TRAUMATIC INJURIES TO

THE TEETH

INTRODUCTION
Traumatic injury: Defined as a damage to a part of
body tissue.
Considered as an emergency situation in dentistry.
Due to technological advancements and hectic
lifestyles, incidence of trauma is on rise.
Effects the progress, behavior and psychological well
being of child
Can lead to inferiority complex- failure of child in
future.
Management merits special attention

Terminologies Regarding TDI

Crown craze or crack: Crack or incomplete fracture
of enamel without loss of tooth structure in
horizontal or vertical direction
Crown fracture: Confined to enamel; to enamel and
dentin; to enamel, dentin and pulp; may be
horizontal, vertical or oblique direction involving
mesioincisal or destoincisal line angles
Crown root fracture: With or without pulp
involvement
Root fracture: Involving apical, middle or cervical
third in either horizontal or vertical direction

 Intrusion- displacement of the tooth into its socket

Extrusion- partial displacement or tooth out of its socket
Labial displacementpatients lip

movement

of

tooth

towards

Palatal/Lingual displacement- towards patients palate

Lateral displacement- mesial or distal displacement
Avulsion- (lost or exarticulated) -complete displacement
of tooth from its socket

CLASSIFICATI
ON

ELLIS AND DAVEY CLASSIFICATION

(1960)
CLASS I

Simple fracture of crown, involving

little or no dentin

CLASS II

Extensive fracture of the crown

involving considerable dentin, but not
the dental pulp

CLASS
III

Extensive fracture of the crown

involving considerable dentin, and
exposing the pulp

CLASS IV

Traumatized tooth which becomes non

vital with or without loss of crown
structure

CLASS V

Teeth lost as a result of trauma

CLASS VI

Fracture of the root with or without

loss of crown structure

CLASS VII

Displacement
of
tooth
fracture of crown or root

CLASS VIII

Fracture of the crown en mass and its

replacement

CLASS IX

Traumatic injuries of primary teeth

without

MODIFIED ELLISS
CLASSIFICATION

[ BY MCDONAD, AVERY AND LYNCH(1983)]

CLASS I

Simple fracture of crown, involving little

or no dentin

CLASS II

Extensive fracture of the crown

involving considerable dentin, but not
the dental pulp

CLASS III

Extensive fracture of the crown

involving considerable dentin, and
exposing the pulp

CLASS IV

Loss of the entire crown

Clinical Classification By
Andreasen
(1992)
A. INJURIES
TO HARD DENTAL
TISSUES AND
PULPincomplete fracture
Enamel infraction:
N 502.50 (crack) of enamel without loss of the
tooth structure
Uncomplicated crown fracture:
contained to enamel
N 502.50 Uncomplicated crown fracture: Enamel
fracture- Involving enamel only
N 502.50 Uncomplicated crown fracture: enamel
dentin fracture-Involving enamel and
dentin, but not involving pulp
N 502.52 Complicated crown facture: involving
enamel, dentin and exposing pulp

N 502.53 Root fracture:Fracture involving dentin,

cementum and pulp
N 502.54 Uncomplicated crown root fracture:
involving
enamel,
dentin,
and
cementum but not involving pulp
Complicated crown root fracture:
involving
enamel,
dentin,
and
cementum and exposing pulp

Root fracture

B) INJURIES TO THE PERIODONTAL TISSUES

N
injury to
Concussion:
503.2 tooth supporting structure
0
with
out
abnormal
loosening or displacement
of tooth, but marked
reaction to percussion
with
Subluxation:
abnormal loosening but
without displacement o
the tooth
N
Intrusive luxation (central
503.2 dislocation): displacement
1
into the alveolar bone

N
503.2
0

Extrusive
luxation(peripheral
dislocation, partial
avulsion): Partial
displacement of tooth out
of its socket
Lateral luxation:
displacement other than
axial direction

N
503.2
2

Exarticulation (complete
avulsion): Complete
displacement of tooth out
of its socket

C) Injury to the supporting bone

Compression fracture of alveolar socket
(N 502.40,502.60): a crushing of socket bone during
intrusive injury to dentition
Alveolar socket wall fracture : fracture of labial or lingual
socket wall
Alveolar process fracture
Maxillary fracture (N 802.42)
Mandibular fracture (N 802.21)

D) Injuries to gingiva or oral mucosa

Laceration of gingiva or oral mucosa (S 01.50):
A shallow or deep wound in mucosa resulting
from a tear.
Contusion of gingiva or oral mucosa (S 00.50):
A bruise usually produced by impact from a
blunt object ad not accompanied by a break in
the continuity of mucosa; causing submucosal
hemorrhage.
Abrasion of gingiva or oral mucosa (S 00.50): A
superficial wound produced by rubbing or
scraping of mucosa leaving a raw bleeding
surface.

 WHO recently (1993) has recommended

Andreasens classification following only
injuries to dental hard tissues and
periodontal
tissue
in
WHO

classification of trauma to anterior

teeth

Epidemiological Classification of TDI

Including WHO International Codes

Code
Code
Code
Code
Code
Code
Code

0:
1:
2:
3:
4:
5:
6:

No injury
Treated Dental Injury
Enamel Fracture only
Enamel/dentin fracture
Pulp injury
Missing due to trauma
Excluded tooth

Classification by Ulfohn

Evolved from clinical endodontic point

of view:

a. Fracture of enamel
b. Fracture of the crown with indirect
pulp exposure through the dentin
c. Fracture of the crown with direct pulp
exposure.

Garcias Godoy Classification

0
1
2
3
4
5
6
7
8
9
10
11
12

Enamel crack
Enamel fracture
Enamel dentin fracture without pulp exposure
Enamel dentin fracture with pulp exposure
Enamel dentin cementum fracture without pulp
exposure
Enamel dentin cementum fracture with pulp
exposure
Root fracture
Concussion
Luxation
Lateral displacement
Intrusion
Extrusion
Avulsion

PREVALENCE
History of trauma in both primary and permanent teeth
Boys show more frequency than girls in permanent teeth
No significant sex difference in primary teeth
Peak incidence in 1-2.5 yrs
8-11 yrs
Facial injuries- common in boys of 6-12 yr of age,
mandible is most affected
Seasonal variation: injury increases during winter

Prevalence Of TDI To Anterior Teeth In

Primary Dentition
Country

Author

Year

Age-y

Prevalence %

Germany

Kessler

1922-37

0-3

4.5

Denmark

Andreasen

1972

3-7

30.2

Denmark

Ravn

1976

1-3

70

Dominician
republic

Garciagodoy

1983

3-5

35

Brazil

Cunha

2001

0-3

16.3

1999

1-5

15

South africa Hergreaves

Brazil

Kramer

2003

0-6

35.5

Norway

Skaare

2005

1-8

1.3

Prevalence of TDI To Anterior Teeth in

Permanent Dentition
Country

Author

Year

Age-yrs

Prevalence
%

Canada

Ellis

1948

Schooler

4.2

Denmark

Andreasen &
Ravn

1972

7-16

22.3

Dominican
republic

Garcia-godoy F

1985

6-17

12.2

India

Rai- Munshi

1998

3-16

5.29

India

Gupta & Tandon

2002

School
children

13.8

India

Pradeep
tangade

2007

12-15

4.41

Germany

Bauss

2004

12

10.3

Teeth involved37% upper central incisor

18% lower central incisor
6% lower lateral incisor
3% upper lateral incisor
Frequency increased with increase in over jet
More prone place of trauma:
Home > school > roadside
WHO suggests children who are careless and come
from broken homes are prone to injuries

ETIOLOGY

Unintentional TDI

1) Falls And Collisions: (30-40%)

Frequent during first year of life due to lack of

motor co-ordination
Peak incidence just before school age

2) ACCIDENTS: (20-25%)
Bicycle accidents, automobile accidents,
play ground accidents

3) Sports:
Sports like cricket, football, baseball, basketball,
wrestling, kabbadi, etc

4) Inappropriate use of teeth

Biting a pen, opening hairclips
5) Biting hard items
6) Presence of illness, physical limitations or learning
difficulties

Intentional TDI
Batterred Child Syndrome:
Abused or neglected child who have suffered
serious physical abuse
Occurs in approx. 0.6% of children
10% Of all injuries involve teeth
Luxation of four
incisors and bruising of
upper buccal sulcus as
a result of blow to the
mouth

PREDISPOSING FACTORS
Facial profile: More common in,
Angles class II type I malocclusion
Angles class I type II malocclusion
Inadequate lip coverage
Cerebral palsy:
Dentinogenisis imperfecta
Epileptic patients

Mechanism of dental trauma

(Andreasen and Bennett)
- Direct trauma: occurs when the tooth itself is hit
Direct trauma to the upper teeth
transmitted though lip resulting in
extrusive luxation of central
incisor and laceration of gingiva

- Indirect trauma: inflicted when lower dental arch is

forcefully closed against the upper

Severity Of Injuries To The Teeth Depends

On
Energy of impact
Resiliency of the impacting object
Shape of the impacting object
Angle of direction of the impacting
force

EXAMINATION AND DIAGNOSIS

HISTORY
When- Time interval indicates the feasibility of replacing an
avulsed tooth or direct capping for an exposed dental pulp
Where- Need for tetanus prophylaxis
How- May indicate the need for change in drug regimen or
head harness in severe epilepsy patient to protect them
from further falls
Nature of accident can give information on type of injury
sustained.

Additional information:
a. Previous accidents involving the teeth
b. Prior treatment for the present injury
c. General health of the patient
Episodes of amnesia, unconsciousness, vomiting or headache
indicate cerebral involvement.

Subjective symptoms:
- spontaneous pain
- sensitivity or discomfort to touch
- pressure of eating or chewing
- pain from temperature variation
- reaction to sweet and sour food
- mobility
- displacement
- variation in occlusion

1.

Clinical
Examination
Extraoral wounds and palpation of

the facial

skeleton
2. Injuries to oral mucosa/gingiva
3. Examination of crowns of the teeth
4. Displacement of teeth
5. Abnormal mobility of teeth or alveolar fragments.
6. Palpation of alveolar process
7. Tenderness of teeth to percussion
8. Reaction of teeth to pulpal sensibility testing

Radiographic examination
Intra and Extra Oral Radiographs

Clinical evaluation of injury to the teeth

Treatment given Else where or source of referral?
History of previous injury: sustained or repeated
injury influences the vitality and recuperative
capacity of the pulp
Examination: of entire injured site after cleaning all
debris and blood
Signs and symptoms:
- Pain
- Crepitation
- Limited mandibular opening
- Step defects in bone contour
Anesthesia/Paresthesia

Displacement: -Intrusion
- Extrusion
- Avulsion
Abnormalities of occlusion
Mobility of teeth and alveolar fragment
Test for mobility
Reaction of teeth to percussion & pulp testing

Heat

Cold

Electrical

LDF

Pulp Response To Trauma

1.
2.
3.
4.
5.

Bacteria invades pulp in cases of complicated

crown fracture or through periodontal ligament
through fracture line.
May become partly or totally severed and/or
crushed at apical foramen during luxating
injuries.
Traumatic insults ends up with any of following:
Tertiary dentin formation
Internal resorption
Pulp calcification
Bone metaplasia
Pulp necrosis with and without infection

 In case of severance of vascular supply to the

pulp due to luxation or root fracture, width of
pulp-periodontal
interface
is
decisive
for
revascularization.
If infection in pulp occurs during ischemic phase
after luxation or replantation, revascularization
becomes permanently arrested.
Prognosis of primary teeth showing pulp
obliteration is favorable and normal root
resorption can be expected. (Jacobsen and
Sangnes)
Evidence of abnormal hard tissue formation in
pulp chamber may exhibit normal periradicular
conditions with partial obliteration or pathologic
periradicular changes indicating pulp necrosis
(Jacobsen and Kerekes)

EMERGENCY CARE (ABCD)

Maintaince of air way: Suctioning and placing the
patient in prone position or on the side.
Endotracheal intubation and/or tracheostomy in
few serious cases
Control of bleeding:

-By direct pressure

-Suction
-Clamping of the vessel
-Ligation of vessel

Appropriate fluid replacement

Tetanus Prophylaxis
Anesthesia prior to debridement

Clinical management of crown

fracture
Infractions:
Common in traumatic injuries of permanent
dentition
Infraction pattern depends upon the direction of
force and on the impact site location on each
affected tooth
Visualized by Transillumination

Injury usually limited to enamel or stops at DEJ

Treatment:
Do not require definitive treatment
Vitality test should be done
Endodontic therapy: when patient develops symptoms of
necrotic pulp or radiographic signs of periapical pathosis
Prognosis:
Pulp Necrosis: ( 0-3.5%)

ENAMEL FRACTURES

Involves the loss of portion of coronal tooth enamel

Usually present no threat to pulp
Instead it is annoying to tongue, lip,or buccal
mucosa
Can become an esthetic concern of the patient

Clinical management:
Two methods depending on esthetic concern and extent
of tooth loss
1) Recontouring of injured tooth, the adjacent teeth,
and/or the opposite teeth
2) Restoration or missing tooth structure with composite
Treatment should be performed immediately to prevent potential
drifting, tilting, or supraeruption of adjacent and/or opposite
teeth
Prognosis:
Pulp necrosis (o-1%)

ENAMEL AND DENTIN FRACTURES

Uncomplicated crown fractures: Expose large
number of open dentinal tubules to oral cavity,
provides direct communication channel to pulp

Need for treatment

To avoid undesirable esthetic

problem

To avoid
1. Labial protrusion
2. Drifting or tilting of adjacent
teeth
3. Supraeruption of opposing
teeth
4. Bacterial contamination of
dentin and pulp
by oral
fluids

 Immediate treatment:
1. Placing GIC
2. Adapting a temporary crown

1.
2.
3.
4.

Permanent Treatment:
Reattachment of the crown fragment
Restoration with laminate veneer
Restoration with composite resin
Restoration with full coverage crown

Prognosis:
Pulp Necrosis (0-6%)

Factors effecting prognosis

1) Residual dentin thickness: 2mm or more is
sufficient for shielding the pulp from most
form of irritation
2) The area of exposed dentin
3) The length of time the dentin is exposed to
oral fluids

Clinical recognition:
Symptoms: thermal sensitivity/ pain on
mastication
Examination should attempt to reveal minor
pulp
exposures
Clinical management:
Investigations:
Periapical radiograph
Pulp vitality test
Recommended restorations
Adhesive resin
Composite resin system

Conventional treatment:
Application of the hard setting CaOH over the exposed
dentinal surface prior to restoration of the tooth with
dentin bonding agent and composite resin restoration
Action of CaOH:
Antimicrobial
Production of irrational(reparative) dentin
Disadvantage of CaOH:
Dissolve when exposed to 37% phosphoric acid for 60
sec
Have some softening effect on composite resin

 New concept and approaches:

Controversy exists regarding placement of base or line over
exposed dentin
White et al: vital dentin etched for 30 sec with 10% phosphoric
acid and restored with an adhesive resin restoration resulted in
no pulp inflammation or bacterial leakage.

Dentin bonding agent helps in maximizing bonding area

and minimize gap formation between tooth surface and
composite resin.

GIC application to deepest aspect of fracture and then

using dentin bonding agent can compensate for dimensional
stability of resin agent.

Recommended Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.

Clinical assessment/diagnosis, selection of

composite shade
Local anesthetic administration
Cleaning of fractured tooth, gentle irrigation
Rubber dam isolation
Placing of glass inomer liner over exposed
dentin
Preparing the enamel surface
Etching the enamel with 37% phosphoric
acid(30sec),water rinsing(20sec), drying
Applying bonding agent
Restoring the tooth with composite resin and
finishing

Reattachment Of Fractured Segment

1.
2.
3.
4.
5.

Clinical
assessment/diagnosis,
selection
of
composite shade
Local anesthetic administration
Cleaning of fractured tooth, gentle irrigation
Rubber dam isolation
Placing of glass-inomer liner over exposed dentin

6. Etching the enamel segment with 37% phosphoric

acid(30sec),water rinsing(20sec), drying
7. Applying bonding agent
8. Reattaching the fractured tooth segment with
composite resin, finishing and polishing
9. Validating occlusion

Reattachment of
fragment

Pulp testing

Lining with GIC

Etching the enamel

Removing the etchent

Applying bonding
agent

Bonding the fragment

Light polymerization

Removing the surplus

Finfishing and final

restoration

Advantages of immediate fragment

reattachment
1. Short treatment time
2. Immediate hermetic seal of dentinal tubules
3. Immediate restoration of function and
esthetics

Contraindicated

Unruly patient
Concomitant luxation injury prevents dry
operatory field.

Clinical results
Esthetics and retention are of concerned.
Pulp necrosis found later is attributed to the
injury and not to the procedure.
Discoloration or degradation of composite
material at fracture line.
60% of bonded fragments are lost after 5 years
due to new trauma or nonphysiological use of
restored tooth.

Use of Veneer to improve esthetics

after fragment reattachment
Preparation of tooth

Final enamel reduction

restoration

Initial enamel reduction

Completed preparation

Final

Indications
Discolored crown due to pulp necrosis
Autotransplanted premolars
Supplement for bonded fragments.

Restoring technique using crown matrix

Fractured incisor

Gingival Bevel
using metal strip

Facial bevel

Palatal chamfer

Final preparation

Shade selection

Corner matrix cover

only 1-2 mm
outside preparation

Dentin build-up

Light curing and removal

of matrix

Applying enamel
composite

Finished restoration

CROWN FRACTURES WITH PULP EXPOSURE

(COMPLICATED CROWN FRACTURES)
Usually small amount of bleeding from
the exposed vital pulp
Sensitivity to
mastication

thermal

changes

or

May be asymptomatic: depends upon

patients pain threshold, amount of
pulpal tissue exposed, and maturity of
the tooth
Untreated
cases:
initial
pulpal
inflammation followed by granulation,
pulp polyp and pulpal necrosis

 Clinical management:
Pulp capping
Partial Pulpotomy (Cvek Pulpotomy)
Cvek reported 96% success
Fuks et al: reported 94% success
Endodontic therapy
Primary aim is to preserve vitality: pulp capping and
partial Pulpotomy is recommended.
Periodic recall evaluation is necessary
When pulp shows radiographic evidence of pathosis or
becomes
symptomatic
endodontic
therapy
is
necessary.

Contraindication of Pulpotomy
Not indicated in mature teeth with concurrent
displacement injuries; displacement injuries
involve vascular damage
Partial calcification of pulp
Degenerative and/or inflammatory changes with
in the pulp
Fracture is extensive and requires post for
restoration- Pulpectomy followed by endodontic
therapy is recommended

Potential complication of pulpotomy/pulp capping

procedures
Canal calcification
Internal resorption
Pulp necrosis

Complicated Crown Fracture

Vital pulp exposure
Open apex

Closed apex

Pulp capping Pulpotomy

Root apex closure
RCT

RESTORATION

RCT

Necrosed pulp/ Discoloured crown

Closed apex

Open apex

RCT Apexification
RCT
RESTORATION

Crown Root Fractures

A fracture involving enamel, dentin and
cementum.
According to pulpal involvement can be
complicated or uncomplicated.
Accounts for 5% of injuries affecting the
permanent dentition and 2% in the primary
dentition.
Anterior region- direct trauma
Posterior region- indirect trauma

Clinical recognition:
Most commonly by a fracture line superior to the
marginal gingiva on the facial aspect of the crown and
following an oblique course below the marginal
gingiva on the lingual surface
Symptoms: Slight discomfort on moving the fracture
segment
Radiograph contributes little to diagnosis

Clinical management:
Emergency treatment- stabilization of the coronal
fragment to adjacent teeth with composite splint
Definitive treatment initiated with in few days
after the injury
Treatment depends on location and type of fracture
If coronal fragment includes more than one third of
the clinical root extraction/endodontics is advised
Vertical crown root fracture should be extracted.

Prognosis:

- essential recall evaluation is necessary

- assessed by radiographs obtained at

time to time

- success is judged by: lack of

symptoms, maintenance of pulp vitality,
stable periodontal attachment apparatus
and/or pulp canal space on radiograph

- failure: clinical symptoms or

degenerative changes in IOPA, necessitate
endodontic treatment or extraction

Removal Of Coronal Fragment And

Supragingival Restoration
Treatment principle
Allow gingival healing whereafter the coronal
portion can be restored.
Indications
Limited to superficial fractures that do not
involve pulp chisel fractures.

CLINICAL MANAGEMENT OF
TRANSVERSE ROOT FRACTURE
Occurs in maxillary teeth
commonly
Involves dentin, cementum, pulp
and periodontal ligament
Account for approx 6% of all
trauma
Principally occurs in adult patients
where the root is solidly supported
in bone and periodontal
membrane, in younger patient
teeth are more likely to be avulsed

 Clinically- transverse root fractures/

luxations / fracture of alveolar
process appear exactly same
Differential diagnosis depends on
reliable radiograph
Transverse root fracture is actually a
luxation of coronal segment only

Clinical and radiographic diagnosis

Clearly evident on radiograph

Fracture line may be missed if radiograph is
performed immediately after the injury because at
that stage the line may be barely discernible
Multiple radiographic exposure may be necessary
for disclosure of root fracture

 Radiograph recommended:

- a steep occlusal exposure: ideal for

fractures in apical third

- two conventional periapical

bisecting angle
exposures: better for
fractures located coronally
Direction of fracture line is oblique in
the apical and middle third and changes
to more horizontal in cervical one third

Clinical findings:
- tooth will be slightly extruded with lingually displaced
crown
- coronal segment may be laterally displaced
- 99% of cases the apical segment remains vital
- coronal segment may or may not be vital and may or may
not be mobile depending on,
a. state of tooth at the time of fracture
b. extent of fracture
c. location of fracture

Nature of fracture line

Andreasen and Hjorting-Hansen

classified transverse root fractures into
four categories
1) Coronal and apical segment may
have union by hard tissue
2) Union by fibrous tissue
3) Union by bony ingrowth across the
fracture
line
4) Ingrowth of chronic granulation tissue

Healing by deposition
of cementum

Connective tissue
healing

Granulation tissue healing

Union by hard tissue:

is most desirable
but occurs relatively infrequently.
Can occur in
2 fractured tooth segments are brought together and
remain without mobility
when there is small amount of luxation of coronal
segment (concussion is far better than extrusion)
Small amount of separation of segments
Foramen of coronal segment is large
Patient is young rather than elderly.

 Hard tissue union does not occur in

teeth with restorations or marginal
periodontal disease.
If hard tissue union occurs, the root
may show a stage of Tunnelling
resorption. No effect on prognosis
but appears on radiographs.

 Union by way of fibrous tissue:

- is more common

-where slight mobility exists during healing

process.
Union by in growth of bone:

- Occurs principally during growth spurts of child.

- Coronal segment of fractured tooth moves with

the growing bone and leaves a bony interface b/w the
two fractured segments.

Union by granulation tissue

occurs if infection exists.
Fracture line communicating with oral cavity.
Increased luxation of two segments.
Decreased diameter of fractured foramen
in coronal segment

From the management point of view, the

transverse fractured tooth segments can be
considered separate entities. On practical
level, all treatment regimens are directed at
management of the coronal segment only.

Clinical management
Factors effecting are,
1. the position of the tooth after it
has been fractured.
2. the mobility of the coronal
segment.
3. the status of the pulp.
4. the position of the #ed line.

Position of the tooth

Typically - Slightly lingually placed

- Slightly extruded.
Laterally luxated tooth must be repositioned as soon
as possible.
Administration of local anesthesia.
Grasping the coronal segment and returning it to
normal position.
If mobile - splinting to adjacent teeth.

Mobility of

coronal segment

Related to the force of impact encountered by the

tooth and to the extent of infrabony support of the
coronal segment (related to position of the fracture
line)
Immediate immobilization possibility of
optimum consolidation and repair across the
fracture line.
Maintenance of pulp vitality.
If mobility is minimal, no immobilization is
necessary.

 Splinting period 8-10 weeks.

Semi permanent splinting achieved by joining
teeth across their contact points with pins and
composite restoration.
Tooth bonded composite resin splints or glassinomer splints,often fracture across the
interdental regions.
Use of wire plus an acid etched composite splint
provides relatively firm fixation

Maintenance of excellent oral hygiene is

absolutely critical.

Use of orthodontic band splinting is

contraindicated because it add additional injury to
an area already traumatized.

Status of pulp
- Vital response may be obtained using a pulp tester.
- Pulp may/may not show positive pulp test.
- Patient signs and symptoms are used as an indicator of pulp
status.
- Separation across the fractured root segments often produces
an interruption to the innervation of the coronal segment that
would respond in a nonvital fashion to vitality testing, the
collateral correlation established by the fracture often allows
for maintenance of pulp vitality.
- Coronal pulp should be considered vital unless, pain , a sinus
tract , or granulation tissue across the fracture line is present.

 Revascularization & Reinnervation

depends on
Severity of injury
Healing capacity of the pulp.
Stage of root development.

Pulp necrosis is reported in approx

---40%
Apical segment remains vital in
almost all cases.

 - Endodontic manipulation is confined to coronal

segment only.
- If the apical end of the coronal segment is wide
open, calcium hydroxide paste used as an intracanal
dressing to obtain closure of the coronal segment
apex. Once this is achieved, CaOH is removed and
final root filling is placed.
- If coronal fragment is nonvital & mobile, root
canal treatment can be performed once the tooth is
splinted in position.
- If apical segment is definitely is nonvital, surgical
removal of this segment is necessary.

Position of the fracture line

Three zones
- Apical
- Middle
- Coronal

Fracture in the Apical zone

extends from 5mm below alveolar crest to the
apex of tooth.
- easiest to manage
- simply watch & observe.

Fracture in coronal zone

coronal segment is fractured above the level of
alveolar bone.
- the crown of the tooth will be lost, and after
some gingival recontouring and endodontic
therapy, the tooth can be restored with a
prosthetic crown

Facture in middle zone

- Most troublesome.

- These extend from the alveolar bone margin

to 5mm below it.
Splinting is mandatory
If communication occurs between oral cavity
through gingival crevice coronal segment lost.
Apical segment is retained after removal of
coronal segment to minimize bony resorption.
A small flap technique is performed to cover the
submerged apical segment, there by preserving
the bone.

 In case attempting for post preparation

in apical segment (if sufficient length
of root exists) problems faced are,
1. how is sound and sterile RCT
performed?
2. how can an accurate impression of
root canal and root face be obtained?

Alternative are,
1. periodontal adjustment
disadvantage - unfavorable cosmetic result
2. orthodontic extrusion.
disadvantage - treatment may be prolonged
and the prognosis may be just poor.
3. intra alveolar transplantation of fractured
tooth.

Kahnberg described two methods

1) a flap operation with apical exposure
a bony transplant was positioned above
surgically extruded root to keep it in position.
2) careful extrusion of the tooth by marginal
luxation, interdental suturing, and surgical
dressing.

LUXATION INJURIES
1.

These injuries can range from a mild blow to a tooth to a more severe forms that either force a tooth
into, or partially dislocate it from the alveolar socket.

2.

Depends on direction of impact.

3.

Comprise 15-61% of dental traumas to permanent teeth.

4.

Primarily involve maxillary central incisor region.

Clinical And Radiographic

Concussion Subluxation Extrusion Intrusion
Findings

Lateral
luxation

Abnormal
mobility

-/+

-/+

Tenderness to
percussion

+/-

+/-

Percussion
sound

Normal

Dull

Dull

Metallic

Metallic

Positive
response to
sensibility
tests

+/-

+/-

Radiographic
dislocation

-/+

Prevalence of pulp necrosis according

to type of luxation of permanent
teeth (Andreasen & Pedersen)
Type of luxation

Number of teeth

Pulp necrosis

Concussion

178

5 (3%)

Subluxation

223

14 (6%)

Extrusive luxation

53

14 (26%)

Lateral luxation

122

71 (58%)

Intrusive luxaton

61

52 (85%)

Prevalence Of Pulp Necrosis After

Luxation Of Permanent Teeth
According To Stage Of Root
Development (Andreasen & Pedersen)
Stage of root
development

Number of teeth

Pulp necrosis

Incomplete

279

21 (8%)

Complete

358

135 (38%)

Prevalence Of External Root

Resorption Related To Luxation
Injuries (Andreasen & Pedersen)
Number of
teeth

Surface
resorption

Inflammatory Ankylosis
resorption
resorption

178

8 (4%)

0 (0%)

0 (0%)

Subluxation 223

4 (2%)

1 (0.5%)

0 (0%)

Extrusive
luxation

53

3 (6%)

3 (6%)

0 (0%)

Lateral
luxation

122

32 (26%)

4 (3%)

1 (1%)

Intrusive
luxation

61

15 (24%)

23 (38%)

15 (24%)

Concussion

Root Canal Resorption ( Internal Root

Resorption)
Root canal replacement resorption
Internal tunnelling resorption
Usually found in coronal fragment of root
fracture
Self limiting

Root canal inflammatory resorption

Oval shaped enlargement within pulp chamber
Apical located-active revascularization
Requires endodontic treatment

CONCUSSION
Frequency of 23%

No bleeding from gingival

sulcus

Pulp necrosis risk very

limited

CONCUSSION
Least severe- involves primarily the

supporting structures
No loosening or displacement of the tooth
splinting not required
Manifestations:
1.

Sensitive to mastication

2.

Tenderness on percussion

Management
Pulp testing: Electric pulp testing not diagnostic.
Pulp may not respond initially to vitality tests even though
the pulp may remain vital
Treatment:
Relieving from occlusion:
- reducing the contact on the traumatized tooth
or
- reducing the contact on the opposing tooth or teeth
Follow up care:
Recall 1-2 weeks after trauma and at 6 months
interval for minimum of 1 year.

SUBLUXATION
Bleeding is often seen due to damage to supporting
structures and periodontal ligament
Manifestation:
Tooth is slightly mobile, although not to the degree
that a splint is required
Sensitive to mastication and /or to percussion

Management
Vitality test: Electrical/Thermal tests- not diagnostic
immediately after trauma.
Treatment:
If several teeth are traumatized or subluxated,
- splinting placed to stabilize
- recommended period of splinting: 7-10 days
Follow-up care:
- greater potential for pulpal necrosis.
- endodontic treatment initiated in case of
symptoms of pulpal necrosis

EXTRUSIVE LUXATION
7% frequency

Teeth appear elongated

Most
often
lingual
deviation of crown
Always accompanied by
bleeding from PDL
Percussion sound is dull.
Expanded
periodontal
space especially apically.

Management
- reposition the luxated tooth into its alveolar
socket under local anesthesia.
- if clot has formed apical to the displaced
tooth, tooth may be more difficult to reposition
and more force and pressure may be required.
- require splinting to stabilize.
Duration of splinting
2-3 weeks with a flexible splint ( Andreasen and
Andreasen)

LATERAL LUXATION

LATERAL LUXATION

More severe than extrusive luxation- because tooth

displaced laterally may also be associated with
communution or fracture of alveolar socket.
-

Anesthesia is recommended

Requires more forceful degree of reduction:

manipulation with thumb and index finger can often
reduce the injured tooth

 11% frequency
Periodontal injury is accompanied by fracture of
the labial bone plate as well as contusion injury to
the lingual cervical periodontal ligament.
Crowns are displaced lingually and are usually
associated with fractures of the vestibular part of
the socket wall.

Procedure of reduction:
1. Force the displaced apex out of its locked
position with in labial bone
2. Place axial pressure in an apical direction
3. Manipulate the tooth into its natural position
Splinting:
Recommended duration: minimum of 14 days and
remove it when no abnormal mobility remains
In case of marginal breakdown : 6-8 weeks

INTRUSIVE LUXATION
Comprise 0.3-1.9%
Due to locked position in
bone- not sensitive to
percusssion.
Extent of intrusion may
vary from 1 mm to complete
burial of the displaced tooth.
Percussion elicits high
pitched metallic sound.

 Most severe luxation

Results on severe damage to periodontal
ligament, resulting in greater incidence of
external root resorption.
Patient presents with:
- apparent avulsive injury
( completely intruded and submerged)
- partially intruded into the socket.
PDL space partially or totally obliterated.

Treatment:
Allow the tooth to re erupt on its own (Immature
tooth)
Orthodontically extruding the intruded tooth over 2-4
weeks ( Completed root development)
Surgical repositioning (multiple intrusion or deep
intrusion > 7 mm)
Prognosis:
Incidence of both external root resorption and marginal
bone loss is greater in intruded teeth that are surgically
repositioned
Pulpal necrosis occurs in almost all intrusive luxations,
therefore root canal therapy should be anticipated.

Orthodontic extrusion

Orthodontic extrusion
Spontaneous re-eruption

TOOTH AVULSION

TOOTH AVULSION
Complex injury affecting multiple tissue
compartments
1-6% of all traumatic injuries to permanent
dentition
Fights and sports injuries
Most commonly affected: Maxillary Incisors
Age: 8-12yrs, as loosely structured PDL offer
least resistance to extrusive forces

MANAGEMENT
Depends on,
- Extraoral time
- Type of storage
- Root Maturity
In emergency visit emphasis is placed on preservation
& healing of attachment apparatus
In second visit emphasis is placed on prevention /
elimination of pulpal infection

EMERGENCY TREATMENT AT THE ACCIDENT SITE

Replant if possible / place in an appropriate storage
medium
Most important factor is the speed with which the tooth
is replanted
Usually requires emergency personnel at the injury site
with some knowledge of protocol
Information can also be given if consulted on phone

MANAGENMENT IN THE DENTAL OFFICE

Emergency visit:
Clinical examination, diagnosis & treatment planning
Medical & accident history to be taken
Inj:Tetanus toxoid
Prepare socket / root, replant
Functional splint
Local & systemic antibiotics
Management of soft tissues

PREPARATION OF THE ROOT

Surface should be rinsed with saline if visibly
contaminated
Better to replant with minor debris than risk destroying
PDL cells
Examine alveolar socket

Extra Oral Dry Time < 60Min in Closed Apex

or 15-120Min in Wet Non-physiologic Media
Revascularization is not possible, but chance for PDL
healing exists
PDL healing would be expected if dry time is less
than 15-20min
Emdogain found to be extremely valuable in the
20-60min dry period

Extra Oral Dry Time < 60 Min in Open Apex

/15min-6hrs in Physiologic Media (HBSS/Milk)
/15-120Min in wet Non Physiologic media (Water/Saliva)
Soak in 1% Doxycycline for 5 min, gently rinse off debris
& replant
-Reduces the chances of micro-abscesses in pulp &
significantly enhances vascularization
1% Doxycycline Soln. can be prepared by dissolving
50mg Doxycycline in 1000ml saline

Extra Oral Dry Time > 60 Min in Closed Apex

Remove the PDL by placing in citric acid for 3-5min
& gently scrape using scaler
Soak in fluoride (APF / NaF) for 20min.
Cover the root with Emdogain & replant
Aledronate was found to have similar resorption
slowing effects as fluoride
Endodontics may be performed extraorally but no
advantage exists in emergency visit

Extra Oral Dry Time > 60 Min in Open Apex

International

Association

of

Dental

Trauma

recommendation: Should not be replanted

If replanted- treat as with closed apex
Endodontic treatment may be performed extraorally
as apical seal easier to achieve

SPLINTING:
Semi rigid fixation for 7-10 days
e.g. Flexible wire, Monofilament, TTS etc.
In case of avulsion + alveolar fracture

- splinting for 4-8 weeks

Splint removed after initiation of root canal treatment
Adjuncts: Doxicycline 4.4mg on day one followed
by 2.2-4.4mg doxicycline for 7 days
Chlorhexidine mouth wash

After 7-10 days,

SECOND VISIT

- Initiate root canal treatment

- Remove the splint
- If signs of resorption- long term CaOH treatment
- CaOH changed every 3 months for 6-24 months
- Canals obturated when radiographically intact lamina
dura is seen
-In case of open apex- check for revascularization
- if infected: perform apexification

Follow-up care
- Recall intervals at 3 months, 6 months and yearly
for at least 5 years
- If osseous replacement is identified then timely
revision of long term treatment plan
- If inflammatory root resorption is seen a new
attempt at disinfection of root canal is made
- The adjacent teeth should also be tested

Complications:
1. Surface resorption
2. Replacement resorption
3. Inflammatory resorption

STORAGE MEDIA
Suggested storage media in order of preference
1. HBSS, Cell Storage media, Viaspan
2. Milk ( cool milk 40C is preferable to room temp. milk
230C)
3. Saliva, either in the vestibule of mouth / in container
into which pt. spits
4. Physiologic saline
5. Water (hypotonic environment causes rapid cell lysis
& increased inflammation on replantation)

COMMERCIALLY AVAILABLE MEDIA

1) Cell Culture Media
2) Hanks Balanced Salt Solution (HBSS)
3) Viaspan
4) Dentosafe etc.
Presently considered to be impractical as they are not
generally available at accident sites

PATIENT INSTRUCTIONS
- Soft diet for 2 weeks
- Brush teeth with a soft toothbrush after each meal
- Chlorhexidine mouthrinse (0.1%) twice a day for 1
week
- Regular follow up

TRAUMATIC INJURIES TO THE

PRIMARY DENTITION

Traumatic injuries to the primary teeth are common

Affects 30% of the preschool children
Causes for high incidence:
1. Young children tend to be unstable on their feet
(lack of motor co-ordination)
2. Running around with new found mobility- suffer
accidents and damage the teeth.

Consequence of trauma to primary dentition

- Primary teeth are in close relation to their developing
permanent successors
- An acute impact can be transmitted to the developing
permanent dentition
- Infection developed subsequent to injury to primary tooth
may damage the successional tooth

Factor determining damage to permanent dentition:

1. Age of the child:
- below 4 years 60% chances of damaging
permanent tooth
2. Direction of impact
3. Type of injury: Intrusive luxation- 69%
Avulsion- 52%
Extrusion-34%
Subluxation-34%

INCIDENCE
11 to 30%
Most common age group affected: 1.5-2.5 years
At this age child starts walking
No sex differences in incidence as in permanent
dentition
Owing to resilient bone surrounding the primary
teeth, injuries usually result in avulsions, luxations,
etc., rather than fractures of crown

ASSESSMENT
History
Vitality tests: unreliable and should not be attempted
Radiographic examination: helpful
( in case of missing tooth to determine whether
fully intruded or avulsed )
- easiest method is to take an anterior oblique
occlusal view.
Often a child is upset at the initial visit and it may be
appropriate to postpone radiographic examination to
the review visit.

TREATMENT APPROACHES
The treatment strategy following injury to the
primary teeth is dictated by concern for safety of the
permanent dentition.
- Relieve pain
- Restore dentition
In very young children co-operation is the main problem
Advise parents regarding - analgesia
- soft diet
- oral hygiene
Recall the child after a week when he or she is less upset

Laceration of soft tissues

Often the injured area is obscured by blood,
- clean up by irrigating or wiping the area
with water or normal saline
Examine for soft tissue injury,
- if severely lacerated sutured( under LA if
cooperative or referred for GA)
Antibiotic coverage for 5 days
Recall or review after 7-10 days

Contusion and abrasion

of soft tissue

Tooth fractures
Factors to be considered
1. Any other injuries to the tooth, such as luxationgreater chance of damage to permanent tooth.
2. Patient co-operation
3. Exfoliation time of the tooth
4. Motivation of parents to keep up with the follow up
appointments

TREATMENT
Enamel fracture
small chip- 1. Left as it is
2. Edge smoothened off and topical
fluoride applied
larger chip- composite resin restoration
Enamel and dentine fracture
protect pulp- CaOH / GIC lining followed by
composite restoration or using strip crown

Whole crown fracture

Coronal pulpotomy and strip crown
Pulpectomy and strip crown
Extraction
Root fractures
Uncommon in small children
If coronal fragment stable- leave it alone and
monitor
Root communicates with gingiva- poor
prognosis, should be extracted
Best to extract coronal fragment and leave the
root to resorb if not accessible to forceps.

Displacement injuries to the primary teeth

Avulsion never attempt to reimplant due to danger
of damaging the underlying permanent teeth
Luxation injuries
Slight injury- left as it is, advise soft diet and oral
hygiene instructions
Displaced palatally- less then 2mm- reposition
- more than 2mm- extraction
If the tooth does not show an improvement in
mobility within 2 weeks- extraction

Intrusion injuries
Establish where they are in the alveolus and leave them
alone
If less than of the crown intruded- allow to re-erupt,
normally occurs in 2-4 months of injury
If more than of the crown intruded- still can reerupt, careful monitoring required.
Damage to alveolus causing pain- extraction

Radiograph: anterior lateral radiograph should be taken to

determine the position of primary tooth in relation to the
permanent tooth
If very close or touching the permanent toothextraction
Complication: 1/3 of the re-erupted primary teeth undergo
pulpal necrosis

Extrusive luxation
Extrusive injuries in primary dentition cause
interference in occlusion
Treatment
If extrusion is less than 1-2mm- leave them and
monitor
If extruded more than 2mm- extraction

Follow Up Care After Injury To Primary Teeth

1. Should be monitored- after one week, after one
month, three months, six months, one year and
yearly, until exfoliation.
2. If periapical pathology occurs- extraction
3. Discoloration of primary teeth is not always an
indicator of loss of vitality

Injuries to permanent teeth

Can be classified as follows
1. White or brown discolouration with or with out
hypoplastic defect.
2. Dilaceration of the crown of the tooth- causing
eruption disturbance or failure
3. Dilaceration of the root of the tooth- causing
eruption disturbance or failure

4. Odontome- like formation

5. Root duplication
6. Partial or total failure of root development
7. Total failure of tooth development.