Introduction to Management of traumatized teeth

Diagnosis Classification management

Examination and Diagnosis

Examination of a patient with dental injuries should include the following :
chief complaint

history of present illness medical history clinical examination.

Radiographic examination

Chief Complaint

History of Present Injury

Few questions must be asked I broke my tooth , my tooth feels loose Or sometimes the injury is obvious 1. When and how did the injury occur? The date and time of the accident how it took place 2.Have you had any other injuries to your mouth or teeth in the past? Crown or root fractures may have occurred as a result of an earlier injury but are observed at a later time. 3.What problems are you now having with your tooth or teeth? Pain, mobility, and occlusal interference

Medical history
1. Soft tissue

Clinical examination

The purpose of the soft tissue evaluation is to determine the extent of tissue damage and to the patients medical condition identify and remove foreign objects from affects the treatment wounds.

2.Facial Skeleton
The facial skeleton is evaluated for possible fractures of the jaw or alveolar process

3.Teeth and Supporting Tissues: Mobility, displacement, periradicular damage, pulp status and Crown color change

1. Mobility. Teeth are examined (gently) for mobility,

examining adjacent teeth also for movement which if present indicates alveolar fracture If there is no mobility, the teeth are percussed for sounds of ankylosis (metallic sound). Absence of mobility may indicate normal status or "locking" of the tooth in bone, such as in intrusion

2. Displacement. 3.Periradicular damage. Injury to the

supporting structures of teeth may result in swelling and bleeding involving the periodontal ligament , such teeth are sensitive to percussion even light tapping

4.Pulpal status may be determined by symptoms, history, and clinical tests as electrical pulp test (EPT) and carbon dioxide ice. These tests are generally reliable in evaluating and monitoring pulpal status except in teeth with incomplete root development

A. Pulp testing. Carbon dioxide ice or the EPT is used to test teeth that have
been injured; several adjacent and opposing teeth are included in the test. An initial lack of response or a high reading on the pulp tester is normal Retesting is done in 4 to 6 weeks; the results are recorded and compared with the initial responses. If the pulp responds in both instances, the prognosis is good. A pulp response that is absent initially and present at the second visit indicates recovery of vitality If the pulp fails to respond both times, the tooth is retested in 3 to 4 months. Continued lack of response may indicate pulp necrosis

Radiographic examination.

Radiographs are examined for fractures of bone or teeth and stage of development Conventional angulations may miss any irregularities therefore multiple exposures are taken to ensure complete diagnosis

Radiographic evaluation. The initial radiograph made after the injury will not show the pulp condition but it is useful in making a general evaluation and for comparison with following radiographs Another radiograph is taken after 4-6 weeks
Resorptive changes, particularly external changes, may occur soon after injury Inflammatory resorption can be intercepted by endodontic intervention Pulp space calcification or obliteration is a common finding after luxation injuries." canal obliteration may be partial or nearly complete (after several years) and does not require root canal treatment

Crown color changes: Pulp injury may cause discoloration, even after only a few days. Initial changes tend to be pink. Subsequently, if the pulp does not recover and becomes necrotic, there may be a grayish darkening of the crown

classification
1.Enamel fracture 2.Crown fractures without pulp involvement: 3. Crown fractures with pulp involvement 4. Crown root fracture 5. Root fracture 6. Luxation 7.Avulsion 8.Fracture of alveolar process

Enamel fracture

Chips and cracks confined to enamel do not constitute a hazard to the pulp. The prognosis is good

Grinding and smoothing the rough edges or restoring lost tooth structure is the treatment

CROWN FRACTURES WITHOUT PULP EXPOSURE

prognosis is good 1. Restoring fractured part by composite resin 2. reattachment of dentin-enamel crown fragments Advantage : Dental anatomy is restored perfectly with normal tooth structure In primary teeth Such fractures are not important to restore thus the fracture site may be smoothed without restoring.

CROWN FRACTURES WITH PULP EXPOSURE 3 factors are very important 1.The extent of fracture: a small fracture may undergo vital pulp therapy and can be restored by an acid-etched composite restoration. An extensive fracture may require root canal treatment with a post and core-supported crown 2. the stage of root development: The stage of root maturation is an important factor in choosing between pulpotomy and pulpectomy. 3.the length of time since injury: the sooner a tooth is treated, the better the prognosis for preserving the pulp.

In immature teeth : a shallow pulpotomy is much preferred than a normal pulpotomy It allows completion of root development Cvek technique or shallow pulpotomy

pulp tissue is removed to a depth of about 2 mm below the exposure. After the bleeding stops hard-setting calcium hydroxide liner and then fill the cavity with hard setting cement such as IRM, or glass ionomer. When the cement has set, the tooth may be restored with acid-etched , Composite is used to restore the tooth If MTA is used in place of calcium hydroxide, it is not necessary to wait for bleeding to stop completely. Treatment is evaluated after 6 months and then yearly. In teeth with complete roots root canal therapy is the treatment

Cvek technique

Primary teeth
In case of primary teeth treatment includes pulpotomy, root canal therapy, or extraction, depending on patient age and cooperation.

CROWN-ROOT FRACTURES

These fractures are usually oblique and involve both crown and root. it may or may not involve pulp exposure

Teeth with crown-root fractures are often painful such injuries often require urgent care. This may consist only of removing loose tooth fragments but often also includes pulp therapy If the root is immature, pulpotomy and also "Vital Pulp Therapy" is preferable to pulpectomy, whereas pulpectomy is the treatment of choice in patients with fully developed teeth.

Primary Teeth A crown-root fracture in primary teeth usually dictates extraction.

Root fractures

Fractures of roots have been called intraalveolar root fractures, horizontal root fractures and transverse root fractures. Radiographically, a root fracture is visualized if the x-ray beam passes through the fracture line. Because these fractures often are transverse-to oblique (involving pulp, dentin, and cementum), they may be missed if the central beam's direction is not parallel or close to parallel to the fracture line so a steep vertical angulations is added to the normal angulation about (45 degrees)

The more cervical the fracture is the more mobility and the more chance of pulp necrosis is If the coronal segment is mobile splinting is indicated

initial treatment includes repositioning of the coronal segment (if displaced) and stabilization by splinting. Repositioning of the coronal segment may be as easy as applying finger pressure to the crown to align the segment, or it may be more complicated, requiring orthodontic approaches. When the coronal segment has been repositioned, it must be stabilized to allow repair of the periodontium

Stabilization may be accomplished by the use of orthodontic wire and acid-etched resin. Splinting time must be sufficient to allow calcification to take place up to 12 weeks

Managing these fractures endodontically is difficult , must be referred to an endodontist

Managing root fractures endodontically

1.Rct for coronal and apical parts 2.Rct for coronal part and apical part is left untreated or surgically removed 3.Apexification at the fracture site before root canal treatment for coronal part apical part Is left 4. Intraradicular splint by using a post to stabilize two segments 5.Endodontic implant where the apical part of the implant will replace the surgically removed apical part 6.Root extrusion and endo treatment after removal of coronal part In case of primary teeth coronal part is removed and the apical part is left any attempt of Removal will endanger the successor

LUXATION INJURIES

The cause is usually a sudden impact, such as a blow or striking a hard object during a fall 1.Concussion. The tooth is sensitive to percussion only. There is no increase in mobility The pulp may respond normally to testing, and no radiographic changes are found. 2.Subluxation. sensitive to percussion and also have increased mobility. Often sulcular bleeding is present, indicating vessel damage and tearing of the periodontal ligament. No displacement is found, and the pulp may respond normally to testing. Radiographic findings are unremarkable.

concussion

3.Extrusive luxation. These teeth have been partially displaced from the socket along the long axis have greatly increased mobility, and radiographs show displacement.

4.Lateral luxation. Trauma has displaced the tooth lingually, buccally, mesially, or distally, that is out of its normal position away from its long axis.

5.Intrusive luxation. Teeth are forced into their sockets in an axial (apical) direction they have decreased mobility and resemble ankylosis

Treatment of Luxation Injuries

1. concussion injuries no immediate treatment is necessary. The patient should allow the tooth to "rest" (avoid biting) until sensitivity has subsided.
2.Subluxations may likewise require no treatment unless mobility is moderate; if mobility is graded 2, stabilization may be necessary. 3.Extrusive and lateral luxation injuries require repositioning and splinting The length of time needed for splinting varies with the severity of injury. Extrusions may need only 2 to3 weeks, whereas luxations that involve bony fractures need up to 8 weeks.' Root canal treatment is indicated for teeth with a diagnosis of irreversible pulpitis or pulp necrosis.

Treatment of intrusive luxation injuries depends on root maturity If the tooth is incompletely formed with an open apex, it may re-erupt. If it is fully developed, active extrusion will be necessary soon after the injury, usually by an orthodontic appliance. In extreme cases of intrusion, in which the tooth has been totally embedded into the alveolus surgical repositioning may be necessary. Root canal treatment is indicated for intruded teeth with the exception of those with immature roots, in which case the pulp may revascularize.

Primary teeth
Concussion and subluxation injuries require no treatment. Teeth with lateral and extrusive luxations may be left untreated, or extracted depending on the severity of injury. Teeth with intrusive luxations are evaluated to determine the direction of intrusion.
Radiographs provide valuable information If the tooth appears foreshortened on the film, the apex is oriented toward the x-ray cone. Therefore these teeth should present no danger to the permanent successor and may be left to re-erupt. If the tooth appears elongated, the apex is oriented toward the permanent successor and may pose a risk to the permanent tooth bud. The tooth should be carefully extracted

Avulsions

An avulsed tooth is one that has been totally displaced out of its alveolar socket. If the tooth is replanted soon after avulsion the periodontal ligament has a good chance of healing. Time out of socket and the storage media used are the most critical factors in successful replantation. It is important to preserve the periodontal ligament cells and the fibers attached to the root surface by keeping the tooth moist and minimizing handling of the root.

Key points in restoring avulsed teeth: 1.Rinse in water for 10 min 2.No scrubbing of the tooth 3.Replacing the tooth in socket gently 4. Hold it in place by the patients fingers take the patient to the dentist

Replantation within 1 hour:

If immediate replantation is not possible The tooth should be transported in such a way as to keep it moist. The best transport medium is a commercially available storagetransport medium or physiologic saline (usually neither is available); milk is an excellent alternative Saliva is acceptable for maintaining root surface cell vitality

1. The tooth is placed in a cup of physiologic saline. 2. The area of injury is radiographed, looking for evidence of alveolar fracture. 3. The avulsion site is examined carefully for any loose bone fragments that may be removed.

4. The socket is gently irrigated with saline to remove contaminated clot 5. In the cup of saline, the tooth is grasped with extraction forceps by the crown to avoid handling the root. 6. The tooth is examined for debris, which, if present, is gently removed with gauze moistened with saline. 7. The tooth is replaced into the socket 8. Proper alignment is checked Soft tissue lacerations are tightly sutured 9. The tooth is stabilized for 1 to 2 weeks with a splint 10. Antibiotics should be prescribed 11. Supportive care is given; a soft diet and mild analgesics are prescribed Root canal treatment is indicated for mature teeth and should be done optimally after 1 week and before the splint is removed

Immature teeth with wide-open apices; they may revascularize but must be evaluated at regular intervals of2, 6, and 12 months after replantation.
Replantation more than 1 hour after avulsion. If a tooth has been out of the alveolar socket for more than 1 hour (and not kept moist in a suitable medium), periodontal ligament cells and fibers will not survive regardless of the stage of root development.

Therefore treatment efforts before replantation include treating the root surface with fluoride to slow the resorptin process
1. The area of tooth avulsion is examined and radiographs are examined for evidence of alveolar fractures. 2. Debris and pieces of soft tissue adhering to the root surface are removed. 3. The tooth is soaked in a 2.4% solution of sodium fluoride (acidulated to pH 5.5) for 5 to 20 minutes.

Sequelae to Replantation

1,Surface resorption 4. The pulp is extirpated, and the canal is cleaned, shaped, and filled while the tooth is They are repaired by deposition of new cementum, which represents healing. held in a fluoride-soaked piece of gauze. 5. The socket is irrigated 2.Inflammatory resorption with saline Anesthesia may be necessary Due to pulp necrosis and PDL injury first. can be prevented by RCT 6. The tooth is gently replanted into the 3.Replacement resorption: tooth socket, checking for proper alignment and structure is resorbed and replaced by occlusal contact. bone 7. The tooth is splinted for 3 to 6 weeks This result in ankylosis where bone fuses directly to the root surface the tooth lack Primary teeth arent replanted physiologic mobility, failure of the tooth to For risk of endangering successor erupt along with adjacent teeth (leading infraocclusion in young individuals), and a "solid" metallic sound when percussed.

Treating the surface with fluoride before replantation slows down the replacement resorption (in 50% of pts) which results in infraocclusion as the patient grows

After two years and the root started to resorb Immediately after replantation