TRAUMA

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TRAUMA

• DR.BILAL ARJUMAND
• MIHS

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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

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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

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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.

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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

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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

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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

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The Ellis Classification

1. Enamel Fracture
2. Dentin Fracture without Pulp Exposure
3. Crown fracture with Pulp Exposure
4. Root Fracture
5. Tooth Luxation
6. Tooth Intrusion

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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
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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

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• 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.

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

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

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• 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-UpThe clinician should schedule follow-up
  examinations at 3,6, and 12 months and annually
  thereafter. Prognosis is good.

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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

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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.
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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.

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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

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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

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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.
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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

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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

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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

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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
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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

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Healing patterns after horizontal root fractures.
A, Healing with calcified tissue. B, Healing
with interproximalconnective tissue. C,
Healing with bone and connective tissue. D,
Interproximal connective tissue without healing.
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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

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• 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.

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Conservative root canal treatment of the coronal
and apical segments. Note the filling material
in the fracture line that compromisesthe healing
response
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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

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

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Subluxation

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

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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

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Extrusive Lateral Luxation

• Extrusive Luxation
• Rupture of PDL and Pulp
• Lateral Luxation
• Rupture of PDL and Pulp
• 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

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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

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Intrusive Luxation

• Result of apical impact
• Extensive damage to PDL and Alveolar plate
• Risk of Pulp necrosis, resorption ankylosis
  high
• 2 distinct situation exist

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• 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.

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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

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