose fragments.
- Perform a pulpectomy and obturate the root canal with gutta
percha and a sealer.
- Expose the fracture surface with a gingivectomy and
ostectomy.
- Restore the tooth with a post-retained porcelain jacket crown.
Surgical exposure of fracture surface

Treatment procedure.
■ After administration of a local anesthetic, the coronal fragment is removed and the
fracture surface carefully examined.
■ It is important to observe that most crown-root fractures contain a lingual step. In
some cases, this step is apart of an incomplete or complete fracture extending
apically. It is therefore essential to determine whether the lingual step in the root is
part of a secondary fracture.
■ This can be done during the gingivectomy by placing a sharp explorer or similar
instrument at the base of the step and with a gentle palatal movement, check whether
abnormal mobility can be detected.

■ Axial fracture lines running from the pulp chamber to the root surface
should also be carefully explored. If these fractures are over looked, an
inflammatory reaction in the periodontium will develop after completion
of the restoration.
■ The use of a conventional cast core and separate crown instead of single
unit restoration has the advantage that future changes the position of the
gingiva and subsequent loss of esthetics can easily be corrected.

■ Disadvantage: - After gingivectomy, regrowth of the gingiva often takes place, leading
to development of a pathologic lingual pocket and inflammation of the surrounding
gingiva despite good marginal adaptation and will result in facial migration of the
restored teeth. (Migration has been found to be approximately 0.5 mm in a 5-year
period)
■ Ostectomy:-It is imperative in maintaining a positive osseous architecture and alveolar
crest scalloping to form a smooth, harmonious, flow from tooth to tooth.
Disadvantage: - Smidt, (2005)
■ Sacrifices the bony support of the neighboring teeth, it may lead to unfavorable root and
furcation exposure and reverse bone and soft tissue architecture
■ Increased clinical crown length in the operated area may result in an unpleasant esthetic
outcome
■ Potential risk for root sensitivity is increased
■ A loss of 0.5-1.0 mm of osseous crest may be expected during healing
■ Delayed healing of 2-6 months.

 Indicated in teeth where the coronal fragment comprises 1/3or less
of the clinical root.
(2) Remove loose fragments.
(3) In teeth with mature root formation, perform pulpectomy and obturate the root canal with gutta-percha
and a sealer. In teeth with immature root formation, perform a cervical pulpotomy
(4) Expose the fracture surface via orthodontic extrusion of the root
(5) When the root is extruded, perform a gingivectomy and ostectomy, if needed, to restore symmetry of
gingival contour.
(6) Restore the tooth temporarily and splint to adjacent teeth for a retention period of 6 months.
(7) After the retention period, restore definitively.
Orthodontic extrusion of apical fragment
(Heithersay)

 Malmgren et al 1991 report an average of five weeks of active treatment is needed
for 2-3 mm of extrusion followed by retention period of 8-10 weeks
 Bondemark et al 1997 described a new way for extruding teeth orthodontically
with the use of magnets, total of 9-11 weeks were needed for 2-3 mm extrusion
■ Olsberg et al. (2002) recommended that orthodontic movement of the injured
immature teeth be postponed until root development is seen to resume by giving a
temporary dressing with calcium hydroxide. Once the apexification is completed,
root canal therapy is indicated because orthodontic wires are fixed to a radicular
post.

■ Prior to orthodontic extrusion, there should be at least 14 mm overall root structure
and 4mm of gutta-percha to maintain the apical seal, and 10mm of post retention.
Also the distance from fracture level to apex should be no less than 12mm after
extrusion of 2mm.Hence at least 10mm of root should be within the bone to
maintain 50:50 crown/root ratio Lovdhal (1995).
■ A central incisor can be extruded 2-4 mm, while a lateral incisor can be extruded 4-
6 mm A non-vital tooth can be extruded, 3-5 mm during 3-4 weeks Rapid extrusion
of teeth, in comparison to conventional orthodontic extrusion, may in rare cases
elicit root resorption. However, both histologic and clinical studies of extruded
teeth indicate that root resorption after extrusion is very rare.

■ Cook (1980) reported that ideal rapid extrusion of a single root requires forces of the magnitude
of 0.7N to 1.5 N, using these light forces about 4-6 mm of extrusion can be
achieved over 6-8weeks
■ According to Heda et al (2006) suggested force is 0.2-0.3N.
■ Relapse may follow orthodontic extrusion, the prime reason being the stretched
state of marginal periodontal fibers. To avoid relapse, fibrotomy should be
performed before the retention period, which should last at least 3-4 weeks.
■ Bondemark et al (1997) described a new way with the use of an attractive magnet:
the first one is attached to the fractured root, and a larger one is embedded in a
removable appliance. A total of 9-11 weeks were needed for 2-3 mm of extrusion,
with constant forces, no friction and no material fatigue with promising results.

■ Olsburgh et al (2002) described the technique of orthodontic extrusion
after extirpating the pulp, a calcium hydroxide dressing was left, followed
by the sealing of a titanium post 1mm in diameter, with a temporary
cement. Brackets were bonded from the upper left second deciduous
molar to the upper right one; and teeth were ligated for anchorage. The
deactivated elastic thread joining the post to the arch was changed once a
week, for 1 month, followed by 6 months retention period.

■ Advantage:-
■ Good esthetics
■ Restores gingival health.
■ Vitality of the pulp is maintained in some cases.
■ Disadvantage:-
■ The procedure is slow and cumbersome

Surgical extrusion of apical fragment
 Indicated in teeth where the coronal fragment comprises less
than half root length
1) Administer antibiotics and local anesthesia.
2) The pulp can be extirpated and the root canal filled with gutta percha
and a sealer prior to intra-alveolar transplantation; or endodontics can be postponed and the root canal
entrance sealed with a zinc oxide eugenol cement.
3) The PDL is incised, the tooth luxated with an elevator and the tooth extracted with forceps.
4) The root surface is inspected for incomplete root fractures, which would contraindicate transplantation.
5) The root is repositioned at a level 1mm coronal to the alveolar crest. If desirable, the root can be rotated
to achieve a maximum periodontal surface area within the socket.
 Tegsjo ( 1978) and Buhler and Kahnberg

6) The tooth is stabilized using interproximal sutures.
7) Take a postoperative radiograph.
8) After 2 to 3 weeks, the transplant is usually firm. If the root canal has not been filled,
calcium hydroxide can be used as an interim dressing which will ensure apical hard tissue
closure. A temporary restoration can now be fabricated
9) After 6 months, a permanent root filling as well as a definitive crown restoration can be
completed.
10) If a gutta-percha root filling has been made prior to transplantation, the tooth can be
restored after 2 months.

■ Advantage: -
■ It is a safe and rapid method for the treatment of crown-root fractures.
■ Disadvantage: -
■ Pulp vitality must be sacrificed.
■ Bone support may be lost around the tooth.
■ Risk of external root resorption

VITAL ROOT SUBMERGENCE
(Johnson and Jensen -1997)
The root fragment is retained in socket and left vital. Gingival tissue is sutured over the exposed root
stump to achieve primary closure. Later the root is replaced by an implant.
 Indicated in young individuals where the above mentioned treatment alternatives cannot be carried
out in order to maintain the dimensions of the alveolar process.
1) Administer a local anesthetic.
2) A flap is raised.
3) The supra-alveolar fragments of the tooth are removed.
4) The flap is closed over the exposed root including the pulp.
5) Insert a space maintainer.

Vital Root Submergence
Advantage
■ Preservation until the time, the root is replaced with an implant and thus
has cosmetic and functional importance.
■ Potential to support a post crown alveolar bone

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

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

IADT 2020 –Uncomplicated crown-root fracture
• Pulp sensibility tests usually positive
• Tender to percussion.
• Coronal, or mesial or distal, fragment is usually present
and mobile
• The extent of the fracture (sub- or supraalveolar)
should be evaluated

Imaging, radiographic assessment, and findings
■ Apical extension of fracture usually not visible
■ Missing fragments should be accounted for: - If fragment is missing and
there are soft tissue injuries, radiographs of the lip and/or cheek are
indicated to search for tooth fragments or foreign debris
■ Recommended radiographs: - One parallel periapical radiograph - Two
additional radiographs of the tooth taken with different vertical and/or
horizontal angulations - Occlusal radiograph
■ CBCT can be considered for better visualization of the fracture path, its
extent, and its relationship to the marginal bone; also, useful to evaluate the
crown-root ratio and to help determine treatment options

Treatment
■ Until a treatment plan is finalized, temporary stabilization of the loose fragment to
the adjacent tooth/teeth or to the non-mobile fragment should be attempted
■ If the pulp is not exposed, removal of the coronal or mobile fragment and
subsequent restoration should be considered
■ Cover the exposed dentin with glassionomer or use a bonding agent and composite
resin

■ The treatment plan is dependent, in part, on the patient's age and
anticipated cooperation. Options include:
• Orthodontic extrusion of the apical or non-mobile fragment, followed by
restoration (may also need periodontal re-contouring surgery after
extrusion)
• Surgical extrusion
• Root canal treatment and restoration if the pulp becomes necrotic and
infected
• Root submergence
• Intentional replantation with or without rotation of the root
• Extraction
• Autotransplantation

Follow up
■ Clinical and radiographic evaluations are necessary:
• after 1 wk
• after 6-8 wk
• after 3 mo
• after 6 mo
• after 1 y
• then yearly for at least 5 ys

Favorable outcomes
■ Asymptomatic
■ Positive response to pulp sensibility testing
■ Continued root development in immature teeth
■ Good quality restoration

Unfavorable outcomes
■ Symptomatic
■ Discoloration
■ Pulp necrosis and infection
■ Apical periodontitis
■ Lack of further root development in immature teeth
■ Loss of restoration
■ Breakdown of the restoration
■ Marginal bone loss and periodontal inflammation

IADT 2020 - Complicated crown-root
fracture
■ Pulp sensibility tests usually positive
■ Tender to percussion.
■ Coronal, or mesial or distal, fragment is usually present and mobile
■ The extent of the fracture (sub- or supraalveolar) should be evaluated

Imaging, radiographic assessment, and findings
■ Apical extension of fracture usually not visible
■ Missing fragments should be accounted for: - If fragment is missing and there
are soft tissue injuries, radiographs of the lip and/ or cheek are indicated to
search for tooth fragments or foreign debris
■ Recommended radiographs: - One parallel periapical radiograph - Two
additional radiographs of the tooth taken with different vertical and/or
horizontal angulations - Occlusal radiograph
• CBCT can be considered for better visualization of the fracture path, its
extent, and its relationship to the marginal bone; also useful to evaluate the
crown-root ratio and to help determine treatment options

Treatment
■ Until a treatment plan is finalized, temporary stabilization of the loose fragment to
the adjacent tooth/teeth or to the non-mobile fragment should be attempted
■ In immature teeth with incomplete root formation, it is advantageous to preserve
the pulp by performing a partial pulpotomy. Rubber dam isolation is challenging
but should be tried. - Non-setting calcium hydroxide or non-staining calcium
silicate cements are suitable materials to be placed on the pulp wound
■ In mature teeth with complete root formation, removal of the pulp is usually
indicated - Cover the exposed dentin with glass-ionomer or use a bonding agent
and composite resin

■ The treatment plan is dependent, in part, on the patient's age and anticipated
cooperation. Options include:
• Completion of root canal treatment and restoration
• Orthodontic extrusion of the apical segment (may also need periodontal re-
contouring surgery after extrusion) • Surgical extrusion
• Root submergence
• Intentional replantation with or without rotation of the root
• Extraction
• Autotransplantation

Follow up
■ Clinical and radiographic evaluations are necessary
• after 1 wk
• after 6-8 wk
• after 3 mo
• after 6 mo
• after 1 y
• then yearly for at least 5 y

Favorable outcomes
■ Asymptomatic
■ Continued root development in immature teeth
■ Good quality restoration

Unfavorable outcomes
■ Symptomatic
■ Pulp necrosis and infection
■ Apical periodontitis
■ Lack of further root development in immature teeth
■ Loss of restoration
■ Breakdown of the restoration
■ Marginal bone loss and periodontal inflammation

ROOT FRACTURE
■ Involving dentin, cementum and pulp
■ Comprising 0.5-7% in permanent and 2-4% in primary dentition
Mechanism
• Frontal impact – compression zones – shearing stress zones

Classification According to Basrani (1985)
Classification is done according to the following factors.
■ Direction
■ Localization
■ Number
■ Extension
■ Position of root fragments.

A. The direction of the line of fracture with respect to the long axis of the tooth.
1.Horizontal: When the line of fracture is perpendicular to the long axis of the
tooth.
2.Oblique: When the line of fracture follows an angle in relation to the long axis of
the tooth.
3.Vertical: When the line of fracture is parallel to the long axis of the tooth.
B.Location of the fracture.
1. Cervical third: The line of fracture is close to the cervical third of the tooth.
2.Middle third: The line of fracture approximately divides the root into two halves.
3.Apical third: The line of fracture is in the apical portion of the root.

C.According to the number of fracture line.
1.Simple: When only one line of fracture divides the root into two portion.
2.Multiple: When the root is divided into more than two fragments.
3.Communuted: When the root fractures in multiple small pieces
D.According to the extension of the line of fracture.
1.Partial: The line of fracture involves the portion of the root.
2.Total: The line of fracture involves the entire root.
E.Position of root fragments
1.Without displacement: When segment face each other.
2.With displacement: When the fractured segments are not aligned.

CLINICAL FINDINGS
■ Maxillary central incisor – age group 11-20 years
■ Primary dentition – uncommon – age group 3-4 years
■ Associated with other types of injuries
■ Hansien in 1967 reported that with the permanent incisors in various
stages of eruption and incomplete root development the root fractures are
unusual . Jacobsen in 1968 showed that this was related to the elasticity
of alveolar socket which rendered the teeth more susceptible to luxation
than to fractures
Examination
• Slight extruded tooth
• Slight mobility

Horizontal or oblique plane :
● Horizontal plane can usually be detected in the regular periapical 90o angle film
with the central beam through the tooth (cervical third)
● Oblique fracture , 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.

■ Occlusal exposure, IOPA in mesial and distal direction
■ CBCT is not indicated in acute examination

Healing and pathology
■ Healing with calcified tissue
■ Interposition of connective tissue
■ Interposition of bone and connective tissue
■ Interposition of granulation tissue

Healing patterns
Four types of healing of root fractures:
(Andreasen and Hjorting-Hansen)
1. Healing with calcified tissue : Radiographically fracture line is discernible but the fragments
are in close contact

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

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

4. Lack of healing with interposition of granulation tissue :
Radiographically a widening of the fractured line, a developing radiolucency corresponding to
fracture line or both become apparent

TRANSVERSE ROOT FRACTURE
■ Transverse root fractures are fractures that involve the dentin, cementum, pulp and
periodontal ligament. They occur most commonly in the maxillary teeth and are
usually caused by an injury received in a fight or sporting event or by an inanimate
object striking the teeth. While not a common type of dental injury, they account for
approximately 6% of all dental traumas.
■ The following four items are important in the treatment of the transversely root
fractured tooth.
The position of the tooth after it has been fractured.
The mobility of the coronal segment.
The status of the pulp.
The position of the fracture line.

Position of the Tooth
■ Typically, a transversely fractured tooth is slightly lingually placed and
slightly extruded. Such a laterally luxated tooth must be repositioned into its
correct alignment as soon as possible after injury.
■ Often, this involves giving the patient a local anesthetic to properly grasp the
coronal segment and return it to its normal position.
■ If the coronal segment is mobile, it should be splinted to the adjacent teeth. If
the tooth is in its correct position no relocation is necessary.

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