Traumatic dental

injuries II
By
By

Dr. Laila Kenawi

http://www.dentaltraumaguide.org/Permanent_teeth.aspx
1-i- Horizontal4- Root fracture
Apical 1/3

Middle 1/3
Cervical 1/3
l e te
omp plete
C
A) ncom
ii- Chisel B)
I
(oblique)

g le.
Si n
A) i ple.
ult
B) M
iii- Vertical
 Biological consequences:
Horizontal fracture

coronal segment apical segment

displacement not displaced

the necrosis of coronal Very rare necrosed,

segment in 25% cases
 Diagnosis of root fracture
1. Mobility of the tooth.
2. Displacement of coronal
segment.
3. Pain on biting.
4. Radiograph:
Root fractures are not always
horizontal, so root fracture is often
missed by radiograph unless x-
ray beam passes directly through
the fracture line.
 Treatment modalities include
include::

1) Apical 1/3 with no mobility or displacement

no ttt & healing will occur & follow-up.
2) Mobility of the coronal segment.
Prognosis depends on:
A. Amount of dislocation.
B. Communication between
fracture site & gingival
sulcus.
C. Location & direction of
fracture.
D. The quality of the treatment.
E. Stage of root development.
Squeals to root fracture ((Andreasen
Andreasen 1967)
1) Healing with calcified tissue.
2) Healing with inter-proximal connective
tissue.
3) Healing with inter-proximal bone &
connective tissue.
4) Inter-position of granulation tissue without
healing.
Treatment modalities
1) Root canal therapy for both segments:
2) Root canal ttt of the coronal segment & no
ttt of the apical segment.
3) Root canal ttt of the coronal segment &
surgical removal of the apical part.

4- Apexification of the coronal

segment.
5) Root canal treatment for both segments,
followed by endodontic stabilizers:

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6) Root canal ttt of the coronal segment with
endodontic endosseous implant.
 7) Root extrusion.
If the fracture is at the coronal 1/3 of the root, near
the alveolar crest & the amount of the crown left is
very mobile.

8) Extraction
Vertical root fracture.
 5) Crown - root fracture:
C/R fracture may be:

Uncomplicated Complicated
Diagnosis of C/R fracture
1. Fragments may be loose & attached
only to the periodontal ligament.
2. Pain when loose fragments are
manipulated.
3. The fragments are easy to remove
& bleeding from the periodontal
ligament often fills the fracture
line.
4. Transillumination.
5. Periapical and occlusal exposure. A
cone beam exposure can reveal the
whole fracture extension.
 Treatment:
All loose fragments must be removed
 6) Tooth Luxation
30
- 44% of dental injuries.
Biological consequences:
Luxation injuries ---} result in:
1- damage to the attachment apparatus (PDL &
cementum) with sensitivity depend on the type
& direction of the injury.
2- The apical neuro-vascular supply to the pulp is
affected - altered or complete loss of tooth
vitality.
* Pulp necrosis in teeth after traumatic luxation
injuries by period ranged from 4 to 18 months
* Displacement of deciduous teeth may affect
permanent successor.
1) Concussion:

Normal mobility.
No displacement.
Tooth tender to percussion.
No ttt + Follow up
 2) Subluxation:
• Mobility
• No displacement.
• Tooth tender to percussion.

Treatment:
1- Splinting 2-3 weeks
2- RCT If no respond by follow up
Necrosis in : 12-20 % of cases
 3) Lateral luxation.

1. Mobility .

2. Horizontal Displacement.

3. Very painful, especially if

the tooth in premature

occlusion.
A) Immediate repositioning of the teeth, then
splinting for 2
- 3weeks.

B) Definite treatment is root canal treatment &

Ca(OH)2 is put in 1- 2 weeks after the injury for
a period of 6- 12 months.
C) If a clot is organised- ---- extract and manage as
avulsed tooth
4) Extrusive luxation.
5) Intrusive luxation.
 o t
Treatment f ro nt
e o e
g p m
ta lo
S ve
A) Immature. de

Tooth with an open apex---- follow up -------Reerupt

 B) Mature.

• Tooth is buried in the alveolus with

only the incisal tip showing, will

require surgical exposure.

• Less extensive intrusion can be

treated by attaching an orthodontic

appliance.
Prognosis of luxation injuries
1- Pulp death (necrosis)
2- Pulp calcification:
3- Crown discoloration e.g.
- Yellow discoloration pulp
space calcification.
- Gray discoloration pulp
necrosis.
4- Resorption (External or Internal)
6) Avulsion.
The preservation of an
intact & viable
periodontal ligament is
the most important
factor in achieving
healing without root
resorption.
 Factors affecting prognosis of an
avulsed tooth:

1- Extra-oral time:
2- Storage media:
3- Handling of the tooth during
the extraoral time
 Extra-oral dry time:
Extra-oral
˂˂ 60 minutes
Root preparation
• Closed Apex • Open Apex
•• Rinse
Rinse root
root (Water
(Water or
or Saline)
Saline) •• Soak
Soak inin doxycycline
doxycycline for for 55 min
min
•• Replant
Replant •• Rinse
Rinse debris
debris
•• Better
Better chance
chance for
for periodontal
periodontal •• Revascularization
Revascularization ---possible
---possible
healing
healing •• Follow
Follow upup
•• Revasculsrization
Revasculsrization notnot possible
possible •• Apexification
Apexification atat 11stst sign
sign ofof pulp
pulp
•• RCT
RCT after
after 7-10
7-10 days
days infection
infection
 Extra-oral dry time:
Extra-oral
˃ 60 minutes
Root preparation
• Closed Apex • Open Apex
•• 55 min
min in
in etching
etching agent
agent to
to •• Repalnt
Repalnt and
and treat
treat as
as closed
closed
remove
remove period
period ligament
ligament apex
apex
•• Soak
Soak in
in Fluoride---
Fluoride--- resist
resist •• RCT
RCT may
may be
be performend
performend
resorption
resorption outside
outside mouth
mouth
•• Emdogain---stimulate
Emdogain---stimulate new new •• Poor
Poor prognosis----Ankylosis
prognosis----Ankylosis
P.L.formation
P.L.formation
--make
--make root
root more
more
resistant
resistant to
to
resorption
resorption
•• Better
Better chance
chance for
for periodontal
periodontal
healing
healing
•• Revasculsrization
Revasculsrization not not possible
possible
•• RCT
RCT after
after 7-10
7-10 days
days
2- Storage media:

Storage media is critical, if replantation

is delayed

The ideal way to transport the tooth is to

have it replaced in its sockets.

 Storage media in ascending order of desirability

A. Water.
B. Saliva.
C. Saline.
D. Milk.
E. Hank’s balanced salt
solution (HBSS) (cell
culture media)
F. Via-span: Media used
for transplantation
operation
3- Handling of tooth during extra-oral time:
Avoid scrubbing the tooth & handle the
tooth by holding the crown.
Management of an avulsed tooth
1) Examination of the socket.
2) Cleansing of an avulsed tooth.
3) Replantation of the tooth & splinting
for 1-2 weeks.
4) Support replantation by:

Antibiotic coverage.
Mouth wash.
5) Root canal ttt after 1-2 weeks & Ca(OH)2
placement for 6-12 months, to prevent
resorption.

Ca(OH)2 is an effective antibacterial agent (Seword

1963) & favorably influences local environment at
the resorption site. It promotes healing & also
changes the environment in dentin to a more
alkaline pH, which in turn promotes hard tissue
formation (Toronstad Endo Dent Traumatol 1988).
The immature tooth might revascularize, so
replantation, splinting & long term follow up is
necessary.
Sequels to replantation:

1)Healing with normal periodontal ligament.

2) Surface resorption:
Small superficial cavities in cementum and
outermost dentin.
3) Replacement resorption:

(A) Ankylosis:

Form of replacement of resorption,

where resorption of cementum &

replaced by bone.
(B) Resorption of cementum & dentin, until

loss of the tooth.

 4) Inflammatory resorption:

Root canal therapy can be expected to arrest

inflammatory resorption that involves replanted
teeth.
 References
• Hargreaves andCohen. Pathways of the
Pulp.
• Garg N.and Garg A. Textbook of
Endodontics.1stedition.Management of
traumatic injuries. P 339- 363
• Ingle J, Bakland LK, Baumgartner
JG.Endodontics.6th edition
• http://www.dentaltraumaguide.org/Per
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manent_teeth.aspx