1. Treatment of dento-alveolar injuries
Dr. Mohammad A. Barayan

2. N.B Boys are three times more at risk than girls.
Definition :
Injury which is limited to the teeth and supporting structures of the alveolus.
N.B Boys are three times more at risk than girls.
Causes :
1- Traffic Accident.
2- Falls.
3- During Epileptic seizures.
4- Sport injuries.

4. 3) Previous dental history 4) History of trauma (when ,how ,where )
1) Personal history
2) medical history
3) Previous dental history
4) History of trauma (when ,how ,where )

5. 2) where did the accident occur ?
History of trauma
1) When did the accident occur ?
The shorter the time between accident and treatment the better prognosis.
2) where did the accident occur ?
If the accident occurred in dirty place prophylactic tetanus is indicated
3) how did the injury occur ?
Direct force under the chin → → condylar fracture
Direct force to teeth → → Crown F, Root F, displacement

6. (2)Clinical Examination
Extraoral Examination
Laceration ; Abrasions ; Contusions on the head and neck can be noted visually
Any asymmetries including deviation in mouth opening.
Intraoral Examination
Soft tissue ( tongue ; gingiva .. )
Teeth ( displacement ; mobility ; tooth fracture ; colour change )
Begins immediately when the patient enters the office . Hematoma in the fioor of the moth indicate mand F . If ther is more than 2 teeth alveolar F should be suspected . Non vital tooth often appear dis colored

7. (3)Vitality test
Vitality test just following traumatic injury often given false negative response
Types of vitality test
1) Thermal pulp test
cold test
heat test
2) Electrical pulp test
3) Cavity test

8. Treatment *soft tissue injuries 2- Adequate debridment of the wound
1- Determination of child immunization status:-
If the child had received a primary immunization activated with booster injection of toxoid .
Unimmunized child can be protected by tetanus antitoxin.
2- Adequate debridment of the wound

9. (4)Radiographic Examination
1- stage of root formation
2- presence of root fractur
3- periapical radiolucencies
4- injury of the supporting periodontal membrane
(degree of intrusion or extrusion o the tooth)
5- size of the pulp
N. B. If a jaw fracture is suspected extaoral radiographs indicated (panoramic and lateral oblique views )
All traumatized teeth should be take a x-ray

10. Classification of tooth fracture
Ellis classification:
Class I:
crack or fracture of E only
Class II:
fracture of E , D with out pulp exposure
Class III:
fracture of E , D with pulp exposure
Class IV:
Fracture line passes beneath the gingival margin
Class V:
Root fracture
a) vertical b) horizontal (apical , middle , cervical)
There are more than 2 classification for classifyng dental trauma but the ellis classifictaion is the most famous and used

11. Class I : 1- a crack of the enamel without loss of tooth structure.
Do not require immediate treatment.
2- fracture of enamel only smoothing the sharp edge
regular vitality test , radiograph
If the patient came immediately after the trauma (vitality t ,x-ry) very important to provide the basis for comparison of subsequent examination if the patient came very late (no apparent effect or dest calcification or necrosis or resoption )

12. Class II : Immediate treatment of the crown is required to:
1) protect the pulp
2) restore the esthetics and function.
Cover the expose of the dentine by a layer of calcium hydroxide to reparative dentine formation.
A- Reattachment of tooth fragment.
B- Acid-etch composite resin restoration

13. Class III : The treatment depends on many factors such as:
1) vitality of the exposed pulp.
2) Size of the exposure.
3) Time elapsed since the exposure.
4) Degree of root maturation.
5) Restorability of the fractured crown.
The main objective of treatment is to maintain the vitality of the tooth.

14. Direct pulp capping Large exposure Small exposure Late Early Closed
open
closed
Close
Open
pulpectomy
Pulpectomy
Apexification
Pulpotomy
pulpotomy
Direct pulp capping

15. Apexification :

16. 1- tooth can be extruded orthodontically
Class IV :
Treatment usually involve removing the loose fragment .
1- tooth can be extruded orthodontically
2- crown lengthening to gain access to placement of restoration.

17. Class v : 1) Horizontal Root fracture
When the fracture occur near the apical 1/3, the prognosis is more favourable than the middle or cervical 1/3 because :
1) more alveolar support
2) immobilization of the tooth is much easier
Treatment of root fracture depends upon :
1) Condition of the pulp
2) amount of mobility or the level of the fracture line
If you tack x_ray immediately following the trauma may be not see the R F , tack anther x-ray after 1-2 weeks . If the F segments close proximity and the pulp remain vital callus may reunite the two segments

18. 1) reduction , splinting the tooth
(A) apical 1/3 root fracture
1) reduction , splinting the tooth
2)the tooth should be checked periodically for vitality and radiograph.
Reduce the occ surface Digital pressure , composite splint .

19. (B) middle 1/3 root fracture :
1) reduction , splinting the tooth
2)the patient recall 2-3 months , checked the vitality ,radiograph
3)if the tooth non vital and no healing the following treatment is performed:
a) R C T of both fragments
b) apical fragment removed surgically
c) intraradicular pin to stabilize both segments

20. (C) cervical 1/3 root fracture :
1)reductin , splinting the tooth
2)recall the patient periodically and checked the vitality and radiograph
3)if there is radiolucent and pulp necrosis the following treatment is performed
a) extraction the tooth
b) removed the apical fragment and endo-osseous implant placed
c) orthodontic extrusion
d) if the fracture is 1-2mm infrabony remove the coronal segment and osteoplasty to expose the root

21. 2) vertical root fracture :
usually the prognosis is not favorable
treatment of V R F :
1)extraction of the tooth
2)using co2 laser and ND:YAG laser beam

22. * Concussion
A mild blow to the tooth resulting in mild sensitivity requires little or no treatment
Need only regular vitality test

23. *subluxation Mobility of the tooth without displacement
Tooth may be sensitive to percussion
If mobility is extensive splint the tooth using the acid –etch splinting technique.
Regular vitality test and radiograph
Often hemorrhage around the gingival margin Toled don’t use the affected tooth , reduce the occlusion

24. Displacement of anterior teeth :
1) lateral luxation
2) intrusive luxation
3) extrusive luxation
4) avulsion

25. Displacement of the tooth in any direction other than the axial one
1) Lateral luxation :
Displacement of the tooth in any direction other than the axial one
If the patient comes immediately after trauma reposition, splinting
Once the tooth have solidified in their position orthodontic treatment is required
The root displaced on the opposite direction to the crown . There is mobility and tender to percussion . X-ray widening in PDL . The prognosis for tooth retention is fair and for pulp retention it is poor

26. 1) Intrusion: Displacement the tooth into the socket A) primary tooth:
will re-erupted over a period of few months. If the intruded tooth is in contact with underlying permanent tooth should be remove
B) permanent tooth:
a) immediate surgical repositioning , splinting
b) orthodontic extrusion
c) incomplete root formation the tooth will erupt spontaneously
The crown appear short . Discontanus PMS . . Almost pulp is necrosis especially in mature apex . Tender to percussion no mobility . External R resoripion, loss of marginal bony support complcation of surgical reposition

27. 2) Extrusion : Partially displacement the tooth out of the socket .
A) primary tooth: Treatment usually extracted
B) permanent tooth :
reposition and splinting
If the vitality of tooth is lost start root treatment immediately placing calcium
hydroxide in the canal for 6-12 month followed permanent filling.
The crown appear long . Mobility

28. Complete displacement of the tooth from the socket .
3) Avulsion:
Complete displacement of the tooth from the socket .
There are tow important factors to be consider in cases of avulsion
1)time between the injury and treatment
2)condition under which the tooth have been restored
The tooth must be kept moist to prevent damage to the fibers of PDL

29. In many cases the initial patient contact is by phone
The tooth should be handled by the crown
The tooth should be placed in suitable storage medium (milk, unsalted water, lens solution )or in buccal vestibule or under the tongue .
At the dental office :
a) information about tetanus immunization should be obtained
b) replantation , splinting for 1_2weeks but in immature apices 2-3weeks
c) calcium hydroxide should be placed
d) RCT
Primary tooth: usually the treatment is extraction

30. Alveolar fracture there may be concomitant injuries
Small fracture through the alveolar
process.
there may be concomitant injuries
(crown, root fracture and soft tissue) managed by referral to an oral and maxillofacial surgery .
Treatment: redaction , splinting

31. Types of splinting : 1) acid_etched composite splinting
2) Interdental wiring
3) ( vacuum_formed plastic) splint
4) arch bare splint
More rigid and the longer the stabilization, the more root resorption , ankylosis that can be expected .
we can used the Composite with orthodontic wire or heavy nylon suture

32. Stabilization periods for dentoalveolar injury
Duration of immobilization
Dentoalveolar injury
7 _ 10 days
1) Mobile tooth
2 _ 3 weeks
2) Tooth displacement
2 _ 4 months
3)Root fracture
4) Avulsion
4 _ 6 weeks
5) Alveolar fracture

33. سبحانك اللهم وبحمدك
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نستغفرك ونتوب إليك

34. Thank you