1. The traumatic dental injuries

2. I- Causes of traumatic injuries

3. Injuries
Sport related - 1.5% -3.5%

6. Injuries
Playground - school

8. Injuries
Fights

9. Injuries
Road traffic accident

10. II- Incidence of traumatic injuries.

11. Age distribution Traumatic injuries can occur at any age.
Most commonly at the age of 2 to 5 years ” children are learning to walk”.
Another age is 7 to 12 years “ increased sports activity, and learning bicycle, etc

12. Sex
Prior to 1960s boys to girls ratio in traumatic injuries used to be 3:1 but because of more involvement of females in sports, it has reduced to 2:1.

13. site
Maxillary central incisor is most commonly affected (80%) tooth followed by
maxillary lateral incisor and mandibular incisors

14. IV -Predisposing factures .
Mentally handicapped patients and those with neurological disorders.
Class II div 1 malocclusion.
Destructive defects of teeth ..Enamel hypoplasia.
Contact of sports ..act of violence.

15. III- Prognosis of traumatic injuries.

16. The outcome of dental injury is influenced by patient age, severity, and treatment
offered. In most of the cases, immature permanent teeth with injuries have better
prognosis than mature teeth with same injuries.
Follow-up evaluation is also important, e.g. if root resorption is detected early, it
can be arrested.
Extent of trauma can be assessed by four factors (Hallet;1954)
Energy of impact: more mass or high velocity creates more impact.
Direction of impacting force:
Shape of impacting object: Sharp or blunt
Resilience of impacting object: Hard or soft

17. IV- Classification of traumatic injuries.

18. The currently recommended classification is one based on the WHO and
modified by JO Andreasen and FM Andreasen. This classification is used by
International Association of Dental Traumatology.
1- Soft Tissue Injuries:
Lacerations
Contusion
Abrasions
2- Tooth Fractures:
Enamel fracture
Complete..chipping
Incomplete.. cracks
B- Crown-fractures-uncomplicated
(no pulp exposure)
c. Crown-fractures-complicated
(with pulp exposure)
d. Crown-root fractures
Uncomplicated crown—root fracture
Complicated crown—root fracture without pulp exposure
e. Root fractures
3- Luxation Injuries
concussion
Subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation
Avulsion
4- Facial Skeletal Injuries
Fracture of alveolar process of mandible
Fracture of alveolar process of maxilla
Fracture of body of mandible
Fracture of body of maxilla

19. V- Diagnosis of traumatic injuries.

20. I- CASE HISTORY
Chief Complaint
Medical History
Dental history

21. Chief Complaint Patient should be asked for pain and
other symptoms (bleeding) . These
should be listed in order of importance
to the patient . ”PATIENTS OWN WORDS”

22. Medical History • Allergies, as reaction to medication
• Systemic disorders like bleeding problems, diabetes, epilepsy, etc.
• Any current medication patient is taking
• Condition of tetanus immunization—In case of contaminated wound, booster dose should be given if more than 5 years have elapsed since last dose. But for
clean wounds, no booster dose needed, if time elapsed
between last dose is less than 10 years.
Neurological assessment : signs of dizziness or nausea and vomiting
May indicate brain concussion ………..further investigations

23. When, how, where of the trauma are significant..
Dental history
Past dental history
To reveal any special dental procedures
To determine the pts cooperation level, attitude.
To explore the incidence of any previous traumatic injury.
History of Present Illness
When, how, where of the trauma are significant..

24. When where How The Shorter the time
between trauma and the treatment, the better the prognosis
“predict the condition of the pulp”
where
Location of the
Accident is important
for prognosis and ttt
plan.
‘Street accident ‘
Vaccine
How
Direct trauma
Indirect trauma

25. II- clinical examination:
Extraoral Examination
Intraoral Examination

26. Extraoral Examination
Mental status, orientation, consciousness level and vital signs.
General condition
Head and neck findings “nasal hemorrhage, neck pain”
Facial fractures, facial asymmetries.
Hemorrhage.
Impacted foreign body.
TMJ deviations.
Soft tissue examination.

27. Intraoral Examination
Soft Tissue examination:
Lacerations of lips and intraoral soft tissues must be radiographically examined
for presence of any tooth fragments and/or other foreign bodies.
Hematomas “ hematoma of the floor of the mouth indicate mandibular fracture”.
Penetrating wounds ..cut wounds.

28. B- Hard Tissue examination:” Teeth and its supporting structures”
Check the occlusion: Abnormalities in occlusion can indicate fracture of
jaws or alveolar process.
Several teeth out of alignment: indicate
fracture of mandible or maxillary basal bone.
Check mobility in all the directions. If
adjacent teeth move along with the tooth
being tested, suspect the alveolar fracture.
In crown fracture, the crown is mobile but
tooth will remain in position

29. Looseness of individual teeth , displacement from the socket.
Tooth displacement:
Extrusion & Intrusion.
Lateral luxation.
Avulsion.
Tooth discoloration
Crowns fracture
Mobility of crown &mobility of tooth
Each cusp and incisal edge must be percussed with mirror handle to check
incomplete fracture.
pulp involvement
Root fracture can be felt by placing finger on mucosa over the
tooth and moving the crown.

30. Root fracture can be felt by placing finger
on mucosa over tooth and moving the crown

31. III- Condition of Pulp
The sensitivity is not reliable in traumatized teeth, because THE TOOTH
is in state of shock “THE EDEMA IS PRESSING ON THE NERVE FIBERS
PREVENTING THE TRANSMISSION OF IMPULSES “.
Teeth which give a +ve response at initial exam cant be assumed to
be healthy and will continue to give +ve response.
Teeth which give a -ve response at initial exam cant be assumed to
be necrotic and will continue to give - ve response.
Various studies have shown that pulp may take as long as nine months
for normal blood flow to return to the coronal pulp of the traumatic tooth.

32. If the sensitivity are not reliable , then why we use it ??????????
They are performed at the time of initial examination and recorded to
establish a baseline reference for comparison with subsequent repeated
tests in future

33. PULP SENSITIVITY TESTS
They test nerve function and not the presence or absence of blood circulation.
Thermal Test
Cold test:
Ice rod (0°C).
• use of ethyl chloride (–4°C):
–Cotton pellet saturated with ethyl chloride–
Spray of ethyl chloride:
After isolation of tooth with
rubber dam, ethyl chloride spray
is employed. The ethyl
chloride evaporates so rapidly
that it absorbs heat and
thus, cools the tooth.

34. Frozen carbon dioxide (dry ice) is available in the form of
solid stick which is applied to facial surface of the tooth.
Advantage of using dry ice is that it can penetrate full
coverage restoration and can elicit a pulpal reaction to the
cold because of its very low temperature (–78°C).
• EndoIce Dichlorodifluoromethane (Freon) (–21°C) and 1, 1, 1,
2-tetrafluoroethane (–15 to –26°C) are also used as cold
testing material.
COLD WATER BATH

35. HOT test:
ELECTRIC PULP TEST
VITALITY TESTS

36. IV- Radiographic Examination
Three angulations recommended by International Association of
Dental Traumatology (IADT) are:
1. Occlusal view
2. Lateral view from mesial or distal aspect of the tooth
3. 90° horizontal angle with central beam through the tooth
It should be done in the area of suspected injury and in sof tissue injury before
suturing.
An occlusal exposure of anterior region may show lateral luxations, root
fractures or alveolar region. Periapical radiographs can assess
the crown as well as cervical root.

37. Radiograph showing
root fracture in
premolar

38. V- Clinical Photographs
Clinical photographs are helpful for establishing clinical record for monitoring
the patient and treatment progress.
They also help in being as additional means of documenting injuries for
Legal purposes and insurance.

40. The role of endodontics after Traumatic dental injuries.
Theraputic aim is: to maintain
the pulp vitality

41. The currently recommended classification is one based on the WHO and
modified by JO Andreasen and FM Andreasen. This classification is used by
International Association of Dental Traumatology.
1- Soft Tissue Injuries:
Lacerations
Contusion
Abrasions
2- Tooth Fractures:
Enamel fracture
Complete..chipping
Incomplete.. cracks
B- Crown-fractures-uncomplicated
(no pulp exposure)
c. Crown-fractures-complicated
(with pulp exposure)
d. Crown-root fractures
Uncomplicated crown—root fracture
Complicated crown—root fracture without pulp exposure
e. Root fractures
3- Luxation Injuries
concussion
Subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation
Avulsion
4- Facial Skeletal Injuries
Fracture of alveolar process of mandible
Fracture of alveolar process of maxilla
Fracture of body of mandible
Fracture of body of maxilla

42. Crown-fractures 1- CROWN INFRACTION
Def: is an incomplete fracture or crack of enamel without loss of tooth structure.
Biological Consequences
• Fracture lines ……weak points …….bacteria & their products can travel to pulp………..little possibility of necrosis.
A 5 years Follow up period is the important endodontic prevention measure.

43. Diagnosis
fiberoptic light source, resin curing light, indirect
light or by transillumination
dyes.
Treatment
Just follow up:
• Regular pulp testing should be done and recorded
for future reference.
• Follow-up of patient at 3, 6 and 12 months
interval is done
, but if rough edges are present:
• Smoothening of rough edges .
• Repairing by composite if needed.

44. Prognosis Sequel: Prognosis is good for infraction cases
Pulp resolution.
Pulp necrosis
Internal resorption.
Calcific metamorphosis.

45. 2- Uncomplicated Crown Fracture
Def: fracture involving enamel or enamel and dentin
but pulp is not involved.
Incidence: most frequent dental injury.( 1/3 to ½
of dental trauma.)
Biological Consequences
• if dentin is exposed, a direct pathway for irritants through dentinal tubules to the pulp .
• Pulp may remain normal or may get chronically inflamed depending upon
proximity of fracture to the pulp, size of
dentinal tubules and time of the treatment provided. .

46. Diagnosis Treatment Prognosis
sensitivity to air, heat and cold liquids .
Treatment
• In case of enamel fractures, selective grinding of incisal edge.
• For esthetic reasons, composite restorations can be placed
after acid etching.
If there is involvement of both enamel and dentin:.
• Calcium hydroxide placed over exposed dentin closure of dentinal tubules.
If the fracture fragment of crown is available, reattach it
It requires acid etching and application of bonding agent.
After removal of any soft tissue remnants, fractured site is disinfected.
Prognosis
Patient should be recalled and sensitivity testing is done at
the regular interval of 3, 6 and 12 months. Prognosis is good.

47. Rebonding of fractured crown

48. 3- COMPLICATED CROWN FRACTURE
Def :Crown fracture involving enamel, dentin and
pulp
Incidence
It occurs in 0.9 to 13 % of all the dental injuries.
Biological Consequences
• the first reaction after the injury (first 24hrs) is ………..hemorrhage and local inflammation which doesn’t extend beyond 2mm into the pulp.
After 48 hrs, there's greater chances of :
Direct bacterial contamination.
Progression of inflammation apically.
Pulp necrosis. .

49. Treatment plan and prognosis:
Diagnosis
It is made by clinically evaluating the fracture and by
pulp testing and taking radiographs
Treatment plan and prognosis:
It depends on :
Stage of root maturation Maintaining the pulp
vitality is main concern at least until the root continue
to develop.
“The pulp produces dentin and if the pulp dies before
The apex closes, root wall development will be
permanently arrested”
The time between the trauma and the treatment
Concomitant periodontal injury
The restorative treatment plane: pulpotomy rather than pulp capping in case of complex restorations

50. Treatment options are :
Vital pulp therapy …pulp capping or pulpotomy ……..immature .
Pupectomy …RCT….mature.
Regenerative therapy…RET…immature .

51. 4- CROWN ROOT FRACTURE
Def. : fracture involves enamel, dentin and cementum with or without the involvement of pulp.
It is considered as more complex type of injury because of its greater severity and involvement of the pulp.
It’s a periodontal rather than an endodontic challenge.
Chisel shaped fracture of 22 splitting crown and root

52. Biological Consequences
• Identical to complicated or uncomplicated fracture depending upon
the pulp involvement.
• In addition to these, periodontal complications are also present
because of encroachment of the attachment apparatus.
Diagnosis
A tooth with crown root/fracture exhibits following features:
• Coronal fragment is usually mobile. Patient may complain
of pain on mastication due to movement of the coronal
portion.
• plaque accumulation in the line of fracture.
• Patient may complain of sensitivity to hot and cold.
• Radiographs are taken at different angles
• Indirect light and transillumination.

53. Treatment Infracrestal Supragingival extraction Treatment with
Objectives of treating crown root fracture :
• Restoration of the coronal portion as complicated or uncomplicated
crown fracture.
• Allow subgingival portion of the fracture to heal.
Depending upon extent of fracture following should be
considered while management of crown root fracture:
Infracrestal
extraction
Supragingival
Treatment with
restoration
Subgingival
Crown lengthening
Gingivectomy
Alveloplasty
Osteoplasty
Orhodontic extrusion

54. Crown-root fracture without pulp
involvement can be treated by removing the coronal segment and restoring it with composite

55. B A C
Fractured fragment reattachment. (A) Photograph showing fractured 11; (B) Radiograph showing oblique
fracture in middle third of crown; (C) Palatal view of fractured segment; (D and E) Fractured fragment removed and preserved in saline; (F) Root canal treatment initiated and working length radiograph taken D E F

56. (G) Master cone radiograph; (H) Postoburation radiograph; (I and J) Post-space preparation;
(K) Fiber post-cementation; (L) Fractured fragment reattached;

57. (M) After suturing and surgical dressing; (N) Postoperative photograph;
(O) Postoperative radiograph; (P and Q) Follow-up after 6 months

58. When root portion is long enough to
Accommodate postsupported crown, remove
the coronal segment, extrude root
fragment and perform endodontic therapy
Orthodontic extrusion of root;
(B) Restoration of tooth after endodontic therapy

59. ROOT-fracture Diagnosis and clinical presentation:
These are uncommon injuries “only 3%” but represent a complex
healing pattern due to involvement of dentin, cementum,
pulp and periodontal ligament.
Diagnosis and clinical presentation:
Clinical mobility of the tooth
Displacement of the coronal segment: (no mobility ‘apical
fracture’ to extensive mobility ‘’cervical fracture’).
Palpation tenderness over the root
Radiographic evidence: Since root fractures are usually
oblique, 3 angled x-rays(45, 90, 110 degrees) to be taken
Pain on bitting
Sulcular bleeding

60. A to D Diagnosis of location of root fracture. (A) Palpating
the facial mucosa with one finger and moving crown with other finger;
(B to D) Arc of mobility of incisal segment of tooth with root. As fracture
moves incisally, arc of mobility increases

61. (A) Radiographic beam parallel to fracture;
(B) Radiographic beam oblique to fracture

62. CLASSIFICATION OF ROOT FRACTURES:
VERTICAL fracture
OBLIQUE fracture
(chisel #)
HORIZONTAL fracture
COMPLETE
2 separate parts
INCOMPLETE:
crack in the root without separation
SINGLE
MULTIPLE lines of fractures

63. Treatment objectives : repositioning and splinting of root segments into close proximity as much as possible
Treatment:
No mobility, No displacement …..No TTT……spontaneous healing 80%.
Displacement and mobility ……. Repositioning and splinting.
Splinting period: 2-4 weeks
Splint type : flexible splint to allow functional movement and avoid ANKYLOSIS
follow up :
3,6,12 months and yearly for 5 years

65. Prognosis: It depends on : Mobility
Contamination of the pulp with oral fluids
Location and direction of the fracture
Stage of root development
Time elapsed since injury

67. All the 3 types considered success
Healing pattern of Root Fracture
According to the Andreasen and Hjorting—Hansen, root
fracture can show healing in following ways:
• Healing with calcified tissue in which fractured fragments
are in close contact
• Healing with interproximal connective tissue in which
radiographically fragments appear separated by a
radiolucent line and the fragment edges are rounded.
• Healing with interproximal bone and connective tissues.
Here fractured fragments are seen separated by a distinct
bony bridge radiographically.
All the 3 types considered success
• Interproximal inflammatory tissue without healing,
radiographically it shows widening of fracture line

69. Various treatment options of Complications:
Pulp necrosis occurs in 25% usually in the coronal segment while the apical segment remain vital.
Calcification is common in vital cases.
Various treatment options of Complications:
• Root canal therapy for both coronal and apical segment,
when they are not separated
root canal therapy of coronal segment and no treatment of apical
segment .
• Root canal therapy for coronal segment and surgical
removal of apical third if apical segment is separated

72. • Apexification procedure of coronal segment.
Intraradicular splint
Endodontic implants,
Orthodontic extrusion
extraction