5. Endodontic management of traumatized
teeth
Orthodontic management of traumatized
teeth
Conclusion
References
6. Introduction
Traumatic dental injuries usually imply
wound healing
processes in the periodontium, the pulp and
sometimes
associated soft tissue.
The outcome of these determines the
final healing of such injuries
7. The general response of soft
and mineralized tissues to surgical and
traumatic injuries is
a sensitive process, where even minor
changes in the treatment
procedure may have an impact upon the
rate and
quality of healing
8. Epidemiology
Dental trauma is common in childhood &
adolescent
Incidence of dental trauma is 31-40% of
boys & 16-30% of girls at 5 years of age
Incidence of dental trauma is 12-33% of
boys & 4-19% of girls at 12 years of age
Boys are affected almost twice as often as
girls in both the dentitions
9. Classification
-Classification by Rabinowitch(1956)
- Classification by Ellis and Davey(1960)
- Classification by WHO 1978
- Andreasen’s modification of WHO
classification 1981
- Classification by Garcia Godoy(1981)
- modification of Ellis classification by
Mc Donald,Avery and Lynch(1983)
- Classification by Ulfohn(1985)
- Classification by Heithersay and Marde
- Classification by Hargreaves and Craig
- Currently recommended classification by WHO
modified by Andreasen and Andreasen
10. I. Classification by Rabinowitch 1956
Injuries to primary teeth
- Fracture of enamel, or slightly into dentine
- Fractures into dentine
- Fractures into the pulp
- Fractures of the root
- Comminuted fractures
- Displaced teeth
11. II. Classification by Ellis and Davey 1960
- Class I – simple fracture of crown involving
only enamel
- Class II- extensive fracture of crown with
considerable amount of dentine, with no pulp
exposure
- Class III- extensive fracture of crown, with
dentinal involvement and pulp exposure
- Class IV- traumatized tooth becomes non vital
with or without loss of crown structure
12. - Class V – tooth lost due to trauma
- Class VI- fracture of root with or without
crown fracture
- Class VII – displacement of the tooth
without crown or root fracture
- Class VIII – fracture of the crown en
masse
- Class IX- fracture of deciduous teeth
13. III. WHO Classification 1978
873.60- enamel fracture
873.61- crown fracture involving enamel, dentine
without pulpal involvement
873.62- crown fracture with pulpal involvement
873.63- root fracture
873.64- crown root fracture
873.66- luxation
873.67- intrusion or extrusion
873.68- avulsion
873.69- other injuries like soft tissue
lacerations
14. IV. WHO classification modified by
Andreasen 1981
873.64- uncomplicated crown root fracture
without pulp exposure
873.64 – complicated crown root fracture
without pulp exposure
873.66- concussion- injury to tooth
supporting structure without loosening or
displacement of tooth
15. 873.66- subluxation – an injury to tooth
supporting with abnormal loosening or
displacement of tooth
873.66- lateral luxation, displacement of
tooth in a direction other than maxillary and
accompanied by fracture of alveolar socket
16. V. Classification by Garcia and
Godoy(1981)
Class I- enamel fracture
Class II- enamel and dentine fracture
Class III- enamel and dentine fracture with
pulp exposure
Class IV- enamel, dentine and cementum
fracture
17. Class V- root fracture
Class VI – concussion
Class VII- luxation
Class VIII- extrusion
Class IX- avulsion – total displacement
18. VI. Modification of Ellis classification by Mc
Donald, Avery,Lynch (1983)
Class 1: simple fracture of crown involving
little or no dentine
Class 2: extensive fracture of crown involving
considerable dentine but not dental pulp
Class 3: extensive fracture of crown with
pulp exposure
Class 4: loss of entire crown
19. VII. Classification by Ulfohn(1985)
a. Fracture of enamel
b. Fracture of the crown with indirect pulp
exposure through the dentine
c. Fracture of crown with direct pulp
exposure
20. VIII. Classification by Heithersay and Marde
Class I- fracture line does not extent below
the level of attached gingiva
Class II- fracture line extends below attached
gingiva, not below alveolar craest
Class III- fracture line extends below alveolar
crest
Class IV- fracture line is within coronal third
of root but below level of alveolar crest
21. Class I: no fracture /fracture of enamel only
with or without displacement of tooth
Class II: fracture of crown involving enamel,
dentine without pulp exposure, with/without
tooth displacement
Class III: Fracture of crown exposing pulp,
with/without displacement of tooth
Class IV: fracture of root with/ without
coronal fracture, with/without displacement
of tooth
Class V: total displacement of tooth
IX. Classification by Hargreaves and
Craig
22. X. Classification currently recommended
by WHO modified by Andreasen and
Andreasen
Soft tissues
Lacerations – 873.69
Contusion-N 902.0
Abrasions-N 910.00
26. Classification according to J O
Andreasen & F M Andreasen
Injuries to hard dental tissues and pulp
Injuries to the periodontal tissues
Injuries to the supporting bone
Injuries to gingiva or oral mucosa
27. General aspects in dental injury
History
Clinical examination
Mechanical stimulation
Thermal tests
Electrometric tests
Laser doppler flowmetry
Radiographic examination
36. Electric pulp test
Current is carried ionically through the
electrolytes of tooth
- Teeth wity temporary crown- dist b/n
crown and electrode-1mm or else thermal
pulp test with carbon dioxide
snow
- Stage of eruption
- Teeth orthodontic treatment
37. Laser doppler flowmetry
Laser beam – coronal aspect of pulp
Reflected light scattered by RBCs- Doppler
frequency shift
Scattered light- detected and processed to
yield a signal
38. Laser doppler flowmetry
Laser beam – coronal aspect of pulp
Reflected light scattered by RBCs- Doppler
frequency shift
Scattered light- detected and processed to
yield a signal
42. -
Steep occlusal exposure – root fractures,
lateral luxations with oral displacement of
crown
Extraoral r/g- direction of dislocation of
Intruded primary incisors
Bone fractures – intraoral r/g unless fracture
is confined to facial/ lingual bony plate
70. Pulp protection
Dentine exposure – changes in the pulp ?
Lining the deepest part of fracture with hard
setting Ca(OH)2 followed by resin bonding
Splint – prior to application of splint, pulp
dentine protection
75. Bonding resins
- Allows clinician –manipulate the composite
material
- Air inhibited layer – tight bond b/n
the composite and the bonding resin
76. Insertion of composite material
Setting against a matrix – smooth finish
Resin crown form
Odus Pella and Interberg crown forms
77. Points to bear in mind :
- Minimum labial finishing after
composite polymerizing
- Composite excess should not extend > 1mm
- Vent holes , air escape
79. Polymerising composite material
Factors
- Time of application
- Plane of direction of light source
- Distance b/n light and composite
- Shade of composite
- Nature of filler particle
- Temperature
85. 1) It is a conservative procedure
2) Appears more natural than any other
composite.
3). color stability (Busato et al, 1998).
86. 4) Total chairside time for re-attachment
of incisal edge is less than constructing
a composite resin incisal
edge(Cavalleri and Zerman, 1995).
5) The method is much more economical.
87. [I;
Techniques
1.Placement of a circumferential bevel
before are attaching the fragment
(Simonsen, 1979 and Burke,
1991 andWalker, 1996).
2. Placement of an external chamfer at
the fracture line
after bonding(Baratieri, 1994).
3. Use of a v-shaped enamel notch.
88. 4. Placement of an internal groove
( Walker, 1996 and Baratieri, 1994).
5. Leaving a superficial overcontour of
Restorative material over the fracture
line (Reis et al, 2001 and
Badami et al, 1995).
Indian J.Sci.Res. 6(2) : 163-170, 2015
Chaudhary et al
89. Adv- restoring fracture with material
that abrades the same way as the opposing
teeth
Minimal chair time
Prior to advent of DBA, reattachment was
done with acid etching
90. Bonding using DBA – bond strength –
50-60 % of intact teeth
Remaining dentine thickness – min 0.2mm
Gluma Dentine bonding system
Most important aspect – retrieval of the
fragment
91. Treatment strategy
Depends on distance b/n pulp and fracture
surface
If small- fracture surface – covered with hard
setting Ca(OH)2, provisional restoration
Liner placement on enamel- removal of
temporary restoration
92. Interim period – fragment kept moist
If distance b/n pulp and fracture
surface is more – reattachment at
the time of injury
Temporary restoration – not eugenol
Due to complexing action of eugenol
with calcium in sound dentine
93. **
The purpose of this study was to determine the
effects of various drying and wetting storage
periods on the fractured fragment and to
reach a final conclusion as to which rehydration
period is both better and more practical under
clinical conditions.
94.
95. Results -Compared to a 30-minute period, a
24-hour rehydration of the tooth fragment
before treatment seems to salvage enough
moisture to result in an increase in reattachment
strength.
Operative Dentistry, 2012, 37-5, 501-508
F Shirani et al
114. Fracture strength – increased , prep limited
to enamel
Better esthetic results
Good material adaptation
Minimal plaque retention
Strength and survival- improved
115. Patient selection
- If composite build up is done – at least 2
weeks should elapse before initiating
preparation and impressions for ceramic veneer
- Dimensional stability of composite
116. Prognosis
Permanent teeth
Follow up after trauma
- Pulp sensibility – lowered imm after injury
- 1-8 weeks
- Pulp testing done without removing temp restn
117. Enamel infractions
- Isolated infractions – risk if pulp necrosis
less
Enamel fractures
- Risk of pulp necrosis – 0.2-1.0%
118. - Enamel dentine fractures without pulp
Involvement
- risk- 1-6%
- Stage of root development
• Constricted apices – greater risk
• Extent of periodontal injury
119. • Extent and location of fracture
horizontal, proximal superficial fractures - >>
Deep proximal fractures
• Effect of treatment
• Time interval
131. Treatment
Emergency – stabilization of coronal
fragment
Definitive treatment – initiated soon
Multiple fractures, removal of loose
fragments , coverage with glass ionomer
cement
132. Incomplete fractures of immature permanent
teeth- amenable to orthodontic extrusion,
Pulp capping, restoration
133. Definitive therapy includes
1. Removal of coronal fragment and
supragingival restoration
2. Surgical exposure of fracture surface
3. Orthodontic extrusion of apical fragment
4. Surgical extrusion of apical fragment
150. Fractures involving dentine,cementum and pulp
and relatively uncommon among dental traumas
0.5- 7 % of injuries affecting permanent
dentition
Mechanism – frontal impact – compression
zones labially and lingually
151. Histologic level – injury to periodontal ligament,
stretching or laceration of pulp at fracture
level
Clinical findings
Max central incisors, 11-20 years
Uncommon in younger individuals
152. Associated with alveolar fractures
Slightly extruded tooth , lingual direction
Site of fracture – tooth mobility
Diagnosis entirely based on radiograph
153. Radiographic findings
Fracture line – at optimal angle for
radiographic disclosure
Visible only if central beam directed within a
maximum range of 15-20 degree of fracture
plane
If ellipsoid radiolucent line – seen ,
two additional r/g should be taken
154. One with increased angulation – 15 degree
Second – negative angulation of 15 degree to
original
Usually missed, later revealed – due to devpt
of haemorrhage or granulation tissue b/n
fragments / resorption
155.
156. The aim of this study was to investigate
the accuracy of cone-beam computed
tomography (CBCT) in the
diagnosis of vertical root fractures in a tooth
with gutta-percha and prefabricated posts
The CBCT scans revealed a high accuracy in
the diagnosis of vertical root fractures; the
accuracy did
not decrease in the presence of gutta-percha.
.
157. The presence of prefabricated posts also had
little effect on the accuracy
of the system, which was, of course, not
statistically significant
158.
159.
160. Fracture line –
Single line – usual finding
Direction varies
Apical/mid root fractures – facio oral
direction in an incisal direction
Cervical fractures – more horizontal
161. Fractures at the apical third – detected with
steep occlusal exposure
Teeth with incomplete root formation –
‘green stick fracture’
Seen as – break in continuity of root canal
wall/ root surface of immature root
Can also heal by hard tissue formation
163. Healing with calcified tissue
Interposition of connective tissue
Interposition of bone and connective tissue
Interposition of granulation tissue
164.
165. Healing with calcified tissue
Uniting callus of hard tissue
Dentine, osteodentin, cementum
Inner part – dentine , outer- cementum
First layer- cellular, atubular
Later – normal tubular dentin
166. Cementum deposition – preceded by
resorptive processes
Discontinuous layer interspersed with
connective tissue derived from PDL
Widening of root canal space- internal
surface resorption, followed by hard tissue
formation
Limited peripheral rounding of fracture
edges
167. Partial pulp canal obliteration confined to
apical fragment
C/E
- Normal mobility
- Normal percussion to percussion,
decreased response to pulp sensibility
testing
168. Seen in cases of concussion, subluxation
No dislocation of coronal fragment
Immature root formation
172. Connective tissue fibres – running // fracture
surface
New apical foramen – formed at fracture level
Peripheral rounding of fracture edges
Slight ingrowth of bone
PDL space around apical fragment
173. r/g
Rounding of fracture edges
Radiolucent line
external, internal surface resorption & pulp
canal obliteration
174.
175. c/p
Teeth – firm/ slightly mobile
Weak pain- percussion
Sensibility test- normal
177. Interposition of bone and connective tissue
b/n fragments
Bone into root canal
Result of trauma prior to completed alveolar
Process, coronal fragment continues to erupt
178.
179. r/g
Bony bridge b/n fragments with periodontal
space around pulp canal obliteration
c/p
Teeth – firm
React normally to pulp test
180. Interposition of granulation tissue
Histologically- granulation tissue
Coronal pulp – necrotic – inflammatory
changes , Often, communication b/n gingival
crevice & fracture line
Apical – contain vital pulp
181. r/g
Widening of fracture line, rarefaction of
alveolar bone
c/p
Coronal fragment – loose, extruded,
sensitive to percussion
Fistulae labial mucosa
183. Treatment
Reduction of displaced coronal fragment and
firm immobilization
Digital manipulation – repositioning
Socket wall fracture ?
Radiographic evaluation
184.
185.
186.
187.
188.
189.
190.
191. Immobilization – rigid splint
(acid etch resin splint)- passively applied
2-3 months – fixation period
Immature teeth with incomplete root
fractures – heal by hard tissue union
If splinted/ not – teeth monitored
radiographically and for pulp sensibility
192. Proximity of cervical fracture line to
the gingival crevice – poor chance of healing
Consider – removal of coronal fragment,
orthodontic/surgical extrusion
Fracture at cervical third of root –
conservative management
Good oral hygiene- permanent fixation of
coronal fragment to adjacent teeth
193. If tooth – unsalvagable- extraction
With great caution- with little / no
sacrifice to labial bone
Preserve the marginal socket wall
Another option – preservation of apical
fragment containing vital pulp
194. Primary teeth with root fractures without
dislocation – preserved
Coronal fragment – usually removed inorder
to prevent pulp necrosis
Never apical fragment is removed – damage
195. Pulpal healing
Survival following root fracture >> than
luxation injury
Periodontal ligament contributes to
revascularization
Escape of pulpal edema through fracture
Minimizing pressure
196. Fracture reduces the impact to the
apical area
Close c/l and r/g follow ups
Extrusion of coronal fragment, tenderness
to percussion
r/g signs of pulp necrosis – seen after 2
months
197. Factors contributing to necrosis
- Displacement of coronal fragment
- Forceful application of splints
- Non splinting
- Teeth with completed root formation
198.
199.
200. Factors affecting type of healing
Presence of restorations
Presence of marginal periodontitis
- Interposition of connective tissue
201. Management of pulp necrosis
- Apical fragment – vital
- Coronal fragment – root filled
If fracture line is in cervical third of root,
pulp necrotic – intraradicular splinting –
uniting fragments and serving as root filling
207. Pulp canal obliteration
Common finding
Partial pulp canal obliteration – fracture
region & apical region
Can extend into 1-2 mm of coronal fragment
Complete obliteration
208. Both types – progress at the same rate
Well advanced – 9-12 months
Approach full density – 1-2 years
Obliteration of
Apical segment –healing with calcified
tissue
Apical and coronal – connective tissue
210. Root resorption
60% cases
Detected within 1 year after injury
Should be differentiated from resorption
of bone at the level of root fracture
Types
External surface resorption
236. Conclusion
management of traumatic dental
injuries can be both demanding and
challenging that requires immediate
Intervention as they are accompanied by
the emotional factors of the patient
The successful treatment requires
often a multidisciplinary approach involing
Different specialities
237. References
1.Ingle JI, Bakland LK. Endodontics. 5th ed. Hamilton, Ontario,
Canada: BC Decker; 2002:795.
2. Malmgren O, Malmgren B, and Frykholm A. Rapid orthodontic
extrusion of crown root and cervical root fractured teeth. Endod Dent
Traumatol 1991;7(2):49-54.
3. Ehrmann EH. Restoration of a fractured incisor with exposed
pulp using original tooth fragment: report of case. JADA 1989;
118(2):188-185.
4. Morse DR, O’Larnic J, Yesilsoy C. Apexification: review of the literature.
Quintessence Int 1990;21(7):589-598.
5. Baratieri LN, Monteiro S Jr, Caldeira de Andrada MA. Tooth
fracture reattachment: case reports. Quintessence Int 1990;21(4):
261-270.
238. . Deliperi S, Bardwell DN, Coina C. Reconstruction of devital
teeth using direct fiber-reinforced composite resins: a case report.
J Adhes Dent 2005;7(2):165-171.
7. Villat C, Machtou P, Naulin-Ifi C. Multidisciplinary approach to
the immediate esthetic repair and long-term treatment of an oblique
crown-root fracture. Dent Traumatol 2004;20(1):56-60.
8. Textbook and color atlas of traumatic dental injuires - andreasen