residency rec

1. TRAUMATIC
INJURIES OF
TEETH
Prepared by:
Dr. Rea Corpuz

2.  Case History
 Chief complaint
 History of present illness
 Medical History
Traumatic Injuries of
Teeth

3.  Clinical Examination
 External Examination
 Soft Tissues
 Facial Skeleton
 Teeth and Supporting Structures
Traumatic Injuries of
Teeth

4.  Radiographic Examination
 Periapical
 Occlusal
 Panoramic
Traumatic Injuries of
Teeth

5.  (1) Concussion
 (2) Luxation
 (3) Fracture
Traumatic Injuries of
Teeth

6.  tooth is not mobile
 not displaced
 periodontal ligament (PDL)
absorbs injury + inflammed
 leaves tooth tender to
biting pressure + percussion
Concussion

7.  Visual sign:
 not displaced
 Percussion test:
 tender to touch or tapping
 Mobility test:
 no increased mobility
Concussion

8.  Pulp Sensibility Test:
 positive result
 it is important in assessing
future risk of healing
complications
 lack of response to the test
indicates an increased risk
of later pulp necrosis
Concussion

9.  Radiographic findings:
 no radiographic
abnormalities
 Radiographs:
 occlusal
 periapical
 lateral view from mesial +
distal aspect of tooth in
question
Concussion

10.  Treatment Objectives:
 usually there is no
treatment
 Treatment:
 monitor pulpal condition
for at least 1 year
Concussion

11.  Patient Instructions:
 soft food for 1 week
 brush with soft bristle
 rinse with chlorhexidine
0.1% to prevent plaque
accumulation
Concussion

12.  tooth is displaced in
a labial, lingual or lateral
direction
 PDL is usually torn
 fractures of supporting
alveolus may occur
Luxation

13.  similar to extrusion injuries
 partial or total separation
of periodontal ligament
Luxation

14.  Visual sign:
 displaced, usually in a
palatal/lingual or labial
direction
 Percussion test:
 usually gives a metallic
(ankylotic) sound
 Mobility test:

Luxation

15.  Pulp Sensibility Test:
 likely give a lack of
response except for teeth
with minor displacement
 test is important in assessing
risk of healing complications
 positive result at the initial
examination indicates a reduced
risk of future pulp necrosis
Luxation

16.  Radiographic findings:
 widened periapical ligament
space best seen on occlusal
or eccentric exposures
 Radiographs:
 occlusal
 periapical
 lateral view from mesial +
distal aspect of tooth in
Luxation

17.  Treatment Objective:
 reposition + splint a displaced
tooth to facilitate pulp +
periodontal ligament healing
Luxation

18.  Treatment:
 rinse the exposed part of root
surface with saline before
repositioning
 apply local anesthesia
 reposition tooth with forceps
or with digital pressure to
disengage it from its bony
socket
Luxation

19.  Treatment:
 gently reposition it into
its original position
 stabilize the tooth for 4 weeks
using a flexible splint
 4 weeks is indicated due to
associated bone fracture
Luxation

20.  Patient Instructions:
 soft food for 1 week
 brush with soft bristle
 rinse with chlorhexidine
0.1% to prevent plaque
accumulation
Luxation

21.  Ellis and Davey classification
of crown fracture is useful in
recording extent of damage to
crown
 Class I – simple fracture
of crown involving little
or no dentin
 Class II – extensive fracture
of crown involving considerable
dentin but not dental pulp
Fracture

22.  Class III – extensive fracture
of crown with an exposure
of dental pulp
 Class IV – loss of entire crown
Fracture

23.  Enamel Fracture
 Enamel-Dentin Fracture
 Enamel-Dentin-Pulp Fracture
 Root Fracture
Fracture

24.  fracture confined to the
enamel with loss of tooth
structure
Enamel Fracture

25.  Visual sign:
 visible loss of enamel
 no visible sign of exposed
dentin
 Percussion test:
 not tender
 if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Enamel Fracture

26.  Mobility test:
 normal mobility
 Sensibility test:
 usually positive
 test may be negative initially
indicating transient pulpal
damage
Enamel Fracture

27.  Sensibility test:
 monitor pulpal response
until definitive pulpal
diagnosis can be made
 test is important in assessing
risk of future healing
complications
 lack of response at initial
examination indicates an increased
risk of later pulpal necrosis
Enamel Fracture

28.  Radiographic findings:
 enamel lost is visible
 Radiographs:
 occlusal
 periapical
 recommended to rule out
possible presence of root
fracture or a luxation injury
Enamel Fracture

29.  Treatment:
 if tooth fragment is available,
it can be bonded to the tooth
 grinding or restoration with
composite resin depending on
extent + location of fracture
Enamel Fracture

30.  fracture confined to enamel
+ dentin with loss of tooth
structure, but not involving
pulp
Enamel-Dentin Fracture

31.  Visual sign:
 visible loss of enamel
+ dentin
 no visible sign of exposed
pulp tissue
 Percussion test:
 not tender
 if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Enamel-Dentin Fracture

32.  Mobility test:
 normal mobility
 Sensibility test:
 usually positive
 test may be negative initially
indicating transient pulpal
damage
Enamel-Dentin Fracture

33.  Sensibility test:
 monitor pulpal response
until definitive pulpal
diagnosis can be made
 test is important in assessing
risk of future healing
complications
 lack of response at initial
examination indicates an increased
risk of later pulpal necrosis
Enamel-Dentin Fracture

34.  Radiographic findings:
 enamel-dentin lost
is visible
 Radiographs:
 occlusal
 periapical
 recommended to rule out
displacement or possible
presence of root fracture
Enamel-Dentin Fracture

35.  Treatment:
 if tooth fragment is available,
it can be bonded to the tooth
 otherwise perform provisional
treatment by covering exposed
dentin with glass ionomer
or a permanent restoration
using a bonding agent +
composite resin
Enamel-Dentin Fracture

36.  (Complicated Crown Fracture)
 a fracture involving enamel +
dentin with loss of tooth
structure + exposure of pulp
Enamel-Dentin-Pulp
Fracture

37.  Visual sign:
 visible loss of enamel
+ dentin
 exposed pulp tissue
 Percussion test:
 not tender
 if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Enamel-Dentin-Pulp
Fracture

38.  Mobility test:
 normal mobility
 Sensibility test:
 usually positive
Enamel-Dentin-Pulp
Fracture

39.  Sensibility test:
 test is important in assessing
risk of future healing
complications
 lack of response at initial
examination indicates an increased
risk of later pulpal necrosis
Enamel-Dentin-Pulp
Fracture

40.  Radiographic findings:
 lost of tooth substance
is visible
 Radiographs:
 occlusal
 periapical
 recommended to rule out
displacement or possible
presence of luxation or root
fracture
Enamel-Dentin-Pulp
Fracture

41.  Treatment:
 if young patients with open
apices, it is very important to
preserve pulp vitality by
pulp capping or partial
pulpotomy in order to secure
further root development
 this treatment is also
treatment of choice in patients
with closed apices
Enamel-Dentin-Pulp
Fracture

42.  Treatment:
 Calcium hydroxide compunds
+ MTA are suitable materials
for such procedures
 in older patients with closed
apices + luxation injury with
displacement, root canal
treatment is usually
treatment of choice
Enamel-Dentin-Pulp
Fracture

43.  fracture involving:
 enamel
 dentin
 cementum
 with loss of tooth structure
 but not exposing pulp
Crown-Root Fracture
without pulp involvement

44.  Visual sign:
 crown fracture extending
below gingival margin
 Percussion test:
 tender
Crown-Root Fracture
without pulp involvement

45.  Mobility test:
 coronal fragment mobile
 Sensibility test:
 usually positive for apical
fragment
Crown-Root Fracture
without pulp involvement

46.  Radiographic findings:
 apical extension of fracture
usually not visible
 Radiographs:
 occlusal
 periapical
 recommended to detect fracture
lines in root
 cone beam exposure can reveal
whole fracture extension
Crown-Root Fracture
without pulp involvement

47.  Treatment:
 Fragment removal only
• removal of superficial coronal
crown-root fragment
• subsequent restoration of
exposed dentin above gingival
level
Crown-Root Fracture
without pulp involvement

48.  Treatment:
 Fragment removal + gingivectomy
(sometimes ostectomy)
• removal of coronal segment
with subsequent endodontic
treatment + restoration with
a post-retained crown
Crown-Root Fracture
without pulp involvement

49.  Treatment:
 Orthodontic extrusion of
apical fragment
• removal of coronal segment
with subsequent endodontic
treatment + orthodontic
extrusion of remaining root
with sufficient length after
extrusion to support a post-
retained crown
Crown-Root Fracture
without pulp involvement

50.  Treatment:
 Surgical extrusion
• removal of mobile fractured
fragment
• subsequent surgical
repositioning of root in a more
coronal position
Crown-Root Fracture
without pulp involvement

51.  Treatment:
 Decoronation (root submergence)
• implant solution is planned,
root fragment may be left in
situ after in order to avoid
alveolar bone resorption
• thereby maintaining volume of
alveolar process for later
implant installation
Crown-Root Fracture
without pulp involvement

52.  Treatment:
 Extraction
• with immediate or delayed
implant-retained crown
restoration or a coventional
bridge
• fractures with severe apical
extension, the extreme being
a vertical fracture
Crown-Root Fracture
without pulp involvement

53.  fracture involving:
 enamel
 dentin
 cementum
 with loss of tooth structure
 exposure of pulp
Crown-Root Fracture
with pulp involvement

54.  Visual sign:
 crown fracture extending
below gingival margin
 Percussion test:
 tender
Crown-Root Fracture
with pulp involvement

55.  Mobility test:
 coronal fragment mobile
 Sensibility test:
 usually positive for apical
fragment
Crown-Root Fracture
with pulp involvement

56.  Radiographic findings:
 apical extension of fracture
usually not visible
 Radiographs:
 occlusal
 periapical
 cone beam exposure can reveal
whole fracture extension
Crown-Root Fracture
without pulp involvement

57.  Treatment:
 Fragment removal + gingivectomy
(sometimes ostectomy)
• removal of coronal segment
with subsequent endodontic
treatment + restoration with
a post-retained crown
Crown-Root Fracture
with pulp involvement

58.  Treatment:
 Orthodontic extrusion of
apical fragment
• removal of coronal segment
with subsequent endodontic
treatment + orthodontic
extrusion of remaining root
with sufficient length after
extrusion to support a post-
retained crown
Crown-Root Fracture
with pulp involvement

59.  Treatment:
 Surgical extrusion
• removal of mobile fractured
fragment
• subsequent surgical
repositioning of root in a more
coronal position
Crown-Root Fracture
with pulp involvement

60.  Treatment:
 Decoronation (root submergence)
• implant solution is planned,
root fragment may be left in
situ after in order to avoid
alveolar bone resorption
• thereby maintaining volume of
alveolar process for later
implant installation
Crown-Root Fracture
with pulp involvement

61.  Treatment:
 Extraction
• with immediate or delayed
implant-retained crown
restoration or a coventional
bridge
• fractures with severe apical
extension, the extreme being
a vertical fracture
Crown-Root Fracture
with pulp involvement

62.  fracture confined to the
root of tooth involving:
 cementum
 dentin
 pulp
Root Fracture

63.  Visual sign:
 coronal segment may be
mobile
 some cases displaced
 transient crown discoloration
(red or gray) may occur
 bleeding from gingival sulcus
may be noted
Root Fracture

64.  Percussion test:
 tooth may be tender
 Mobility test:
 coronal segment may be
mobile
Root Fracture

65.  Sensibility test:
 the test is important in assessing
risk of healing complications
 a positive sensibility test
at the initial examination
indicates a significantly
reduced risk of later pulpal
necrosis
Root Fracture

66.  Sensibility test:
 may give negative results
initially
 indicating transient or permanent
neural damage
 pulp sensibility test is usually
negative for root fractures
except for teeth with minor
displacements
Root Fracture

67.  Radiographic findings:
 root fracture line is
usually visible
 fracture involves root of
the tooth in a horizontal
or diagonal plane
Root Fracture

68.  Treatment:
 rinse exposed root surface
with saline before repositioning
 if displaced, reposition the
coronal segment of the tooth as
soon as possible
 check that correct position
has been reached radiographically
Root Fracture

69.  Treatment:
 stabilize the tooth with flexible
splint for 4 weeks
 if the root fracture is near
cervical area of the tooth
stabilization is beneficial for
a longer period of time (upto 4
months)
Root Fracture

70.  Treatment:
 monitor healing for at least
1 year to determine pulpal
status
 if pulp necrosis develops, then
root canal treatment of the
coronal tooth segment to
the fracture is indicated
Root Fracture

71. References:References:
 BooksBooks
McDonald, Avery et al: Dentistry for theMcDonald, Avery et al: Dentistry for the
Child and AdolescentChild and Adolescent
• (pages 458-459)(pages 458-459)
 InternetInternet
http://www.dentaltraumaguide.orghttp://www.dentaltraumaguide.org