DENTAL

TRAUMATIC
INJURIES
Submitted to- Submitted by-
Dr. Rajinder Bansal Nishtha Manchanda
Head of the Department P.G. 2nd year
Department of Conservative Department of Conservative
CONTENT
INTRODUCTION
AETIOLOGY
PREDISPOSING FACTORS
DIRECT AND INDIRECT TRAUMA
EPIDEMIOLOGY
CLASSIFICATION
CLINICAL EVALUATION OF THE PATIENT
MANAGEMENT OF THE INJURY
CROWN FRACTURES
VITAL PULP THERAPY
REVASCULARISATION
APEXIFIFCATION
CROWN AND ROOT FRACTURES
ROOT FRACTURES
LUXATION INJURIES
AVULSION
SPORTS IMJURY
CONCLUSION
INTRODUCTION
Trauma to oral and maxillofacial area comprises of 5% of the total injuries

Dental injury is the most common injury of the facial injuries

Traumatic injuries to the teeth result in damage to dental and periradicular

structures

The management and consequences of these injuries are multifactorial and

knowledge of the interrelating healing patterns of these tissues is essential
AETIOLOGY
The most accident prone times include;
2-4 years for primary dentition
7-10 yrs for permanent dentition
Aetiological factors include;
1. Falls
2. Collision
3. Playing and running
4. Contact sports
5. Road traffic accident
6. Child abuse; ESPN Emotional-Sexual-Physical-Neglect
 PREDISPOSING FACTORS
1. Angle class II div 1
2. Increased overjet; 3-6mm..double, the risk
>6mm….triple the risk
3. Incompetent lip closure
4. Improperly fitted mouthguard (twice the risk)
5.Cerebral palsy: due to – abnormal muscle tone
and function in oral area producing protrusion of
maxillary anterior teeth. Poor skeletal and
muscle co-ordination
6.Epileptic patients
 DIRECT AND INDIRECT TRAUMA
Direct trauma; involves the tooth directly
- favours anterior teeth
Indirect trauma
- seen when the lower arch forcefully close
against the upper arch
-favours crown and crown-root fracture of the
premolar and molar region
EPIDEMIOLOGY
Dental trauma is common in childhood and adolescence.
Boys show more frequency than girls in permanent teeth, no significant sex
difference in primary teeth
Peak incidence in boys- 2-4 year and 9-10 year
Facial injuries- common in boys of 7-12 yr of age, mandible is most affected
Teeth involved- 37% upper central incisor
18% lower central incisor
6% lower lateral incisor
3% upper lateral incisor
In primary dentition; anterior segment is commonly affected
especially the maxillary central incisor, concussion, subluxation,
and luxation are the commonest
In permanent dentition; luxation and fracture injuries are the
commonest
TYPES AND NOMENCLATURE
• 1. Avulsion: The complete displacement
of the tooth out of its socket
• 2. Concussion: An injury to the tooth-
supporting structures without any
displacement; but with pain to
percussion or only – tooth
• 3.Intrusion: Displacement of the tooth
into the alveolar bone, characterized by
crushing of alveolar socket
• 4. Extrusion: Partial
displacement of the tooth out of
its alveolar socket,
characterised by separation of
the periodontal ligament .
Apart from axial displacement,
the tooth will usually have an
element of protrusion. The
alveolar socket bone remains
intact
• 5. Subluxation: An injury to the
tooth-supporting structures, but
without displacement of the
tooth. Bleeding from the
gingival sulcus in early case.
• 6. Lateral luxation- Displacement of the tooth out of its socket
other than axially, characterised by separation of the periodontal
ligament
CLASSIFICATION
BY SWEETS (1955)
Class I – A simple of crown exposing no dentin.
Class II – A parallel of crown involving little dentin.
Class III – Extensive fracture of crown involving more dentin but no pulp
exposure.
Class IV – Extensive fracture of crown exposing pulp.
Class V – Complete fracture of crown exposing pulp.
Class VI – Fracture of root with or without loss of crown structure.
Class VII – Tooth loss as a result of trauma.
Disadvantages :
 1) No stress has been laid on injuries to supporting structures soft
tissue and bone.
2) Indicates more towards the permanent teeth than primary
teeth
BY RABINOWITCH (1956)-
1. Fractures of the enamel or slightly into the dentin
2. Fractures into the dentin
3. Fractures into the pulp
4. Fractures of the periodontium
5. Comminute fractures of alveolar socket.
6. Displaced teeth
BENETTS CLASSIFICATION (1963)
According to injuries to periodontium and alveolus considering the anatomy and
morphology of the teeth
Applied partially for primary and permanent teeth.
Class I – Traumatized tooth without coronal or root fracture.
a) Tooth luxated in alveolus.
b) Tooth subluxated in alveolus.
Class II – Coronal fracture
a) Involving enamel
b) Involving enamel + dentin.
Class III – Coronal fracture with pulp exposure.
Class IV – Root fracture a) Without coronal fracture.
b) With coronal fracture.
Class V – Avulsion of tooth.
CLASSIFICATION BY ELLIS and DAVEY’S (1970)
Class I - Simple crown fracture with little or no dentin affected
Class II - Extensive crown fracture with considerable loss of dentin, but with the
pulp not affected.
 Class III - Extensive crown fracture with considerable loss of dentin and pulp
exposure.
 Class IV - A tooth devitalized by trauma with or without loss of tooth structure.
 Class V - Teeth lost as a result of trauma.
 Class VI - Root fracture with or without the loss of crown structure.
 Class VII - Displacement of the tooth with neither root nor crown fracture
 Class VIII - Complete crown fracture and its replacement.
 Class IX - Traumatic injuries of primary teeth.
BY GARCIA – GODOY (1981)
Enamel crack
Enamel fracture
Enamel Dentine fracture without pulp exposures
Enamel Dentine fracture with pulp exposure
Enamel- Dentine-cementum fracture without pulp exposure
Enamel- Dentine-cementum fracture with pulp exposure
Root fracture
Concussion
Luxation
Lateral displacement
 Intrusion
Extrusion
 Avulsion.
• WHO CLASSIFICATION (1994)
In Geneva
Can be applied for both primary as well as permanent dentition
International diseases of dentistry and stomatology
 INJURIES TO THE HARD DENTAL
TISSUES AND PULP
• Enamel infraction N Enamel fracture
502.50- An incomplete (Uncomplicated
fracture (crack) of the crown fracture) N
enamel without loss of 502.50: A fracture
tooth substance with loss of tooth
substance confined to
enamel.
 Complicated
• Enamel - dentin
crown fracture N
fracture 502.52 A
(Uncomplicated fracture involving
crown fracture) N enamel and dentin
502.51: A fracture and exposing the
with loss of tooth pulp
substance confined to
enamel and dentin but
not involving pulp.
• Uncomplicated crown Complicated
root fracture N 502.54 crown root
A fracture involving fracture N 502.54
enamel, dentin and A fracture
cementum but not involving enamel,
involving the pulp. dentin and
cementum and
exposing pulp.
Root fracture N 502.53:

A fracture involving dentin,

cementum and the pulp.
 Injuries to the periodontal tissues
• Concussion N 503.20: Subluxation N
An injury to the tooth 503.20
supporting structures An injury to the
without abnormal tooth supporting
structures with
loosening or
abnormal loosening
displacement of the but without
tooth. displacement of the
tooth.
 Lateral luxation N
Extrusive luxation
503.20 Displacement of
(peripheral dislocation,
the tooth in a direction
partial avulsion) N
other than axially. This is
503.20
accompanied by fracture
Partial displacement of of the alveolar socket.
the tooth out of its socket.
• Intrusive luxation (central Exarticulation
dislocation) N 503.21: complete
Displacement of the tooth avulsion) N
into the alveolar bone. This 503.22
injury is accompanied by
Complete
fracture of the alveolar
displacement of
socket
the tooth out of
its socket.
 Injuries of the supporting bone
• Comminution of Fracture of the
alveolar socket
alveolar socket wall
(mandible N 502.60,
(mandible N 502.60,
maxilla N 502.40):
Crushing and Maxilla N 502.40) A
compression of the fracture contained to
alveolar socket. the facial or lingual
intrusion and lateral
socket wall.
luxation
Fracture of the alveolar
process (Mandible N
502.60, Maxilla N
502.40) - A fracture of the
alveolar process which
may or may not involve
the alveolar socket.
Fracture of mandible and maxilla

(Mandible N 502.61, Maxilla N 502.42)

A fracture involving the base of the mandible or maxilla and often the
alveolar process (jaw fracture). The fracture may or may not involve
the alveolar socket.
 Injuries to gingival or oral mucosa
• Laceration of Contusion of gingival or oral
gingival or oral mucosa N S00.50 A bruise
mucosa N S01.50: usually produced by an
A shallow or deep
impact from a blunt object
wound in the
and not accompanied by a
mucosa resulting
from a tear and break of the continuity in the
usually produced mucosa, causing sub-
by a sharp object. mucosal hemorrhage
Abrasion of gingiva or
oral mucosa N S00.50

A superficial wound
produced by rubbing or
scraping of the mucosa
leaving a raw bleeding
surface.
• BY ANDREASEN ( 1981)-
Classification of trauma in injury
of hard tissues and pulp
873.64 -
873.62 - 873.64 -
873.61 Compli
873.60 - Compli Uncom 873.63 -
-Uncom cated
Incompl cated plicated Root
plicated crown
ete crown crown fracture
crown and root
fracture fracture and root .
fracture fracture
. fracture
.
Injuries to the periodontal tissues
873.67 -
873.67 - Extrusive
873.66 873.68 -
Intrusive luxation
873.66 - -Subluxat 873.66 - Exarticul
luxation (peripher
Concussi ion Lateral ation
(central al
on. (loosenin luxation. (Avulsed
dislocatio dislocatio
g). tooth).
n). n, partial
avulsion).
 Injuries Mandible
Mandible to the supporting
Mandible
bone
Mandible
No. 802.20,
No. 802.20, No. 802.20, No. 802.21,
maxilla No.
Maxilla No. Maxilla No. Maxilla No.
802.40 –
802.40 – 802.40 – 802.42 –
comminutio
Fracture of Fracture of Fracture of
n of
alveolar alveolar mandible /
alveolar
socket wall process. maxilla.
socket
 Injuries to Gingiva/ Oral
873.69 - mucosa
920.X0 910.00 -
Laceration -Contusion Abrasion
of of of gingiva
gingiva/ora gingiva/ora or oral
l mucosa l mucosa mucosa
• BY MCDONALD (2004)
• Class 1 - Simple fracture of the crown involving little or no dentin
• Class 2 - Extensive fracture of the crown involving considerable
dentin but not the dental pulp
• Class 3 - Extensive fracture of the crown with an exposure of the
dental pulp
• Class 4 - Loss of the entire crown.
 CLINICAL EVALUATION OF PATIENT
1. History of the trauma-
HOW;
-to know extent of injury
-direct or indirect to rule out head injury involvement
-Discrepancy between history and clinical findings raises suspicion of physical abuse.
WHERE;
- whether contaminated soil or not; which may be an indication for tetanus prophylaxis or
not
WHEN;
-time interval between injury and presentation would determine treatment option and
2. Medical History-
Any known allergies to any medication
Any underlying systemic condition (blood disorder)
Tetanus immunization
• 3. Clinical examination-
Neurological examination- According to Davis
Evaluate function of the eyes- Check for the functioning of the
Extraocular muscles
Determine blood-pressure and pulse.
Look for normal respiration without obstruction of the airway or danger
of aspiration.
Confirm normal vocal functions.
Evaluate movement of the neck for pain or limitation.
Confirm hearing (tinnitus or vertigo).
Sensory function should be evaluated through light contact to various
areas of the face.
Evaluate motor function : smile ,movement of tongue, muscular
movement of face
Soft tissue examination

 Inspection of the tongue,

 Oral mucosa, palate, floor of the mouth & gingiva for lacerations

Check for areas of tenderness, swelling or bruises.

Check for the presence of impacted foreign bodies or tooth

fragments in the wound
Hard tissue examination

Teeth are examined for fracture or infractions.

If crown facture have occurred note if pulp is exposed .

Mobility test- injuries results in

Mobility of individual teeth- luxation injuries.

Mobility of group of teeth –possible alveolar fracture.

Degree of mobility should be recorded-

Grade 0-no loosening or change
Grade 1-horizontal loosening≤1mm
Grade 2-horizontal loosening >1mm
Grade 3- axial (vertical) loosening
Percussion test
Percussion test can provide information about the relationship
between the tooth and adjacent bone
Tenderness to touching or tapping a tooth indicates damage to PDL.
Tap first with a finger before proceeding to using mirror handle.
High metallic tone- indicates lateral or intrusive displacement.
Follow up examination indicates ankylosis.
Pulpal sensitivity test

Used to asses the neurovascular supply to the pulp.

Traumatized tooth gives a false negative reading

These tests should be repeated at 3weeks ,6weeks,12 months and

yearly interval following accidents.

Carbondioxide (-780c) or diflurodchlormethane (-400c)placed on the

incisal third of the facial surface gives more accurate response.
EPT relies on electric impulses directly simulating the nerves of
the pulp. These test have limited value in young teeth but are
useful in cases where dentinal tubules are closed and do not allow
dentinal fluid to flow in them. This situation is typical of
traumatized tooth that are undergoing premature sclerosis.

Laser doppler flowmetry can detect blood flow more consistently

and provide accurate reading of vitality status of the pulp.
 Radiographic examination
Multiple radiographic exposures from several angulation provide
the most reliable information about changes in dentoalveolar
complex following traumatic injuries.
One occlusal exposure Determine extend of
injury from trauma
+
Three periapical bisecting angle exposures

Radiographic examination of soft tissue-

Penetrating lip lesions
To locate any foreign bodies.
Orbicularis oris muscles close tightly around the foreign bodies in
the lip making them impossible to palpate which can be identified
radiographically.
This is accompanied by placing a dental film between the lips and
the dental arch and using 25% of the normal exposure time.
 MANAGEMENT OF TRAUMATIC INJURIES
CROWN FRACTURES-
1. Infraction: An incomplete fracture of the tooth without actual loss of tooth
substance.
2. Uncomplicated crown fracture: A fracture with loss of tooth substance
confined to enamel.
3. Enamel-dentin fracture: A fracture with loss of tooth substance confined to
enamel and dentin, but not involving the pulp.
4. Complicated crown fracture: A fracture involving enamel, dentin and pulp.
ROOT FRACTURES
CROWN FRACTURES-
ENAMEL FRACTURES/ INFRACTION-
involve the loss of the coronal tooth enamel subsequent to a force
directed perpendicularly or obliquely to the incisal edge of the
traumatized tooth
BIOLOGIC CONSEQUENCES-
No or minimal trauma
Vitality of tooth is maintained
DIAGNOSIS AND CLINICAL
PRESENTATION-
 includes superficial rough edge that may
cause irritation to the tongue or lips.
Sensitivity to air or liquids can be present.

Enamel fracture
TREATMENT-
 does not usually pose a threat to the health
of pulp; rather it is an annoyance to the
tongue, lips or buccal mucosa.
smoothing of sharp enamel edges,
recontouring and restoring the injured
tooth, to prevent the laceration of tongue,
lips or oral mucosa. Recontouring followed
by direct composite
 CROWN FRACTURES-
DENTIN /UNCOMPLICATED CROWN FRACTURES-
 Involve the loss of tooth confined to enamel and dentin but not involving the pulp

INCIDENCE-
Most commonly reported dental injury
Least one third to one half of all reported dental trauma.

BIOLOGIC CONSEQUENCES-
Little danger of resulting in pulp necrosis.
Iatrogenic trauma( esthetic restoration) can compromise the health of the pulp
DIAGNOSIS AND CLINICAL PRESENTATION-
 Rough edges on the tooth
 Sensitivity to air an, hot , cold liquids and pain on mastication

TREATMENT-
The objective in treating a tooth with a fractured crown without pulpal exposure is three fold:
1. Elimination of discomfort.
2. Preservation of vital pulp.
3. Restoration of fractured crown
Treatme
nt in
two
Tempor • exposed dentin is protected by sedative
steps-
ary cement such as zinc oxide eugenol
• Vitality is tested and patient is recalled
restorati after 1 month to check the pulpal status
on
Perman • Use of adhesive composite system for
restoring the fractured tooth if
ent dentin thickness is more than 0.5mm
• If thickness is less than 0.5mm use a
restorati Ca(OH)2 or GIC base below the
composite filling
on
CROWN FRACTURES
COMPLICATED CROWN FRACTURES
A crown fracture involves the enamel, dentin and pulp.

INCIDENCE-
0.9% to 13% of all dental injuries

BIOLOGIC CONSEQUENCES-
A crown fracture involving the pulp,
If left untreated, always leads to pulp necrosis
TREATMENT-
1) Vital pulp therapy, comprising pulp capping, partial
pulpotomy, or full pulpotomy
2) Pulpectomy
choice of
treatment
depends on-
the time
stage of concomitant restorative
between
developmen periodontal treatment
trauma and
t of the tooth injury plan
Stage of development of the tooth
Loss of vitality in an immature tooth can have catastrophic
consequences. Root canal treatment on a tooth with a
blunderbuss canal is time consuming and difficult.
It is probably more important that necrosis of an immature
tooth leaves it with thin dentinal walls that are susceptible to
fracture both during and after the apexification procedure.
In an immature tooth, vital pulp therapy should always be
attempted if at all feasible because of the tremendous
advantages of maintaining the vital pulp.
Time Between Trauma and Treatment
For 48 hours after a traumatic injury, the initial reaction of the
pulp is proliferative.
 After 48 hours, chances of direct bacterial contamination of the
pulp increase, with the zone of inflammation progressing apically;
as time passes, the likelihood of successfully maintaining a healthy
pulp decreases.
Concomitant Attachment Damage
A periodontal injury will compromise the nutritional supply of the
pulp.
Restorative Treatment Plan
In a mature tooth, pulpectomy is a viable treatment option.
If performed under optimal conditions, vital pulp therapy after
traumatic exposures can be successful and simple composite resin
restoration will suffice as the permanent restoration.
 If a more complex restoration is to be placed (e.g., a crown or
bridge abutment), pulpectomy may be the more predictable
treatment method.
Vital pulp therapy
Treatment initiated to preserve and maintain pulp tissue in a
healthy state, tissue that has been compromised by caries ,trauma .

Includes- Pulp capping, pulpotomy.

Both procedure permit preservation of pulp tissue for the continued

development of root
Vital Pulp Therapy: REQUIREMENTS FOR SUCCESS
Vital pulp therapy has an extremely high success rate if the following
requirements can be met-
1. Treatment of a noninflamed pulp- Treatment of a healthy pulp has been
shown to be an important requirement for successful therapy.
2. Bacteria-tight seal- If the exposed pulp is effectively sealed from bacterial
leakage, successful healing of the pulp with a hard tissue barrier will
occur independent of the dressing placed on the pulp
3. Pulp dressing- Calcium hydroxide has traditionally been used for vital
pulp therapy. Its main advantage is that it is antibacterial
Pulp Capping
Pulp capping implies placing the dressing directly on the pulp exposure without any removal of the
soft tissue

Indications-
Pulp capping should be used primarily for small exposures( < than 1 mm) soon after injury (possibly
within first 24 hours).
No or minimal bleeding at exposure site.

Contraindications-
Excessive tooth mobility
Thickening of periodontal ligament
Radiographic evidence of furcal or perriradicular degeneration
 Uncontrollable hemorrhage at the time of exposure
Purulent exudate from the exposure
 PULP CAPPING AGENTS

Ca(OH)2 , Zinc oxide eugenol cement , corticosteroids, inert material such as

cyanoacrylate , tricalcium phosphate ceramic, collagen fibres ,MTA.
Ca(OH) 2 has been the most widely accepted as the agent of choice.
Commercially available compounds of calcium hydroxide in modified form are Dycal,
Prisma VLC Dycal, Pulpdent.
DIRECT PULP CAPPING
Direct Pulp capping: - the treatment of an exposed vital pulp by
sealing the pulpal wound with a biocompatible material placed
directly on a mechanical or traumatic exposure to facilitate the
formation of reparative dentin and maintenance of the vital pulp.
PROCEDURE-
Tooth is isolated with rubber dam.
The exposed pulp is washed with weak
disinfectant and covered with cotton
dipped in NaOCl to control the
bleeding
The capping material is placed over
the cavity followed by permanent
restoration.
Zones under calcium hydroxide
Three identifiable histologic zones under the calcium hydroxide in 4 to 9 days:
 (1) coagulation necrosis

 (2) deep-staining basophilic areas with varied osteodentin, and

 (3) relatively normal pulp tissue, slightly hyperemic, underlying an

odontoblastic layer.
Mechanism of bridge formation
1. Immediately after vital pulpal therapy: A necrotic layer is observed
below the Ca(OH)2.
2. After 1 to 2 weeks: a deposit of calcium carbonate granules ,beneath this
layer osteo-odontoblasts derive from pulp cells emerge.
3. After 4-5 weeks: Osteodentin is formed by osteo-odontoblasts.
4. Final Stage : Dentin bridge is formed composed of 2 layers of hard tissue
osteodentin and dentin with dentinal tubules.
The new dentin bridge is visible clinically after approximately 2-3 months.
MTA
MTA ( mineral trioxide aggregate)biocompatible pulp capping
agent. It produces more dentinal bridging in shorter period of
time with less inflammation.
MTA permit cementoblast attachment and growth and osteocalcin
production
Superior marginal adaptation and is non resorbable .
Stimulates cytokine release , induces pulpal cell proliferation and
promotes hard tissue formation.
Soluble components of MTA released during and after setting on
the dentin interface cause the release of growth factors and
bioactive molecules such as TGF beta and adrenomedullin.
Composition
Is mixture of three powder ingredients ;
 75 wt% Portland cement
 20 wt% bismuth oxide (Bi2O3 Trace amount of
 SiO2 , CaOH,MgO, K2SO4)
 5 wt% of gypsum
Portland cement is a mixture of tricalcium silicate, dicalcium
silicate, tricalcium aluminate, tetracalcium aluminoferrite
MTA products have been reported to have a smaller mean particle
size, fewer toxic heavy metals, has a longer working time, and
Pulp capping with MTA
Place MTA directly over the exposure site as it requires 3-4 hours
to set ,a hard setting material must be placed over it before final
restoration is completed.
1.5 mm of thick MTA is considered as a effective pulp capping
material.
PULPOTOMY
Pulpotomy
Defined as the surgical removal of the damaged and inflamed
tissue to the level of a clinically healthy pulp, followed by a pulp
dressing.
A variety of dressing materials have been used for this purpose
including Ca(OH)2, phenol ,formaldehyde , glutaraldehyde ,Ferric
sulphate, Electrosurgical, LASERS, and MTA.
PARTIAL PULPOTOMY/ CVEK PULPOTOMY:
Removal of coronal pulp tissue to the level of healthy pulp.
It is the removal of only the outer layer of damaged and
hyperemic tissue in exposed pulps, is considered to be a procedure
staged between pulp capping and complete pulpotomy
1. Anesthetize the tooth
2. Fractured surface cleaned, disinfected
3. Rubber dam is placed
4. A 1-2 mm deep cavity is prepared in to the pulp using a sterile diamond
bur at high speed with copious water coolant.
5. Excess blood carefully removed by rinsing with sterile saline and dried
with sterile cotton pellet.
6. Pure calcium hydroxide mixed with sterile saline solution is placed on to it
7. Prepared cavity is filled with material with the best chance of a bacterial
tight seal(zinc oxide eugenol, glass ionomer cement)
8. Exposed dentin is etched and restored with composite resin.
Follow-up-
Maintenance of pulp sensitivity tests and
radiographic evidence of continued root
development.
Treatment was considered successful:

1. Clinically no signs or symptoms of pulp or periapical disease

2. Radiographically continued growth of the root and canal narrowing

and no widening of PDL.

3. No periapical radiolucency
Deep PULPOTOMY
involves removal of the entire coronal pulp to the level of root
orifices.
Indication
when it is predicted that pulp is inflamed to the deeper levels of
coronal pulp.
traumatic exposure after 72 hours
carious exposure
.
Technique:
 Anesthetize the tooth
 Fractured surface cleaned, disinfected
 Rubber dam is placed
 Coronal pulp is removed as in the partial pulpotomy but to the level of
root orifices
 Calcium hydroxide dressing ,bacterial tight seal
 Coronal restoration are carried out as with partial pulpotomy
FOLLOW UP:
A major disadvantage of the full pulpotomy is that sensitivity
testing is not possible because of the loss of the coronal pulp.

Radiographic follow-up to assess sign of apical periodontitis and

to ensure the continuation of root formation.
REVASCULARIZATION
Revascularization can be broadly defined as the restoration of
vascularity to a tissue or organ.
Skoglund et al. showed that pulp revascularization was possible in
dog teeth and it took approximately 45 days
The young tooth has an open apex and a short root that allows
new tissue to grow into the pulp space relatively quickly.
 The pulp is necrotic but usually not degenerated and infected so
that it can act as a scaffold into which the new tissue can grow.
Revascularization of the pulp space in a tooth with necrotic infected
pulp tissue and apical periodontitis has been thought to be impossible
until recently.
 Nygaard-Østby and Hjortdal successfully regenerated pulps after vital
pulp removal in immature teeth but were unsuccessful when the pulp
space was infected.
Thus, if the canal is effectively disinfected, a scaffold into which new
tissue can grow is provided and the coronal access effectively sealed,
revascularization should occur in immature tooth.
 A scientific finding, which may explain in part why apexogenesis can
occur in these infected immature permanent teeth, is the discovery
and isolation of a new population of mesenchymal stem cells (MSCs)
residing in the apical papilla of incompletely developed teeth.
 These cells are termed stem cells from the apical papilla (SCAP), and
they differentiate into odontoblast-like cells forming dentin
 Apical papilla is apical to the epithelial diaphragm, and there is an
apical cell-rich zone lying between the apical papilla and the pulp.
Several case reports have documented revascularization of necrotic root canal
systems by disinfection followed by establishing bleeding into the canal system
via over instrumentation.
 An important aspect of these cases is the use of intracanal irrigants with
placement of antibiotics (e.g. a mixture of ciprofloxacin, metronidazole, and
minocycline paste) for several weeks.
 This particular combination of antibiotics effectively disinfects root canal
systems and increases revascularization of necrotic teeth, suggesting that this is
a critical step in revascularization.
IMMATURE TOOTH: APEXIFICATION
By Frank
 Method to induce development of the root apex of an immature
pulpless tooth by formation of osteocementum or other bone like
tissue.
The use of Ca(OH)2 for apexification was first reported by Kaiser
(1964)
Materials used
Ca(OH)2 ,Tricalcium phosphate, collagen calcium phosphate,
osteogenic protein -1 , bone growth factors and MTA.
INDICATION:
Non vital pulp of teeth with open apices and thin dentinal walls in
which standard instrumentation cannot create an apical stop.
technique
 DISINFECTION OF THE CANAL: Root canal system is disinfected to
ensure periapical healing.
Canal length is estimated with preoperative radiograph.
Access to the canal is made and a file is placed to this length. when length
has been confirmed by radiograph; filing is performed with copious
irrigation
Canal is dried with paper points and Calcium hydroxide spun in to the
canal with a lentulo-spiral instrument. The disinfecting action of calcium
hydroxide is effective after its application for at least 1 week.
HARD TISSUE APICAL BARRIER
 Pure calcium hydroxide mixed with sterile saline to a thick consistency. Calcium
hydroxide is placed against the apical soft tissue with a plugger to initiate hard
tissue formation followed by backfilling with calcium hydroxide to completely
fill the canal. 6-18 months are required for hard tissue formation at the apex.
Calcium hydroxide removed from access cavity to the level of the root canal
orifices. Temporary root filling is placed in the access cavity.
After 3 months intervals radiograph is exposed to evaluate whether a hard tissue
barrier has formed or Ca (OH)2 has washout of the canal.
When completion of a hard tissue barrier is suspected , calcium hydroxide
should be washed out of the canal with sodium hypochlorite.

Radiograph taken to evaluate the radiodensity of the apical stop. When a

hard tissue barrier is indicated on the radiograph and can be probed with
an instrument , the canal is ready for filling.

The creation of physiological hard tissue barrier with calcium hydroxide

predictable takes from 3-18 months.
FILLING OF THE ROOT CANAL
Avoid excessive lateral force during filling because of the thin walls of the root.
Hard tissue barrier formed by calcium hydroxide therapy consists of
irregularly arranged layers of coagulated calcified soft tissue and cementum
like tissue.
Islands of soft connective tissue give the barrier a “ Swiss cheese” consistency
Filling should be completed to the hard tissue barrier and not forced toward
radiographic apex.
CROWN AND ROOT FRACTURE
This fracture involves enamel, dentin and cementum.
The fracture usually starts at the midportion of the crown facially
and extends below the gingival level palatally.
If the fragment is still kept in place by fibers of the periodontal
ligament ,the patient will generally complain about sensitivity to
pressure and /or percussion due to slight mobility of the fragment.
 5% of all dental injuries
.

Treatment principles:

Crown root fractures have immediate implications for the endodontic restorative
and periodontal prognosis due to the subgingival position of the line of fracture.

Treatment objective must therefore be aimed at exposing the fracture margins

supragingivaly so that all clinical procedure can be managed with strict moist
control and bleeding control.

It’s a multidisciplinary approach.

Removal of the coronal fragment with subsequent restoration above gingival level

To allow the subgingival portion of the fracture to heal

(presumably with formation of a long junctional epithelium),
whereafter the coronal portion can be restored either by: bonding
the original tooth fragment where the subgingival portion of the
figment has been removed using a dentin bonding system, a
composite build-up using dentin and enamel bonding systems, or a
crown restoration
Indication. This procedure should be limited to superficial fractures
that do not involve the pulp.

Treatment procedure. The loose fragment is removed as soon as

possible after injury. Rough edges along the fracture surface
below the gingiva may be smoothed with a chisel. The remaining
crown is covered with a temporary crown whose margin ends
supragingivally. Once gingival healing is seen (after 2-3 weeks), the
crown can be restored.
Fragment removal and surgical exposure of subgingival fracture

If the fracture extends below the alveolar crest , the subgingival
fracture is exposed by gingivectomy and/or osteotomy after
removal of the coronal fragment..
Following gingival healing the tooth is restored with a post
retained crown.
Clinical and radiographic appearance
of complicated crown root fracture

Coronal fragment is removed

.combined gingivectomy and
osteotomy done to expose the fracture
site.
Post retained full crown fabricated

Final restoration
 Fragment removal and orthodontic extrusion
To orthodontically move the fracture to a supragingival
position.
Done when root portion is long enough to accommodate
post retained crown
Coronal fragment is initially stabilized to adjacent teeth.
After pulp capping ,pulpotomy or endodontic therapy
orthodontic traction is applied to the labial surface of the
fragment or to a hook or screw post is cemented into the
root canal root is extruded over a period of 2-3 weeks .
 2-3 mm of extrusion after 11 weeks -Bondemark et al
Clinical picture Orthodontically extrud

Removal of fractured crown Extruded fragment 2-3

Hook cemented into canal Final restoration

Comparison between different treatment modalities of crown root
fractures
ROOT FRACTURE
Root fractures are fractures involving dentin, cementum and the
pulp.
Radiographic appearance- radiolucent lines separate the root into
two or more fragments. Apical fragment is always in situ whereas
the coronal fragment is often displaced.
3% of all dental injuries.
3 angled radiographs .
TREATMENT
Coronal : Root fracture

 Has poor prognosis

 if coronal segments are rigidly splinted , chances of healing are similar to mid-root
fracture
if the fracture occurs at the level or coronal to the crest of alveolar bone, prognosis is
extremely poor.
If reattachment of the fractured segment is not possible ,extraction of the coronal
segment is indicated.
The level of fracture and length of the remaining root are evaluated for restorability. If
apical root segment is long enough forced eruption of this segment can be carried out.
Mid-root /apical root fractures : Pulp
necrosis in 25% of the cases

Treatment options:
1. Treatment of the coronal segment only:
Done when coronal segment pulp becomes necrotic and there is
no radiographic or clinical evidence that the apical segment is
irreversibly inflamed or necrotic.
Pulp space therapy in the coronal segment with calcium
hydroxide dressing. Obturation done after the formation of
2. Treatment of both the coronal and apical
segment:
Both coronal and apical segment are necrotic .
Pulp space therapy in both the segments with calcium hydroxide
dressing. Obturation done following evidence of healing.
Success of this treatment depends on the segment being well
aligned and width between the segment are minimal.
3. Treatment of coronal segment and removal of
the apical segment Surgically:
Surgical removal of the apical segment in case of failure of
endodontic therapy in the apical segment .
This is viable treatment if the remaining root is long enough to
provide adequate periodontal support.
Follow- up :

After the splinting period is completed clinicians should schedule follow

up examination at 3, 6 & 12 months and yearly thereafter

Prognosis

Factors that influence healing are as follows-

 Fracture location- Mid root and apical fractures tend to result in less
mobility of the coronal fragment which is thought to favor better healing
Diastasis- more the diastasis, more necrosis of pulp, more mobility ,
slower the healing
Tooth maturity- younger the tooth, more vasculature better the healing
 VERTICAL ROOT FACTURE
5% of total crown root fractures.
The line of fracture is parallel to the long axis of the tooth and can extend from the crown
to the apex or is localized in the apical, middle or cervical third of the root
May or may not involve the pulp chamber
Seen most often in teeth that have had endodontic treatment

Clinical examination;
Bite test
Transillumination
Periodontal probing test.
Radiographic examination.
Surgical exploration
Deep narrow isolated periodontal pocket.

Periradicular halo radiolucency

Classification of vertical root fracture
class 1 – incomplete supraosseous- no periodontal defect.

Class 2- incomplete intraosseous – minor periodontal defect.

Class 3- complete or incomplete intraosseous – major periodontal

defect
Clinical features
Periradicular halo radiolucency
Deep narrow isolated periodontal pocket.
Spontaneous pain on mastication

Treatment of vertical fractures

Single rooted tooth

Complete fracture- extraction

Coronal fracture–removal of fractured fragment- reposition the root coronally
 Apical fracture- surgical removal

Multi rooted tooth

Fracture involves one root-hemisection
 Class I fracture Class II fracture Class III fracture
No periodontal defect Minor periodontal defect Major periodontal defect

Viable or Nonviable Non viable

Viable pulp nonviable pulp pulp pulp

Temporary Exploratory/corrective surgery Hemisection,

Temporary
crown Root amputation,
crown
or extraction

(3 months) Ca(OH)2
Permanent
restoration
(3-9 months)

obturation

Permanent restoration
LUXATION INJURIES
Concussion
Subluxation
Extrusive luxation
 Lateral luxation
Intrusive luxation

30 - 44% of all dental injuries

 permanent dentition - 15-40%
 primary dentition - 62-69%
Concussion
Injury to the tooth supporting structures without abnormal
loosening or displacement of the tooth.
Defining character is marked reaction to percussion.
Radiographic appearance: tooth is found in its normal position In
the socket.
Biological consideration: impact results in injury to the PDL,
including edema and bleeding. Future impact may be damage to
the neurovascular supply to the pulp.
Treatment
 relief of occlusal interferences
 soft diet for 2 weeks
 monitor pulp response periodically
Expected out come : pulp & PDL
Pulp necrosis - open apices - 0%
- closed apices - 4%
Root resorption is very rare and consist exclusively in surface
resorption
Subluxation
Results from slight injury to the periodontal tissue with a slight
increase in mobility.
There might be HEMORRHAGE FROM THE GINGIVAL SULCUS.
Radiographic appearance: tooth is in its normal position in the
socket.

Biological consideration:
impact results in injury to the PDL ,whereby edema, bleeding and
tearing of PDL fibers may occur.
A secondary effect of the impact may be total or partial rupture of
the neurovascular supply to the pulp.
Treatment -
relief of occlusal interferences
soft diet for two weeks
monitor pulp response periodically
immobilization of 2 weeks for patient comfort
Pulpal complication is rare.
Pulp necrosis - Open apex- 0%
- Closed apex – 15%
Chances of surface resorption.
Extrusive luxation
Defined as an injury whereby the tooth suffers axial displacement
partially out of the socket.

Tooth appears elongated and is usually displaced palatally.The

tooth is very loose with bleeding from the gingival sulcus.

Radiographic appearance: tooth appears dislocated with the

apical part of the socket empty.
Biological consideration.
Impact results in almost disruption of PDL.
Gingival fibers prevent the tooth from being
avulsed
Rupture of apical neurovascular bundle
causing excessive mobility of the tooth and
pulpal infraction.
Negative pulp sensitivity.
 Clinical appearance
Repositioning

Mobility and percussion testing

Applying splinting material

Pulp sensitivity testing and radiographic Polishing the splint

Consists of atraumatic repositioning and fixation(2-3weeks) which
prevents excessive movement during healing period.
Expected outcome : pulp & PDL healing
Pulp necrosis - open apex - 9%
 - Closed apex - 55% (Root canal therapy can be
initiated just prior to splint removal)
Inflammatory resorption can be seen in all stages of root
development in association with pulp necrosis.
 Lateral luxation
lateral eccentric displacement of the tooth in its socket and is
accompanied by communition or fracture of the alveolar bone
plates.
Tooth is displaced in its socket usually in palatal direction.
Tooth is immobile due to its locked position in the socket and
there is high ankylotic percussion note.
There may be bleeding from gingival sulcus.
The root apex can be palpated in the sulcus area
Radiographic appearance- tooth appears displaced with the apical
or lateral part of the socket empty.
Biological consideration:
Injury similar to extrusive luxation.
It is further complicated by the presence of a fracture of the labial
bone as well as a compression zone in the cervical area palataly.
Treatment principles implies repositioning to facilitate pulpal and
periodontal healing and the tooth should be splinted during the
healing period due to marked remodeling process
Treatment
Local anaesthetic administered
Tooth repositioned by placing coronal and palatal pressure on the apical
root with index finger and labial pressure on the palatal aspect of the crown
with the thumb.
Splinting with an acid etch technique for three weeks.
Clinical and radiographic follow up should be done periodically for signs of
marginal or periradicular breakdown. if these signs are present then
splinting should be maintained for another 3-4 weeks.
Expected outcome: pulp & PDL healing
Pulpal necrosis: Open apex- 9%
 Closed apex- 77%
Root canal therapy should be initiated prior to splint removal.
Due to compression to the PDL ,both inflammatory and
replacement resorption may occur.
INTRUSIVE LUXATION
This type of luxation the tooth is forced into the socket an locked
in position in bone.
Crown of the tooth appears shortened.
There is bleeding from the gingiva. The percussion tone is high
and metallic. High ankylotic tone is usually the pathognomonic
feature for diagnosis .
Radiographic appearance: tooth appears dislocated in an apical
direction with partial disappearance of the space.
Biological consideration:

Disruption of the marginal gingival seal

Contusion of the alveolar bone
Disruption of PDL cementum and disruption of neurovascular supply
to the pulp.
Optimal PDL healing is dependent on the presence of large
noninjuried areas of PDL which is usually not the case after intrusion.
Bone will therefore often replace the PDL and result in ankylosis
Treatment
Depends entirely upon the stage of root development

Immature root formation

spontaneous re eruption can be anticipated

luxation of the tooth slightly with the forceps done if no signs
of re-eruption after 10 days
pulpal healing is monitored during the period of re-eruption at
3, 4, 6 weeks after injury
in case of negative response of the pulp or periapical
Completed root development
spontaneous re-eruption is unpredictable
orthodontic extrusion is indicated over a period of 2-3 weeks
prophylactic endodontic therapy is indicated as frequency of pulp
necrosis is found in 100% of cases

Expected outcome:
Pulpal necrosis- Open apex- 63%
 Closed apex – 100%
External surface ,inflammatory and replacement resorption are
very frequent findings ,especially in teeth with complete root
development. severe complication can be seen as late as 5-10 years
after trauma.
AVULSION
In this type of trauma the tooth is displaced totally out of its
socket. Clinically the socket is found empty or filled with a
coagulum.
Radiographic appearance: the socket is empty; fracture lines in
the socket may be present.
0.5-16% in permanent dentition
7-13% in primary dentition
Biological consideration:

PDL pulp the avulsed tooth begin to suffer ischemic injury which is soon aggravated by
drying , exposure to bacteria or chemical irritants.

Treatment out come is strongly dependent on the length of dry extra-alveolar period
and storage media.

If the extra alveolar period is less than 1 hour complete or partial PDL healing is
possible.

PDL death can be expected after more than 1 hour of drying and progressive root
resorption will result.
Treatment strategies-
Limiting the extent of periradicular inflammation .
Allow favorable ( cemental) rather than unfavorable ( osseous
replacement or inflammatory resorption ) healing.
Treatment objectives-
Avoid attachment damage.
Avoid pulpal infection.
Clinical management--
Emergency treatment at the accident site.
Management in the dental office.
Emergency treatment at the accident site.
Replant if possible or place in an appropriate storage media.
Single most important factor to ensure a favorable outcome after
replantation is the speed with which the tooth is replanted. Every
effort should be made to replant the tooth in 15-20 min.
Storage media:
 Milk
 patients own saliva or place it in the vestibule of the mouth
water (least desirable medium).
Storage medium
Hank’s balanced salt solution
pH – 7, Osmolarity - 270 – 290 m Osm / litre
(appropriate for cell growth, non toxic and
contain essential nutrients)
Shelf life – 2 years

Save-A-Tooth® EMT ToothSaver™

Dento-Safe ® is an tissue culture
medium which contain dexamethsone.
Teeth can be stored for 20 min
Milk -
The improved viability of cells stored in milk may be caused by;
Physiological osmolarity of milk
Cyto-protective effects of other nutrients constituent.
pH buffering system in which cells can survive for long periods of time.
Milk with lower fat content may be more appropriate at maintaining cell
viability.
Ice cold milk acted as more suitable storage medium
Contact Lens Solution-
They contain buffered isotonic saline solutions with the addition
of preservatives.
Storage in contact lens solution has shown to be better than milk
at room temperature.
Propolis
It is an antibacterial and anti-inflammatory resionous bee hive
product .
Demonstrated more viable PDL cells than either HBSS milk or
saline.
Viaspan
Cold storage medium – Organ transplantation
pH – 7.4, Osmolarity – 320 m Osm / Litre
Superior long term storage medium
37.6 % vitality of fibroblast after 168 hrs
 76.7% of PDL cells after 24 hrs
Gotorade®
Oral rehydration fluid.
Potential transport medium that is commonly found at atheletic
field.
pH -3 , Osmolarity – 280 to 360 mOsm/l.
Preserved significantly more cells than water .
Management in the dental office
Preparation of the socket
Preparation of root.
Replant.
Functional splint.
Local and systemic antibiotics
Preparation of the socket
 Facial and palatal palpation to check for any collapse of socket.
 Socket is gently rinsed with saline.
 Palpation of the socket and surrounding apical areas and pressure on
the surrounding teeth are used to ascertain if alveolar fracture
 Preparation of the root
Depends on the maturity of the tooth
Open apex Vs closed apex
Extra oral dry time of the tooth.
Extra oral dry time < 60 min
Closed apex
A dry time of less than 15-20 min is considered optimal where
periodontal healing would be expected.
 Tooth should be held by the crown
 Irrigated with sterile saline
 Replanted with gentle digital pressure.
 Clinical appearence Replant

Semi- rigid splint

Gentle rinse the tooth surface

Flush the socket coagulum with saline Follow up

 Extra –oral dry time> 60 min (closed apex)
When the root has been dry for 60 min or more the periodontal ligament cells
are not expected to survive. In these cases the root should be prepared to be
resistant to resorption.
Preparation of root surface-
Eliminate the necrotic tissue from the root surface
mechanically-curettage
Chemically- EDTA, citric acid, sodium hypochlorite
Hold the tooth by the crown and irrigate the root surface with sterile saline.
Soak the tooth in a 2% stannous flouride for 5 min and replanted
Clinical picture

Splinting

Preparation of root

Follow up
Endodontic therapy

Preparation of the socket

Extra –oral dry time> 60 min (open apex)
Replant?
If yes treat as closed apex tooth. Endodontic treatment out of the
mouth.
Pediatric dentists consider prognosis to be poor and potential
complication of ankylosed tooth so severe that they recommend
that these teeth are not replanted.
Splinting :
semi rigid fixation for 7 -10 days
New titanium trauma splint has been shown to be effective.
 Adjunctive therapy
Systemic antibiotic - to avoid infection during the first week after
replantation

 Amoxicillin- Adult 500mg x3/day for 7 days

Children-50mg/kg in divided doses every 8

hrs

Doxycycline 100mg x 2/day for 7 days

Tetracycline has the additional benefit of decreasing root

resorption by affecting the motility of the osteoclasts and reducing
the effectiveness of collagenase.
SPORTS DENTISTRY
Protection equipment for prevention of dental traumatic injuries

Mouth guards
Helmets Face masks
 Mouth guards-

Designed to protect the lips and intraoral soft tissues from bruises
and laceration; protect the teeth from various luxation injuries .

 Classification (According to the American society for testing

and materials 1986).
Type I : stock mouth guards.
Type II : mouth formed mouth guards.
Type III: custom fabricated.
Stock mouth guard-

Preformed rubber or polyvinyl type polymer

Inexpensive and ready to use without modifications
Least protective due to poor fit .
Less comfort to wear.
Can interfere with athlete’s ability to breathe and speak and often cause
the athlete to gag.
Mouth formed mouth guards-
Intermediate between the stock and custom fabricated types.
Two types: shell lined & boil and bite.
Shell lined variety
Is fabricated by placing freshly mixed ethyl methacrylate in to
hard shell which is then inserted into athletes mouth until material
sets.
Often to bulky and uncomfortable.
Termoplastic boil –and –bite variety
Fabricated by placing the mouth guard form into boiling water to
soften the material. The softened material is then placed into
Custom-fabricated mouth guards-

Custom made professionally over a dental cast of the athlete arch

(mainly in case of malocclusion).
Superior adaptation and retention, interfere least with breathing
and speech.
Technique for fabrication- vacuum forming technique, heat
pressure technique.

Vacuum forming technique

Heat pressure technique.Polyvinyl acetate sheets
CONCLUSION

Trauma to teeth is a common occurrence that every dental

surgeon must be prepared to assess, evaluate and treat when
necessary.
Tooth trauma leaves not only physical permanent scars but also
psychological impact on its victims. Understanding the basic
principles and therapeutic protocols can help to provide the
appropriate treatment and prevent the complication. A simple
enamel fracture to an avulsed tooth can be restored or put back in
it’s socket now with excellent post operative results.
THANK YOU
REFERENCES

Cohen’s- Pathways of the pulp, 11th edition

Ingle’s endodontics, 5th edition

Grossman’s endodontic practice, 12th edition

Textbook and color atlas of traumatic injuries to teeth by

Andreasan

Dentistry for Child and Adolescent- Mc Donald