Dr. Mohammad A. BarayanDr. Mohammad A. Barayan

DefinitionDefinition: :

Injury which is limited to the teeth Injury which is limited to the teeth and supporting structures of the and supporting structures of the alveolusalveolus..

N.BN.B Boys are three times more Boys are three times more at risk than girlsat risk than girls..

CausesCauses: : 11 - -Traffic AccidentTraffic Accident..

22 - -FallsFalls..

33 - -During Epileptic seizuresDuring Epileptic seizures..

44 - -Sport injuriesSport injuries..

Diagnosis

HistoryClinical

examination Vitality testRadiographic

Examination

11)) Personal history

2) medical history

3) Previous dental history

4) History of trauma )when ,how ,where )

11 ) )When did the accident occurWhen did the accident occur? ? The The shortershorter the time between accident and the time between accident and treatment the treatment the betterbetter prognosis prognosis..

22 ) )where did the accident occurwhere did the accident occur? ? If the accident occurred in If the accident occurred in dirty placedirty place prophylactic tetanus prophylactic tetanus is indicatedis indicated

33 ) )how did the injury occurhow did the injury occur? ? Direct force under the chin →Direct force under the chin → →→ condylar fracture condylar fractureDirect force to teeth Direct force to teeth → →→ → Crown F, Root F, displacement Crown F, Root F, displacement

Extraoral Examination

Laceration ; Abrasions ; Contusions on the head and neck can be noted visuallyAny asymmetries including deviation in mouth opening.

Intraoral Examination

Soft tissue ( tongue ; gingiva .. )Teeth ( displacement ; mobility ; tooth fracture ; colour change )

Vitality test just following traumatic injury often given false negative response

Types of vitality testTypes of vitality test

11)) Thermal pulp testThermal pulp test cold testcold test

heat testheat test

22 ) )Electrical pulp testElectrical pulp test

33)) Cavity testCavity test

*soft tissue injuries

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

11 - -stage of root formationstage of root formation

22 - -presence of root fracturpresence of root fractur

33 - -periapical radiolucenciesperiapical radiolucencies

44 - -injury of the supporting periodontal membraneinjury of the supporting periodontal membrane

((degree of intrusion or extrusion o the toothdegree of intrusion or extrusion o the tooth))

55 - -size of the pulpsize of the pulp

N. B. If a jaw fracture is suspected extaoral N. B. If a jaw fracture is suspected extaoral radiographs indicated )panoramic and lateral radiographs indicated )panoramic and lateral oblique views (oblique views (

Ellis classificationEllis 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 marginClass V:

Root fracture a) vertical b) horizontal

(apical , middle , cervical)

Class IClass I: :

1 -a crack of the enamel without loss of tooth structure.Do not require immediate Do not require immediate treatmenttreatment..

22-- fracture of enamel only fracture of enamel only smoothing the sharp smoothing the sharp edgeedge

regular vitality test , regular vitality test , radiographradiograph

Class IIClass II: :

Immediate treatment of the crown is required to:

1 )protect the pulp2 )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

Class IIIClass III: :

The treatment depends on The treatment depends on many factors such asmany 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 The main objective of treatment is to maintain the vitality of the is to maintain the vitality of the toothtooth..

Small exposureLarge exposure

EarlyLateEarlyLate

OpenClose openclosedopenclosedopenClosed

Direct pulp capping

pulpotomy

pulpectomy

pulpectomy

Pulpotomy

pulpectomy

pulpectomy

Pulpectomy

Apexification

pulpectomy

ApexificationApexification: :

Class IV:

Treatment usually involve removing the loose fragment.

11 - -tooth can be tooth can be extruded extruded orthodonticallyorthodontically

22 - -crown lengthening crown lengthening to gain access to to gain access to placement of placement of restorationrestoration..

Class vClass v: : 11 ) )Horizontal Root fractureHorizontal Root fracture

When the fracture occur near the When the fracture occur near the apical 1/3, the prognosis is more apical 1/3, the prognosis is more favourable than the middle or cervical 1/3 favourable than the middle or cervical 1/3 becausebecause: :

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

)A (apical 1/3 root fracture

11 ) )reduction , splinting the reduction , splinting the toothtooth

22))the tooth should be the tooth should be checked periodically for checked periodically for vitality and radiographvitality and radiograph..

))BB ( (middle 1/3 root middle 1/3 root fracturefracture: :

11 ) )reduction , splinting the reduction , splinting the toothtooth

22))the patient recall 2-3 the patient recall 2-3 months , checked the months , checked the vitality ,radiographvitality ,radiograph

33))if the tooth non vital and no if the tooth non vital and no healing the following healing the following treatment is performedtreatment is performed::

a) R C T of both fragmentsa) R C T of both fragments b) apical fragment removed b) apical fragment removed

surgically surgically c) intraradicular pin to c) intraradicular pin to

stabilize both segmentsstabilize both segments

))CC ( (cervical 1/3 root fracturecervical 1/3 root fracture: :

11))reductin , splinting the toothreductin , splinting the tooth 22))recall the patient periodically and recall the patient periodically and

checked the vitality and radiographchecked the vitality and radiograph33))if there is radiolucent and pulp if there is radiolucent and pulp

necrosis the following treatment is necrosis the following treatment is performedperformed

a) extraction the tootha) extraction the tooth b) removed the apical fragment b) removed the apical fragment

and endo-osseous and endo-osseous implant placedimplant placed

c) orthodontic extrusionc) orthodontic extrusion d) if the fracture is 1-2mm d) if the fracture is 1-2mm

infrabony remove the infrabony remove the coronal segment and coronal segment and osteoplasty to expose the rootosteoplasty to expose the root

2) vertical root fracture :2) vertical root fracture :

• usually the prognosis is not usually the prognosis is not favorablefavorable

• treatment of V R F :treatment of V R F :

1)extraction of the tooth 1)extraction of the tooth

2)using co2 laser and ND:YAG laser 2)using co2 laser and ND:YAG laser beam beam

* *ConcussionConcussion

• A mild blow to the tooth resulting in A mild blow to the tooth resulting in mild sensitivity requires little or no mild sensitivity requires little or no treatmenttreatment

• Need only regular vitality test Need only regular vitality test

**subluxationsubluxation

• Mobility of the tooth without Mobility of the tooth without displacementdisplacement

• Tooth may be sensitive to percussionTooth may be sensitive to percussion

• If mobility is extensive splint the If mobility is extensive splint the tooth using the acid tooth using the acid ––etch splinting etch splinting technique.technique.

• Regular vitality test and radiograph Regular vitality test and radiograph

• 1) lateral luxation 1) lateral luxation

• 2) intrusive luxation 2) intrusive luxation

• 3) extrusive luxation 3) extrusive luxation

• 4) avulsion 4) avulsion

1) Lateral luxation1) Lateral luxation : :

• Displacement of the tooth in Displacement of the tooth in any direction other than the any direction other than the axial one axial one

• If the patient comes If the patient comes immediately after trauma immediately after trauma reposition, splintingreposition, splinting

• Once the tooth have solidified Once the tooth have solidified in their position orthodontic in their position orthodontic treatment is requiredtreatment is required

1) Intrusion:1) Intrusion: • Displacement the tooth into the socket Displacement the tooth into the socket

A) primary tooth:A) primary tooth: will re-erupted over a period of few will re-erupted over a period of few

months. If the intruded tooth is in months. If the intruded tooth is in contact with underlying permanent contact with underlying permanent tooth should be remove tooth should be remove

B) permanent tooth:B) permanent tooth: • a) immediate surgical repositioning , a) immediate surgical repositioning ,

splinting splinting

• b) orthodontic extrusion b) orthodontic extrusion • c) incomplete root formation the c) incomplete root formation the

tooth will erupt spontaneouslytooth will erupt spontaneously

2) Extrusion :2) Extrusion :

• Partially displacement the tooth out of the Partially displacement the tooth out of the socket .socket .

A) primary tooth:A) primary tooth: Treatment usually extracted Treatment usually extracted

B) permanent tooth :B) permanent tooth :• reposition and splinting reposition and splinting • If the vitality of tooth is lost start root If the vitality of tooth is lost start root

treatment immediately placing calcium treatment immediately placing calcium • hydroxide in the canal for 6-12 month hydroxide in the canal for 6-12 month

followed permanent filling.followed permanent filling.

3) Avulsion:3) Avulsion:

• Complete displacement of the Complete displacement of the tooth from the socket .tooth from the socket .

• There are tow important factors to There are tow important factors to be consider in cases of avulsion be consider in cases of avulsion

• 1)1)timetime between the injury and between the injury and treatment treatment

• 2)2)conditioncondition under which the tooth have under which the tooth have been restored been restored

• The tooth must be kept moist to The tooth must be kept moist to prevent damage to the fibers of prevent damage to the fibers of PDLPDL

• In many cases the initial patient contact is In many cases the initial patient contact is byby phonephone

• The tooth should be handled by the crown The tooth should be handled by the crown • The tooth should be placed in suitable The tooth should be placed in suitable

storage medium (milk, unsalted water, lens storage medium (milk, unsalted water, lens solution )or in buccal vestibule or under the solution )or in buccal vestibule or under the tongue .tongue .

• At the dental office :At the dental office :• a) information about tetanus immunization a) information about tetanus immunization

should be obtained should be obtained • b) replantation , splinting for 1_2weeks but b) replantation , splinting for 1_2weeks but

in immature apices 2-3weeksin immature apices 2-3weeks• c) calcium hydroxide should be placed c) calcium hydroxide should be placed • d) RCTd) RCT

• Small fracture through the alveolar Small fracture through the alveolar

process. process.

there may be concomitant injuriesthere may be concomitant injuries

(crown, root fracture and soft tissue) managed by (crown, root fracture and soft tissue) managed by referral to an oral and maxillofacial surgery .referral to an oral and maxillofacial surgery .

• Treatment: redaction , splintingTreatment: redaction , splinting

Types of splintingTypes of splinting: :

1) acid_etched composite splinting 1) acid_etched composite splinting 2) Interdental wiring 2) Interdental wiring 3) ( vacuum_formed plastic) splint 3) ( vacuum_formed plastic) splint 4) arch bare splint 4) arch bare splint

• More rigid and the longer the More rigid and the longer the stabilization, the more root resorption , stabilization, the more root resorption , ankylosis that can be expected .ankylosis that can be expected .

Stabilization periods for dentoalveolar Stabilization periods for dentoalveolar injuryinjury

Dentoalveolar injuryDentoalveolar injury Duration of Duration of immobilization immobilization

11 ) )Mobile toothMobile tooth 77 _ _ 1010 daysdays

22 ) )Tooth Tooth displacementdisplacement

22 _ _ 33 weeksweeks

33))Root fractureRoot fracture 22 _ _ 44 monthsmonths

44 ) )AvulsionAvulsion 77 _ _ 1010 daysdays

55 ) )Alveolar fractureAlveolar fracture

44 _ _ 66 weeksweeks