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traumatic injuries
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CONTENTS Introduction Classification Etiology and causes Clinical examination Enamel fractures Uncomplicated crown fracture complicated crown fracture Crown root fracture Root fracture Luxation injuries Avulsion conclusion
Introduction
Traumatic dental injuries are everyday occurrences and their prevalence has been continuously rising. Trauma has been one of the main etiological factor for numerous restorative and endodontic procedures. A thorough knowledge of various types of traumatic injuries is mandatory to treat these cases successfully.
• Ellis classification
class 1
class 2
class 3
class 4
class 5
Class 6
Ellis And Daveys Classification
• Class I – simple crown fracture with plain enamel involvement
• Class II – extended crown fracture with noticeable dentinal involvement, without pulp
exposure• Class III - extended crown fracture with noticeable dentinal
involvement, with pulp exposure• Class IV – teeth that lost vitality, with or without loss of
crown • Class V – traumatically avulsed teeth• Class VI – crown fracture with or without loss of crown
• Class VII - tooth luxation without crown or root fracture• Class VIII – cervical crown fracture• Class IX - traumatic injuries on primary teeth
• WHO classification (1978)873.60 – crown fracture involving only enamel873.61 – crown fracture involving enamel and
dentin without pulp exposure873.62 – crown fracture involving enamel and
dentin with pulp exposure873.63 – root fracture873.64 – crown root fracture873.66 – tooth luxation873.67 – tooth intrusion or extrusion873.68 – tooth avulsion873.69 – other injuries ( soft tissue injuries )
• Andreasen modification of WHO classification
873.64 – complicated and uncomplicated crown root fracture
873.66 – concussion
Subluxation
Luxation injuries with alveolar fractures
• WHO classification (1995)
S.02.5 - Fracture Of ToothS.02.50 - Fracture of enamel only + enamel infractionS.02.51 - Fracture of crown of tooth without
pulpal involvementS.02.52 - Fracture of crown of tooth with
pulpal involvementS.02.53 - fracture of root of toothS.02.54 - Fracture of crown with root of tooth,
with or without pulpal involvementS.02.57 - multiple fractures of tooth
• Andreasen classification Injuries to teeth
Crown infraction and uncomplicated fracture without involvement of dentinUncomplicated crown fracture with involvement of dentinComplicated crown fractureUncomplicated crown root fracture Complicated crown root fractureRoot fracture
• Injuries to periodontal tissues
Concussion
Subluxation
Intrusive luxation
Extrusive luxation
lateral luxation
Exarticulation
• Garcia Godoys classification
Class 0 – enamel crackClass 1 – enamel fracture Class 2 – enamel- dentin fracture without pulp exposure Class 3 – enamel-dentin fracture with pulp exposure Class 4 – enamel-dentin-cementum fracture without pulp
exposureClass 5 – enamel-dentin-cementum fracture with pulp
exposureClass 6 – root fractureClass 7 – concussion
Class 8 – luxation ( loosening )
Class 9 – lateral displacementClass 10 – intrusionClass 11 – extrusionClass 12 – avulsion
• Pulver classificationClass I
Division I – no external fracture, no displacementDivision II – displacement but no fractureDivision III – fracture of enamel only, no
displacementDivision IV – displacement and fracture of
enamel onlyClass II
Division I – fracture of enamel and dentin only, no displacement
Division II - displacement and fracture of enamel and dentin only
Class III
Division I – fracture (with exposure of pulp), no displacement
Division II – displacement and fracture (with exposure of pulp)
Class IV
Division I – fracture of root
Class V
Division I – intrusion
Division II – partial avulsion
Division III –complete avulsion
Heithersay and Morile classification (sub gingival fractures)
Class 1 – fracture line does not extend below the level of attached gingiva
Class 2 – fracture line extends below the level of attached gingiva but above the crest of alveolar bone
Class 3 – fracture line extend below the level of crest of alveolar bone
Class 4 – fracture line is within the coronal third of root but below the level of crest of alveolar bone
Ingle classification
Soft tissuesLacerationsContusionsAbrasions
Tooth fracturesEnamel fractureCrown fracture – uncomplicatedCrown fracture – complicatedCrown root fractureRoot fracture
Luxation injuriesTooth concussionSubluxationIntrusive luxationLateral luxationExtrusive luxationAvulsion
Facial skeletal injuriesAlveolar processBody of mandibleTMJ
Causes and incidence
1. Accidental falls
2. Traffic accidents
3. Acts of violence
4. Sports
7 to 10 years – most accident prone
Maxillary cental incisors, lateral incisors and
then mandibular incisors
Most common dental trauma – enamel fracture or
uncomplicated crown fracture
Clinical examination
Soft tissues- adjacent to fractured teeth should be carefully examined and palpated
Facial bones
Teeth1. Fracture2. Mobility3. Displacement4. Injury to periodontal tissues
5. PULPAL TRAUMAevaluated both initially and at various
times following the trauma
Pulp stunning
Pulp test unpredictable in trauma – why???(Pillegi et al,EDT’96)
LDF – promising practical problems
PULSE OXIMETRYmeasuring vascular health by evaluating
oxygen saturation
highly effective – recently traumatised teeth(Velayutham et al’07)
Prognosis of pulp after different levels of fracture
LEVEL OF FRACTURE PROGNOSIS OF PULP
Enamel infractionEnamel infraction 97 – 100% survival97 – 100% survival
Enamel fractureEnamel fracture 99-100% survival99-100% survival
Enamel – dentin fractureEnamel – dentin fracture
uncomplicateduncomplicated
75-98% survival75-98% survival
0.2%-0.5% obliteration0.2%-0.5% obliteration
Enamel – dentin fractureEnamel – dentin fracture
complicatedcomplicated
Direct pulp capping:72-81%Direct pulp capping:72-81%
Vital amputation 94 -100%Vital amputation 94 -100%
All crown root fracturesAll crown root fractures Worse than crown fractures, no Worse than crown fractures, no reports availablereports available
(Olsburg et al’01)
Prognosis of pulp after luxation injuries
Type of luxation injury Type of luxation injury Pulp deathPulp death
concussionconcussion 4%4%
sub-luxationsub-luxation 12%12%
lateral luxationlateral luxation 77%77%
extrusive luxationextrusive luxation 55 – 98%55 – 98%
intrusive luxationintrusive luxation 100%100%
Barnett et al ‘02
Radiographic examination
- embedded fragments in soft tissues
- dislocations
- root and jaw fractures
- resorptive and calcific changes
Soft tissue injuries
control bleeding, repositioning displaced tissues and suturing
LacerationLaceration
ContusionContusion
AbrasionAbrasion
Enamel fracture
• Chips and cracks confined to enamel
• Enamel infractions – transillumination, indirect light or disclosing dyes
• Cracks – no treatment
• Follow up
Crown fractures (uncomplicated)
• Outcome – formation of irritation dentin or pulp necrosis
Composite Build Up Restores About 100% Strength Recovery
Reattachment of fractured fragment – restores around 50% to 60% of original strength
(worthington et al ’99)
GO IN FOR REATTACHMENT WHENEVER POSSIBLE !!!
Methods of reattachmentA. using circumferential bevel before reattaching
B. using a V shaped notch
C. placing a internal groove
D. placing a chamfer at the fracture line after reattaching
E. superficial over contour over the fracture line
F. simple reattachment
Fracture strength of different reattachment techniquesSuperficial over contour, placing a internal groove provided fracture strength as high as sound teeth (Reis & others ‘01)
Influence of materials used in reattachment on Influence of materials used in reattachment on fracture strength fracture strength
Different material combinations used to bond tooth fragments to remaining crown were found to have no influence on fracture strength after bonding
(Reis, Kraul et al ’02)
Crown fracture (complicated)
0.9 to 13% - all dental injuries Consequence First 24 hrs – proliferative response with inflammation not
extending more than 2mm into pulp
Treatment1. Vital pulp therapy
2. Pulpectomy
Factors affecting treatment selectionFactors affecting treatment selectiona.a. TimeTimeb.b. Attachment damageAttachment damagec.c. Restorative treatment planRestorative treatment pland.d. Level of developmentLevel of development
VITAL PULP THERAPYVITAL PULP THERAPY PULP CAPPINGPULP CAPPING - no absolute indications- no absolute indications
- a bacteria tight coronal seal more difficult- a bacteria tight coronal seal more difficult- 80% success rate- 80% success rate
PARTIAL PULPOTOMY Shallow or CVEK pulpotomy Advantage over deep pulpotomy
Procedure
Prognosis – 94 to 96%
Material of choiceMaterial of choice
CaOH or MTACaOH or MTA
The reparative dentin is consistently more uniform and thicker under MTA compared with CaOH
Heide And Cvek – Safe to proceed with shallow pulpotomies upto 1 week post fracture
FULL PULPOTOMY
Traumatic exposures after 72 hours Technique Prognosis – 75%
Contraindicated – mature teethpulpectomy has a success rate 95%, whereas if apical
periodontitis develops, the prognosis of RCT drops to 80%.
Other treatmentsOther treatments
a.a. PulpectomyPulpectomy
b.b. Apexification proceduresApexification procedures
CaOH apexificationCaOH apexification MTA apexificationMTA apexification
CROWN – ROOT FRACTURE
Complicated and uncomplicatedComplicated and uncomplicated
Treatment modalitiesTreatment modalities
ReattachmentReattachment
Restorative TreatmentRestorative Treatment
Crown root fracture and biological width
Biological width – Biological width – connective tissue attachment + connective tissue attachment + junctional epitheliumjunctional epithelium
Andersean et al – 4mm tooth structure above crest of alveolar bone
Methods Methods a.a. Periodontal surgeryPeriodontal surgery
b.b. Surgical extrusionSurgical extrusion
c.c. Orthodontic extrusionOrthodontic extrusion
Periodontal surgery
Apically repositioned flap surgeryApically repositioned flap surgeryesthetics??esthetics??
When to go for gingivectomy???When to go for gingivectomy???
Surgical extrusion (intra-alveolar transplantation)
ProcedureProcedure
AdvantagesAdvantages
DisadvantagesDisadvantages
surgical extrusion of average 4.25mm ( 3 – 7mm) can be performed without any complication and good
long term success (caliskan et al ’99 )
Healing after surgical extrusion
Orthodontic extrusion
Slow or forced extrusionSlow or forced extrusion
ProcedureProcedure
Time of treatment – 2 to 3 weeksTime of treatment – 2 to 3 weeks
Stabilisation – 2-3 monthsStabilisation – 2-3 months
Orthodontic extrusion with supracrestal fibrotomy ( Ami Smidt et ’05 )
Force required –25 to 30 g ( Reitan and Vanarsdall ’94 )
50 to 75 g ( Profitt and Fields ’93 )
Root fracture
• Types – Types – transverse or obliquetransverse or obliquesingle or multiplesingle or multiplecomplete or incompletecomplete or incomplete
• Radiographs – angled within 4 degrees of fracture lineRadiographs – angled within 4 degrees of fracture line• Additional radiograph at 45 degrees ( INGLE )Additional radiograph at 45 degrees ( INGLE )• At least 3 angled radiographs – 45, 90 , 110 degrees At least 3 angled radiographs – 45, 90 , 110 degrees
( COHEN( COHEN ) )
• Displacement - none to severeDisplacement - none to severe• Biological consequenceBiological consequence
pulp necrosis of coronal part – 25%pulp necrosis of coronal part – 25%pulp necrosis of apical part – rare
Emergency treatmentEmergency treatment
a. Repositioning – finger pressure or a. Repositioning – finger pressure or orthodontic interventionorthodontic intervention
b. Splinting - 2 to 4 weeksb. Splinting - 2 to 4 weeks
• Healing pattern of root fracturesHealing pattern of root fractures(Andresean and Hjorting-Hansen)
1. Healing With Calcified Tissue
2. Healing with interproximal connective tissue
3. Healing with interproximal bone and connective tissue
4. Interproximal inflammatory tissue without healing
First 3 types - success
• TREATMENT OPTIONSTREATMENT OPTIONS
a.a. Root canal therapy of both segmentsRoot canal therapy of both segments
b.b. Root canal treatment of coronal segment Root canal treatment of coronal segment alonealone
c.c. Use of intraradicular splintUse of intraradicular splint
d.d. Root extrusionRoot extrusion
Cvek modification of root canal therapy of coronal segment alone
• PrognosisPrognosis- amount of dislocation, stage of root development - amount of dislocation, stage of root development and quality of treatment.and quality of treatment.
• Fracture location on prognosisFracture location on prognosisMore apical the fracture, better the prognosis More apical the fracture, better the prognosis
MISCONCEPTIONMISCONCEPTION
- location did not influence outcome ( Zachrisson and
Jacobsen )
- fracture location matters less as long as it is not too close to the alveolar crest
( Jacobsen )
• ComplicationsComplications
a.a. Pulp necrosisPulp necrosis
b.b. Pulp canal obliterationPulp canal obliteration
Deep root fracture without pulp necrosis
Deep root fracture with pulp necrosis
Autotransplantation for shallow root fracture
Deep root fracture with coronal and apical pulp necrosis
Luxation injuries
Largest group – 30 to 44%
Includes1. Concussion2. Subluxation3. Extrusive luxation4. Lateral luxation5. Intrusive luxation6. Avulsion
concussion
No displacement Normal mobility Sensitivity to percussion
Management
symptomatic
D. Diagnosis
root fracture, subluxation
subluxation
Sensitivity to percussion Increased mobility No displacement
Mangement
optional splinting for 2 to 3 weeks
D. Diagnosis
root fracture
Pulp death in 12 to 20%
Lateral luxation
Displacement labially, mesially, distally or palataly
Management
repositioning
splinting (2 – 3 months)
Extrusive luxation
Displacement in coronal direction
Differential Diagnosis
root fracture
Management
1. Repositioning
2. Splint – 1 - 3 weeks
Intrusive luxation
Displacement in apical direction
into alveolus Poorprognosis
Management
1. No treatment in immature teeth
2. Repositioned – surgical or
orthodontic or combination
Sequalae to luxation injury
Yellow discoloration Grey discoloration Resorption – 5 to 15% Incomplete root formation
Primary teeth – pulp space obliteration by calcification
Healing events2 weeks afterreplantation Most
Healing with minorinjury to the periodontal ligament
Healing with moderate injury to theperiodontal ligament and associated infection in the pulp and/or dentinal tubules
Healing afterextensive injury to theperiodontal ligament
Hank’s Balanced Salt Solution (HBSS),
Viaspan® ,Euro-Collins® , Custodiol
Minimum Essential Medium (MEM)
Saline , Water, Saliva, Milk, Propolis ,
Red mulberry, Egg white, Coconut water,
Gatorade ,Ricetral,,Green tea , Conditioned medium
Contact lens solution , Salvia extract,
Tooth rescue box (Dentosafe)
Storage medium
Desired – PDL viability
Saliva, saline and tap water
Hanks balanced salt solution (HBSS) standard saline solution
non toxic, pH balanced and contains essential nutrients
‘Save-A-Tooth’
– no longer recommended
Milk
PDL cell viability – physiological osmolality
Milk with a lower fat content more useful at maintaining cell viability than milk with higher fat content
(Sigalas et al ’04)
longer shelf life milk with lower fat content – tested (Ozan et al’07)
Propolis
Multifunctional material
anti inflammatory, antibacterial, antioxidant, antifungal, antiviral and tissue regenerative
properties
10% Propolis better than milk, HBSS
(Ozan et al’07)
Order of preference
By literaturePropolisPropolis
HBSSHBSS
Long shelf life Milk with low Long shelf life Milk with low fat contentfat content
Milk with high fat contentMilk with high fat content
SalineSaline
SalivaSaliva
By availabilityLong shelf life milk with low Long shelf life milk with low
fat contentfat content
Milk with high fat contentMilk with high fat content
SalineSaline
SalivaSaliva
Contact lens solution – alternative (Sigalas et al’04)
Treatment objectives
Avoid or minimize – inflammation
1. attachment damage
2. pulpal infection
PREPARARTION OF SOCKET
Left undisturbedLeft undisturbed
Light aspiration – remove blood clotLight aspiration – remove blood clot
Alveolar bone collapse – reposition using blunt Alveolar bone collapse – reposition using blunt instrumentsinstruments
Rinse of emdogainRinse of emdogain
Clinical Management of avulsed teeth
Preparation of rootPreparation of root
Extra oral time
Less than 60 minutesLess than 60 minutes Greater than 60 minutesGreater than 60 minutes
Closed apexClosed apex Open apexOpen apex
Root development
Replantation of a tooth with completed root formation
Replanting a tooth withincomplete root formation
Extra oral time more than 60 minutes
‘EXARTICULATION’
Attachment damage and pulp necrosis
Why osseous replacement or replacement
resorption occurs???
External inflammatory resorption after avulsion???
Development of inflammatory root resorption and pulp necrosis
Development of ankylosis
EMDOGAIN EMDOGAIN - Increase resistance to root resorption- Stimulate PDL regeneration
(Fillipi et al’01)- inhibits epithelial cell growthinhibits epithelial cell growth
How does it act ??How does it act ??
Emdogain – does not prevent progressive root resorption.
(Schjott at al’05)
Splinting
Splinting – technique and durationSplinting – technique and duration
Splinting technique – physiological tooth Splinting technique – physiological tooth movementmovement
Duration – minimalDuration – minimal
Splinting techniques
a. Rigid
b. Semi rigid
TypesBracket splint
Composite Resin splint
Acrylic or gold cap splints
Orthodontic bands + arch bar splints
Composite – wire splint / bonded metal wire splint
Titanium trauma splint (TTS)
TTS required reduced chair side time – application and removal
(VonArx et al’01)
TTS and composite wire splint – less gingival irritation, well tolerated
(Fillipi et al’02)
TTS and composite wire splint – allowed physiological mobility
Duration of splinting
Root fracture – 2 to 4 weeks (2 – 4 months)
Avulsion – 7 to 10 days
Avulsion with alveolar fracture – 4 to 8 weeks
Lateral luxation – 3 to 4 weeks
Extrusive luxation – 4 to 8 weeks
Sub luxation – 2 to 3 weeks (optional)
concussion – 1 to 2 weeks (optional)
Adjunctive therapy Systemic and topical antibiotic application
Tetracycline – affects osteoclast motility + reduction of collagenase effectiveness
(Sae-Lim et al’98)
Systemic pencillin
Chlorhexidine rinses
Tetanus booster – within 48 hours
Various factors influence the outcome of teeth that
had undergone trauma. Correct diagnosis, quality and
timeliness of initial and long term treatment can improve
the prognosis of the traumatized teeth.
Conclusion
REFERENCES
- Essentials of traumatic injuries to the teeth J.O.Anderasen and F.M. Anderasen
-Treatment planning for traumatized teeth - Mitsuhiro tsukiboshi
-cohen’s pathways of the pulp tenth edition
- Ingle’s –Endodontics 6th edition
- Storage Media For AvulsedTeeth: A Literature Review Brazilian Dental Journal (2013) 24(5): 437-445
- Transport media for avulsed teeth: A review Aust Endod J 2012; 38: 129–136
- A proposal for classification of tooth fractures based on treatment needJournal of Oral Science, Vol. 52, No. 4, 517-529, 2010
Assessment of pulp vitality: a reviewInternational Journal of Paediatric Dentistry 2009; 19: 3–15
STUDY OF STORAGE MEDIA FOR AVULSED TEETH Brazilian Journal of Dental Traumatology (2009) 1(2): 69-76
Fracture resistance of tooth fragment reattachment: effects of different preparation techniques and adhesive materials Dental Traumatology 2010; 26: 9–15;