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• Examination and diagnosisExamination and diagnosis
Consider traumatic injuries as emergency,Consider traumatic injuries as emergency,
• To relieve pain. To relieve pain.
• Reduce psychological stress.Reduce psychological stress.
• Facilitate reduction of # or avulsion.Facilitate reduction of # or avulsion.
• For good prognosis.For good prognosis.
When did injury occurred ?When did injury occurred ?
• Time interval between injury and treatment started.Time interval between injury and treatment started.
• Alter possible prognosis and line of treatment specially in Alter possible prognosis and line of treatment specially in
cases of re-implantation, pulp exposure, bone# and severe cases of re-implantation, pulp exposure, bone# and severe
soft tissue injuries.soft tissue injuries.
Where did injury occurred ?Where did injury occurred ?
• For tetanus prophylaxis.For tetanus prophylaxis.
• How did injury occurred ?
• Direction of blow which tells possible structure affected.
• Object in mouth like pacifier labial displacement of teeth.
• Young child and women with multiple soft tissue injury at deferent stage of healing improper history child abuse.
Treatment else where ?Treatment else where ?
• Storage of avulsed teeth.Storage of avulsed teeth.
• Medication taken.Medication taken.
• Re-implantation and immobilization considered.Re-implantation and immobilization considered.
History of previous injury ?History of previous injury ?
• Sustained repeated injury influence pulp vitality test.Sustained repeated injury influence pulp vitality test.
• Affects healing capacity of pulp and PDL. Affects healing capacity of pulp and PDL.
General health and medical history ?General health and medical history ?
• Allergic reactionAllergic reaction
• EpilepsyEpilepsy
• Bleeding disorderBleeding disorder
• Differs emergency and later treatmentDiffers emergency and later treatment
ExaminationExamination
• Color changeColor change of traumatized tooth noted occurs in post injury period. of traumatized tooth noted occurs in post injury period.
• Deranged Deranged occlusionocclusion
• Abnormal Abnormal mobilitymobility
• PalpationPalpation of alveolar process of alveolar process
• PercussionPercussion
• Vitality testVitality test
• Radiographic examinationRadiographic examination
Management of patientManagement of patient
• Emergency managementEmergency management
A- Airway with cervical spine controlA- Airway with cervical spine control
B- Breathing and ventilationB- Breathing and ventilation
C- Circulation and hemorrhage controlC- Circulation and hemorrhage control
D- Disability neurological states D- Disability neurological states
• Central nervous system injuryCentral nervous system injury
Classification based on tissue and siteClassification based on tissue and site
All injuries to the face may be divided into two basic All injuries to the face may be divided into two basic
groups,groups,
• Injuries to soft tissuesInjuries to soft tissues
• Injuries to bone Injuries to bone
• Rabinowitch Classification (1956)
• Fractures of the enamel
• Fractures into the dentin
• Fractures into the pulp
• Fractures of the root
• Comminuted fractures
• Displaced teeth
Ellis and Davey Classification (1960)Ellis and Davey Classification (1960)
• Class 1Class 1 - Simple fracture of the crown involving little or no - Simple fracture of the crown involving little or no
dentin.dentin.
• Class 2 Class 2 - Extensive fracture of the crown involving - Extensive fracture of the crown involving
considerable dentin, but not the dental pulp.considerable dentin, but not the dental pulp.
• Class 3Class 3 - Extensive fracture of the crown involving - Extensive fracture of the crown involving
considerable dentin and exposing the dental pulp. considerable dentin and exposing the dental pulp.
• Class 4Class 4 - The traumatized teeth that become non-vital with - The traumatized teeth that become non-vital with
or without a loss of crown structure.or without a loss of crown structure.
• Class 5Class 5 - Teeth lost as a result of trauma - Teeth lost as a result of trauma
• Class 6Class 6 - Fracture of the root with or without a loss of the - Fracture of the root with or without a loss of the
crown structure.crown structure.
• Class 7Class 7 - Displacement of a tooth without fracture of the - Displacement of a tooth without fracture of the
crown or root.crown or root.
• Class 8Class 8 - Fracture of crown en masse and its replacement. - Fracture of crown en masse and its replacement.
• Class 9Class 9 - Traumatic injuries to primary teeth. - Traumatic injuries to primary teeth.
Modification of Ellis classification by McDonald, Avery Modification of Ellis classification by McDonald, Avery
and Lynch (1983)and Lynch (1983)
• Class 1Class 1 - Simple fracture of the crown involving little or no - Simple fracture of the crown involving little or no
dentin.dentin.
• Class 2Class 2 - Extensive fracture of the crown involving - Extensive fracture of the crown involving
considerable dentin, but not the dental pulp.considerable dentin, but not the dental pulp.
• Class 3Class 3 - Extensive fracture of the - Extensive fracture of the
crown with an exposure of the dental crown with an exposure of the dental
pulp.pulp.
• Class 4Class 4 - Loss of the entire crown. - Loss of the entire crown.
WHO Classification (1992)WHO Classification (1992)
• Adapted from Adapted from WHO Geneva 1992.WHO Geneva 1992.
• Based on anatomy, therapeutic and prognostic Based on anatomy, therapeutic and prognostic
consideration.consideration.
• It is applied to both primary and permanent teeth.It is applied to both primary and permanent teeth.
• Code numbers used according to the Code numbers used according to the International International
classification of diseases 1992classification of diseases 1992
Injuries to the hard dental Injuries to the hard dental
tissues and pulptissues and pulp
Enamel infraction N Enamel infraction N
502.50:502.50: An incomplete An incomplete
fracture (crack) of the fracture (crack) of the
enamel without loss of enamel without loss of
tooth substance.tooth substance.
Injuries to the hard dental Injuries to the hard dental
tissues and pulptissues and pulp
Enamel infraction N Enamel infraction N
502.50:502.50: An incomplete An incomplete
fracture (crack) of the fracture (crack) of the
enamel without loss of enamel without loss of
tooth substance.tooth substance.
Enamel fracture Enamel fracture
(Uncomplicated (Uncomplicated
crown fracture) N crown fracture) N
502.50:502.50: A fracture A fracture
with loss of tooth with loss of tooth
substance confined to substance confined to
enamel.enamel.
Enamel - dentin fracture Enamel - dentin fracture
(Uncomplicated crown (Uncomplicated crown
fracture) N 502.51: fracture) N 502.51: A A
fracture with loss of tooth fracture with loss of tooth
substance confined to substance confined to
enamel and dentin but not enamel and dentin but not
involving pulp.involving pulp.
Complicated crown Complicated crown
fracture N 502.52fracture N 502.52
A fracture involving A fracture involving
enamel and dentin enamel and dentin
and exposing the and exposing the
pulp.pulp.
Uncomplicated crown Uncomplicated crown
root fracture N root fracture N
502.54502.54
A fracture involving A fracture involving
enamel, dentin and enamel, dentin and
cementum but not cementum but not
involving the pulp.involving the pulp.
Complicated crown Complicated crown
root fracture N root fracture N
502.54502.54
A fracture involving A fracture involving
enamel, dentin and enamel, dentin and
cementum and cementum and
exposing pulp. exposing pulp.
Root fracture N Root fracture N
502.53:502.53: A A
fracture involving fracture involving
dentin, cementum dentin, cementum
and the pulp.and the pulp.
Injuries to the periodontal Injuries to the periodontal
tissuestissues
Concussion N 503.20: Concussion N 503.20:
An injury to the tooth An injury to the tooth
supporting structures supporting structures
without abnormal without abnormal
loosening or displacement loosening or displacement
of the tooth.of the tooth.
Subluxation N 503.20Subluxation N 503.20
An injury to the tooth An injury to the tooth
supporting structures supporting structures
with abnormal with abnormal
loosening but without loosening but without
displacement of the displacement of the
tooth. tooth.
Subluxation N 503.20Subluxation N 503.20
An injury to the tooth An injury to the tooth
supporting structures supporting structures
with abnormal with abnormal
loosening but without loosening but without
displacement of the displacement of the
tooth. tooth.
Extrusive luxation Extrusive luxation
(peripheral (peripheral
dislocation, partial dislocation, partial
avulsion) N 503.20avulsion) N 503.20
Partial displacement Partial displacement
of the tooth out of its of the tooth out of its
socket. socket.
Lateral luxation N Lateral luxation N
503.20503.20
Displacement of the Displacement of the
tooth in a direction tooth in a direction
other than axially. This other than axially. This
is accompanied by is accompanied by
fracture of the alveolar fracture of the alveolar
socket.socket.
Intrusive luxation (central Intrusive luxation (central
dislocation) N 503.21:dislocation) N 503.21:
Displacement of the Displacement of the
tooth into the alveolar tooth into the alveolar
bone. This injury is bone. This injury is
accompanied by fracture accompanied by fracture
of the alveolar socket. of the alveolar socket.
Exarticulation Exarticulation
(complete avulsion) (complete avulsion)
N 503.22N 503.22
Complete Complete
displacement of the displacement of the
tooth out of its socket. tooth out of its socket.
Injuries of the supporting Injuries of the supporting
bonebone
Comminution of alveolar Comminution of alveolar
socket (mandible N socket (mandible N
502.60, maxilla N 502.60, maxilla N
502.40): 502.40): Crushing and Crushing and
compression of the alveolar compression of the alveolar
socket. intrusion and lateral socket. intrusion and lateral
luxation.luxation.
Fracture of the Fracture of the
alveolar socket wall alveolar socket wall
(mandible N 502.60, (mandible N 502.60,
Maxilla N 502.40)Maxilla N 502.40)
A fracture contained A fracture contained
to the facial or lingual to the facial or lingual
socket wall.socket wall.
Fracture of the alveolar Fracture of the alveolar
process process
(Mandible N 502.60, (Mandible N 502.60,
Maxilla N 502.40)Maxilla N 502.40)
A fracture of the alveolar A fracture of the alveolar
process which may or may process which may or may
not involve the alveolar not involve the alveolar
socket.socket.
Fracture of mandible and maxilla Fracture of mandible and maxilla
(Mandible N 502.61, Maxilla N 502.42)(Mandible N 502.61, Maxilla N 502.42)
A fracture involving the base of the A fracture involving the base of the
mandible or maxilla and often the alveolar mandible or maxilla and often the alveolar
process (jaw fracture). The fracture may or process (jaw fracture). The fracture may or
may not involve the alveolar socket. may not involve the alveolar socket.
Injuries to gingival or oral Injuries to gingival or oral
mucosamucosa
Laceration of gingival Laceration of gingival
or oral mucosa N or oral mucosa N
S01.50:S01.50: A shallow or A shallow or
deep wound in the mucosa deep wound in the mucosa
resulting from a tear and resulting from a tear and
usually produced by a usually produced by a
sharp object.sharp object.
Contusion of gingival or Contusion of gingival or
oral mucosa N S00.50oral mucosa N S00.50
A bruise usually produced A bruise usually produced
by an impact from a blunt by an impact from a blunt
object and not object and not
accompanied by a break of accompanied by a break of
the continuity in the the continuity in the
mucosa, causing sub-mucosa, causing sub-
mucosal hemorrhage.mucosal hemorrhage.
Abrasion of gingiva or Abrasion of gingiva or
oral mucosa N S00.50oral mucosa N S00.50
A superficial wound A superficial wound
produced by rubbing or produced by rubbing or
scraping of the mucosa scraping of the mucosa
leaving a raw bleeding leaving a raw bleeding
surface. surface.
BY ANDREASENBY ANDREASEN
Classification of trauma in injury of hard Classification of trauma in injury of hard tissues and pulp.tissues and pulp.
• This is based on W.H.O. classification.This is based on W.H.O. classification.
• 873.60 873.60 Incomplete fracture. Incomplete fracture.
• 873.61 873.61 Uncomplicated crown fracture. Uncomplicated crown fracture.
• 873.62 873.62 Complicated crown fracture. Complicated crown fracture.
• 873.64 873.64 Uncomplicated crown and Uncomplicated crown and root fracture.root fracture.
• 873.64 873.64 Complicated crown and Complicated crown and root fracture.root fracture.
• 873.63 873.63 Root fracture. Root fracture.Injuries to the periodontal tissues:Injuries to the periodontal tissues:• 873.66 873.66 Concussion. Concussion.• 873.66 873.66 Subluxation (loosening). Subluxation (loosening).
• 873.67 873.67 Intrusive luxation (central Intrusive luxation (central dislocation).dislocation).
• 873.67 873.67 Extrusive luxation (peripheral Extrusive luxation (peripheral dislocation, partial avulsion).dislocation, partial avulsion).
• 873.66 873.66 Lateral luxation. Lateral luxation.• 873.68 873.68 Exarticulation (Avulsed tooth). Exarticulation (Avulsed tooth).
Injuries to the supporting bone:Injuries to the supporting bone:• Mandible No. 802.20, maxilla No. Mandible No. 802.20, maxilla No.
8.2.40 – comminution of alveolar socket.8.2.40 – comminution of alveolar socket.
• Mandible No. 802.20, Maxilla No. Mandible No. 802.20, Maxilla No. 802.40 – Failure of alveolar socket wall.802.40 – Failure of alveolar socket wall.
• Mandible No. 802.20, Maxilla No. Mandible No. 802.20, Maxilla No. 802.40 – Fracture of alveolar process.802.40 – Fracture of alveolar process.
• Mandible No. 802.21, Maxilla No. Mandible No. 802.21, Maxilla No. 802.42 – Fracture of mandible / maxilla.802.42 – Fracture of mandible / maxilla.
Injuries to Gingiva/ Oral mucosa:Injuries to Gingiva/ Oral mucosa:
• 873.69 873.69 Laceration of gingiva/oral Laceration of gingiva/oral mucosa.mucosa.
• 920.X0 920.X0 Contusion of gingiva/oral Contusion of gingiva/oral mucosa.mucosa.
• 910.00 910.00 Abrasion of gingiva or oral Abrasion of gingiva or oral mucosa.mucosa.
• BASRANI CLASSIFICATIONBASRANI CLASSIFICATION• Crown fractures.Crown fractures.
– Fracture of enamel.Fracture of enamel.– Fracture of enamel and dentin.Fracture of enamel and dentin.
•Without pulp exposure.Without pulp exposure.•With pulp exposure.With pulp exposure.
• Root fractures.Root fractures.• Crown root fractures. Crown root fractures.
BY ULFOHNBY ULFOHN
• His classification is based on clinical endodontics His classification is based on clinical endodontics and does not reveal the extent of fracture or and does not reveal the extent of fracture or amount of dentin exposed.amount of dentin exposed.
• He based his classification on 3 aspects:He based his classification on 3 aspects:• Clinical state of the pulp.Clinical state of the pulp.• Pulp and dentin as one organ.Pulp and dentin as one organ.• Determination of treatment.Determination of treatment.• Crown fractures:Crown fractures:
– Of enamel.Of enamel.– With indirect pulp exposure through dentine.With indirect pulp exposure through dentine.– With direct pulp exposure.With direct pulp exposure.
ETIOLOGYETIOLOGY
• Iatrogenic injuries in new Iatrogenic injuries in new
bornborn
• Fall in infancy Fall in infancy
• Child physical abuseChild physical abuse
• Automobile / bicycle AccidentAutomobile / bicycle Accident
• Drug related /Mental Drug related /Mental
retardationretardation
• Dentinogenesis imperfectaDentinogenesis imperfecta
• Contact sportsContact sports
Management of infraction and Management of infraction and fracture of enamelfracture of enamel
• Smoothening of rough edges.Smoothening of rough edges.
• Composite resin using acid-etch Composite resin using acid-etch technique technique
Treatment of enamel and Treatment of enamel and dentine Fracturedentine Fracture• Most effective method is placement of a Most effective method is placement of a
protective material over exposed dentin to protective material over exposed dentin to allow the pulp to form a protective barrier allow the pulp to form a protective barrier e.g. Ca(OH)2 placement (Dycal).e.g. Ca(OH)2 placement (Dycal).
• The fracture site must be covered with a The fracture site must be covered with a restoration material such as acid-etch restoration material such as acid-etch composite restoration.composite restoration.
• Because of the extent of fracture and Because of the extent of fracture and because of esthetics reason – crown may be because of esthetics reason – crown may be required.required.
• Re-attachment of fractured fragments can Re-attachment of fractured fragments can also be done also be done
Treatment of fracture with Treatment of fracture with pulpal involvementpulpal involvement
• Depends on maturity of the tooth.Depends on maturity of the tooth.
Incomplete Root Formation
PULP CAPPING
PULPOTOMY
APEXIFICATION
APEXOGENESIS
Complete root formation
PULPECTOMY
ENDODONTIC TREATMENT
Treatment guideline for avulsed tooth with open apex • Avulsed Tooth Immature Pulp
• Open apex – 2 mm
No Dry Storage Time Dry Storage Time
Repositioning of avulsed tooth with complete root formation
Tooth and socket are cleaned with saline
Prepare socketReposition tooth
Splinting is done