Trauma in Dentistry

Chapter 01
Introductory Chapter: Etiology,

Diagnostic, and Treatment
Procedure at Traumatic Cases in
Dentistry
Serdar Gözler
1. Introduction
Dental trauma presents one of the most important situations where clinicians
are called upon to make unscheduled diagnostic and treatment approaches in an
area that is outside their routine experience. Guidelines have been outlined for man-
agement of numerous dental and medical conditions. Traumatic cases in dentistry
are classified by many sources; however, the World Health Organization’s (WHO)
classification system is the most comprehensive system which allows for minimal
subjective interpretations. The WHO traumatic classification system is built up
according to the following situations [1]:
1. Fracture of enamel of tooth,
2. Fracture of crown without pulpal involvement,
3. Fracture of crown with pulpal involvement,
4. Fracture of root of tooth,
5. Fracture of crown together with the root,
6. Unspecified tooth fracture,
7. Tooth luxation,
8. Intrusion and/or extrusion of teeth
9. Avulsion of teeth,
10. Other type of injuries including burns and laceration.
Most of the reported traumatic cases come from falls while children play [2]. At
the present time, the dental trauma term must also be included for dental treatment
sourced from traumatic cases. There are various invasive restorative dental treat-
ment models in modern dentistry at the present time. For example, dental implant
treatments, tissue repair purpose treatments, augmentations of maxillary sinuses,
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Trauma in Dentistry
and full mouth ceramic restoration treatments are restorative treatments which
have extreme trauma risks.
Traumatic cases need urgent diagnosis and quick treatment. However, accord-
ing to a review article by Andrease et al., there are few studies showing a positive
relationship between treatment delay and pulpal and periodontal ligament heal-
ing complications [3]. Practical and most economic reasons are fulfilled such as
demand for acute treatment (i.e. within a few hours) or delayed (i.e. after the first
24 hours) in traumatic cases. But it is commonly accepted that all injuries should be
treated within few hours, for the comfort of the patient and also to reduce wound
healing complications.
Another type of dental trauma is post-op developed traumatic cases which
are based on bad occlusion usually. In many cases, sinus augmentation may be
necessary; in this case, augmented sinus tissue must be supported by a biomate-
rial. Implants are placed when the biomaterial is set like a wall. The implants will
bear occlusal forces after finishing implant-supported crowns. In some cases,
biomaterial wall cannot bear the occlusal forces of implant-supported crowns and
then collapses. That kind of problems is related to premature contact originated
occlusal trauma. Traumatic occlusion is the most important reason for the break-
ing of the restorations or collapse of the operating area under the pressure of high
occlusal load. Early occlusal contacts force the area with all cumulative occlusal
pressure of the jaws. There may not be a problem if there is an adequate thickness
set at the sinus augmentation. But in some cases, under the high occlusal forces,
the biomaterial wall cannot bear the load and collapses consequently. Sometimes,
sinus wall tears and the implant is mobilized to the far side of the sinus. The first
action must take out the dislocated implant from the exposed sinus and repair
the sinus wall. Generally, the accepted protocol is to wait after repair of the sinus
area and then continue the implant treatment again [4, 5]. There are various
approaches for the planning of dental implants: the number of implants, their
locations, inclinations, quality of supporting bone, etc. In its wider sense, this
includes considerations of multiple inter-related factors of ensuring adequate
bone support, implant location number, length, distribution, and inclination,
splinting, vertical dimension esthetics, occlusal schemes, and more [6]. Every dif-
ferent alternative of the planning of implant treatment will have a different effect
on implant-supported restoration. The difference is related to the occlusal scheme
of the prosthetic restoration.
Dentists must take their decisions according to their past experiences because
the patients in avulsion are rare except children patients and emergency patients
[7]. Additionally, clinicians must trust the preparation guidelines for trauma
standards and the protocols stated before.
The protocols are set before but they have not tested for prospectively longitudi-
nal studies in human. However, all protocols are set before and have found a strong
place for routine applications clinically.
Periodontal wound healing protocols must be taken specially and must be based
on biological reasons.
Permanent teeth’s avulsions are the most serious of all dental traumatic cases.
The prognosis of the treatment depends on the time taken at the place of accident
or the time immediately after the avulsion [7]. Appropriate emergency manage-
ment and treatment plan are important for a good prognosis. Guidelines are usu-
ally useful for delivering the best treatment possible in an efficient manner. The
International Association of Dental Traumatology (IADT) has developed a consen-
sus statement after a review of the dental literature and group discussions.
2
Introductory Chapter: Etiology, Diagnostic, and Treatment Procedure at Traumatic Cases…
DOI: http://dx.doi.org/10.5772/intechopen.86630
Unlike deciduous teeth, permanent teeth rarely undergo root resorption. Even
in the presence of periodontal and radicular inflammation, resorption will occur
primarily on the support bone side of the attachment apparatus and the root will be
resistant to it [8].
Facial trauma that results in fractured, displaced, or lost teeth (deciduous or
permanent) can have significant negative functional, esthetic, and psychologi-
cal effects on children. Clinicians should collaborate to educate the children and
parents about the prevention and treatment of traumatic injuries to the oral and
maxillofacial area.
2. D
iagnosis and treatment procedures according to the types of the
traumatic cases
2.1 Radiographic examination
Several radiographic images must be taken from every patient in different

angles, but the final decision is up to the clinician [9].
The following are suggested:
• X-ray image with 90° parallel with central rays through the examined tooth.
• Occlusal radiological examination.
• A lateral angulated dental periapical image which includes the mesial or distal
aspects of the teeth examined as much as possible.
Cone-beam computerized tomography is extremely useful at this stage. It can be

used for radiographic examination in detail of root fractures, mobility of teeth, peri-
odontal status, and peripheral destructions of teeth. The CBT Radiographic System
may not be available in every clinic; it may not be used routinely, but advantages of
the system cannot be compared with those of conventional systems. Information for
dental application of CBT is documented very well in the scientific literature.
Figure 1.
Nonrigid splints can be used for stabilization of mobilized and fractured teeth.
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Trauma in Dentistry
2.2 Clinical examination, basic principles, and suggestions
There are many protocols and approaches to the clinical examination. They are
very well classified and documented in current textbooks for assessment of TDIs [1].
2.3 Fixation with splints and their using period
According to the recent researches, using short-term nonrigid splints for treat-
ment of luxated, fractured, and avulsed teeth is supported (Figure 1). Basically,
splints are essentials for the patient’s comfort and improvement of functions, and
they are useful to maintain the location and correct position of teeth [9–11].
2.4 Medical treatment, antibiotics
There is no strong evidence for using systemic antibiotics for traumatic cases,
luxation management, and coverage improvement of root fractures of teeth. This
option is not mandatory and it is up to the dentist’s own decision according to the
past experience. Root fractures and related injures of teeth and soft tissue may
need surgical intervention. Use of antibiotic option is harmonized to the surgical
operations and especially it may be useful for the soft tissue healing procedure
[12, 7]. Soft tissue injuries, treatment methods, and healing procedure informa-
tion are neither comprehensive nor detailed information is found in textbooks,
the scientific literature, and, most recently, the Dental Trauma Guide (DTG)
that can be accessed on http://www.dentaltraumaguide.org. Additionally, the
DTG, also available on the IADT’s web page http://www.iadt-dentaltrauma.org,
provides a visual and animated documentation of treatment procedures as well as
estimations of prognosis for the various TDIs [13].
2.5 Use of antibiotics
There is no strong evidence for using systemic antibiotics for traumatic cases,
luxation management, and coverage improvement of root fractures of teeth. This
option is not mandatory and it is up to the dentist’s own decision according to the past
experience. Root fractures and related injures of teeth and soft tissue may need surgi-
cal intervention. Use of antibiotic option is harmonized to the surgical operations and
especially it may be useful for soft the tissue healing procedure [14, 15, 2, 16].
2.6 Sensitivity tests
Sensitivity tests (cold test and electrical pulp test) are necessary for improving
the pulp condition. Especially in an emergency atmosphere of a traumatic condi-
tion, revealing of pulp condition is one of the important attempts for treatment
steps. Therefore, at least two signs and symptoms are necessary to make the diag-
nosis of necrotic pulp. Regular follow-up controls are required to make a pulpal
diagnosis.
2.7 Vitality of permanent teeth
The basic principle is that maximum endeavor should be made for the protection
of pulp vitality in a permanent tooth improving root development. Loss of a tooth
in the period of childhood will produce occlusal source many complications. The
immature permanent tooth can recover easily after exposing the pulp in traumatic
4
tooth/root fractures. In traumatic cases, root canal treatments are the most reason-
able treatment for maintaining root development [8]. Additionally, emergency
treatment of traumatized teeth can accelerate healing of the teeth.
2.8 Traumatic occlusion
As a dental practitioner, we may cause occlusal trauma. We change the occlusal

surfaces of teeth when we make functional and esthetical restorations in clinical
practice. Usually, natural teeth have adapted and shaped occlusion in the develop-
mental period of humans, especially the development of the craniofacial area [17].
Muscles, bones, and teeth must be in full harmony. But sometimes, they may not be
in accordance with accepted rules or standards, especially anatomically. The neural
system also adapts to that inappropriate structure and there does not exist any high
neuronal impulse in the neural system that may cause excessive contraction of mas-
ticatory muscles [18]. The dentist may change this complex, improper but harmonic
structure. Dental treatment procedures may disrupt this harmonic relationship
when we make composite restoration, orthodontic treatment, prosthetic, and/or
implant restoration. In order to avoid traumatic occlusion, occlusal compliance in
dental restorations should be at the highest possible level.
Occlusal trauma may be spotted in the following situations:
1. Prosthetic restorations
2. Implant supported prosthesis
3. Composite fillings
4. Orthodontic treatment
5. Oral surgery operations
6. Accidents
The main reason for the occlusal trauma is premature contact in the occlusion.
Every dentist must be able to manage premature contacts in dental treatments.
Occlusal trauma is one of the most common problems of dental treatment. Every
dentist must be extremely careful about avoiding dental premature contacts.
Trauma itself is not a disturbance, trauma is a result of an event. Trauma is the
damage of tissue and/or organs. Trauma and its consequences may be acute or chronic.
The acute situation is the result of the quick reflex response of the neuromuscular
system to the premature contacts; however, the chronic situation may be developed
within days, weeks, or years. The perception of the occlusal irregularity and a reaction
to that problem is managed by the central nervous system (CNS). During human life,
the main function of the masticatory muscles is to break food down into pieces small
enough to be swallowed. CNS is like a protection mechanism of the stomatognathic
system in that function. These are strong muscles that generate very large forces
across in very short distances and apply them via rigid teeth. Such large forces can
easily damage the teeth and their supporting tissues, tongue, cheeks, and the joints
unless they are controlled precisely and effectively [3]. If the trauma is a system for
protection of the stomatognathic structures, pain is the alarm ring bell of that system.
One of the biggest problems of prosthetic restorations is occlusal premature
contacts. Early occlusal contacts cause the imbalance of dentures and it may
5
Trauma in Dentistry
fracture the ceramic restorations. Unbalanced dentures are the reason for occlusal
trauma and they may cause irritation on soft tissue and then tissue deteriorations
consequently (Figure 2).
Occlusal premature contacts are effective on the way from the first contact to the
maximum intercuspal position (MIP). It is not easy to detect premature contact at
developing occlusion (Figure 3).
Figure 2.
Occlusal trauma caused by an upper denture.
Figure 3.
Occlusal trauma: premature contact is affected on the way before of the way of MIP (maximum intercuspal
position) peak point.
6
Figure 4.
Premature contacts can be described easily by computerized occlusal analyzing system. Occlusal papers or
similar methods can not much help for finding premature contact.
Figure 5.
Cervical area of a tooth has been destroyed under the traumatic occlusion.
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Trauma in Dentistry
The best method is computerized occlusal analyzing system for detecting the
traumatic premature contact (Figure 4).
Abfractions are the reason for the wrong linear inclination of teeth and the tooth
cervical area is damaged because of those kinds of problems of occlusal trauma
(Figure 5).
Sometimes, the cervical area at the labial surface of the tooth is abraded in time
because of the direction of occlusal force. If the teeth are covered by ceramic crown
restoration, abrasion of teeth continues inside the ceramic restoration. Restorations
are not protective against the abrasion (Figure 6). The only way to stop the abrasion
is the occlusal adjustment of the restoration.
Figure 6.
Abfraction continues under the restorations. Crown restorations cannot protect the teeth from traumatic
occlusal forces.
Figure 7.
Ceramic restorations have been broken under the traumatic occlusal strokes.
8
Figure 8.
(a–c) Implant selection, their locations, and surgical steps are almost perfect; (a) everything seems normal
when controlling with articulating paper, (b) but the patient is never relaxed with his new restorations. The
problem can be detected when examining restoration with computerized occlusal analysis technic: there is
severe premature contact detected on the right second molar area (c). The patient relaxed just after occlusal
adjustment (c).
The ceramic materials are often used in restorative treatments. Premature

contacts on the ceramic restorations must be eliminated; otherwise, periodontal
receptors will never stop sending neuronal impulse and the muscles will never
be relaxed. In this case, ceramic restoration has been broken because of the high
occlusal pressure of premature contacts (Figure 7).
The abrasion effect of occlusal trauma is much more dramatically developed
in the cases of implant prosthesis because implant restorations have no resilient
features and the force transmits directly to the bone without resistance of any force
breaker system like periodontal ligaments of natural teeth. In an implant-supported
prosthesis, if occlusal equilibration is not made, the patient can never be relaxed. In
Figure 8a and b, implant planning and surgery phase is perfect and the treatment
with a full arch ceramic restoration is also finished, but the patient is never relaxed
with his new restorations. The problem can be detected when examining restora-
tion with computerized occlusal analysis technic: there is severe premature contact
detected on the right second molar area. The patient relaxed just after an occlusal
adjustment procedure (Figure 8c).
3. Conclusion
The most exposed group to dental trauma is young adults and children.
Fractures of the upper part of the teeth and luxations are the most frequent cases.
For a healthy result, the most important approach is the proper diagnosis and then
proper treatment consequently.. This action plan is not only for tooth level, but is
also a proper approach for other type traumatic injuries; the guidelines which have
been developed and set by “The International Association of Dental Traumatology
(IADT)” are important supportive materials for the clinicians. There are many
specialists and researchers on “Dental Traumatology” who added important and
useful suggestions.
In some cases, the collected data from traumatic injury may not be clear and
precise. In those cases, clinicians can use the basic and agreed of opinions of IADT
board specialists. Suggestions and opinions for unexpected situations are also
developed by the IDTA members.
There are various guidelines for any kind of levels of urgent and long-term
traumatic cases which are prepared and set by TDIs.
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Trauma in Dentistry
10
References
[1] Bastone EB, Freer TJ, Mcnamara the management of traumatic dental
JR. Epidemiology of dental trauma: injuries: 1. Fractures and luxations of
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[2] Perez R, Berkowitz R, Mcllveen L, [10] Flores MT, Malmgren B, Andersson

Forrester D. Dental trauma in children: L, Andreasen JO, Bakland LK, Barnett
A survey. Dental Traumatology. F, et al. Guidelines for the management
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[3] Andreasen JO, Gerds TA, Lauridsen
E, Ahrensburg SS. Dental trauma guide [11] Von Arx T, Filippi A, Lussi
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techniques. Dental Traumatology.
[4] Cotruţă AM, Mihăescu CS, Tănăsescu 2001;17(6):266-274
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[6] Gross MD. Occlusion in implant
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JO, Bakland LK, Malmgren B, Barnett F, 2001;17(5):227-230
et al. Guidelines for the management of
traumatic dental injuries. II. Avulsion of [15] Kargul B, Caglar E, Tanboga
permanent teeth. Dental Traumatology. I. Dental trauma in Turkish
2007;23(3):130-136 children, Istanbul. Dental
Traumatology. 2003;19(2):72-75. DOI:
[8] Trope M. Root resorption due to 10.1034/j.1600-9657.2003.00091.x
dental trauma. Endodontic Topics. 2002
[16] Case I, De Rossi SS, Stern I, Sollecito
[9] Diangelis AJ, Andreasen JO, TP, Fushima K, Gallo LM,
Ebeleseder KA, Kenny DJ, Trope M, et al. Dislocation of the. Journal
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[17] Hattori Y, Satoh C, Kunieda T,

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[18] Iwase M, Ohashi M, Tachibana H,

Toyoshima T, Nagumo M. Bite force,
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12
Chapter 02
Dental Implants and Trauma

Tosun Tosun and Koray Meltem
Abstract
Implant dentistry treatment target to avoid any kind of edentulous state includ-
ing tooth loss due to trauma. In the literature there are numerous case reports and
few clinical studies documenting treatment options of post-trauma patients by
dental implants. Principally there are some limitations of dental implant applica-
tion related to the age and available bone volume of patients. Implant candidate
should complete bone growth as the metallic implants do not follow bony develop-
ment phases. Most often traumatic dental injuries occur in childhood and implant
treatment should postponed. In this aspect the major problem associated with
dental implant placement is the lack of adequate bone volumes at the future time of
surgery as such cases receives traumatic dental injury in the early years and disuse
atrophy occurs during waiting period. Future trends and strategies in dental trau-
matology in general and with special attention to dental implant applications are
based on the education of population in terms of emergency treatments and urgent
transport of patients to the clinics.
Keywords: dental implant, trauma, implant placement, dental lasers, erbium laser,
traumatic injuries, iatrogenic factors
1. Introduction
Dental implant applications are wide spreading globally and in last three decades
it is the major attraction field for both clinicians and patients. Implant dentistry
treatments target to avoid any kind of edentulous state including tooth loss due
to trauma. Tooth loss after trauma could be related to traumatic dental injuries
depending from violence, falls, traffic accidents, gunshots or to late consequences
of trauma such as recurrent endodontic lesions, vertical root fractures, external or
internal root resorptions and ankylosis which bring teeth to untreatable condition.
Trauma-related tooth loss most often involve anterior maxillary teeth and generally
is rehabilitated as single tooth implant replacement or several teeth are affected
and rehabilitation is made as a solution of partially edentulous case but being in
the anterior region with the rules of single-tooth replacement to preserve esthetics.
Patient age constitute another aspect of post-trauma cases where accidents mainly
happen in childhood period which is not favorable for dental implant applications
due to incomplete bony growth. For the patients in development stage there should
be followed special attention for future dental implant rehabilitation. Thus, care
must be taken to find suitable treatment solutions in order to provide interim
prosthetic treatment, to follow normal bone growth, avoid hard tissue atrophy and
preserve alveolar bony dimensions for upcoming implant surgery in the late ado-
lescent age. In the present chapter post-trauma applications of dental implants are
discussed and possible treatment strategies are evaluated.
1
Trauma in Dentistry
2. E
tiology, prevalence of traumatic dental injuries and implant
dentistry
Traumatic dental injuries (TDIs) have different frequencies worldwide, but

always low prevalence among communities [1–6]. Etiologic factors of TDIs are
various from country to country and with age groups [7]. Globally the most
common etiology of TDI in men is violence. For women there are three most com-
mon injury factors: violence, falls and traffic injuries [6, 8–10]. Ballistic injuries
(gunshots) form a severe type of traumatic maxillofacial injury [11, 12] and can
be classified in between the etiologic factors of TDIs. TDI studies most often cover
children and adolescents. There are few studies involving adults [1, 6, 13, 14].
Studies show that the TDIs affect mainly anterior maxilla and especially central
incisors [3, 8, 15–17]. Generally teeth involved by TDIs are lost in the long run and
subsequently this anatomic lack may result in significant esthetic and functional
problems [6].
The consensus statements of International Association of Dental Traumatology
(IADT) propose to delineate approaches for the immediate or urgent care for
management of primary and permanent teeth injuries [9, 10, 18]. The emergency
treatment after TDIs is highly important for the future management of dental struc-
tures [15, 16]. Although attempts is to preserve natural dentition and despite best
efforts at retaining and maintaining trauma-compromised teeth, studies show that
in the long run affected teeth are loose and replaced by dental implants [19]. Studies
and case reports are shown that implant placement after TDIs is a suitable treatment
of choice [20–22].
In the epidemiological study, Ugolini et al. [1] determined the prevalence,
types, and characteristics of occupational (work-related) TDIs in a large working
community where among 212 traumatized teeth, upper incisors took the first place
with 67.5%, lower incisors showed 17.5% incidence, upper canines were only 3.3%,
lower canines with 1.9% were less than uppers, and bicuspids and molars had 9.9%
prevalence. In conclusion occupational TDIs exhibit a low prevalence and the most
frequent dental injury type were fractures. Possible etiologic risk factors for occupa-
tional TDIs were mentioned to be the age, gender and existence of previous dental
treatments.
Rozi et al. [15] studied complications of permanents teeth after TDIs in 50
children [age range 7–18 years (mean, 11 years); 32 (64%) males and 18 (36%)
females]. According to the findings of this study, TDIs mostly involved the maxil-
lary central incisors by 90% incidence. Uncomplicated enamel and dentin fracture
without pulp exposure was the most common type of TDI with 62%. Only 50%
of the cases showed luxation type injuries. The urgent and proper timing in treat-
ment was underlined and it was considered to be the primary important strategy to
increase the prognosis.
Zaleckiene et al. [2] reviewed etiology, prevalence and possible outcomes of
dental trauma. TDIs prevalence was found to be different among countries. TDIs are
more prevalent in permanent than in primary dentition. Treatment strategies are
directed to eliminate undesired consequences, but TDIs in the young patient is often
complicated and can continue during the rest of his/her life.
Atabek et al. [16] examined epidemiological and dental data from TDIs to pri-
mary and permanent teeth during the period from 2005 to 2010. The study included
120 girls (35.3%) and 220 boys (64.7%) with an average age of 9 years. The maxillary
central incisors were most commonly affected teeth with a prevalence of 66.24%.
The main cause of TDIs was found to be the falls by 70.1% incidence. In primary den-
tition highest percentage of injuries were subluxations with 36.4% rate. In permanent
2
dentition, uncomplicated crown fractures by 44.9% incidence were most frequent

type of injury. In conclusion they stated that the prognosis of dental trauma cases
varies depending on the time elapsed after the trauma before treatment started.
Zengin et al. [3] evaluated TDIs recorded using the World Health Organization
classification modified by Andreasen et al. As the prevalence in a group of
5800 patient 255 had TDI (4.4%). TDIs were related mostly to the age group of
11–20 years. As gender distribution most affected were males (153 cases) and
females got less injuries (102 cases). The main cause of traumatic injury was related
to falls with 68.2% incidence, and generally trauma was taken place during outdoor
activities by 56.1% prevalence. Upper central incisors took first place among the
most frequently injured teeth with primary teeth injuries of 64.5% and permanent
teeth injuries of 72.5%. Uncomplicated crown fracture was the most frequent type
of TDI seen in both primary dentition with a percentage of 63% and permanent
dentition with 47% incidence. In the population of the study, TDIs prevalence was
considered to be low.
Unal et al. [17] through a retrospective study identified TDIs of 591 children
(range 0–14 years, average age: 10.79 ± 2.06) referred to university hospital between
years 2007 and 2012 in Sivas, Turkey. TDIs mostly occurred in the children of
12–14 years age group with 14% incidence. Dento-enamel fractures was the most
common type of injury in primary teeth with 58% prevalence. Complicated crown
fractures were most frequent type of TDI in permanent teeth with an incidence of
39%. The major etiologic factor of TDI was falls having 30% prevalence. The upper
central incisors (71%) were the mostly affected teeth in both primary and perma-
nent teeth. Only 63 children (11%) were referred to the clinic less than 30 minutes
after trauma. The findings of this study showed that initial treatment after dental
trauma should be performed immediately.
Kovacs et al. [4] in a retrospective study assessed the prevalence of TDIs in
deciduous and permanent teeth among children and teenagers in Targu Mures
city of Romania, between 2003 and 2011. The prevalence of TDIs was 24.5%. In
the primary dentition the most frequent type of TDI was lateral incisor’s luxation.
In the permanent dentition, dento-enamel fractures without the exposure of the
dental pulp were the most common type of TDI.
Hasan et al. [5] investigated a total of 500 of preschool children in Kuwait.
The study reported TDIs etiologic factors, frequency, trauma type classification,
injury localization and involved teeth numbers, treatment performed after injury.
Among 500 children 56 subject got TDI involving 68 primary teeth with a preva-
lence of 11.2%. Fifty-three of 56 children got TDIs due to falls (94.6%). Upper
primary central incisor was the most traumatized tooth with 55 units and 80.8%
frequency. TDIs prevalence among such population was considered to be low.
Glendor [23] reviewed 12-years international literature regarding TDI to point
the prevalence and incidence. TDIs were found to be a global phenomenon all over
the world with variations in prevalence, etiologic factors, gender and localization
of involved teeth. Across the world with slight differences from country to country,
approximately 1/3 of preschool children got TDI in the primary dentition. Regarding
TDI to the permanent dentition it could be concluded that although few variations
among countries, about 1/4 of school children and almost 1/3 of adults received trauma.
According to Locker [13], 15.5% of the Canadians with age between 18 and
50 years old, living in the province of Ontario reported a history of injury to the
mouth and teeth. The survey of this study involved 2001 adults who called by
random digit dialing and answered to a questionnaire via telephone. Among the
people who got TDI, 2/3 declared that injuries happened before the age of 18 years
and 1/3 after adolescence.
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Trauma in Dentistry
Kaste et al. [14] reported findings of 7707 patients. According to Kaste’s study,
approximately one-quarter (24.9%) of the US population aged 6–50 years had at
least one traumatized teeth.
Zerman and Cavalleri [6] examined 2798 patients having 6–21 years old age,
with a follow-up period of 5-years in Verona, Italy. Among abovementioned popula-
tion 178 were TDI cases, 131 males and 47 females, having 326 traumatized incisor
teeth with a prevalence of 7.3%. Most frequent causes of injuries were falls and
traffic accidents. A very large number of dental injuries occurred to children aged
between 6 and 13 years. Most injuries involved two teeth. About 80% of the teeth
were maxillary central incisors.
3. Dental implant treatment in post-traumatic dento-alveolar defects
In the literature there are numerous case reports and few clinical studies document-
ing treatment options of post-trauma patients by dental implants [24–29]. In those
reports and studies cases underwent to trauma due to violence, falls, traffic injuries,
gunshots which were later rehabilitated by use of dental implants are described in
details. Treatment approaches reported are various as the cases exhibit different
conditions related to the type of trauma, anatomy and age. Principally there are some
limitations of dental implant application related to the age and available bone volume
of patients. One of the main criteria for dental implant placement is the presence of
complete bone growth as the metallic implants do not follow bony development phases
[30–34]. Most often TDIs occur in childhood and implant treatment should postponed
as mentioned [31]. Thus, the children who receives TDIs should wear removable or
adhesive prosthesis until their skeleton mature. In this aspect the major problem asso-
ciated with dental implant placement is the lack of adequate bone volumes at the future
time of surgery as such cases receives TDI in the early years and disuse atrophy occurs
during waiting period [21]. Maxillary central incisors area which is commonly affected
zone by TDIs is most apparent site of the dentition and requires proper dimensions
and proportions to establish esthetic and require complex treatment solutions such as
bone grafting with autogenous or synthetic graft materials, guided bone regeneration
applications; immediate, early or delayed implant placement methods (Figures 1–7).
Nicoli et al. [24] wrote records of a multidisciplinary treatment made in a
gunshot injury case. Patient got severe anatomic defect in the mandible which was
rehabilitated by use of an implant-supported fixed-removable dental prosthesis.
In order to restore intermaxillary relation an immediately loaded provisional lower
overdenture and upper removable prosthesis were delivered.
Figure 1.
Traffic accident case: central incisor number 21 was lost due to a traffic incident trauma; bone volüme was
reduced in the buccal side and soft tissue was injured by a vertical laceration in the medial part of keratinized
mucosa.
4
Following interim prosthesis installations, in order to increase the maxillary

bone volume, nasal floor elevation and maxillary sinus lifting operations were
performed. Subsequently definitive implant-supported fixed-removable prostheses
were delivered in both arches to improve masticatory function and esthetics.
Fındık et al. [25] presented rehabilitation of a wide mandibular traumatic defect
due to a work-related accident with iliac free flap, distraction osteogenesis, and
dental implants. Distraction osteogenesis, free flap and dental implant placements
were considered as an effective and esthetic treatment option for rehabilitation of
post-trauma defects.
Balla et al. [26] described 5-year follow-up of surgical and prosthetic recon-
struction of a gunshot injury using dental implants which was found to be
Figure 2.
Titanium/zirconia alloy dental implant (Bone Level SLA, Straumann AG, Swiss) was placed.
Figure 3.
Titanium mesh was placed on the buccal side and secured into the implant by cover screw.
Figure 4.
After 6 weeks of healing period a mucosa former abutment was placed. The laceratio formed after traffic
accident still persist on the buccal mucosa.
5
Trauma in Dentistry
Figure 5.
Intraoral appearance of implant supported lithium disilicate single crown placed on top of custon zirconia
abutment.
Figure 6.
OPG after crown placement.
Figure 7.
Appearance after prosthesis delivery: note hypertrophic sequelae of upper left lip due to traffic accident.
effective treatment modality in restoring a patient to near normal function and

esthetics. According to this study, maxillofacial injuries made by gunshot create
serious esthetic, functional, and psychological consequences. Disabling char-
acteristic of such severe maxillofacial ballistic defects brings the need of chal-
lenging extensive reconstructive multiple surgeries and competitive prosthetic
rehabilitation phases.
Jain and Baliga [27] described two cases with maxillofacial trauma and had
undergone open reduction and internal fixation where implant placement was done
for upper anterior teeth.
Sharma and Swamy [28] reported a gunshot case who lost six teeth in maxilla
and was rehabilitated by rotated flap, bone grafts and three dental implants sup-
porting a FPD.
6
Wang et al. [29] mentioned the treatment a 17-year-old boy having maxillofacial
ballistic defects. They described multiple techniques for restoration of facial mor-
phology and function. Multiple examinations and surgical procedures including
osteomyocutaneous and muscular flaps in combination with dental implants were
used to restore facial morphology, functions of mastication and articulation.
Generally implant placement is planned after orthodontic treatment to gain
adequate space [21]. But there are exceptions reported depending from the needs
and anatomy of individuals such as Kuo et al. [35] who reported a case where after
a traumatic loss of upper incisor an implant was placed and subsequent orthodontic
treatment was performed.
Kulkarni et al. [36] reported ballistic injury of a 24-year-old man. Maxillofacial
deficiency was restored with autogenous iliac bone graft. Following 3 months of
healing dental implants were placed. After osseointegration period of 5 months fixed-
removable hybrid prosthesis was installed. At the end of third year of hybrid prosthesis
usage, it was renewed by a porcelain fused to metal bridge. Follow-up on radiographies
showed that the crestal bone levels around implants were stable. Kulkarni et al. [36]
stated that the rehabilitation of gunshot injuries is expanded within time and needs
several interventions to obtain functional and esthetics requirements.
Seymour et al. [37] mentioned the need of team approach in the rehabilitation
severe trauma cases and underlined the importance of communication between
general practitioners and specialist especially in the complex dental implant
treatments.
Chesterman et al. [38] described guidelines regarding the replacement of single
teeth lost due to trauma with implant supported restorations. The protocol pro-
posed includes: evaluation of tooth replacement methods; planning for tooth loss
and provision of an implant supported restoration; planning of an implant sup-
ported restoration.
Alani et al. [39] stated that with advances in both adhesive technologies and
implant dentistry, there are a variety of options for the restoration of edentulism
subsequent to TDIs.
Pae et al. [22] described a panfacial fracture case who was managed with a
mandibular implant-supported fixed-removable and a maxillary partial removable
prosthesis where due to the lack of intraoral landmarks, overall facial anatomic
landmarks were used to restore the oral cavity.
Kamoi [40] reported treatment history of a 44-year-old woman who had severe
injuries due to traffic accident. The patient got maxillofacial soft tissue lacerations
followed by hard tissue fractures, several teeth loss associated with alveolar bone
resorption. Several facial reconstructions were made by plastic surgeons. To replace
missing upper teeth a sinus grafting procedure was performed by use of a rib bone
anchorage and simultaneous placement of five dental implants. After 11 months of
healing period, upper overdenture and a mandibular PFM’s were fabricated. The
outcome of the treatment was found to be satisfactory.
Robinson and Cunningham [41] described the oral rehabilitation of an adult
male who suffered severe dentoalveolar trauma as a result of a motor vehicle acci-
dent. After extraction of fractured roots, dental implants were placed. Following
certain healing period for osseointegration, PFM crowns and FPD’s were installed.
In a 3-year follow-up period, the outcomes of the treatment were considered to be
successful regarding patient’s esthetic and functional expectations.
Schneider et al. [42] reported the surgical and prosthodontic rehabilitation of
a patient traumatized by a self-inflicted gunshot wound to the mandible which
required rehabilitation with a free fibula microvascular graft, single stage dental
implant placement, and rehabilitation with CAD/CAM and laser assembled pros-
thetic components.
7
Trauma in Dentistry
Nissan et al. [43] evaluated the outcome of dental implants placed in the post-
traumatic anterior maxilla after ridge augmentation with cancellous freeze-dried block
bone allografts. After 6 months of healing, implants were placed. The study group
was composed of 20 consecutive patients with a mean age of 25 ± 7 years, received 31
implants, 12 of them were immediately restored. Graft and implant survival rates were
92.8 and 96.8%, respectively. There were no changes in bone to implant contact (BIC)
levels. The authors considered predictable the usage of cancellous block allografts in
the reconstruction of post-traumatic defects of anterior maxilla.
Yamano et al. [44] gave treatment history of a 15-year-old male patient who had
a snowmobile accident. Patient got maxillofacial defects and fractures in mid-face
and mandible. A multidisciplinary rehabilitation was performed to restore func-
tion and esthetics. Treatments involved usage of autologous corticocancellous bone
grafts, fixture placement and implant-supported prosthesis fabrication.
A ballistic maxillofacial injury case and her treatment modality was described by
Torabi et al. [45] The patient received trauma in maxilla, mandible and nasal areas
with heavy problems in her esthetics and functions. Dental implants were used in
conjunction with natural abutments to restore dentition.
Bird and Veeranki [46] reported a maxillofacial ballistic injury case rehabilitated
with iliac crest bone graft, dental implants, and an economical acrylic resin fixed
prosthesis. A 3-year follow-up revealed positive treatment outcomes and it was
concluded that although facial gunshots cause severe defects, they can be restored
and rehabilitated by a multidisciplinary approach. They outlined the importance of
and biomechanical considerations for implant positioning.
Kelly and Drago [12] described a patient who suffered significant trauma to
the lower and mid-face secondary to a gunshot injury. The size and severity of
the defects are in proportion with the functional and esthetic complications faced
during the late phases of the treatment. Regardless to the amount of facial trauma,
successful treatment can be performed by appropriate clinical and radiographic
examinations and diagnosis followed with correct treatment strategies and applica-
tions strictly linked to surgical and prosthodontic principles.
Gökçen-Röhlig et al. [47] described the rehabilitation of a patient with a
mandibular defect caused by a gunshot wound who was treated with four osseo-
integrated implant-supported mandibular overdenture and maxillary removable
prosthesis. Despite anatomic limitations, the patient’s esthetic and functional
demands were fulfilled.
Sándor and Carmichael [48] proposed to respect growth and delay implant
reconstruction until the cessation of skeletal or alveolar growth.
In the 2-year follow-up report of a traffic accident and traumatic injury happen
to 16 years old male patient who was rehabilitated by autogenous graft and four
dental implants, outcomes were found to be satisfactory and stable [49].
Sipahi et al. [50] reported a self-inflicted gunshot maxillofacial defect case who
was restored with dental implants and various prosthetic attachments. During
short-term follow-up period no complications were occurred. The outcome of a
fixed-removable implant-supported mandibular prosthesis and a maxillary obtura-
tor was considered successful in the management of a serious traumatic injury.
Clinical evaluation of a mandibular ballistic injury patient was described by
Cakan et al. [51]. The patient was treated with cemented crowns for 2 maxillary
implants and an implant-supported screw-retained fixed partial denture sup-
ported by eight mandibular implants. Although difficulties to properly position the
implants because of inadequate bone volume, esthetic and functional demands of
the patient were fulfilled.
Schwartz-Arad and Levin [20] examined a patient pool of 53 individuals having
dental implants after traumatic injury history in the anterior maxilla. They found
8
significantly lower complications in the group of patients which did not

have inflammatory lesions in their history. Meanwhile patients who lost their teeth
due to inflammatory lesions after traumatic injuries got statistically significant
amount of complications and failures with dental implants. They underlined the
necessity for scrupulous diagnosis of teeth and alveolar bone after a traumatic
injury in order to reduce complications and advised individualized treatment plan-
ning for each case as the methodology is multidisciplinary.
Schwartz-Arad et al. [21] mentioned the difficulties in the dental implant based
rehabilitations in patients who got traumatic injuries in childhood where implant
placement is contraindicated during growth period and on the other hand they
need replacement of missing teeth and also preserve adequate jaw bone volume for
future implant placement. Various treatment strategies were suggested until the
end of growth and development. Among them, orthodontic extrusion of the root
fragment and a temporary crown application technique in order to preserve alveolar
bone, autogenous tooth transplantation, intentional extraction and immediate
tooth replantation, distraction osteogenesis, and decoronation could be mentioned.
Five-year follow-up results of 42 single-tooth implant treatment in 34 trauma-
related edentulous patients were evaluated by Andersson et al. [52]. In this patient
pool the most frequently lost teeth were upper central incisors with an incidence of
75%. In the second place there were lateral incisors with 21% frequency. In growing
patients, implant treatment was generally postponed until completion of develop-
ment. Preservation of roots in the alveolar process seemed to maintain the bone
volume enabling better conditions for later implant placement. According to the
findings of this study, the functional and esthetic outcome of single-tooth implant
treatment can be recommended for replacing tooth losses after trauma in the
anterior region of the maxilla.
Tipton [53] reported a case who had TDI due to an accident and rehabilitation
protocol with a team approach for dental implant restoration. The outcome was
considered excellent regarding the teamwork among the dentist, implant surgeon,
and laboratory technician following traumatic injury of the dentition.
4. Prerequisites for dental implant placement after trauma
Systemic conditions and history of the patient should be favorable to the surgery.
In the medical history of the patient possible genetic, autoimmune and connective
tissue diseases must be investigated in order to reduce risk factors [54]. In the history
of patient presence of recent cerebrovascular disturbance and myocardial infarct,
ongoing immunosuppressive [55] or chemotherapy, fibrous dysplasia [56–58], intra-
venous bisphosphonate therapies [59–64], uncontrolled diabetes [65–69], narcotic
dependencies or psychiatric diseases form absolute contraindication for dental
implant treatment [70]. In such conditions alternative prosthodontic treatments
should be planned. Some form of diseases, treatments and drug therapies which
affect metabolic activity of body and habits are considered to be relative contraindi-
cations as they reduce success and longevity of osseointegration. In the presence of
any relative contraindication it must be evaluated the need of dental implant treat-
ment for the patient and health conditions in the decision-making phase. Among
relative contraindications there are past radiotherapies with irradiated jawbones
[71–74], diabetes, autoimmune connective tissue diseases (rheumatoid arthritis
[75–77], Sjögren’s syndrome [78], Lupus Erythematosus [79], Papillon-Lefevre syn-
drome [80–82], Behcet disease, Myasthenia Gravis, Ectodermal Dysplasia [83–87],
Skeleroderma [88–90]), calcium-phosphate metabolism disorders and endocrine
diseases (osteoporosis, osteopenia, Paget disease, hyper and hypothyroidism, kidney
9
Trauma in Dentistry
nephritis, aldosteronism, Cushing syndrome), viral diseases (HIV, Hepatitis III),

aggressive periodontitis, smoking, drug abuse, oral bisphosphonate usage, unstable
psychological state. Other risk factors which should be evaluated during treatment
planning are parafunctions-bruxism and facial dystonia [91].
Animal model studies have shown that metallic implants do not change location
in concordance with three-dimensional bony growth [92–95]. Dental implants
do not follow bone development during growth period [34, 92–101]. Studies have
shown that implants placed in the early ages remain in infra-occlusion by time [99].
For this reason as the consensus, implant treatment is made after confirming bony
development period of patient by hand-wrist radiographies and comparisons in
radiography-skeleton atlas [98, 100]. Ulnar sesamoid cartilage and middle finger’s
middle phalanx distal cartilage ossification rate is inspected and compared with
images in skeleton atlas. For the minimal age of implant surgery decision instead of
chronological age, skeletal age of patient is taken in consideration. Patients who are
within the active bone growth period can receive removable prosthesis or adhesive
prosthesis. In children adhesive prosthesis such as Maryland type are splinting
teeth together and apply stationery anchorage against three-dimensional enlarge-
ment of jawbones during active bone growth. Growing patients should periodically
controlled and adhesive prosthesis should modify in case of need. In future implant
placement plans traumatized roots should be kept in place as space maintain-
ers although their prognosis is poor. Slow orthodontic extrusion of traumatized
hopeless roots is one of the bone guidance methods in order to create adequate hard
tissue volume for upcoming dental implant rehabilitation [102].
The first prerequisite in implant dentistry is the presence of adequate vital
bone volume to entirely cover the implant body [103]. If trauma happens in child-
hood ending with tooth loose, patient should wait certain years until active bone
growth completes before implant placement and during waiting period bone
volume decrease in edentulous areas by disuse atrophy. In atrophic crests various
augmentation method could be applied. The first choice of augmentation material
is autogenous bone grafts. Autogenous bone graft blocks can be placed over recipi-
ent residual bone site and fixed by mini-screws, or ‘Bone Lamina’ technique which
consist in splitting a bone block in thin layers and fix them onto the augmentation
area by mini-screws as shields to create a certain volume and fill inside the shields
with particulate autogenous or synthetic grafts. Autogenous bone grafts are always
considered as the golden standard in augmentation procedures. Secondly osteo-
conductive ceramic alloplast (hydroxylapatite, tricalcium phosphate) or xenografts
(bovine, mini-pig, single-hoofed) are preferred. Demineralized, demineralized
freeze-dried or frozen homolog transplants although are osteoinductive they have
non-predictable life-time and may not be adequate to complete osteogenesis phases
in time scale. Other augmentation alternative is the usage of titanium grid-mesh
(Ti-mesh) shields to obtain tent effect and fulfill them by particulated graft materi-
als. Similarly, Guided Bone Regeneration (GBR) technique can be applied by use
of resorbable or non-resorbable membranes alone or in conjunction with graft
materials according to the defect size. Split-bone technique is suitable for crests
thicker than 3 mm in buccopalatal section and mainly is adequate for pliable maxilla
rather than less elastic mandible. Crestal bone is splinted in equal two pieces by
micro-saws, piezoelectric inserts or Erbium Yttrium Aluminum Garnet (Er:YAG)
laser until bypassing cortical bone. Once spongious bone is arrived special splitter
osteotome inserts are placed into osteotomy site. To avoid unpredictable fractures
vertical release osteotomies should be made in the extremities of the working field.
Distraction osteogenesis is another technique well documented for bone augmenta-
tion. But distraction appliances are difficult to maintain for children in the interac-
tive play age and could be further traumatized often.
10
The choice of augmentation method depends on the defect size, volume,

tridimensional shape of hard tissues and biotype of soft tissues. If the vertical
dimension of the crest is normal but bucco-palatal width is missing GBR, Ti-mesh,
Split-bone, onlay graft, Bone Lamina techniques could be used. When the verti-
cal bone height is lost onlay grafting, Bone Lamina, distraction osteogenesis and
Ti-mesh would be preferences. Soft tissue thickness establishes biotype of mucosa.
Thin biotypes are difficult to manage as they are fragile and difficult elongate in
order to achieve tension free flap. Flaps which cover wound should be overlay
on grafted area without pressure in order to obtain normal blood supply. If there
would be several tensions on the flap, vascular network will suffer and due to
the lack of nutrition surgery can fail. Flap design gain certain importance to have
profuse blood circulation. Flaps with larger base than free edge, possibly without
vertical release incisions can maintain vascular network without interruption of
capillary arteriae and vessels. Anatomic studies have shown that within the buccal
and palatal mucosa, capillary networks do not constitute anastomosis on the top
crestal region of maxilla and mandible [104]. Thus by mid-crestal incisions there
is no interruption of vessels and this type of incision should be choice of prefer-
ence. Mucosal flaps according to depth could be ‘full-thickness’ where epithelium,
connective tissue and underlying periosteum are excited and elevated together;
or ‘split-thickness’ where periosteum is left attached to the cortical bone to avoid
blood supply interruption (because capillary arteriae network is situated within the
periosteum and 70% nutrition of the cortical bone derives from periosteum), and
to have elasticity of the flap (periosteum do not have elastic behavior). Thick bio-
type mucosa has an advantage in terms of elongation. To elongate a full-thickness
flap the basal portion of it which is constituted by periosteum should be gently
incited horizontally. In such manner the rigidity of the periosteum is alternated and
underlying connective tissue portion would elongate easily as contains elastin fibers
of collagen. Split-thickness flaps could be preferred only in thick biotype mucosa as
the thin biotype is difficult to split and fragile.
Implant’s primary stability is another prerequisite to achieve osseointegration.
Studies have shown that dental implants can integrate with surrounding bone
if they have less than 100 microstrain or less than 150 micron micromovement
[105–109]. Early loading of dental implants do not interfere with surrounding
bone mineral apposition speed and osteogenesis phases continues to integrate with
implant surface if primary stability is achieved [105–111]. Osteoblast phenotype
morphology and physiology are not altered in immediately or early loaded implants
[108, 110]. Adequate primary stability for a dental implant could be interpreted by
insertion torque values greater than 30 N/cm2. Primary stability and in the fol-
lowing time period stability of implants could be measured by use of Resonance
Frequency Analysis (RFA) method [112–114]. RFA works by vibrations transmit-
ted to implant body and measurement of implant’s resistance values in numbers
expressed in Implant Stability Quotient (ISQ ) units. Studies conducted with RFA
showed that peri-implant bone strength follows Normal Distribution Curve (bell
curve) as seen in many natural phenomena. Initial strength of interfacial bone to
the implant due to inflammatory reactions and acidic environment decreases and
reach the weakest point in the third week after implant placement. Meanwhile
mineral apposition and developing ossification take place and secondary stabil-
ity increase after third week to reach initial stability ISQ values approximately
in the sixth week. The studies made on micro-movement and micro-strain have
shown the possibility of osseointegration in immediate loading situation unless the
threshold of 100 micron of mobility is not exceed [105–107]. Based on such results,
it has been introduced ‘immediate loading’ protocol by use of splinted implants for
totally edentulous patients [106, 109]. There are promising results and developing
11
Trauma in Dentistry
protocols of immediate loading for partially edentulous and missing single-tooth

cases, where the requirements are presence of primary stability more than 30 N/cm2,
implant length more than 10 mm, implant diameter more than 3.75 mm for tita-
nium or zirconia dental implants and 3.3 mm for titanium-zirconia alloy implants,
rigid splint of implants (in partially edentulous cases), non-functional loading,
temporization (immediate delivery of provisional crowns or bridges to shape soft
tissue contours). In patients where there are short implants but adequate primary
stability, or patients with parafunctions, patients with low density bone (type III or
IV), ‘early loading’ protocol which previews 6 weeks healing period can be applied.
If the primary stability of an implant is less than 30 N/cm2 insertion torque, healing
period should be elongated to 3 months for the lower and 6 months for the upper
jaw bones which is called ‘delayed loading’ protocol as proposed by Branemark at
the beginning years of modern scientific implant dentistry.
TDI cases mostly involve anterior maxilla with early or delayed loss of single
tooth (except gunshots) which is mainly central incisor. In single-tooth replace-
ments there are special rules to follow in order to obtain suitable esthetics.
Maintenance of soft tissue envelope contours and the presence of papillae are highly
important. The preservation of soft tissue integrity is related to flap nutrition, thus
flapless surgery is the primary choice. The ‘tunnel technique’ may be an alternative
to conventional open flap surgery and graft application, in order to apply minimally
invasive surgery. Another approach is to avoid vertical release incisions and apply
only sulcular incision to keep intact vessels of flap and cause less reduction of blood
supply.
Papilla protective flap design is thought to preserve papillae, where two vertical
incisions exclude papillae in both distal and mesial sides and a narrow full thickness
flap band is raised. In long term follow-ups it has been noted that those two vertical
incisions lead the formation of scar areas which would apparent on the buccal side
of mucosa. On the other hand, in case of intra-operative treatment plan change,
upon need of augmentation, the graft materials would be under incision lines. The
presence of incisions on the grafted area will increase microbial contamination risk
of graft by micro-leakage and cause inadequate blood supply to the graft. Thus,
papilla protective flap design is almost a disappeared technique.
The second rule to follow in single-tooth replacements is the preservation of
buccal bony wall. In jaw bones anatomy, buccal portion of alveolar bones is mostly
very thin [115–117]. This thin buccal wall would be resorbed rapidly due to acidic
inflammatory environment which may take place in case of nutrition lack due to
flap raising, or after trauma and post-traumatic extraction where crestal bone could
be fractured. To avoid traumatic extractions periotomes, electro-dynamomagnetic
device inserts, piezoelectric device inserts, special extraction drill-chain appliances,
very thin Er:YAG laser sapphire tips are developed. ‘Ridge preservation’ techniques
which aims to immediately graft extraction sockets to avoid future resorptions are
proposed. Some authors proposed not only hard tissue grafting but also mucosa
transplants by punch technique to cover entirely socket orifice. On the horizontal
plane palato-position of the implant placement is another rule to follow to preserve
buccal width of alveolar bone. Palato-position of an implant is obtained by center-
ing the insertion point of first drills on the palatal wall of the socket, but not to
the apical bottom; the location should be slightly palatal to the inter-incisal line of
adjacent teeth. Plato-positioning helps also to balance the future unavoidable senile
resoption pattern of buccal alveolar bones which is physiological. A single-tooth
implant should keep equal distance to the neighboring teeth. The collar platform
level of the single-tooth implant should not be embedded more than 2 mm apically
from the cementoenamel junction (CEJ) of adjacent teeth. If the implant collar
exceeds CEJ criteria, longest crowns in comparison to natural dentition should be
12
fabricated and the future bacterial colonization of inner implant spaces will execute
pumping effect of contaminants deriving from the micro-gaps between abutment-
implant connection during chewing cycles which will result in collar area bone
resorption and subsequent mucosal recessions and papilla loosening.
In adolescent patients who completed their skeletal growth and in adults after
traumatic loss of teeth if the available soft tissue and bone volumes are favor-
able, implants could be placed immediately. Immediate implant placement may
be excluded when the soft tissues have lost their integrity to cover wound area by
tension-free flaps; or when hard tissues have great volume loss and primary anchor-
age possibility would poor (e.g., traffic accidents, gunshots). In such situations
primary wound healing should be waited. The risk in immediate implant placement
after trauma is associated with the contamination of defect area by foreign bodies
and microorganisms. To clean extraction socket generally conventional curettage is
followed. But bacterial contamination can still persist within the lamina cribrosa of
socket or in the spongy bone. The best method to avoid contaminants and bacteria
from the wound area would be usage of Er:YAG laser irradiation associated with
conventional curettage as the studies have shown Er:YAG’s high bactericidal effect
against microbiota [118–120].
In the anterior region of jaws titanium implant body and abutment reflection
may be apparent by time as buccal bone senile resorption pattern is from distal
(outside) to medial (inside). Solution to mask metallic reflection is the usage of
ceramic materials. Recently full ceramic zirconia implants and abutments gained
again popularity. After first attempts of alumina implants in the 1970s and their
mechanic failures caused an interval of approximately 30 years. In last two decades,
firstly CAD/CAM zirconia abutments and following one-piece zirconia and recently
two-pieces zirconia implants were introduced in the market. Nowadays most
sophisticated applications of single-tooth replacements are made by full ceramic
implants, zirconia-titanium or titanium implants and zirconia abutments support-
ing leucite-reinforced ceramic or lithium disilicate ceramic crowns.
Future trends and strategies in dental traumatology in general and with special
attention to dental implant applications are based on the education of population
in terms of emergency treatments and urgent transport of patients to the clinics;
trained clinics on emergency treatments; preparation of patients to future implant
rehabilitations by interim treatment which care preservation of hard and soft
tissues.
5. Conclusions
Edentulism due to trauma could be properly rehabilitated by dental implant

placements. Reports in the literature have been adequately evidenced safe usage of
dental implants after traumatic injuries. There are various considerations to plan
suitable treatment option in the edentulous areas of jawbones after trauma. At the
first side the systemic conditions of patient should permit dental implant surgery.
Secondly the skeletal age of patient should be adequate to implant placement as
it is shown that implants do not migrate following bony development and embed
in an infra-occlusion by time. The third level of consideration is the availability
of soft and hard tissues. Rehabilitation strategies are developed according to the
defect size, volume, tridimensional shape of hard tissues and biotype of soft tissues.
Special attention is paid to preserve mucosal contours and papillae by use of flapless
technique or proper incisions, as well as hard tissue augmentation options are
planned taking in consideration the available vascularity, defect wall number, bone
height and fixation of graft material. In the implant placement phase the primary
13
Trauma in Dentistry
stability is the main target in order to initiate osseointegration. There are several
implant insertion techniques such as drilling, narrow drill/wider implant, osteo-
tome, bone splint and laser-assisted which are decided basing on possible primary
anchorage within the residual bone. After achievement of primary stability it
should be decided the loading type of implants which is related to implant number,
localization, length, diameter, splinting options. Basically functional immediate,
non-functional immediate, early or delayed loading protocols can be applied. Once
loading protocol is fixed it should be emphasized the prosthetic supra-structure
design and material. In conclusion missing teeth due to trauma could be success-
fully rehabilitated by dental implants following detailed and careful diagnosis in
order to establish proper individual treatment plan and by application of consecu-
tive treatment steps.
14
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22
Chapter 03
Biomaterial Used in Trauma

Patients
Mehmet Yaltirik, Meltem Koray, Hümeyra Kocaelli,
Duygu Ofluoglu and Cevat Tugrul Turgut
Abstract
The development of bone tissue engineering and bone regeneration is always of

interest to improve methods to reduce costs of trauma patient. Ability to use autog-
enous bone forming cells attached to bone morphogenetic proteins would be ideal.
There are many clinical reasons to develop bone tissue engineering alternatives, for
use in the reconstruction of large defects and implants. The traditional methods of
bone defect management include autografting and allografting cancellous bone,
vascularized grafts, and other bone transport techniques. However, these are the
standard treatments. Since bone grafts are avascular and dependent on the size of
the defect, the viability can limit their application. In large defects, the grafts can
be resorbed by the body before osteogenesis is complete; tissue loss develops in the
living organism due to infection, trauma, congenital, and physiological reasons.
Placing tissue defects in the dentist and maxillofacial surgery and accelerating
wound healing are an important issue. From an old Egypt, material used in treat-
ment of different doctors with various causes. Oral surgery, periodontology, and
implantology, which are surgical branches of the dentistry, need to increase bone
formation in the treatment of bone defects, congenital defects, and defects around
the implant. Many years of work have been done to obtain ideal biomaterials, and
many materials have been used. We have prepared detailed information on biomate-
rials used in dentistry, oral, and maxillofacial surgeries in this book to help dentists
and dental students.
Keywords: biomaterials, trauma, maxillofacial surgery
1. Introduction
Bone not only supports and protects various organs but it also facilitates
mobility [1], with the help of the soft collagen protein and stiffer apatite mineral.
Bone is maintained dynamically through two different processes: modeling and
remodeling [2]. In bone modeling process, the new bone is formed without prior
bone resorption, while in the bone remodeling process, bone formation follows
bone resorption [1]. Bone remodeling is a lifelong process that begins in early fetal
life and is maintaining bone function by continuously replacing damaged bone with
new bone tissue [3, 4].
The use of alloplastic materials in the remodelization of traumatized lesions and
fractures in the compensation of tissues lost for various reasons such as trauma first
started in ancient Egypt [5]. All substances are called biomaterials, which help to
1
Trauma in Dentistry
eliminate any deficiencies in the living organism and help the organism to complete
this deficiency regularly and quickly [5].
Bone grafting is one of the most common surgical procedures to set up bone
regeneration procedures [6]. Bone grafting procedures were the second most
frequent tissue transplantation after blood transfusion [7]. Autologous bone
is still gold standard in bone regeneration [8]. Bone grafting procedures vary
between natural grafts to synthetic bone substitutes and biological factors [9].
Synthetic bone substitutes and biological factors, calcium phosphate (CaP)-
based biomaterials (e.g., hydroxyapatite (HAp), CaP cements, and ceramics),
and recombinant human bone morphological proteins (rhBMPs) are most
frequently used [10].
This chapter will describe the biomaterials used in the reconstruction of defects
in the head and neck region [5].
2. Structure of bone
Bone is a connective tissue that forms the skeleton of the body, acts as a support
to the muscles and organs, protects them against. Bone tissue consists of two differ-
ent bone structures as compact or cortical spongiosa or cancellous bone [5].
Bone tissue is examined in two separate parts: the matrix between the cells and
the cells [5].
2.1 Cells
2.1.1 Osteoprogenitor cells
These cells are the result of differentiation of stromal cells arising from embryo-
nal mesenchymal cells in periosteum and endosteum. Cells related to direct bone
formation are osteoblasts, osteocytes, connective tissue, fibroblast, and fat cells.
2.1.2 Osteoblasts
They play a role in the synthesis, preparation, and mineralization of the bone
matrix. They are then implanted into the tissue with calcification of the bone matrix
to become osteocytes.
2.1.3 Osteocytes
They surround with osteoblasts, mineral matrix and then consequent balance of
the calcium (Ca) level.
2.1.4 Bone marrow cells
They are cells similar to squamous epithelial cells found in inactive regions in the
bone.
2.1.5 Osteoclasts
Osteoclasts digest the mineral matrix of the bone with acid phosphatase, which
they secrete, and then resorb it by digesting collagen and other organic matrix
structures with lysosomal enzymes.
2
Biomaterial Used in Trauma Patients
2.2 The intercellular tissue (bone matrix)
Cell-to-cell tissue forms 10–29% water, 60–70% of the bone dry weight is the
inorganic structure (bone salts), and 30–40% of the bone dry weight, 90–96% of
the organic structure is collagen, which is also the main component of connective
tissue and constitutes one-third of all body proteins [5].
3. Healing mechanism of bone defects
Bone repair can be defined in two procedures: primary bone healing and
secondary bone healing. The large segmental bone loss in the defect is an
extreme condition in bone healing, which can be caused by trauma, diseases,
developmental deformities, revision surgery, and tumor resection or
osteomyelitis [11, 12].
Primary (direct) bone healing mainly happens when the fracture gap is less
than 0.1 mm, and the fracture site is rigidly stabilized. Secondary bone healing is
the more common form of bone healing and occurs when the fracture edges are
less than twice the diameter of the injured bone [11]. Blood clothing, inflammatory
response, fibrocartilage callus formation, membranous ossifications, and bone
modeling are involved in bone healing.
Bone substitutes mainly involve three important biological properties: osteogen-
esis osteoinduction, and osteoconduction [13].
3.1 Bone formation mechanism with bone graft materials
3.1.1 Osteogenesis
Bone graft materials in osteogenesis include organic materials that have bone
formation capacity directly from osteoblast cells. Even in environments where
undifferentiated mesenchymal cells are not present in the tissue, such organic
materials have the ability to be osteogenic. The only graft material with osteogenic
character is autogenous bone. Autogenous bone is obtained from the oral surgery,
iliac bone, tuber maxilla, and mandibular symphysis [5].
3.1.2 Osteoinduction
Osteoinduction, with osteoinductive materials, has the capacity to convert

undifferentiated mesenchymal cells in tissue into osteoblasts and chondroblasts. In
oral surgery, bone allografts are the most commonly used osteoinductive materials.
Bone allograft is derived from different human bone tissues with different genetic
structure.
3.1.3 Osteoconduction
The growth of bone tissue with osteoconduction is characterized by the forma-

tion of appositional bone. That is why osteoconduction occurs in the presence of
bone or undifferentiated mesenchymal cells.
As a result, although bone has a very variable metabolism, resistance depends on
the amount of collagen, the arrangement of fibrils, the presence of minerals, and
the presence of minerals on proteins and glucosamines.
3
Trauma in Dentistry
4. Basic features of biomaterials
1. Biological suitability: the applied biomaterial should be acceptable to the

tissue [5].
2. It should be bioinert and biocompatible. It should be osteoconductive and

osteogenic.
3. The surface should have an immediate stabilization property and surface

porosity to allow for increased stabilization.
4. It should not be toxic.
5. It must be easily sterilized.
6. It must be resistant to infection.
7. There should be no color features that can affect surrounding textures.
8. It must be easy to apply and must cause minimal trauma during application.
9. It must be resistant to bending and twisting and should be elastic; elasticity

should be close to the applied texture. It must be cut and shaped during
application.
10. Resorption should be resistant.
11. The application must be acceptable to the patient.
12. The application should be able to give definite results.
13. It is easy to remove or cut in case of failure.
14. Must be easy to store.
15. It must be cheap and easy to obtain.
5. Classification of biomaterials
A. Bone source biomaterials [5]
a. Autogenous bone graft (autograft)
I. Cortical and cancellous bone in or out of mouth
b. Homogeneous bone graft (allograft)
I. Isograft: fresh cancellous bone marrow
II. Fresh frozen bone
III. Frozen dried bone
4
c. Heterogeneous bone graft (xenograft)
I. Demineralized bone
II. Protein-extracted bone
B.Bone-free biomaterials (alloplastics)
a. Tissue sources
I. Dentin
II. Cementum
III. Cartilage
IV. Sclera
V. Dura mater, etc.
b. Metals
c. Gelatin film
d.Polymers
e. Calcium sulfate
f. Calcium carbonate
g. Calcium phosphates
h.Calcium phosphate ceramics (CaP ceramics)
i. Bioactive glass
5.1 Bone source biomaterials
In the treatment of traumatic defects, congenital deformities, tumor surgery

are in used. Today, homogeneous bone grafts (allografts), heterogeneous bone
grafts (xenografts), and alloplastic materials are used in oral and maxillofacial
surgery [5].
An osseous graft from an anatomic site and transplanted to another site within
the same individuals is called autologous bone grafting [14, 15]. With osteocon-
ductive, osteoinductive, and osteogenic properties, an autologous bone graft can
integrate into the host bone more rapidly and completely [15]; therefore, it is
regarded as the gold standard bone defects [16].
Cancellous autografts are the most commonly used form. Few osteoblasts and
osteocytes, but abundant mesenchymal stem cells (MSCs), survive as a result of
ischemia during transplantation, which helps maintaining osteogenic potential and
the ability to generate new bone from the graft [17]. Autograft-derived proteins,
which are attributed to the osteoinduction of the graft, are also preserved and pres-
ent when the autografts are appropriately treated [15, 18].
5
Trauma in Dentistry
Cortical autografts have excellent structure and are mechanically supportive,

due to osteoprogenitor cells [14]. Unlike the autologous cancellous graft, the
creeping substitution of cortical autograft is mainly mediated by osteoclasts after
the rapid hematoma formation and inflammatory response in early phase of bone
regeneration, since the revascularization and remodeling processes are strictly
hampered by the dense architecture [15].
5.1.1 Autogenous bone graft (autograft)
Autogenous grafts: the fresh autogenous graft taken from the same organism
contains osteogenic cells and does not cause an immunological reaction; this
group is the most advantageous graft material. However, the disadvantages of
this group include the need for a second operation in the donor area, long-term
postoperative pain and limitation of movement, and prolonged maintenance.
Autogenous bone grafts can be obtained from crista iliaca: grafts costal grafts and
cranial bones, structurally separated as cortical bone, cancellous, and corticocan-
cellous bone [5].
Intraoral cancellous bone: Upper jaw tuber region, toothless regions, exocytoses,
recovery sites ramus mandibula, interlobar alveolar bone, lower jaw semispherical
region and ramus mandibula, and bone fragments arising during operation [5].
Oral cancellous bone: The iliac bone is obtained from bone, ribs, and other
endochondral bones.
Corticocancellous bone: The corticocancellous bone does not have the osteogene-
sis-enhancing properties as cancellous bone. This type of graft is most commonly of
rib or ilium origin [5].
5.1.2 Homogeneous bone graft (homograft)
An autogenous bone graft is obtained from the individual itself.

Isograft: The tissues taken from living things with the same genetic structure as
the recipient are called isografts or syngenesioplastic grafts.
Allografts are tissues from the same species but from living things that are
genetically identical to the recipient. Bone allografts are obtained from human
beings of different genetic types and from bones extracted from humans, such as
cadavers or hip fractures, and are maintained in bone banks by a series of proce-
dures [11]. It has many advantages compared to being obtained from living people.
The advantages are elimination of donor site, reduction of anesthesia and duration
of operation, loss of blood loss and complications at low level. The disadvantage is
that the touch is taken by another person [5].
Considering the limitation of autologous bone grafts is the best alternative to
autografts and has been used effectively in clinical practice in many cases, especially
for patients who have poor healing potential, established nonunion, and extensive
comminution after fractures [15, 17]. The allograft may be machined and custom-
ized and is therefore available in a variety of forms, including cortical, cancellous,
and highly processed bone derivatives [14]. Allografts are found to be immunogenic
and have higher failure rate, which are believed to be caused by activation of major
histocompatibility complex [19].
Cancellous allografts are the most common types of commercial allogeneic
grafts and are supplied predominately in the form of blocks [14]. Compared to
autografts, a similar but slower sequence of events happens in the incorporation
process of allografts [15].
Cortical allografts confer rigid mechanical properties and are mainly applied
in spinal augmentation for filling large defects [14]. In consideration of immune
6
responses and for safety, frozen or freeze dried products that are free of marrow
and blood are commonly transplanted [15].
Demineralized bone matrix is highly processed allograft derivative with at least
40% of the mineral content of the bone matrix removed by the acid, while colla-
gens, noncollagenous proteins, and growth factors remain [17].
Demineralized bone matrix osteoconductivity is conferred by providing a
framework for cell populating and for generating new bone after the treatment
[18]. Osteoinductive property of demineralized bone matrix is mainly determined
by the remaining growth factors, which are directly correlated with preparation
methods. Demineralized bone matrix is similar to that of the autogenous graft, with
growth factors triggering an endochondral ossification cascade and culminating in
new bone formation at the site of implantation [18].
Recent techniques in preparing immunoglobulin complications of allografts to
remove the disease carrying potentials are freezing, freezing and drying, or expo-
sure to radiation. The applied bone has a slower revascularization and more resorp-
tive activity than autogenous grafts [5].
The mechanism of revascularization begins with an acute infinite response and
lasts for a long time, followed by chronic infilamations. It meets cellular immuno-
logical response in frozen bone applications.
5.1.3 Heterogeneous bone graft (xenograft)
Heterogeneous bone grafts are called grafts from a different species. The hetero-
geneous term is used for tissues from different species. Heterogeneous bone grafts
have been proposed to fill small jaw defects, and many clinicians have indicated that
these grafts have any osteogenic potential but instead are matrix for bone formation.
Studies done with inorganic calf bone showed successful results in graft osteotomy
sites but not in posttraumatic deformity and hypoplastic area corrections [5].
5.1.3.1 Clinical use of the allogeneic bone
Allogeneic bones prepared for different frozen, dried, or frozen oral surgical
procedures are available in different anatomical shapes. Cancerous iliac bone is
divided into particles of about 2–10 mm in diameter for use in bone defects. Small
cancellous particles are used in the periapical areas after curettage with limited
alveolar edge corrections [5].
Researchers who have expected to make use of osteoconductive effects of
alloplastic bone materials (hydroxylapatite, tricalcium phosphate, etc.) and bone
allografts and autogenous bone grafts cause postoperative complications in the
donor area have been directed to obtain bone grafts with both osseoinductive and
osseoconductive allogenic, low antigenic properties. For this purpose, autolyzed,
degenerated (allogenic) bone was studied. In contrast to lyophilized or other allo-
genic human bones, researchers indicate that the allogenic bone is osteoconductive.
The use of lyophilized and sterile human allogenic bone in parts or powder forms is
offered. The powder forms of this bone are suggested for filling the cyst cavity [5].
5.2 Bone-free biomaterials (alloplasts)
Allogenic grafts which lost vitality have been seen, organic, and inorganic
inanimate materials and synthetic materials obtained from animals such as ceramic
hydroxylapatites, tricalcium phosphates, and various “alloplastic materials.”
The most important problem in the alloplastic material is the tendency of the
immunological system to encapsulate and isolate foreign bodies [5].
7
Trauma in Dentistry
Alloplasts have been using in bone defects due to various reasons, such as cra-
nial, mandibular, maxillary, nasal, zygomatic, TME reconstructions, or traumatic
augmentations, are metals, polymers, hydroxylapatite, and associated calcium
triphosphate c eramics or combinations of these materials.
5.2.1 Tissue sources
I. Dentin: It consists of hydroxyapatite crystals with a strong structure. This

crystal structure is histologically resistant and resistant to osteoblast, osteo-
clast, blood vessel, and nerve tissue in a strong collagen network.
II. Cement: It is a bony matter that is directly related to the collagen fibers of the
jawbone through the periodontal membrane.
III. Cartilage
IV. Sclera
V. Dura mater
5.2.2 Metals
Metal biomaterials are widely used in electrosurgical surgery, orthognathic

surgery, and orthopedic surgery. Metallic stiffness is a desirable feature for
implants that will encounter load force, especially during functioning. The metal
groups used are alloys such as gold, platinum, stainless steel, titanium, and
chromium-cobalt.
Bioinorganic ions, such as silicon, magnesium, strontium, zinc, and copper, can still
be regarded as essential cofactors of enzymes, coenzymes, or prosthetic groups [20].
Mechanism of magnesium ions on fracture healing is not yet fully explained;
recent investigations showed that the osteogenerative effect of Mg2+ on undifferen-
tiated human bone marrow stromal cells (hBMSCs) and osteogenic hBMSCs was
likely attributed to connected the subsequent orchestrated [20].
Strontium to reduce bone resorption and osteoclast activity [20] were also
observed under rat osteoclasts and primary mature rabbit osteoclasts, respectively.
The adverse effect of strontium in cardiovascular diseases and venous thrombosis
has been highlighted [20].
Silicon is a silica-based synthetic bone substitute, which is used in orthopedic;
bioglass cannot be ignored when discussing the effect of silicon on bone regenera-
tion. Bioglass has a key role because of the fact that the hydroxyapatite coating,
but not the leaching silicon ions, played an active role in the processes leading to
new bone formation [19]. Zinc is involved in the structural, catalytic, or regulatory
action of several important metalloenzymes, and alkaline phosphatase (ALP) is
among them. ALP not only generates phosphates by hydrolyzing pyrophosphates
but also creates an alkaline environment, which favored the precipitation and
subsequent mineralization of these phosphates in the extracellular matrix, which
were produced by osteoblasts [20].
Copper has been recognized as a cofactor for several other enzymes in body, one
of which is related to the musculoskeletal system [20]. Lithium has attracted atten-
tion due to its role in osteogenesis [20]. Like copper, cobalt was recently showed to
stimulate angiogenesis [20].
8
5.2.3 Gelatin film
It can be used as resurfacing, porous, nonantigenic, and in the middle ear

surgery for pleural injuries in dura mater application.
5.2.4 Polymers
Polymethylmethacrylates are self-polymerized acrylics that are identified as

bone cement.
Polymethylmethacrylate (PMMA) remains a key component of modern practice
and is nonbiodegradable and nonresorbable, which makes it more like grouting
than cement, and thus cannot be considered a bone substitute material, which is
used in clinics [19].
5.2.5 Calcium sulfate
When combined with other synthetic bone substitutes and/or growth factors
[20], one of the promising approaches is to load antibiotics to this biomaterial.
5.2.6 Calcium carbonate
The outer layer of corals in the calcium carbonate structure releases a calcare-
ous substance called aragonite. The physical structure is similar to cancellous bone
and consists of trace elements such as 98% calcium carbonate, 2% fluorine, zinc,
copper, iron, and strontium. It is an excellent tissue-compatible material that can
completely resurface during the healing process and has an osteoconductive effect
on new bone formation [5].
5.2.7 Calcium phosphate
Calcium phosphate material is similar to HA in terms of its behavior in the tis-

sue. However, calcium phosphate has the most pronounced multiplication property,
which is closely related to bone without the need for porosity.
5.2.8 Calcium phosphate ceramics (CaP ceramics)
Calcium phosphate ceramics are calcium hydroxyapatites, which is a

chemical composition similar to the mineral phase of calcified tissues [17].
Hydroxyapatite (HAp) is occurring mineral form of calcium apatite with the for-
mula of Ca10[PO4]6[OH]2 and comprises about 50% of the weight of the bone,
which accounts for its excellent osteoconductive and osteointegrative properties
[14, 17].
5.2.9 Bioactive glass
Bioactive glass, known as bioglass, refers to a synthetic silicate-based ceramics

and was originally constituted by silicon dioxide (SiO2), sodium oxide (Na2O),
calcium oxide (CaO), and phosphorus pentoxide (P2O5) [20]. The optimized
constitutions lead to a strong physical bonding between bioglass and host bone. If
hydroxyapatite coating on the surface of bioglass takes place, it absorbs proteins
and attracts osteoprogenitor cells [20].
9
Trauma in Dentistry
6. Principles of biomaterial trauma applications
Correcting the deformities, the first thing to note in augmentation is the pres-
ence of the epithelium that can cover the implanted material completely and
without tension. In cases where deformity is common and tissue loss is large, skin
and soft tissue transplantation may be required before biomaterial is applied. If the
defect in the bone tissue is too large, graft should be considered, and functional
stress in the receiving area, load, and the trauma to it should be considered.
Bone defect may result in delayed union or even nonunion if the treatment is
improper. Therefore, bone grafting techniques should take place in the surgical
process. Even though various synthetic bone substitutes offer diversity options, the
treatment outcome is still incomparable to the autologous bone graft in terms of
bone healing quality and time management. Ions such as magnesium, strontium,
silicon, copper, and cobalt are feasible solution for bone defect. Therapeutic effect
and mechanism of ions have been understood. Bioinorganic ions can be applied
with growth factors and induce new bone formation.
Every surgeon should use the technique in the direction of the prepared plan,
determine the biomaterial, and apply it on the model. Atraumatic work should
be performed as much as possible during the operation, the material used should
conform to the defect contours, the stabilization should be esthetic of the patient,
and the appropriate tools should be used in the biomaterials during surgery to
manipulate the material so as not to create sharp or irregular edges. Stabilization is
provided by sewing, wire, and nails. Good closure of the incision is important in the
postoperative period. Careful evaluation of each phase will ultimately bring success.
Acknowledgements
This chapter was performed by Mehmet Yaltirik, Meltem Koray,

Hümeyra Kocaelli, Duygu Ofluoglu, and Cevat Tugrul Turgut in Istanbul
University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery.
Conflict of interest
We declare that there is no conflict of interest with any financial organization

regarding the material discussed in the chapter.
10
11
Trauma in Dentistry
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Mksillofasiyal Cerrahide Kullanılan
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Universitesi Yayinlari İstanbul; 2002.
Waas MAJ. Patient satisfaction with
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[17] Albrektsonn T, Zarb G, Worthington
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Periodontology. 1986;13:862-868 [19] Bouchard P, Ouhayoun JP, Nilveus
RE. Expanded polytetrafluoroethylene
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[10] Braley S. The silicones in maxillofacial
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12
Chapter 04
Dental Traumatology in Pediatric

Dentistry
Asli Topaloglu Ak, Didem Oner Ozdas, Sevgi Zorlu
and Pinar Kiymet Karataban
Abstract
In this chapter, epidemiology of dental trauma will be discussed in terms

of its incidence and prevalence among primary and permanent dentition.
Dental trauma causes and its distribution in accordance with age and sex will
be highlighted. Classification of dental trauma based on soft and hard tissue
injuries will be outlined, and subsequently, clinical examination and diagnosis
will be featured. Treatment modalities and variations between permanent and
primary dentition will be discussed along with the new treatment era namely
regenerative approach and decoronation. Splints, techniques, and follow-up
routines will also be discussed. Last but not least, prevention of dental trauma
will be discussed.
Keywords: dental trauma, children, splints, classification
1. An epidemiological approach to dental traumatology
Traumatic dental injuries are a public dental health problem worldwide and can
occur throughout life. Various interventions and treatment options are available,
depending on the specific traumatic injury sustained, but the fact is, every trauma is
a unique case, which requires unique diagnosis and treatment.
The International Association of Dental Traumatology reports that one of every
two children sustains a dental injury, most often between the ages of 8 and 12 years.
The suggestion is in most cases of dental trauma; a rapid and appropriate interven-
tion can lessen its impact from both oral and esthetic standpoint. To that end, the
association has developed guidelines for the evaluation and management of trau-
matic dental injuries.
Although the oral region comprises a small part as 1% of the total body area,
5% of all bodily injuries are oral traumatic injuries. Traumatic dental injuries tend
to occur at childhood or an young age during which growth and development take
place. In preschool children, with injuries to the head being the most common, oral
injuries make up as much as 17% of all bodily injuries, in contrast to later in life
when injuries to hands and feet are the most common.
Dental injuries are the most common and are seen in as many as 92% of all
patients seeking consultation or treatment for injuries to the oral region. Also, soft-
tissue injuries are seen in 28%, simultaneously with dental injuries, and fractures
involving the jaw are seen more rarely, in only 6% of all patients presenting with
oral injuries [1–8].
1
Trauma in Dentistry
Trauma has a multitude of consequences for the traumatized individual, family

members, and society. The impact is not only physical but also psychosocial and
economic. Every pediatric patient should be given the opportunity to receive a com-
plete dental treatment for traumatic dental injuries, but a complete treatment plan
involving participation of specialists in several disciplines can often be complicated
and expensive. In contrast to many other traumatic injuries treated on an outpatient
basis, traumatic dental injuries are mostly irreversible, and thus, treatment will
likely continue for the rest of the patient’s life [9–14].
Constructing a complete treatment plan can be challenging because of the
diversity of evidence-based interventions and reported outcomes in clinical
studies. Besides, there is evidence that clinical researchers may prefer report-
ing outcomes that enhance results—this is known as outcome reporting bias.
International Association for Dental Traumatology suggests that this diversity
and reporting bias shall be eliminated by a standardized trauma manage-
ment guideline in order to make the outcomes relevant to patients, clinicians,
and policy makers as findings of research are to influence practice and future
research [15].
It has been reported that, anterior teeth, especially the maxillary central and
lateral incisors are predominantly affected by traumatic dental injuries for both
primary and permanent dentitions. Traumatic dental injuries generally affect a
single tooth except certain trauma events, such as traffic accidents, violence, and
sports injuries, which result in multiple tooth damage.
Besides its numerous beneficial effects, active participation in sports activities
may increase the risk for traumatic injuries to oral and dental tissues. These injuries
are most prominent in boxing, basketball, hockey, and soccer.
Traumatic dental injuries in the primary dentition appear to be rather stable
at approximately 30% in most studies. It is been reported that one-third of all
preschool children have suffered from traumatic injuries to the primary dentition
in most of the countries. Although variations were observed within and between
countries, one-fourth of all school children and almost one-third of adults have also
suffered traumatic injuries to the permanent dentition [16–19].
2. Incidence and prevalence of dental trauma
The prevalence of dental injuries varies within countries regarding the research
reports. According to two surveys in US, the prevalence of traumatic dental injuries
varies between 18.4 and 16% in 6–20 years old and 27.1 and 28.1% in 21–50 years
old age groups. In UK, dental trauma prevalence varies between 23.7 and 44.2% in
11–14-year age groups and mostly observed in schools [20–23]. In other European
countries, the prevalence varies between 13.5 and 20.3% in 6–24-year age groups.
In Middle East and Asia, the prevalence varies between 16.2 and 32% in 8–16 years
old age groups as the 10–11 years age groups revealed the highest score. There is an
absolute need for an international standardized trauma registration either being
able to detect trends over time or to make reasonable comparisons between and
within countries [24–32].
In most studies, it is been reported that the incidence of traumatic dental
injuries in children shows a range of 1–3% in the population. The peak incidence for
traumatic dental injuries per 1000 individuals is found up to 12 years of age. The
incidence is lower in older ages. Boys are more often affected than girls.
The variation of both prevalence and incidence presented in the literature
reflects the local differences, environmental variations, behavioral, cultural, and
2
Dental Traumatology in Pediatric Dentistry
socioeconomic diversities as well as the lack of standardization in methods and

classifications [12, 16, 33].
2.1 Etiologic risk factors
Etiologic factors are very much related to the age, gender, environment, and
activity of the patient.
Age is an important factor, as school children and adolescent are the main groups
who are mostly prone to traumatic injuries. It is estimated that 71–92% of all trau-
matic dental injuries occur before the age of 19 years; other studies have reported a
decrease after the age of 24–30 years.
While in preschool children, the most common cause of traumatic dental inju-
ries are accidental falls, in school age children, injuries are often caused by sports
activities or hits by another person. Traffic accidents and assaults are the predomi-
nant etiologic factors in adolescents and young adults, and oral injuries occur most
frequently during leisure time and during weekends associated with the western
lifestyle today.
Gender is also a risk factor as males experience traumatic dental injuries at least
twice more often than females. Yet, recent studies have shown a reduction in this
gender difference in sports, which might be due to an increased interest in sports
among girls Traebert et al. reported that girls can be exposed to the same risk
factors of TDI as boys, which is a characteristic of modern Western society. Thus,
environment and the activities of a person are undoubtedly more determining fac-
tors of TDIs than gender.
Another factor to be pointed is that in many countries, an increasing number
of old people are possessing their own teeth, which, in near future, may lead to the
increase in prevalence of dental traumatic injuries due to accidental falls in geriatric
population [16, 33–35].
3. Guideline on management of acute dental trauma
3.1 Examination
Before making a treatment in trauma cases, dentist must check the circumstances
written in below:
1. Patient’s name, age, gender (include weight for young patients), address, and
contact numbers
2. Symptoms of central nervous system should be checked after the accident
3. General health of the patient
4. Three W′ s must be asked “when, where, and how the injury occurred”
5. Treatment the patient received elsewhere
6. Previous dental injury history
7. Disturbances in the bite
3
Trauma in Dentistry
8. Tooth reactions to thermal changes or sensitivity to sweet/sour
9. Soreness of the teeth during eating or by touching
10. If the patient is feeling spontaneous pain in the teeth.
Access for risk of concussion or hemorrhage:
• Symptoms may be delayed for minutes to hours
• It must be asked if there is a loss of consciousness
• Difficulty of speech and /or slurred speech
• Nausea/vomiting
• Fluid from ear/nose
• Confusion of situations
• Blurring in vision or uneven pupils.
3.2 History
• Timing
• Mechanism of injury
• Location
• Bleeding must be checked. Also, previous dental traumas should be asked.
3.3 Examination
Clinical examination consists of visual inspection, palpation, thermal testing,

and electric pulp testing. First and foremost, account for all teeth:
• Extent of injury
• Lacerations
• Teeth position
• Appearance of tissue should be tested along with the color of tooth (purple,
blue, gray, or yellow) and its mobility
• Pulp testing (percussion, EPT, and thermal): but if the traumatized tooth is
immature, EPT may not be accurate
• Palpation of soft tissue must be recorded. Because the recordings will help you
for follow-up appointments. Taking photographs may help to make proper
4
examination and diagnosis. These views are going to help the comparison of
preoperative and follow-up of traumatized teeth.
3.4 Radiographs: AAE-recommended guidelines
• Occlusal
• Periapicals radiographs with different lateral angulations
• CBCT if more serious of an injury.
3.4.1 Panorex
• Periapical-radiographs taken from the same angle every time will help to make
good treatment decisions. Using a film holder will hold the radiograph in a
paralleling technique
• Occlusal
• CBCT.
3.5 Types of dental trauma on hard tissue and pulp
Enamel infraction
Enamel fracture
Enamel-dentin fracture
Enamel-dentin-pulp fracture
Crown-root fracture w/o pulp involvement
Crown-root fracture with pulp involvement.
3.6 Types of dental trauma on periodontal tissue
Concussion
Subluxation (loosening)
Intrusive luxation (central dislocation)
Extrusive luxation (partial avulsion)
Lateral luxation
Retained root fracture.
3.7 Types of dental trauma on supporting bone
Exarticulation (complete avulsion)

Comminution of the alveolar socket
Alveolar socket wall fracture
Alveolar process fracture
Mandible or maxilla fracture.
3.8 Types of dental trauma on gingival or oral mucosa
Gingival or oral mucosal laceration

Gingival or oral mucosal contusion
Gingival or oral mucosal abrasion (Figures 1–3) [9, 11–13, 15, 36, 37].
5
Trauma in Dentistry
Figure 1.
Types of dental trauma: gingival laceration.
Figure 2.
Types of dental trauma: intrusive luxation (central dislocation).
Figure 3.
Types of dental trauma: crown-root fracture with pulp involvement.
6
4. Dental trauma in primary dentition
Pain treatment and prevention of teeth germs must be our main goal in the treat-
ment strategy of the traumatized primary teeth. Due to behavioral management
problems or a severe trauma with a soft tissue bleeding, treatment may be over-
looked or limited to extraction. However, in the overall treatment, primary teeth
must be followed up clinically and radiographically in the long term.
In this section, treatment of primary dentition will be explained based on IADT
treatment guidelines.
Enamel fracture: this type of fracture involves only enamel. There is no radio-
graphic abnormality observed. Sharp edges are recommended to be smoothened.
There is no need for follow-up.
Enamel dentin fracture: fracture involves enamel and dentin. Pulp is not
exposed. There is no radiographic abnormality observed. The relation between
the fracture and the pulp chamber can be revealed. In case behavioral manage-
ment is succeeded with the patient, involved dentin can be sealed completely
with glass ionomer to prevent microleakage. Composite resin restorations are
good choices if lost tooth structure is large. Clinical examination is required after
3–4 weeks.
Crown fracture with exposed pulp: fracture involves enamel and dentin
and the pulp is exposed. Radiographic findings can reveal the stage of root
development. Preservation of pulp vitality can be accomplished by partial
pulpotomy. Unless there is an cooperation with the patient, extraction is an
alternative treatment approach. Clinical follow-up is required after 1 week,
6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and
1 year as well (Figure 4).
Crown/root fracture (without pulp exposure): this type of fracture involves
enamel, dentin, and root structure. The pulp may or may not be exposed. Tooth
displacement may be observed as well. Radiographical evaluation will reveal single/
multiple fragments of the traumatized tooth. In case the fracture involves only a
small part of the root, only fractured fragment is removed and coronal restoration
can be done if the stable fragment is adequate for restoration. Otherwise, extrac-
tion is required. Clinical follow-up is required after 1 week, 6–8 weeks, and 1 year.
Radiographic follow-up is required after 6–8 weeks and 1 year as well. Monitoring is
vital until eruption of the successors.
Crown/root fracture (with pulp exposure): this type of fracture involves
enamel and dentin and the pulp is exposed. The stage of development of root can
be determined by the radiographic evaluation. Preservation of pulp vitality can be
accomplished by partial pulpotomy using calcium hydroxide paste and reinforced
Figure 4.
Crown fracture in primary dentition.
7
Trauma in Dentistry
glass ionomer as liner and composite/compomer restorations. Unless there is a co-

operation with the patient, extraction is an alternative treatment approach. Clinical
follow-up is required after 1 week, 6–8 weeks, and 1 year. Radiographic follow-up is
required after 6–8 weeks and 1 year as well.
Root fracture: the fracture involves the alveolar bone and may extend to
adjacent bone leading to segment mobility and dislocation. Frequently, an occlusal
interference is reported. Radiographic evaluation is required to assess the fracture
line position. Treatment should be repositioning the displaced segment and splint-
ing. Stabilization must be for 4 weeks. Monitoring the fracture line is essential.
If there is no displacement, 1 week, 6–8 weeks, and 1 year clinical follow-up are
required. After 1 year, radiographic evaluation should be repeated until eruption
of the successors. If the traumatized tooth/teeth are extracted as treatment choice
after 1 year, both clinical and radiographic examination are still required for
monitoring successors.
Alveolar fracture: the tooth is displaced, usually in a palatal/lingual or labial
direction leading to mobility. Occlusal radiographic findings will reveal increased peri-
odontal ligament space apically at its best. If there is no occlusal interference, the tooth
is allowed to reposition spontaneously. If there is minor occlusal interference, slight
grinding is indicated. When there is more severe occlusal interference, the tooth can
be gently repositioned by combined labial and palatal pressure after the use of local
anesthesia. In severe cases, when the crown is dislocated in a labial direction, extrac-
tion is indicated. Follow-ups are required as follows: 1 week and 2–3 weeks of clinical
examination, and 6–8 weeks and 1 year clinical and radiographic examinations.
Concussion: clinically, tooth is sensitive to touch. There is no mobility or sulcular
bleeding observed. Radiographic evaluation discloses no pathology as well. Observation
is the only treatment option. Only clinical follow-up is required after 1 and 6–8 weeks.
Subluxation: an increased mobility is observed though the tooth is not dis-
placed. There might be cervical bleeding. There is no abnormality in the radio-
graphic evaluation. Occlusal radiography can screen possible root fracture and
displacement. Observation is the only treatment option. Soft brushing and use of
antibacterial agents is recommended. Only clinical follow-up is required after 1
and 6–8 weeks. Parents should be informed about an occurrence of possible crown
discoloration. Unless a fistula is formed, monitoring is required.
Extrusive luxation: the tooth appears elongated due to its displacement out of
its socket. Thus, it can be excessively mobile. Increased apical periodontal ligament
space is disclosed in radiographic evaluation. For minor extrusion (<3 mm) in an
immature developing tooth, careful repositioning or leaving the tooth for spontane-
ous alignment can be the treatment options. Extraction is indicated for severe extru-
sion in a fully formed primary tooth. Clinical follow-up is required after 1 week,
6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and 1 year
as well. Parents should be informed about the possible occurrence of discoloration.
Lateral luxation: the tooth is displaced, usually in a palatal/lingual or labial direc-
tion and will be immobile. If there is no occlusal interference, the tooth is allowed to
reposition spontaneously. For minor occlusal interference, slight grinding is indicated.
If there is more severe occlusal interference, the tooth can be gently repositioned after
the use of local anesthesia. If the crown is dislocated severely in a labial direction,
extraction is indicated. Clinical follow-up is required after 1 week, 6–8 weeks, and
1 year. Radiographic follow-up is required after 6–8 weeks and 1 year as well.
Intrusive luxation: when the apex is displaced toward labial bone plate, the
apical tip appears shorter than its contra lateral and the tooth is left for spontane-
ous repositioning. When the apex is displaced toward the permanent tooth germ,
tooth appears elongated and must be extracted. Clinical follow-ups are required for
1 week, 3–4 weeks, 6–8 weeks, 6 months, and 1 year after, whereas radiographic
8
follow-up is 6–8 weeks and 1 year later. Clinical and radiographic monitoring is
essential until eruption of the permanent successor.
Avulsion: clinical findings reveal that tooth is not in the socket; however,
radiographic examination is required to confirm and not to overlook intrusion.
Replantation of the avulsed teeth is not recommended. Clinical follow-ups are
required for 1 week, 6 months, and 1 year after, whereas radiographic follow-up is
for 6 months and 1 year after to monitor successors’ eruption.
5. C
lassification, definition, examination, and treatment planning in
dental traumas
5.1 Hard tissue and pulp in permanent dentition
Enamel infraction: no need to restore.

Enamel-fracture: it is a kind of uncomplicated crown fracture. An enamel
fracture is a crown fracture limited to loss of enamel only. Small enamel fractures
can be polished. Composite resin restoration may be preferred for more involved
enamel fractures (Figure 5).
Enamel-dentin fracture: it is a kind of uncomplicated crown fracture. The
tooth should be restored with composite resin. If the fragment is available, reattach-
ment of fragment can be attempted (Figure 6).
Figure 5.
Enamel fracture.
Figure 6.
Enamel-dentin and pulp fracture.
9
Trauma in Dentistry
Enamel-dentin-pulp fracture: a complicated crown fracture involves enamel and

dentin with pulp exposure. If the pulp exposure is visible, only a pink spot or bluish
exposure site is cleaned and pulp-capping agent is applied. For larger pulpal expo-
sures, partial pulpotomy and direct pulp-capping procedures are performed. Crown
restoration method is the same as in uncomplicated crown fractures. Pulp capping and
restoration should be performed at the same appointment, if possible (Figures 6–8).
Crown fracture combined with luxation results in ischemic changes that can
lead to pulp necrosis. In these cases, there is no response to vitality tests. It is possible
that the tooth has sustained a luxation injury and pulp necrosis (coagulation necro-
sis) is present. According to Dr. Tsukiboshi, for young patients under 18 years of
age, regardless of pulp vitality, the restoration of the tooth should be done. Then, the
patient should be followed for 1, 3, and 6 months to determine pulp vitality. After
the waiting period, if pulp necrosis occurs, root canal treatment needs to be per-
formed. Adult patients with a traumatized mature tooth with closed apex, after the
confirmation of pulp necrosis in the first appointment, root canal treatment should
be completed. Otherwise, pulpectomy may be performed (Figures 9 and 10).
Crown-root fracture w/o pulp involvement: the treatment is similar to the
uncomplicated crown fracture. Firstly, necessity of pulp capping or partial pulp-
otomy is evaluated and then, rearrangement of the fragment is performed. If no
need to pulp capping or partial pulpotomy, flowable composite resin may help to
combine the fractured parts of the crown.
Crown-root fracture with pulp involvement: in these cases, the fractured
segment accounts for the larger part of the crown and the fracture line has extended
to the alveolar crest or below. These teeth may be seen too difficult to restore, but
the location of the fracture line may help to decide the treatment procedure. If the
location of the fracture line is located within the coronal third of the root, crown
restoration is possible after the extrusion of the root. There are two ways for extru-
sion of the root: orthodontic or surgical.
Figure 7.
Pulp capping after dental trauma.
Figure 8.
Restoration during first appointment.
10
Figure 9.
Young patient’s traumatized teeth with open apex.
Figure 10.
Closure of apex of traumatized incisor after 1.5 years.
5.2 Root fracture
Root fracture is a fracture that involves cementum, dentin, and pulp. The
fracture line may be horizontal, oblique, or vertical. But vertical root fractures may
generally occur in endodontically treated teeth. For that reason, in this chapter,
horizontally or obliquely fractured teeth will be considered.
Root fractures are classified as shallow or deep according to the location of
fracture line. Root fracture is generally diagnosed by radiographs. Sometimes,
displacement of the coronal segment is not present. So, the fracture line is easily
missed by conventional radiographic techniques. Therefore, it is better to take the
radiograph from different angles. Or cone beam computed tomography may be
used to diagnose the root fractures. Otherwise, fracture lines may be discovered
after several months.
While performing electric pulp testing, tooth may not be responding to it. In
that cases, three possibilities may be thought: pulp tissue is severed at the fracture,
there is no severance of the pulp, only the subluxation in the apical fragment or the
pulp is severed, and the apical fragment is subluxated.
5.2.1 Treatment planning of deep root fractures
The treatment of deep root fracture is simple: repositioning and fixation of coro-
nal segment. Depending on how deep the fracture is and how mobile the coronal
11
Trauma in Dentistry
segment is, fixation may be required for up to 3 months. Six months later, if there
is no pulp necrosis, there will be no need to root canal treatment. In case of pulp
necrosis, root canal treatment is done up to the fracture line [9, 10, 36–39].
5.2.2 Treatment planning of shallow root fractures
Restorative treatment can be very difficult. Sometimes extraction is the best

treatment planning. If the extraction is the chosen treatment, the patient’s age, oral
condition, oral hygiene habits, the tooth’s position, and the occlusion should be
evaluated and then autotransplantation may be considered as an alternative plan.
5.3 Subluxation
Subluxation is clinically defined as injury to the periodontal tissues accompa-

nied by bleeding from gingival sulcus, an increase in mobility but no dislocation
of the tooth. There is sensitivity in percussion, and high mobility and bleeding are
important criteria in diagnosis of subluxation. Electric pulp testing is important. In
immature tooth, electric pulp testing will not respond, so re-test with electric pulp
testing after a week is advised.
5.3.1 Treatment planning
In immature tooth: only follow-up is necessary. Root canal treatment is indicated

in the presence of pulp necrosis. When there is a possibility of pulp necrosis, root
canal treatment can be initiated without anesthesia.
In mature tooth: follow-up visits without invasive treatment are advised
6–12 months after injury to allow pulp vitality to be recovered. In case of pulp
necrosis, root canal treatment is indicated.
5.4 Extrusive luxation
Extrusive luxation results in damage to the periodontal tissues as the tooth is dis-
placed in coronal direction. The periodontal tissue and the root are not completely
separated, but the blood supply at the apex is disrupted. There is high mobility,
bleeding, and electric pulp testing response is negative. Radiographically, there is
widening in periodontal ligament space.
Repositioning, fixation, and follow-up are the steps of treatment planning. Root
canal treatment is avoided until pulp necrosis is confirmed. After confirmation of
pulp necrosis, root canal treatment is indicated. In ımmature tooth, apexification
and apexogenesis may be applicable.
5.5 Lateral luxation
Lateral luxation is an injury to the periodontal and alveolar supporting tissues

that the tooth displaces laterally. The crown of the tooth is displaced palatally or
lingually, and the tooth may be apically displaced with alveolar bone fracture on the
labial side. The blood supply is completely disrupted at the apical side, but peri-
odontal tissues have not been separated. Radiographically, the root shape and alveo-
lar socket are not aligned. Sometimes, the traumatized teeth may be locked because
of fracture on alveolar bone. This situation may be confused with ankylosis.
12
Repositioning, fixation, and regular follow-up are the steps of treatment of

lateral luxation. In fixation period, if alveolar fracture occurs, fixation period will
take at least 3 months. Root canal treatment may be delayed until pulp necrosis has
been confirmed. In young adults, apexification and apexogenesis may be treatment
alternatives (Figures 11 and 12).
5.6 Intrusive luxation
Intrusion is a luxation injury that results in apical displacement of tooth. In some

cases, alveolar bone fracture is also seen. In the diagnosis of ıntrusion, differential
Figure 11.
Lateral luxated central incisor.
Figure 12.
Splinting after lateral luxation.
13
Trauma in Dentistry
diagnostic criteria should be detected. If the tooth is intruded apically compared

with adjacent teeth, intrusion should be thought. Reduced mobility may also be
seen. Percussion sound is a metallic sound. There is no percussion sensitivity.
If there is no clear periodontal ligament in radiograph, the intrusion should be
suspected. CBCT images are important to differentiate the diagnosis of lateral or
intrusive luxation (Figure 13).
The healing of intruded tooth may be affected by some factors such as patient’s
age, root development degree, and depth of intrusion.
According to some studies, as age increases, the incidence of pulp necrosis,
loss of marginal bone, and root resorption also increase. If intrusion is more than
7 mm, the more complications may be seen compared with those that are intruded
less than 3 mm. Time between injury and treatment, type of fixation, and use of
antibiotics may also affect the results.
Figure 13.
An intruded central incisor.
Figure 14.
An avulsed tooth.
14
Spontaneous re-eruption, orthodontic extrusion, and the surgical extrusion are

the main options of intrusive luxation.
Dr. Tsukiboshim suggests spontaneous re-eruption when the depth of intrusion
is shallow and the root is immature whereas surgical extrusion is indicated when the
depth of intrusion is deep and the root is mature.
5.7 Transient apical breakdown (TAB)
TAB is a phenomenon linked to the repair processes in the traumatized pulp

or pulp and periodontium of luxated mature teeth, which returns to normal
when repair is completed. This phenomenon is described by Frances Andreasen
in 1986.
5.8 Avulsion
Avulsion is defined as the condition that the whole tooth is completely separated
from the supporting tissues.
The success rate for an avulsed tooth after replantation depends on the vitality of
periodontal ligament and attachment of the tooth (Figure 14) [9–12, 15, 24, 26, 27,
31, 36–40].
6. Splinting
6.1 A splint may be necessary to stabilize the traumatized tooth after injury
Dental splint is a rigid or flexible device or compound used to support, protect,

or immobilize teeth that have been loosened, replanted, fractured, or subjected to
certain endodontic surgical procedures (Figures 15–17).
6.1.1 Flexible splinting assists in healing
Characteristics of the ideal splint include:
1. easy to fabricate in the mouth and without extra trauma to the tooth
2. passive if not orthodontic forces are intended
3. allows for physiologic mobility
4. nonirritant to soft tissues, periodontal tissues, and noncarcinogenic
5. does not interfere with occlusion
6. easy to permit endodontic access and vitality testing
7. easy to clean
8. easy to remove
9. allows for pulp testing and endodontic treatments
10. relatively inexpensive
15
Trauma in Dentistry
11. provides patient comfort and esthetic appearance
12. easily accessible and easy to maintain oral hygiene.
6.1.2 Types of splints
Rigid splints: are used in cervical root fractures and alveolar bone fractures.
Stainless steel wire >0.5 mm, direct composite resin or titanium ring splint (TTS),
or direct composite resin reinforced with fiberglass ribbon can be used.
Flexible splints: allow for optimal pulp and periodontal ligament healing. Nylon,
stainless steel wire <0.4 mm, nickel titanium wires up to 0.016 with composite
resin, and glass ionomer cement splints are used.
Figure 15.
Splint with ligature wire.
Figure 16.
Arch wire and composite splint.
Figure 17.
Composite resin splint.
16
Compound splints: orthodontic bracket and wire are used as compound splint
materials.
Instructions to patients having a splint placed include to:
1. taking a soft diet
2. avoid eating on teeth having splint
3. maintain a detailed oral hygiene
4. use chlorhexidine/antibiotics if prescribed
5. reach the dental office immediately if splint breaks/loosens.
Before beginning or continuing orthodontic treatment, traumatized teeth must

be checked carefully.
It is recommended that even if there is a minor trauma to the teeth, one should
wait for at least 3 months for orthodontic movement. Any kind of dental traumas to
hard or soft dental tissues (e.g., minor concussions, subluxations, and extrusions)
also requires a 3-month waiting period. For moderate to severe trauma/damage to
the periodontium, at least 6 months of waiting period is recommended.
In root fracture cases, the tooth must not be moved for at least 1 year. If
there is radiographic evidence of healing, those teeth may be moved success-
fully [15, 36–39].
7. Regenerative endodontic treatment of necrotic immature permanent

teeth due to dental trauma
An immature permanent tooth is defined by the British Society of Pediatric

Dentistry as a tooth that is not fully formed, particularly the root apex. A vital
pulp is necessary for the development and maturation of the tooth root [40].
Completion of the root development of the teeth and closure of the root apex takes
place 2–3 years after the eruption of the teeth. If pulp necrosis occurs for any reason
(trauma, caries, etc.) before root development is complete, the root development
undergoes a standstill, so the root remains without closure. In such cases, root canal
treatment is both inevitable and difficult to do, because the root canal is very large,
and the dentin walls are very thin and fragile [16, 40–43].
As a result of trauma, opening of the pulp tissue into the oral cavity may lead to
infection by reaching the pulp tissue of oral microorganisms [44]. However, dam-
age to the vascular nerve pack at the apex of the severely traumatized tooth causes
necrosis of pulp tissue [41, 44].
The completion of the root formation of immature teeth that have necrotic
pulp, or the induction of a calcified barrier formation at the root apices is defined as
apexification [21].
There are various difficulties in the treatment of immature necrosed young
permanent teeth:
• the difficulty of cleaning and shaping the canals
• difficulty of canal disinfection
• the risk of breakage of thin fragile dentin walls during mechanical obturation
17
Trauma in Dentistry
• short crown/root ratio
• material carried out of the apex
• it is difficult or impossible to perform a possible retreatment in the future due

to thin canal walls.
Until now, two apexification procedures for these teeth have been performed
successfully. First of these procedures is conventional apexification inducing the
formation of a barrier to apical calcification using calcium dihydroxide. Second
is a one-step apexification method that provides production of an artificial apical
barrier using mineral trioxide aggregate (MTA). In both the methods, constriction
of apical foramen of an immature tooth has been shown [16, 38, 42, 43].
Traditional apexification treatment requires a large number of sessions, and
problems with patient compliance may occur. Long-term use of calcium hydroxide
may lead changing physical properties of dentin.
As a result of requirements of short-term completion of canal treatments, accel-
eration of healing and reduction of the sessions was sought response to one-step
apexification with apex closuring by using MTA that has been on the agenda [25].
Advantages of MTA apexification over calcium hydroxide apexification are
more such as reliable barrier formation, reduction in treatment time, requirement
of lesser visits, hence reducing the root fractures and preventing the changing
of physical properties of dentin. In addition, since the MTA is not cytotoxic, its
biological properties are advantageous and induce tissue repair.
Despite the popularity among clinicians, there are disadvantages of the apexifi-
cation technique compared with MTA:
• the inability to control the applied condensation pressure and increased risk of
fracture of thin dentin walls at large pressures
• it is difficult to remove after hardening, and surgical methods are needed for
removing
• the high alkalinity of the material affects the stiffness of the root dentin over
time
• high cost
• short shelf-life
• the challenges of clinical practice.
However, the risk of development of cervical root fractures remains high after
apexification treatments [28].
The disadvantages of traditional apexification treatments have led the research-
ers to quest an alternative treatment approach that restores the function of the pulp
dentin complex and persists its development. This quest led to arise of regeneration
and regenerative endodontic treatment.
In biology dictionaries, regeneration is defined as the regrowth by an animal or
plant of an organ, tissue, or part that has been lost or destroyed [21].
Regenerative endodontics is one of the most exciting new developments in
endodontics. The current (2016) American Association of Endodontists’ Glossary
of Endodontic Terms defines regenerative endodontics as “biologically-based
18
procedures designed to physiologically replace damaged tooth structures, including

dentin and root structures, as well as cells of the pulp-dentin complex” [21].
Regenerative endodontic procedures, a new approach to preventing tooth loss,
aim to restore the damaged pulp and dentin structures, create a new pulp tissue in
the canal, and provide root maturation [16, 28, 38, 43].
Seeking to find the ideal treatment method within the regenerative endodontics
continues. The most studied methods in this area are: root canal revascularization,
stem cell therapy, pulp implants, scaffold implants, injectable scaffold applications,
three-dimensional cell software, and gene therapy. However, only the root canal
revascularization could be used clinically in the treatment of traumatized necrotic
young permanent teeth [28].
Revascularization term is used to indicate the restoration of blood flow to the
necrotic pulp cavity. Despite the fact that pulpless teeth can sustain their presence
in the mouth for a long time after successful endodontic treatment, the viability
of the dental pulp offers many advantages, including the formation of reparative
dentin, the completion of apical closure, and the development of dentin walls. Via
the root canal revascularization, the pulp tissue is regenerated and the permanence
of the tooth vitality is ensured [28, 38].
There are also negative aspects such as the fact that some dental pathologies,
such as progressive decay, cannot be recognized by patients due to the loss of
sensitivity to environmental changes by pulpless teeth.
In addition, the elimination of the negative consequences of traditional root
canal treatment procedures is the reason why revascularization is preferred in the
treatment of necrotic traumatized young permanent teeth.
At the basis of revascularization lies the rationale that “new cells can develop in
the presence of sterile tissue matrix and pulp vitality can be restored,” because when
dental canal infection is under control, it becomes a necrotic, avulse tooth condition
with sterile pulp cavity. Regeneration in the apical tissues after the avulsion and
replantation suggests regeneration may occur in the pulp tissue of a necrotic and
infected tooth [16, 43, 45].
In the revascularization method, after the necrotic root canal is totally
disinfected, it is aimed to provide a fibrin matrix with the blood clot formed
by the bleeding from the tooth apex provided by the over instrumentation.
Revascularization is observed through the new cell development via the differentia-
tion of few stem cells preserved vital, in this provided sterile matrix [16, 43].
Hargreaves et al. recommended three major components of pulp regeneration
called triad of regenerative endodontics:
a. a dependable stem cell source that has capability of differentiating into

odontoblasts
b. a suitable scaffold to support cell growth and differentiation, and
c. signaling molecules that have capability to stimulate cellular proliferation and

direct cellular differentiation [28].
Stem cells are nondifferentiated cells that are capable of differentiating them-
selves into specialized cells, which can be transformed into many different cell
types, when appropriate conditions are achieved within the body or in the labora-
tory. They are self-renewing and thus can generate any tissue for a lifetime unlike
other progenitor cells [21].
Stem cell sources that play a role in the regeneration and root development
of pulp tissue in the treatment of revascularization include dental pulp cells that
19
Trauma in Dentistry
maintain the viability of the root canal, stem cells originating from the apical
papilla, and periodontal ligament [16, 19].
Blood clot is a very rich source of growth factors and has an important role in
the differentiation, maturation, and regeneration of fibroblast, odontoblast, and
cementoblast [23].
7.1 The importance of root canal disinfection in revascularization treatments
Absence of bacteria in the root canal is critical for successful revascularization

therapy, because the development of new tissue stops when it encounters bacteria in
the canal cavity.
The most effective root canal disinfection method is provided by drugs applied
to the root canal in addition to chemical irrigation.
However, a good preparation in open apex tooth and the use of cytotoxic
antiseptics may remove pulp cells that are well fed and viable in the apical region.
Removal of these tissues means removal of cells with the potential to convert to
pulp and dentin [16, 41, 43, 46].
Sato et al., who applied the triple antibiotic paste in vitro for the first time,
reported that triple antibiotic paste is effective in the treatment of dentin infected
by Escherichia coli [46].
7.2 Patient selection criteria for revascularization treatment
The success of the treatment is based on the right case selection. No studies have
been conducted on the success of revascularization therapy in individuals with
genetic disease, severe medical disease, or poor immune system. Therefore, revas-
cularization therapy procedures should be limited to systemically healthy people.
Revascularization therapy is not suitable for individuals allergic to triple antibi-
otics used in the canal.
It is not indicated in patients who cannot adapt or participate in the treatment
process due to being a long-term and follow-up procedure, and in individuals who
are fearful or uncooperative [42, 45, 47].
7.3 Tooth selection criteria for revascularization treatment
First of all, the tooth to be treated should be necrosis. Other regenerative thera-
pies are considered such as pulp capping or partial pulpotomy with regenerative
medicaments in teeth with vital pulp and partial pulpitis.
The presence of radiolucency in the periapical region as well as vitality tests has
long been used as a determining factor. In both cases, vital pulp cells and apical
papilla can still be present in the canal and apex.
Another criterion is the presence of infection. However, as a hypothesis, the
presence of long-term infection adversely affects the survival of the pulp tissue and
stem cell continuity, and makes it difficult to control the infection.
Since apex opening greater than 1 mm increases success, it should be preferred
in immature young permanent teeth. Although a very few researchers recommend
to expand the apex with a hand piece in the teeth with closed apex having less than
1 mm apex opening, but in the guidelines, the indication is limited to the open apex
teeth.
Furthermore, the loss of coronal tissue in the teeth that will be treated with
revascularization should not exceed the size for allowing it to be restored, and tis-
sue damage should not be large, requiring to be made post/core [16, 41–43, 47].
20
8. Procedures in regenerative endodontics
An informed consent document must be taken before the treatment. This docu-
ment should include the informations of complications such as tooth coloration or
treatment failure, side effects such as pain or infection that may be able to emerge,
two (or more) appointments will be needed, and what type of antibiotics will be
used. Also, besides the nontreatment option, the patient must be informed about
the tooth extraction (when deemed the tooth is nonsalvageable), and calcium
hydroxide and MTA apexifications as the alternative treatments of revasculariza-
tion. Following the consent document signing, treatment can be commenced
[16, 18, 19, 25, 28, 38, 41–44, 46–49].
8.1 First appointment
Under local anesthesia and rubber dam isolation, an access cavity is prepared for
the treatment. Each root canal opening is expanded to facilitate the placement of
the medicament. The remaining root canal is not instrumented.
Copious, passive irrigation is made with 20 ml of 1.5% sodium hypochlorite
(NaOCl), for 5 minutes to each canal, followed by a sterile saline solution or EDTA
(20 ml for each canal, 5 minutes). It is important to maintain the vitality of stem
cells in the apical tissues. Therefore, an irrigation system such as needle with
closed end and side vents is used to minimize the odds of extrusion of irrigant
agents into the periapical area. Also, the irrigation needle should be positioned
approximately 1 mm from the root end to minimize cytotoxicity to stem cells in
the apical tissues.
After sufficient irrigation, the canals are gently dried with sterile paper points.
Calcium hydroxide, or low concentration of triple antibiotic paste, can be used
to fill the canals.
A triple antibiotic paste is an antibiotic mix made from tablets of ciprofloxacin,
metronidazole, and minocycline in a ratio of 1:1:1. For preparation, after removal of
the coatings on the tablets, the tablets are pulverized and mixed in a 1:1:1 ratio in a
sterile saline to form a paste-like consistency.
Triple antibiotic paste has been associated with tooth discoloration; therefore, if
it is used, to minimize risk of staining, pulp chamber is sealed with a dentin bond-
ing agent and ensure that it should remain below cemento-enamel junction (CEJ).
For minimizing the coronal staining, modified triple antibiotic paste obtained
by adding another antibiotic (e.g., clindamycin, amoxicillin, and cefaclor) instead
of minocycline, or minocycline-free double antibiotic pat, may also be used.
After delivering the paste into the canals via syringe, a sterile cotton pellet is
placed into the canal below the CEJ and the cavity is sealed with temporary filling
so as not to allow microleakage.
8.2 Second appointment (1–4 weeks after first visit)
In the second appointment, 1–4 weeks after the first visit, the response of the
initial treatment is evaluated. If the clinical signs/symptoms persisted, the first
appointment treatment procedures are repeated with antimicrobials, or alternative
antimicrobials.
If the tooth has become asymptomatic, the second session is started through the
anesthesia with 3% mepivacaine free of vasoconstrictor.
After the tooth is isolated with rubber dam, the temporary filling and cotton
pellet are removed.
21
Trauma in Dentistry
Following the removing of the paste from the canals by irrigation with 20 ml of
17% EDTA, the canals are dried with sterile paper points.
Bleeding into canal system to the level of CEJ is created by 2 mm over-instru-
menting through rotating a precurved K-file. The using of platelet-rich plasma
(PRP), platelet-rich fibrin (PRF), or autologous fibrin matrix (AFM) has been
considered as the alternatives to create a blood clot, especially when bleeding into
the canal cannot be achieved.
Bleeding is stopped at a level allowing for 3–4 mm of restorative material.
In order to ensure the formation of blood clot, place a sterile cotton pellet for
3–4 minutes upon the bleeding. If it is necessary, placing a resorbable matrix (e.g.,
CollaPlug™, Collacote™, and CollaTape™) over the blood clot is applicable.
For stabilizing the white MTA that is used as a capping material, 3–4 mm layer
of light-curing glass ionomer is flowed gently over it. Because the MTA has been
associated with discoloration, it should be placed just below the level of the CEJ,
over the blood clot. If there is an esthetic concern, alternative materials of MTA like
bioceramics or tricalcium silicate cements should be considered.
Finally, the access cavity is restored with a suitable restorative material [16, 18,
19, 25, 28, 38, 41–44, 46–49].
8.3 MTA as a coating material
MTA, with quite good physical properties in terms of covering and sealing, is
one of the most ideal coating materials to be used for the hermeticity of coronary
closure.
In addition, the application with glass ionomer resin increases its covering
properties and durability.
To allow more root growth, the MTA should be 1–2 mm thick below the CEJ.
Placing the MTA on the formed clot is a technically difficult procedure. Care
should be taken during condensation, because the material can be moved from the
CEJ to the apical point [16, 43].
8.4 Follow-up, goals, and success in revascularization treatment
Appointments are given to the patient at intervals of 3–6 months, and root
formation is monitored clinically and radiographically.
The success of pulp revascularization treatment depends on three elements: root
canal disinfection, the presence of a scaffold (blood clot), and hermetic coronary
filling [38, 45].
The degree of success of regenerative endodontic procedures is largely measured
by the degree to which primary, secondary and tertiary goals are achieved.
Primary goal: elimination of symptoms and healing of bone tissue.
Secondary goal: the increase in the thickness and/or the length of the root walls
(although it is a desirable condition).
Tertiary goal: positive response to vitality test (indicates the presence of a more
organized vital pulp tissue).
Five different types of responses to revascularization treatments are available:
Type 1—thickening and root development of canal walls
Type 2—the root of the root end is blunt and closed and the root growth is stopped
Type 3—root development continues, but the apex remains open
Type 4—common calcification in canal cavity
Type 5—hard tissue barrier formation between root apex and coronal MTA.
22
Figure 18.
A necrotic, immature, 21 numbered teeth, due to dental trauma from a year ago.
Figure 19.
First day of treatment: it is clearly seen that the root canal is very large, and the dentin walls are very thin.
Figure 20.
Third month of the treatment: the lateral walls were thickened by the continued growth of dentin/hard tissue
and the root length was increased.
23
Trauma in Dentistry
If the treatment becomes success, in clinical and radiographical follow-ups,

there should be no pain or swelling, apical radiolucency should be disappeared
(usually observed 6–12 months after treatment), the root canal walls should
be thickened (observed before the increase of the root length between 12 and
24 months), and the root length should be prolonged. Pulp should respond posi-
tively to vitality tests.
If there is no evidence of recovery, if the fistula does not disappear, and pain and
swelling persist or no root growth is observed within 3 months, apexification with
calcium hydroxide or MTA can be tried.
If pulp necrosis develops afterward, traditional endodontic treatment protocols
should be performed [16, 18, 19, 25, 28, 38, 41–44, 46–49].
8.5 The advantages of revascularization treatment
Revascularization can be completed in a single session after the infection is

controlled, and there is no need for repeated sessions as in the treatment of calcium
hydroxide. This is very economical.
The greatest advantage is that it can regenerate the vitality of the tooth and
maintain the root development.
The lateral walls are supported by the continuation of the dentin/hard tissue
deposition, and the durability of the root is increased [16, 18, 19, 25, 28, 38, 41–44,
46–49] (Figures 18–20).
24
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27
Chapter 05
Evaluation and Management of

Mandibular Fracture
Guhan Dergin, Yusuf Emes and Buket Aybar
Abstract
The mandibular bone is an important component of the facial bone, which has
a unique role in digestive system, speech, and facial esthetics. For these important
functions of mandibular bone, it is vital that surgeons should not only treat func-
tion but also consider the esthetics together. Mandibular fractures are among the
most common traumatic injuries of the maxillofacial region. Even though treatment
modalities are well established and being practiced for a long time, untreated and
postoperative complications still decrease the patient’s quality of life. This chapter
aims to describe the cause, clinical presentations, diagnoses, and current treatment
methods on the basis of resent literature.
Keywords: mandibular fracture, open reduction, rigid fixation, trauma
1. Introduction
The mandibular bone, which is an important anatomical and functional struc-

ture, constitutes the lower height and width of the facial skeleton. The mandible
is a complex bony structure and has a vital anatomical articulation with other
cranio-maxillofacial components. It has a fundamental function in digestive system
and also plays an important role in speech and facial expression. The mandible is a
v-shaped bone articulating with the temporal bone at the temporomandibular joint
(TMJ). Mandibular bone has a horizontal and vertical portion.
The cartilaginous mandibular bone is a v-shaped bone articulating with the
temporal bone at the temporomandibular joint (TMJ) [1]. Mandibular bone has a
horizontal and vertical portion. The horizontal portion of mandible has two main
structures, the basal and alveolar (tooth bearing) bones. Symphysis, parasymphy-
sis, the body, and the alveolar bone compose the horizontal section of the man-
dible. The vertical mandible consists of the angle, ramus, condylar, and coronoid
processes [2].
2. Brief historical overview
The first description of a mandibular fracture diagnosis and treatment goes back
to the Egyptians in 1650 BC. Hippocrates described the reapproximation of fracture
fragments and immobilization of the fractured mandible using circumdental wires
and external bandaging.
1
Trauma in Dentistry
Since then, many effective treatment methods and devices have been introduced
to maxillofacial traumatology for the treatment of mandibular fracture includ-
ing the facial bandage, extra oral fixation apparatus, intraoral acrylic, and metal
splints, wires, arch bars, and stainless steel and titanium plate osteosynthesis. More
recently resorbable screws and plates have been used for fracture management [3].
3. Etiology (epidemiology)
Mandible fractures have many different etiologies such as interpersonal vio-

lence, traffic accidents, gunshot wounds, sport accidents, work accidents, and falls
[3]. The etiology of mandibular fractures varies from time to time, culture to cul-
ture. Students in different periods demonstrate differences in etiology depending
on the age, demographic pattern of countries, and environmental conditions and
social, socioeconomic, and cultural configurations. In developed countries, vehicle
and sport accidents are main causes of mandibular fractures, while in developing
countries and rural areas, inter personal violence, gunshot wounds, and falls in
foregrounds [3–7].
4. Clinical and radiological assessment
4.1 Clinical
Complete history trauma should be obtained after cardiopulmonary and vital

neurological functions of the patient are stabilized. Checking the airway by secur-
ing cervical spine is vital before assessment. Depending on the consciousness
or neurologic status of the patient, history can be obtained from the patient or
accompanying family members. Assessments including time, cause of trauma, pain,
function of cranial nerves and altered sensation, visual changes, malocclusion, and
general systemic conditions should be noted. Some mandibular fractures accom-
panying multiple injuries, as in traffic accidents, frequently require trauma team
evaluation and consultation.
A neurologic examination is a vital point in the assessment of maxillofacial
trauma. Functions of cranial nerves such as altered sensation, pupillary reflex,
visual changes, and extraocular movements should be evaluated. Motor function
of facial expression (nerve VII), symmetrical tongue movements, and mastication
muscle (nerve V) should be checked. Sensation of the face should be also noted.
The mandible should be carefully evaluated by extraoral palpation. Mandibular
contours such as ramus, lateral and inferior borders, and symphysis and parasymphy-
sis area should be checked, and continuity of the mandibular bone should be noted.
Movements of fragments can be evaluated by bidigital palpation. Ecchymosis and
crepitation should be assessed. Check mandibular movements. Deviations and restric-
tion of movements should be evaluated considering condylar trauma. Also the condy-
lar head should be evaluated by palpation to check if it is in the articular fossa or not.
Mucosal laceration, oral bleeding, ecchymosis, and sublingual hematomas
should be checked by the intraoral inspection. Rule out fresh oral bleeding in the
sublingual space or bilateral symphysis fracture to secure airway, especially for
anticoagulant drug users. Examination of the occlusion including loose, fractured,
or missing teeth should be performed carefully.
2
Evaluation and Management of Mandibular Fracture
4.2 Radiological
In most cases clinical examination cannot be sufficient to intensively evaluate

the entire fractures lines, displaced small fragments, root fractures of teeth, and
neighboring anatomical structures [8]. Plain films, OPTG, and computed tomog-
raphy (CT) can provide additional data about the fracture for better evaluation of
the patient. Periapical or occlusal radiographs are useful and practical imagining
techniques for viewing specific areas of concern [9].
Although it is expensive, computed tomography (CT) is the most compre-
hensive imagining technique for evaluation of maxillofacial traumas. Detailed
0.5 mm thick slices provide excellent axial, coronal, and sagittal assessments
of fracture lines, neighboring anatomical structures such as nerves. Also high
velocity impaction traumas with multiple injuries require extensive stabiliza-
tion of the patient. Additionally, 3D evaluations help to provide models for
reconstruction and they are essential for proper approximations of fracture
fragments with prepended titanium plates. Nowadays the use of cone-beam
computed tomography (CBCT) in maxillofacial surgery has been providing less
radiation and an accurate and reliable imagining alternative to conventional CT
[10, 11].
Rarely, angiography and embolization can be used in the treatment of displaced
TMJ fracture. Also MRI imagining can be helpful to evaluate soft tissue injuries
such as TMJ disc.
4.3 Classification of mandibular fractures
Mandible fractures have a unique property within the maxillofacial traumas

considering their history and treatment approach. The cornerstone of understand-
ing the mandibular fractures is the classification of mandibular fractures. There are
many fracture classifications in literature based on the type of fracture, cause of the
fracture, reducibility, anatomic site, condition and inter-fragmental situation, and
the presence of dentate or edentate segments. Some of these classifications are more
widely accepted and used, and some of them are mostly seen in books but not used
practically. Mandibular fractures are most commonly described as their anatomic
location [3].
4.4 Fracture classifications based on anatomic site
1. Angle
2. Alveolar process
3. Body
4. Condyle
5. Coronoid
6. Ramus
7. Symphysis/parasymphysis
3
Trauma in Dentistry
Fractures can be also classified as pathologic Fractures and traumatic frac-

tures. Pathological fractures occur due to the failure of the bone which has lost its
mechanical strength as a result of a pathological condition such as tumors, cysts,
infections, etc. Traumatic fractures occur due to an impact which disrupts the
continuity of the osseous tissue.
5. Biomechanics
The mandibular bone is exposed to many kinds of linear and angular forces
underload such as compression and tension, shear, torsion, and bending [12].
External forces cause mandibular bone to undergo plastic and elastic deformation.
On the other hand, muscles have some vertical and horizontal forces on frag-
ments. These forces may cause displacement of fragments or may act as a stabilizer
for fragments. The temporalis, masseter, and medial pterygoid muscle pull are
responsible for vertical displacements of fragments. Horizontal displacements are
mainly caused by lateral and medial pterygoid muscle pull. Some muscles have
complex force on fragments such as mylohyoid, digastric, and geniohyoid which
have a torsion effect on fragments.
Champy and co-workers described a zone of tension in the alveolar part of the
mandible and a zone of compression on the lower border. This information allowed
ideal lines for mandibular internal fixation to be identified along the physiological
tension lines [3].
5.1 Muscle forces
Muscles have pull direction, and this pull effect may compress fragments to each
other and prevent displacement. Fractures under the effect of these kinds of muscle
pull vector are called favorable fractures.
On the other hand, some muscle pulls cause displacements of fragment.
Fractures at these kinds of disadvantageous situations are called unfavorable
Figure 1.
Horizontally favorable fractures.
4
fractures. Favorable/unfavorable fracture concept is essential for mandibular

fracture treatment decision which will be discussed later in this chapter.
Horizontally favorable fractures: reduced biomechanically by the masseter and
temporalis muscle pull (Figure 1).
Horizontally unfavorable fractures: Displacement of fracture fragments
increased or is provoked by the masseter and temporalis muscle pull (Figure 2).
Vertically favorable fractures: The pull vector of the pterygoid muscle promotes
the reduction of the fracture segments (Figure 3).
Figure 2.
Horizontally unfavorable fractures.
Figure 3.
Vertically favorable fractures.
5
Trauma in Dentistry
Vertically unfavorable: The actions of the pterygoids tend to displace the

fracture (Figures 3 and 4).
5.2 Tension and compression zones
Pulling force applied by muscles of oro-maxillofacial region creates zone of

compression and tension within the mandible. The superior portion of the mandible
is termed as the tension zone, and the inferior portion is termed as the compression
zone (Figure 5). Champy’s principle of osteosynthesis lines is based on these tension
Figure 4.
Vertically unfavorable fractures.
Figure 5.
Tension zone marked in red (−) and compression zones marked in blue (+).
6
Figure 6.
Champy’s principle of osteosynthesis lines.
and compressions zones which has been proven to be the guiding line to establish
effective treatment for open reduction of mandibular facture (Figure 6) [3, 13].
6. Principle of mandibular fracture treatment
The trauma patient should first be provided with airway clearance. In a patient
lying in the supine position, foreign bodies such as missed pieces of broken teeth
and intraoral bleedings may create a danger of closing the airway. Although the
blood in the mouth may be swallowed by the unconscious patient at first, it may
cause vomiting as time passes. Breathing can be provided by pulling the mandible
forward with a properly positioned cervical collar. It must be kept in mind that in
patients with compound fractures, it may be difficult to position the lower jaw with
the help of a cervical collar.
Antibiotics are preferred especially in open fractures and delayed healing. The
patient should be given anti-inflammatory drugs, and if there are no clean wounds,
the necessity of tetanus vaccine should be considered.
6.1 Prognosis of the teeth in the fracture line
Fractures of the fracture line, excessively displaced, and teeth which have their
cement exposed, if they are not to be temporarily held in the mouth to maintain
occlusion, must be extracted [14].
The teeth with apical infection and teeth with excessive periodontal defects,
teeth with root fractures, and teeth that prevent the reduction of fracture segments
should be extracted [15] (Figure 7).
6.2 Aim of fracture treatment
The purpose of fracture treatment is to return the mechanical strength of the

fracture site to its healthy state and to achieve an improvement in the masticatory
muscles’ normal functions.
The first stage of treatment is to return the fracture parts to their normal
anatomic position (reduction). The second stage is the fixation of the parts in their
7
Trauma in Dentistry
Figure 7.
Teeth that prevent the reduction of fracture segments.
normal anatomical position (fixation). If the history of the trauma does not exceed
8–10 days, the fixation of the fractures can be done manually. In order to control the
pain, local anesthesia can be applied. Mobile dentoalveolar structures must be fixed
using wires or similar methods [16].
6.3 Closed versus open treatment
Fractures of the mandible can be treated either with open method or closed
method.
6.3.1 Closed reduction
Anatomically restoration of the fragments without visualization the fracture line

is called closed reduction. In closed reduction both tooth-borne and bone-borne sta-
bilization can be used to immobilize fracture to obtain correct maxilla-mandibular
relation which is called intermaxillary fixation (IMF). Intermaxillary fixation (IMF)
which is also called maxillomandibular fixation (MMF) is usually the basis of closed
methods. Intermaxillary fixation is fixing the mandible and maxilla together when
the teeth are occluded so that the patient cannot open his/her mouth for a certain
period to allow secondary healing. The patient should be prescribed analgesics.
One week of antibiotic use is required if there is an open fracture. The treatment
continues until the hard callus is formed (4–6 weeks). Optimum bony union can be
established in 4–6 weeks, but in complicated fractures, or compromised patients
longer treatment periods can be required for healing. Closed method is still used
today due to the advantage of elastic traction which helps successful repositioning
of the fragments and its low cost. Arch bars, IVY loops, and intermaxillary fixation
screws are all well-known appliances for closed reduction methods [17].
The use of vacuum-formed splints has also been recommended in the past for
closed reduction.
In the closed methods, arch bars are often used with ligature wires. The wire is
passed through the interdental gap. One end of the wire is passed under the arch bar,
and the other end is passed over the arch bar. With a fine-tipped tool, the wire is placed
under the cingulum of the tooth, and the wire is bent to secure the arch bar to the tooth.
Intermaxillary fixation screws are also used to obtain the occlusion in open
reduction. However iatrogenic root injury is a major concern for this method. Also
loosening of the screw and covering of the screw head with oral mucosa and screw
fractures have been reported as complications regarding the use of IMF screws.
8
The most important disadvantage of closed therapy is the continuation of

intermaxillary fixation for 4 weeks. This may lead to undernourishment of the
patient and weight loss. Also the patient must be informed about oral hygiene due
to difficulty in cleaning the teeth under IMF. Non-displaced favorable fractures and
grossly comminuted fractures with soft tissue lost can be the candidate of closed
reduction. Edentulous mandibular fractures are also controversial cases which
mostly require periosteal blood supply. Some authors suggest closed reduction
with gunning splints and circummandibular wires. On the other hand, some other
authors claim that open reduction with minimum periosteal striping can be a good
alternative for such cases [18].
6.3.2 Open reduction
Open reduction is preferred when closed treatment is not possible or has failed.
In open reduction, there is a surgical approach to the fracture, and the fracture seg-
ments are repositioned to their anatomical positions. This stage is called reduction.
This is followed by the fixation step. Fixation can be either rigid or semirigid in
open reduction. Compression plates and bicortical screws are used in rigid fixation.
While this is a reliable method and allows the patient to quickly return to daily
functions, this technique has some disadvantages [19].
Semirigid fixation is performed using mini-plates. These smaller plates are
placed on the stress areas in the fracture area. It is thought that micromove-
ments caused by semirigid fixation have a positive effect on the callus formation.
Monocortical screws are used so that anatomical structures are preserved. It
may be possible to perform even under local anesthesia and with an intraoral
approach. Occasionally occlusion can be obtained using intermaxillary fixation
and elasticity.
The patient is given a soft diet during semirigid fixation. It is not mandatory to
remove the plates after healing [20].
6.3.2.1 Indications for closed reduction
• -No or little displacement.
• Little or no fracture mobility.
• Possibility of regaining pre-injury occlusion.
• The absence of infection.
• The patient’s cooperation can be maintained and the follow-up is possible.
• Closed reduction can also be preferred in patients whom a surgical approach is

not recommended, such as patients having fractures due to medicine-related
osteonecrosis of the jaws.
6.3.2.2 Disadvantages of rigid fixation
• External approach may be required (requires skin incision and scar risks).
• The risk of damage to the alveolar is inferior and tooth roots.
• The need for a second surgical procedure to remove the plates.
9
Trauma in Dentistry
6.3.2.3 Condyle fractures
When closed reduction is delayed in condyle fracture patients, open reduction

may be required. The delaying of closed reduction causes muscles to spasm and
prevent a successful repositioning of the fragments. Also medial pterygoid and
temporalis muscles may get fibrotic when the treatment is delayed. As more time
passes, the risk of ankylosis increases in the untreated condyle fracture patient.
When an open reduction of the condyle fracture is planned, usually and extraoral
approach is required. The most common incision fort his procedure is the preauricular
incision which directly leads to the temporomandibular joint. Another approach is the
submandibular incision which does not involve the temporal mandibular joint directly.
Sometimes, to obtain reduction of the fragments, an intraoral incision at the
sigmoid notch region may be used [21, 22].
6.3.2.4 Ramus fractures
Ramus fractures rarely require reduction. Chewing muscles adhering to the area
effectively splint fractures. Elastic IMF is applied if occlusion is affected (Figure 8).
6.3.2.5 Angulus fractures
Triangular in shape, mandibular angle is the anatomic region between anterior

border of masseter ligaments attachments and the most posterior superior attach-
ment of masseter muscle. Angle fractures are anatomically unique regions that are
developed laterally by the masseter and medially by medial pterygoid muscles which
may stabilize the fracture in same situations. Vertical and horizontal fracture lines
of this kind of fracture are essential fort the reduction of choice. Also the presence
of unerupted third molars in this region is the weak point of this anatomical region.
Unfavorable fractures of angle fracture may displace medially. Accompanying
fractures such as condyle may alter the displacement of angle fractures.
Access to the site is provided through various incisions, and incisions are made
along the external oblique line. The plates should be placed so that they will not be
directly under the incision line. Sometimes a transbuccal approach using a trocar
may be required. Extraoral approaches may also be rarely used for angulus com-
minuted or pathological fracture reduction with Risdon incision just 1 cm bellow
the angulus. Open reduction or closed reduction both can be used for this kind
of fractures considering the complexity, age, displacement, and accompanying
fractures to the angulus fracture. In open reduction monocortical single plate at
the superior border of angulus as Champy’s method or bicortical two mini-plates
Figure 8.
Parasymphysis fractures accompanying ramus fractures, rarely require reduction.
10
can be selected as treatment method. Also the presence of uncontinuity defect or

pathological fracture reconstruction plates should be consider fort the fracture
managements. Load-sharing and load-bearing principles of fracture treatment
must be the main guide as in all mandibular fractures [23] (Figures 9 and 10).
6.3.2.6. Symphysis/parasymphysis fractures
Considering the treatment plan, it should be noted that this region is under the
influence of torsion forces. Open reduction, especially for unfavorable displaced
fractures, is mostly preferred because of the easy access and complex forces upon
symphysis/parasymphysis region. Also closed reduction can be used for favor-
able and non-displaced fracture. Champy’s two-plate technique, one on tension
and another on compression zone, is ideal for open reduction (Figures 11–13).
Arch bar with one mini-plate at compression zone is also acceptable for fracture
management. Anterior mandibular traumas should be evaluated very carefully.
Figure 9.
Angulus fracture.
Figure 10.
Open reduction with monocortical single plate at the superior border of angulus as Champy’s method.
11
Trauma in Dentistry
Figure 11.
Open reduction with monocortical with double plate, one at the superior border and the other at compression
zone, as Champy’s principle.
Figure 12.
Open reduction with mini plates.
Figure 13.
Radiological view of open reduction of right parasymphysis fractures accompanying left angulus fracture.
Accompanying uni- or bilateral condyle fracture to symphysis/parasymphysis

fractures is not rare.
Symphysis fractures can be treated either with closed or open reduction. Even
though mini-plates are successful in the management of symphyseal fractures,
12
some clinicians prefer lag screws for rigid fixation. Lag screws have the advantage
of needing minimal time and a minimal intraoral incision similar to the incision for
genioplasty, which has cosmetic advantages [24].
In the 1990s the use of 3D plates for the management of mandibular fractures
has started to be recommended. Unlike compression plates and mini-plates, these
3D plates are placed on the week parts of the bone.
Even though not conclusive, recent studies show that 3D plates have better
results in the condyle region with relatively poorer results in the body of the man-
dible, especially if the body is dentate.
6.3.2.7. Mandibular body fractures
Treatment principles of mandibular body fractures are based on Champy’s line

of osteosynthesis especially for simple fractures of the body. Intraoral access to this
fracture is not difficult. One mini-plate at tension zone is sufficient for load-sharing
fixation. Comminuted fractures may require additional mini-plates and screws.
Also continuity defects such as pathological fractures need further load-bearing
fixation systems such as reconplates. Mandibular continuity defects are defined as
loss of the continuity of mandibular bone through a bone gap. Fractures close to
mental foramen require additional care not to injure the mental nerve [17].
7. Timing of the surgical management
Just like other anatomical regions, all fractures involving the mandible should be
treated as soon as possible. However, an immediate intervention is rarely applicable.
In patients who do not have airway problems and who do not have severe painful
fractures, treatment can be delayed to the next day even though in cases of open
fractures, the risk of infection increases as the time passes.
8. Complications
Infection is the most common complication within fracture management,

especially in comminuted fractures and gunshots. Infection rates of authors vary
between 0.4 and 32% [17, 25]. Postoperative infection increases the risks of the
ununion and fibrous union of the fractures. Infection is not only the cause of the
ununion or fibrous union of fractures, mobility and unstable fixation techniques
also enhance ununion and fibrous unions in fractures. Fractures because of high-
impact traumas, gunshot, or pathological fractures may cause hard and soft tissue
lost which can result in esthetical and functional problems. In such cases extraoral
surgical approaches may cause facial nerve damages. Inferior alveolar nerve injuri-
ous can be rarely seen in open reduction of parasymphysis and mandibular body
fracture repairs. Hardware-related postoperative complications are hardware fails,
screws and plate fractures, and tooth roots jeopardized by fixation screws.
9. Conclusion
Mandibula is one of the the main skeletal component of the face and their
fractures are among the most common traumatic injuries of the maxillofacial region
which jeopardize both esthetic and function patients. The occlusion, form, and
function should be all considered in the managements of mandibular fractures.
13
Trauma in Dentistry
14
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213-222. DOI: 10.1055/s-0032-1322535 [12] Draper ERC. Basic biomechanics.
In: SPF H, ID MC, editors. Sciences
[5] Edwards TJ, David JD, Simpson DA, Basic to Orthopaedics. WB Saunders
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1994;64:307-311. DOI: 10.1111/j.1445- [13] Champy M, Loddé JP, Schmitt R,
2197.1994.tb02216.x Jaeger JH, Muster D. Mandibular
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[6] Ellis E, Moos KF, El-Attar A. Ten plates via a buccal approach.
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An analysis of 2,137 cases. Oral 1978;6(1):14e21. DOI: 10.1016/
Medicine, Oral Pathology, Oral S0301-0503(78)80062-9
Surgery. 1985;59:120-129. DOI:
10.1016/0030-4220(85)90002-7 [14] Andreasen JO. Etiology and
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[7] Sakr K, Farag IA, Zeitoun IM. Review injuries: A clinical study of 1298
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Maxillofacial Surgery. 2006;44:107-111.
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mandible fractures on CT. American Surgery. 2007;238-24. (Suppl)
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[16] Brandt MT, Haug RH. Open versus of mandibular condylar fractures
closed reduction of adult mandibular in adults? The Laryngoscope. 2016
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literatüre regarding the evolution of lary.26076
current thoughts on management.
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Surgery. 2003;61:1324-1332. DOI: mandibular angle fractures using one
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[17] Omeje KU, Rana M, Adebola AR, 1996;54:864-867. DOI: 10.1016/
Efunkoya AA, Olasoji HO, Purcz N, S0278-2391(96)90538-8
et al. Quality of life in treatment of
mandibular fractures using closed [24] Kushner GM, Alpert B. Open
reduction and maxillomandibular reduction and internal fixation of acute
fixation in comparison with open mandibular fractures in adults. Facial
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randomized prospective study. Journal 10.1055/s-0028-1085298
of Cranio-Maxillo-Facial Surgery.
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Pogrel AAH, Perrot D, editors.
[18] Smith BR, Teenier TJ. Treatment Complications in Oral and Maxillofacial
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by open reduction and rigid internal 1997. pp. 121-146
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GM. Management of comminuted
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[20] Chrcanovic BR. Open versus closed

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[21] Zachariades N, Mezitis M,

Mourouzis C, et al. Fractures of the
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[22] Khelemsky R, Moubayed SP,

Buchbinder D. What is the evidence
for open versus closed treatment
16
Chapter 06
Orthodontic Approach in Facial

and Dental Trauma
Sanaz Sadry
Abstract
In this review, the prevalence of dental trauma, prevention and diagnosis of

traumatic injuries, the effects of dental trauma in patients in need of orthodontic
treatment, orthodontic intervention to dental traumatized teeth, and treatment
options for poor anterior teeth due to trauma are discussed. Dental trauma is a
condition that is frequently encountered in dentistry. When orthodontic treatment
of traumatized teeth is planned, the orthodontist should be considered before orth-
odontic treatment and during orthodontic treatment. Prognosis is divided into two
types as treatment options of bad anterior teeth, retaining the tooth in the mouth or
pulling the tooth and restoration of the opening. The multidisciplinary teamwork
and the role of the orthodontist in this team are important in order to achieve
optimal results in the clinical intervention of these cases. Autotransplantation,
orthodontic closure, or opening of the space are discussed when tooth extraction
and toothless space restoration are required. It is very important to decide if orth-
odontic forces should be applied or not, and if orthodontic force is necessary, when
should it be applied. Information on orthodontic forces applied to traumatized teeth
was given in this chapter.
Keywords: orthodontic approach, dental trauma, tooth movement,

autotransplantation, orthodontic space closure
1. Introduction
Dental trauma (traumatic dental injury) affects the teeth and soft and hard tissues
around the oral cavity. According to research worldwide, dental trauma is often seen
as a result of sporting activities, falls, traffic accidents, and fights and often requires
emergency intervention [1, 2]. Because of the high rate of trauma in patients present-
ing with orthodontic treatment today, the orthodontist should plan how to perform
dental movements in these patients and consider the long-term prognosis of these
teeth before starting treatment. The orthodontists in the multidisciplinary team
who intervenes in the trauma have a major role in obtaining optimal results in the
traumatic tooth [3]. While interfering with dental trauma cases, treatment guidelines
may not be applicable as standard for each patient. Each case should be evaluated and
treated accordingly. General health of the patient, severity and type of the trauma,
chronological and dental age of the patient, dental and anatomical development
status, and whether the patient carries a device in the mouth during trauma are some
of the factors determining the treatment. It is important to decide whether orthodon-
tic force can be applied to dental traumatized teeth, and if it is to be applied, it will
be applied after the trauma. Excessive amount of orthodontic force on dental teeth
1
Trauma in Dentistry
can cause undesirable effects such as root resorption [4, 5]. Patients with orthodontic
attachments at the mouth during orthodontic treatment may also be exposed to
dental trauma. When dental trauma occurs during orthodontic treatment, the path to
be followed for treatment is based on clinical experience and individual case reports
presented in the literature [3, 6, 7]. Dental injuries vary widely from simple enamel
fractures to complicated fractures and often require complicated treatment of more
than one type of injury. The knowledge and skills of the physician are very important
in cases where such emergency treatment is required, and the first treatment is
extremely important on prognosis [8].
2. Prevalence
Most of the dental trauma data available have been collected retrospectively from
cross-sectional studies or from longitudinal studies of patient records. The prospective
studies are based on subpopulations such as school children [9–12], children present-
ing to a pediatric dental service, or patients presenting to an accident and emergency
department [13–15]. Permanent incisors of children that sustain damage by accident
in the United Kingdom increases with age from 5% at age 8 to 11% by age 12, and
injuries are more frequent in males than females [16–19]. Two comprehensive national
studies conducted in the United States reported that one of six adolescents and one of
four adults suffered traumatic dental injuries [20]. The majority of permanent tooth
injuries occur in the age group of 6–15 and especially between the ages of 8 and 11 years.
The upper teeth, especially the central incisors, are affected more by the lower teeth.
This occurs more in boys than girls [21].
The researchers found that the injuries were mostly caused by traffic acci-
dents, sports, and violence as a result of the incidents, and mostly due to falling
in girls; they reported an uncomplicated crown fracture (55.4%), fracture (8.6%),
complicated crown fracture (5.5%), luxation (4.3%), and avulsion (2.0%).
Although the oral region of the human body constitutes 1% of the whole body, the
statistics indicate that one fourth of the school age children and one third of the
adults suffer from trauma [22].
3. Etiology
1. Human behavior: risk taking, problems experienced in relations with relatives,

hyperactivity, and stress
2. Environmental factors: deprivation and overcrowding
3. Unconscious injuries: fall and crash, physical activities, traffic accidents, unsuitable
teeth uses, and biting hard objects
4. Conscious injuries: physical exertion and iatrogenic procedures.
5. Predisposing factors: occlusal relationship, increased overjet amount, insufficient

lip closure, history of previous trauma, and socioeconomic level [22].
The risk of trauma was found to increase as the amount of overjet increased.
Incidence of trauma in the maxillary incisors was four times higher than the man-
dibular incisors. When the overbite was 0 mm, the risk of trauma in the mandibular
incisors was the highest [23].
2
Orthodontic Approach in Facial and Dental Trauma
4. Classification
The WHO system was modified by Andreasen and Andreasen to further clarify
the luxation and intrusion groups. This classification is as follows:
• Injuries involving hard tissues and pulp: Incomplete fracture of the crown, uncom-
plicated crown fracture, complicated crown fracture, and root fracture
• Supportive tissue injuries: Alveolar socket involvement (observed with intrusion

and lateral luxation). Alveolar process fracture and maxilla mandibular fracture
• Gingiva or oral mucosa injuries: Gingiva or oral mucosa rupture, gingiva or oral
mucosa injury, and abrasion of the gingiva or oral mucosa
The treatment plan for patients with traumatized tooth is evaluated in two parts as
the prognosis of the traumatized tooth and the treatment of possible malocclusion [24].
5. Examination and diagnosis
Before an orthodontic treatment, a thorough anamnesis must be taken to

determine whether the patient has suffered dental injuries. Before the examination,
a comprehensive patient history is taken. The general health status of the patient,
time of injury, and direct or indirect trauma are determined. In order to determine
the state of the healing capacity of the tissues, whether the patient has been trau-
matized in the same area before, if any treatment has been performed in which the
area, the tooth showing the damage in the support tissues or pulp, the sensitivity
to spontaneous toothache, and hot-cold and sweet-sour foods are questioned. In
the clinical examination, extraoral tissues, intraocular tissue, periodontal tissues,
alveolar bone, and teeth are examined carefully. Abnormalities in the occlusion
indicate a fracture in the alveolar and jaw. Sensitivity of the teeth during contact
and whether the teeth are luxated are determined. According to the localization of
the root fractures, there is luxation in the teeth. The mobility of the root fracture
increases as the fracture line approaches the crown. Sensitivity to percussion refers
to injuries in periodontal fibers. Thermal tests and vitalometer applications are used
to determine the vitality of pulp in teeth injured due to trauma.
It is not always possible for the patient to remember whether he has had a dental
injury, so that the patient should be evaluated clinically and radiographically prior
to the treatment, and this evaluation should include the following:
The tooth should be checked for coloration and recorded. Crown yellow
colorations, pulp canal obliteration; dark coloring may be a sign of pulpal
hemorrhage or necrosis. It should be examined whether there is mobility in
horizontal and vertical direction. With palpation, the apical area of the teeth
should be checked for sensitivity. Percussion should be examined. In percussion,
metallic sounds may be a sign of ankylosis, and blunt sounds may be a sign of
root fracture. Thermal and electrical pulp tests and pulp response should be
considered. Thermal tests were used to determine the neurovascular support of
the traumatic tooth pulp; electrical pulp test plays an important role in deter-
mining the pulp necrosis of the tooth.
Radiographs are an important factor in the diagnosis of traumatic dental inju-
ries. Depending on the type of malposition (e.g., lateral luxation) and the type
of fracture (specimen, root fracture), it is important to take periapical film from
various angles to perform an accurate examination.
3
Trauma in Dentistry
Unexpectedly developing dental trauma may affect the oral function and
psychology of the patient. It is necessary to eliminate the negative effects of pain
and trauma on the teeth and periodontal tissues as soon as possible after dental
trauma occurs in individuals receiving fixed orthodontic treatment. Regardless of
the stage of fixed orthodontic treatment, dental trauma during treatment disrupts
the routine functioning of active orthodontic treatment. The first emergency
intervention in the trauma area is relieving of the pain, and the orthodontic force is
rapidly removed from the teeth in the trauma area. Then, according to the severity
of dental trauma, treatment is carried out with an individual approach that includes
multidisciplinary treatment methods [20].
Brin et al. reported that increased overjet and insufficient lip closure were the
greatest risk factors for dental trauma and that early orthodontic treatment to reduce
overjet would reduce the risk of dental trauma. The use of mouthguard in individuals
interested in contact sports is also an application that reduces the risk of dental injury
[23, 24]. Bauss et al. reported different treatment approaches according to the type of
dental trauma in patients with dental trauma during orthodontic treatment [7].
6. Treatment sequence and timing
Orthodontic treatment should usually be initiated during mixed dentition. When

trauma occurs at an early age, the treatment will be shorter and less complicated,
given the age, dental and skeletal development, and maturity of the patient [20].
7. Observation periods before orthodontic treatment
7.1 Crown and crown-root fractures
If crowns and crown-root fractures without pulp are treated appropriately,

their prognosis is good. Before the orthodontic treatment, the 3-month observation
period is sufficient. Crown and crown-root fractures containing the pulp can be
treated orthodontically after partial pulpectomy and hard tissue barrier formation.
Hard tissue barrier is observed radiographically 3 months after treatment [20].
This type of fracture includes enamel, dentin, and cement. Pulp may or may
not be exposed. As a result of the traumatic forces that come out of the teeth,
crown-root fractures are frequently encountered [25]. It has been reported
that vertical crown-root fractures should be extracted. In diagonal crown-root
fractures, the broken tooth must be orthodontically extruded to expose the
subgingival fracture line [26]. The distance of healthy gingival tissue on the
alveolar bone is defined as the biological width. This width is ideally consid-
ered to be equal to the sum of the connective tissue attachment (1 mm) to the
sum of the epithelial attachment (1 mm). The extraction of the fractured tooth
by obtaining the biological width is important for the ideal restoration of the
tooth [25].
7.2 Luxated teeth
Clinical experiences showed that light injuries such as confusion and sub-
luxation require at least a 3-month observation period. The need for endodontic
treatment usually arises after moderate to severe limb injuries. Radiographic
improvement revealed that orthodontic treatment should be postponed until it
is out.
4
7.3 Endodontically treated teeth
Wickwire and colleagues compared root resorption of endodontically treated

teeth with vital teeth after orthodontic treatment, and more root resorption was
found in devital teeth [27]. Mirabella and Arthun suggested that endodontic
application is a protective treatment and that root canal-filled teeth are resorbed for
unknown reasons [28]. Hunter and colleagues in their study showed no difference
between the vitality of vital and devital teeth root resorption after orthodontic
treatment [29]. Hamilton and Gutman stated that if the root canal filling is properly
shaped three dimensionally and cleaned, minimal resorption will be seen during
the movement of orthodontic teeth [28].
7.4 Root canal calcified teeth
Calcification of the root canal is usually seen after autotransplantation of imma-

ture teeth, and these teeth can be moved in a limited manner. However, closely
monitoring the root canal calcified teeth during orthodontic treatment is extremely
important [20].
8. Special treatment principles in various trauma types
It is essential that radiographic examination is performed before starting orth-

odontic treatment, even in light injuries such as uncomplicated crown fracture. If
the vitality of pulp is suspected, it is recommended to undergo a 3-month observa-
tion period before orthodontic treatment [20].
• Crown-root extrusion and cervical root fracture: This type of fracture includes
enamel, dentin, and cement. Pulp may or may not be exposed. As a result of the
traumatic forces that come out of the teeth, crown-root fractures are frequently
encountered [30]. It has been reported that vertical crown-root fractures
should be extracted. In diagonal crown-root fractures, the broken tooth must be
orthodontically extruded to expose the subgingival fracture line [26]. The dis-
tance of healthy gingival tissue on the alveolar bone is defined as the biological
width. This width is ideally considered to be equal to the sum of the connective
tissue attachment (1 mm) and to the sum of the epithelial attachment (1 mm).
The extraction of the broken tooth by obtaining the biological width is impor-
tant for the ideal restoration of the tooth [30]. In crown-cervical or cervical root
fractures, it may be necessary to orthodontically extrude the fractured root piece
during restoration of the tooth. The fast extrusion technique has been developed
to save these teeth. A hook is placed in the root canal with this technique, and the
root is extruded in the axial direction [31]. Relapse may occur after orthodontic
extrusion. Fibrotomy should be performed at least 3–4 weeks before the reten-
tion period to avoid relapse [32].
• Slow orthodontic extrusion: It is the extraction of the tooth with slow forces
(20–30 gr). Biodiversity cannot be achieved by orthodontic extrusion only,
because the movement of the teeth formed by orthodontic extrusion
follows the gingiva and the alveolar bone. Orthodontic extrusion takes
4–5 months and then 12 weeks of retention. After orthodontic movement,
periodontal surgery is needed to reshape the gingiva. Periodontal fibers can
be cut to prevent recurrence (fiberotomy), and prosthesis can be applied
2–3 months later [30].
5
Trauma in Dentistry
• Fast orthodontic extrusion: Under normal conditions, bone and gingival move-
ment is performed by lightweight extrusive forces. When stronger pulling forces
(> 50gr) are applied, rapid movement will exceed the physiological capacity
of the tissues, and the movement in the support tissues is very low. After rapid
extrusion is performed, a retention phase is required to adapt the periodon-
tium to the new position of the tooth and allow the bone to be reshaped. The
researchers reported that radiographs and histological analyzes revealed rare
resorption in the root after rapid orthodontic extrusion [33].
• Root fractures: Dentin is broken into cement and pulp. Root fracture and luxa-
tion injuries can occur simultaneously; attention should be paid to root fractures.
Post-traumatic root fractures are not frequently seen, and the incidence of post-
traumatic root fractures in continuous teeth ranges from 0.5 to 7%. Horizontal
root fractures are usually seen in the middle 1/3 of the root, followed by apical
and coronal in the remaining 2/3 parts. Horizontal fractures are frequently seen
in maxillary anterior teeth and in men aged 11–20 years. In general, root frac-
tures have completed the continuation of the apex, and the teeth are affected.
Simple fractures away from the cervical line have better prognosis [34]. In cases
close to the cervical line, the fracture fragment can be excised with rapid extru-
sion, and crown restoration is possible [35]. If the granulation tissue and the
coronal fragment are found to have necrosis among the fragments, endodontic
treatment should be performed on the coronal fragment before orthodontic
treatment. Following a successful canal treatment, the healing of the fracture
line is caused by connective tissue. A 2-year observation period is recommended
prior to orthodontic movement in teeth with root fracture, but this period can be
reduced to 1 year if there is no complication [36].
Observation period prior to orthodontic treatment of the teeth with root

fracture is determined as 2 years. Clinical experience has shown that most com-
plications, such as pulp necrosis, occur 1 year after trauma. If no complication
occurs, the observation period may be shortened. There are two types of treatment
options, orthodontic or surgical extrusion, in teeth with complicated crown-root
or cervical root fracture [20]. The orthodontic success of teeth with root fractures
depends on the localization of the fracture and the type of healing. Radiographic
and histological examinations showed that different types of healing are seen after
root fractures: (1) Recovery with calcified tissues, (2) connective healing, and (3)
improvement of bone growth between fractures. Healing with calcified tissues is
the healing of the fracture with dentin and cement. Full interlocking of the frac-
ture may not be completed, but the fracture has been combined. The orthodontic
movement of the teeth with a hard tissue callus and a fractured root fracture can
occur without the fracture line. The fracture margins are covered with cement
and periodontal ligaments in the healing of the intervening tissues. Orthodontic
movement of teeth with root fractures and broken pieces is separated from the
connective tissue to move away from each other. In the orthodontic treatment plan
of fractured teeth root with intervening connective tissues, the tooth should be
seen as a short-rooted. This means that the teeth broken from apical one third have
sufficient periodontal support for orthodontic tooth movement [37].
• Luxated teeth: In clinical examinations, it was found that if there was no resorption
in the luxated teeth, it showed the same prognosis with non-traumatized teeth [38].
• Avulse teeth: In order to achieve a complete improvement in the avulsion injuries

that occur in permanent teeth, the tooth must be inserted into the socket as
6
soon as possible. Storing the avulsed tooth in milk for more than 60 minutes
or 30 minutes dry causes ankylosis in the tooth after reimplantation [38, 39].
Orthodontic movement of the tooth is not recommended until after the reim-
plantation periodontal recovery is complete (6 months). It should be empha-
sized that the tooth may be ankylosis if orthodontic force is not performed as
expected [3]. Replantation is considered primarily when the avulsed tooth is
intact. Replantation is the insertion of the avulsed tooth into the alveoli with
acute trauma. The loss of the permanent tooth after trauma is a condition that
requires an orthodontic treatment plan. The main question is whether the cavity
will be preserved for dental autotransplantation, implant placement, or bridge.
Autotransplantation can be performed with both mature and immature teeth.
However, in most cases with autotransplantation, the best prognosis is observed
if the 3/4 of the tooth germ is formed or if the entire root is formed, but the
apex is open. At this stage, the pulp maintains its vitality and continues its root
development. Transplanted teeth lose only a small portion of the root length
[21]. Bone-supported implants have been widely used instead of lost anterior
teeth in recent years. Implants are fixated within the jaw and do not erupt during
dental and alveolar development. For this reason, growth and development must
be completed before implant placement [20].
• Space closure: Space formed of loss maxillary lateral incisors can be closed by
positioning the maxillary canine in the lateral cutting region. Rather than the
tooth that has been lost, rather than a prosthetic lateral tooth, the closure of the
lateral tooth leads to more esthetic results periodontally. Canines are bled, to
achieve more esthetic results. The length of the clinical crown can be changed
through gingivectomy [40]. Following the orthodontic closure of the lost central
tooth, if the shifted teeth are decided to be reshaped, the lateral tooth intrusion
and the canine tooth are extruded to obtain the gingival contour of the central
and lateral teeth [41]. In cases where the maxillary central teeth are lost, it is a
complex condition where the lateral tooth is replaced by the mesial movement
of the central tooth. The space is not fully closed, which poses risk. In cases
where laterals are replacing the centrals, the lateral cutter should be raised in
the mesiodistal direction, and the buccal root torque is required [42]. Extrusion
of the canine tooth and intrusion of premolar teeth are performed in order to
obtain the optimum gingival marginal contour of the anterior teeth. Lateral root
torque is applied to the canine tooth and canine root torque to the repositioned
premolar. Canine tooth is worn as composite or porcelain (porcelain veneers are
more suitable and preferable) and restored to give it lateral form. The width of
the canine tooth is reduced to provide optimal esthetic and functional occlusion
by increasing the length and width of the first premolar teeth that are extruded
and mesialized by composite restorations. The canine tooth with a more yellow
color is bleached after its mesialization to the lateral tooth position [41].
In cases where the incisors are lost, the esthetic and functional results cannot
be obtained by closing the space, and the completion of jaw growth should be
expected. In this case, space should be maintained, and set-up models should be
studied for different alternatives of tooth positions [43].
• Maintaining the space: The space can be maintained if it is not suitable. In patients
with normal occlusion and dysesthesia with poorly aligned normal occlusion if
more than one incisor is lost in the same arch, in class II division or class III patients
who have lost one tooth in the upper jaw, there is a large discrepancy between
the crowns of the central and lateral incisors and the space may be maintained in
7
Trauma in Dentistry
patients with lip deficiency [44]. Various space maintainers can be used to protect
the space. The best option is to use the traumatized tooth as space maintainer when
the prognosis is poor. But teeth should be checked. In case of ankylosing, it should
be extracted without a severe infraocclusion [45].
• Opening of the space with orthodontic treatment: In their study, Kokich and
Crabill applied an orthodontic site development technique to a 7-year-old patient
who lost the central tooth due to avulsion. The researchers reported that the
ongoing teeth would move massively instead of rolling over to the space and would
carry the alveolar bone here. The neighboring teeth are allowed to move in the
toothless space by applying a space maintainer until the tooth is complete. Since
there was no stenosis in the patient, it was decided to reopen the toothless cavity,
which was closed after the teeth, and place the implant. This technique is called
“orthodontic site development.” When the teeth are taken back to their original
place, the missing tooth’s cavity is filled with bone. With orthodontic site develop-
ment, researchers have reported that bone does not undergo any resorption or
contraction over time, thus providing a suitable site for implant placement [46].
• Autotransplantation: 43 years ago, Slagsvold and Bjercke developed a new

method by transplanting partially formed teeth. In these teeth, endodontic
treatment is usually not required after application. Most traumatic injuries are
between 7 and 10 years of age, which makes it possible for autotransplantation
of developing premolar. Dental autotransplantation has been reported to be a
highly successful technique. Pediatric patients with orthodontic tooth extrac-
tion are suitable for autotransplantation [47]. Due to root anatomy, mandibular
premolar teeth are preferred for this procedure. The most appropriate time
for transplantation is when the 2/3 part of the root of the tooth is formed and
has a larger apical opening of 1 mm. One hundred eighteen unfinished teeth
were examined for 1–13 years, and in this period, 96% of the pulp regeneration
rate was observed in the transplantation process [41]. Vilhjalmsson et al. [48]
reported their success rate in autotransplantation as 80.5% in 2011. As the root
growth of the tooth continues and normal periodontal ligament formation is
observed, these teeth can be moved orthodontically without being different from
the other teeth. It is recommended that the tooth be observed for 3–4 months
before orthodontic movement [48].
• Crown and root malformations: Malformations of permanent teeth due to trau-

matic injuries sometimes cause permanent teeth to remain buried. If the root
development of the tooth is sufficient, the tooth can be placed in the appropriate
position by means of surgery and orthodontics [49].
• Intrusive teeth: In intrusion injuries, the tooth is displaced in the apical direc-
tion. Intrusion injuries are a type of trauma that is frequently encountered.
Intrusion injuries lead to serious damage to the tooth, periodontium, and pulp.
Ankylosis, pulp necrosis, and pulp calcification are among the most common
adverse effects of traumatic intrusion. Special attention should be paid to these
teeth during orthodontic treatment [30]. In severe intrusion injuries, peri-
odontal ligament regeneration may occur, but a rapid progressive replacement
resorption, marginal bone loss, inflammatory root resorption, ankylosis, and
pulp necrosis may occur in less severe intrusion injuries [3].
The incidence of replacement resorption in intrusive cutters varies between 5

and 31%. The relationship between the severity of the intrusion and the type of root
8
resorption was examined, and a significantly higher rate of replacement resorption

was seen in the severely intrusive apex closed teeth [33].
Treatment: In the case of closed and severely intramedullary apex closed teeth,
the tooth should be immediately placed in the previous alveolar position (early
orthodontic extrusion) to allow the extirpation of non-vital pulp and to prevent the
formation of inflammatory resorption. Since active surgery or orthodontic extru-
sion will cause a secondary trauma in the periodontal ligament, the teeth should be
spontaneously re-erupted in individuals under 17 years of age who have suffered
low and moderate trauma [39]. In 2 weeks, active extrusion may be considered if no
movement occurs in the tooth. A serious intrusion force may compress the tooth in
alveolus, thus the tooth can be lightly luxated prior to orthodontic extrusion [3].
Early orthodontic extrusion: For orthodontic extrusion of 1–2 teeth that have
been intrinsic, extrusion force may be applied by using a movable apparatus and
vertical elasticities between the teeth attached to the tooth. With this application,
the reactive forces are aimed to be absorbed by the palatal mucosa under the acrylic
instead of the adjacent teeth [50]. It is important to avoid anchoring from the
neighboring teeth as much as possible in the treatment of a tooth affected by the
intrusion. The use of conventional brackets and wire methods is not suitable in such
cases, since the extent of the trauma that affected these teeth is unknown [50].
Success rate: early orthodontic extrusion prevents ankylosis [51].
• Immature teeth: If the intrusion and root end are not closed and the intrusion
is too severe, it can be left to eruption or can be opened slightly by finger pres-
sure. An orthodontic extrusion force is required if the intrusion is too severe or
if the tooth does not start within 2–4 weeks [44].
• Replanted teeth: Most of the root resorption after replantation occurred within 1
year after the trauma. During this time, if there is no complication, the replanted
tooth can be moved. Replanted and intrusive teeth show good prognosis in early
recovery in 5 or 10 years after trauma and slow resorption can be seen [52].
• Ankylosis: In the adolescent growth phase, ankylosis causes the formation of an

infraocclusion in the tooth. A metallic sound is detected in the ankylosis percus-
sion by the absence of periodontal cavity. A clinically ankylosing tooth cannot
be moved with orthodontic forces. Surgical luxation of the ankylosing tooth and
leaving it for eruption or orthodontically extruding it is a successful method. In
this technique, surgical luxation and ankylosing area are aimed to create con-
nective tissue attachment and to move the tooth orthodontically [53]. Recently,
good results have been reported in the case reports that the tooth was moved
within a few weeks with the alveolar osteotomy and distraction osteogenesis of
the ankylosing tooth [54–56]. Replanted avulse teeth often suffer from ankylosis.
The root of the replanted tooth is gradually resorbed and replaced by bone.
Ankylosis tooth growth in the developmental period does not follow the devel-
opment of occlusion. In this phase, the tooth should be pulled, or the root should
be left as space maintainer until it is resorbed [57]. When the alveolar growth is
about to be completed, distraction osteogenesis and surgical block osteotomy can
be performed to bring the tooth to the appropriate vertical position on the dental
arch. The purpose of this method is to make the bone level suitable to facilitate
subsequent prosthetic procedures. During this period, it should not be forgotten
that the process of ankylosis continues [58, 59]. The progression of the infarction
varies from individual to individual, depending on age, growth rate, and growth
direction of the jaws. If the patient has a growth model, the infraposition is more
severe. Severe infraposition, especially ankylosis with rapid alveolar growth,
9
Trauma in Dentistry
occurs if it occurs between the ages of 10 and 12. In such cases, the ankylosing
tooth should be removed after 2 to 3 weeks following diagnosis [45].
• Extraction of ankylosing incisors: Decoronation technique has been devel-

oped to prevent bone loss in the extraction of ankylosing teeth. The crown
of the ankylosing tooth is removed, and the stem is left in the alveoli. In
children, a new marginal bone is formed to resorb the coronal root. Thus,
the height of the alveolar bone increases vertically and is also preserved
faciolingually [60].
9. The effect of orthodontic tooth movements on traumatized teeth
• Pulp vitality: In a study, Brin et al. stated that, in traumatic teeth, there was mostly
no response to vitality tests following orthodontic treatment. Since there are few
studies on this subject, it is not yet clear whether orthodontic dental movements
increase the risk of pulp necrosis in traumatic teeth [61].
• Root resorption: If 20% of the root surface is affected by ankylosis, a metallic

sound can be detected in percussion [38]. This is the first indication that ankylosis
has begun to occur. Ankylosis usually begins to form on the buccal and palatal
surfaces in the first stage, so it cannot be observed in conventional radiographs
for up to 1 year. Following an injury, a 4–5-month observation period was recom-
mended before any orthodontic force was applied [62]. Linge et al. reported that
after orthodontic treatment, 1.07 mm resorption was observed in trauma teeth and
0.64 mm in unstressed teeth [62]. In patients who had trauma and root resorption,
periapical radiographs should be taken 6–9 months after starting orthodontic
treatment. If minor root resorption is seen and if it is decided to continue treat-
ment, a radiograph should be taken again after 3 months, and the prognosis of
resorption should be examined. If severe root resorption is observed, treatment
should be ceased for 3 months. In maxillary incisor teeth with severe root resorp-
tion, permanent tooth mobility has been reported in cases where root length is less
than 9 mm or equal to 9 mm [64, 65].
9.1 Prognosis
In mild to moderate luxation injuries (such as confusion or subluxation) of the

teeth, if the orthodontic treatment is performed carefully, the risk of root resorp-
tion is reduced. After severe luxation (extrusion, lateral luxation, intrusion, and
replantation), it is more dangerous to move the tooth. Orthodontic treatment is
important to assess the risk of root resorption 6 months after onset. If progressive
resorption is observed at this stage, treatment may be interrupted for 3 months to
reduce the risk of severe resorption [66].
In conclusion, the prognosis of the whole treatment can be summarized as follows;
1. The prognosis of the traumatized tooth is good, and the prognosis of malocclu-
sion is good: Treatment procedures for malocclusion are the same as untreated
teeth the treatment procedures [20].
2. Good prognosis of traumatic tooth but poor prognosis of malocclusion:

Orthodontic treatment is complex. It requires a long treatment period, and
there are serious anchorage problems. In order not to overload the traumatized
tooth, sometimes limited therapeutic purposes should be considered [20].
10
3. Poor prognosis of traumatic tooth but good prognosis of malocclusion:

Traumatic tooth must be extracted but may be left as a space maintainer until
the start of orthodontic treatment. The prognosis of orthodontic treatment is
good, and optimal results are obtained [67].
4. Malignancy of the traumatized tooth is poor, and the prognosis of malocclu-

sion is poor: Traumatic tooth must be extracted but can sometimes be left as
space maintainer. Depending on the patient’s age, the treatment options may
include the use of prosthesis, implant, or the autotransplantation of premolar
teeth [68, 69]. Orthognathic treatments may also be a treatment option [20].
9.2 Retention
During treatment, closure or preservation of the space is decided according to the

retention period. Retention plan can be divided into three groups: group with limited
retention and partial permanent retention. The need for retention of patients who
are traumatically injured and undergoing orthodontic treatment depends on many
factors. The most important ones [20] are the elimination of the cause of malocclu-
sion, appropriate occlusion, reconstruction and reorganization of soft tissues and
bone around placed teeth, and correcting skeletal deviations during growth develop-
ment period. The need for retention is limited if these goals are achieved.
10. Result
Dental injuries are considered an emergency in dentistry. Increased overjet

reduction and the use of mouthguard are protective applications that reduce the
risk of dental trauma. The knowledge of the physician is of paramount importance
in cases of dental trauma that require urgent treatment, and the first treatment is
extremely important on prognosis. In trauma cases, the prognosis of traumatized
tooth with existing malocclusion should be evaluated. After the treatment of trau-
matized teeth, the teeth should be evaluated clinically and radiographically at the
end of the observation period required for orthodontic treatment. Dental trauma
is generally seen in individuals who continue to grow and develop, and orthodontic
treatment, which is a conservative method in the treatment of traumatized teeth, is
an ideal treatment option that meets the esthetic and functional needs of patients.
11
Trauma in Dentistry
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[53] Isaacson RJ, Strauss RA, Bridges- of ankylosed and infrapositioned
Poquis A, Peluso AR, Lindauer SJ. reimplanted incisors in adolescents.
Moving an ankylosed central incisor Scandinavian Journal of Dental
using orthodontics, surgery and Research. 1984;92:391-399
distraction osteogenesis. The Angle
Orthodontist. 2001;71:411-418 [61] Andersson L. Dentoalveolar
ankylosis and associated root resorption
[54] Kofod T, Wütz V, Melsen B. in replanted teeth. Experimental and
Treatment of an ankylosed central clinical studies in monkeys and man.
incisor by single tooth dento- Swedish Dental Journal. Supplement.
osseous osteotomy and a simple 1988;56:1-75
distraction device. American Journal
of Orthodontics and Dentofacial [62] Linge BO, Linge L. Apical root
Orthopedics. 2005;127:72-80 resorption in upper anterior teeth.
[55] Chang HY, Chang YL, Chen HL. 1983;5:173-183
Treatment of a severely ankylosed
central incisor and a missing lateral [63] Levander E, Malmgren O, Eliasson
incisor by distraction osteogenesis S. Evaluation of root resorption in
and orthodontic treatment. American relation to two orthodontic treatment
Journal of Orthodontics and Dentofacial regimes. A clinical experimental study.
Orthopedics. 2010;138:829-838 European Journal of Orthodontics.
1994;16:223-228
[56] Kokich VG, Crabill KE. Managing
the patient with missing or malformed [64] Levander E, Malmgren O. Long-
maxillary central incisors. American term follow-up of maxillary incisors
Journal of Orthodontics and Dentofacial with severe apical root resorption.
Orthopedics. 2006;129(4 suppl):55-63 European Journal of Orthodontics.
2000;22(1):85-92
[57] Kawanami M, Andreasen J, Borum
M, Schou S, Hjörting E, Kato H. [65] Tsukiboshi M. Crown-Root
Infraposition of ankylosed permanent Fracture. Treatment Planning for
maxillary incisors after replantation Traumatized Teeth. Quintessence Pub
related to age and sex. Endodontics & Co; 2000. p. 35, 45
Dental Traumatology. 1999;15:50-56
[66] Reminghton D, Joondeph D,
[58] Alcan T. A miniature tooth- Arthun J, Riedel R, Chapko M. Long
borne distractor for the alignment term evaluation of root resorption
of ankylosed teeth. The Angle occurring during orthodontic
Orthodontist. 2006;76:77-83 treatment. American Journal of
Orthodontics and Dentofacial
[59] Chae J, Paeng J. Orthodontic Orthopedics. 1989;98:43-46
treatment of an ankylosed maxillary
central incisor through single-tooth [67] Koroluk L, Tulloch J, Phillips C.
osteotomy by using interdental space Incisor trauma and early treatment
regained from microimplant anchorage. for class II division 1 malocclusion.
15
Trauma in Dentistry
American Journal of Orthodontics

and Dentofacial Orthopedics.
2003;123:117-125
[68] Andersson L, Ermani Z, Högstrom

J. Single tooth implant treatment in
the anterior region of the maxilla
for treatment of tooth loss after
trauma :A retrospective clinical and
interview study. Dental Traumatology.
2003;19:126-131
[69] Bowden D, Patel H.

Autotransplantation of premolar
teeth to replace missing maxillary
central incisors. British Journal of
Orthodontics. 1990;17:21-28
16
Chapter 07
Platelet-Rich Plasma in Trauma

Patients
Mehmet Yaltirik, Meltem Koray, Hümeyra Kocaelli
and Duygu Ofluoglu
Abstract
Platelet-rich plasma (PRP) was mixed with thrombin and excess calcium result-
ing in activated platelets trapped within the fibrin network; within the matrix,
platelets secrete bioactive substances that diffuse into the surroundings tissues. PRP
is prepared from the patient’s own blood, a variety of manufacturing techniques in
vastly different cell counts, and growth factor concentrations. The clinical use of
PRP is treatment of soft tissue diseases and injuries, treatment of burns, hard-to-
heal wounds, tissue engineering, and implantology in dentistry. An essential crite-
rion for PRP is for it to be autologous, for the donor of the blood, and the recipient
of the PRP to the same person. Most of the literatures suggest that PRP does not
appreciably impact bone healing or induce bone formation. PRP might augment
recruitment of osteoblast progenitors to injection sites or in sites expected to expe-
rience delayed healing. In this capacity, PRP might be utilized to initiate repair of an
otherwise poorly healing bony lesion. PRP stimulates bone repair in fractures. Early
through late healing process is compromised with fractures, including reduced cell
proliferation, delayed chondrogenesis, and decreased biomechanical properties. In
this chapter, the importance of the PRP in oral and maxillofacial surgery in trauma
patients is studied
Keywords: platelet-rich plasma, trauma, oral surgery
1. Introduction
Today, regenerative therapy is the most preferred treatment because it is a

method that meets the expectations of the patient close to the ideal. With the prog-
ress of technology, new materials about growth factors are entering our lives. Tissue
engineering is currently working hard to develop regenerative materials. The health
sector and tissue engineering benefit from each other in this respect.
First-generation platelet concentrate platelet-rich plasma (PRP) was used as
a biomaterial to speed up the process of healing of the tissues. PRP contains high
concentrations of platelets and growth factors in the low-volume plasma. These
growth factors stimulate cell proliferation, matrix formation, and angiogenesis [1].
In 2001, platelet-rich fibrin (PRF), a second-generation platelet concentrate
product, was developed in France, which was first developed for use in oral and
maxillofacial surgery [2]. PRF preparation technique is based on the principle of
collecting platelets and growth factors in the fibrin matrix by centrifuging venous
1
Trauma in Dentistry
blood from the patient. There are many forms of PRF materials such as P-PRF,
L-PRF, A-PRF, I-PRF, and T-PRF used in oral and maxillofacial surgery.
2. Platelets
Platelets are cytoplasmic fragments of mature megakaryocytes in bone mar-

row. They are responsible for tissue regeneration by clotting, at the onset of wound
healing, and by growth factors released from alpha granules. They are isolated from
peripheral blood vessels [3].
Because of their short lifespan, the megakaryocytes should produce about
1.5–4 × 1010 platelets per day to keep the platelet count in the normal blood count
at 1.5–4.5 × 105 per microlitre (μL) of blood [4].
In 1960s, the interaction between platelets and endothelial cells supporting capil-
lary endothelin integrity was revealed [5, 6]. Initial work by Folkman and colleagues
used autologous PRP-augmented media to feed microvascular endothelial cells to
enhance vascular integrity preservation in organs subjected to perfusion for trans-
plantation. It has been determined that human platelet lysate (HPL) was prepared
by repeated freezing/thawing cycles throughout the 1980s, and cell lines and primer
fibroblasts were promoted by fresh blood or old platelet concentrates [7–9].
Platelets are quite active in terms of metabolism. Growth factors were released by
platelet function with the phenomenon of “activation of macrophages by an increase
in connective tissue healing, bone regeneration and repair, mitogenesis of fibro-
blasts, and angiogenesis of the wound area” by stimulating cell proliferation [10, 11].
After the resulting tissue damage, the platelets appear and the basal membrane
of the collagen capillaries and the subendothelial microfibrils directly change shape.
The alpha granules in the platelets engage the cell plasma membrane and release
protein contents around with activation [11].
If the defects are small, platelet clotting is sufficient, and large wounds may
require blood clots. The blood clot is activated from intrinsic and extrinsic pathways.
“Intrinsic pathway” begins when there is a change in tissue damage or in blood. The
“extrinsic pathway” begins with blood contact with factors other than blood, such
as damaged tissue. Although they start differently in two ways, they converge on the
next steps and share the reaction series. Coagulation in the presence of calcium and
thrombin occurs by fibrinogen polymerization of fibrinogen monomers. The fibrin
clot also provides a matrix environment for migration of fibroblasts and other tissue-
forming cells, including endothelial cells, other than hemostasis [12].
3. Wound healing
Wound healing is a complex but a controlled mechanism regulated by growth

factors and extracellular matrix.
Healing stages are:
1. hemostasis,
2. inflammation,
3. proliferation (granulation and contraction), and
4. remodeling (maturation) [13].
2
Platelet-Rich Plasma in Trauma Patients
3.1 Hemostasis
Platelets behave like workers who close the damaged gas and water lines and seal
damaged blood vessels. Blood vessels react to injury by vasoconstriction, but this spasm
ends loosely. Thrombocytes secrete vasoconstrictor substances to facilitate this process,
but this is not the main role. The primary role of platelets is to form clots. Adenosine
diphosphate (ADP) leaks from damaged tissues. Platelets adhering to type 1 collagen,
which is activated by ADP, thus become active. They are viscous glycoproteins that
secrete and cause platelet aggregation [14]. At the same time, thrombocytes secrete
factors that interact with and stimulate intracellular coagulation by intrinsic thrombin
production, which initiates fibrinogen to fibrin. Platelets also secrete platelet-derived
growth factors, known as one of the initiating factors for the healing process.
3.2 Inflammation
Inflammation is clinically associated with pain, swelling, temperature, and

erythema, occurring between the first and fourth days after injury. Neutrophils
perform their first defense against infection by phagocytosing existing debris and
microorganisms. When the neutrophils digest bacteria and debris, they complete
their task and die.
In wound repair, communication between soluble proteins and cells is ensured.
These soluble proteins are growth factors and cytokines released by the cell. The
role of the extracellular matrix in wound healing is activation of platelets, epithelial
migration, and interaction with cells through receptors called integrins that lead to
the movement of fibroblasts [15].
Macrophages secrete bacterial phagocytes and extracellular enzymes, to break
down necrotic tissues and form the second line of defense. Secreted extracellular
enzymes and matrix metalloproteinases (MMP) are calcium and zinc sources for the
active site. MMP is responsible for necrotic tissue removal and repair of damaged
tissue. MMP metalloproteinases are inactivated by tissue inhibitors (TIMPs) and
uncontrolled activities are counterbalanced. Macrophages, fibroblast growth factor,
epidermal growth factor, transforming growth factor-beta (TGF-β) and interleukin 1,
etc. stimulate proliferation by secretion of cytokines and growth factors [16].
3.3 Proliferation
Proliferation begins after the injury of tissues and continues until the size of the
wound and the systemic condition of the patient is up to 21 days in acute injuries.
Characteristically, “angiogenesis,” “collagen deposition,” “granulation tissue”
formation, “wound contraction,” and “epithelialization” are seen at this stage.
Cells are introduced into the proliferation phase: macrophages, fibroblasts,
pericytes, endothelial cells, and keratinocytes.
Fibroblasts are responsible for the secretion of collagen. In case of a damaged
home, “plumber” cells are pericytes that renew outer layers of capillaries and
endothelial cells that “glue.” This process is called angiogenesis. Keratinocytes play
the role of “roof plumber” and are responsible for epithelization.
3.4 Remodeling
Similarly, collagen tissue must be rearranged to provide greater tensile strength

in wound repair. In addition, the density of cells and capillaries is reduced. The
3
Trauma in Dentistry
main cells involved in this process are fibroblasts. Remodeling can last up to 2 years
after wounding [17].
4. Three therapeutic improvements through the wound healing

mechanism: primary, secondary, and tertiary healing
4.1 Primary wound healing
Primary wound healing is called healing if the cleaved cleft is closed without any
complications. Within 24 h, the minimal space existing between them is filled with
fibrin and makes fibrinous adhesion.
4.2 Secondary wound healing
The healing form of granulation tissue in open wounds is called “secondary

wound healing.” Initially wounded with clots and exudates, the wound is filled
by fibroblasts 4–5 days after injury. In this type of healing, the wound surface is
covered with scar tissue after 30–40 days following injury.
4.3 Tertiary wound healing
In case of infection, in the over-devitalized tissues and in the presence of a

foreign body, the improvement observed by closing the wound after a few days is
called “delayed primary healing” (tertiary wound healing).
5. Platelet-rich plasma (PRP)
Platelet-rich plasma (PRP) was first developed in the early 1970s, but it was used
rarely. PRP was mixed with thrombin and excess calcium resulting in activated
platelets trapped within the fibrin network; within the matrix, platelets secrete
bioactive substances that slowly diffuse into the surroundings tissues. PRP was
introduced to the dental community by Whitman and colleagues, who hypothesized
that the activation of platelets and the subsequent release of growth factors would
enhance surgical healing [10]. PRP is now commonly applied to surgical sites and
injuries to promote wound healing. PRP is rich in growth factors (PRGF), platelet-
rich fibrin matrix (PRFM), and platelet-rich fibrin (PRF) [18].
The natural blood clot contains 95% of red blood cells, 5% of platelets, and 1%
of white blood cells; thrombocyte-rich plasma obtained by centrifugation of blood
tissue contains 4% of red blood cells, 95% of platelets, and 1% of white blood cells.
Platelet concentrates in plasma are called “platelet-rich plasma.” The goal of using
platelet-rich plasma is to accelerate healing. High levels of platelets and growth
factors also include all components of clotting factors. At least 5 ml of plasma is
required for platelet-rich plasma to be clinically effective in order to have 106 μl
of platelets. The platelet-rich plasma should be prepared in nonclotted form and
should be used within 10 min from the start of coagulation [19, 20].
“Platelet-rich plasma” is administered by “injection” to the site of interest or by
mixing with “grafts.” “Platelet-rich plasma” has a long storage period, but should be
used quickly when used. It takes up to 7 days in the region where the growth factors
are applied [21].
1. Preparation of platelet-rich plasma

Nowadays, there are many preparation methods. These are as follows:
4
a. Preparation with standard blood bank procedures:

• It can be prepared in Aferez units
• It can be prepared from whole blood donors
2. It can be prepared with the aid of a test tube with 20–60 cc of blood.
3. It can be prepared using commercially available automatic preparation devices

[22, 23].
4. PRP is subjected to a process known as differential centrifugation. It is pre-

pared clinically by “PRP method” or “buffy coat method” [22, 23].
In the PRP method, an initial centrifuge (3000 rpm for 3 min) at low speed
separates red blood cells (RBC), and then a second centrifuge (4000 rpm for 3
min) is applied at high speed to concentrate the platelets. In the initial centrifuge,
the venous blood is centrifuged in tubes containing citrate dextrose. Acid citrate
dextrose is an anticoagulant agent.
After the initial centrifugation, the whole blood is divided into three layers:
1. A top layer (platelet poor plasma) containing mostly “platelets” and “white
blood cells (WBCs)” is of 40%.
2. An intermediate layer is rich in white blood cells known as the buffy coat and is of 5%.
3. A lower layer consisting mostly “red blood cells” is of 55% [23].
For the production of pure PRP (P-PRP), the top layer and the cover of the
intermediate layer known as the buffy coat are transferred into an empty sterile
tube. For the production of leucocyte-rich PRP (L-PRP), the top layer known as
“PPP” is transferred to the entire layer of the “buffy coat” and a few “red blood
cells.” By the second centrifuge, the “red blood cells” and the PRP are separated.
The PRP obtained after the second centrifugation is activated with thrombin and
calcium chloride to prepare a PRP gel. PRP gel contains high amounts of platelets
and natural fibrinogen. It takes approximately 30 min to prepare PRP with this
technique. Prepared PRP should be used within 6 h.
6. Things to be aware of when preparing PRP
• In acid citrate dextrose (ACD-A), tubes should be obtained with whole blood by
venipuncture.
• Blood should not be chilled at any time before platelet separation or platelet
separation.
• Whole blood must first be centrifuged at “low speed.”
• Supernatant containing platelets (floating on top of the precipitate) should be

transferred into another sterile tube (no anticoagulant).
• Tube should be centrifuged at a higher speed (hard spin) to obtain platelet

concentrate.
5
Trauma in Dentistry
• At the end of centrifugation, bottom 1/3 of the tube consists of PRP and the
top 2/3 consists of PPP. At the bottom of the tube platelet, pellets are observed.
• It is necessary to suspend platelet pellets in a minimum amount of plasma (2–4 ml)

by removing the PPP and gently shaking the tube [24, 25].
There are also several factors that influence platelet concentration, such as the
size of the platelets, the biological differences between individuals, and the hema-
tocrit variability. It is more critical after the second centrifuge because the process
of separating red blood cells intended for the first centrifugation may not be fully
realized and erythrocytes may be present in the transferred volume. The remain-
ing erythrocytes form a pellet at the base of the tube. Approximately, 20% of the
platelets remain adsorbed on erythrocyte globules [26].
Another issue to be aware of is the impossibility of obtaining platelet-rich plasma
from a non-anticoagulated blood. Platelets are responsible for the initiation of hemo-
stasis and healing. Since platelets do not have platelets in the serum, it is not possible to
obtain platelet-rich plasma from the serum, only anticoagulant platelets are possible.
Clinically, acid citrate dextrose or citrate phosphate dextrose is frequently used
for anticoagulation. Citrate phosphate dextrose, acid citrate dextrose, has similar
properties but has been suggested to be 10% less effective in protecting throm-
bocyte vitalites in studies. EDTA is not recommended because it will damage the
platelet membrane.
Dual centrifugation technique is necessary to prepare platelet-rich plasma. Not
enough platelets can be obtained with a single centrifugation and a mixture of both
platelet-rich plasma and thrombocyte poor plasma cannot be separated completely [26].
7. Mechanism of action of platelet-rich plasma
Growth factors alone do not increase bone production. Platelets increase in the
area applied with platelet-rich plasma. The increase in platelets also increases the
growth factors numerically. PRP also contributes to bone regeneration by increasing
the number of stem cells in a small number. Marx used a combination of bone graft
and platelet-rich plasma in mandibular defects and attributed the contribution of
platelet-rich plasma to bone regeneration to the function of growth factors in the
environment [27].
Platelet-rich plasma is the basis for the activation of defense mechanisms by the
activation of macrophages and the formation of a nonspecific immunoreaction with
the leukocytes and interleukins involved.
The platelet-rich plasma has antimicrobial properties against microorgan-
isms such as “Escherichia coli,” “Staphylococcus aureus,” “Candida albicans,” and
“Cryptococcus neoformans” [28].
8. Duration of action and storage of platelet-rich plasma
The duration of action of PDGF and TGF-β in the platelet-rich plasma was investi-
gated and a reduction in cell growth stimulating activity between 4 h and 3 days after
venous blood ingestion was reported [29]. It is recommended to use PRP within the
first 6 h after its preparation to keep the prepared biomaterials at a minimum level of
contamination and to minimize disease transmission risks [30, 31]. It has been suggested
6
that the degranulation of platelets and the release of growth factors are within the first
3–5 days; therefore, the effect of platelet-rich plasma is also 7–10 days [32]. Although the
direct effects of platelets and growth factors are lost, bone regeneration is expected to
continue, since the lifespan of active osteoblasts is approximately 3 months [33, 34].
9. Classification of platelet-derived blood concentrates
9.1 Pure platelet-rich plasma (P-PRP)
Using only the upper part of the yellowish layer to inhibit the presence of leuko-
cytes, resulting biomaterial leads to a lower platelet count. Because it is possible to
prepare clinically, it is a low-cost application [33, 35].
9.2 Leukocyte and platelet-rich plasma (L-PRP)
Blood in sterile tube containing no anticoagulants is subjected to initial centrifuga-

tion. All of the poor plasma and buffy coat layers from the cell and a portion of the bot-
tom layer containing the red blood cells are transferred to a new tube. At a high speed, a
second centrifugation is carried out and the poor plasma layer from the cell is withdrawn
by pipetting. Coagulation is achieved by adding thrombin or calcium chloride as the
activator. L-PRP, which takes time to prepare by hand, also has low density [35].
9.3 Pure platelet-rich fibrin (S-PRF)
The “P-PRP,” “L-PRP,” and “P-PRF” biomaterials all contain too much tombo-
cytes from physiological values. It is reported in the literature that biomaterials
with platelet content 2.5 times more than the number of platelets present are most
effective [36].
9.4 Leukocyte and platelet-rich fibrin (Choukroun’s PRF) (L-PRF)
L-PRF is a platelet concentrate containing all components of blood. There is

no need for any anticoagulant agents in the preparation of L-PRF, so it can be
regarded as a second-generation platelet concentrate. It is used in oral, maxillofa-
cial, otorhinolaryngology, and plastic surgery. In the technique of preparing L-PRF,
platelets and leukocytes are obtained with high efficiency. With the activation of
L-thrombocytes, thrombocyte and leukocyte growth factors are embedded in the
fibrin matrix [37–44]. In the biomaterial prepared, leukocytes act as an infection-
preventive cells and immunomodulator [45, 46].
9.5 Advanced platelet-rich fibrin (A-PRF)
For L-PRF preparation, centrifugation for 12 min at a speed of 2700 rpm is

required, but at a slower speed such as 1500 rpm for A-PRF preparation, longer
time such as 14 min is required. Studies have shown that the number of viable cells,
including platelets, is higher in A-PRF. Clinically, it will be beneficial for increasing
amounts of growth factor and cytokine release. Reported that the levels of growth
factors (TGF, PDGF-AB, VEGF) released from A-PRF are less than those of L-PRF
when compared to that of L-PRF [47].
7
Trauma in Dentistry
9.6 Injectable platelet-rich fibrin (I-PRF)
One of the latest developments in PRF technology is the production of injectable

PRF (I-PRF). For preparation of I-PRF, blood samples are taken in plastic tube without
anticoagulant and centrifuged at 2400–2700 rpm at about 700°C for 2–3 min [48].
9.7 Titanium platelet-rich fibrin (T-PRF)
During PRF preparation, different products are obtained using different materials
for blood processing. Medical titanium tubes to produce PRF and 111333, named this
material T-PRF [49]. In one study, it was observed that T-PRF samples had a fairly
regular network than L-PRF samples [49]. In addition, the T-PRF fibrin network
was observed to cover the wider area of the L-PRF fibrin network and the fibrin was
thicker in the T-PRF specimens. T-PRF was obtained by centrifugation of 20 ml of
blood at 2800 rpm for 12 min in medical titanium tubes in a human study. T-PRF
membranes were found to have positive effects on palatal mucosal wound healing [49].
9.8 Concentrated growth factor (CGF)
The most important different CD34 stem cell content from the thrombo-
cyte-rich plasma and fibrin of the concentrated growth factor is the content.
CGF-CD34 is the name of the layer containing platelets, leukocytes, growth
factors, and cytokines by separating the autologous blood into its components
by centrifugation at four different rpm at the same time. Concentrated growth
factor does not cause any infection or immunological reaction as it is prepared
from the own blood of the person, and no chemicals are used during the pro-
cess. CGF causes less inflammation, bleeding, and pain than other materials.
Due to the stem cell content of CD34, regeneration capacity is higher than other
biomaterials [50].
10. In vitro applications of thrombocyte-rich plasma
Although the clinical use of PRP and PRF is widespread in oral and maxillofacial
surgery, the mechanism of cellular action has not yet been clearly elucidated. Although
in vitro studies have been carried out on dental-derived cells, there is no comprehen-
sive study describing the mechanism of action of stem cells. A limited number of
in vitro studies do not provide a convenient and reliable basis for clinical practice.
Thrombin-activated plasma stimulate “adhesion,” “migration,” and “myofibro-
blastic differentiation” of human gingival fibroblasts [51]. In another study, PPP
and 50% PRP resulted in the greatest increase in cellular proliferation and differ-
entiation at various concentrations, the proliferation of osteoblast and periodontal
connective tissue cells in platelet-rich plasma and platelet-poor plasma, and the
effect on calcium formation [52].
Functions of the platelet-rich plasma are obtained from periodontal ligament
tissue and pulp of human tooth root cells [53]. Colony formation and cellular
proliferation of dental cells reduced platelet-rich plasma at concentrations of 0.5
and 1% [53].
Thrombocyte-rich fibrin regulates cell proliferation in a cell-type-specific man-
ner, and that the thrombocyte-rich fibrin can promote cell proliferation [54].
In vitro studies of “platelet-rich plasma” have shown that the “PDGF-AB” and
“TGF-β” factors are in high concentrations in platelet-rich plasma preparations
and that the platelet—the proliferation [55, 56]. In another study of the same
8
researchers, it was observed that the fibrinogen used with growth factors in plate-
let-rich plasma effectively increased wound healing in periodontal tissues.
11. Clinical studies on platelet-rich plasma
Contrary to in vitro studies, there is extensive literature in clinical trials.

Thrombocyte-rich plasma in dentistry is used to increase tissue regeneration in
periodontal disease, to accelerate healing of alveolar plugs after tooth extraction,
and to accelerate osseointegration around dental implants [48, 56, 57].
First time, 88 mandibular bone defects were treated with autogenous bone graft,
some with autogenous bone graft, and some with platelet-rich plasma. As a result
of the study, it was observed that platelet-rich plasma significantly increased bone
regeneration [27]. After tooth extraction, many complications can occur. There are
studies showing that the graft site is covered with thrombocyte-rich plasma and local
conditions such as “dry socket” and “abscess” formation are prevented, and condi-
tions are improved. It has been reported that high aftertouch growth factor concen-
tration increases tissue regeneration [58–62]. There are also studies in the literature,
which show conflicting results with other studies suggesting that the platelet-rich
plasma administered after tooth extraction does not have a significant effect. There
are also observations that thrombocyte-rich plasma does not increase bone regen-
eration alone, as is the case with osseointegration at dental implant placement and
studies that give positive platelet-rich plasma to accelerate new bone formation.
There are reports of positive results associated with thrombocyte-rich fibrin
in sinus augmentation therapy prior to placement of the dental implant [62–66].
Co-use of deproteinized bovine bone (Bio-Oss) and thrombocyte-rich fibrin is
only compared with Bio-Oss use; combined use of maxillary bone atrophy has been
reported to give better results [67, 68].
Contradictory results have also been observed in the use of platelet-rich plasma in
periodontal surgery. There are studies reporting increased tissue regeneration when
applied with platelet-rich plasma graft materials [68, 69] while some studies suggest no
improvement in healing process after thrombocyte-rich plasma implantation [70, 71]. The
same conflicting results exist in the literature for thrombocyte-rich fibrin. Thrombocyte-
rich fibrin in the third molar withdrawal of the mandible did not increase bone repair.
It has been demonstrated that the application of “thrombocyte-rich plasma” is
effective in the “bison-linked osteonecrosis (BRONJ)” treatment of the jaw. The
application of surgical debridement procedures in conjunction with autologous
thrombocyte-rich plasma was reported that increased bone and soft tissue regen-
eration, increased neovascularization, and reduced tissue inflammation [71–76].
According to some investigators, thrombocyte-rich plasma regeneration capacity is
a low biomaterial and may have a short-lived effect in the early phase of bone heal-
ing, flattening between the third and sixth months of treatment.
11.1 Use of platelet-rich plasma in surgical sockets
Thrombocyte-enriched plasma to the suction ports and stitch area of 170

patients after withdrawal of third molar teeth and alveolar osteitis was prevented
with less pain and more intense bone formation [48].
In 20 patients with “periodontal defect” and “vertical root fracture” in two
groups as thrombocyte-rich plasma and autogenous bone graft applied, only
autogenous bone graft was applied. As a result, epithelialization of the group with
autogenous bone grafting with thrombocyte-rich plasma and bone healing was
faster [77].
9
Trauma in Dentistry
11.2 Use of platelet-rich plasma in jaw reconstructions
“Autogenous bone graft” and “platelet-rich plasma” combination in “man-

dibular reconstruction” significantly improves bone healing [78]. Patients who
underwent “partial mandibulectomy” combined “autogenous bone graft” and
“thrombocyte-rich plasma” for reconstruction. After 6 months, they found that
the biopsy bone they had received was sufficient and they applied the implant
after 1 year [79].
11.3 Use of platelet-rich plasma in distraction osteogenesis
Implants in patients were done by injecting “mesenchymal stem cells” and “plate-
let-rich plasma” into the distraction range to obtain three-dimensional bones in the
distraction osteogenesis of the mandible and to shorten the consolidation period. They
reported that platelet-rich plasma was effective at the end of the study [80].
Injected mesenchymal stem cell and thrombocyte-rich plasma derived from
bone marrow were used for “achondroplasia” and “congenital pseudoarthrosis. As a
result of the study, they reported that short-term minimally invasive procedure is an
advantage of increasing bone regeneration [81].
11.4 Use of platelet-rich plasma in individuals with alveolar cleft
Patients with alveolar congenital defects were using bone and tibia-derived
grafts plus thrombocyte-rich plasma and reported that the corresponding region
was rapidly restored according to the patient group, who had never used thrombo-
cyte-rich plasma [82].
Autogenous bone grafts, in five of 12 patients with alveolar cleft, and the
remaining seven were combined with autogenous bone and thrombocyte-enriched
plasma in the remaining seven and closed the scales. They reported that regen-
eration in patients who were closed by a combination of autogenous bone and
thrombocyte-rich plasma in a computed tomography scan was better than the
other group [83].
11.5 Use of thrombocyte-rich plasma in oriented bone regeneration technique
Lecovic et al. reported that the combination of thrombocyte-rich plasma and

bovine peroneal bone mineral was effective in the treatment of intrabony defects
in patients with chronic periodontitis, although no directed tissue regeneration was
performed [84].
11.6 Use of platelet-rich plasma after peripheral nerve injury
Peripheral nerve injuries may occur after surgical operations in the maxillofacial
region and after trauma to the maxillofacial region. “Microsutures,” “fibrin-
cyanoacrylate adhesives,” “grafting,” and “laser” applications are preferred in the
treatment of injured nerve tissue. However, the regenerative capacity of the nerve
tissue is limited and heals very slowly. The use of platelet-rich plasma was consid-
ered to speed up this process of healing. An animal study was conducted using rats,
although there is no human study on the subject. After the sciatic nerves of the rats
were cut bilaterally, the nerve was connected with “cyanoacrylate” on one side and
“platelet-rich plasma” on the other side. The number of nerve fibers formed on the
treated side of the biopsied platelet-rich plasma after 12 weeks was higher than the
other side [85].
10
11.7 Use of platelet-rich plasma in soft tissue injuries
Platelet-rich plasma is also effective in soft tissue injury as it is effective in hard

tissue repair. Two groups were formed in the study in which 59 patients with acute
traumatic soft tissue injury were treated. Thirty-two patients were treated with
routine wound care while the remaining 27 patients were treated with routine
thrombocyte-rich plasma as well as with routine wound healing. As a result, wound
healing was faster in the platelet-rich plasma group [85].
12. Conclusion
Platelet-rich preparations are a safe (PRP) and is a preparation of plasma

that contains an increased concentration of platelets compared to blood. PRP is
autologous: for the recipient of the PRP to be the same person. PRP is used for both
soft and hard tissue and also used in clinical dentistry, because it accelerates bone
formation and induces healing.
Many studies support the use of autologous PRP in clinical practice, including
for soft tissue injuries, chronic diabetic ulcers; injuries to muscles, tendons, or liga-
ments; bone fractures; molar extractions; urologic, dental, ophthalmic, and plastic
surgery procedures; and periodontal, sinus lift, and oral/maxillofacial surgeries.
Since growth factors play crucial roles in soft and hard tissue regeneration, the
proposed mechanism for the enhanced healing outcomes by PRP is through the
release of critical growth factors by activated platelets [86, 87].
Bone lesions and defects may arise out of many kinds of traumas. Due to the
high prevalence of trauma, bone is the most transplanted tissue.
The use of autologous grafts is a gold standard to the biomaterial filling of bone
defects. However, the limitation of tissue available, risks of infection, and necrosis
re-motivated the proposition on synthetic biomaterials, which by turn are not
biologically functional and adapted to remodeling bone tissue.
The use of biological factors, such as PRP and bone morphogenetic proteins (BMP),
has shown good results in bone reconstructions, since they are directly associated with
the tissues. Platelet growth factors such as platelet-derived growth factor (PDGF),
transforming growth factor-b (TGF-b), fibroblast growth factor (FGF), vascular endo-
thelial growth factor (VEGF)-A, and insulin-like growth factor (IGF-1) regulate bone
regeneration, proliferation, and differentiation of osteoblasts, for the therapeutic use.
The use of PRP in the treatment of bone lesions has shown significant results
from 1990s. PRP also used as an alternative to fibrin glue or platelet gel is frequently
employed in maxillofacial defects. The therapeutic benefits and the reparative
power of PRP consist of one action faster than conventional treatments maximized
by autologous growth factors and are free from immune complications.
PRP action with the concentration of bone marrow had better consolidation
and greater bone quantity by area in the PRP group. The superior result obtained
can be explained by the immediate recruitment of all proteins necessary to start the
healing cascade, while the concentration of bone marrow demanded longer time
to recruit these elements. Thus, it can be assumed that the monitoring for a period
of time up to 4 weeks, this group might have had similar results of consolidation.
However, there were no new studies that could confirm this hypothesis.
Several studies reporting the association of PRP and artificial bone grafts
showed improvement in the quality of healing. However, only PRP was used, and
the short-term and/or long-term results, were positive but not significant. PRP
could be beneficial and contribute to the morphological and functional improve-
ment in chronic tendinopathy [86, 87].
11
Trauma in Dentistry
In treatment of tendinopathy, PRP plays an important role. Physical therapy and a

program of activities after injection of PRP, adopted in most studies, demonstrate better
results in tendon lesions [88].
Platelet-rich plasma is a blood-derived product used for local healing. Interest in
their activity over the last two decades has increased significantly in different dis-
ciplines. It is widely accepted that these materials stimulate soft and hard tissues to
mimic the physiological healing process. The reason is that it contains high amounts
of blood components such as fibrinogen, platelets, etc.
These biomaterials have been proposed for various uses in oral and maxillofacial
surgery. Most studies in the literature: improvement of alveolar sockets after shrink-
age, osseointegration of dental implants, sinus lifting procedures, improvement
of periodontal bone defects, etc., examine the effects on the case. It has also been
observed that platelet concentrations increase cell migration and neovascularization
in vitro studies.
In addition to having many advantages of platelet-rich plasma, there are also
disadvantages: increased risk of malign transformation as the PDGF release
increases in chronic wounds, and the lack of factor V of the bovine thrombin used
for anticoagulants and immunological reactions.
The activity of the platelet concentrates is expected with the high amounts of active
growth factors and cytokines they contain. Nowadays, the preparation of these platelet
concentrates is very different from each other. When platelet concentrates are com-
pared, thrombocyte-rich fibrin is thought to have a higher regenerative potential than
thrombocyte-rich plasma.
Platelet-rich plasma is a blood-derived product used for local healing. Interest
in their activity over the last two decades has increased significantly in different
disciplines. It is widely accepted that these materials stimulate soft and hard tissues
to mimic the physiological healing process. The reason is that fibrinogen contains
high amounts of blood components such as platelets.
Bone defects caused by infection, tumor, trauma, metabolic disease, or massive
osteolysis due to prosthesis still remain a major clinical concern. Unfortunately, the
self-repair capacity of the critically bone defected is extremely limited and this condition
generally requires bone grafting. Osteoinductivity, osteoconductivity, and osteogenesis
are optimal bone graft substitute. Allografts or xenografts have unique osteoconductive
properties and rarely cause disease transmission. Because of these limitations, synthetic
bone grafts are being used. Osteoinductive growth factors, autogenic bone marrow, and
mesenchymal root cells promote osteogenesis while demineralized bone matrix (DBM)
and platelet-rich plasma (PRP) induce formation of progenitor cells from surrounding
tissues. However, each of these substitutes has its own significant limitations and none of
them meets full expectations to serve as bone substitute in instance of bone defect.
Both PRP and DBM are osteoinductive substitutes that have shown satisfactory
results for fracture healing. A number of growth and differentiation factors are liber-
ated, including platelet-derived growth factor (PDGF), vascular endothelial growth
factor (VEGF), transforming growth factor-1 (TGF-1), insulin-like growth factor-1
(IGF-1), hepatocyte growth factor, platelet factor-4, fibroblast growth factor (FGF),
trombospondin-1, osteonectin, and fibronectin via activation of platelets. These factors
play an important role in intracellular matrix formation, osteoid production, and the
collagen synthesis involved in fracture healing. DBM is an organic collagen matrix that
includes various types of bone morphogenetic proteins (BMP), which are responsible
for its osteoinductive properties. PRP can be prepared easily with two-step centrifuga-
tion of autogenous blood, and DBM can be obtained commercially.
Through positive impacts of PRP and DBM based on these findings, the pres-
ent study evaluated the impact of individual and combined applications of PRP
and DBM on fracture healing of critical bone defects. Allogeneic PRP would
12
have beneficial effect on treatment of segmental bone defects, comparable to

DBM. Possibility of agonistic or additive osteoinductive effects of DBM and PRP
combination was also investigated [89].
Despite the large number of clinical trial studies, there is little evidence of the
cellular effect of blood derivatives. The lack of standard protocols leads to the lack
of reliable clinical results. Frequent and unnecessary application of blood-derived
products, especially in the maxillofacial region, results in both an increase in proce-
dures and a significant increase in costs to clinicians and patients. The indications
of the protocols for the application and preparation of blood derivatives should
be made absolutely widespread and systematic in order to clarify the benefits for
patients of blood derivatives. This can be achieved through a collaborative work
between clinical and in vitro researchers. Further research on thrombocyte-rich
plasma and thrombocyte-rich fibrin activity on dental cell biology, more clinical
application of platelet concentrates, and greater use in the oral and maxillofacial
region may provide a stable basis for more predictable outcomes.
Conflict of interest
We declare that there is no conflict of interest with any financial organization

regarding the material discussed in the chapter.
13
Trauma in Dentistry
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19
Chapter 08
Oral Mucosal Trauma and Injuries

Meltem Koray and Tosun Tosun
Abstract
Trauma-related oral lesions are common in clinical practice of dentistry and they
can impair patients’ normal oral function and cause pain in patients’ eating, chew-
ing, and talking. An injury to the oral mucosa can result from physical, chemical, or
thermal trauma. Such injuries can result from accidental tooth bite, hard food, sharp
edges of the teeth, hot food, or excessive tooth brushing. Some injuries can also be
caused by iatrogenic damage during dental treatment or other procedures related to
oral cavity. In this chapter, oral mucosal trauma and injuries will be examined in four
subclasses: physical and mechanical traumas of oral mucosa; chemical injuries of the
oral mucosa; radiation injuries; and electrical, thermal burns.
Keywords: trauma, soft tissue injuries, mucosa, traumatic injuries
1. Introduction
Trauma-related oral lesions are common in clinical practice of dentistry. Such

lesions can impair patients’ normal oral function and can cause pain in patients’
eating, chewing, and talking. After receiving a diagnosis with anamnesis, treatment
can be provided if the causative factor is removed. An injury to the oral mucosa can
result from physical, chemical, or thermal trauma. Such injuries can result from
accidental tooth bite, hard food, sharp edges of the teeth, hot food, or excessive
tooth brushing. Some injuries can also be caused by iatrogenic damage during den-
tal treatment or other procedures related to oral cavity [2]. This section focuses on
common causes, diagnoses, and treatment of traumatic injuries. In the following, a
proposed classification of oral mucosal trauma and injuries is described:
Classification of oral mucosal trauma and injuries:
A. Physical and mechanical traumas of oral mucosa
1. Linea alba
2. Chronic biting
3. Epulis fissuratum
4. Inflammatory papillary hyperplasia
5. Denture stomatitis
6. Traumatic ulcer
7. Recurrent aphthous stomatitis
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Trauma in Dentistry
8. Nicotine stomatitis
9. Lip-licking dermatitis
10. Traumatic fibroma
11. Trauma associated with sexual practice
B. Chemical injuries of the oral mucosa
1. Chemical burn
2. Post-anesthetic ulceration of palate
3. Contact allergic stomatitis
C. Radiation injuries
1. Oral mucositis
2. Actinic chellitis
D. Electrical and thermal burn
1. Electrical burn
2. Thermal burn
2. Physical and mechanical traumas of oral mucosa
2.1 Linea alba (white line)
Localization: Buccal mucosa, at the level of the occlusal line of the teeth. It is a
horizontal streak on the buccal mucosa at the level of the occlusal plane extending
from the commissure to the posterior teeth.
Clinical features: Lesions are mostly asymptomatic. The common visual symp-
tom of linea alba is the presence of whitish, linear, filament-like plicae formations,
horizontally parallel to the occlusal level of bicuspids and molar teeth in both left
and right sides of buccal mucosa (Figure 1). Palpation should give a tactile sensa-
tion of normal mucosa texture. It is more prominent in individuals with reduced
overjet of the posterior teeth. It is often scalloped and restricted to dentulous areas.
The diagnosis is based on clinical grounds alone [11].
Etiology: Lesions mainly arise from occlusal traumas of posterior teeth gener-
ated due to the parafunctional cheek sucking of patient. The sucking habit is also
associated with friction between buccal tubercules and irritates the buccal mucosa
by pressure. Prevalence of such lesions is about 6.2–13% in the population [4, 5, 9].
Treatment: No treatment is required; the white streak may disappear spontane-
ously in some people. But very sharp-edged teeth can be corrected.
2.2 Chronic biting (Morsicatio buccarum)
Localization: The lesions made by chronic bite trauma (nibbling) on the buccal
mucosa generally cause keratinized shreds, tissue tags, or erosive and desquamative
surfaces [20]. These lesions according to their localizations are called as “morsicatio
buccarum” if they are localized on the buccal mucosa, “morsicatio labiorum” if they
2
Figure 1.
Linea alba seen on the buccal mucosa.
Figure 2.
Diffuse irregular white area of lower lip due to chronic biting.
appear on the labial mucosa, and “morsicatio linguarum” if they occur on the lateral
borders of the tongue [21]. The lesions are seen on the buccal mucosa, bilateral
chewing line, labial mucosa, and lateral edges of the tongue.
Clinical features: Lesions are apparent as shallow whitish wrinkles which
are diffuse and present irregularly on the buccal, labial mucosa, and tongue.
Epithelial desquamation occurs on the surface (Figures 2 and 3). In some cases,
erosions and petechiae may be seen. The lesions could be diagnosed by clinical
inspection [11].
Etiology: It is often related to chronic biting of the oral mucosa seen in psycho-
logically tense patients. Parafunctional bite of the buccal mucosa, lips, and tongue
until wear of superficial epithelium and wound formation is consciously made by
those patients. The incidence of morsicatio buccarum was reported to be 2.5% in
Caucasian populations [16].
Treatment: Treatment is usually unnecessary. It is recommended to stop the habit.
Psychological treatment can be suggested for stopping a bad habit. Acrylic splint can
be made on the occlusal surface of the teeth. It is accepted as a precancerous lesion.
2.3 Epulis fissuratum
Localization: The lesion presents as multiple or single inflamed and elongated

papillary folds, usually in the mucolabial or mucobuccal grooves around poorly
fitting partial or complete denture.
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Trauma in Dentistry
Figure 3.
Chronic biting of the buccal mucosa with diffuse irregular lesions.
Figure 4.
Epulis fissuratum.
Clinical features: Epulis fissuratum, reactive fibrous hyperplasia, or denture-induced

fibrous hyperplasia is a relatively common hyperplasia of the fibrous connective tissue.
Clinically, it presents as a raised sessile lesion in the form of folds with a smooth surface
with normal or erythematous overlying mucosa. Because of chronic irritation, it may get
traumatized and present with an ulcerated surface. It is considered as an overgrowth of
intraoral tissues resulting from chronic irritation. This mucogingival hyperplasia is a reac-
tive condition of oral mucosa to excessive mechanical pressure on mucosa (Figure 4).
Etiology: Trauma and irritation are the two main etiological factors responsible
for occurrence of epulis. It is attributed to reactive tissue response to chronic irritation
and trauma caused by a poorly fitted partial or complete prosthesis [13]. Prevalence of
epulis fissuratum lesions was found to be 4.3% in Chilean population [22].
Treatment: Surgical excision and construction of a new denture adequate
for the newly established mucosal contours. Excision can be performed by either
conventional surgical approaches or by use of laser.
2.4 Inflammatory papillary hyperplasia
Localization: Inflammatory papillary hyperplasia of the palate is a benign epi-

thelial proliferation that develops in patients who have complete acrylic maxillary
dentures. Lesions are mostly seen in the hard palate. In few examples, they could be
detected also in the lower jaw.
4
Figure 5.
Inflammatory papillary hyperplasia on the hard palate.
Clinical features: Inflammatory papillary hyperplasia lesions are generally asymp-

tomatic and have color spectrums varying from red to pink. It presents as hyperplastic
nodules 3–4mm wide, with erythematous and cobblestone appearance (Figure 5).
Etiology: Most often, patients wearing removable upper dentures show
symptoms of inflammatory papillary hyperplasia. But rarely, it can be seen also in
maxillary normal dentition. Pathogenic etiology is unclear. Continuous usage of
prosthesis without night rest, inadequate denture flange edges, poor oral hygiene
habits, allergic reactions against denture liners, abuse of tobacco, senility, and
several systemic reactions are other reasons [6].
These dentures are often old, ill-fitting, badly cleaned, and worn all the time.
Treatment: Surgical excision and construction of a new denture. Different
techniques have been described, including supra-periosteal excision, the bladeloop
technique, or electrosurgery, with or without soft tissue grafts, cryosurgery, and
laser [8]. Iegami et al. [23], reported that inflammatory papillary hyperplasia could
completely be eliminated by the generated pressure combined with antioxidant and
anti-inflammatory pastes and following this, a new set of complete dentures could
be delivered to the patient.
2.5 Denture stomatitis
Localization: Denture stomatitis is seen under ill-fitting total or partial

dentures.
Clinical features: It is characterized by diffuse erythema, edema, and some-
times petechiae and white spots that represent accumulations or Candida hyphae
(Figure 6). Denture stomatitis is usually asymptomatic.
Etiology: Mechanical irritation from C. albicans dentures or a tissue response to
microorganisms living beneath the dentures.
Treatment: Improvement of denture fit, oral hygiene, and topical or systemic
antifungals or tissue disinfection by diode laser irradiation [3]. In the management
of denture stomatitis, a more conservative approach regarding the usage of mouth
rinses was advised by Koray et al. [19], in order to prevent the adverse effects and
complications of systemic drugs.
2.6 Traumatic ulcers
Localization: Presence of traumatic ulcers is a relatively common finding in dental

practice. Such lesions arise from trauma related to bite of buccal mucosa, lateral border
of the tongue or lips during chewing. Traumatic ulcers seen in the mucobuccal folds
5
Trauma in Dentistry
Figure 6.
Denture stomatitis located on the denture-bearing area of maxilla.
Figure 7.
Traumatic ulcer after accidental mucosal biting.
Figure 8.
Traumatic ulcer caused by sharp edges of prosthesis.
and gingiva are related to different irritant factors such as hard foods and inappropri-
ate hard brushing. Traumatic ulcer due to lip biting after inferior dental nerve block
is seen on the lower lip. During orthodontic treatment, traumatic ulcers can occur
especially on the buccal mucosa due to the irritation of braces or appliance wires.
Clinical features: Traumatic ulcers could be of solitary shallow or deep discon-
tinuity type showing on the epithelium and are associated with peripheral keratosis
of mild to severe degree [2]. The bottom of the ulcerative lesions is made of whitish
or yellow pseudomembrane. Upon elimination of the causative factor, often the
ulcer heals with or without scar depending on the extent of the damage occurred.
Etiology: They could originate from accidental mucosal biting (Figure 7),
sharp edges of prosthesis (Figure 8), sharp or pointed food stuff (Figure 9), during
6
Figure 9.
Traumatic ulcer caused by sharp or puncturing food stuff.
Figure 10.
Traumatic ulcers during orthodontic treatment.
Figure 11.
Lip biting after injection of local anesthetic solutions.
orthodontic treatment (Figure 10), lip biting after injection of local anesthetic solu-
tions (Figure 11), neonatal teeth (Figure 12), or faulty tooth brushing [1]. During
dental treatments, iatrogenic damages can result in traumatic ulcer formation. Some
medical treatments can cause oral ulcerations, such as brutal intubation for general
anesthesia, ENT surgeries, or endoscopic interventions and iatrogenic malpractice
applications. A high prevalence of traumatic ulcer of about 21.5% was reported
among lower classes of Brazilian population [24]. Most prevalent types of lesions were
reported to be traumatic ulcer and actinic cheilitis (7.5% for each) [25]. Among the
7
Trauma in Dentistry
Figure 12.
Traumatic ulcer caused by neonatal teeth.
etiological factors of traumatic ulcers could be mentioned traumas caused by bites,

dental appliances, inappropriate tooth brushing, misfit of removable partial or total
dentures, irritating caries edges, malocclusion and puncturing restorations [25].
Treatment: Most often, traumatic ulcers can heal spontaneously and unevent-
fully without complications in a brief period of time. But, in case of persistent
traumatic factors, such as presence of sharp tooth morphology, cutting edges of
restorations, and puncturing appliance contours, especially inadequate surfaces of
removable prosthesis, continuous trauma arising from above-mentioned causes can
lead to formation of chronic ulcers.
2.7 Recurrent aphthous stomatitis
Localization: Non-keratinized oral mucosa is most frequently affected.

Clinical features: Recurrent lesions related to multifactorial chronic inflamma-
tion named as recurrent aphthous stomatitis (RAS) exhibit round or ovoid shape,
pseudomembrane-covered ulcerations on the non-keratinized oral mucosa. Ulcers
are surrounded by erythematous halo with superficial necrotic center and they are
painful [10] (Figure 13).
Etiology: RAS is a complicated condition and the precise etiology still remains
unknown. Several predisposing factors have been reported, such as trauma allergy,
genetic predisposition, endocrine disturbances, emotional stress, and hematologi-
cal deficiencies. Detailed examination of RAS history can explore the original
etiology [27].
Figure 13.
Recurrent aphthous stomatitis on the buccal mucosa.
8
Treatment: The real etiological factors of RAS are still unclear and all treatment
strategies are symptomatic. Fruit consumption would be useful to replace antioxidants
via vitamin replenishment. Topical therapies such as mouth rinses are preferred as they
have less risk of adverse effects [26, 27]. Pain relief is the main strategy of treatment.
Anti-inflammatory coverage and reduction in function helps to decrease lesion dura-
tion, frequency, and recurrence. Topically applied medicaments such as antibiotics,
local analgesics, glucocorticoids, astringents, hyaluronic acid gel, and low-level laser
therapy are treatments of choice [10].
2.8 Nicotine stomatitis (smoker’s palate)
Localization: Nicotine stomatitis is a common tobacco-related type of keratosis

that exclusively occurs on the hard palate.
Clinical features: The palatal mucosa initially appears with redness.
Subsequently, around the minor salivary gland ducts with inflamed and dilated
orifices, many micronodules of punctate red centers form and make diffuse,
grayish-white color wrinkles [5]. This type of lesion is not precancerous.
Etiology: Elevated temperature, rather than the tobacco chemicals, is respon-
sible for this lesion. Among elderly Indian and Thailandian people, the general oral
mucosal lesion type is smoker’s palate with an incidence of 43%. Lesions mostly
involve maxillary hard palate region with a prevalence of 23.1% [17, 18].
Treatment: Cessation of smoking.
2.9 Lip-licking dermatitis
Localization: Lips and its surrounding dermis

Clinical features: Erythematous lesions involve perioral skin and lips. Lesions
may be associated with skin peeling, crusting, and fissuring to different degrees
(Figure 14). Most often a burning sensation is present [11].
Etiology: Chronic licking
Treatment: Elimination of licking, and topical steroids.
2.10 Traumatic fibroma
Localization: The most common sites of traumatic fibroma are the tongue,
buccal mucosa, and lower labial mucosa.
Traumatic or irritation fibroma is a common benign exophytic and reactive oral
lesion that develops secondary to injury.
Figure 14.
Lip-licking dermatitis due to sucking a ball all day.
9
Trauma in Dentistry
Figure 15.
Traumatic fibroma of the buccal mucosa.
Clinical features: Lesions are shown as broad-based, with light color in respect
to neighboring normal tissue, superficially whitish as the secondary trauma causes
formation of hyperkeratotic ulcerative surface.
Etiology: Recurrent repair process triggers the formation of fibromas which are
accompanied by granulation and scar tissue. Fibroma is a result of a chronic repair
process that includes granulation tissue and scar formation resulting in a fibrous
submucosal mass. After surgical removal, recurrence may happen if repetitive
trauma factor is not eliminated. Otherwise, lesions do not have malign neoplastic
character and risk of repeated lesion formation [14] (Figure 15). According to
Sangle et al. [28], traumatic fibroma with an incidence of 36.5% is the most com-
mon clinical lesion type; whereas histologically, the fibrous hyperplasia was found
to be the most common one with a recurrence of 37.4%. Clinically, lesions with
reactive characteristics may be sessile (51%) or pedunculated (49%) [28].
Treatment: Surgical excision.
2.11 Trauma associated with sexual practice
Localization: Oro-genital stimulation has become a popular practice during the

last few decades and this is more common among homosexual males and females
Clinical features: This generally manifests as erythema, ecchymosis, or petechiae
in the soft palate. These lesions may be noticed during routine oral examinations.
Etiology: Dentists should be aware of the reason and oral symptoms of lesions
related to oro-genital sex habit. Among oro-genital sex actions, the most traumatic
one is so called “fellatio” where male genital organ is taken into the mouth of part-
ner to suck it and can cause lacerations to buccal mucosa and cheeks [2].
Treatment: The lesions are generally asymptomatic and heal within 7–10 days.
3. Chemical injuries of the oral mucosa
3.1 Chemical burn
Localization: Gingiva and mucobuccal folds are main localization regions of

such lesions.
Clinical features: The wounds have irregular shape and white color, are overlaid
by a pseudomembrane, and are very painful. Lesions can cover an extended area. If
the lesions are contacted shortly, a shallow whitish and wrinkled appearance occurs.
Brief contacts cannot cause necrosis [5].
10
Figure 16.
Acid/arsenic injury.
Etiology: Caustic chemical and drug materials when they come in contact with the
oral mucosa are often very irritating and cause direct mucosal trauma. Inappropriate
usage of medications, such as aspirin application onto the neighboring mucosa of
painful teeth with decay, may result in mucosal trauma. Iatrogenically, during dental
treatments irrigant solutions (sodium hypochlorite or formalin) or some endodontic
pastes with arsenic can irritate the mucosa [2] (Figure 16). However, such injuries are
not very common since the introduction of rubber dam in dental practice.
Treatment: The best treatment of chemical burns of the oral cavity is preven-
tion. The proper use of a rubber dam during endodontic procedures reduces the risk
of iatrogenic chemical burns. Superficial burns of mucosa can heal in a short period
of time (within 1 or 2 weeks) as the turn-over of oral mucosa is very high [5]. Oral
surgery and antibiotics are necessary in very rare cases. Gel with hyaluronic acid can
accelerate the healing process. Possible treatments after chemical injuries, in relation
with the severity of wounds, are topical and intralesional corticosteroid applications,
caustic acid ingestion, commissuroplasty, mucosal flaps, free radial forearm flap and
free jejunal graft, surgeries made with electrocautery or soft tissue laser, and wound
coverage by periodontal pack [29].
3.2 Post-anesthetic ulceration of palate
Localization: Post-anesthetic ulceration due to dental nerve block is seen on

palatal mucosa. Ischemic necrosis of tissues may follow injections of local anes-
thetics. This can be due to the irritating nature of a solution, pressure from large
volumes, or constriction of the vasculature by vasopressors [30, 31].
Clinical features: The floor of the ulcer is covered with grayish-white necrotic
slough with sloping edge and erythematous margins; on palpation, the ulcer is
slightly tender with no indurations present.
Etiology: Post-anesthetic ulceration can occur following the rapid injection of
local anesthetic solutions, particularly those containing a vasoconstrictor.
Treatment: Management is usually conservative. It mainly consists of reassur-
ing the patient, prescribing analgesics, and combination of topical antiseptic and
anesthetic preparations. Healing generally occurs within 8–10 days after the onset
of the lesion. Rarely surgical intervention is necessary when ulcer does not heal. An
oral protective emollient orabase paste can also be prescribed [7].
3.3 Contact allergic stomatitis
Localization: Contact area of oral mucosa due to denture base materials, restor-
ative materials, mouthwashes, dentifrices, chewing gums, food, and other substances.
Various chemical or natural agents in contact with the mucosa can irritate and cause
11
Trauma in Dentistry
Figure 17.
Contact allergic stomatitis due to amalgam.
contact stomatitis. For example, cinnamaldehyde or cinnamon essential oil, which are
commonly used as flavoring agents in foods, beverages, candies, and hygiene products
by contact with mucosal surfaces, may trigger the formation of allergic stomatitis [32].
Clinical features: Diffuse erythema, edema, occasionally small vesicles, and
shallow erosions appear immediately after contact with the allergen on the affected
mucosal surfaces. Lesions are associated with burning symptom. In chronic aller-
gies, whitish, hyperkeratotic, erythematous lesions form [11] .
Etiology: Denture base materials, restorative materials like amalgam
(Figure 17), mouthwashes, dentifrices, chewing gums, food, and other substances
may be responsible.
Treatment: Contact allergic stomatitis can be diagnosed by an accurate
examination and clear understanding of medical history of the patient. Clinician’s
diagnostic ability and experience are highly important to avoid further unneces-
sary examinations, invasive and expensive diagnostic procedures [32]. Treatments
include removal of suspected allergens, and use of topical or systemic corticoste-
roids, antihistamines.
4. Radiation injuries
4.1 Oral mucositis
Localization: Developments in oncology have led to improved survival rates for

different cancers. Unfortunately, those treatment regimens have side effects such
as formation of oral mucosal lesions. The most common wound type during che-
motherapy is oral mucositis which appears by inflamed erosive or ulcerative lesions
on mucosal surfaces in the oral cavity [33]. Generally, buccal mucosa is affected by
radiation treatment of head and neck tumors [15].
Clinical features: After radiotheraphy, at the end of first week, the first oral
manifestations can appear. Lesions are erythematous and edematous. In the fol-
lowing days, ulcerative erosions with whitish-yellow exuadate appear. As salivary
glands are involved, xerostomia occurs and is followed by tongue papillary changes
with loss of taste, burning sensation, and pain during function. Speech is also
affected negatively [11].
Etiology: Chemotherapy, radiotherapy, or their combinations can lead oral
mucositis. The majority of patients (approximately 20–40%) receiving con-
ventional chemotherapy regimens for solid tumors, in relation to the dose and
12
cytotoxicity of the drug used, have oral mucositis. It is a side effect of radiation
treatment of head and neck tumors.
Treatment: Supportive care, cessation of radiation treatment, B-complex
vitamins, and sometimes low doses of corticosteroids are suggested.
4.2 Actinic chellitis
Localization: This type of lower lip lesion is mainly caused by solar irradiation
(chronic or excessive exposure to sun light) [35]. Actinic cheilitis (AC) generally
involves vermillion border of lower lip.
Clinical features: At the beginning, vermillion border of the lower lip is
involved with mild erythema associated with edema, dryness, and fine desquama-
tion. In later phases, smooth epithelium, small whitish-gray areas mixed with
red regions, and scaly formations appear. Thin nodules and erosive surfaces may
develop with time. The lesions could be precancerous [11].
Etiology: Long-term exposure to sunlight can lead to AC. People exposed to sun light
exhibited AC with a prevalence of 9.16%. AC is more frequent among those patients
who were exposed to solar irradiation more than 10 years, compared to those who were
exposed for less than 10 years. AC is mostly seen in Caucasian males over 50 years of age.
Treatment: Surgical and non-surgical treatment options of AC are available.
Surgical treatment or vermilionectomy is an invasive treatment choice and may
include some side effects, such as secondary wound healing with delayed re-epithe-
lialization, non-aesthetic appearance of lip, pain during the healing phase, edema,
secondary infection, scarring, and disaesthesia [37]. Conventional surgical interven-
tion or electrosurgery, laser ablation, and cryosurgery are alternative methods [38].
Except scalpel vermilionectomy, the other surgical methods mainly do not permit
the histopathological examination of all tissues removed as they change the protein
nature of specimen by thermal side effects [36, 38]. Among non-surgical therapies
include the usage of topical pharmacotherapy with 5-fluorouracil, trichloroacetic
acid, imiquimod, ingenol mebutate, and diclofenac. The non-surgical approach is
less invasive and has fewer secondary effects. But contrarily, in a systematic review
by Carvalho et al. [34], the surgical treatment was found to be more favorable than
non-surgical for AC. However, it is very important to protect lips from sunlight.
5. Electrical and thermal burn
5.1 Electrical burn
Localization: Commissures of the mouth often result in severe facial scarring

and deformation. Most commissural electrical burns involve mucosa, submucosa,
muscle, nerve, and vascular tissue.
Clinical features: Damage made accidentally to lingual or/and labial arteries
can cause abundant bleeding. When burned tissues spontaneously start to loosen
or slough and occasional trauma occurs, this type of bleeding happens. Generally,
this is observed 3–4 days after burn injury [12]. Pressure should be applied to the
hemorrhage site to stop the bleeding and the patient should be taken to the nearest
hospital emergency room for definitive care.
Etiology: The majority of electrical burns are home accidents. Generally,
children play with live electric extension cables/cords and may contact or suck them
and are injured by current. Especially in the cable/plug junctions, in non-fitted
appliance plugs, the electric current flows through tongue or oral cavity when they
are in contact with saliva, and the electric energy burns oral tissues. Children under
three years of age are mostly affected by this type of injury [12].
13
Trauma in Dentistry
Treatment: Whatever is the severity of burned injury, the basic treatment

strategy involves pain relief, infection control, and acceleration of wound repair
[39]. Application of antibiotic ointments to the burn area has been recommended
by some authors. Systemic antibiotics are recommended by most clinicians to
prevent wound infection. Facial disfigurement takes place if splints are not applied.
Microstomia reduces mouth opening, renders oral hygiene difficult, and decreases
functions of speech and chewing. Most of the cases need plastic surgery. [12].
5.2. Thermal burn
Localization: Oral mucosa, especially tongue and palatal mucosa.

Clinical features: Clinically, the condition appears as a red or white, painful
erythema that may undergo desquamation, leaving erosions (Figure 18). In exces-
sive damage to tissues, necrosis could appear. In mild lesions, wounds can heal
spontaneously within a week [11].
Etiology: Thermal burns mostly happen by accidental ingestion of hot sub-
stances. High incidence of thermal burns with a prevalence of 24.6% is seen among
children and young patients [40]. Usually caused due to contact with very hot foods,
liquids, hot metal objects or iatrogenic usage of lasers (diodes, Nd:YAG, Er:YAG or
CO2), piezoelectric surgery, or electrosurgery devices.
Treatment: No treatment is required for simple lesions. Care should be taken
in deep lesions to avoid contamination during healing period. Saline would be
prescribed to accelerate wound healing and avoid bacterial ingrowth. Ozone
therapy and laser biomodulation could help for good prognosis. In severe damages,
prophylactic antibiotic coverage is recommended. In hard tissue damages related to
thermal burn, the necrotic area should be removed surgically in order to avoid dam-
age to surrounding vital tissues and obtain blood supply for repair and subsequent
regeneration.
Figure 18.
Thermal iatrogenic burn during aerator usage.
14
15
Trauma in Dentistry
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Chapter 01

Introductory Chapter: Etiology,

1. Fracture of enamel of tooth,

2. Fracture of crown without pulpal involvement,

3. Fracture of crown with pulpal involvement,

4. Fracture of root of tooth,

5. Fracture of crown together with the root,

6. Unspecified tooth fracture,

8. Intrusion and/or extrusion of teeth

10. Other type of injuries including burns and laceration.

2.1 Radiographic examination

Several radiographic images must be taken from every patient in different

• Occlusal radiological examination.

Cone-beam computerized tomography is extremely useful at this stage. It can be

2.2 Clinical examination, basic principles, and suggestions

2.3 Fixation with splints and their using period

2.4 Medical treatment, antibiotics

2.5 Use of antibiotics

2.6 Sensitivity tests

2.7 Vitality of permanent teeth

2.8 Traumatic occlusion

As a dental practitioner, we may cause occlusal trauma. We change the occlusal

2. Implant supported prosthesis

5. Oral surgery operations

The ceramic materials are often used in restorative treatments. Premature

[2] Perez R, Berkowitz R, Mcllveen L, [10] Flores MT, Malmgren B, Andersson

1985;25(3):246-251. DOI: 10.1016/j.

[17] Hattori Y, Satoh C, Kunieda T,

[18] Iwase M, Ohashi M, Tachibana H,

Dental Implants and Trauma

Traumatic dental injuries (TDIs) have different frequencies worldwide, but

dentition, uncomplicated crown fractures by 44.9% incidence were most frequent

3. Dental implant treatment in post-traumatic dento-alveolar defects

Following interim prosthesis installations, in order to increase the maxillary

effective treatment modality in restoring a patient to near normal function and

significantly lower complications in the group of patients which did not

4. Prerequisites for dental implant placement after trauma

nephritis, aldosteronism, Cushing syndrome), viral diseases (HIV, Hepatitis III),

The choice of augmentation method depends on the defect size, volume,

protocols of immediate loading for partially edentulous and missing single-tooth

Edentulism due to trauma could be properly rehabilitated by dental implant

[1] Ugolini A, Parodi GB, Casali and luxations of permanent teeth.

injuries in children. Experience of a Rehabilitation of the work accident-

Dental Implants. Atlas of the Oral [56] Esfahanizadeh N, Yousefi H.

undergoing bisphosphonate treatment: [71] Doğan GE, Halici Z, Karakus E,

[78] Almeida D, Vianna K, Arriaga P, review. International Journal of

[84] Kutkut A, Abu-Eid R, Sharab L, [91] Gómez-de Diego R, Mang-de la Rosa

dento-alveolar development. A clinical Journal of Oral & Maxillofacial

[98] Thilander B, Odman J, Gröndahl K, [106] Szmukler-Moncler S,

[108] Meyer U et al. Ultrastructural [116] Zhang W, Skrypczak A,

[114] Levin BP. The correlation

[115] Khoury J, Ghosn N, Mokbel N,

Biomaterial Used in Trauma

The development of bone tissue engineering and bone regeneration is always of

Keywords: biomaterials, trauma, maxillofacial surgery

2.1.1 Osteoprogenitor cells

2.1.4 Bone marrow cells

2.2 The intercellular tissue (bone matrix)

3. Healing mechanism of bone defects

3.1 Bone formation mechanism with bone graft materials