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Dental Trauma
It's any accident injuring hard tissue (teeth, alveolar bone) or soft tissue
(PDL, gingiva, lip ....)

**NOTES
• Trauma is mostly seen in school children.
• More in boys than girls.
• Class II malocclusion is mostly injured.
• Upper incisors are the most traumatized.
• Any trauma in the chin may affect the condyle and cause indirect
fracture because bone resorbed force which spread & when it
reach the weakest point cause fracture.
• Condyle is important because it's a center of growth of the jaw.
َ ‫ غالبا‬..‫ للطفل واكتسر السن ولم يجدوا الجزء المكسور في المكان‬trauma ‫• إذا حصل‬
lower ‫ في الـ‬film ‫ نحط ال‬..‫ لذلك نعمل أشعة‬lower lip ‫بيكون دخل في ال‬
.‫ و نتأكـد؛ ألنه غالبا َ ما بنحس ألن المنطقة مورمة‬vestibule

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 Classification of trauma:
_ according to extend:

Crown Crown & Root Root

_ according site of fracture:

Incomplete Uncomplicated Complicated

Q\ crown fracture always indicate pulp therapy [×]

According to extent of fracture..

:‫مالحظـة‬
‫ و يقدر يمسك يف الـ‬acid etch ‫ ألنه بيحصل له تخريش بالـ‬MTA ‫ فوق الـ‬GIC ‫*الزم نحط‬
.acid etching ‫ الذي ال يؤثر عليه الـ‬MTA ‫ بعكس الـ‬,composite
GIC ‫ هو الـ‬etching by acid ‫*السمنت الوحيد الذي يحصل له‬

** cervical fracture has poor prognosis because it's within the alveolar crest,
exposed to oral environment & always contaminated.

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Periodontal ligament injury:
• periodontal injury may occur without any injury in the tooth.
• Concussion / cause tenderness to touch, low trauma energy and no
clinical findings
• subluxation / as concussion but more sever pain & bluish gingiva
• luxation / intrusive, extrusive & lateral.
• Avulsion / complete displacement.

‫ و‬artery forceps ‫ بـ‬crown ‫ للسن و جابوه للعيادة نمسكه من الـ‬avulsion ‫✓ إذا حصل‬
anti- ‫ و المريض الزم ياخذ لقاح‬، debris ‫ عشـان نزيل الـ‬running water ‫نحطه تحت‬
tetanus

Injury of supporting bone:

may appear as asymmetrical jaw.

_communication of alveolar socket / in case of intrusion .

_ fracture of alveolar socket wall .
_ fracture of the jaw / may occur during extraction .

Soft tissue injury:

_laceration --> small surface but deep.
_Contusion --> surface is intact but blood vessels and connective tissue are
damaged.
_abrasion --> include most of the surface but superficial.

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Q\ which one is the most painful?
Abrasion is the most painful because more nerve endings and receptors are
exposed.

_Direct fracture --> the tooth itself is hit

_ Indirect fracture --> the hit is in one place and fracture is another place.
_ sometimes trauma cause fracture of condyle without any effect on the tooth.
_ high energy & mass speed ---> crown fracture.
_ low energy & mass speed --> root fracture.
_ trauma with blunt object --> cause luxation or alveolar fracture.
_ trauma with sharp object --> cause crown fracture.
* pulp response is different according to severity, energy & type of trauma.

Favorable response:
_ recovery: wide apex --> more chance of recovery.

Older people are more susceptible to necrosis because there is no Co_lateral

circulation & apex is closed.

Q\ why pulp is the only tissue when traumatized doesn't heal?

Because it has only one source for blood vessels (apex)

_ after trauma, odontoblast form tertiary dentine and cause calcification ---
>favorable response
Because it indicate pulp is still vital but its problem is future difficulty of RCT.
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 follow up ‫ البعض يقول نعمل‬calcification ‫ إنه يعمل‬pulp ‫**هناك رأيين إنه إذا كانت استجابة الـ‬
..‫ للقنوات‬complete obliteration ‫ و نلحقه قبل ما يحصل‬RCT ‫فقط و البعض يقول نعمل‬
Unfavorable response:
_ infection, necrosis.
_ don't do pulp tests after trauma because it give false results.
_ Internal & external resorption worst type of response.

Peri radicular response:

_transient apical breakdown. -->may be due to occlusal trauma.
_ internal resorption is regular while external resorption is irregular.
_ internal & external resorption have iatrogenic mechanism.
_ orthodontic treatment may cause trauma to the bone and cause external
resorption.
_ internal resorption may be due to blood borne bacteria (retrograde infection).

General guidelines for trauma managements:

• psychological support, history as site of trauma, object caused it, site of
pain and to know the clinical tests required.
• chief complain and medical history.
• control bleeding and pain.
• protection, resorption & stabilization by splint.
• if the tooth is mobile, don't do RCT because it cause more mobility and
trauma during instrumentation.
You can do access to remove pulp (cause of pain) and TF.

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Examination:
1. Mobility test:
‫ إذا حسينا حركة نعرف إن فيه‬, ‫ و نحرك‬alveolar bone ‫*نضع أصبع على السن و أصبع على الـ‬
fracture
cervical ‫ حصل في منطقة الـ‬fracture ‫ عالية جد ًا معناه الـ‬crown ‫*إذا حركنا و كانت حركة الـ‬
more apical ‫ يكون‬fracture ‫*إذا كان في حركة و لكن خفيفـة معناه الـ‬

2. Pulp test:
.‫ أشهر و نقارن النتيجة‬6 ‫نعمله ليس لغرض التشخيص و إنما مرجع لنا بحيث نعيد نعمل الفحص بعد‬

3. radiograph: best is CBCT.

_ stainless steel post is the worst & cause fracture easily because there is not any
flexibility --> cause crack in the dentine
_ fiber post is better because it's similar to dentin by having some degree of
flexibility so it's more safe for root, but it's disadvantage is retention of fiber post
depend on the cement only.

Management:
• fracture in enamel, dentine and near the pulp ---> indirect pulp
capping.
• fracture in enamel, dentine and pinpoint pulp Exposure ---> direct
pulp capping.
• fracture in enamel, dentine and deeper in the pulp ---> partial
pulpetomy --> only part of coronal pulp is removed & this is
according to time of fracture because with long time; spread of
inflammation.

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 enamel & dentin ‫صغي ندخل أعمق ألن كمية الـ‬
‫ر‬ ‫• ف األطفال ى‬
exposure ‫حت إذا كان الـ‬ ‫ي‬
‫ عشان تمسك الـ‬liner , base & composite ‫قليلة و ال يوجد مساحة كافية للـ‬
restoration
• cervical pulpetomy ---> more than partial but not complete
• partial pulpectomy --> only part of the canal is entered.

How to decide type of treatment?

Depends on many factors:
1) age:
If the patient is young and apex is open---> do pulpetomy because of the wide
apex and chance for revascularization and resisting necrosis is high.
‫أكي من ساعة ىنيك فرصة‬
‫ قوية أو لها ر‬trauma ‫حت إذا كانت الـ‬
‫ى‬

_ in case of closed apex ---> RCT is done because no chance for success of
pulpetomy or partial pulpectomy.

2) type of restoration used:

Ex: Small exposure & open apex but large crown fracture and need fiber post?
We do partial pulpectomy even if the exposure is small.

3)Bacteria contamination:
Depends on Time, site of fracture and size of exposure.
Ex: Large exposure & less time --> high chance for bacterial contamination -->
pulpetomy.
_ no direct pulp capping in primary teeth.

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 • Material used for pulpetomy :
_ Calcium hydroxide has unpredictable effect.
_ Disadvantage of MTA is discoloration.
_ Bioceramic has advantages of MTA beside not causing discoloration
so it's better than MTA .

• Management of crown /root fracture:

Remove mobile fragments & examine if there is pulp exposure.

** If it's uncomplicated ---> filling but if the fracture of the root extend
subgingivally --> gingivectomy then restoration .
** If it's complicated fracture --> if open apex --> partial pulpectomy
** If it’s small exposure -->direct pulp capping

** If root fracture with extrusion -->return to its position &splint with

flexible wire as NiTi wire .
** If the fracture is deep in the root --> use flexible splint
** If the fracture is near the crown -->use rigid splint

Follow up for 6 months

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Q\ In case of horizontal root fracture & we do RCT, is it done for both parts?
▪ It depends if we don't need to use fiber post & splint, RCT is done for the
coronal part only and the fracture line is considered the apex. the apical
part is still vital and not inflamed.
▪ here avoid using ZnO eugenol & gutta percha because it may induce
resorption, so use MTA or Bioceramic.
▪ if the coronal part is mobile and we need to do splint by fiber post, do RCT
for both parts &fiber post reach the apical part to fix the mobile coronal
part.

‫ إنمـا هـو جهـود شخصيـة مـن أعضـاء اللجنـة العلميـة‬،‫• هـذا الملخـص غيـر معتمـد مـن دكتـور المـادة‬
.21‫بالدفعـة‬
.‫ و إن أخطأنا فالتمسـوا لنـا العـذر‬،‫• إن أصبنـا فمن هللا‬
.‫• خالـص تمنياتنـا لكـم بالتوفيـق و النجـاح فـي حياتكـم العلميـة و العمليـة‬

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