2Diagnostic steps dental trauma Medical and health historyHistory of the dental injury and immediate care providedNeurologic evaluationClinical examination of the head and neckOral examination of soft and hard tissuesRadiographic examinationPhotographic documentation
3HISTORY When With time blood clots begin to form, periodontal ligaments of teeth dry out, and saliva contaminatesthe woundHow Locating specific injuries, and cause will give info about severityWhere Prophylactic tetanus toxoid, insurance and litigation
4Clinical Examination Chief Complaint Pain and bleeding Don't fit together now Possible displacements or a bone fracturePain on closure Crown, root, or bone fracturesNeurologic ExaminationHead and neck injuries?Patient is communicating?Ringing in the ears?Paresthesia of the lips or Tongue?Referred immediately for appropriate medical treatment.External ExaminationExternal signs of injuryLacerations of the head and neck(TMJ) should be palpated externally while the patient opens and closes.Zygomatic arch, angle, and lower border of the mandible palpated and note made of any areas of tenderness, swelling, or bruising of the face, cheek, neck, or lips for possible bone fractures.
5Clinical Examination Cont…. Hard-Tissue ExaminationAfter visual examination and abnormal findings are noted, radiographs of the injured areas should be takenThermal and Electric TestsTraumatized tooth vulnerable to false negative readings from these testConduction capability of the nerve endings or sensory receptors or both is sufficiently deranged to inhibit the nerve impulse from an electric/thermal stimulusTeeth that yield a negative response (or no response) cannot be assumed to have necrotic pulps, because they may give a positive response laterTransition from a negative to a positive response at a subsequent test may be considered a sign of a healthy pulpThe persistence of a negative response would suggest that the pulp has been irreversibly damagedTests should be repeated at 3 weeks; 3, 6, and 12 months; and at yearly intervals after the accidentRadiographic ExaminationsRoot fractures, subgingival crown fractures, tooth displacements, bone fractures, or foreign objectsSoft-tissue laceration it is advisable to radiograph the injured area before suturing to be sure that no foreign objects have been embedded
6PREVENTION OF DENTAL INJURIES Face GuardsCage-type guards attached to helmetFace guards of clear polycarbonate plasticMouth GuardsStock mouth guardBoil-and bite mouth guardCustom-made mouth guard
9The Ellis Classification Enamel FractureDentin Fracture without Pulp ExposureCrown fracture with Pulp ExposureRoot FractureTooth LuxationTooth Intrusion
10INJURIES TO PERIODONTAL TISSUE ConcussionSubluxationExtrusive LuxationLateral LuxationIntrusive LuxationAvulsionNo loosening but pain on percussionAbnormal loosening but no displacementPartial displacement from socketDisplacement other than axially withcommunication or fracture of alveolar socketDisplacement into alveolar bone withcommunication or fracture of alveolar socketComplete displacement of tooth from socket
11Injuries to Gingiva or Oral Mucosa LacerationWound in mucosa resulting from TearContusionBruise not accompanied by break, causing sub mucosal haemorrhageAbrasionSuperficial wound results from rub or scrap
12CROWN INFRACTIONA crown infraction is an incomplete fracture of enamel without loss of tooth structure.Biologic Consequences:"weak points" through which bacteria and their by- products can travelDiagnosis and Clinical Presentation:Indirect light or transilluminationRoutine examinationTreatmentinvolves establishing a baseline pulp status with routine sensitivity testing.Follow-UpThe clinician should schedule follow-up examinations at 3,6, and 12 months and annually thereafter.
13Photograph of traumatized tooth illuminated with a resin curinglight. Enamel craze lines are clearly visible
14UNCOMPLICATED CROWN FRACTURE An uncomplicated crown fracture is a fracture of the enamel or the enamel and dentin without pulp exposure.If the fracture involves the enamel only, the consequences are minimalIf dentin is exposed a direct pathway exists for noxious stimuli to pass through the dentinal tubules to the pulpThe reaction of the pulp depends on a number of factors, including time of treatment, distance of the fracture from the pulp, and size of the dentinal tubules
15A, Uncomplicated crown fracture of the maxillary central i ncisor.B, The fractured segment is bonded to tooth after placement ofa calcium hydroxide base
16Maxillary right central incisor with an UNCOMPLICATED CROWN FRACTURE involving the enamel and dentin
17Diagnosis and Clinical Presentation Enamel fracture includes a superficial, rough edge that may cause irritation to the tongue or lip. Sensitivity to air or liquids (hot or cold) is not a complaintEnamel and dentin fracture also includes a rough edge on the tooth , sensitivity to air and hot and cold liquids may be a chief complaint.Commonly a lip bruise or laceration is presentTreatmentSmooth the sharp edges and leave, if esthetically acceptable. Placing bonded composite resins may be necessary for esthetics.
18Enamel and Dentin Fracture Rx as soon as possibleA hard-setting calcium hydroxide base is placed over exposed dentinal tubules to disinfect the fractured dentinal surface and stimulate closure of the tubules, making them less permeable to noxious stimuli followed by restoration with a bonded resin techniqueFractured tooth fragment if located can be bonded to get esthetic resultsIf the tooth fragment is not located, a lip radiograph should be taken to ensure the fragment has not lodged in the lipFollow-Up:The clinician should schedule follow-up examinations at 3,6, and 12 months and annually thereafter. Prognosis is good.
19COMPLICATED CROWN FRACTURE A complicated crown fracture involves the enamel, dentin,and pulp.A crown fracture involving the pulp, if left untreated, will always result in pulp necrosisThe manner and time sequence in which the pulp becomes necrotic allows a great deal of potential for successful intervention to maintain pulp vitality
20Cervical pulpotomy of an immature maxillary incisor tooth followed by pulpectomy after root formation. A, Pulpotomy is initiated. B, Six months later a hard-tissue barrier has formed and the root continues to develop. C, One year later root development is complete. D, A pulpectomy followed by a permanent root canal therapy is performed.
21TREATMENTThere are two treatment options (1) Vital pulp therapy comprising pulp capping, partial pulpotomy, and cervical pulpotomy (2) Pulpectomy. Choice of treatment depends on the stage of development of the tooth, time between the accident and treatment, concomitant periodontal injury, and restorative treatment plan.
22CROWN AND ROOT FRACTURE A crown and root fracture is a fracture involving enamel,dentin, and cementum. The pulp may or may not be involvedBiologic consequences of a crown root fracture are identical to an uncomplicated (if the pulp is not exposed) or complicated (if the crown is exposed) crown fracture.Periodontal complications are also present because the fracture may encroach on the attachment apparatus
23Diagnosis and Clinical Presentation Crown root fractures are result of direct trauma that produces a chisel type of fractureFragments may be firm, looseThe periodontal injury causes pain on pressure and biting, and exposed dentin or pulp causes pain to air and hot or cold liquids.Indirect light and transillumination is an effective way of diagnosing these fractures.The "cracked tooth syndrome" in a posterior tooth is also an example of a crown root fracture
24Crown and root fracture of maxillary left central incisor Crown and root fracture of maxillary left central incisor. A, Chisel type of fracture has resulted in multiple fragments, one of which extends below the attachment level.B, Radiograph of the same tooth.
25TreatmentInjuries are treated in the same manner as uncomplicated or complicated crown fractures, with additional treatment for any attachment injuryAll loose fragments are removed.A periodontal assessment is made as to whether thetooth can be treated periodontally to allow it to be adequately restored.Surgical access or orthodontic extrusion to the site for proper restoration of defectExtraction if not managable
26ROOT FRACTUREA root fracture is a fracture of the cementum and dentin involving the pulpWhen a root fractures horizontally, the coronal segment is displaced to a varying degree; generally the apical segment is not displacedPulpal circulation intact in apical segment and pulp necrosis in coronal segmentRigid stabilization of the segments (for 2 to 4 months)will allow healing and "reattachment" of the fractured segments
27Diagnosis and Clinical Presentation Clinical presentation is similar to that of luxation injuriesImperative to take at least three angled radiographs so that at least at one angulation the x-ray beam will pass directly through the fracture lineTreatmentRepositioning of the segments in as close proximity as possible and rigidly splinting to adjacent teeth for 2 to 4 monthsIf a long period has elapsed between the injury and treatment, it will likely not be possible to reposition the segments
28A, At this angle, no "fracture" is seen. B, The "fracture" appears complicated in nature.C, Only at this angle, the true nature of the fracture can be seen
29Healing Patterns Healing with calcified tissue-Radiographically, the fracture line is visible, but the fragments are in close contact.Healing with interproximal connective tissue. Radiographically,the fragments appear separated by a narrow radiolucent line, and the fractured edges appear rounded.Healing with interproximal bone and connective tissue-Radiographically, a distinct bony ridge separates the fragmentsInterproximal inflammatory tissue without healing-Radiographically, a widening of the fracture line, adeveloping radiolucency
30Healing patterns after horizontal root fractures Healing patterns after horizontal root fractures. A, Healing with calcified tissue. B, Healing with interproximal connective tissue. C, Healing with bone and connective tissue. D, Interproximal connective tissue without healing.
31Treatment of Complications 1. Coronal Root FracturesFractures in the coronal segment had a poor prognosisIf Reattachment of the fractured segments is not possible, extraction of the coronal segment is indicated.The level of fracture and length of the remaining root are evaluated for restorabilityIf the apical root segment is long enough, forced eruption of this segment can be carried out to enablea restoration to be fabricated
322. Mid 3rd FractureIn almost all cases the necrosis occurs in the coronal segment with apical segment remaining vitalEndodontic treatment is indicated in the coronal root segment only unless periapical pathologyThe coronal segment is obturated after a hard-tissue barrier has formed apically in the coronal segmentand periradicular healing has taken place.When both the coronal and apical pulp are necrotic, treatment is more complicated. Treatmentthrough the fracture is extremely difficultIf healing of the fracture is completed, followed by necrosis of apical end, prognosis is much improved.
33Conservative root canal treatment of the coronal and apical segments Conservative root canal treatment of the coronal and apical segments. Note the filling material in the fracture line that compromises the healing response
343. Apical root fracturesNecrotic apical segments can be surgically removedRemoval of the apical segment in midrootfractures leaves the coronal segment with a compromised attachmentEndodontic implants are used to provide additional support to the tooth
35Orthodontic forced eruption of a tooth that has undergone aroot fracture at thecervical bone level
36INJURIES TO PERIODONTAL TISSUE ConcussionSubluxationExtrusive LuxationLateral LuxationIntrusive LuxationAvulsionNo loosening but pain on percussionAbnormal loosening but no displacementPartial displacement from socketDisplacement other than axially withcommunication or fracture of alveolar socketDisplacement into alveolar bone withcommunication or fracture of alveolar socketComplete displacement of tooth from socket
37Concussion Not brought to dentist until tooth discolors Impact force causes edema and haemorrhage in PDLTooth is tender to percussion (t.t.p.)No rupture of PDL , tooth firm in socket
38SubluxationIn addition to previous findings there is rupture of some PDL fibresTooth is mobile in socket but not displaced
39Treatment of Concussion & Subluxation Occlusal reliefSoft diet for 7 daysImmobilisation with splint if t.t.pCHX 0.2% mouthwash, twice dailyLittle risk of pulp necrosis or resorption
40Extrusive & Lateral Luxation Extrusive LuxationRupture of PDL and PulpLateral LuxationCompression injury of alveolar plateRxLA buccal and palatalAtraumatic repositioning of tooth with firm pressureFunctional splint 2-3 weeksAntibiotics age related dose of amoxicillinCHX mouth washSoft diet 2-3 weeks
41Treatment LA buccal and palatal Atraumatic repositioning of tooth with firm pressureFunctional splint 2-3 weeksAntibiotics age related dose of amoxicillinCHX mouth washSoft diet 2-3 weeksEndodontic Rx on subsequent visit depending on clinical and radio graphical examinationWith severe damage more chances of resorption
42Intrusive Luxation Result of apical impact Extensive damage to PDL and Alveolar plateRisk of Pulp necrosis, resorption & ankylosis high2 distinct situation exist
43Open Apex:Two treatment courses for open apex intrusive luxationDisimpact with forceps if necessary and allowed to erupt spontaniously for 2-3 months, if no movement then start orthodontic extrusionDisimpact and surgically reposition using functional splint for 7-10 days , monitor pulpal status clinically and radiographically and start endo if necessaryNon setting CAOH in root canal in advocatedOnce apexification is achieved obturation is done.
44Closed Apex Elective orthodontic/surgical extrusion immediately Functional splint for 7-10 days after extrusionElective RCT at 10th dayMaintenance of CaOH in RC during ortho RxFinally obturate with GP