Professor.

Abeer Elgendy

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Intending learning objectives:

1. List information needed for examination of a traumatized

patient
2. Enumerate classifications of traumatic injuries.

3. Describe treatment strategies for management of different

types of dental traumatic injuries

4. Identify criteria of success or failure of different types of

treatment modalities
5. interpret the sequalae of luxation injuries

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Tooth trauma has been and continues to be a common occurrence
that every clinician should be prepared to assess and treat. Statistics
show that more than half of all children traumatize either their primary
or permanent dentition before leaving school. Multiple causes
contribute to tooth trauma mainly falls, collisions, sports, violence and
automobile accidents. The extent of any traumatic injuries depends
on several factors among, which are the energy of impact, shape of
impacting object and the direction of impact.

Causes of Traumatic dental injuries:

Multiple causes contribute to tooth trauma mainly falls, collisions,
sports, violence and automobile accidents. The extent of any
traumatic injuries depends on several factors among, which are the
energy of impact, shape of impacting object and the direction of
impact
1. Traffic accidents
2. Falling while running
3. Violence
4. Sports trauma

Incidence:
 Age: 2-5 years for deciduous dentition and 7-12 years for
permanent dentition
 Sex: boys more than girls
 Site : mostly maxillary central incisors followed by maxillary
lateral incisors.

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Classification of traumatic injuries to teeth:
Many classifications of injuries and supporting tissues have been
suggested, among which are:

Ellis classification (1970):

Class I: Crown and root intact
Class II: Crown fracture without pulp exposure.
Class III: Crown fracture with pulp exposure.
Class IV: Coronal fracture extending subgingival.
Class V: Root fracture.
Class VI: Tooth displacement.
Class VII: Injuries to deciduous teeth.

WHO classification (1978):

873.60: Enamel fracture.
873.61: Coronal fracture without pulp exposure.
873.62: Coronal fracture with pulp exposure.
873.63: Root fracture.
873.64: Crown root fracture.
873.66: Tooth luxation.
873.67: Intrusion and extrusion.
873.68: Avulsion.
873.69: Other injuries (soft tissues).
802.20: Fracture of alveolar process of mandible.
802.40: Fracture of alveolar process of maxilla.
802.21: Fracture of body of mandible.
802.41: Fracture of body of maxilla.

However, for simplicity, another classification is considered which

is the classification presented by Mahmoud Torabinejad from
Loma Linda University. He classified traumatic dental injuries into:
I- Injury to Tooth:
a. B- Crown fracture
b. C- Root fracture

II- Injury to Periodontium:

a. Luxation injuries
b. Avulsion

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Examination and Diagnosis
The examination process of trauma patients is similar to the regular
examination of all endodontic patients including case history, clinical
examination with the aid of the vitality test and radiograph

Chief Complain
The chief complaint may appear obvious in traumatic injuries. However, the
patient should be asked about severe pain and other significant symptoms .

History of Injury
 To provide information about the accident in a chronologic order
 To determine what effect it had on the patient.
 How did the injury happen? To assist in locating specific injuries and
teeth involved.
 When and where did the injury happen?
 Have you had dental treatment before?
 Have you noticed any symptoms since the injury?

Medical History
The patient medical history is often significant especially to clear
Allergic reactions to medications Disorders e.g. Bleeding problems ,diabetes
and epilepsy . Current medications; to avoid unwanted drug interaction
Tetanus immunization status

Clinical Examination
Extra oral examination
Head and neck neurological examination for:
 Abnormal signs and symptoms
 Abnormal affirmative response .
 Facial bones; the maxilla, mandible and TMJ are palpated externally to
detect any possible fractures, or deviation from the normal bony contour.
Laceration of the soft tissues.
Intraoral examination
 Soft tissue examination
Lacerations of lips and tongue must be radiographically examined for
embedded foreign objects. Areas adjacent to fractured teeth should be
carefully examined and palpated for areas of swelling, tenderness and
bruising .

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 Hard tissue Examination
Several teeth are out of alignments with movement: means alveolar fracture
of mandible or maxilla. The mandible should be examined for fractures by
placing the four fingers on the occlusal plane of the posterior teeth with the
thumbs under the mandible and then rocking it gently but with firm pressure
from side to side and from anterior to posterior direction, sound of the
broken parts may be heard

Displaced tooth is tender to percussion due to accumulation of extravasated

fluid and hemorrhage in the gingival sulcus is a common finding . Mobility
of the tooth is recorded and crown mobility should be differentiated from
tooth mobility .

Sensitivity tests
The electrical pulp test and carbon dioxide ice test are generally reliable in
evaluating and 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. So teeth that respond negatively to pulp testing can't be assumed
necrotic and may give positive response later. Also teeth that respond
positively at the initial test had to be followed up later. Laser Doppler
Flowmetry can detect pulp vitality within 4 weeks after injury .

Radiographic examination
It revels root fractures, sub-gingival crown fracture, tooth displacements,
bone fracture . Limitations of the radiograph include inability to reveal
fracture line running in mesio-distal direction, diagonal fracture line in
bucco-lingual direction and hairline fracture. Dimension of root canal space,
apical closure and proximity of the fracture line to pulp are outlined from the
radiographs. Occlusal or panoramic radiographs are helpful tools for bone
fracture detection Recently, Cone Beam a new 3D image device that aids in
detecting accurately the position of fracture lines
Treatment considerations:
When determining the treatment options for traumatically injured
teeth, the status of both the pulp and the Periodontium should be
considered. Treatment considerations should be always directed
toward:
Immediate needs (emergency visit)
Definitive care (subsequent visits)
It is worth mentioning that thorough diagnosis of the case is
mandatory before initiating any treatment.

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I- Injury to Tooth
A- Crown Fracture
Fracture of the coronal portion can result in an injury, which can be
categorized as follows:
(1) Crown Infraction

(2) Uncomplicated crown fracture (enamel) without plural exposure

(3) Uncomplicated crown fracture (enamel & dentin fracture) without

plural exposure.

(4) Complicated crown fracture in which the fracture line exposes the
pulp chamber.

(5) Crown-root fracture (fracture involving the crown and the root).

(1) Crown Infraction:

This is a situation in which the trauma did not cause any loss of tooth
structure i.e. tooth is intact and not displaced. This type of impact
usually results in craze lines, which can be easily visualized by
transillumination. No line of treatment is required at the emergency
visit; however, careful follow-up of the case is a must.
Sequale of crown infraction: (Fig 1)
Follow-up of such cases may reveal an injury to the pulp, which can
result in any of these conditions:
Calcific metamorphosis (calcification)
Internal resorption
Pulpal necrosis

Fig 1: Enamel infraction

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(2) Enamel Fracture: (Fig 2)
This injury involves the loss of a portion of enamel. This condition
usually does not require any emergency treatment except
smoothening the rough surface. If larger part of enamel is lost, acid-
etch the surface and restore the lost part with composite. Tooth
should be followed up.

Fig 2: Enamel Fracture

(3) Enamel & Dentin fracture (without pulp exposure):

This type of fracture exposes large number of dentinal tubules to the
oral environment. To avoid undesirable esthetic and biologic
sequelae, the missing tooth structure should be replaced immediately
(during the emergency visit).
(Fig 3)

Fig 3: Enamel & Dentin fracture without pulp exposure

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Treatment:
1. Pulp protection: Placement of calcium hydroxide on exposed
dentin. Acid etch the surrounding tooth structure and replace
fractured tooth structure by composite resin. Tooth should be
followed up to ensure pulp vitality.
2. If the tooth fragment is available, attempt to reattach it. (fig 4)

Fig 4: Reattachment of the broken tooth fragment

(4) Crown fracture with pulp exposure: (Fig 5)

In this type of fracture there are several factors to be considered:

Length of time the pulp was exposed.
Maturity of the tooth (open / closed apex).
Amount of pulpal tissue exposed
(Size of exposure).

Fig 5: Crown fracture with pulp exposure

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Treatment options
1. Mature:
Removal of the pulp in a mature tooth is not as significant as in
an immature tooth because a pulpectomy in a mature tooth has
an extremely high success rate. However, it has been shown
that under optimal conditions (criteria for success of vital pulp
therapy), vital pulp therapy (rather than removal) can be carried
out successfully on a mature tooth. Therefore, this form of
therapy can be an option under certain circumstances, even
though a pulpectomy is the treatment that affords the most
predictable success.
2. Immature

Treatment options for immature according to the previously

mentioned factors are:

Immature
(Open apex)

Vital Non-vital
(APEXOGENESIS)

1.Apexification
PULPOTOMY PULP CAPPING 2.Regeneration

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(5) Crown-root fracture: (Fig 12)
This is considered a complicated type of fracture as the fracture
line passes through the crown and the root i.e. supra and subgingival
(oblique fracture). Treatment of such cases is as follows:
Removal of the coronal segment of the tooth.
Complete root canal treatment.
Placement of post and core followed by full coverage.

Fig 12: Crown root fracture

In treating such cases it is difficult to place the margin of the

restoration on solid tooth structure. To achieve this two treatment
options are considered:
a- Crown lengthening: This procedure is done to expose the root
margin by performing gingivectomy and contouring of the alveolar
crest (if needed).
b- Root extrusion: This is done by extruding the root out of the
socket bringing its margin supragingival. Root extrusion can be done
either surgically or orthodontically.

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Fig 13: Basic technique for root extrusion. A, Root fracture at or below crestal bone. B,
Root canal therapy completed. C, Cementation of a post-hook. D, Occlusal view; horizontal
wire is bent to cross midline of the tooth to be extruded.Wire is embedded with acid-etched
composite on adjacent teeth. E, Elastic is attached to activate extrusion. F,When satisfactory
extrusion has been completed, the tooth is stabilized until periodontal and bony repair are
complete. G, Periodontal and bony repair completed.H, Permanent restoration.

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B- Root fracture: (fig 14)
Trauma to anterior teeth can result in root fracture. Unlikely to
happen, trauma may cause vertical root fracture. This injury if
happened indicates tooth extraction. More likely, root fractures are
horizontal (transverse).
N.B.: Before going into the details of horizontal root fracture, it is
important to note that horizontal root fractures, tooth extrusion and
fractures of the alveolar process appear clinically the same.
Therefore, thorough differential diagnosis is of prime importance as
the line of treatment for each of the aforementioned situations is
different.

Fig 15: horizontal root fracture

Diagnosis of horizontal root fracture:

Clinically:
Tooth appears slightly extruded.
Tooth mobility: The more coronal the fracture line, the greater the
mobility. Horizontal fractures at the apical 1/3 may not present any
mobility.

Radiographically:
Horizontal root fractures are easily visualized on the radiograph;
however, multiple radiographic exposures with different vertical
angulations are needed.

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Treatment of horizontal root fracture:

Emergency treatment:
The emergency care for root fracture is similar to any other bony
fracture which is repositioning and fixation (if needed).
Displaced tooth due to horizontal root fracture should be repositioned
by adjusting the occlusion and removing any occlusal interference.
Fixation is done by splinting the traumatized tooth with neighboring
teeth using an orthodontic wire and composite resin. Tooth should be
fixed for 8-10 weeks to give a chance for hard tissue union.

N.B.:If the tooth position following trauma is not changed with minimal
mobility therefore, nothing should be done in the emergency visit.

Definitive treatment:
Patient with horizontal root fracture should be seen one week after
emergency visit for evaluation and treatment planning. The line of
treatment depends basically on the level of fracture.

(1) Fracture at the apical 1/3 (best prognosis):

Most of teeth with horizontal root fracture at the level of the apical
1/3 needs no treatment. If any sign of irreversible pulpal damage of
the coronal segment appears, root canal treatment in the coronal
segment should be done without touching the apical segment. In the
future, during the follow up of the case it appeared that the apical
segment shows signs of necrosis (radiographic changes), it should be
removed surgically.

(2) Fracture at the cervical 1/3 (good prognosis):

This situation is similar to crown-root fracture (look under crown
fracture) where the coronal segment is removed and the root is
exposed either by crown lengthening or root extrusion.

(3) Fracture at the middle 1/3 (worst prognosis):

This situation is unfavorable because it is difficult to retain either of
the coronal or apical segments. The treatment options depend
basically on the presence or absence of displacement between the
two segments:

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(i) If the two segments are facing each other i.e. no displacement,
then perform root canal treatment of the two segments and place a
rigid stabilizer (post) inside the root canal after obturation.

(ii) If there was displacement, perform root canal treatment in the

coronal segment only hoping that apical segment can retain its
vitality. If signs of apical segment necrosis appeared in the follow up
period, remove the apical segment surgically and place an
endodontic endosseous implant to stabilize the tooth.

(iii) If there was displacement with great mobility of the coronal

segment, extract the coronal half and extrude the apical segment
orthodontically. Once the apical segment is brought supragingival,
complete root canal treatment is to be done and restore the tooth with
post/core and full coverage.

Prognosis of horizontal root fracture:

Correct management of the tooth with a horizontal root fracture
depends on a complete understanding of what is expected to happen
between the two fractured segments (coronal segment and apical
segment). There are four possibilities for healing:
1- Union of the two segments by calcified tissue which is considered
the most favorable type of healing (unlikely to happen)
2- Union of the two segments by fibrous tissue (more likely to
happen)
3- Lack of union due to ingrowth of hard and soft connective tissue
between the two segments.
4- Lack of union due to ingrowth of inflammatory tissue between the
two segments which is considered the worst type of healing.
N.B.: The healing by any one of the first three possibilities is
considered favorable. Which one of these four possibilities is likely to
take place depends on two factors:
Time between trauma and initiation of treatment.
Level of fracture (coronal, middle or apical 1/3). The level of
fracture is considered the deciding factor because it is responsible for
the amount of tooth mobility and the absence or presence of
communication between the fracture site and the oral environment.

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II- Injury to Periodontium
These injuries involve injury to the periodontium only or injury to both
of pulp and periodontium. Therefore, our diagnosis and treatment
should be directed toward both tissues. These injuries involves:
(A) Luxation injuries:
Displacement of the tooth while still in the socket.
(B) Avulsion
Displacement of the tooth outside the socket.
A- Luxation injuries (Fig 16)
Classification:
(1) Concussion & Subluxation
(2) Extrusion & Lateral luxation
(3) Intrusive luxation (Intrusion)

Concussion& subluxation Lateral luxation

Extrusion Intrusion

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(1) Concussion & Subluxation:
The concussion is considered the least severe form of luxation
injuries where no recognized changes occur. The subluxation is
another mild form of luxation where slight mobility without
displacement is the only clinical sign.

Diagnosis:
Clinically the traumatized tooth is very tender to percussion with or
without slight mobility. Usually pulp is vital with no radiographic
changes.

Treatment:
Only palliative treatment is needed with relief of occlusion and
follow up the case.

(2) Extrusion and lateral luxation:

This type of injury involves either partial extrusion of the tooth out of
the socket or displacement in a lingual, buccal, mesial or distal
direction (lateral luxation).

Diagnosis:
Clinically, tooth may appear longer than neighboring dentition
(Extrusion) or abnormally inclined in any one of the four planes
(lateral luxation).
Tooth is mobile
Usually the injured tooth interferes with the normal occlusion.
Radiographically, widening of the periodontal membrane space.

Treatment:
Emergency treatment:
Similar to horizontal root fractures, our first concern in the emergency
visit is to reposition the tooth and stabilize it. This is done as follows;
Reposition the tooth in its socket by application of firm pressure
being guided by the surrounding teeth and the normal occlusion.
Stabilize the tooth in its normal position by splinting it with the
neighboring teeth by composite resin and orthodontic wire.

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N.B. In case of injuries to the peridontium tooth should not be splinted
for more than 1-2 weeks to prevent ankylosis and/or external root
resorption.

Definitive treatment (After 1-2 weeks)

Remove the splint
Assess pulp vitality. Usually these teeth will need root canal
treatment.
After cleaning and shaping and before root canal obturation, the
root canal should be injected with calcium hydroxide paste to prevent
external root resorption.

(3) Intrusive luxation (Intrusion):

This type of injury is characterized by displacement of the tooth inside
the socket. It is considered the most severe form of luxation as it
usually results in damage of the alveolar socket with greater
incidence of external root resorption.

Diagnosis:
Tooth is more fixed than the surrounding dentition.
Tooth is shorter or even not visible at all in its position (complete
intrusion inside the socket)
Radiographically, intruded tooth appears as if it is in the eruption
phase. Alveolar fracture can be seen if present.

Treatment:
Emergency treatment:
Most of the clinicians prefer not to do anything in the emergency visit
and give the tooth the chance to re-erupt again (the younger the
patient, the better the chance for this to happen).

Definitive treatment (After 1 week):

If tooth appears to be re-erupting in one week period, then it is better
to give it the chance and patient should be seen every week to
monitor the condition. If complete eruption occurred, pulp vitality
should be assessed and root canal treatment should be done if pulp
affection was found. If no re-eruption occurred, tooth extrusion
orthodontically appears to be the best line of treatment. This
procedure is expected to take 3-4 weeks. Once tooth returns to its

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normal position, it should be splinted for 1-2 weeks to prevent re-
intrusion. Root canal treatment in this situation is a must and the root
canal must be packed with calcium hydroxide paste before obturation
to prevent external root resorption.

Table 1: Sequale of luxation injuries:

Necrosis Calcification Resorption

Concussion 2% 2% 0%

Subluxation 6-47% 10-26% 4%

Extrusion& 64% 30% 36%

lateral luxtion
Intrusion 100% < 10% 86%

B- Avulsion
This type of injury is characterized by complete extrusion of the tooth
out of the socket.

Biologic considerations:
When a tooth is avulsed, the attachment apparatus of the tooth
(periodontium) is damaged together with the vascular and the neural
supply. On replantation of such tooth some tissue reactions take
place which should be considered.

(i) Surface resorption: This occurs with mild forms of trauma being
characterized by resorption of the cementum with formation of new
cementum and periodontal ligament.

(ii) Replacement resorption: This occurs with extensive trauma

where an abnormal attachment lead to a condition that bone comes
into direct contact with the root without the presence of periodontal
ligament (ankylosis).

(iii) Inflammatory resorption: This occurs as a consequence to

pulpal necrosis where toxins pass from inside the root canal to the
outer surface of the root.

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Treatment of avulsion:

Emergency treatment:

1- Management outside the dental office:

All efforts are to be made to minimize the damage to the remaining
periodontal membrane cells and fibers on the root surface. Viability of
such cells and fibers is greatly affected by dryness (prolonged extra-
oral time) and by aggressive handling of the tooth. Factors to be
considered are:

(i)Tooth handling:
Tooth should be handled from the crown and avoid any scrapping of
the root surface. At the emergency visit, tooth handling is depending
on the maturity of he tooth (open or close) and the extra oral dry time.

(ii) Extra-oral time

The most critical factor in the success of replantation of an avulsed
tooth is the speed with which the tooth is returned to its socket
(ideally 30 minutes and not to exceed 2 hours). Instructions over the
phone to the person at the scene of the accident can guide in
immediate placement of the tooth in its socket before transferring the
patient to the dental clinic.

(iii)Transport media:
If the person at the scene of the accident couldn’t replant the tooth,
the tooth should be placed in a transport media and brought with the
patient to the dental clinic. The suggested storage media is as milk,
water or saline. Milk is considered the most appropriate storage
media as it is readily available and have a pH and osmolarity
compatible to vital cells. If none of these storage media is available,
tooth can be placed in the buccal vestibule of the patient’s mouth.

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(2) Management in the dental office:
Similar to other injuries to the periodontium, the emergency care of
an avulsed tooth is repositioning and splinting. However, there are
some treatment considerations which should be regarded.

Table 2: Emergency treatment according to Extra-oral dry time

Closed apex Open apex

Extra-oral dry time The root should be The tooth should be

< 60 minutes rinsed with water or soaked in minocycline
saline and replanted in for 5 minutes, gentle
a gentle fashion rinse with water or
saline and replanted
Extra-oral dry time Remove the periodontal Replant?! If yes treat as
>60 minutes ligament by placing in in closed apex.
an etching acid for 5 Endodontic treatment
minutes, soak in could be performed
fluoride and replant outside the mouth
before replantation

(i) Root surface:

If the tooth was not replanted at the site of the accident, then the
dentist must minimize the extra-oral time as much as possible by
quickly replanting the tooth in the socket. Scrapping the external root
surface should be avoided to preserve as much periodontal cells as
possible (within 30 minutes).

(ii) Socket:
Minimal manipulation should be done to the socket. Avoid curetting
the inside of the socket only irrigate it with saline to remove formed
blood clot which can prevent the tooth from being well placed in the
socket.

(iii) Splinting:
Once the tooth is placed in the socket, it should be stabilized by
splinting it to the neighboring teeth. Apply acid etch on the labial
surface of the surrounding teeth and cover it by composite resin

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reinforced by an orthodontic wire. Tooth should be splinted for 1-2
weeks.

(iv) Endodontic treatment:

Endodontic treatment should not be started in the emergency visit to
avoid further trauma. However, 1-2 weeks later root canal treatment
should be initiated.

Table 2: Endodontic treatment according to Extra-oral dry time

Closed apex Open apex

Extra-oral dry time Start Endodontic Avoid Endodontic
< 60 minutes treatment within 7-10 treatment and wait for
days the evidence of
revascularization.
Extra-oral dry time Start Endodontic If Endodontic treatment
>60 minutes treatment within 7-10 was not performed
days outside the mouth, start
the apexification
procedure

(v) Calcium hydroxide dressing:

In cases in which Endodontic treatment is delayed or signs of root
resorption are present, thorough cleaning and shaping of the root
canal, calcium hydroxide paste should be injected inside the canal
until evidence of healing is present. Follow-up of the case should be
every 3 months with reapplication of calcium hydroxide up to one
year. Finally, root canal must be obturated.

N.B.: If any of the previously discussed injuries to the periodontium

occurred to immature teeth with open apex, then case should be
followed up radiographically hoping that pulp can retain its vitality and
complete root formation (apexogensis). If signs of pulpal inflammation
or necrosis appears, root canal treatment should be started and
apexification should be performed.

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