classification treatments

1. Treatment of Traumatized Tooth

2. Etiology of Traumatic Injuries
• Automobile injury
• Battered child
• Child abuse
• Drug abuse
• Epilepsy
• Fall from height
• Sports related injuries

3. CLASSIFICATION OF DENTOFACIAL
INJURIES

4. Classification by Ellis and Davey (1960)
Class I Simple fracture of the crown involving little (or) no dentin.
Class II Extensive fracture of the crown involving considerable
dentin, but not the dental pulp.
Class III Extensive fracture of the crown involving considerable
dentin and exposing the dental pulp.
Class IV The traumatized teeth that become nonvital with (or)
without loss of crown structure.
Class V Teeth lost as a result of trauma.
Class VI Fracture of the root with or without a loss of crown
structure.
Class VII Displacement of a tooth without fracture of crown (or) root.
Class VIII Fracture of crown en masse and its replacement.
Class IX Injuries to primary dentition

5. A.Enamel fracture
B.Enamel and dentine
fracture
C.Dentine fracture
involving pulp
D.Root fracture
E.Extrusion
F. Intrusion

6. WHO Classification of Traumatic Injuries
873. 60 Enamel fracture.
873.61 Crown fracture involving enamel and dentine without pulp
exposure.
873.62 Crown fracture with pulp exposure.
873.63 Root fracture.
873.64 Crown root fracture
873.66 Luxation.
873.67 Intrusion or extrusion
873.68 Avulsion.
873.69 Other injuries such as soft tissue and laceration.

7. 873.60: Enamel fracture
873.61: Enamel and dentin fracture
873.62: Crown fracture with pulp exposure
873.63: Root fracture

8. 873.64: Crown root fracture
873.66: Luxation
873.67: Extrusion/intrusion
873.68: Avulsion

9. 873-69: Soft tissue injuries

10. ENAMEL FRACTURES
 These injuries involve the loss of the portion of coronal
tooth enamel subsequent to a force directed
perpendicularly or obliquely to the incisal edge of the
traumatized tooth.

11. Diagnosis And Clinical Presentation
• Enamel fracture includes superficial rough edge that
may cause irritation to the tongue or lips.

12. Immediate treatment • Re-contouring the injured tooth,
adjacent teeth and / or the opposing
teeth
• Eliminate the sharp enamel edges
associated with minor injuries and
prevents the laceration of tongue, lips
or oral mucosa.
When the shape and
extent of the fracture
precludes re-contouring
a restoration is
necessary
• Restoration of the missing tooth
structure with composite resin

13. DENTIN FRACTURES
 These injuries involve the loss of tooth substance
confined to enamel and dentin but not involving
the pulp.

14. Diagnosis And Clinical Presentation
• An enamel and dentin fracture also
includes a rough edge on the tooth, but
sensitivity to air and hot and cold
liquids and pain on mastication may be a
chief complaint.
• The intensity of these symptoms is related
directly to the amount of exposed dentin
and to the maturity of tooth.

15. The tooth should be tested with:
a) Electric pulp tester,
b) Ice,
c) Ethyl chloride spray,
d) Periapical radiograph.

16. Temporary
restoration:
• After the fracture, as soon as possible the
exposed dentin should be protected by
sedative cement such as zinc oxide
eugenol held in a crown form.
Permanent
restoration
• For uncomplicated crown fractured teeth
includes the use of adhesive resin and
composite resin systems.

17. COMPLICATED CROWN FRACTURES
 These injuries involve the loss of tooth substance
confined to enamel and dentin but involving the
pulp.

18. Pulp Capping and Pulpotomy
• Pulp capping and pulpotomy are the measures
that permit apexogenesis to take place and may
avoid the need for root canal therapy.
• The choice of treatment depends on the:
– Size of the exposure,
– The presence of hemorrhage
– The length of time since the injury.

19. Pulp Capping
• Pulp capping implies placing the dressing
directly on to the pulp exposure

20. Indication
s:
• On a very recent exposure (< 24 hours) and probably on
a mature, permanent tooth with a simple restorative
plan.
Technique
:
• After adequate anesthesia, a rubber dam is placed.
• Crown and exposed dentinal surface is thoroughly
rinsed with saline followed by disinfection with 0.12
percent chlorhexidine or betadine.
• Pure calcium hydroxide mixed with anesthetic solution
or saline is carefully placed over the exposed pulp and
dentinal surface.
• The surrounding enamel is acid etched and bonded with
composite resin.
Follow-up • Vitality tests, palpation tests, percussion tests and
radiographs should be carried out for 3 weeks; 3, 6 and
12 months; and every twelve months subsequently.
Prognosis • Prognosis is up to 80 percent

21. Pulpotomy
• Pulpotomy refers only to coronal extirpation of
vital pulp tissue.
• Two Types
• Partial pulpotomy
• Full (cervical) pulpotomy

22. Partial Pulpotomy
• Partial pulpotomy also termed as “Cvek
Pulpotomy”, it implies removal of the coronal
pulp tissue to the level of healthy pulp

23. Indication
s:
It is indicated in young permanent teeth with incomplete
root formation.
Technique
:
• After anesthetizing the area rubber dam is applied.
• A 1-2 mm deep cavity is prepared into the pulp using a
diamond bur.
• Wet cotton pellet is used to impede hemorrhage and
thereafter a thin coating of calcium hydroxide mixed
with saline solution or anesthetic solution is placed over
it.
• The access cavity is sealed with hard setting cement like
IRM.
Follow-up • 1. Absence of signs or symptoms
• 2. Absence of resorption either internal or external
• 3. Evidence of continued root formation in developing
teeth..
Prognosis • Prognosis is good (94-96%).

25. Cervical Pulpotomy/Deep Pulpotomy
• Cervical pulpotomy involves removal of entire
coronal pulp to the level of root orifices

26. Indication
s:
When the gap between traumatic exposure and the
treatment provided is more than 24 hrs.
• When pulp is inflamed to deeper levels of coronal pulp.
Technique
:
• Coronal pulp is removed same as in partial pulpotomy
except that it is up to level of root orifice.
Follow-up • It is same as pulp capping and partial pulpotomy.
• Main disadvantage of this treatment is that sensitivity
tests cannot be done because of loss of coronal pulp.
• Thus radiographic examination is important for follow-
up.
Prognosis • 80-95 percent success rate.

28. Apexification
• If the pulp tissue is necrotic, apexification is the
process which stimulates the formation of a calcified
barrier across the apex.
• Apexification is done to stimulate the hard tissue
barrier.
• Initially all canals are disinfected with sodium
hypochlorite solution to remove any debris and
bacteria from the canal.

29. Apexification
• Following this calcium hydroxide is packed against
the apical soft tissue and later backfilling with
calcium hydroxide is done to completely obturate the
canal.
• When completion of hard tissue is suspected (after 3-
6 months), remove calcium hydroxide and take
radiograph.
• If formation of hard tissue is found satisfactory, canal
is obturated using softened gutta-percha technique.

31. CROWN ROOT FRACTURE
• Crown root fracture involves enamel, dentin and
cementum with or without the involvement of
pulp.
• It is usually oblique in nature involving both
crown and root.
• This type of injury is considered as more complex
type of injury because of its more severity and
involvement of the pulp

32. Diagnosis
• Coronal fragment is usually mobile.
• Patient may complain of pain from mastication due to movement of
the coronal portion.
• Inflammatory changes in pulp and periodontal ligament are seen
due to plaque accumulation in the line of fracture.
• Patient may complain of sensitivity to hot and cold.
• Radiographs are taken at different angles to assess the extent of
fracture.
• Indirect light and transillumination can also be used to diagnose
this type of fracture.

33. Treatment
• The main objective of the treatment is to:
• a. Allow subgingival portion of the fracture to heal.
• b. Restoration of the coronal portion.
• If there is no pulp exposure, fragment can be treated by
bonding alone or by removing the coronal structure and then
restoring it with composites.
• If pulp exposure has occurred, pulpotomy or root canal
treatment is indicated depending upon condition of the tooth.

34. Treatment
• When the fracture extends below the alveolar crest level, the
surgical repositioning of tissues by gingivectomy, osteotomy,
etc. should be done to expose the level of fracture and
subsequently restore it.
Prognosis
• Long term prognosis depends on quality of coronal restoration.
• Otherwise the prognosis is similar to complicated or
uncomplicated fracture.

35. LUXATION INJURIES
• Luxation injuries cause trauma to supporting structures of
teeth ranging from minor crushing of periodontal ligament and
neurovascular supply of pulp to total displacement of the teeth.
• They are usually caused by sudden impact such as blow,

36. CONCUSSION
• Tooth is not displaced.
• Mobility is not present.
• Tooth is tender to
percussion because of
edema and hemorrhage in
the periodontal ligament.
• Pulp may respond normal
to testing.

37. SUBLUXATION
• Teeth are sensitive to percussion and have some mobility.
• Sulcular bleeding is seen showing damage and rupture of
the periodontal ligament fibers.
• Pulp responds normal to testing.
• Tooth is not displaced.

38. Treatment of Concussion and Subluxation
Rule out the root fracture by taking radiographs.
Relief the occlusion by selective grinding of opposing teeth
Immobilize the injured teeth.
Endodontic therapy should not be carried out at first visit because
both negative testing results and crown discoloration can be
reversible.
Follow-up is done at 3 weeks, 3, 6 and 12 months.
Prognosis there is only a minimal risk of pulp necrosis and root
resorption.

39. LATERAL LUXATION
• Trauma displaces the tooth lingually,
buccally, mesially or distally, in other
words out of its normal position away
from its long axis.
• Sulcular bleeding is present indicating
rupture of PDL fibers
• Tooth is sensitive to percussion.

40. LATERAL LUXATION
• Clinically, crown of laterally luxated
tooth is usually displaced horizontally
with tooth locked firmly in the new
position.
• Here percussion may elicit metallic
tone indicating that root has forced into
the alveolar bone.

41. EXTRUSIVE LUXATION
In extrusive luxation
• Tooth is displaced from the socket
along its long axis
• Tooth is very mobile
• Radiograph shows the displacement
of tooth.

42. Treatment of Lateral and Extrusive Luxation
Repositioning of laterally luxated teeth require minimal force for
repositioning.
Before repositioning laterally luxated teeth, anesthesia should be
administrated.
Tooth must be dislodged from the labial cortical plate by moving
it coronally and then apically.
Thus tooth is first moved coronally out of the buccal plate of
bone and then fitted into its original position

43. Treatment of Lateral and Extrusive Luxation
For repositioning of extruded tooth, a slow and steady
pressure is required to displace the coagulum formed
between root apex and floor of the socket.
After this tooth is immobilized, stabilized and splinted
for approximately 2 weeks.
Local anesthesia is not needed while doing this.

44. Follow-up:
• Splint is removed 2 weeks after extrusion.
• If tooth has become nonvital, inflammatory root
resorption can occur, requiring immediate endodontic
therapy.
• Pulp testing should be performed on regular intervals.
Prognosis
• It depends on stage of root development at the time of
injury.
• Commonly seen sequel of luxation injuries are pulp
necrosis,root canal obliteration and root resorption.

45. INTRUSIVE LUXATION
• Tooth is forced into its socket in an apical direction .
• Maximum damage has occurred to pulp and the supporting
structures .
• When examined clinically, the tooth is in infraocclusion .
• Tooth presents with clinical presentation of ankylosis
because of being firm in socket.

46. INTRUSIVE LUXATION
• On percussion metallic sound is heard.
• In mixed dentition, diagnosis is more difficult as intrusion can
mimic a tooth undergoing eruption.
• Radiographic evaluation is needed to know the position of
tooth.

47. Treatment
In immature teeth, spontaneous re-eruption is seen.
If reeruption stops before normal occlusion is attained,
orthodontic movement is initiated before tooth gets ankylosed
If tooth is severely intruded, surgical access is made to the
tooth to attach orthodontic appliances and extrude the tooth.
Tooth can also be repositioned by loosening the tooth
surgically and aligning it with the adjacent teeth.

48. ROOT FRACTURE
• These are uncommon injuries but represent a
complex healing pattern due to involvement of
dentin, cementum, pulp and periodontal ligament.
Diagnosis
• Displacement of coronal segment usually reflects
the location of fracture.
• Radiographs at varying angles (usually at 45°,
90° and 110°) are mandatory for diagnosing root
fractures.

49. Treatment of Root Fractures
If there is no mobility of tooth and tooth is
asymptomatic, only apical third fracture is suspected.
In this case to facilitate pulpal and periodontal ligament
healing, displaced coronal portion should be repositioned
accurately.
It is stabilized by splinting for 2-3 weeks

50. Apical segment of fractured root contains vital healing
pulp whereas coronal pulp has become necrotic.
Root canal therapy for both coronal and apical segment, when
they are not separated.
Root canal therapy of coronal segment and no treatment of apical
segment, when apical segment contains vital pulp.
Root canal therapy for coronal segment and surgical removal of
apical third.
Apexification type procedure of coronal segment, i.e. inducing
hard tissue barrier at exit of coronal root canal and no treatment
of apical segment. This is most commonly used procedure
nowadays.

51. PROGNOSIS
• It depends on:
• Amount of dislocation and degree of mobility of coronal
segment:
– More is the dislocation, poorer is the prognosis.
• Stage of tooth development:
– More immature the tooth, better the ability of pulp to
recover from trauma.

52. According to the Andreasen and Hjorting—Hansen,
root fracture can show healing in following ways:
• Healing with calcified tissue
in which fractured fragments
are in close contact
• Healing with interproximal
connective tissue in which
radiographically fragments
appear separated by a
radiolucent line
Interproximal
inflammatory
tissue seen in
root fracture
Healing of
root fracture
with calcified
tissue

53. According to the Andreasen and Hjorting—Hansen,
root fracture can show healing in following ways:
• Healing with interproximal bone
and connective tissues. Here
fractured fragments are seen
separated by a distinct bony
bridge radiographically
Healing of root
fracture by
interproximal bone

54. According to the Andreasen and Hjorting—Hansen,
root fracture can show healing in following ways:
• Interproximal inflammatory tissue
without healing, radiographically it
shows widening of fracture line
Healing of root fracture by
formation of connective tissue
between the segments

55. AVULSION
 It is defined as complete
displacement of the tooth from the
alveolus.
 It is usually the result of trauma to
an anterior tooth and is both a
dental and an emotional problem.

56. Consequences of Trauma To Primary Teeth
• Infection
• Abscess
• Loss of space in the dental arch
• Ankylosis
• Failure to continue eruption
• Color changes
• Injury to the permanent teeth

57. Consequences of Injury To Permanent Teeth
• Infection
• Abscess
• Loss of space in the dental arch
• Ankylosis
• Resorption of root structure
• Abnormal root development
• Color changes

58. Storage Media For Avulsed Tooth
1. Hank’s balanced salt solution
2. Milk
3. Saline
4. Saliva
5. Visapan
6. CPP-ACP (Casein phospho-peptides–amorphous
calcium phosphate)
7. Coconut water
8. Water

59. Hank’s Balanced Solution (Save-A-Tooth)
• This pH-preserving fluid is best used with a trauma
reducing suspension apparatus.
• The HBSS is biocompatible with the tooth
periodontal ligament cells and can keep these cells
viable for 24 hours because of its ideal pH and
osmolality.

60. Composition of HBSS is:
• Sodium chloride, potassium chloride, glucose, calcium
chloride, magnesium chloride, sodium bicarbonate, sodium
phosphate.
• Researches have shown that this fluid can rejuvenate
degenerated ligament cells and maintain a success rate of over
90 percent if an avulsed tooth is soaked in it for 30 minutes
prior to replantation.

61. Visapan
• Visapan has pH of 7.4 and osmolarity of 320 mosm/L.
• These properties are advantageous for cell growth. It can
preserve the viability of fibroblasts for 24 hours.

62. Coconut Water
• Studies have shown that electrolyte
composition of coconut water is
similar to intracellular fluid.
• So it can be also used as storage
media for an avulsed tooth because
of its ease of availability,
economical and sterile nature.
• It has been shown to be equally
effective as HBSS in maintaining
the cell viability.

63. MANAGEMENT OPTIONS FOR
AN AVULSED TOOTH

64. If the tooth has been out of its socket less than 15
minutes
• Wash out the socket with the same solution, reimplant the
tooth firmly, have the patient bite down firmly on a piece
of gauze to help stabilize the tooth and when possible
secure it to adjacent teeth with wire, arch bars, or a
temporary periodontal pack.
• Put the patient on a liquid diet, prescribe antibiotics
preferably penicillin VK and plan next dental appointment.

65. If the tooth has been out 15 minutes to 2 hours,
• Soak for 30 minutes to replenish nutrients.
• Local anesthesia will probably be needed before
reimplanting as above.

66. If the tooth was out over two hours,
• The periodontal ligament is dead, and should be removed,
along with the pulp.
• The tooth should soak 30 minutes in 5 percent sodium
hypochlorite and 5 minutes each in saturated citric acid, 1
percent stannous fluoride and 5 percent doxycycline
before reimplanting.
• The dead tooth should ankylose into the alveolar bone of
the socket like a dental implant.