The traumatic injuries of permanent teeth and complex therapy

Dr. Katalin Déri

Semmelweis EgyetemDepartment of Pedodontics and Orthodontics

Risk Risk

• Angle II/1

• Predisposing factors:

overjet

protrusion of upper incisors

insufficient lip closure

InjuriesInjuriesSport related - 1.5% -3.5%Sport related - 1.5% -3.5%

InjuriesInjuriesPlayground - schoolPlayground - school

InjuriesInjuriesFightsFights

InjuriesInjuriesCar accidentCar accident

Age distributionAge distributionTherapeutic significance

8-13 years the highest incidence

• Peak at the age of 10

SexSex

0

25

50

75

100

Boys - 153 Girls - 59 All - 212

Clinical data

0,0 22,5 45,0 67,5 90,0

Upper central incisors- 85.39%

Upper lateral incisors -10.06%

Lower central incisors- 3.57%

Lower lateral incisors -0.97%

Incidence of injured teeth in %Incidence of injured teeth in %

AnamnesisAnamnesis general anamnesisgeneral anamnesis

circumstances of injurycircumstances of injury

black-out, amnesia, headache, black-out, amnesia, headache, nausea, vomitnausea, vomit

previous injuries : consequences, previous injuries : consequences, complicationscomplications

dental anamnesisdental anamnesis

Most important Most important questionsquestions

When?When? Time past between the injury and the treatmentTime past between the injury and the treatment

Where?Where? Risk of infectionRisk of infection

How?How? Mechanism of the injury, polytraumaMechanism of the injury, polytrauma

0

9

18

26

35

0 day 1 day 2 days 5 days 1 week 2 weeks 3 weeks 4 weeks 6 weeks 2 months 6 months 1 year 3 years

Time elapsed after injury

Clinical examinationClinical examination

Extraoral examinationExtraoral examination

Intraoral examinationIntraoral examination

Photo documentationPhoto documentation

X-rayX-ray

Type of injuriesType of injuries

• Traumatic injuries involving:Traumatic injuries involving:

the permanent teeththe permanent teeth

the alveolar bonethe alveolar bone

the soft tissuesthe soft tissues

Classification of dental injuriesClassification of dental injuries(International Association of Dental Traumatology, 2001)(International Association of Dental Traumatology, 2001)

1.1. Coronal fractureCoronal fracture

2.2. Coronal and root fractureCoronal and root fracture

3.3. Root fractureRoot fracture

4.4. Fracture of processus alveolarisFracture of processus alveolaris

5.5. Luxations and avulsionLuxations and avulsion• (contusion, subluxation, lateral luxation, extrusion, intrusion, (contusion, subluxation, lateral luxation, extrusion, intrusion,

avulsion)avulsion)

Classification of dental Classification of dental injuriesinjuriesPedodontics and Orthodontics textbookPedodontics and Orthodontics textbook1.1. Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis

2.2. Luxatio partialis dentis Luxatio partialis dentis permanentispermanentis

3.3. IntrusioIntrusio

4.4. Fractura coronae dentis Fractura coronae dentis permanentispermanentis

5.5. Fractura radicis dentis Fractura radicis dentis permanentispermanentis

Avulsion Avulsion : complete displacement of a tooth : complete displacement of a tooth

Luxatio totalis dentis Luxatio totalis dentis permanentispermanentis

Luxatio partialis dentis Luxatio partialis dentis permanentispermanentis

loosening of the tooth or a loosening of the tooth or a partial displacement of the partial displacement of the tooth out of its sockettooth out of its socket

a. subluxation

b. lateral luxation

c. extrusion

a. b. a. b. c. c.

Luxatio partialis dentis Luxatio partialis dentis permanentispermanentisDisplacementDisplacement

• subluxation:

• sensitive to touch

• slightly mobile

• no displacement

• bleeding

• extrusion:

• axial (and lateral) displacement

• mobile

clinical examination

Luxatio partialis dentis Luxatio partialis dentis permanentispermanentisDisplacementDisplacement

• lateral luxation:

• lateral displacement

• locked in the alveolar bone

• no mobility

• not sensitive

• ankylotic signs

Luxatio partialis dentis Luxatio partialis dentis permanentis - luxatio permanentis - luxatio lateralislateralis

3.3. Intrusion Intrusion

displacement of the displacement of the tooth into the tooth into the alveolar bonealveolar bone

(axial dislocation)(axial dislocation)

Fractura coronae dentis Fractura coronae dentis permanentispermanentis Types of coronal fracture

• Most frequent injury

enamel onlyenamel only enamel and dentineenamel and dentineenamel and dentineenamel and dentinewith the pulp exposedwith the pulp exposed

Fractura coronae dentis Fractura coronae dentis permanentispermanentis

fracture without fracture without complicationcomplication

complicated fracture (with complicated fracture (with pulp exposition)pulp exposition)

Fractura radicis dentis Fractura radicis dentis permanentispermanentisRoot fracture

Fractura radicis dentis Fractura radicis dentis permanentispermanentis

1.1. cervical thirdcervical third

2.2. middle thirdmiddle third

3.3. apical thirdapical third

+1.+1. axial fractureaxial fracture

Complex therapyComplex therapy

Treatment of the injuries: AvulsionTreatment of the injuries: Avulsion1. 1. Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis

• Actions out of surgery:

Suitable storage: in wet agent

1. physiological saline

2. saliva

3. milk

4. Dentosafe-Zahnrettungsbox

Treatment of the injuries: Treatment of the injuries: AvulsionAvulsion

Aim: replantation as soon as possible• the ligaments and cells loose their vitality after 1

hour

1. Preparation of the tooth and the alveolar socket

2. Replantation

3. Stabilization – using the neighboring• teeth for splinting

• acrylic splint

• composite bonding with orthodontic archwire

• brackets

4. Woundtreatment (debridement, suturing, hemorrhage control)

Prognosis: max. 1 hour extra-alveolary

Fixation: closed apex - 7-10 days

• open apex - 2 weeks (neurovascular reanastomosis)

In mature tooth with closed apex, or in immature tooth with open apex but time elapsed > 30 min.

• In 1 week root canal treatment - Ca(OH)2 should be placed

• to prevent the initiation of inflammatory root resorption

Treatment of the injuries: Avulsion1. Luxatio totalis dentis permanentis

Instructions1. pulpy diet

2. toothcleaning with soft toothbrush

3. 0,1 % chlor-hexidine

Supplementary therapy1. Antibiotic treatment

2. Tetanus (immunization status?)

Treatment of the injuries: AvulsionTreatment of the injuries: Avulsion Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis

If replantation is not possible ( e.g.: in the case of loss of the tooth )

1. Temporary solution:

• acrylic bridge

• orthodontic appliance (with an acrylic tooth)

2. Final solution:

• orthodontic treatment

• implantation

• combined treatment

Treatment of the injuries: AvulsionTreatment of the injuries: Avulsion Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis

Temporary solution

Healing after replantationHealing after replantation

regeneration of the gingiva

revascularisation of the ligaments

renewal of the Sharpey ligaments

open apex - revascularisation and reinnervation

• Cave: high bacterial contamination- healing is limited or impossible

Treatment of the injuries: Treatment of the injuries: DisplacementDisplacement2. 2. Luxatio partialis dentis permanentisLuxatio partialis dentis permanentis

• Subluxation

•no need to splint for stabilization

•observation - x-rax (1 year)

•root canal treatment (pathological sign)

Treatment of the injuries: Treatment of the injuries: DisplacementDisplacement2. 2. Luxatio partialis dentis permanentisLuxatio partialis dentis permanentis

• lateral luxation

• extrusion

1. reponation ( following the injury )

• fixation for 2-3 weeks

2. later : orthodontic reposition

3. root canal treatment ( in case of the tooth with closed apex )

Treatment of the injuries:Treatment of the injuries: 3. Intrusion3. Intrusion

Open apex : there is a chance of Open apex : there is a chance of spontaneous re-eruption spontaneous re-eruption

Closed apex :Closed apex :

1.1. surgical or orthodontic repositionsurgical or orthodontic reposition

2.2. splintsplint

3.3. root canal treatmentroot canal treatment

Treatment of the injuries:Treatment of the injuries: 3. Intrusion3. Intrusion

orthodontic or surgical repositionorthodontic or surgical reposition

Treatment of the injuries:Treatment of the injuries:Fractura coronae dentis Fractura coronae dentis permanentispermanentis

The treatment of The treatment of crown fracture crown fracture depends on which depends on which third of the crown third of the crown is injuredis injured

Treatment of the injuries:Fractura coronae dentis permanentis

a. Enamel injuries:

1. Minor enamel fractures : polishing, fluoride solution ELMEX

2. Larger enamel fractures (1-2mm or more): composite restoration

Treatment of the injuries:Treatment of the injuries:Fractura coronae dentis permanentisFractura coronae dentis permanentis

b. Enamel – dentine injuries without pulp exposition - immature tooth

1. Calcium hydroxide liner

2. Temporary crown ( celluloid, acrylic ) – 1 year (GIC) – protective covering

3. X – ray control

4. Final restoration (closed apex)

b. Enamel – dentine injuries without pulp exposition -mature tooth

• Final restoration

Fractura coronae dentis Fractura coronae dentis permanentis temporary crown - permanentis temporary crown - incisal restorationincisal restoration

Rebonding of fractured crownRebonding of fractured crown

Treatment of the injuries:Treatment of the injuries:Fractura coronae dentis Fractura coronae dentis permanentispermanentis

c. Pulp exposition• Important:

1. size of the pulp exposure

2. time between the injury and the treatment

3. root development

Treatment of the coronal fracture in case of pulp exposition

exposition timeroot

development  

small 1 – 2 hours

open or closed apex

direct pulp capping

larger than1 mm more, than 3 hours open apex pulpotomy

x-large long time closed apex pulpectomy

Direct pulpcapping - Ca(OH)2/ MTA

Pulpotomy – partial or total elimination of coronal pulp tissue

sterile round steel bur or excavator

haemorrhage control

Ca(OH)2/MTA + GIC /polikarboxilate cement

Pulpectomy – elimination of all the pulp tissue -

Ca(OH)2

Final root canal filling (closed apex)

Regular re-call!!!

Treatment of the injuries:Treatment of the injuries: Root fracture Root fracturea. fracture in cervical third:

• Worst prognosis

1. Elimination of coronal part

• root canal treatment

• orthodontic extrusion

• restoration

2. Extraction + implantation

b. fracture in middle third:

1. Reposition of coronal part

2. Splint ( 1-2 months )

3. Root canal filling

4. Transradicular fixation can be an option (silver point)

c. Fracture in apical third

• observation,

• In case of necrosis - In case of necrosis - Ca(OH)2, Ca(OH)2,

• - Final root canal filling after healing- Final root canal filling after healing

• If coronal part is dislocated If coronal part is dislocated

• - reposition and fixation for 1 month - reposition and fixation for 1 month

Treatment of the injuries:Treatment of the injuries: Root fracture Root fracture

Fractura radicis dentis Fractura radicis dentis permanentis Healingpermanentis Healing

Soft tissue hard tissue

granule tissue

Possible consequences of Possible consequences of traumatic injuriestraumatic injuries

Peripheral (external) root resorptionPeripheral (external) root resorption

• Trauma with damage to the periodontal structures, pulp may not become involved

MacrophaMacrophagesges , osteoclast , osteoclastss

In cases of severe trauma, with some degree of displacement of the tooth

Diagnosis – 1 week after injuryDiagnosis – 1 week after injury

Possible consequences of Possible consequences of traumatic injuriestraumatic injuries

Inflammatory root resorptionInflammatory root resorption

Trauma with damage to the periodontal AND pulp Trauma with damage to the periodontal AND pulp tissuestissues

BaBacterial toxinescterial toxines

Rapid, progressive Rapid, progressive

Intrusion, replantationIntrusion, replantation

Diagnosis – 2-4 weeks after the injuryDiagnosis – 2-4 weeks after the injury

Severe cases – total root resorption in 1 monthSevere cases – total root resorption in 1 month

Possible consequences of Possible consequences of traumatic injuriestraumatic injuries

Ankylosis injury to the periodontal ligament and subsequent

inflammation

associated with invasion by osteoclastic cells

cement resorption – repaired by bone regeneration

mechanical lock / fusion between alveolar bone and root surface

Diagnosis:

Radiological : 2 months

Clinical: 1month – typical ankylotic sound for percussion

Possible consequences of Possible consequences of traumatic injuriestraumatic injuries

• Pulpal necrosis

• signs:

• discoloration

• no response for vitality test

• sensitive for percussion

• periapical laesion

• if 2 of them presents - root canal treatment –Ca(OH)2

• Obliteration

• Calcific metamorphosis of the dental pulp ( progressive canal calcification / dystrophic calcification)

• Although the radiograph may give the illusion of complete obliteration, an extremely fine root canal and remnants of the pulp will persist

• yellowish opaque colour of the crown

• rct can be done if necessary

Possible consequences of Possible consequences of traumatic injuriestraumatic injuries

PreventionPrevention

• Protectors

• Requirements:

cover of the teeth, gingiva, alveolar bone

do not influence the relation of jaws

do not disturb breathing

resistant and durable

hygienic

possible application on fixed orthodontic appliances

PreventionPrevention

• Mouthguard:

• Confectional

• Prefabricated

• Individual

Education!!!Education!!!

Warning - Child Warning - Child abuse!!!!abuse!!!!

Signs:Signs:

• time elapsed after the injury: weeks or monthstime elapsed after the injury: weeks or months• confused, frightened childconfused, frightened child• parents and child don’t tell the same storyparents and child don’t tell the same story• anamnesis is not in accordance with theanamnesis is not in accordance with the

result of clinical examinationresult of clinical examination• recurring injuriesrecurring injuries

Case reportCase report• 20 20 years old boyyears old boy

• Street fightStreet fight

• oral surgery ambulance – ‘’dental splint’’oral surgery ambulance – ‘’dental splint’’

• orthodontic clinic – 3 days afterorthodontic clinic – 3 days after

• still very mobile upper front teethstill very mobile upper front teeth

RadiographsRadiographs

13 13 root fracture in middle thirdroot fracture in middle third13, 12, 11, 21, 22, 23 13, 12, 11, 21, 22, 23 extrusionextrusion, , palatal dislocationpalatal dislocationall upper anterior teeth are very mobileall upper anterior teeth are very mobile

except except 13, all 13, all upper upper anterior anterior teeth teeth show show vitalityvitality

Treatment planTreatment plan• Slow reposition of dislocated teeth with fixed Slow reposition of dislocated teeth with fixed

orthodontic appliance (1 year )orthodontic appliance (1 year )

• 13 13 rct ; transradicular fixation (silver point) rct ; transradicular fixation (silver point) /temporary//temporary/

• Frequent control of all the upper anterior teethFrequent control of all the upper anterior teeth

• first patological sign - rctfirst patological sign - rct

• After debonding – fix and removable retainerAfter debonding – fix and removable retainer

TreatmenTreatmentt

13 transradicular fixatio13 transradicular fixationn((silver point and endomethasonsilver point and endomethason))

after treatmentafter treatment 22 months later months later

Pulpal necrosis of Pulpal necrosis of 22 22

Needle Needle controlcontrol

RCF controlRCF controlSign of rootSign of root resorptio resorptionn

Result of Result of treatmenttreatment

Thank you for Thank you for youryour kind kind attention!attention!