traumatic injuries of teeth

TRAUMATIC INJURIES OF

TEETH

Prepared by:Dr. Rea Corpuz

Case History

Chief complaint

History of present illness

Medical History

Traumatic Injuries of Teeth

Clinical Examination

External Examination

Soft Tissues

Facial Skeleton

Teeth and Supporting Structures


Radiographic Examination

Periapical

Occlusal

Panoramic


(1) Concussion

(2) Luxation

(3) Fracture


tooth is not mobile

not displaced

periodontal ligament (PDL) absorbs injury + inflammed

leaves tooth tender to biting pressure + percussion

Concussion

Visual sign:

not displaced

Percussion test:

tender to touch or tapping

Mobility test:

no increased mobility

Concussion

Pulp Sensibility Test:

positive result

it is important in assessing future risk of healing complications

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

Concussion

Radiographic findings:

no radiographic abnormalities

Radiographs:

occlusal periapical lateral view from mesial + distal aspect of tooth in question

Concussion

Treatment Objectives:

usually there is no treatment

Treatment:

monitor pulpal condition for at least 1 year

Concussion

Patient Instructions:

soft food for 1 week

brush with soft bristle

rinse with chlorhexidine 0.1% to prevent plaque accumulation

Concussion

tooth is displaced in a labial, lingual or lateral direction

PDL is usually torn

fractures of supporting alveolus may occur

Luxation

similar to extrusion injuries

partial or total separation of periodontal ligament

Luxation

Visual sign:

displaced, usually in a palatal/lingual or labial direction

Percussion test:

usually gives a metallic (ankylotic) sound

Mobility test: usually immobile

No increased mobility

Luxation

Pulp Sensibility Test:

likely give a lack of response except for teeth with minor displacement

test is important in assessing risk of healing complications

positive result at the initial examination indicates a reduced risk of future pulp necrosis

Luxation


widened periapical ligament space best seen on occlusal or eccentric exposures

Radiographs:

occlusal periapical lateral view from mesial + distal aspect of tooth in question

Luxation

Treatment Objective:

reposition + splint a displaced tooth to facilitate pulp + periodontal ligament healing

Luxation

Treatment:

rinse the exposed part of root surface with saline before repositioning

apply local anesthesia

reposition tooth with forceps or with digital pressure to disengage it from its bony socket

Luxation

Treatment:

gently reposition it into its original position

stabilize the tooth for 4 weeks using a flexible splint

4 weeks is indicated due to associated bone fracture

Luxation

Patient Instructions:

soft food for 1 week

brush with soft bristle

rinse with chlorhexidine 0.1% to prevent plaque accumulation

Luxation

Ellis and Davey classification of crown fracture is useful in recording extent of damage to crown

Class I – simple fracture of crown involving little or no dentin

Class II – extensive fracture of crown involving considerable dentin but not dental pulp

Fracture

Class III – extensive fracture of crown with an exposure of dental pulp

Class IV – loss of entire crown

Fracture

Enamel Fracture

Enamel-Dentin Fracture

Enamel-Dentin-Pulp Fracture

Root Fracture

Fracture

fracture confined to the enamel with loss of tooth structure

Enamel Fracture

Visual sign:

visible loss of enamel

no visible sign of exposed dentin

Percussion test:

not tender if tenderness is observed evaluate tooth for a possible luxation or root fracture injury

Enamel Fracture

Mobility test:

normal mobility

Sensibility test:

usually positive

test may be negative initially indicating transient pulpal damage

Enamel Fracture

Sensibility test:

monitor pulpal response until definitive pulpal diagnosis can be made

test is important in assessing risk of future healing complications

lack of response at initial examination indicates an increased risk of later pulpal necrosis

Enamel Fracture


enamel lost is visible

Radiographs:

occlusal periapical recommended to rule out possible presence of root fracture or a luxation injury

Enamel Fracture

Treatment:

if tooth fragment is available, it can be bonded to the tooth

grinding or restoration with composite resin depending on extent + location of fracture

Enamel Fracture

fracture confined to enamel + dentin with loss of tooth structure, but not involving pulp


Visual sign:

visible loss of enamel + dentin

no visible sign of exposed pulp tissue

Percussion test:



Mobility test:

normal mobility

Sensibility test:

usually positive

test may be negative initially indicating transient pulpal damage


Sensibility test:

monitor pulpal response until definitive pulpal diagnosis can be made





enamel-dentin lost is visible

Radiographs:

occlusal periapical recommended to rule out displacement or possible presence of root fracture


Treatment:

if tooth fragment is available, it can be bonded to the tooth

otherwise perform provisional treatment by covering exposed dentin with glass ionomer or a permanent restoration using a bonding agent + composite resin


(Complicated Crown Fracture)

a fracture involving enamel + dentin with loss of tooth structure + exposure of pulp


Visual sign:

visible loss of enamel + dentin

exposed pulp tissue

Percussion test:



Mobility test:

normal mobility

Sensibility test:

usually positive


Sensibility test:





lost of tooth substance is visible

Radiographs:

occlusal periapical recommended to rule out displacement or possible presence of luxation or root fracture


Treatment:

if 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

this treatment is also treatment of choice in patients with closed apices


Treatment:

Calcium hydroxide compunds + MTA are suitable materials for such procedures

in older patients with closed apices + luxation injury with displacement, root canal treatment is usually treatment of choice


fracture involving:

enamel dentin cementum with loss of tooth structure but not exposing pulp

Crown-Root Fracture without pulp involvement

Visual sign:

crown fracture extending below gingival margin

Percussion test:

tender


Mobility test:

coronal fragment mobile

Sensibility test:

usually positive for apical fragment



apical extension of fracture usually not visible

Radiographs:

occlusal periapical recommended to detect fracture lines in root cone beam exposure can reveal whole fracture extension


Treatment:

Fragment removal only

• removal of superficial coronal crown-root fragment

• subsequent restoration of exposed dentin above gingival level


Treatment:

Fragment removal + gingivectomy (sometimes ostectomy)

• removal of coronal segment with subsequent endodontic treatment + restoration with a post-retained crown


Treatment:

Orthodontic extrusion of apical fragment

• removal of coronal segment with subsequent endodontic treatment + orthodontic extrusion of remaining root with sufficient length after extrusion to support a post- retained crown


Treatment:

Surgical extrusion

• removal of mobile fractured fragment

• subsequent surgical repositioning of root in a more coronal position


Treatment:

Decoronation (root submergence)

• implant solution is planned, root fragment may be left in situ after in order to avoid alveolar bone resorption

• thereby maintaining volume of alveolar process for later implant installation


Treatment:

Extraction

• with immediate or delayed implant-retained crown restoration or a coventional bridge

• fractures with severe apical extension, the extreme being a vertical fracture


fracture involving:

enamel dentin cementum with loss of tooth structure exposure of pulp

Crown-Root Fracture with pulp involvement

Visual sign:

crown fracture extending below gingival margin

Percussion test:

tender


Mobility test:

coronal fragment mobile

Sensibility test:

usually positive for apical fragment



apical extension of fracture usually not visible

Radiographs:

occlusal periapical cone beam exposure can reveal whole fracture extension


Treatment:

Fragment removal + gingivectomy (sometimes ostectomy)

• removal of coronal segment with subsequent endodontic treatment + restoration with a post-retained crown


Treatment:

Orthodontic extrusion of apical fragment

• removal of coronal segment with subsequent endodontic treatment + orthodontic extrusion of remaining root with sufficient length after extrusion to support a post- retained crown


Treatment:

Surgical extrusion

• removal of mobile fractured fragment

• subsequent surgical repositioning of root in a more coronal position


Treatment:

Decoronation (root submergence)

• implant solution is planned, root fragment may be left in situ after in order to avoid alveolar bone resorption

• thereby maintaining volume of alveolar process for later implant installation


Treatment:

Extraction

• with immediate or delayed implant-retained crown restoration or a coventional bridge

• fractures with severe apical extension, the extreme being a vertical fracture


fracture confined to the root of tooth involving:

cementum dentin pulp

Root Fracture

Visual sign:

coronal segment may be mobile

some cases displaced

transient crown discoloration (red or gray) may occur

bleeding from gingival sulcus may be noted

Root Fracture

Percussion test:

tooth may be tender

Mobility test:

coronal segment may be mobile

Root Fracture

Sensibility test:

the test is important in assessing risk of healing complications

a positive sensibility test at the initial examination indicates a significantly reduced risk of later pulpal necrosis

Root Fracture

Sensibility test:

may give negative results initially

indicating transient or permanent neural damage

pulp sensibility test is usually negative for root fractures except for teeth with minor displacements

Root Fracture


root fracture line is usually visible

fracture involves root of the tooth in a horizontal or diagonal plane

Root Fracture

Treatment:

rinse exposed root surface with saline before repositioning if displaced, reposition the coronal segment of the tooth as soon as possible

check that correct position has been reached radiographically

Root Fracture

Treatment:

stabilize the tooth with flexible splint for 4 weeks

if the root fracture is near cervical area of the tooth stabilization is beneficial for a longer period of time (upto 4 months)

Root Fracture

Treatment:

monitor healing for at least 1 year to determine pulpal status

if pulp necrosis develops, then root canal treatment of the coronal tooth segment to the fracture is indicated

Root Fracture

References:References:

BooksBooks

McDonald, Avery et al: Dentistry for theMcDonald, Avery et al: Dentistry for the Child and AdolescentChild and Adolescent

• (pages 458-459)(pages 458-459)

InternetInternet

http://www.dentaltraumaguide.orghttp://www.dentaltraumaguide.org

traumatic injuries of teeth

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