1. TRAUMA
DR.BILAL ARJUMAND
MIHS

2. Diagnostic steps dental trauma
Medical and health history
History of the dental injury and immediate care provided
Neurologic evaluation
Clinical examination of the head and neck
Oral examination of soft and hard tissues
Radiographic examination
Photographic documentation

3. HISTORY When With time blood clots begin to form, periodontal
ligaments of teeth dry out, and saliva contaminates
the wound
How Locating specific injuries, and cause will give info about severity
Where Prophylactic tetanus toxoid, insurance and litigation

4. Clinical Examination Chief Complaint Pain and bleeding
Don't fit together now Possible displacements or a bone fracture
Pain on closure Crown, root, or bone fractures
Neurologic Examination
Head and neck injuries?
Patient is communicating?
Ringing in the ears?
Paresthesia of the lips or Tongue?
Referred immediately for appropriate medical treatment.
External Examination
External signs of injury
Lacerations 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.

5. Clinical Examination Cont….
Hard-Tissue Examination
After visual examination and abnormal findings are noted, radiographs of the injured areas should be taken
Thermal and Electric Tests
Traumatized tooth vulnerable to false negative readings from these test
Conduction capability of the nerve endings or sensory receptors or both is sufficiently deranged to inhibit the nerve impulse from an electric/thermal stimulus
Teeth that yield a negative response (or no response) cannot be assumed to have necrotic pulps, because they may give a positive response later
Transition from a negative to a positive response at a subsequent test may be considered a sign of a healthy pulp
The persistence of a negative response would suggest that the pulp has been irreversibly damaged
Tests should be repeated at 3 weeks; 3, 6, and 12 months; and at yearly intervals after the accident
Radiographic Examinations
Root fractures, subgingival crown fractures, tooth displacements, bone fractures, or foreign objects
Soft-tissue laceration it is advisable to radiograph the injured area before suturing to be sure that no foreign objects have been embedded

6. PREVENTION OF DENTAL INJURIES
Face Guards
Cage-type guards attached to helmet
Face guards of clear polycarbonate plastic
Mouth Guards
Stock mouth guard
Boil-and bite mouth guard
Custom-made mouth guard

7. CLASSIFICATION OF INJURY TO DENTAL TISSUE
Enamel Infraction
Uncomplicated Crown Fracture
Enamel Fracture
Enamel Dentine Fracture
Complicated Crown Fracture
Uncomplicated Crown Root Fracture
Complicated Crown Root Fracture
Root Fracture

9. The Ellis Classification
Enamel Fracture
Dentin Fracture without Pulp Exposure
Crown fracture with Pulp Exposure
Root Fracture
Tooth Luxation
Tooth Intrusion

10. INJURIES TO PERIODONTAL TISSUE
Concussion
Subluxation
Extrusive Luxation
Lateral Luxation
Intrusive Luxation
Avulsion
No loosening but pain on percussion
Abnormal loosening but no displacement
Partial displacement from socket
Displacement other than axially with
communication or fracture of alveolar socket
Displacement into alveolar bone with
communication or fracture of alveolar socket
Complete displacement of tooth from socket

11. Injuries to Gingiva or Oral Mucosa
Laceration
Wound in mucosa resulting from Tear
Contusion
Bruise not accompanied by break, causing sub mucosal haemorrhage
Abrasion
Superficial wound results from rub or scrap

12. CROWN INFRACTION
A 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 travel
Diagnosis and Clinical Presentation:
Indirect light or transillumination
Routine examination
Treatment
involves establishing a baseline pulp status with routine sensitivity testing.
Follow-Up
The clinician should schedule follow-up examinations at 3,6, and 12 months and annually thereafter.

13. Photograph of traumatized tooth illuminated with a resin curinglight.
Enamel craze lines are clearly visible

14. UNCOMPLICATED 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 minimal
If dentin is exposed a direct pathway exists for noxious stimuli to pass through the dentinal tubules to the pulp
The 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

15. A, Uncomplicated crown fracture of the maxillary central
i ncisor.
B, The fractured segment is bonded to tooth after placement of
a calcium hydroxide base

16. Maxillary right central incisor with an UNCOMPLICATED CROWN FRACTURE involving the enamel and dentin

17. Diagnosis 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 complaint
Enamel 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 present
Treatment
Smooth the sharp edges and leave, if esthetically acceptable. Placing bonded composite resins may be necessary for esthetics.

18. Enamel and Dentin Fracture
Rx as soon as possible
A 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 technique
Fractured tooth fragment if located can be bonded to get esthetic results
If the tooth fragment is not located, a lip radiograph should be taken to ensure the fragment has not lodged in the lip
Follow-Up:The clinician should schedule follow-up examinations at 3,6, and 12 months and annually thereafter. Prognosis is good.

19. COMPLICATED 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 necrosis
The manner and time sequence in which the pulp becomes necrotic allows a great deal of potential for successful intervention to maintain pulp vitality

20. Cervical 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.

21. TREATMENT
There 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.

22. CROWN AND ROOT FRACTURE
A crown and root fracture is a fracture involving enamel,dentin, and cementum. The pulp may or may not be involved
Biologic 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

23. Diagnosis and Clinical Presentation
Crown root fractures are result of direct trauma that produces a chisel type of fracture
Fragments may be firm, loose
The 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

24. Crown 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.

25. Treatment
Injuries are treated in the same manner as uncomplicated or complicated crown fractures, with additional treatment for any attachment injury
All loose fragments are removed.
A periodontal assessment is made as to whether the
tooth can be treated periodontally to allow it to be adequately restored.
Surgical access or orthodontic extrusion to the site for proper restoration of defect
Extraction if not managable

26. ROOT FRACTURE
A root fracture is a fracture of the cementum and dentin involving the pulp
When a root fractures horizontally, the coronal segment is displaced to a varying degree; generally the apical segment is not displaced
Pulpal circulation intact in apical segment and pulp necrosis in coronal segment
Rigid stabilization of the segments (for 2 to 4 months)
will allow healing and "reattachment" of the fractured segments

27. Diagnosis and Clinical Presentation
Clinical presentation is similar to that of luxation injuries
Imperative to take at least three angled radiographs so that at least at one angulation the x-ray beam will pass directly through the fracture line
Treatment
Repositioning of the segments in as close proximity as possible and rigidly splinting to adjacent teeth for 2 to 4 months
If a long period has elapsed between the injury and treatment, it will likely not be possible to reposition the segments

28. A, 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

29. Healing 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 fragments
Interproximal inflammatory tissue without healing-
Radiographically, a widening of the fracture line, a
developing radiolucency

30. Healing 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.

31. Treatment of Complications
1. Coronal Root Fractures
Fractures in the coronal segment had a poor prognosis
If 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 restorability
If the apical root segment is long enough, forced eruption of this segment can be carried out to enable
a restoration to be fabricated

32. 2. Mid 3rd Fracture
In almost all cases the necrosis occurs in the coronal segment with apical segment remaining vital
Endodontic treatment is indicated in the coronal root segment only unless periapical pathology
The coronal segment is obturated after a hard-tissue barrier has formed apically in the coronal segment
and periradicular healing has taken place.
When both the coronal and apical pulp are necrotic, treatment is more complicated. Treatment
through the fracture is extremely difficult
If healing of the fracture is completed, followed by necrosis of apical end, prognosis is much improved.

33. Conservative 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

34. 3. Apical root fractures
Necrotic apical segments can be surgically removed
Removal of the apical segment in midroot
fractures leaves the coronal segment with a compromised attachment
Endodontic implants are used to provide additional support to the tooth

35. Orthodontic forced eruption of
a tooth that has undergone a
root fracture at the
cervical bone level

36. INJURIES TO PERIODONTAL TISSUE
Concussion
Subluxation
Extrusive Luxation
Lateral Luxation
Intrusive Luxation
Avulsion
No loosening but pain on percussion
Abnormal loosening but no displacement
Partial displacement from socket
Displacement other than axially with
communication or fracture of alveolar socket
Displacement into alveolar bone with
communication or fracture of alveolar socket
Complete displacement of tooth from socket

37. Concussion Not brought to dentist until tooth discolors
Impact force causes edema and haemorrhage in PDL
Tooth is tender to percussion (t.t.p.)
No rupture of PDL , tooth firm in socket

38. Subluxation
In addition to previous findings there is rupture of some PDL fibres
Tooth is mobile in socket but not displaced

39. Treatment of Concussion & Subluxation
Occlusal relief
Soft diet for 7 days
Immobilisation with splint if t.t.p
CHX 0.2% mouthwash, twice daily
Little risk of pulp necrosis or resorption

40. Extrusive & Lateral Luxation
Extrusive Luxation
Rupture of PDL and Pulp
Lateral Luxation
Compression injury of alveolar plate Rx
LA buccal and palatal
Atraumatic repositioning of tooth with firm pressure
Functional splint 2-3 weeks
Antibiotics age related dose of amoxicillin
CHX mouth wash
Soft diet 2-3 weeks

41. Treatment LA buccal and palatal
Atraumatic repositioning of tooth with firm pressure
Functional splint 2-3 weeks
Antibiotics age related dose of amoxicillin
CHX mouth wash
Soft diet 2-3 weeks
Endodontic Rx on subsequent visit depending on clinical and radio graphical examination
With severe damage more chances of resorption

42. Intrusive Luxation Result of apical impact
Extensive damage to PDL and Alveolar plate
Risk of Pulp necrosis, resorption & ankylosis high
2 distinct situation exist

43. Open Apex:
Two treatment courses for open apex intrusive luxation
Disimpact with forceps if necessary and allowed to erupt spontaniously for 2-3 months, if no movement then start orthodontic extrusion
Disimpact and surgically reposition using functional splint for 7-10 days , monitor pulpal status clinically and radiographically and start endo if necessary
Non setting CAOH in root canal in advocated
Once apexification is achieved obturation is done.

44. Closed Apex Elective orthodontic/surgical extrusion immediately
Functional splint for 7-10 days after extrusion
Elective RCT at 10th day
Maintenance of CaOH in RC during ortho Rx
Finally obturate with GP