traumatic injuries of the tooth

8/12/2019 Traumatic Injuries of the Tooth

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TRAUMATIC INJURIES OF THE TOOTH

Traumas that affect the hard tissues and cause pulpal and

periodontal lesions are of great relevance to present day dentistry, because

of their frequency, the functional and esthetic disturbances that accompany

them and the rapidity with which these problems must be treated.

Fracture:is understood to be the cracking or breaking of a tooth that has

been subjected to a force or impact greater than its resistance.

Even though endodontic techniques used by the specialist can

resolve the pulpal complications caused by the fractured teeth, the

fundamental aspect of prevention must be understood and practiced by the

general dentist who will have a complete understanding of the value of

rapid action to save the vitality of the pulp.

CLASSIFICATION OF FRACTURES

A) ELLIS CLASSIFICATION

Class I !imple crown fracture with little or no dentine affected.

Class II E"tensive crown fracture with considerable loss of dentin,

but with the pulp not affected.

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Class III E"tensive crown fracture with considerable loss of dentin

and pulp e"posure.

Class I$ % tooth devitali&ed by trauma with or without loss of tooth

structure.

Class $ Tooth lost as a result of trauma.

Class $I 'oot fracture with or without the loss of crown fracture.

Class $II (isplacement of the tooth with neither root nor crown

fracture.

Class $III Complete crown fracture and its replacement.

Class I) Traumatic injuries of primary teeth.

B) W.H.O. CLASSIFICATION

The *orld +ealth rgani&ation adopted the following classification

in #-/ with a code number corresponding to the international

classification of disease0

/1.23Enamel fracture.

/1.2#Crown fracture involving enamel 4 dentin without pulp e"posure.

/1.25Crown fracture with pulp e"posure.

/1.21'oot fracture.

/1.26Crown root fracture.

/1.227u"ation.

/1.2Intrusion or e"trusion.

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/1.2/%vulsion.

/1.2-ther injuries such as soft tissues.

C) BY ANDREASEN

#8 Classification of trauma in injury of hard tissues and pulp.

This is based on *.+.. classification.

/1.23Incomplete fracture.

/1.2#9ncomplicated crown fracture.

/1.25Complicated crown fracture.

/1.269ncomplicated crown and root fracture.

/1.26Complicated crown and root fracture.

/1.21'oot fracture.

58 Injuries to the periodontal tissues0

/1.22Concussion.

/1.22!ublu"ation :loosening8.

/1.2Intrusive lu"ation :central dislocation8.

/1.2E"trusive lu"ation :peripheral dislocation, partial avulsion8.

/1.227ateral lu"ation.

/1.2/E"articulation :%vulsed tooth8.

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18 Injuries to the supporting bone0

;andible


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ii. *ith pulp e"posure.

58 'oot fractures.18 Crown root fractures.

E) BY ULFOHN

+is classification is based on clinical endodontics and does not

reveal the e"tent of fracture or amount of dentin e"posed.

+e based his classification on 1 aspects0

i8 Clinical state of the pulp.

ii8 ?ulp and dentin as one organ.

iii8 (etermination of treatment.

Crown fractures

a8 f enamel.

b8 *ith indirect pulp e"posure through dentine.

c8 *ith direct pulp e"posure.

F) BY HEITHERSAY AND MORILE

They classified subgingival fractures based on the level of tooth

fracture in relation to various hori&ontal planes of periodontium.

Class I =racture line does not e"tend below the level of attached

gingiva.

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Class II=racture line below the level of attached gingiva but not below

the level of alveolar crest.

Class III=racture line e"tends below the level of alveolar crest.

Class I$=racture line is within the coronal third of root, but below the

level of alveolar crest.

ETIOLO!Y

#8 =irst year of life %lthough infrequent injuries at this age may

occur due to fall from a baby carriage.

58 Aefore school age Incidence of dental injuries reaches its peak.

ccurs due to falls, collisions and bumps.

18 !mall children Child abuse, as seen in battered child syndrome,

?layground accidents, bicycle accidents.

68 Teen age !ports such as hockey, football, basketball, wrestling

and +orse riding.

@8 7ate teens %utomobile accidents.

28 lder age group 'ights :related to alcohol abuse8, wife abuse.

8 ;entally retarded patients due to lack of motor coordination.

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/8 Epileptic patients ;ainly due to fall during sei&ures.

-8 (rug addicts B =rom violent with clenching.

#38(entinogenesis imperfecta 'oot fracture due to reduce hardness of

dentin.

"REDIS"OSIN! FACTORS

B Increased overjet with protrusion of upper incisors and

insufficient lip closure are significant predisposing factors to

traumatic dental injuries.

MECHANISMS OF DENTAL INJURY

The e"act mechanisms of dental injuries are unknown, and without

e"perimental evidence.

Injuries can be

(irect Indirect

B ccurs when tooth

itself is struck e.g.

playground equipment.

B run in anterior region.

B 7ower dental arch is

fully closed against the upper,

in a fight4fall.

B Crown or crown root

fractures in the premolar and

molar region 4 jaw fractures.


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FACTORS THAT CHARACTERI#E THE IM"ACT AND E$TENT

OF INJURY

1) Energy o !"#act:

B This factor includes both mass and velocity.

B 7ow velocity blows causes more damage to surrounding

tissues rather than tooth.

B +igh velocity impacts crown fractures are not associated

with damage to the supporting structure.

$) Re%!&!ency o !"#act orce:

*hen the blow to the tooth absorbed by surrounding tissues and less

forces act on the tooth lu"ation results rather than a fracture of tooth.

') S(a#e o !"#act!ng o*ect:

B !harp object Clean crown fracture with minimal

displacement because energy is spread rapidly over a limited

area.

B Alunt impact area of resistance in crown portion is

increased, impact is transmitted to apical portion causing

lu"ation or root fractures.

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+) D!rect!on o !"#act!ng orce:

B Impact can meet the tooth at different angles. ;ost often

tilting the tooth facially perpendicular to long a"is of the root.

B (epending on different angles, different fracture lines are

seen.

Due to fronta% &'(acts four cateor&es of fracture a((ear

B +ori&ontal crown fracture.

B +ori&ontal fracture at the neck of tooth.

B blique crown root fracture.

B blique root fractures.

E"IDEMIOLO!Y

1. ,re-a&ence o enta& !n*ur!e%:

B ?rimary dentition ##B13.

B ?ermanent dentition @B5-.

$. Se/ an Age !%tr!ut!on:

!e" Aoys affected almost twice as often as girls.

%ge ?eak incidence at 5B6 and /B#3 years of age.

'. Locat!on o !n*ur!e%:

B ;ost commonly involved are ma"illary central incisors.

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B 7east involved are mandibular central and ma"illary lateral

incisors.

+. Ty#e o enta& !n*ur!e%:

B ?ermanent dentition 9ncomplicated crown fractures

mostly.

B ?rimary dentition7u"ation mostly.

Seasona% *ar&at&ons

B ?revalence increases during winter months.

D&anos&s

The following modified principles of D?'I


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Inspection0 Tooth structure, adjacent soft tissues.

5. Colour0 7ocali&ed spots, diffuse area of white, gray,

brown.

1. Transillumination.

6. ?ulp vitality tests B Thermal

B Electrical

@. 'adiograph ?ulp canal, periapical region, root

fracture.

2. ?ercussion (egree of periapical involvement.

?alpation 0 Changes in form, si&e, consistency and mobility of teeth.

CRO/N FRACTURES

1) FRACT0RESOFENAEL:

These are fractures of the crown of the tooth involving only the

enamel which may be accompanied by a crack that affects the dentin.

This can be classified into three0

+ori&ontal 7ine of fracture perpendicular to long a"is of the tooth.

blique Inclined to long a"is.

$ertical ?arallel to long a"is.

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Accor!ng to Ing&e:

This involves chips and cracks confined to the enamel, did not cross

(EG but terminate at it. %lso known as Dcrown infractionsF by %ndreasen.

D&anos&s

B Transillumination.

B (yes.

B $itality. Aoth immediately and after 2B/ weeks concussion

to apical neuro vascular bundle. ;ainly involve children and

majority of cases go unnoticed.

Treat'ent

#8 !moothening of rough edges.

58 Composite resin using acidBetch technique.

"ronos&s

>ood

!equlae0 B ?ulp necrosis.

B Internal resorption.

B Calcification.

B Trauma to primary may result in malformation of permanent

successors.

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$) CROWN FRACT0RE IN2OL2IN3 ENAEL AND DENTIN WITHO0T

,0L,E4,OS0RE.

De%cr!#t!on: %lso known as Duncomplicated crown fracturesF by

%ndreasen and Class II by DEllisF.

1. Anter!or teet( 5"ore co""on).

S!te:

B Incisal pro"imal corners.

B Incisal edges.

B 7ingual chisel type fractures.

$. ,o%ter!or teet( cu%#%.

Inc&0ence

The enamel 4 dentin fracture is very common accounting for about

one third of dental injuries.

D&anos&s

B %s the tooth fracture involves dentin, dentinal tubules are

e"posed through which harmful bacteria and other substances

have a direct pathway to pulp.

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B Thus along with the e"tent and degree of fracture, pulp

vitality should be checked.

B Electric pulp test is more reliable than a cold thermal test for

vitality. If nonBvital appropriate endodontic therapy should be

provided.

"ercuss&onTenderness on percussion should be check.

Mo,&%&t.These two dictate the periodontal ligament status.

Treat'entEmergency 4 immediate follow up

O,-ect&*e of treat&n a toot1 w&t1out (u%( e2(osure &s t1ree fo%0

#. Elimination of discomfort.

5. ?reservation of vital pulp.

1. 'estoration of fractured crown.

E'erenc.

B ?rimary goal of treatment is to protect the pulp.

#. ;ost effective method is placement of a protective

material over e"posed dentin to allow the pulp to form a protective

barrier e.g. Ca:+85placement :(ycal8.

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5. The fracture site must be covered with a restoration

material such as acidBetch composite restoration.

The advantages are0

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B (egree of pulp e"posure varies from a pinpoint e"posure to a

total unroofing of coronal pulp.

B ?ulp e"posure complicates the treatment as healing and

repair are harmed.

B Traumatic e"posure of the pulp lacerates the tissues and

e"poses the pulp to the oral environment.

B Initial reaction is hemorrhage followed by an inflammatory

response which is either distructive :necrotic8 or prolifeative

:polyp8 reaction.

Inc&0ence

B Crown fracture are less than those not involving the pulp.

B 'ange5B#1.

D&anos&s

The condition of the e"posed pulp will affect the treatment choice

and must be carefully evaluated.

This depends on four factors0

#. 7ength of time the pulp has been e"posed.

5. ;aturity of tooth %pe" formed or not formed.

B Check 'adiographically.

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3) ROOTFRACTURE

This type of injury is limited to fractures involving the roots only.

Cementum, dentin, pulp.

Inc&0ence

B These are relatively uncommon. ccurring in or less of

injuries of permanent teeth.

B ;a"illary central incisors predominately in age group of ##B

53 years.

D&anos&s

a) C&!n!ca& !n!ng%: 5Hor!7onta& Fracture)

B !light e"trusion of tooth.

B ;ay be displaced lingually :coronal segment8.

B ;obility of tooth.

B Tenderness on palpation over the root.

) Ra!ogra#(%

B =racture line seen on radiograph is oblique.

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B 'oot fracture is only visible only if the central beam is

directed within a ma"imum of #@B53 deviation from the

plane.

B 'oot fractures occasionally escape detection on radiograph

taken immediately after injury, while later clearly reveal the

fracture. This is due to development of either hemorrhage or

granulation tissue.

B The fracture occurs most often in the age or middle third of

the root and only namely in the coronal #41rd.

'adiographic and histologic observation in humans show that the

healing events after root fractures occur in one of way0

a8 +ealing in calcified tissue.

b8 Interposition of connective tissue.

c8 Interposition of bone and connective tissue.

d8 Interposition of granulation tissue.

C%ass&f&cat&on of Root Fractures

A. Ba%e on !rect!on o racture &!ne 6!t(

&ong a/!% o toot(:

B +ori&ontal fracture perpendicular to long a"is of tooth.

B blique fracture is at an angle to long a"is.

B $ertical fracture parallel to long a"is.

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B. Ba%e on &ocat!on:

B Cervical third.

B ;iddle third.

B %pical third.

C. Accor!ng to nu"er o racture &!ne%:

B !imple only one fracture line dividing root into two

fragments.

B ;ultiple when root is divided into more than 5 fragments.

B Comminuted multiple fracture lines.

D. Accor!ng to e/ten%!on o &!ne o racture:

B ?artial =racture involves a portion of root.

B Total entire root is involved with fracture line.

E. ,o%!t!on o root rag"ent%:

B *ithout displacement segments face each other.

B *ith displacement when fracture segments are not aligned.

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Treat'ent

Hor!7onta& racture treat"ent

B *hen a hori&ontal 4 a diagonal fracture of the root occurs

immobili&e the tooth by splinting it to adjacent teeth to keep

it at rest.

B (epending on the location of fracture the treatment varies

considerably.

B *hen a fracture occur in the middle or coronal third the

prognosis is less favourable because of difficulty of

immobili&ing the tooth.

B 'epair does not occur due to constant movement of the tooth

as well as e"posure of pulp to oral environment :coronal

fracture8.

#8

a8 %nestheti&e the tooth.

b8 Tease off the broken coronal part from the

residual periodontal attachment on the lingual.

c8 Endodontic treatment should be completed in

one visit.

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B *ith the pulp being vital in the root and the tooth is stable

with or without ligation no additional treatment is required.

B If pulp becomes nonBvital or undergoes necrosis with time,

the endodontic treatment should be done till the fracture

fragment :i.e. coronal to the fracture8.

B If tooth fails to recover and symptoms persist the apical

fragment can be removed surgically.

4ert&ca% fracture

B $ertical fracture is not as amenable to conservative

endodontic treatment as hori&ontal fracture.

D&anos&s

B (iagnosis is difficult to establish by radiograph, percussion

or other means.

a) S.'(to's

B ?atient C4o sensitivity.

B ?atient may 4 may not be able to locate the affected tooth.

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,) E%ectr&c (u%( test

B Tooth may react normally to E?T or may become

hypersensitive.

c) Ra0&ora(1

B In cases of hair line fracture no visible changes on

radiograph.

0) Occ%usa% (ressure test

B *hen asked to bite 4 chew on a cotton applicator or a rubber

polishing wheel patient gets sharp pain.

Causes

B Condensation of guttaBpercha.

B Cementation of inlay in endodontically treated tooth.

B Cementation of a post.

B E"cessive enlargement of 'C with engineBdriven

instruments.

B Traumatic occlusion.

Treat'ent

B If a fracture passes through its furcation the prognosis may be

favourable, provided the tooth can be hemisected e.g. A7

fracture of mandibular molar.

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B Endodontic therapy followed by hemisection and full

coverage restoration of mesial and distal segments usually

suffice.

B *hen a longitudinal fracture of an anterior tooth occurs

prognosis is hopeless.

B The successful termination of root fracture depends on the

location of fracture, on the pro"imity of the fracture surfaces,

on whether the fracture is comminuted and on the ability to

mobili&e the fragments.

CRO/NROOTFRACTURES

B These are the fractures that occur simultaneously by in the

crown and the root, affecting the enamel dentin and the

cementum.

B The pulp may or may not be involved in the fracture.

B =racture may be0 $ertical %cc to the position

blique

B In majority of cases, the direction of the fracture is from

buccal to lingual.

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Et&o%o.

B Teeth with e"tensive plastic restoration.

B Teeth undergone endodontic treatment and did not have a

definitive restoration placed.

B Teeth with incorrect intraradicular anchorage 4 screws, post.

B Teeth damaged due to0 B Aru"ism.

B Aad habits.

B Alows

B Crown root fracture constitute @ of traumati&ed teeth.

C%ass&f&cat&on

%ccording to e"tent of fracture line.

#8 Total fractured line is complete and coronal

fragment is held only by the ?(7.

58 ?artial Incomplete fracture line.

%ccording to the pro"imity to the pulp chamber0

#8 *ithout pulp e"posure.

58 *ith pulp e"posure.

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S.'(to's

B !pontaneous pain that increases on mastication.

B Temperature change causes pain.

S&ns

B ;arked mobility on e"ploration and palpation, depending on

whether the fracture line is partial 4 complete.

B ;ay not be any color change.

D&anos&s

#8 cclusal pressure 0 %sk the patient to bite on an orangeBwood stick,

the patient will e"perience pain on biting. In some instances it is

possible to visuali&e the separation of fractured parts.

58 'adiographic e"amination0

B =racture may not be visible 'adiographically because the

fractured segments are not displaced.

Treat'ent

#8 =racture without pulp e"posure :emergency treatment8.

58 %nesthesia.

18 'emoval of the fractured segment.

68 ?rotection of the remaining dentin.

@8 Temporary restoration.

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Fo%%ow u( treat'ent

B If a pulp appears normal clinically and 'adiographically a

definitive restoration is placed.

58 =racture with pulp e"posure :emergency treatment8.

a8 %nesthesia.

b8 'emoval of the fractured segment.

c8 ?ulp protection, e"tirpation of the pulp, or

treatment of necrotic pulp.

d8 Temporary restoration.

Fo%%ow u( treat'ent

a8 >ingivectomy and or alveoloplasty when indicated.

b8 %ppropriate treatment.

c8 (efinitive treatment.

,rogno%!%: *hen the fracture line is not very deep, the prognosis is

favorable.

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LU$ATION

De!n!t!on:

%ccording to >rossman is the displacement or dislocation of a tooth

from its socket.

C%ass&f&cat&on

IJ ?artial tooth is partially displaced from its socket.

Total in which tooth is completely avulsed from its socket.

/+H+O+ C%ass&f&cat&on of Lu2at&on

a) 89'.

i8 Concu%%!on tooth is sensitive to percussion but is not

displaced.

ii8 Su&u/at!on tooth has abnormal mobility but is not displaced.

iii8 Lu/at!on tooth is loose and tooth is displaced.

) 89'.9

i8 Intrusion indicates displacement of the tooth into its

socket accompanied by fracture of the alveolar socket.

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ii8 E"trusion partial displacement of a tooth out of its

socket.

7u"ation injuries comprise of #@B63 of dental traumas.

Aet&o%o.

B =all injuries.

B =ight injuries.

C%&n&ca% F&n0&ns

,art!a& &u/at!on:

B !oft tissue become swollen and are covered with blood.

B Tooth may appear loose especially if e"truded.

B ?(7 is torn in several places usually.

B =racture is not commonly seen :according to >rossman8 as

forces which causes lu"ation are directed parallel with the

long a"is of teeth rather than at right angles.

B %ccording to %ndreasen two or more teeth are lu"ated

simultaneously and show concomitant crown or root

fractures.

B (iffuse ache in the affected area with little discomfort.

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B Tooth may feel numb shortly after the blow.

B If intrusion occurs, only a small portion of crown may be

visible because of swelling of the tissues.

B Intrusion seen more in primary teeth.

D&anos&s

B (iagnosis is based on case history, clinical e"amination,

radiographic e"amination and vitality test.

Ra0&ora(1&c f&n0&ns

B The width of the periodontal space is increased on

radiographs of e"trusive lu"ations, while it is partially or

totally disappears in intrusive lu"ations.

Treat'ent

INTR0SION:

B %n intruded tooth requires no immediate treatment :unless it

is a primary tooth that can affect the permanent tooth bud8

because the tooth will slowly erupt.

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B >round tooth out of occlusion to prevent additional trauma.

B (epending on the degree of impact pulp may be vital or nonB

vital. :$ital as the vascular supply to the pulp is not always

severed or even impared8.

B If pulp becomes nonBvital 4 necrotic endodontic treatment

must be done.

B !plints are removed after a period of 5B1 weeks.

CONCUSSIONANDSUBLU$ATION

B Treatment is confined to occlusal grinding of opposing teeth,

supplemental with respected vitality and radiographics

evaluation of tooth during follow up period.

B Immobili&e the tooth in cases of marked mobility.

Treat'ent

1) At %!te o !n*ury:

a8 *ash the tooth in running water without

brushing or cleaning it, and e"amine it to be certain that the tooth is

intact.

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b8 +ave the patient rinse tooth, replace tooth in its

socket using gentle, steady finger pressure. If the patient is

cooperative and able, have the patient gently close the teeth together

to force the tooth back into its original position.

c8 If the patient 4 parent cannot replace the tooth

in the socket carry it in a suitable transporting media.

d8 Take the patient to the dentist.

$) Treat"ent !n enta& o!ce:

a8 If the tooth is in its socket ligate, stabili&e and disocclude the

implanted tooth. If the tooth is out of its socket or is

improperly positioned, replant the tooth properly before

ligation.

b8 Take a radiograph to verify the position of the tooth in its

socket and to e"amine it for any root or alveolar bone

fracture check adjacent teeth for possible fracture.

c8 (o not attempt endodontic treatment at this time unless the

tooth requires venting :drainage8.

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d8 In this case open and perform emergency root canal therapy

and place a sedative dressing. Endodontic treatment should

be completed at a later date.

Factors affect&n t1e success of re(%antat&on

1) E/tra ora& t!"e:

9niversal agreement e"ists shorter the e"tra oral time the better

the prognosis for retention of replanted tooth.

B -3 of replanted teeth with e"traoral time of within 13

minutes showed no resorption of roots.

$) Storage "e!a an tran%#ortat!on o a-u&%e toot(:

B To prevent further damage to the ?(7 tooth should be

replanted at site of injury.

B *hen replantation is delayed tooth should be stored in a

physiologic medium to prevent further injury to ?(7.

B 9nder no circumstances the tooth should be allowed to dry,

as it causes clinical necrosis.

B (o not wipe the tooth rinse it under water.

et(o% u%e are:

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#8 !aliva B Aest storage media, patients mouth.

B 'eadily available.

58 ;ilk B


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Instruct&ons to t1e (at&ent

#8 !oft diet.

58 Arush with soft brush gently.

18 9se of chlorhe"idine mouth wash :3.#8 for days.

68 'egular follow up to be maintained.

Co'(%&cat&on

B 'oot resorption.

B %nkylosis.

"RE4ENTIONOFTRAUMATICINJURIES

A) ,re-ent!-e "ea%ure% !n %#ort%

#8 =ace mask.

58 ;outh protectors.

a8 !tock variety.

b8 ?reBformed.

c8 Custom made.

A) ,re-ent!-e "ea%ure ur!ng ane%t(et!c #roceure:

a8 ;outh protectors.

?revention of oral trauma in the comatose Tongue stent.

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CONCLUSION

Aicycle and automobile accidents, home and play ground injuries

have all taken their toll in fractured crowns and roots nonBvital pulps and

avulsed or dislocated teeth.

These dental injuries meant a life of discomfort and disfigurement

as no replacement can equal function and esthetics of intact dental

structures.

Considering the multiplicity of etiologic factors, one can easily

understand why preventive measures are difficult to institute.

+owever, certain accidentBprone individuals can be protected. =or

e"ample mouth guards have proven effective in the prevention of dental

injuries due to contact sports and during anesthetic procedures.

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References

#8 Endodontic practice byLou!% I. 3ro%%"an)Ithedition.

58 Endodontic by;o(n Ie Ing&eIIIrdedition.

18 ?athways of the pulp bySte#(en Co(en $Ithedition.

68 =ractures of the teeth byEnr!


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traumatic injuries of the tooth

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