Dental Traumatic Injuries

Traumatic Dental Injuries

Sex: Boys more than girls Age: mostly in the 1st 10 yrs of life, decreases with age Two peaks are seen one at age 2-4 yrs, then 8-10 yrs (Andreasen and Ravn 1972) Socioeconomic: higher class more trauma

Predisposing factors
Increased overjet Inadequate lip coverage Maxillary central incisor most commonly involved

Dental Trauma Radiography: Recommendations

ALL traumatically injured teeth should be examined radiograhically. Most root fractures are disclosed by radiographic examination

Dental Trauma Radiography: Recommendations

Ideal method for radiographing a traumatized anterior region is by using:
One occlusal film Three different angulations for each traumatized tooth
Central beam directed between lateral and central incisors (right and left) Beam directed between central incisors

Dental trauma/ clinical classification WHO

Injuries to dental tissue and pulp
Enamel infarction Enamel fracture , uncomplicated Enamel dentine fracture, uncomplicated Complicated crown fracture Uncomplicated crown root fracture Complicated crown root fracture Root fracture

Dental trauma/ clinical classification WHO

Injuries to periodontal tissue Concussion Subluxation (loosening) Extrusive luxation (partial avulsion) Lateral luxation Intrusive luxation (central dislocation) Avulsion or exarticulation or complete luxation

Enamel infraction
Definition: incomplete fracture (crack) in enamel without loss of tooth structure. Treatment: require no treatment, in case of multiple lines you can use an unfilled resin to seal the enamel surface as these lines may take up stains

Infraction

Infraction

Uncomplicated Crown Fracture

Definition: Fracture clinically and radiographically involves enamel or dentin and enamel the pulp is not exposed. Sensibility testing: usually positive ,may be negative initially indicating transient pulpal damage; monitor pulpal response until a definitive pulpal diagnosis can be made

Uncomplicated Crown Fracture

(enamel only or enamel and dentin)

Uncomplicated Crown Fracture

Treatment Rationale : Enamel fracture: Immediate treatment of enamel fracture is smoothing the sharp edges to prevent lacerations.

 Enamel and dentine fracture: a) Reattachment of the fractured piece if tooth fragment is available, reattachment is done using dentine bonding systems and composite. b) Urgent care option is to cover the exposed dentin with a material such as glass ionomer or a permanent restoration using a bonding agent and composite resin. c) Definitive treatment for the fractured crown may be restoration with accepted dental restorative materials.

Complicated Crown Fracture

Definition: Fracture involves enamel and dentin and the pulp is exposed.

Complicated Crown Fracture

Clinical findings
Normal mobility Percussion test: not tender. If tenderness is observed, evaluate for possible luxation or root fracture injury. Exposed pulp sensitive to stimuli.

Radiographic findings
Enamel dentin loss visible. Radiographs recommended: periapical, occlusal, to rule out tooth displacement or possible presence of root fracture. Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.

Treatment: Objective is to maintain vitality and restore normal esthetic and function. treatment depends on the maturity of the tooth, associated luxation injury, time since injury and size of pulp exposure. Treatment options are: pulp capping, pulpotomy, pulpectomy.

Crown root fracture

Definition: Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed.

Crown root fracture without pulp involvement

Clinical findings
A fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp. Crown fracture extending below gingival margin. Percussion test: Tender. Coronal fragment mobile.

Treatment

Emergency treatment is to stabilize the loose

segments of the tooth by a bonding system. Definitive treatment may include removal of the segment followed by a restoration. If the fracture was sub gingival gingivectomy, osteotomy or surgical or orthodontic extrusion of the tooth may be needed

 In case of pulp exposure the same treatment recommendations as for complicated crown fracture Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge

Root fractures
Definition: fracture involving dentine, cementum and pulp.

Horizontal Root Fractures

Cervical third (C) communicating non-communicating Middle third (M) Apical third (A)

M
C

Clinical findings
The coronal segment may be mobile and may be displaced. The tooth may be tender to percussion. Bleeding from the gingival sulcus may be noted.

 Sensibility testing may give negative results initially, indicating transient or permanent neural damage. Monitoring the status of the pulp is recommended. Transient crown discoloration (red or grey) may occur.

 The fracture involves the root of the tooth and is in a horizontal or oblique plane. Fractures that are in the horizontal plane can usually be detected in the regular periapical 90o angle film with the central beam through the tooth. This is usually the case with fractures in the cervical third of the root.

 If the plane of fracture is more oblique which is common with apical third fractures, an occlusal view or radiographs with varying horizontal angles are more likely to demonstrate the fracture including those located in the middle third.

Treatment: Young teeth with incomplete fractures need no fixation and will heal with hard tissue union. Apical root fracture with no mobility will also heal with hard tissue union without any need to do splinting.

Middle root fracture and cervical root fracture not comminuting with gingival crevice reduction of displaced coronal segment and immobilization with a semi-rigid splint fo1 month to ensure tissue formation at fracture site, optimal oral hygiene is necessary in these cases.

 Cervical fracture lines communicating to gingival crevice have the poorest chance of healing with hard tissue and may need an alternative treatment as removal of coronal fragment and extrusion of apical fragment surgically or orthodontically and further restoration of coronal loss.

Alveolar fracture
The fracture involves the alveolar bone and may extend to adjacent bone. Segment mobility and dislocation with several teeth moving together are common findings. An occlusal change due to misalignment of the fractured alveolar segment is often noted Sensibility testing may or may not be positive.

Radiographic findings
Fracture lines may be located at any level, from the marginal bone to the root apex. In addition to the 3 angulations and occlusal film, additional views such as a OPT can be helpful in determining the course and position of the fracture lines

Treatment
Reposition any displaced segment and then splint. Suture gingival laceration if present. Stabilize the segment for 4 weeks.

Luxation injuries
Concussion (least severe) Subluxation

Extrusive luxation
Lateral luxation Intrusive luxation (most severe)

Concussion
Definition: injury to the tooth supporting structure without loosening or displacement of the tooth.

concusssion

Concussion
Clinical Findings
Normal appearance Tooth tender to touch No mobility or displacement Vitality tests usually positive

No bleeding from gingival sulcus

No abnormalfindings on x-ray

Treatment: Is confined to soft diet, no need for splinting unless multiple tooth injuries occurs, follow up 4-6 weeks if no abnormal findings controls can be terminated at this time.

Subluxation
Definition: injury to the tooth supporting structure with abnormal loosening of the tooth but no displacement.

Subluxation
Diagnosis
Clinical Findings Tooth is mobile No displacement Tooth tender to touch May be bleeding into gingival sulcus no abnormal findings on x rays unless there is marked mobility there will be a slight widening in PL space.

Subluxation

Treatment: Is confined to soft diet, no need for splinting unless multiple tooth injuries occurs, (for patient comfort can be used for up to 2 weeks) Complications following this type of injury are minimal

Extrusive luxation
Definition: partial displacement of the tooth out of the socket.

Extrusive Luxation Diagnosis

Clinical Findings

Tooth displaced coronally (elongated tooth) bleeding from PL, dull percussion sound. Very mobile Usually negative response to vitality tests On an x ray there is expanded PL space apically

Treatment: Reposition the tooth by gently re-inserting It into

the tooth socket. Stabilize the tooth for 2 weeks using a flexible splint. In mature teeth where pulp necrosis is anticipated or if several signs and symptoms indicate that the pulp of mature or immature teeth became necrotic, root canal treatment is indicated.

Lateral luxation
Definition: displacement of the tooth in a direction other than axially, this is accompanied by fracture of alveolar socket.

Lateral luxation
Diagnosis The tooth is displaced, usually in a palatal/lingual or labial direction. It will be immobile percussion usually gives a high, metallic (ankylotic) sound. Fracture of the alveolar process present. Sensibility tests will likely give negative results

Lateral Luxation

Treatment: If the tooth was luxated and easy to reposition then simply reposition with finger and splint with a non-rigid splint to adjacent teeth for 4 weeks

If the tooth was locked in the bone you need first to unlock the tooth from bone with digital pressure or forceps and then reposition it in the correct place, then compress the bone back to place readapt the gingiva to the neck of the tooth and suture it in place then splint to adjacent teeth with a nonrigid splint for4 weeks.

Intrusive luxation
Definition: displacement of the tooth into the alveolar bone along the axis of the tooth and is accompanied by comminution fracture of the alveolar socket.

Intrusive luxation
Diagnosis The tooth is displaced axially into the alveolar bone. It is immobile Percussion may give a high, metallic (ankylotic) sound. Sensibility tests will likely give negative results

Intrusive luxation

Intrusive luxation
It is considered the most severe injury it causes damage to gingival attachment contusion to PL and bone damage to the hertwig epithelial root sheath

Radiographic findings
Radiographically the PL of the intruded tooth will be partially or totally obliterated. when the tooth is forced through the labial bone plate the intruded incisor will appear shorter on the periapical x-ray compared to its antimere, on the other hand an elongated tooth implies intrusion into a palatal direction

Treatment: depend on two factors: 1.the degree of intrusion (mild < 3mm, moderate 3-6mm, severe >6mm) 2.the root development (open or closed apex).

 Teeth with incomplete apex with mild & moderate intrusion Spontaneous re-erruption has a big chance but the incisal edge must be exposed. The re-erruption will take few weeks . Monitor for signs of pulp necrosis and inflammatory root resorption. Initiate endo therapy and non setting calcium hydroxide if any signs start.

 Teeth with complete apex with mild or moderate intrusion Orthodontic repositioning over a period of 2 weeks. Root canal therapy is to be initiated after 2 weeks and a non setting calcium hydroxide is kept 6-12 months and changed as needed before gutta percha filling is done

Teeth with incomplete or complete apex and severe intrusion the tooth may be buried in the bone and surgical repositioning is suggested The tooth is brought to occlusal level and then splinted for 4-8 weeks with a flexible splint. Root canal therapy is to be initiated after 2 weeks and a non setting calcium hydroxide is kept 6-12 months and changed as needed before gutta percha filling is done

Complication
Risk of ankylosis should be kept in mind; in such case surgical luxation with orthodontic repositioning was suggested by some clinicians.

Avulsion

Avulsion
Definition: is total displacement of the tooth out of its socket. Also called exarticulation or total luxation.

Avulsion
Mature or fully developed tooth
Closed apex

Immature or developing tooth

Open apex

Extraoral dry time

< 1 hour dry time > 1 hour dry time

 In cases of avulsion both the PL and the pulp suffer from extensive damage with the healing highly dependent on the extra-alveolar period and the extra-alveolar handling

Treatment:
Management at the site of accident In case of a telephone call for instructions advice should be given to an adult to immediately replant the tooth in the socket and keep in place with gentle biting. If the tooth was contaminated tell them to wash with milk or tap water to remove the derbies and to handle the tooth from the crown and never touch the root surface. Then they should directly attend the clinic.

 Treatment guidelines for avulsed permanent teeth with closed apex

The tooth has been replanted prior to the patient arriving at the dental office or clinic Clean the area with water spray, saline, or chlorhexidine. Do not extract the tooth. Suture gingival lacerations if present. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks.

 Administer systemic antibiotics. Tetracycline is the first choice Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight) In young patients Phenoxymethyl Penicillin (Pen V), refer to physician for evaluation and need for a tetanus booster.

Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week

If immediate replantation is not possible then the tooth should be kept in a clean container in milk or proper storage media then directly attend the clinic.

Storage media
Viaspan Hanks Balanced Salt Solution (HBSS) Milk Saline Saliva Water Pripolis Egg White

 The tooth has been kept in special storage with extraoral dry time less than 60 min

If contaminated, clean the root surface and apical foramen with a stream of saline and place the tooth in saline. Remove the coagulum from the socket with a stream of saline.

 Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks

Extra-oral dry time longer than 60 min Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in doing delayed replantation is to promote alveolar bone growth to encapsulate the replanted tooth.

The technique for delayed replantation is: Remove attached necrotic soft tissue with gauze. Root canal treatment can be done on the tooth prior to replantation, or it can be done 710 days later as for other replantations.

Treatment guidelines for avulsed permanent teeth with open apex

 Open apex teeth in young patient with a short extra-alveolar time (less than 60 minutes) Give a chance for revascularization and delay endodontic intervention. Review the patient after 2 weeks and then after 3-4 weeks, at the follow up visit look for signs of loss of vitality test vitality and take intra-oral radiographs.

Open apex teeth with long extra-alveolar time (more than 60 minutes) Remove attached necrotic soft tissue with gauze. Root canal treatment can be done on the tooth prior to replantation through the open apex. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.

 Immerse the tooth in a 2% sodium fluoride solution for 20 min Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically. Stabilize the tooth for 4 weeks using a flexible splint.

Do not replant the tooth in the following situations because of very poor prognosis: primary tooth, presence of other emergency treatment and intensive care, if medical history reveals that patient health would be at risk due to re-implantation e.g. congenital heart disease, very short and wide open apex with an extremely prolonged extra-alveolar time.

Complications of avulsion : external inflammatory resorption, ankylosis and infraocclusion, discoloration, loss of marginal bone support. Follow up for avulsed teeth should be for 23 years in order to solve any potential complication that might occur.

Splinting (Stabilization)
To splint or not to splint? Rigid or physiologic splint? Splinting times simplified Splinting materials Dos and Donts of splinting

Splinting (Stabilization)
To splint or not to splint?
Splint
Avulsions, alveolar fractures, extrusive and lateral luxations, root fractures with displacement, intrusive luxation if surgically repositioned

No splint
Concussion, subluxation, intrusive luxation if orthodontically not surgically repositioned, apical third root fracture if no displacement.

Splinting (Stabilization)
Rigid or physiologic splint?
Physiologic splint for luxation injuries and bony fractures of socket wall or alveolar bone Rigid splint is contraindicated for dental traumatic injury

Splinting (Stabilization)
Type of Injury Concussion Subluxation Root fracture (apical 1/3) (no displacement of coronal segment) Splinting Time None None or 2 weeks None

Splinting (Stabilization)
Type of Injury Subluxation Extrusive luxation Avulsion Lateral luxation Intrusive luxationsurgically repositioned Splinting Time 2 weeks 2 weeks 2 weeks 4 weeks 4-8 weeks

Splinting (Stabilization)
Type of Injury Splinting Time

Root fracture (apical 1/3)

Root fracture (mid 1/3) Root fracture (cerv 1/3) Alveolar fracture

No splint
4 weeks 4 months 4 weeks

Types of Splints (flexible/physiologic)

Titanium Trauma Splint (TTS) Ortho wire with brackets Ortho wire with unfilled resin Monofilament line with unfilled resin Unfilled resin Suture(s)

Titanium Trauma Splint (TTS)

Available in two lengths: 51mm and 100 mm Only 0.2 mm thick Easily cut and adapted Uses small amount of bonded composite

Titanium Trauma Splint (TTS)

 It should be somewhere between the incisal and middle one third Check that the teeth are repositioned radiographically Do not place the splint close to gingival margin Do not attach the splint untill the teeth are repositioned

 Do not splint maxillary ant teeth on the lingual Do not leave space between the splint and the tooth surface and the wire