Department of endodontics Traumatic injuries seminar done by Guddu kumarCRI,BDS(2008-2009)BATCH

introduction-

• Dentoalveolar injuries are those injuries involving the teeth, the alveolar portion of the maxilla and mandible, and the adjacent soft tissues. They are among the most serious dental conditions.

Examples of such injuries include the avulsion of teeth, fractures of the teeth, fractures of the alveolar process, and lacerations of the soft tissue.

HISTORY

Hippocrates of Cos , was the first to document treatment regiemes for dentoalveolar traumas in his writings . He was the one who alluded various splinting techniques as well as to expedit healing process.

ETIOLOGY AND INCIDENCE :

Common in

Pediatric-Falls during 1st years of lifeTeenage-contact sports ,background activity ,Adults - motor vehicle accidents, contact sports, altercations,assaults, industrial accidents and iatrogenic medical and dental misadventures

Child abuse is one of the significant etiology causing dentoalveolar trauma.

PREVALANCE:

Primary dentition – 11 – 30 % Permanent dentition – 5 to 20 %

SEX RATIO:

Mem :women – 2:1

Other groups at increased risk :

• Seizure disorders

• Mental disorders

•Congenital abnormalities

Trauma can be

•Direct – most commonly affected teeth is Maxillary centrals (class II division 1 is more prone for such trauma)

Primary dentition – Luxation occurs more commonly(75%) Permanent dentiton – Crown/crown-root fracture (39%)

•Indirect –Forceful impact in the chin may trasmit the forces to the posterior teeth

HISTORY :

•Preinjury data – biographic - demographic•Past Medical History •Time of incident •Occlusion•Location of incident •Loss of consiousness•Nature of incident

PHYSICAL EXAMINATION:

Check for- potential for aspiration -Airway compromise-Neurosensory deficit

MAXILLOFACIAL EXAMINATION:

-Extraoral examination

-Intraoral examination

-Jaws and alveolar bone

-Teeth (displacement, mobility , fracture)

-Percussion

-Pulp vitality testing

PULP VITALITY TESTING METHODS:

•Mechanical stimulation•Theraml test•Carbondioxide snow•Electric pulp testing•Laser doppler flowmetry

RADIOGRAPHIC EXAMINATION:

•Periapical radiodraphs•Occlusal radiographs•Panoramic radiographs

CLASSIFICATIONS:

Two commonly used classifications are-Ellis and Davey’s classification -Andersons classification- Adopted by WHO

Ellis and Davey’s classification(1960):

Class I - Simple fracture of the crown involving only enamel with little or no dentin.Class II - Extensive Fracture of crown involving considerable dentin but not exposing dental pulp.ClassIII - Extensive fracture of crown involving considerable dentin and exposing dental pulp.Class IV - Traumatized tooth that becomes non-vital.Class V - Total tooth loss-Avulsion.Class VI - Fracture of the root with or with out loss of crown structure.Class VII - Displacement of tooth with neither crown or root fracture.ClassVIII - Fracture of crown en masse and its displacement.Class IX - Traumatic injuries of primary teeth.

Anderson’s classification:• Injuries to hard dental tissues and Pulp:1. Enamel infarction2. Enamel fracture3. Enamel-Dentin fracture(uncomplicated crown fracture4. Complicated crown fracture5. Uncomplicated crown root fracture6. Complicated crown root fracture7. Root fracture• Injuries to periodontal tissues:1. Concussion2. Subluxation3. Extrusive luxation(peripheral dislocation,partial avulsion)4. Lateral luxation5. Intrusive luxation(central dislocation)6. Avulsion (exarticulation)• Injuries to supporting bone:1. Comminution of mandibular or maxillary alveolar socket2. Fracture of maxillary or mandibular socket wall3. Fracture of maxillary or mandibular alveolar process• Injuries to gingiva or oral mucosa:1. Laceration of gingiva or oral mucosa2. Contusion of gingiva or oral mucosa3. Abrasion of gingiva or oral mucosa

MANAGEMENT OF DENTOALVEOLAR INJURIES

ENAMEL INFARCTIONS:

• Very common• Appear as crazing within the enamel which do not cross the dentino-enamel junction and appear with or without loss of tooth substance.• Caused by direct impact• Patterns of infarction lines depends on direction and location of trauma • Seen by – visualizing along the long axis of the tooth from the incisal edge - Fiberoptic light sources - Transillumination

ENAMEL FRACTURE:

Clinical feature:

•More common in both primary and permanentdentition then the complicated fracture•Confined to a single tooth•Common in maxillary region

Treatment:

•Restoration with composite resin after corrective grinding and removal of sharp edges

UNCOMPLICATED CROWN FRACTURE:

Clinical feature:

•Dentin exposed after crown fracture often gives rise to sensitivity to thermal changes and mastication•Careful search for any minute pulp exposure to be done during examination .

Treatment:

•Immediate provisional treatment : Placement of calcium hydroxide paste on the exposed dentin and restore•Permanent treatment: Restoration with composite resin or full coverage crown

COMPLICATED CROWN FRACTURE:

Clinical fracture:

•Occurs when there is a fracture of enamel ,dentin along with exposure of pulp .

•Usuallypresents as a fractured segment of the tooth with frank bleeding from exposed pulp.

Treatment:Treatment depends upon the extent and time of pulp exposure • When the exposure is small , which is not exposed for more than 4-5 minutes then it is advisable to do pulp capping .

• When the exposure is large , and is exposed for more than 5 minutes – pulpotomy(pulp is vital)Apexification(pulp is necrotic)Endodontic treatment(pulpectomy)

CROWN –ROOT FRACTURE:

It is defined as the fracture involving enamel,dentin and cementum .Can be either complicated or uncomplicated fracture.Anterior crown fracture – direct traumaPosterior crown fracture- indirect traumaClinical feature:•Fracture lines begins few millimeters incisal to marginal gingiva or to the facial aspect of the crown (in an obliquecourse below the gingival crevice ) Treatment :Emergency treatment- acid etch splitDefinitive treatment-( Before deciding the treatment the fractured fragment to be removed to evaluate the apical extent of the fracture) Uncomplicated with out pulp exposure – restorableComplicated fracture – may require RCT or extraction of root fragment

ROOT FRACTUREIt is the fractures involving dentin,cementum and pulp.Mechanism of Root fracture – Frontal impact.

Clinical feature:• Commonly seen in maxillary central incisor region in age group of 11 to 20 years• Coronal fragments are displaced lingually or slightly extruded• Temporary loss of sensitivity.

Radiographically:1. Radiolucent oblique line which is most often visible only if the central beam is directed with in maximum range of 15-20°

CLASSIFICATION:

1.CORONAL THIRD ROOT FRACTURE

2.MIDROOT FRACTURE

3.APICAL THIRD ROOT FRACTURE

Coronal root fracture

Fracture in the cervical segment were considered to have poor prognosis .

Treatment –extraction of tooth

Mid root fracture

Prognosis and treatment plan depends on follo

wing factors

1.Position of the tooth after root fracture

2.Mobility of the coronal segment

3.Ststus of the pulp

4.Position of the fracture line.

Treatment options-1.root canal therapy of both segments,when the segments are not separated

2.Root canal therapy of coronal segment and removal of apical segment,when the segments are separated.

3.Use of intra-radicular splint,eg-rigid type post to stabilize the two root segments.

4.Root canal treatment of the coronal segment and no treatment of apical one,when the apical segment is vital

Apical third root fracture

Prognosis is favorable becouse pulp in apical segment usually remains vital.

If pulp of coronal segment is non vital –rct can be done.

If tooth fails to recover,apical, segment can be removed surgically.

VERTICAL ROOT FRACTURE( Cracked tooth syndrome )

It runs lengthvise from crown towards the apex .Etiology – mostly iatrogenic.

Clinical Features:•Persistant dull pain of long standing origin .•Pain is elicited by applying pressure

Radiographic Feature:•If the central beam lies in the line of fracture it is visible as a radiolucent line •Widening of PDL

Treatment:•Single rooted teeth- extraction•Multiple rooted teeth- Hemisection and remaining tooth is endodontically treated and restored with crown.

Healing patterns

1.Healing with calcified tissue-fracture line is discernible on radiograph.

2.Healing with interproximal connective tissue-fracture fragments appear

Separated but fracture edges appear rounded

3.Healing with interproximal connective tissue and bone-fragments are separated by a distinct ridge.

4.Interproximal inflmmatory tissue without healing (granulomatous tissue)

-widening of fracture line

CONCUSSION (Sensitivity)

An injury to the tooth supporting structure,when there is some crushing injury to apical vasculature periodontal ligament with resultant inflammatory edema with marked reaction to percussion but no abnormalloosening or displacement.

Clinical feature:•Traumatized tooth has pain on percussion•Sensitivity during masitication.

Radiographically :•Widening of periodontal ligamen space apically.•Reduction in size of pulp after a few months

Treatment:•Sensitivity – symtomatic relief - relieving the tooth from occlusal contact.

SUBLUXATION (MOBILITY, LOOSENESS)An injury to tooth supporting structures with abnormal loosening but with out clinically or radiographically demonstrable displacement of the teeth.

Clinical feature:• Tooth is tender on palpation• Mobility• Evidence of hemorrhage at gingival margin

Radiographically:• Widening of PDL space• Reduction in the size of the pulp after few months

Treatment:• Adjustment of occlusion• Splinting for 10 days

INTRUSIVE LUXATIONDisplacement of the tooth into alveolar bone.

Clinical feature:•Displacement with fracture or crushing of alveolar bone.•Mobile tooth•Gingival bleeding•Metallic sound with pain on percussion•Pain on mastication•Clinically crown appeas shorter.Radiographic feature:•Obliteration of apical portion of PDL space •Crushiong of lamina duraTreatment:• Mostly involves orthodontic or surgical repositioning of the tooth• Stabilization using splits for 2-3 weeks after tooth has come to normal or original position

EXTRUSIVE LUXATION:

It is also called peripheral displacement or partial avulsion.It is partial dispacement of tooth out of its socket.

Clinical feature:•Crown appears longer •Mobile tooth •Gingival bleeding •Pain on percussion.Radiographically:•Widwning of PDLTreatment :•Repositioning of tooth in normal position using digital pressure.•Splint the tooth for 2-3 weeks

LATERAL LUXATIONDisplacement of the tooth in any direction other than axial.

Clinical features:

•Tooth is mobile and displaced•Gingival bleeding•Pain on percussion and mastication

Radiographically:

•Widening of the PDL space on one side and crushing of lamina dura on other side

Treatment:1. Repositioning of tooth followed by splinting for 2-3 weeks

AVULSION: (Exarticulation)

Complete displacement of tooth from its alveolus .

Clinical features:•Bleeding socket with missing tooth

Radiographic features:•Empty socket•Associated bone fractures•If the wound is recent then lamina dura is visible

Treatment:The factors most important for determining the prognosis of the treatment are- the length of time the tooth has been out of the socket(sooner the better) -Periodontal tissues -The manner in which the tooth is preserved

REIMPLANTATION

The following conditions should be considered before reimplanting a permanent tooth:•The alveolar socket should be reasonably intact in order to provide seat for the avulsed tooth .•The extra alveolar period -Short - Long

Storage medium:

•Hank’s balanced salt solution(HBSS)•Milk •Saliva•Saline

Follow up: Minimum of 1 yearComplication : Root resorptionPrognosis: 1. Tooth survival -51 to 89 %2. PDL healing - 9 to 50 %3. Pulp healing - 4 to 15 %

PROCEDURE:The tooth is placed in saline

If contaminated ,the root surface is cleansed with stream of saline

The socket is examined for evidence of fracture.The alveolus is also cleansed with a flow of saline to remove contaminated coagulum

Tooth to be reimplanted using slight digital pressure with light pressure. The reimplanted tooth should fit loosely in the alveolus

Suture gingival laceration

Apply splint for 1 week only as prolonged splinting of replanted tooth causes root resorption

Proper repositioning can now be evaluvated by the occlusion of tooth

Verify position radiographically

Tetanus prophylaxis is important and tetracycline twice a day for 2 week

If apical foramen is closed then perform endodontic therapy after one week prior to removal of splint

STABILIZATION PERIODS FOR DENTOALVEOLAR INJURIES

DENTOALVEOLAR INJURY DURATION OF IMMOBILIZATION

Mobile tooth

Tooth displacement

Root fracture

Replanted tooth (mature)

Replanted tooth(immature)

7-10 days

2-3 weeks

2-4 months

7-10days

3-4 weeks

METHODS OF IMMOBILISATIONSPLINTING: It is the method of fixation is the best for treating both dentoalveolar fracture and subluxed teeth . Splints provide excellent immobilization and have additional advantage that when teeth have had their crown fractured , the splint is able to retain sedative dressing in place and provide good protection for the traumatized tooth.

Types splinting:

•Foil /cement splint: It is an emergency procedure , it is possible to mould a splint using either protective lead foil from an xray pack or thin tinfoil. It can be gently manipulated over both the subluxed tooth and adjuscent firm tooth. Rigidity can be gained using double thickness foil and cemented using cold cure resin.

Cold-cure acrylic splint:

The material is moulded in situ with fingers to provide temporary splinting of the subluxed tooth .

Enamel bound composite resin splint:

Hall in 1983 recommends for fixation of dentoalveolarfracture of maxilla or mandible following repositioning or reimplatation of the teeth.

Composite resin/acrylic resin and wire splint: This technique is used as a rigid splint by incorporating two adjuscent healthy teech on either side of injured teeth.

Orthodontic brackets and wires:

Used for displacement injuries and exarticulation .They have an advantage of allowing more accuratereduction of injury ny gentle forces .

Interdental Wiring:

Interdental wiring on a arch wire ligated to the teethwith ligature wire should not be used except astemporary measure , as it compromises gingival health.Wiring techniques that can be followed are:•Arch bars•Loop wiring•Figure of eight wiring

Thermoplastic splint:

Constructed from polyvinylacetate-poly ethylene in the same way like a mouth caurd

Conclusion:

Dentoalveolar trauma being very common in dental practice requires prompt treatment which aids in saving a tooth.

Treatment modalites in this modern world are very simple and very effective provided the management is done on time .

After all “We can make a difference when it comes to teeth as well”

Reference:.• Contemporary Oral and maxillo facial surgery - James.R.Hupp, Edward Ellis III, Myron R.Tucker.• Text book of oral and Maxillo facial surgery -Neelima Anil Malik• Grossman’s endodontic practice(12th edition)

THANK YOU

presented by guddu kumar