Traumatized Teeth

TRAUMATIZED
ANTERIOR TEETH
Dr. Khin Swe Aye
BDS., DipDSc., MDSc., Dr Dental Science,
FICCDE
Dept. of Conservative Dentistry, UDMY

 Loss of a child’s anterior teeth especially
permanent dentition, cause greater
psychological impact on parents and on child
 CausesCauses
 Simple accidents minor falls, accidents
during sports or childish pranks

 ResultResult
 Facial appearance is altered
(attractive → unattractive
target for teasing and even ridicule by other
children)
 Dentist’s DutyDentist’s Duty
 To preserve the vitality of injured teeth
 To restore them skillfully to their orginal
apperance, without producing additional
trauma or endangering integrity of the teeth


TimeTime
 Important consideration in treatment of TATTAT
 Every effort should be made immediatelyimmediately
and should be given preference and
emergency treatment

Therefore
•further irritation to the pulp could be
prevented,
• avulsed tooth could be replanted with
higher percentage of success,
• more favorable result could be
anticipated

Prevalence of Injuries to Anterior Teeth
TeethTeeth – Maxillary central incisors (most
frequently involved)
SexSex – Boys > Girls (2 : 1)
AgeAge - between 9–10 yrs
HistoryHistory
 When the accident occur?
 How the accident occur?
 Where of the accident occur?
 Whether treatment of any kind taken or not?

Clinical Examination
 Determine type and extent of injury

Chief complaintChief complaint

Neurologic examinationNeurologic examination

Extra-oral examinationExtra-oral examination

Lacerations, Ex: bone contours, TMJ

Intra-oral examinationIntra-oral examination

Radiographic ExaminationsRadiographic Examinations

Root fracture, sub-gingival crown
fracture, bone fracture, foreign objects

Manipulation TestManipulation Test - for mobility


Vitality TestVitality Test – should be recorded, to
compare with vital tests at recall lists

Heat Test, Cold Test, EPT
PrognosisPrognosis - on histologic condition of pulp

PercussionPercussion

To check injury to periodontal membrane
and other supporting structure
SummarySummary - The examination of traumatic
injuries must be thorough and meticulously
recorded

Classification of Traumatic Injuries of
Permanent Teeth
 Class 0Class 0 → Enamel Crack
 Class 1Class 1 → Enamel Fracture
 Class 2Class 2 → Enamel –Dentin #
without pulp exposure
 Class 3Class 3 → Enamel –Dentin #
with pulp exposure
 Class 4Class 4 → E,D,C # without Pulp
exposure
 Class 5Class 5 → E,D,C # with Pulp exposure

 Class 6Class 6 → Root fracture
 Class 7Class 7 → Concussion
 Class 8Class 8 → Luxation (loosening)
 Class 9Class 9 → Lateral Displacement
 Class 10Class 10 → Intrusion
 Class 11Class 11 → Extrusion
 Class 12Class 12 → Avulsion
( WHO CLASSIFICATION )( WHO CLASSIFICATION )

Classification (WHO)
Enamel infraction Enamel fracture Crown fracture without
pulp involvement

Crown fracture with
pulp involvement
Crown-root fracture Root fracture

Concussion Subluxation Extrusive luxation

Lateral luxation Intrusive luxation Avulsion

 Traumatic injuries are classified into
various fracture and luxation types, but
combination injuries often occur
 For the sake of clarity, however, each
type of injury will be described
individually

Enamel infraction and fractureEnamel infraction and fracture
Infraction
An incomplete fracture of the enamel
without an enamel defect (crack)
Enamel fracture
A small chip of enamel only

Crown fracture withoutCrown fracture without
pulpal involvementpulpal involvement
 Fracture involves
only enamel and
dentin with no
direct pulp
exposure

Crown fracture withCrown fracture with
pulpal involvementpulpal involvement
 Fracture involves
enamel, dentin,
and direct
exposure of the
pulp

Crown-root fractureCrown-root fracture
 This fracture
involves enamel,
dentin, and
cementum, and
may or may not
involve pulp
exposure

Root fractureRoot fracture
This fracture involves
dentin, cementum
and pulp
(Note: Root fracture
and luxation injury
may occur
simultaneously)

ConcussionConcussion
 This is minor injury
of the periodontium
with no
displacement of
the tooth nor
mobility

SubluxationSubluxation
 This is an injury of the
periodontium without
displacement of the tooth
but with slight mobility
 Damage to the blood
supply of the pulp and
periodontium is usually
minor but pulpal problems
occasionally result

Extrusive luxationExtrusive luxation
 This injury is
displacement of
the tooth in an
extrusive direction
involving the
periodontal support
and the pulpal
blood supply

Lateral luxationLateral luxation
 The tooth is displaced
from its long axis,
usually with the apical
end displaced labially
and coronal part
palatally
 The pulpal blood
supply is usually
completely severed

Intrusive luxationIntrusive luxation
 The tooth is displaced
apically,
 leading to a crushing of
neuro-vascular bundles
entering the pulp and
severe damage to the
cementum and
periodontium

AvulsionAvulsion
 The tooth is
completely displaced
from the alveolus with
total disruption of the
pulpal blood supply

Examination and Diagnosis
 Patient history
 Clinical examination
 Radiographic examination
 Other factors

Patient history
 When, Where, How it happens?
 Any fragment or avulsed tooth brought
to the dental office?
 Milk is a good storage medium for
avulsed tooth

Clinical examination
 Intraoral examination includes;
 Inspection – laceration, bleeding
 Palpation – mobility
 Percussion - pain
 Thermal test
 Electric pulp test
 Dental record – missing, displacement,
discoloration,

Radiographic examination
 Detect and confirm the fractures – crown,
root, alveolus, avulsion, displacement etc.,
 Good quality radiograph is essential
 Identify the stages of root development

Other factors
 For avulsed tooth, determine the length of
time that the tooth has been out of the
mouth, and storage medium

Example Cases – Case 1
 A 14-year-
old boy fell
and hit his
teeth #21 &
22. Slight
bleeding
and mobility
was
observed.

 NAD
 PLS – within
normal limit

 One month
later,
discoloration
is noted.

 The
diagnosis is
subluxation
resulting in
disruption
of the blood
supply to
the pulp.

A 9-year-old boy fell and hit his
anterior teeth during a ball game.

Note the contusion of the lower lip and crown fracture of tooth
#21. Because the fracture fragments are still attached, there is
possibility of crown-root fracture.

The fracture line reaches subgingivally on the
palatal aspect.

The fracture line extends below he crestal bone
margin. The diagnosis is crown-root fracture.

 A 38-year-old
man hit his
lower face
with a tool
while
gardening

 Palpation of
the lips
indicates
embedded
foreign body
in the upper
lip.

 Tooth
fragment
in the
upper lip

 18-year-old
woman with
enamel fracture
at #11 due to
automobile
accident. Two
months later,
discoloration
was observed.

The canal was filled with CaOH.
5 months later, root fracture was observed

 A 32-year-
old woman
with a
severe
facial injury
in a
automobile
accident.

Extrusive luxation of #12, fracture of alveolar
bone, avulsion of teeth #11 and #22, and
intrusive luxation of #21

Crown FractureCrown Fracture
 Crown fracture may
involve enamel only,
enamel and dentin, or
enamel, dentin and pulp
 Any type of crown fracture
may also be combined with
a luxation injury

Types of Crown Fracture
Enamel fracture Uncomplicated crown fracture
involving enamel and dentin

Types of Crown Fracture
Complicated crown
fracture, involving
enamel, dentin, and
exposing the pulp.
Crown fracture combined
with luxation

Treatment of Enamel FractureTreatment of Enamel Fracture
Preoperativ view – chipping of enamel edge

Treatment of Enamel FractureTreatment of Enamel Fracture
After selective grinding

Treatment of UncomplicatedTreatment of Uncomplicated
Preoperative view –
No tooth fragment available

After restorative treatment with composite resin

Preoperative view -
Tooth fragment has been saved.

After reattachment of the fragment

Treatment of Complicated CrownTreatment of Complicated Crown
Fracture with minimal pulpFracture with minimal pulp
exposureexposure
Preoperative view –
The tooth fragment has been saved.

Fracture with minimal pulp exposureFracture with minimal pulp exposure
After pulp capping and reattachment

Fracture with considerable pulpFracture with considerable pulp
exposureexposure
Preoperative view – The tooth fragment
available

exposureexposure
Note: The root is incompletely formed

exposureexposure
After partial pulpotomy and reattachment of
the tooth fragment.

exposureexposure
Root formation is almost complete after 1
year and 4 months.

Treatment of Crown FractureTreatment of Crown Fracture
combined with luxation injurycombined with luxation injury
Preoperative view – Tooth fragments available

Treatment of crown fractureTreatment of crown fracture
Preoperative view

Treatment of Crown FractureTreatment of Crown Fracture
After restorative treatment. After 3 months, tooth
#21 was suspected for pulp necrosis

Treatment of crown fractureTreatment of crown fracture
Apexification using calcium hydroxide. 9 months
later the RCT is completed

Treatment of Crown Fracture withTreatment of Crown Fracture with
large pulp exposurelarge pulp exposure
Preoperative view – Tooth fragments
available

large pulp exposularge pulp exposure
LA & rubber damExaminatio
n
Exam. Tooth
fragment

Fit the
tooth
fragment
Partial
pulpotomy
After rinsing
and
hemostasis

After placement
of pulp dressing
& composite
resin
Removal of pulp tissue from
the tooth fragment

Beveling of
the tooth
fragment
Beveling of
the original
tooth
Beveling of the
proximal
surface

Try-in of
tooth
fragment
Fitting of
Tofflemire
retainer and
matrix
Acid-etching
and bonding

Acid-etching, bonding,
and composite
placement
Fitting the fragment,
tightening the matrix,
remove the excess and
light curing

After removal of the matrix
band
Finishing and
shaping with a
finishing bur

Finishing and polishing with a white silicone point

Post-operative view

Pulp Capping and PulpPulp Capping and Pulp
HealingHealing

The mechanism of
dentin bridge formation
1. Immediate after vitalImmediate after vital
pulp treatmentpulp treatment
A necrotic layer is
observed below the
calcium hydroxide. The
inflammatory tissue
response is observed
under the necrotic layer

2. After 1 to 2 weeksAfter 1 to 2 weeks
A layer with a deposit of
calcium carbonate
granules is noticed
Beneath that layer,
osteo-odontoblasts
derived from pulp cells
emerge

3. After 4 to 5 weeksAfter 4 to 5 weeks
The osteodentin is
formed by the osteo-
odontoblasts
Perhaps, osteodentin
stimulates the
arrangement of
odontoblasts

3. A few months after
The dentin bridge is
formed
It is composed of two
layers of hard tissue,
osteodentin and
dentin with dentinal
tubules

ApexogenesisApexogenesis
If the pulpotomy is performed successfully in a
tooth with incompletely formed root, normal
narrowing of the pulp cavity and normal
development of the root will occur

CROWN-ROOT
FRACTURE
a and b.
Uncomplicate
d crown-root
fracture
c. Complicated
crown-root
fracture

Treatment of uncomplicated
crown-root fracture
Preoperative view. Uncomplicated crown-
root fracture in an 8-year-old boy

crown-root fracture
The fit of tooth
fragment is
checked
The pulp
horn is
capped
The tooth fragment is
reattached using acid
etching, bonding, and
composite resin

crown-root fracture
After polishing of
the tooth
5 years 3 months after the
treatment

Treatment of complicated
crown-root fracture
16-year-old boy with crown-root fracture on
tooth #21 and on #22

crown-root fracture
Reattachment of
tooth fragment on
tooth #22
Temporary
extraction of
the remaining
root of #21
Note –
periodontal
membrane
is attached
to the root

crown-root fracture
The root is rotated 180 degrees and
replanted into the alveolus with about 4 mm
extrusion. Stabilize with suture

crown-root fracture
Blood clot
Secondary
reattachment zone
(1 to 8 weeks)
Primary reattachment
zone (2 to 7 days)

crown-root fracture
The healing process:
Primary reattachment -
2-7 days: Reattachment between the
periodontal membrane on the root and
the gingival connective tissue

crown-root fracture
Secondary Reattachment –
0-1 week. Blood clot occupy the space
between the root and alveolar cavity.
1-2 weeks. Blood clot is replaced by bony
granulation tissues.
4-8 weeks. Bony granulation tissue is
replaced by bone.

crown-root fracture
Surgical
dressing is
placed
Sutures and
surgical dressing
are removed after
5 days
Follow-up
radiograph, 1
month
postoperative

crown-root fracture
Composite
core built-up
All ceramic
restoration
Follow-up
radiograph –
2 years
postoperative

crown-root fracture
Re-
establishing
biologic width
Biologic width
Prosthesis
margin

crown-root fracture
1 mm, connective
tissue attachment
1 mm epithelial
attachment
1 mm gingival sulcus
>1 mm prosthesis
margin

crown-root fracture
 For biologic width, there should be 3 mm of
tooth structure coronal to the bony margin
 However, it is often wise to add another 1
mm of tooth structure because the margin
of the prosthesis should be placed on
sound tooth structure near the gingival
margin

Orthodontic Extrusion
Re-establishing Biologic width:
 Orthodontic Extrusion
 Surgical extrusion
 Apically positioned flap with osseous
surgery

A case of crown-root fracture, tooth #21,
which has undergone endodontic treatment

Removal of
the tooth
fragment
Appliance for
orthodontic
extrusion using
an elastic band
Resin shell for
esthetic
purpose during
the treatment

After extrusion. The
gingiva has moved
coronally causing
esthetic problem
After
extrusion
Apically positioned
flap

2 weeks after
periodontal surgery
A provisional
restoration should be
placed before the final
prosthesis is made
1 year and 6 months after
the initial examination

Traumatized Teeth

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