injuries to permanent teeth. clinical features, diagnosis

Injuries to permanent teeth. Clinical features, diagnosis and treatment

Epidemiology in permanent dentition:

In the permanent dentition, the most accident-prone time is between 8 and 10 years of age.

Boys appear to sustain injuries to permanent teeth twice as often as girls.

Falls during play account for most injuries to young permanent teeth.

In the teenage years, automobile accidents cause a significant number of dental injuries

Dental injuries usually affect one or two of the anterior teeth, and especially the maxillary central incisors

Distribution of injuries in permanent dentition

The most frequently

injured permanent

teeth:

97% of all injuries

affected the

incisors.

Important for permanent teeth!

The most common age of trauma is between 8 -10 years.

This implies that a traumatized tooth most often has:

an open apical foramen,

a wide root canal,

and fragile dentinal walls in the cervical area.

If pulp necrosis develops:

No further dentin apposition occurs

The root development is stopped

There is a considerable risk of spontaneous root fracture cervically with subsequent loss of the injured tooth

root:crown ratio is disturbed

The primary concern is to maintain pulp vitality to allow continued root formation including physiologic dentin apposition in the critical cervical area.

Injuries to

the

periodonal

tissues

Concussion

An injury to the tooth-supporting structures:

without increased mobility or displacement

of the tooth

but with pain to percussion.

Concussion:

The neurovascular supply is usually intact

In a few areas bleeding edema

In most areas the periodontal ligament is

without damage

Diagnostic signs

Visual signs

Percussion test

Mobility test

Pulp sensibility test

Radiographic findings

Radiographs recommended

Not displaced.

Tender to touch or tapping.

No increased mobility.

Usually a positive result.

No radiographic abnormalities, the tooth is in-situ in its socket.

Occlusal, periapical exposure and lateral view from mesial or distal aspect of the tooth. This should be done in order to exclude displacement.

The test is important in assessing future risk of healing complications. A

lack of response to the test indicates an increased risk of later pulp

necrosis.

Reaction to sensibility tests

• We must test all neighbor teeth and these from other jaw in the traumatized area

The contralateral uninjured tooth or another comparable tooth serves as a control.

• It is important to explain the purpose of the test and the type of reaction to be expected.

The most reliable response is obtained when the electrode is placed upon the incisaledge.

Treatment Guidelines

Usually there is no need for treatment.

• Soft food for 2 weeks.

• Good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Patient instructions

• Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year.

• Monitor pulpal condition for at least 1 year.

Follow-up

Concussion Luxation Injury

Least severe of Luxation injuries

VI!!! Assess vitality in 4 wks

Relieve from occlusion, splinting is not usually required

Checking pulpal status, colour, mobility and radiographically assessing changes in the size of the pulp chamber and in root development.

Subluxation

An injury to the tooth supporting

structures resulting:

in increased mobility

without displacement of the tooth

bleeding from the gingival sulcus

confirms the diagnosis.

Subluxation:

Damage may have happened to the

neurovascular supply

In many areas separation of periodontal

ligament with interstitial bleeding and edema

Some areas have undamaged periodontal

ligament

Loosening of the tooth

Diagnostic signs

Visual signs

Percussion test

Mobility test


Not displaced.

Tender to touch or tapping.

Increased mobility.

Sensibility testing may be negative

initially indicating transient pulpaldamage. Monitor pulpal response until a

definitive pulpal diagnosis can be made

➢ Positive sensibility test result in about half the cases. The

test is important in assessing future risk of healing

complications. A lack of response at the initial test

indicates an increased risk of later pulp necrosis.

Diagnostic signs

• Radiographic

findings

Radiographs

recommended

Usually no radiographic

abnormalities.

Occlusal, periapical

exposure and lateral view

from the mesial or distal

aspect of the tooth.

Treatment Guidelines

A flexible splint to stabilize the tooth for

patient comfort can be used for up to 2

weeks.


Soft food for 2 weeks.

Good oral hygiene. Brushing with a

soft brush and rinsing with

chlorhexidine 0.1 % is beneficial to

prevent accumulation of plaque

and debris.

Follow-up

Clinical and radiographic control at

4 weeks, 6-8 weeks and 1 year.

Subluxation Luxation Injury

Tooth tender to touch and

slightly mobile but not

displaced

Possible hemorrhage from

gingival crevice

VI!!! - Assess vitality in 4

weeks

Partial, axial displacement of the tooth out of its

socket

Partial or total separation of the periodontal

ligament resulting in loosening and displacement

of the tooth

The tooth appears elongated and is extremely

mobile.

There is also bleeding from the gingival sulcus

Extrusion

Extrusion

Severance of neurovascular pulp supply

Separation of periodontal ligament

Coronal exposure of root surface

Diagnostic signs

Visual signs

Percussion test

Mobility test


Appears elongated.

Tender.

Excessively mobile.

Usually lack of response except for

teeth with minor displacements.

The test is important in assessing risk

of healing complications. A

positive result to the initial test

indicates a reduced risk of later

pulp necrosis.

In immature, not fully developed teeth, pulpal

revascularization usually occurs.

Diagnostic signs

• Radiographic findings

Radiographs

recommended

Increased periapical

ligament space.

Occlusal, periapical

exposure and lateral view

from the mesial or distal


Treatment

The exposed root surface of the displaced tooth is cleansed with saline before repositioning.

Reposition the tooth by gently re-inserting it into the tooth socket with axial digital pressure (local anesthesia is usually not necessary).

Stabilize the tooth for 2 weeks using a flexible splint.

Monitoring the pulpal condition is essential to diagnose associated root resorption.

TreatmentPatient instructions

Soft food for 2 weeks.

Good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

Clinical and radiographic control and splint removal after 2 weeks.

Clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months, and 1 year.

Lateral luxation

Lateral luxation implies displacement in a palatal, buccal, mesial, or distal direction accompanied by comminution or fracture of the alveolar socket.

Most often, a palatal luxation occurs

The apex is then displaced in the opposite direction and usually forced through the buccal bone.

Lateral luxation

Severance of neurovascular pulp supply

Entrapment of apex

Fracture of labial bone plate

Severance of periodontal ligament

Compression of periodontal ligament

Lateral luxation

Consider the need for local

anesthesia.

Reposition the tooth gently with

finger pressure on the incisal

edge.

Check the position

radiographically.

Stabilize the tooth with a flexible

splint.

Maintain the splint for 2 - 4

weeks.

Lateral luxation – in a palatal direction

Administer local anesthesia.

Palpate the vestibular sulcus, and localize the displaced root apex. Apply firm, digital pressure in an incisal direction and move the tooth back through the fenestration into the socket.

Reposition the tooth back to its original position by axial pressure.

Reposition fractured bone with finger pressure.

Take a radiograph to verify correct position.

Stabilize the tooth with a flexible splint.

Maintain the splint for a minimum of 4 weeks.

Take a radiograph after about 4 weeks. If there are signs of marginal bone breakdown, the splint is maintained for another 3–4 weeks.

Lateral luxation

Monitoring the pulpal condition is essential to diagnose root resorption.

VI!!! Assess vitality in 4 weeks

If the pulp becomes necrotic, root canal treatment is indicated to prevent infection related root resorption.


Soft food for 1 week.

Good oral hygiene.

Follow-up

Clinical and radiographic control after 2 weeks.

Clinical and radiographic control and splint removal after 4 weeks.

Clinical and radiographic control at 6-8 weeks, 6 months, 1 year and yearly for 5 years.

Intrusion - Intrusive luxation

Displacement of the tooth into the alveolar bone.

This injury is accompanied by

comminution or fracture of the alveolar

socket.

Disruption of neurovascular pulp supply

Contusion of the periodontal ligament

and alveolar bone

Laceration of the periodontal ligament

Disruption of marginal gingival seal

Diagnostic signs

Visual signs

Percussion test

Mobility test


The tooth is displaced axially into the

alveolar bone. Tooth appears shorter

Usually gives a high metallic (ankylotic)

sound.

The tooth is immobile

Sensibility test will likely give negative

results

Diagnostic signs

• Radiographic findings

Radiographs

recommended

The periodontal ligament space may be

absent from all or part of the root.

The cemento-enamel junction is located

more apically in the intruded tooth than

in adjacent non-injured teeth

Occlusal, periapical exposure and

lateral view from the mesial or distal


Intrusion - Treatment

Most severe of luxations

Tooth intrusion is associated with a potential risk of tooth loss

due to progressive root resorption (ankylosis or infection related resorption)

Pulp necrosis is all but certain in mature teeth

Factors determining treatment choice are:

Stages of root development,

Age

Intrusion level.

Degree of

intrusionRepositioning

Spontaneous Orthodontic Surgical

OPEN APEX

Up to 7 mm x

More than 7

mmx x

CLOSED

APEX

Up to 3 mm x

3-7 mm x x

More than 7

mmx

Treatment



Good oral hygiene.

Follow-up

Control after 2 weeks.

Control after 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years

In all LUXATION and especially INTRUSIONinjuries, the apical neurovascular bundle and attachment apparatus will be affected to some degree>>>loss of vitality & internal/external resorption

Treatment:

Common for all treatments

Endodontic treatment can prevent the

necrotic pulp from initiating infection-

related root resorption.

This treatment should be considered in all

cases with completed root formation

where the chance of pulp

revascularization is unlikely.

Endodontic therapy should preferably be

initiated within 3-4 weeks post-trauma.

A temporary filling with calcium

hydroxide is recommended.

Avulsion

The tooth is completely displaced out

of its socket.

Clinically the socket is found empty or

filled with a coagulum.

Severance of neurovascular pulp

supply

Separation of periodontal ligaments

Separation of periodontal ligaments

and exposure of root surface

Diagnostic signs

Visual signs

Percussion test

Mobility test

Sensibility test

Radiographic

findings

The tooth is removed from its socket

Not indicated.

Not indicated.

Not indicated.

Occlusal radiograph - If the visual

appearance of the injury raises

suspicion of a possible intrusion, root

fracture, alveolar fracture or jaw

fracture

Avulsed Permanent Teeth

Incidence

0.5% to 16% of traumatic injuries

Main etiologic factors

Fights

Sports injuries

Automobile accidents

Avulsed Permanent Teeth

• Most commonly avulsed tooth

Maxillary central incisor

• Seldom affected

Mandibular teeth

Most frequently involves a single tooth

• Permanent incisors erupting

• Loosely structured PDL

Most common age - 7 to 11

Treatment Considerations

Extraoral time

Extraoral environment

Root surface manipulation

Management of the socket

Stabilization

Extraoral Time

Shorter time = Better prognosis*

< 30 min → 10% resorption

> 90 min → 90% resorption

*depending on storage medium

Storage Medium

Poor results

Tap Water

Dry

Good protection for 2 hrs

Saliva

Saline

Milk as a Storage Medium

Physiologic osmolality

Markedly fewer bacteria

than saliva

Readily available

15 to 20 minutes seems to be

the limit of drying of an

avulsed tooth to avoid root

resorption

Avulsion: replantation at the site of injury

The best advice

Pick up the tooth by the crown.

Avoid touching the root.

Push the tooth back in place as quickly as possible.

The next best advice

Place the tooth in the child’s mouth between the teeth and the cheek

If this is not possible put the avulsed tooth in a glass of milk.

In all instances dental aid should be sought immediately.

Avulsion: replantation in a dental clinic. The extraoral dry time is less than 60 min

PulpIn teeth with open apex, pulp revascularization is possible, and will be optimized with topical antibiotic treatment - cover the root surface with minocycline hydrochloride (Arestin®, OraPharma Inc.,)

Examine the socket

If there is a fracture of the socket wall, reposition it with a suitable instrument.

Remove the coagulum from the socket with a stream of saline.

Rinsethe root surface and the apical foramen with a stream of saline, and place the tooth in saline.

Consider the need for local anesthesia.


Replant the tooth slowly with gentle finger pressure.


Check position of the replanted tooth both clinically and radiographically.

Suture any gingival lacerations.

Administer systemic antibiotics for a week.

Amoxicillin or clindamycin


Consult a physician for evaluation of the need for tetanus prophylaxis.

Instruct the patient to use 0.1% chlorhexidine mouthrinse twice daily for a week.

Remove the splint after 1–2 weeks.

A short splinting time favors both periodontal and pulpal healing

whereas a rigid long-term splinting leads to dentoalveolar ankylosis.

Endodontic considerations

Avulsion: replantation in a dental clinic. The extraoral dry time is longer than 60 min

The long-term prognosis is poor.

Ankylosis with subsequent root resorption is the expected outcome.

Fluoride treatment of the root surface will delay progress of the resorption.

Remove attached necrotic soft tissue from the root surface with wet gauze.

Immerse the tooth in a 2% sodium fluoride solution for 20 min.


Administer local anesthesia.

Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.

Replant the tooth slowly with gentle finger pressure.



Check position of the replanted tooth both clinically and radiographically.

Suture any gingival lacerations.

Administer systemic antibiotics

Consult a physician for evaluation of the need for tetanus prophylaxis

Instruct the patient to use 0.1% chlorhexidine mouthrinse twice daily for a week.

Remove the splint after 4 weeks.

Endodontic considerations

Endodontic treatment

Mature root apex

Endodontic treatment should always be

started after 7–10 days and prior to removal of

the splint.

The canal is filled temporarily with calcium

hydroxide paste.

The root canal filling should be completed

after 6–12 months.

Endodontic treatment

Immature root apex

In teeth with a wide-open apical foramen, revascularization of the pulp may occur and endodontic treatment is postponed.

These teeth must be followed closely.

With definite signs of necrosis such as apical radiolucency and/or external inflammatory root resorption, endodontic treatment should be started immediately.

It is recommend that a replanted tooth with incomplete root formation is examined radiographically every second week until:

pulp necrosis is confirmed

or continued root formation is evident

Avulsion

Generally, it is best to always replant

teeth even if they have a poor prognosis.

With appropriate treatment, these teeth:

will be lost by progressive replacement

resorption

the positive benefit being that

alveolar height is maintained.

In the young permanent dentition, a

replanted tooth prevents horizontal and

vertical bone loss and facilitates later

alternative treatment - orthodontic

closure, or dental implants.

Injuries to

hard dental

tissues and

pulp

Important!!!

It is most important to

diagnose concomitant

periodontal injuries, since the

risk of complications to crown

fractures is significantly

increased with an additional

luxation injury!

Enamel infraction

▪ An incomplete fracture

(crack) of the enamel

without loss of tooth

structure.

▪ Fracture lines in enamel

Diagnostic signs

Visual signs

Percussion test

Mobility test


A visible fracture line on the surface of the tooth Infraction lines are best seen when the light beam is directed parallel to the long axis of the tooth.

Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.

Normal mobility.

Usually a positive. A lack of response to the test indicates an increased risk of later pulp necrosis

Treatment

Treatment

In case of marked infractions, etching and

sealing with resin to prevent discoloration

of the infraction lines.

Otherwise no treatment is necessary.

Follow-up

No follow-up is needed for infraction

injuries unless they are associated with a

luxation injury or other fracture types

involving the same tooth.

Enamel fracture

Fracture restricted to enamel

with loss of tooth structure.

Diagnostic signs

Visual signs

Percussion test

Mobility test


Radiographic findings

Radiographs

recommended

Visible loss of enamel. No visible sign of exposed dentin

Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.

Normal mobility.

Usually a positive. Monitor pulpalresponse until a definitive pulpaldiagnosis can be made.

The enamel loss is visible.

Periapical, occlusal view – for possible presence of a root fracture or a luxation injury

TREATMENT

If a tooth fragment is available, it can be bonded to the tooth.

Grinding or restoration with composite resin depending on the extent and location of the fracture.

Radiographic examination to rule out luxation injuries or root fractures.

Follow-up

Clinical and radiographic control at 6-8 weeks and 1 year.

ENAMEL-DENTIN FRACTURE

A fracture involves enamel and dentin

with loss of tooth structure,

but not involving the pulp.

Treatment

The fracture involving dentin results in

exposure of dentinal tubules to the

oral environment.

If the dentin is left unprotected,

bacteria or bacterial toxins may

penetrate the tubules, resulting in

pulpal inflammation.

Although the inflammation may be

reversible, pulp necrosis is also a

possible outcome.

The pulp should be protected against

external irritants as quickly as possible.

Treatment Perform a provisional treatment by covering the

exposed dentin with GIC.

After 1 month:

A permanent restoration using a bonding agent and composite resin.

If a tooth fragment is available (and if it is stored properly), it can be bonded to the tooth.

When there is an associated luxation injury, which requires immediate fixation – the procedure is to cover exposed dentin with calcium hydroxide and GIC.

Radiographic examination should be used to rule out displacement or fracture of the root.

FOLLOW-UP

Clinical and radiographic control at 6-8 weeks and 1 year.

Once per year for next 5 years.

ENAMEL-DENTIN-PULP

FRACTURE (COMPLICATED

CROWN FRACTURE)

A fracture involving enamel

and dentin

With loss of tooth structure

Exposure of the pulp.

DIAGNOSTIC SIGNS

Visual signs

Percussion test

Mobility test

Visible loss of tooth structure

and exposed pulp tissue

Not tender. If tenderness is

observed evaluate the tooth

for luxation or root fracture

injury.

Normal mobility

DIAGNOSTIC SIGNS

Sensibility test

Radiographic

findings

Usually positive. The test is important

in assessing risk of future healing

complications. A lack of response at

the initial examination indicates an

increased risk of later pulp necrosis.

The loss of tooth substance is visible.

They are recommended in order to

rule out displacement or the possible

presence of a luxation or a root

fracture.

The overall aim of the treatment is preservation of a vital noninflamed pulp.

The pulp must be sealed from bacteria so that it is not infected during the period of repair.

In most cases this can be achieved by either pulp capping or partial pulpotomy.

Treatment

Treatment – pulp capping

INDICATIONS

Pulp status normal prior to trauma.

No associated luxation injury with damage to the

apical blood supply.

Pulp exposure less than 1 mm.

Interval between pulp exposure and treatment

less than 24 hours.

Treatment – partial pulpotomy

This treatment implies removal of inflamed pulp tissue.

The level of amputation should be about 2 mm below the exposure site.

Neither size of the exposure nor interval between injury and treatment is critical for the prognosis.

Treatment

In young patients with

open apices, it is very

important to preserve pulp

vitality by pulp capping or

partial pulpotomy in order

to secure further root

development

FOLLOW-UP

Clinical and radiographic

control at 6-8 weeks and 1

year.

Once per year for next 5

years.

A fracture involving

enamel, dentin and

cementum with loss of

tooth structure

but not exposing the pulp.

Crown-root fracture without pulp involvement

DIAGNOSTIC SIGNS

Visual signs

Percussion test

Mobility test

Sensibility pulp test

Radiographic

findings

Crown fracture extending below

gingival margin

Tender

Coronal fragment mobile.

Usually positive for apical fragment.

Apical extension of fracture usually

not visible.

Periapical, occlusal and eccentric

exposures. They are recommended

in order to detect fracture lines in the

root

Crown-root fracture without pulp involvement

Treatment

All of the treatment modalities are

technique sensitive and do not need to

be performed during the acute phase.

Prognosis will not be influenced by delay

of treatment within a time frame of one to

two weeks.

Fragment removal only

Removal of a superficial coronal crown-

root fragment and subsequent restoration

of exposed dentin above the gingival

level.

A fracture involving

enamel, dentin, and

cementum with loss of

tooth structure,

and exposure of the pulp.

CROWN ROOT FRACTURE WITH PULP

INVOLVEMENT

DIAGNOSTIC SIGNS

Visual signs

Percussion test

Mobility test

Sensibility pulp test

Radiographic

findings

Crown fracture extending below

gingival margin

Tender

Coronal fragment mobile.

Usually positive for apical fragment.

Apical extension of fracture usually

not visible.

Periapical and occlusal exposure.

EMERGENCY TREATMENT

As an emergency treatment a temporary stabilization

of a loose segments to adjacent teeth can be

performed until a definitive treatment plan is made.

In young patients with open apices, it is important to

preserve pulp vitality by a partial pulpotomy.

This treatment is also the choice in young patients

with completely formed teeth.

In patients with mature root development root canal

treatment can be the treatment of choice.

DEFINITIVE TREATMENT

Fragment removal and gingivectomy

Orthodontic extrusion of apical

fragment

Surgical extrusion

Extraction

PATIENT INSTRUCTIONS


Good oral hygiene

FOLLOW-UP

6-8 weeks and 1 year.

Root fracture

A root fracture involves

dentin, cementum, and the

pulp.

The coronal fragment may

be extruded or displaced in a

palatal direction.

Root fracture

The neurovascular supply is

usually intact at tooth apex

Rupture of neurovascular

supply at fracture line

Separation of PDL and

exposure of root surface

DIAGNOSTIC SIGNS

Visual signs

Percussion test

The coronal segment may be

mobile and in some cases

displaced. Transient crown

discoloration (red or grey) may

occur. Bleeding from the gingival

sulcus may be noted.

The tooth may be tender.

DIAGNOSTIC SIGNS

Sensibility pulp

test

Radiographic

findings

The pulp sensibility test is usually

negative for root fractures

(indicating transient or permanent

neural damage) except for teeth

with minor displacements.

Monitoring the status of the pulp is

recommended.

The test is important in assessing risk

of healing complications.

The root fracture line is usually visible

Treatment

Treatment consists of immediate

repositioning of the coronal fragment and

stabilization with a flexible splint.

Fixation should also be carried out in cases

without dislocation, as close contact

between the fragments is considered

essential during the period of initial repair

The splint (usually for 4 weeks) should

allow:

sensitivity testing

access to the root canal if endodontic

treatment is required

FOLLOW-UP

In apical third and mid-root fractures -

splint removal and clinical and

radiographic control after 4 weeks.

If the root fracture is near the cervical area

the splint should be kept on for up to 4

months.

Clinical and radiographic control after 6-8

weeks.

Clinical and radiographic control after 4

months.

If the root fracture is near the cervical

area the splint should be removed at

this session.

FOLLOW-UP

Clinical and radiographic control after 6

months, 1 year and yearly for 5 years.

Follow-up may include endodontic

treatment of the coronal fragment if pulp

necrosis develops.

The decision for endodontic treatment

may be taken after three months of follow-

up

if the tooth still does not respond to

electrometric or thermal pulp testing

and if radiographs show a radiolucency

next to the fracture line.

Injuries to developing permanent

teeth

Can be expected in 12 – 69% of primary tooth trauma

and 19 – 68% jaw fractures

Intrusive luxation causes most of disturbances

Avulsion – if the apex moved towards the permanent

tooth before the avulsion

Most damage to the permanent tooth bud occur under

3 years of age – during its development stage

White or yellow-brown

hypomineralization of

enamel

Injuries to developing teeth can be:

Injuries

Displacement and dilaceration of

permanent central incisor,

following avulsion of the primary

precursor tooth.

Ankylosis and

subsequent

infraocclusion is a

significant problem when

permanent teeth are

traumatized.

injuries to permanent teeth. clinical features, diagnosis

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