1. Traumatic injuries to anterior teeth

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

3. 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 %)

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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).

17. 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

18. 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

19. 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.

20. 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.

21. 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.

22. 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 ….

23. 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.

24. 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.

25. 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)

26. 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.

27. 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 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.

28. 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 .

29. 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.

30. 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.

31. 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.

32. 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.

33. 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 .

34. 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 .

35. 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.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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

41. 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)
min -6 hrs in HBSS, Cold milk then doxycycline for 5 min Replantation.
min -6 hrs in water or saliva change to HBSS
Replantation.
(Dry media)
1- < 6hrs change to HBSS Replantation.
2- >6hrs No Replantation.

42. B) Closed apex : 1- < 15 min extra oral
B) Closed apex : 1- < 15 min extra oral min -6 hrs HBSS or cold milk. Replantation min -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

43. 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.

44. 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).

45. 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.

46. 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 suggested that pulp contents removed at emergency visit + tetracycline & corticosteroid combination to inhibit inflammatory reaction & decrease incidence of root resorption.

47. 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.

48. 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 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

49. 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%

50. 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

51. 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.

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

53. 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.

54.  -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

55. THANK YOU EVERYONE.....