Traumatic injuries to anterior teeth

contents Definition. Incidence. Predisposing factors. Classification. Management of traumatic dental injuries. ( emergency , intermediate and permanent )

Greatest incidence of trauma to primary dentition 2-3 years due to: Def : Facial trauma that cause fracture, displacement or tooth loss part or whole, lead to –ve significant functional esthetic, psycho effects on children. Incidence : Greatest incidence of trauma to primary dentition 2-3 years due to: 1- start to walk. 2- developing of motor coordination so accidental fall. (80-90 %)

Greatest incidence of trauma in permanent dentition- 10-12 years due to: 1- Accidental falls. 2-Contact sport. 3-Playground injuries. 4-Traffic accidents. 5-Violence. Greatest incidence of trauma in mixed dentition 7-8 years due to: 1- Hyperactivity. 2-Contact sports.

Sex predilection: male > female with ratio 1.5:1 Predisposing factors 1-Occlusal state: ''accident-prone dental profile'' A-Increase overjet> 9mm B-Class II division 1 with lack of lip protection C-Lip incompetence D-Ugly duckling stage

2-Dental factors: a-Hypopalsia b-Badly decayed c-Root canal treatment d-Dental implant 3-Systemic factor a-Neurologic disorder e.g Epilepsy , cerebral palsy 4-Other factors as: contact sports, acts in violence.

Classification of traumatic dental injuries Numeric classification: Ellis & Davey classification 1960. Class 1: simple crown fracture involving no or little dentine Class 2: extensive crown fracture involving considerable dentine but not dentine & pulp. Class 3: extensive crown fracture involving considerable dentine and pulp

Class 4: non vital traumatized tooth with or without crown loss Class 5: tooth is lost as result of trauma.  Class 6: root fracture with or without loss of crown Class 7: displacement of tooth with or without fracture of crown or root Class 8: fracture of crown in mass Class 9: trauma to primary teeth

Ellis& Davey 1970 classification (for anterior permanent teeth) Class I: Traumatized teeth with fracture involving enamel only or enamel & little dentine. Class II: Traumatized teeth with fracture involving enamel & dentine without pulp involvement. Class III: Traumatized teeth with fracture involving enamel & dentine with pulp involvement. Class IV: Traumatized teeth where amutation of crown in mass occurs. Class V: Traumatized teeth with fracture involving roots, with/without crown fracture

Descriptive classification (according to the council of clinical affairs, AAPD) Infraction: incomplete fracture of enamel (crack) without loss of tooth structure. Crown fracture (uncomplicated): enamel fracture or enamel – dentine fracture that doesn't involve pulp. Crown fracture (complicated): enamel –dentine fracture with pulp exposure. Crown/root fracture: enamel, dentine&cementum fracture with/without pulp exposure.

Root fracture: dentine &cementum fracture involving pulp. Concussion: injury to tooth –supporting structures without abnormal loosening or displacement of tooth. Subluxation: Injury to tooth-supporting structure with abnormal loosening but without tooth displacement. Lateral luxation: displacement of tooth in a direction other axially. The periodontal ligament is torn & contusion or fracture of supporting alveolar bone occurs.

Intrusion: apical displacement of tooth into alveolar bone. Extrusion (partial avulsion): partial displacement of tooth axially from the socket. Avulsion: complete displacement of tooth out of the socket.

Management of traumatic dental injuries  Diagnosis……..Treatment……..Prognosis   1-Diagnosis: A-Personal information : patient's name, age (date of birth), source of referral, sex …etc. B-Medical history: Allergies: may effect antibiotics given. Systemic diseases: require medical consultation. Current medication: for drug interaction. Immunization status: especially tetanus. Diseases requiring pre-medications as; rheumatic heart disease.

C-Dental history: Past dental history: Reveal any special procedures done. Determine patient's cooperation. To explore incidence of any previous traumatic injuries. History of injury: (when, where& how). When? Time elapsed since injury. Time is critical factor that will determine technique & prognosis of treatment given. The shorter the time between trauma & treatment, the better the prognosis.

Where? Place of injury. Determine the need for prophylactic tetanus immunization, if accident had occurred in a dirty environment. How? How did injury occur? May be: direct→ causing tooth fracture, displacement or root fracture. Indirect→ may cause sub-condylar fracture or TMJ dislocation.

d-Clinical examination: 1-Medical examination   d-Clinical examination: 1-Medical examination Loss of consciousness - Mental status & orientation Nasal hemorrhage - Headache, nausea, vomiting Neck pain 2-Extra-oral examination Facial fracture: A-Leakage of straw fluid from nose → middle 1/3 maxilla fracture B-Sub-conjunctional → zygomatic fracture C-Limitation of mandibular movement → mandibual or condyle Soft tissue injury: -Laceration. -Abrasion. -Contusion.(hematoma).

3-intra-oral examination A-Soft tissue examination:   3-intra-oral examination A-Soft tissue examination: Laceration of tongue, gingival & lip Embedded tooth fragments should be suspected in case of penetrating wounds ''bi digit by thumb & index exam'' Hematoma of the floor of mouth may be indicated mandibular fracture. B-Hard tissue examination: Type & extent of injury Teeth fracture with/without pulp involvement Tooth displacement & avulsion Color change of tooth as indicated to pulp condition: Brow-black------pulp necrosis Red----------------hyperemia Decrease translucency-------calcific obliteration of pulp

  4-Radiographic examination Root development. Root fracture. Periapical radiolucency. Tooth fragment or foreign body in soft tissue. Periapical, panorama, lateral oblique, chest x ray. 5-Digital manipulation Mobility of injured tooth Mobility of fractured bone segments Important to examine affected as well as adjacent teeth, if both show mobility → alveolar bone fracture

6-Adjunctive diagnostic tests 1- Vitality test Thermal: Cold → Co2 snow, Ethyl oxide. Hot → hot guttapercha, hot instrument. Electric : electric vitalometers, pulp tester. N.B: it has to be noted that injured tooth may be in a state of shock & won't respond to vitality testing, so vitality testing may be postponed 2 weeks.   2-Percussion Sensitivity to slight tapping → periodontium injury, possible periapical pathology, root fracture & displacement. 3-Trans-illumination test Reflecting intense light through crown can be detect enamel cracks, infarction & calcification.

Management of traumatic dental injuries Aim of the treatment : a- Maintain pulp vitality. b-Restore normal esthetics & function &contour and occlusion. 1- Enamel Infarction: only follow up by radiograph & vitality test or sealing with unfilled resin. 2- Crown # uncomplicated (Ellis class I, II ). Class I: small # , rough margin & edges are smoothed. Class II: large fracture , lost tooth structure is restored. 3-Crown # complicated (Ellis class III ). Clinical & radiograph finding reveal loss of tooth structure with pulp exposure.

Treatment 1- primary teeth: A- formocresol pulpotomy Treatment 1- primary teeth: A- formocresol pulpotomy . B-pulpectomy C-Extraction if tooth near exfoliation time.. 2- Permanent teeth: A- DPC. B- Partial plupotomy. C- Apexiognesis. D- Apexification. E- pulpectomy.

Factors that could modify treatment of Ellis class III. 1- Time factor : immediate < 6 hr. … late > 6 hr. 2-Size of exposure : minute or large . 3-Vitality : vital or non vital. 4- Degree of root development & apex closure . 5- Physical condition of child . The prognosis depending on the previous factors ….

Choices of pulp treatment for complicated crown fracture (class III) Pulp capping pinpoint less than 2 hrs closed\open apex Ca(OH)2. Pulpotomy small-large less than 12hrs open apex Ca(OH)2. Apexification non-vital pulp Open apex Ca(OH)2- CMCP, MTA, and BMP. Pulpectomy small\large 12 hrs or more Closed apex Guttapercha.

4- Crown/ root fracture: Fracture in E, D and C with or without pulp exposure. Treatment : Primary teeth: extraction is ttt. Of choice , to preserve the permanent one. Permanent teeth: Emergency ttt. : stabilize coronal fragment. Definitive ttt. : a) remove coronal fragment followed by supragingival restoration. b) If fracture subgingival but supra bony gingivectomy + RCT +restoration.

c) If the fracture subgingival – infra bony gingivectomy + alveoloplasty or orthodontic extrusion + restoration. Prognosis : if the fracture deeply below gingival margin (not restorable ) extraction. 5- Root fracture : clinical finding. (mobile fragment) Diagnosis Radiographic finding . (reveal 1 or more radiolucent lines that disrupt continuity of the root )( multiple x-ray needed in such case)

Types of root fracture : 1- acc. To direction: horizontal / oblique. 2-Acc. To location: cervical 1/3 ,Middle 1/3 and Apical 1/3 Treatment : Primary teeth: Ext. Of coronal fragment without insisting on removing apical fragment ( wait and see). Clinical and radiographic follow up in 4 weeks and advice parents of possible injury to permanent. No splint.

b)Permanent teeth: 1- Apical root fracture 1- No treatment is required just follow up by x-ray up to 6 months and put tooth out of occlusion. 2- Instruct patient not to overload the tooth. 3- 1 month later, union may occur by a calcific or fibrous tissue 4- If fracture line increase in width → indicates failure of union & the need for root canal treatment of coronal & followed by surgical removal of apical fragment. 5- Best prognosis.

2-Middle- third root fractures: Root part attached to the crown isn't enough to stabilized the tooth → spliniting. Teeth with root fractures should be splinted for 4-6 weeks. Aim of splinting: Promote healing of PDL.& neurovascular supply and alveolar supporting. Ideal requirement of splint: Should be –passive , a traumatic , esthetically ,easy removed , hygienic , easy constructed and stable .

Splinting stabilization period: Subluxation 2wk Splinting stabilization period: Subluxation 2wk . Intrusion, extrusion, bilateral luxation 4wk. Root fracture 8-16 wks. Avulsion, replantation open apex 2-4 wk. closed apex 1wk.

3- Cervical third root fracture: 1- If fracture is at bone level → coronal fragment is removed → root canal treatment →restoration. 2- If fracture is 1-2 mm infra-bony → localized osteopalsty (crown lengthening) to enable treatment. → root canal treatment or extrusion by ortho. 3- If fracture is too far infra-bony → extraction. 4- Longitudinal fracture: Extraction.

Requirement of successful treatment of root fracture: 1- Fragments must be immobilized in close contact. 2- Absence of infection. Pattern of root fracture healing: healing by: Calcified tissue. Connective tissue. Bone & connective tissue. Granulation tissue.

6- Concussion: Minor injury to peridontium without displacement or mobility . C/f : TTP, No mobility and sulcular bleeding. R/f: thickening of PDL space. Treatment : Primary teeth : unless associated with inf. No ttt. Permanent teeth : concussion pulp necrosis due to injury to BV. Soft diet , analgesics and tooth out of occlusion.

Prognosis : open apex better prognosis. (Vitality) Prognosis : open apex better prognosis. (Vitality). Concussion may result in : a) pulp necrosis. b) discolor tooth . c) Int. ext. resorption . d) NO Change , complete recovery .

7- Subluxation: Injury of peridontium without displacement and with slight mobility. C/F: pain, mobile and no displacement. R/f : no change. Treatment : primary teeth: follow up. Prognosis return normal permanent teeth: a) stabilize tooth, relive occl. Interference. b) Flexible splint not more than 2 wk. Prognosis tooth with closed apex pulp necrosis .

8- Lateral luxation: Displacement of the tooth in a direction other than axial direction. Diagnosis C/ f : -Tooth is displaced laterally & may be locked firmly into this new position - Tooth is usually not mobile or tender to touch. -Metallic sound on percussion. -Vitality test usually –ve.

R/f : Reveal widening of PDL space & displacement of apex towards or through labial plate of bone. Treatment Primary teeth -Aspiration risk → extract or inform parents about potential damage to successor. - Occlusal interference→ extract or reposition & splint -no harm from tooth → allow spontaneous repositioning or reposition & splint (1-2 weeks) or extract -Follow up for 2 weeks, inform parents about the possibility of permanent damage.

Permanent teeth -Reposition as soon as possible with fingers or forceps. -Splinting for3-4 weeks and may require additional weeks if associated with marginal bone fracture. -Tooth may need to be extruded to free apical lock in cortical bone. -Splinting using rigid splint with consult oral surgeon & suture soft tissue laceration. Open apex 1- Reposition tooth either with digital manipulation or by surgical or orthodontic reposition.

Closed apex: 1- If tooth can be repositioned with digital manipulation → a. reposition the tooth. b. Verify position with x-ray. c. Use passive splint as: fishing line splint for 1-2 weeks of injury. 2- If tooth can't be repositioned by digital manipulation: -surgical or orthodontic repositioning is attempted. -Follow up for 2 weeks. -Monitor sign of pathology by x-ray.

Prognosis -Primary teeth requiring repositioning → increase risk of pulp necrosis compared to teeth left for spontaneous repositioning. -mature permanent teeth with closed apices → pulp necrosis & pulp canal obliteration & external root resorption are common healing complication.

9-Avulsion: Def : - Complete displacement of tooth out of socket, the periodontal ligament is effected and fracture of alveolar bone may occur. Diagnosis Clinical exam : Complete absence of tooth & socket is free from tooth or part of it. Radiographic exam : Free socket

1- < 6hrs change to HBSS Replantation. 2- >6hrs No Replantation. Treatment : To determined best way for treatment it depends on the maturity of tooth: A) Open apex : (wet media) 1- 15 min -6 hrs in HBSS, Cold milk then doxycycline for 5 min. Replantation. 2- 15 min -6 hrs in water or saliva change to HBSS Replantation. (Dry media) 1- < 6hrs change to HBSS Replantation. 2- >6hrs No Replantation.

B) Closed apex : 1- < 15 min extra oral B) Closed apex : 1- < 15 min extra oral. 2- 15 min -6 hrs HBSS or cold milk. Replantation. 3- 15min -2 hrs water or saliva … dry time < 6 hrs change to HBSS replantation. Dry storage >6 hrs … 1- soack in NAOH. 2- sock in citric acid 3-debride &remove PDL gentaly by scaler 4-Naf for 20 min replantation

Technique of replantation: 1- patient prep. Inform parent or patient that.. Need for splint → 1-2 weeks Need for R.C.T+ Ca(OH)2→ 1-2 weeks after replantation because if it too soon; before adequate healing of P.L, it may stimulate replacement root resorption. Uncertain prognosis of replanted tooth.  

2 -Tooth preparation: -Held from crown& rinse under running water tap (no soap) -Avoid scrubbing or brushing with sharp instrument as it may; remove P.L cells & fibers or denude cementum. 3- Socket preparation. -Inspect & clean socket & surrounding tissues with sterile saline by gentle irrigation -Any coagulated tissues inside socket is removed by soft tissue curette or aspiration & repositioning of collapsed walls of socket (alveolar process).

4- Tooth replantation. Tooth to correct anatomical position by gentle pressure + check by radiograph.   5- Check occlusion. Tooth out of occlusion to avoid overloading which may be interfere with reattachment . 6- Splinting. Open apex →2-4 weeks. Closed apex → 1 weeks. Using flexible splint for: 1- Allow normal mobility of tooth like normal tooth. 2- Increase incidence of ankylosis.

7- Endo treatment of replanted tooth. -Open apex High incidence of revascularization especially if replanted < 30 min But if > 2 hrs → decrease % so apexification. -Closed apex Andreasen 1990 recommended 2 weeks after replantation is the ideal time to fill canal with Ca(OH)2 to allow for adequate time for P.L healing otherwise early Ca(OH)2 placement lead to ankylosis& resorption -Trope 2002- suggested that pulp contents removed at emergency visit + tetracycline & corticosteroid combination to inhibit inflammatory reaction & decrease incidence of root resorption.

8- Antibiotics. CHx mouth wash and antibiotic if: a. < 8 years penicillin 50mg/Kg/ day for 7 days. b. > 8 years Doxycyclon for 10 days. 9- Prognosis (4-50%) Depend on: a. Stage of root development: open > closed in chance of revascularization b. Extra – oral dry time: affect physical status of P.L -Best prognosis → immediate replanted.

If can't be replanted within 5 min → place in storage medium in order to maintain vitality of P.L cells & fibers - Pulp revascularization start 4days after injury, by rate 0.5mm/day. Complete revascularization may take 30-40 days -studies have shown that placement of Emdogaine (E. matrix derivative) increase healing of P.L when the gel is: 1- Applied to root surface 2- Placed on the socket

Transport medium for avulsed tooth: 1- Optimal storage environment (OSE) such as save tooth in socket 90% success rate 2-Hank's balanced salt solution HBSS: tissue culture medium -Available in (Save –A-Tooth) medium -The best & the most extensively test has all the metabolite: Ca, Phosphate, K, Glucose -90% of cells stored by HBSS for 24 hrs maintain 70%

  4- Emergency medical (tooth-saver): 70.5% -Commercially available in market. -Container containing solution similar to HBSS. 5- Emdogaine (E. matrix protein): Increase incidence of healing of P.L & increase regeneration of P.L 6- Cold (skimmed) milk: 43.4% Pastrized for no bacteria, maintained vitality of P.L cells for 3 hrs Have same osmolality = PDL cells

7- Eagle's medium: effective but:   7- Eagle's medium: effective but: a-Not available in small container. b-Expensive. 8- Egg white: some success rate =HBSS. 9- Propolis: plant extract by bees (antibacterial). 10- Physiologic (isotonic) saline: 0.9% -Not nutrients to help maintain cell vitality. -Osmolality = PDL cells. 11- Saliva (Buccal vestibule or floor of the mouth). 12- H2O : disadvantage that it is hypotonic increase cell lysis& increase inflammation on replantation.

Reaction of tooth to trauma: 1- pulp hyperemia. 2-int. resorption. 3-ext. resorption. 4-pulp cacification. 5-pulp necrosis. 6-Ankylosis.

Reaction of tooth to trauma: 1- infraction. Pulp hyperemia Reaction of tooth to trauma: 1- infraction. Pulp hyperemia. 2-uncoplicted crown #. Int. hemorrhage . 3-crown /root #. Pulp calcification. 4- root #. Int. resorption. 5- Concussion. Ext. resorption. 6- Subluxation. Pulp necrosis. 7- lat. Luxation. Ankylosis.

 -Effect of trauma on deciduous tooth on under lying developing permanent tooth 1- crown: Hypoplasia (Turner's hypoplasia). Dilacerations. Germination. 2- Root: Arrest of formation. No apical closure. 3- Tooth germ: Odontome. Arrest of formation partial or complete. 4- Eruption: Delayed eruption Retained primary teeth Ectopic eruption

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