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Traumatic Injuries
Traumatic Injuries
Traumatic Injuries
THE TEETH
INTRODUCTION
Traumatic injury: Defined as a damage to a part of
body tissue.
Considered as an emergency situation in dentistry.
Due to technological advancements and hectic
lifestyles, incidence of trauma is on rise.
Effects the progress, behavior and psychological well
being of child
Can lead to inferiority complex- failure of child in
future.
Management merits special attention
movement
of
tooth
towards
CLASSIFICATI
ON
CLASS II
CLASS
III
CLASS IV
CLASS V
CLASS VI
CLASS VII
Displacement
of
tooth
fracture of crown or root
CLASS VIII
CLASS IX
without
MODIFIED ELLISS
CLASSIFICATION
CLASS II
CLASS III
CLASS IV
Clinical Classification By
Andreasen
(1992)
A. INJURIES
TO HARD DENTAL
TISSUES AND
PULPincomplete fracture
Enamel infraction:
N 502.50 (crack) of enamel without loss of the
tooth structure
Uncomplicated crown fracture:
contained to enamel
N 502.50 Uncomplicated crown fracture: Enamel
fracture- Involving enamel only
N 502.50 Uncomplicated crown fracture: enamel
dentin fracture-Involving enamel and
dentin, but not involving pulp
N 502.52 Complicated crown facture: involving
enamel, dentin and exposing pulp
Root fracture
N
503.2
0
Extrusive
luxation(peripheral
dislocation, partial
avulsion): Partial
displacement of tooth out
of its socket
Lateral luxation:
displacement other than
axial direction
N
503.2
2
Exarticulation (complete
avulsion): Complete
displacement of tooth out
of its socket
Code
Code
Code
Code
Code
Code
Code
0:
1:
2:
3:
4:
5:
6:
No injury
Treated Dental Injury
Enamel Fracture only
Enamel/dentin fracture
Pulp injury
Missing due to trauma
Excluded tooth
Classification by Ulfohn
a. Fracture of enamel
b. Fracture of the crown with indirect
pulp exposure through the dentin
c. Fracture of the crown with direct pulp
exposure.
Enamel crack
Enamel fracture
Enamel dentin fracture without pulp exposure
Enamel dentin fracture with pulp exposure
Enamel dentin cementum fracture without pulp
exposure
Enamel dentin cementum fracture with pulp
exposure
Root fracture
Concussion
Luxation
Lateral displacement
Intrusion
Extrusion
Avulsion
PREVALENCE
History of trauma in both primary and permanent teeth
Boys show more frequency than girls in permanent teeth
No significant sex difference in primary teeth
Peak incidence in 1-2.5 yrs
8-11 yrs
Facial injuries- common in boys of 6-12 yr of age,
mandible is most affected
Seasonal variation: injury increases during winter
Author
Year
Age-y
Prevalence %
Germany
Kessler
1922-37
0-3
4.5
Denmark
Andreasen
1972
3-7
30.2
Denmark
Ravn
1976
1-3
70
Dominician
republic
Garciagodoy
1983
3-5
35
Brazil
Cunha
2001
0-3
16.3
1999
1-5
15
Kramer
2003
0-6
35.5
Norway
Skaare
2005
1-8
1.3
Author
Year
Age-yrs
Prevalence
%
Canada
Ellis
1948
Schooler
4.2
Denmark
Andreasen &
Ravn
1972
7-16
22.3
Dominican
republic
Garcia-godoy F
1985
6-17
12.2
India
Rai- Munshi
1998
3-16
5.29
India
2002
School
children
13.8
India
Pradeep
tangade
2007
12-15
4.41
Germany
Bauss
2004
12
10.3
ETIOLOGY
Unintentional TDI
2) ACCIDENTS: (20-25%)
Bicycle accidents, automobile accidents,
play ground accidents
3) Sports:
Sports like cricket, football, baseball, basketball,
wrestling, kabbadi, etc
Intentional TDI
Batterred Child Syndrome:
Abused or neglected child who have suffered
serious physical abuse
Occurs in approx. 0.6% of children
10% Of all injuries involve teeth
Luxation of four
incisors and bruising of
upper buccal sulcus as
a result of blow to the
mouth
PREDISPOSING FACTORS
Facial profile: More common in,
Angles class II type I malocclusion
Angles class I type II malocclusion
Inadequate lip coverage
Cerebral palsy:
Dentinogenisis imperfecta
Epileptic patients
Additional information:
a. Previous accidents involving the teeth
b. Prior treatment for the present injury
c. General health of the patient
Episodes of amnesia, unconsciousness, vomiting or headache
indicate cerebral involvement.
Subjective symptoms:
- spontaneous pain
- sensitivity or discomfort to touch
- pressure of eating or chewing
- pain from temperature variation
- reaction to sweet and sour food
- mobility
- displacement
- variation in occlusion
1.
Clinical
Examination
Extraoral wounds and palpation of
the facial
skeleton
2. Injuries to oral mucosa/gingiva
3. Examination of crowns of the teeth
4. Displacement of teeth
5. Abnormal mobility of teeth or alveolar fragments.
6. Palpation of alveolar process
7. Tenderness of teeth to percussion
8. Reaction of teeth to pulpal sensibility testing
Radiographic examination
Intra and Extra Oral Radiographs
Displacement: -Intrusion
- Extrusion
- Avulsion
Abnormalities of occlusion
Mobility of teeth and alveolar fragment
Test for mobility
Reaction of teeth to percussion & pulp testing
Heat
Cold
Electrical
LDF
1.
2.
3.
4.
5.
Treatment:
Do not require definitive treatment
Vitality test should be done
Endodontic therapy: when patient develops symptoms of
necrotic pulp or radiographic signs of periapical pathosis
Prognosis:
Pulp Necrosis: ( 0-3.5%)
ENAMEL FRACTURES
Clinical management:
Two methods depending on esthetic concern and extent
of tooth loss
1) Recontouring of injured tooth, the adjacent teeth,
and/or the opposite teeth
2) Restoration or missing tooth structure with composite
Treatment should be performed immediately to prevent potential
drifting, tilting, or supraeruption of adjacent and/or opposite
teeth
Prognosis:
Pulp necrosis (o-1%)
To avoid
1. Labial protrusion
2. Drifting or tilting of adjacent
teeth
3. Supraeruption of opposing
teeth
4. Bacterial contamination of
dentin and pulp
by oral
fluids
Immediate treatment:
1. Placing GIC
2. Adapting a temporary crown
1.
2.
3.
4.
Permanent Treatment:
Reattachment of the crown fragment
Restoration with laminate veneer
Restoration with composite resin
Restoration with full coverage crown
Prognosis:
Pulp Necrosis (0-6%)
Clinical recognition:
Symptoms: thermal sensitivity/ pain on
mastication
Examination should attempt to reveal minor
pulp
exposures
Clinical management:
Investigations:
Periapical radiograph
Pulp vitality test
Recommended restorations
Adhesive resin
Composite resin system
Conventional treatment:
Application of the hard setting CaOH over the exposed
dentinal surface prior to restoration of the tooth with
dentin bonding agent and composite resin restoration
Action of CaOH:
Antimicrobial
Production of irrational(reparative) dentin
Disadvantage of CaOH:
Dissolve when exposed to 37% phosphoric acid for 60
sec
Have some softening effect on composite resin
Recommended Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
Clinical
assessment/diagnosis,
selection
of
composite shade
Local anesthetic administration
Cleaning of fractured tooth, gentle irrigation
Rubber dam isolation
Placing of glass-inomer liner over exposed dentin
Reattachment of
fragment
Pulp testing
Applying bonding
agent
Light polymerization
Contraindicated
Unruly patient
Concomitant luxation injury prevents dry
operatory field.
Clinical results
Esthetics and retention are of concerned.
Pulp necrosis found later is attributed to the
injury and not to the procedure.
Discoloration or degradation of composite
material at fracture line.
60% of bonded fragments are lost after 5 years
due to new trauma or nonphysiological use of
restored tooth.
Completed preparation
Final
Indications
Discolored crown due to pulp necrosis
Autotransplanted premolars
Supplement for bonded fragments.
Gingival Bevel
using metal strip
Facial bevel
Palatal chamfer
Final preparation
Shade selection
Dentin build-up
Applying enamel
composite
Finished restoration
thermal
changes
or
Clinical management:
Pulp capping
Partial Pulpotomy (Cvek Pulpotomy)
Cvek reported 96% success
Fuks et al: reported 94% success
Endodontic therapy
Primary aim is to preserve vitality: pulp capping and
partial Pulpotomy is recommended.
Periodic recall evaluation is necessary
When pulp shows radiographic evidence of pathosis or
becomes
symptomatic
endodontic
therapy
is
necessary.
Contraindication of Pulpotomy
Not indicated in mature teeth with concurrent
displacement injuries; displacement injuries
involve vascular damage
Partial calcification of pulp
Degenerative and/or inflammatory changes with
in the pulp
Fracture is extensive and requires post for
restoration- Pulpectomy followed by endodontic
therapy is recommended
Closed apex
RESTORATION
RCT
Open apex
RCT Apexification
RCT
RESTORATION
Clinical recognition:
Most commonly by a fracture line superior to the
marginal gingiva on the facial aspect of the crown and
following an oblique course below the marginal
gingiva on the lingual surface
Symptoms: Slight discomfort on moving the fracture
segment
Radiograph contributes little to diagnosis
Clinical management:
Emergency treatment- stabilization of the coronal
fragment to adjacent teeth with composite splint
Definitive treatment initiated with in few days
after the injury
Treatment depends on location and type of fracture
If coronal fragment includes more than one third of
the clinical root extraction/endodontics is advised
Vertical crown root fracture should be extracted.
Prognosis:
CLINICAL MANAGEMENT OF
TRANSVERSE ROOT FRACTURE
Occurs in maxillary teeth
commonly
Involves dentin, cementum, pulp
and periodontal ligament
Account for approx 6% of all
trauma
Principally occurs in adult patients
where the root is solidly supported
in bone and periodontal
membrane, in younger patient
teeth are more likely to be avulsed
Radiograph recommended:
Clinical findings:
- tooth will be slightly extruded with lingually displaced
crown
- coronal segment may be laterally displaced
- 99% of cases the apical segment remains vital
- coronal segment may or may not be vital and may or may
not be mobile depending on,
a. state of tooth at the time of fracture
b. extent of fracture
c. location of fracture
Healing by deposition
of cementum
Connective tissue
healing
- is more common
Clinical management
Factors effecting are,
1. the position of the tooth after it
has been fractured.
2. the mobility of the coronal
segment.
3. the status of the pulp.
4. the position of the #ed line.
Mobility of
coronal segment
Status of pulp
- Vital response may be obtained using a pulp tester.
- Pulp may/may not show positive pulp test.
- Patient signs and symptoms are used as an indicator of pulp
status.
- Separation across the fractured root segments often produces
an interruption to the innervation of the coronal segment that
would respond in a nonvital fashion to vitality testing, the
collateral correlation established by the fracture often allows
for maintenance of pulp vitality.
- Coronal pulp should be considered vital unless, pain , a sinus
tract , or granulation tissue across the fracture line is present.
- Most troublesome.
Alternative are,
1. periodontal adjustment
disadvantage - unfavorable cosmetic result
2. orthodontic extrusion.
disadvantage - treatment may be prolonged
and the prognosis may be just poor.
3. intra alveolar transplantation of fractured
tooth.
LUXATION INJURIES
1.
These injuries can range from a mild blow to a tooth to a more severe forms that either force a tooth
into, or partially dislocate it from the alveolar socket.
2.
3.
4.
Lateral
luxation
Abnormal
mobility
-/+
-/+
Tenderness to
percussion
+/-
+/-
Percussion
sound
Normal
Dull
Dull
Metallic
Metallic
Positive
response to
sensibility
tests
+/-
+/-
Radiographic
dislocation
-/+
Number of teeth
Pulp necrosis
Concussion
178
5 (3%)
Subluxation
223
14 (6%)
Extrusive luxation
53
14 (26%)
Lateral luxation
122
71 (58%)
Intrusive luxaton
61
52 (85%)
Number of teeth
Pulp necrosis
Incomplete
279
21 (8%)
Complete
358
135 (38%)
Surface
resorption
Inflammatory Ankylosis
resorption
resorption
178
8 (4%)
0 (0%)
0 (0%)
Subluxation 223
4 (2%)
1 (0.5%)
0 (0%)
Extrusive
luxation
53
3 (6%)
3 (6%)
0 (0%)
Lateral
luxation
122
32 (26%)
4 (3%)
1 (1%)
Intrusive
luxation
61
15 (24%)
23 (38%)
15 (24%)
Concussion
CONCUSSION
Frequency of 23%
CONCUSSION
Least severe- involves primarily the
supporting structures
No loosening or displacement of the tooth
splinting not required
Manifestations:
1.
Sensitive to mastication
2.
Tenderness on percussion
Management
Pulp testing: Electric pulp testing not diagnostic.
Pulp may not respond initially to vitality tests even though
the pulp may remain vital
Treatment:
Relieving from occlusion:
- reducing the contact on the traumatized tooth
or
- reducing the contact on the opposing tooth or teeth
Follow up care:
Recall 1-2 weeks after trauma and at 6 months
interval for minimum of 1 year.
SUBLUXATION
Bleeding is often seen due to damage to supporting
structures and periodontal ligament
Manifestation:
Tooth is slightly mobile, although not to the degree
that a splint is required
Sensitive to mastication and /or to percussion
Management
Vitality test: Electrical/Thermal tests- not diagnostic
immediately after trauma.
Treatment:
If several teeth are traumatized or subluxated,
- splinting placed to stabilize
- recommended period of splinting: 7-10 days
Follow-up care:
- greater potential for pulpal necrosis.
- endodontic treatment initiated in case of
symptoms of pulpal necrosis
EXTRUSIVE LUXATION
7% frequency
Management
- reposition the luxated tooth into its alveolar
socket under local anesthesia.
- if clot has formed apical to the displaced
tooth, tooth may be more difficult to reposition
and more force and pressure may be required.
- require splinting to stabilize.
Duration of splinting
2-3 weeks with a flexible splint ( Andreasen and
Andreasen)
LATERAL LUXATION
LATERAL LUXATION
Anesthesia is recommended
11% frequency
Periodontal injury is accompanied by fracture of
the labial bone plate as well as contusion injury to
the lingual cervical periodontal ligament.
Crowns are displaced lingually and are usually
associated with fractures of the vestibular part of
the socket wall.
Procedure of reduction:
1. Force the displaced apex out of its locked
position with in labial bone
2. Place axial pressure in an apical direction
3. Manipulate the tooth into its natural position
Splinting:
Recommended duration: minimum of 14 days and
remove it when no abnormal mobility remains
In case of marginal breakdown : 6-8 weeks
INTRUSIVE LUXATION
Comprise 0.3-1.9%
Due to locked position in
bone- not sensitive to
percusssion.
Extent of intrusion may
vary from 1 mm to complete
burial of the displaced tooth.
Percussion elicits high
pitched metallic sound.
Treatment:
Allow the tooth to re erupt on its own (Immature
tooth)
Orthodontically extruding the intruded tooth over 2-4
weeks ( Completed root development)
Surgical repositioning (multiple intrusion or deep
intrusion > 7 mm)
Prognosis:
Incidence of both external root resorption and marginal
bone loss is greater in intruded teeth that are surgically
repositioned
Pulpal necrosis occurs in almost all intrusive luxations,
therefore root canal therapy should be anticipated.
Orthodontic extrusion
Orthodontic extrusion
Spontaneous re-eruption
TOOTH AVULSION
TOOTH AVULSION
Complex injury affecting multiple tissue
compartments
1-6% of all traumatic injuries to permanent
dentition
Fights and sports injuries
Most commonly affected: Maxillary Incisors
Age: 8-12yrs, as loosely structured PDL offer
least resistance to extrusive forces
MANAGEMENT
Depends on,
- Extraoral time
- Type of storage
- Root Maturity
In emergency visit emphasis is placed on preservation
& healing of attachment apparatus
In second visit emphasis is placed on prevention /
elimination of pulpal infection
Association
of
Dental
Trauma
SPLINTING:
Semi rigid fixation for 7-10 days
e.g. Flexible wire, Monofilament, TTS etc.
In case of avulsion + alveolar fracture
SECOND VISIT
Follow-up care
- Recall intervals at 3 months, 6 months and yearly
for at least 5 years
- If osseous replacement is identified then timely
revision of long term treatment plan
- If inflammatory root resorption is seen a new
attempt at disinfection of root canal is made
- The adjacent teeth should also be tested
Complications:
1. Surface resorption
2. Replacement resorption
3. Inflammatory resorption
STORAGE MEDIA
Suggested storage media in order of preference
1. HBSS, Cell Storage media, Viaspan
2. Milk ( cool milk 40C is preferable to room temp. milk
230C)
3. Saliva, either in the vestibule of mouth / in container
into which pt. spits
4. Physiologic saline
5. Water (hypotonic environment causes rapid cell lysis
& increased inflammation on replantation)
PATIENT INSTRUCTIONS
- Soft diet for 2 weeks
- Brush teeth with a soft toothbrush after each meal
- Chlorhexidine mouthrinse (0.1%) twice a day for 1
week
- Regular follow up
INCIDENCE
11 to 30%
Most common age group affected: 1.5-2.5 years
At this age child starts walking
No sex differences in incidence as in permanent
dentition
Owing to resilient bone surrounding the primary
teeth, injuries usually result in avulsions, luxations,
etc., rather than fractures of crown
ASSESSMENT
History
Vitality tests: unreliable and should not be attempted
Radiographic examination: helpful
( in case of missing tooth to determine whether
fully intruded or avulsed )
- easiest method is to take an anterior oblique
occlusal view.
Often a child is upset at the initial visit and it may be
appropriate to postpone radiographic examination to
the review visit.
TREATMENT APPROACHES
The treatment strategy following injury to the
primary teeth is dictated by concern for safety of the
permanent dentition.
- Relieve pain
- Restore dentition
In very young children co-operation is the main problem
Advise parents regarding - analgesia
- soft diet
- oral hygiene
Recall the child after a week when he or she is less upset
Tooth fractures
Factors to be considered
1. Any other injuries to the tooth, such as luxationgreater chance of damage to permanent tooth.
2. Patient co-operation
3. Exfoliation time of the tooth
4. Motivation of parents to keep up with the follow up
appointments
TREATMENT
Enamel fracture
small chip- 1. Left as it is
2. Edge smoothened off and topical
fluoride applied
larger chip- composite resin restoration
Enamel and dentine fracture
protect pulp- CaOH / GIC lining followed by
composite restoration or using strip crown
Intrusion injuries
Establish where they are in the alveolus and leave them
alone
If less than of the crown intruded- allow to re-erupt,
normally occurs in 2-4 months of injury
If more than of the crown intruded- still can reerupt, careful monitoring required.
Damage to alveolus causing pain- extraction
Extrusive luxation
Extrusive injuries in primary dentition cause
interference in occlusion
Treatment
If extrusion is less than 1-2mm- leave them and
monitor
If extruded more than 2mm- extraction