Traumatic

injuries

Dr. Amr Abdelwahab Byoumi

Lecturer of endodontics
Alazhar university
 CONTENTS
• Definitions

• Incidence

• Treatment plan

• Examination

• Classification of dental injury

 DEFINITIONS

Trauma a physical injury or wound to the body

Traumatology the branch of medicine that deals

with serious injuries and wounds and their long-
term consequences
 INCIDENCE
Age: → More common in ages of 2 - 5 years (deciduous teeth)
More common during the very active age of 7 - 12 years, as a result of
bicycle, skateboard of sports accidents.
Sex: → Boys more than girls.
→ One out of three boys, one out of four girls.
Teeth: → Maxillary central incisors about 80 % of dental injuries, followed
by maxillary lateral, mandibular lateral, mandibular central incisors.
 ETIOLOGY
OF
TRAUMATIC
INJURIES

Automobile injury
Act of violence
Epilepsy
Fall from height
Sports related injuries
PROTECTORS
 TREATMENT PLAN

The treatment planning of traumatized teeth must include:

1) Examination procedures.
2) Urgent care (Emergency treatment).
3) Treatment options.
4) Management of possible sequelae.
The outcome of dental injury is influenced by
PATIENT AGE,
SEVERITY,
TREATMENT OFFERED.

In most of the cases,

immature permanent teeth with injuries have better
prognosis than mature teeth with same injuries.
 EXTENT OF TRAUMA CAN BE ASSESSED BY

1- Energy of impact

2- Direction of impacting force

3- Shape and Resilience of impacting object

 EXAMINATION AND DIAGNOSIS

1-Chief complaint

2-History of injury

3-Medical History
 A) HISTORY:
1. How: → How does trauma occurs?
This will assist in locating special injuries.

2. When: → Avulsed tooth management is directly affected by the time

passed after trauma.

3. Where: → Becomes significant for prognosis.

Provides an idea about the possible contamination and infection.
 Intra-oral examination:
a-Soft tissue examination: Laceration of the lip and tongue must
be radiographically examined for embedded foreign objects.

b- Hard tissue examination:

• Several teeth out of alignment; fracture of mandible , maxilla
• Loose tooth ; displacement from alveolar socket.
• Movement of several teeth ; alveolar fracture.
Sensitivity test: EPT are generally reliable in monitoring pulpal
status. However, it may take as 9 months for normal blood
flow to return to coronal pulp of a traumatized fully formed
tooth.

Laser Doppler flowery can detect pulp vitality within 4 weeks

after injury.
Radiographic examination :
• Multiple radiographs
• 3 angeled radiographic positions ( 45, 90, 110) and one occlusal film

• it reveal root fracture, sub-gingival crown fracture, tooth displacement, bone fracture .
CONE BEAM : 3D IMAGE AID IN DETECTING ACCURATELY THE
POSITION OF FRACTURE LINE, RESORPTION OR DISPLACEMENT
Types
 CLASSIFICATION
I: Crown infraction.
II: Crown fractures: → a) Without pulp exposure.
b) With pulp exposure.
III: Root fracture.
IV: Crown / root fracture.
V: Luxation injuries:→ a) Concussion.
b) Sub-luxation.
c) Lateral luxation.
d) Extrusive luxation.
e) Intrusive luxation.
VI: Avulsion.
I-INJURIES TO THE HARD DENTAL TISSUES AND THE PULP
1-Enamel Infraction ; An incomplete fracture (crack) of enamel without
the loss of tooth substance.
• Biologic consequences:
• Fracture lines are the weak points through which bacteria and their products
can travel to pulp.
Diagnosis: exposing it to fiber-optic light source, resin curing light,
indirect light or by Trans -illumination.
Treatment: vitality tests are necessary to determine extent of pulp
damage.
• Repairing fractured tooth surface by composite if needed for
cosmetic purposes.
• Follow-up of patient at 3, 6 and 12 months interval is done.
Prognosis: Prognosis is good for infraction cases.
 2-Enamel fracture
DIAGNOSIS: Enamel fracture includes superficial rough edge that may cause irritation to
the tongue or lips.
Sensitivity to air or liquids is not a complaint.
Treatment: range from smoothening of rough edge into composite resin restoration.
 3- Enamel-dentin fracture
(uncomplicated fracture)
A fracture with loss of tooth substance confined to enamel and dentin, but not involving the pulp.
DIAGNOSIS: An enamel and dentin fracture also includes a rough edge on the tooth, but
sensitivity to air and hot and cold liquids
Treatment
The objective in treating a tooth are:
1. Elimination of discomfort.
2. Preservation of vital pulp.
3. Restoration of fractured crown.
Treatment is done in two stages :
1. 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.
2. Permanent restoration: The restoration includes the use of adhesive
resin and composite resin systems
Fragment reattachment:
Another opinion of treatment if the fractured part present can repair again
into position of the fractured tooth by using bonding agent.
 4-Complicated crown fracture :
(complicated fracture)
A fracture involving enamel and dentin and exposing the pulp.
Choice of treatment depends on the :
1. Stage of development of the tooth.
2. Time between the accident and the treatment.
The first reaction is hemorrhage and local
inflammation

the pulp proliferation, with no more than a 1.5 -

2-mm depth of pulpal inflammation below the
surface of the fracture.
After 48 hours, chances of direct bacterial contamination, with the zone
of inflammation progressing apically; as time passes, the chance of
successfully maintaining a healthy pulp decreases

partial pulp necrosis shows normal cell nuclei at the bottom.

At the top, porous connective tissue has white and dark patches with
granules.
Treatment
Treatment options for complicated crown fracture are
(1) vital pulp therapy (pulp capping, partial pulpotomy, or full pulpotomy) and
(2) pulpectomy.

• The choice of treatment depends on

1. the stage of development of the tooth
2. the time between trauma and treatment
3. concomitant periodontal injury
4. the restorative treatment plan.
Treatment of exposed pulp
i-Pulp Capping: placing the dressing directly on to the pulp exposure without
any removal of the pulp tissue.
Indications
On a very recent exposure (within 24 hours) and probably on a mature,
permanent tooth
 PROGNOSIS
The success rate of this procedure (80%), indicates that a superficial pulp cap should
not be considered after traumatic pulp exposures.

because superficial inflammation develops soon after the traumatic exposure. If the
treatment is at the superficial level, several inflamed pulps will be treated, lowering the
potential for success.

In addition, a bacteria-tight coronal seal is much more difficult to attain in superficial

pulp capping because there is no depth to the cavity to aid in creating the seal, as there
is with a partial pulpotomy
B- Pulpotomy:

coronal removal of vital pulp tissue.

• Partial Pulpotomy (Cvek pulpotomy)

• Full (cervical) Pulpotomy

 Partial Pulpotomy

• the removal of coronal pulp tissue to the level of healthy pulp

• It is indicated in young permanent teeth with incomplete root formation.
 Partial
pulpotomy
Hard-tissue barrier after calcium hydroxide partial pulpotomy
THE PROGNOSIS IS EXTREMELY GOOD (94% - 96%)

Continued root development after partial pulpotomy

Cervical (full) Pulpotomy
removal of entire coronal pulp tissue to the level of root orifices.
Indications
• 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 with incompletely formed apices and thin dentinal walls .
A major disadvantage of this treatment method is that sensitivity testing is not

possible, owing to the loss of coronal pulp,

so radiographic follow-up is extremely important to assess for signs of apical

periodontitis and to ensure the continuation of root formation.

Successful pulpotomy at 18 months.
C-Apexification

It is always desirable to allow root to develop in an immature tooth.

apexogenesis does not occur unless some vital pulp tissue remains
in the root canal.
MTA APICAL PLUG
 PULP REVASCULARIZATION
REGENERATIVE ENDODONTIC TREATMENT
 PULPECTOMY

removal of the entire pulp to the level of the apical foramen.

Indications:

Pulpectomy is indicated in a complicated crown fracture of mature teeth if conditions are not ideal

for vital pulp therapy or if the tooth would require placement of a post.

This procedure is no different from root canal treatment of a vital nontraumatized tooth.
 Vitality of the pulp
 Size of pulp exposure
 Time elapsed since exposure
 Stage of development of root apex
 Restorability of fractured crown
ROOT FRACTURE

These injuries are relatively infrequent,

occur in less than 3% of all dental injuries
 ROOT FRACTURE

fracture of the cementum, dentin, and pulp.

A. Vertical
B. Horizontal

A-vertical root fracture :

treatment extraction.
b-Horizontal Root Fractures:
are most commonly seen in the anterior region of young adults.
• The coronal segment is displaced to a varying degree, but generally the apical

segment is not displaced.

• Apical pulpal circulation is not disrupted, pulp necrosis in the apical segment is

extremely rare.

• Pulpal necrosis of the coronal segment, occurs in approximately 25% of cases.

 CLASSIFICATION OF HORIZONTAL ROOT FRACTURE

• Location of fracture line: cervical, middle and apical

• Extent of fracture: partial and total
• Number of fracture lines: simple, multiple
• Position of coronal fragment: displaced and not displaced
Diagnosis:

• Clinical mobility of the traumatized tooth (location???????)

• Bleeding from gingival sulcus may be noted

• Displacement of the crown segment ranged from none in apical fracture to severe
in cervical fracture.

• Presence of pain on biting and tenderness to palpation of muco-gingival area .

 Radiographic examination

• 3 angeled radiographic positions ( 45, 90, 110)

• and CBCT.
Treatment of root fracture
1-No mobility or displacement : no treatment.
2-mobility or displacement:
A. Re-positioning of the segments in as proximity as possible.
B. Splinting for 2-4 weeks
C. Follow up 3,6,12 month.
D. 80 % of properly treated root fracture heal successfully.
 REPOSITIONING

release the coronal segment from the bone by gently pulling it

slightly downward with finger pressure or extraction forceps
and, once it is loose, rotating it back to its original position
 WHAT IS A FLEXIBLE SPLINT?
-In the past, orthodontic wire bonded to tooth
OR: fishing line bonded to teeth
-Currently, Titanium Trauma Splint (TTS) is recommended
 FOUR TYPES OF RESPONSES TO ROOT FRACTURES

1. Healing with calcified tissue. the fracture line is discernible, but the fragments are in
close contact .
2. Healing with interproximal connective tissue. the fragments appear separated by a
narrow radiolucent line, and the fractured edges appear rounded .
3. Healing with interproximal bone and connective tissue. the fragments are separated by
a distinct bony ridge .
4. Interproximal inflammatory tissue without healing. a widening of the fracture line
and/or a developing radiolucency corresponding to the fracture line becomes apparent
Prognosis depend on
1- The degree of dislocation and mobility.

2- Communication between the fracture line and the gingival sulcus.

3- Fracture location

4- Quality of treatment.

5- The stage of root development.

because of a very large apical opening in the coronal segment,
revascularization is possible if the segments are well
reapproximated.
Complications
Pulp necrosis occurs in 25 % of root fracture.
Treatment of complication:
1-root canal ttt. of both parts if possible.
2-root canal ttt. of coronal part & no treatment of apical part if vital.
3-Apexification of coronal segment, and no treatment of apical segment.
4-root canal ttt. of coronal part & surgical removal of apical part.
5-root extrusion if the fracture at coronal third and root canal ttt.
ROOT CANAL OBLITERATION

Root canal obliteration is common

prognosis
CROWN ROOT FRACTURE
is a periodontal rather than an endodontic challenge

The tooth must be treated periodontally to enable a well-sealed coronal restoration.

 TREATMENT

• Gingivectomy
• Crown lengthening
• Orthodontic or surgical extrusion

Once the feasibility of the coronal restoration is ensured, the particular crown
fracture is treated as crown fractures.
 FOLLOW UP

follow-up is as for all dental traumatic injuries:

at 3, 6, and 12 months and yearly thereafter for at least 5 years.

LUXATION INJURIES
LUXATION INJURIES:

• The most common type of injury: 30-40%.

• Damage to PDL and cementum , apical neuro-vascular bundle is

affected and displacement.
1. Concussion implies no displacement, normal mobility, and sensitivity to percussion.
2. Subluxation implies sensitivity to percussion, increased mobility, and no displacement.
3. Lateral luxation implies displacement labially, lingually, distally, or incisally.
4. Extrusive luxation implies displacement in a coronal direction.
5. Intrusive luxation implies displacement in an apical direction into the alveolus.

Definitions 1 through 5 describe injuries of increasing magnitude and subsequent sequelae.

 CONCUSSION

• An injury to tooth-supporting structures without abnormal

loosening or displacement but with marked reaction to
percussion.
 SUBLUXATION

An injury to the tooth supporting structures resulting in increased

mobility, but without displacement of the tooth.

Bleeding from the gingival sulcus confirms the diagnosis.

 Subluxation & Concussion:
• DIAGNOSIS
• Teeth are sensitive to percussion and have some mobility.
• Sulcular bleeding is seen showing damage and rupture of PDL.
• Pulp responds normal to testing.
• Tooth is not displaced.

• TREATMENT
• Relief the occlusion by selective grinding of opposing teeth.
• Immobilize the injured teeth (splinting).
Follow-up is done at , 3, 6 and 12 months & RCT if became necrotic.
 LATERAL & EXTRUSIVE LUXATION :
• Trauma displace the tooth out of its normal position away from its long axis.

• Sulcular bleeding is present indicating rupture of PDL fibers.

• Tooth is sensitive to percussion.

Treatment

• Repositioning with minimal force for repositioning.

• The tooth stabilized and splinted for approximately 2 weeks.

 SEMI-RIGID OR FLEXIBLE SPLINTING
◼ Semi rigid splinting allows physiologic movement of the teeth in order to
minimize ankylosis

◼ Experimental studies demonstrated that rigid splinting especially for

prolonged periods, leads to ankylosis &/or external resorption.

◼ Maintaining a slight degree of tooth mobility appears to be beneficial to PDL

healing
the fixation period should be sufficient to
allow the reattachment of PDL.
This will take from 1 – 3 weeks.
 Intrusive LUXATION
• Most severe of luxations***

• Tooth is forced into its socket in an apical direction & Maximum

damage has occurred to pulp and the supporting structures.

• The tooth becomes in infra-occlusion.

• On percussion metallic sound is heard.

• Radiographic evaluation is needed to know the position of tooth.

Treatment:
•In immature teeth, spontaneous re-eruption is seen. If re-eruption 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.
In all LUXATION and especially INTRUSION injuries,

the apical neurovascular bundle and attachment apparatus

will be affected to some degree

>>>loss of vitality & inter nal/exter nal resor ption

Exarticulation
Factors affecting treatment :
1-Extraoral time : the sooner ,the better.
2-Tooth handling: do not scrub.
3-Storage medium: is critical to maintain PDL in a viable state.
4-Root development: complete or incomplete
 FIRST AID FOR AVULSED TOOTH

Find the tooth & pick Clean the tooth Try to replant Place the tooth in a
it up by the crown under running cold the tooth suitable storage medium
water (10 sec)
Emergency ttt at the accident site :
Re-place the tooth in the socket .
Then let the patient bite down gently on piece of cotton to push the
tooth back into its normal position.
 STORAGE MEDIA FOR AVULSED TOOTH

Tissue or cell culture media like Hank’s Balanced salt Solution (HBSS)
Milk
Isotonic Saline
Contact lens solution
Buccal vestibule or under the tongue
water
Hank’s Balanced Salt Solution HBSS :
is biocompatible with the tooth PDL cells and can keep cells
viable for 24 hours because of its ideal pH and osmolality.

Composition of HBSS is:

Sodium chloride, potassium chloride, calcium chloride,
magnesium chloride, sodium bicarbonate, sodium
Phosphate & glucose
TREATMENT OF AVULSION
Preparation of the avulsed tooth
Preparation of the socket
Replantation
Splinting
Follow up
THE MAIN GOAL
2- Emergency treatment at dental office :

A- If the tooth has been out of its socket less than 15 minutes,

take it by the crown, place it in a tooth-preservation solution (Hank’s

solution), re-implant the tooth firmly and splint it to adjacent teeth.

B- If the tooth has been out 15 minutes to 2 hours,

Soak it for 30 minutes to replenish nutrients and re-implant into its socket
and splint to adjacent teeth.
C-• If the tooth was out over two hours:
PDL is dead, and should be removed, along with the pulp.
• The tooth should soak 30 minutes in 5 % NaOCl.

• 5 minutes each in saturated citric acid, 1 % stannous fluoride

and 5 % doxycycline before re-implanted.

• The avulsed tooth should ankylosed into the alveolar bone of

the socket like a dental implant.
 POST-EMERGENCY TREATMENT

• The splint should be removed after 7 days unless the excessive mobility is present.

• Endodontic therapy should be started in 7-10 days except if tooth has an open apex.

• The canal in all cases filled with calcium hydroxide powder to inhibit external resorption.
 Recall the patient after one month

• if radiograph is found to be satisfactory, obturate the tooth with gutta-

percha points.

• If lamina dura is not found to be intact or if there is the evidence of

external resorption, the calcium hydroxide powder is removed and is
replaced with the fresh paste.
 POST OPERATIVE INSTRUCTIONS

• Antibiotics (tetracycline or penicillin)

• Tetanus prophylaxis

• Chx (twice)

• Soft diet ( 2 weeks)

• Soft brushing (1 week)

The goal in delayed replantation is to restore the tooth for esthetic,
functional and psychological reasons, and to maintain alveolar bone
contour.
 Biologic Consequences:

1-Pulpal necrosis: due to cutting of blood supply.

2 Surface resorption.

Small superficial resorption cavities Occur within

cementum and the outer dentin.

It is repair process of physical damage to calcified

tissue by recruitment of cells following removal of
damaged tissues by macrophages.
Surface resorption Inflammatory resorption Replacement resorption