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Scand. J . dent. Res.

1970: 78: 329-342

Etiology and pathogenesis of


traumatic dental injuries
A clinical study of 1,298 cases
J. 0.ANDREASEN
Dental Department, University Hospital (Rigshospitalet), and Department of
Oral Pathology, Royal Dental College, Copenhagen, Denmark
Abstract - The etiology and pathogenesis of traumatic dental injuries were studied on
the basis of a hospital material of 1,298 patients (908 males and 390 females). A total
number of 3,026 injured teeth were treated, including 787 primary and 2,239 permanent
teeth. Repeated dental injuries were found in 24 % of the cases. All traumas were
classified according to the type of injury affecting the lips, oral mucosa, tooth-supporting structures, and hard dental tissues. The type of injury seems to be related to
the dentition, with traumas predominantly involving the tooth supporting structures
in the primary dentition. The origin of trauma was allotted into 9 groups, partly on
the basis of a presumed difference in energy of the impact as well as a difference in
the resiliency of the impact. A statistical analysis revealed significant differences in the
injury pattern between the different trauma groups. The relation between lip injuries
and injuries to tooth or tooth-supporting structures was analyzed separately. It appeared
from this analysis that the lips may act as an impact absorber reducing the chance
of trown fracture and increasing the risk of luxation and alveolar fracture.
(Received for publication 20 February, accepted 23 April 1970)

Traymatic dental injuries leave the dental grofession with severe therapeutic
problems. The population risk for sustaining traumatic dental injuries has
been shown to be of a n impressive magnitude. Thus a study by Schutzmannsky
(1963) showed that 13% of examined
school children at the age of 18 years
had been exposed to dental injuries during adolescence.
Whereas numerous studies have dealt
with the treatment procedures of these
injuries, the etiology and pathogenesis
have attracted minor interest. Consequently, the purpose of the present study
was to examine the following items:
'(1) The relationship between origin of

trauma and subsequent injury pattern to the oral structures,


(2) The interrelationship between injuries to the mineralized oral tissues
(i. e. hard dental tissue and supporting bone) and the soft tissues (i. e.
gingiva, oral mucosa, lips, and chin),
and
(3) The relationship between type of
injury and other variables such as
sex, age, tooth location, and dentition.
Material and methods

The material consists of 1,298 patients


referred to the Dental Department, University Hospital, Copenhagen, for treat-

330

ANDREASEN

ment of traumatic dental injuries during


the period 1955 to 1967. The admissions
to the hospital represent mainly severe
dental injuries whereas minor traumas
are usually treated elsewhere. From the
records of these patients the following
variables were registered: age, sex, history of previous dental injuries, cause of
injury, type and number of teeth involved, and diagnosis of injuries affecting the lips, chin, oral mucosa, toothsupporting structures, and hard dental
tissues, using the classification system
proposed by Andreasen (1970).
The location of the soft tissue injury
was registered; as involving the external
or internal surface of the upper or lower
lip, the chin, or the gingiva. Furthermore,
it was noted whether the injury had
caused swelling, abrasion, or laceration
of soft tissues.
In the statistical analysis of injury
pattern the frequencies of each type of
injury was first compared in two groups
using the u-test (Hald 1952). For comparison of injury pattern between the
trauma groups, the U-values were squared
and added; the resulting value is approximately distributed as x2 (Hald
1952). All $compilations and statistical
tests were carried out with the aid of an
IBM computer.7094.
Results
The sex ratio of treated patients was 908
males to 390 females (2.3 : 1) and the age
distribution is shown in Table 1.
Data on previous dental injuries were
available from the records of 252 cases,
and among these 60 patients (24 %) had
a history of previous dental traumas.
The 1,298 patients represent 3,026 injured teeth: 787 primary and 2,239 permanent teeth. The number of involved
teeth varied from one to fifteen in the
individual patient (Table 2). The loca-

a,
P

0
+

.-

I0!

03

0
0

m
F

2n Eo
m

=m

*0

cu
0

.-

CI

P
L

cu

.-CIfn
0

v,
hl
N

-P

2M3

sa
u4

ETIOLOGY A N D PATHOGENESIS OF TRAUMATIC DENTAL INJURIES

331

Table 3
Location of traumatized primary teeth'

05+

04+

03+

02+

01+

$01

+02

+03

+04

t05

14

85

27 1

224

96

16

13

17

24

13

-03

-04

04-

05-

03-

02-

01-

-01

-02

-05

* According to the Hade~-upsystem of dental designation, + signifies the maxilla, - the mandible. If the symbol is placed to the right of the figure, the right side is indicated, and vice
versa. 0 before the figure indicates a primary tooth.

Table 4
Location of traumatized permanent teeth
~~

8+

7+ 6+

5+

4+

16

3+

31

~~

2+

I+

+1

+2

227

607

639

233

+3
37
~~

0
9-

7-

6-

5-

4
4-

17
3-

69106108
2-

1-

-1

62
-2

+6 +7 + 8

+4

+5

15

-4

-5

14
-3

-6

-7

-8

Table 5
Distribution of injured teeth according t o diagnosis and type of dentition
(The number of diagnoses exceeds the number of teeth due t o multiple diagnoses
for some teeth)

Primary
dentition
Crown fractures without pulp exposure ....
Crown fractures with pulp exposure .........
Crown-root fractures ..............................
Root fractures .......................................
Subluxations .............
.............
Intrusive luxations ....
Extrusive luxations ....
.............
Exarticulations .......................................
Fractures of the labial or lingual bone plate
and/or alveolar socket ........................
Fractures of alveolar process ........ ......
Fractures of mandible or maxilla .............
Other irjuries or exact injury not specified
Total number of injured teeth .......

19
13
14
31
97

(2 %)
(2 %)
(2 %)

(4%)
(12%)

265 (34 %)
101 (L3 %)
33
26
0
172

(4%)
(3 %)
(0%)
(29 %)

Permanent
dentition
433 (19 %)
172 (8 %)
108 ( 5 %)
156 (7 %)

336
61
630
350

(15 %)
(3 %)
(28 %)
(16 %)

109
205
35
334

( 5 %)

2,239

(9%)
(2 %)
(15 %)

All teeth
452
185
122
187
433
186
895
451

(15 %)
(6 %)
(4 %)
(6%)
(14 %)
(6%)
(30 %)
(15 %)

142 5 % )
231 (8%)
36 (1 %)
506 (20 %)
3,026

ANDREASEN

332

tion of the affected teeth is given in


Tables 3 and 4. It appears that no side
predilection exists, and that the maxillary central incisor region is most frequently involved in both dentitions. The
type of injury sustained appears to be
related to the type of dentition, whether
permanent or primary (Table 5). Thus
tooth fractures seem to be more common
in the permanent dentition while luxations and especially intrusions dominate
in the primary dentition. However, these
results must be evaluated with caution,
due to the selected nature of the material.

Complete information on the origin of


trauma was available in 725 patients.
These patients represented 38 different
types of trauma; however, a number of
these included only a few cases and
were, therefore, discarded from further
analysis. The remaining causes of injury
were allotted into nine main groups, and
the injury patterns were registered within these groups. Because of large differences in types and origin of injuries
sustained in the primary and permanent
dentition, separate tabulations were made
according to type of dentition.

Table 6
Relation between origin of trauma and injury pattern (primary dentition)

Group 4 :
Group 3 :
Group 2:
Group 1:
Fa11 against
Total
Fall on a
Fall from a
Fall during
an object
staircase
baby carriage
Play
No. of No. ol No. of No. o No.of No.o! No. of No. 01 No. of No. of
patients teeth iatients teeth ,atients teeth batients teeth Jatients teeth
Crown OT
crown-root
fractures

Root fractures
Luxations

5
10%

0
0%

0
0%

0
0%

0
0%

1
5%

2
5%

4
4%

7
3%

0
0%

2
6%

3
5%

1
5%

2
4%

2
9%

4
10%

5
5%

9
4%

24
46
83 % 8 8 %

29
94 %

93 %

3
10%

0
0%

57

16
40
76 % 77 %

18
32
82 % 8 0 %

87
175
84% 85%

Exarticulations

5
17%

5
10%

2
6%

4
7%

3
14%

6
12%

4
18%

8
20%

14
14%

23
11 %

Bone fractures

0
0%

0
0%

1
3%

4
7%

3
14%

10
19%

0
0%

0
0%

4
4%

14
7%

Gingival
injuries
Injuries to the
upper lip
Injuries to the
lower lip

10
34%

23
44 %

9
29 %

18
30%

6
14
29 % 27 %

4
18%

10
25%

15
52%

29
56%

13
42%

25
43 %

10
22
48 % 42 %

10
19
45 % 4 8 %

43
47 q G

5
12
17 % 23 %

4
13%

6
10%

6
29%

19
37%

4
18 %

10
25%

13
47
18 % 23 %

Injuries to
the chin
Total number
of injuries
Average number
of teeth involved

3
10%

5
10%

1
3%

1
2%

1
5%

4
8%

0
0%

0
0%

29

52
1.8

31

61
2 .o

21

52
2.5

22

40
1.8

23
65
28 % 32 %

5
5%
103

95
47 O/O

10
5%
205
2.0

Exarticulations
Bone
fractures
Gingival
injuries
Injuries to the
upper lip
Injuries to the
lower lip
Injuries to the
chin
Total number
of injuries
Average
number of
teeth involved

Luxations

Crown or
crown-root
fractures
Root
fractures

287

123

2.3

60%
40
14 %
28
10 %
69
24 %
146
51 %
86
30 %
39
14 %

66
54 %
18
15 %
8
7%
31
25 %
58
47 %
35
28 %
13
11 %

160

16
6%

118

62
52 %
13
11 %
10
8%
28
24 %
80
68 %
27
23 %
26
22 %

5%

51
43 %

114
40 %

50
41 %

2.7

319

14 %
86
27 %
207
65 %
78
24 %
89
26 %

45

14
4%
190
59 %
36
11 %

131
41 %

No.of
teeth

No.of
patients

No.of
patients

No.of
teeth

Group 6:
Fall with a bicycle
or motorvehicle

Group 5:
Fall during play,
athletics,
or fainting

7%

Table 7

58

9
16 %
41
71 %
12
21 %
13
22 %
18
31 %
33
57 %
15
26 %
2
3%

12 %

2.5

No. of
patients

144

67 %
31
21 %
49
34 %
51
35 %
85
59 %
45
31 %
10
7%

97

16
11 %

12
8%

No. of
teeth

Group 7:
Injury during
a fight

41

2
5%
29
71 %
4
10 %
13
32 %
10
24 %
20
49 %
19
46 %
16
39 %

10
24 %

4.3

No.of
patients

175

52 %
88
50 %
68
39 %

91

8
5%
104
59 Yo
25
13 %
51
29 %
50
29 %

46
26 o/c

No.of
teeth

Group 8:
Automobile
accident

46

23
61 %
7
15 %
7
15 Yo
11
24 %
22
48 %
18
39 %
3
7%

15 %

19
41 %

2.5

117

15
13 %
65
56 %
14
12 %
20
17 70
31
26 %
63
54 %
50
50 %
3
3%

47
40 %

Group 9 :
Foreign body
striking the
oral
structures
No.of
No.of
patients teeth

Relation between origin of trauma and injury pattern (permanent dentition)

386

16 %

60

25 %
213
55 %
114
30 %

98

33
9%
226
58 %
54
14 %
51
13 %

137
35 %

69
7%
61G
59 %
146
14 %
193
19 %
287
27 %
592
57 %
355
34 %
209
20 %

350
34 %

No. of
teeth

1.042
3.0

No. of
patients

Total

ANDREASEN

334

F i g . 1 . Direct tooth trauma without soft tissue injury. T h e impact has struck the protruding
maxillary central incisors.

Table 8
Chi-square values for comparison ofLinjury patternEbetween different trauma groups

Group 1 Group 2 Group 3 Group 5 Group 6 Group 7 Group 8


Group 2 Involved patients 4.38
Involved teeth
16.56"
Group 3 Involved patients 3.72
Involved teeth
22.27""
Group 4 Involved patients 3.15
11.58
Involved teeth
Group 6 Involved patients
Involved teeth
Group 7 Involved patients
Involved teeth
Group 8 Involved patients
Involved teeth
Group 9 Involved patients
Involved teeth

4.48
20.16" ::
2.03
11.96

2.07
13.15
16.34"

5.59

T h e 5, 1, and 0.1 7'0 levels of significance are denoted *, "", a n d


of freedom are 9 for all values.

In Table 6 the result of this analysis is


listed for the primary dentition. In the
trauma group "fall during play" (Group
1) crown fractures and injuries to the
chin were more common than in other

18.18"

::'""

14.20

19.27':'

r espectively. T h e degrees

groups. "Fall from a baby carriage"


(Group 2) showed many cases with luxation and bone injuries. "Fall on a staircase" (Group 3) was characterized by a
frequent occurrence of bone fractures

ETIOLOGY AND PATHOGENESIS OF TRAUMATIC DENTAL IN JURIES

335

Table 9
Association between different injuries affecting a single tooth (primary dentition).
(The frequency of associated injuries is found in the vertical columns. Each column
represents a separate type of injury t o the hard dental tissues)

Associated injuries to
involved teeth
Crown fractures
Crown-root fractures
Root fractures
Subluxations
Intrusive luxations
Extrusive luxations
Exarticulations
Fractures of facial
bone plate
Fractures of alveolar

Crown Crown- Root Subluxa- Intrusive Extru- Exartifractures root fractures tions luxations sive culations
fractures
luxations
n=5
n = 6 n = 1 6 n = 5 8 n = 7 1 n=139 n = 5 4
0

process

0
0

0
0

1
1

0
0

1
0
3
0
0

0
0
0

0
0

12

0
27

0
0

4
0
0
0

16
29
19
3
71

42

19
27

Injuries to the gingiva


Injuries to the upper lip
Injuries to the lower lip
Injuries to the chin
No. of teeth involved

6
11
6

and lip injuries. Fall against an object


(Group 4) revealed a n increased number
of. patients with exarticulated teeth.
A similar tabulation for the permanent
defitition is given in Table 7. A simple
fall; e.g. during play, athletics, or fainting (Group 5), was often followed by
crown or crown-root fractures (Fig. l),
and the same injury pattern was common among falls associated with bicycle
or motor vehicle accidents (Group 6),
and in the latter group injuries to the
chin was rather common.
Injuries during fight (Group 7) seem
to favor occurrence of fractures, luxations, and bone fractures a t the expense
of crown fractures. Automobile accidents
(Group 8) appeared to show a special
injury pattern with bone fractures and
injuries to the lower lip and the chin as

the outstanding lesion. In the trauma


group encountering foreign bodies striking the teeth (Group 9), crown and root
fractures as w t l l as injuries to the lower
lip were found very frequently.
A n analysis was performed which
compared the injury pattern within the
various trauma groups (Table 8). It appears from this Table that significant
differences in injury pattern are seen
between most of these trauma groups.
A trauma to the oral regions often
results in multiple types of injuries to
the individual teeth, affecting both the
hard dental tissues and the supporting
structures. In Tables 9 and 10 this injury
pattern is shown for the primary and
permanent dentition.
The injuries affecting the primary dentition are usually not of a complex

16

40
14
6
58

67
28
9

13
3

139

54

336

ANDREASEN
Table 10

Association between different injuries affecting a single tooth (permanent dentition).


(The frequency of associated injuries is found in the vertical columns. Each column
represents a separate type of injury t o the hard dental tissues)

Associated injuries to
involved teeth
Crown fractures
Crown-root fractures
Root fractures
Subluxations
Intrusive luxations
Extrusive luxations
Exarticulations
Fractures of facial
bone plate
Fractures of alveolar
process
Injuries to the gingiva
Injuries to the upper lip
Injuries to the lower lip
Injuries to the chin
No. of teeth involved

Crown CrownRoot Subluxa- Intrusive Extrusive Exartifractures root


fractures tions luxations luxations culations
fractures
n = 357 n = 63 n = 89 n = 205 n = 40 n = 415 n = 196

0
8
32
12
35

1
2
1
2

30
0

11

5
5
59
194
104
60
357

32
1
30

12
1
0
0

35
2
40
0
0

11
0
6
0
0
0

0
0
0

13

24

29

0
6
27
13
27
63

11
28
40
36
14
89

5
40
104
63
38
205

0
26
14
17
8
40

69
153
244
148
77
415

7
62
126
70
31
196

40

naturh. However, exarticulations are relatively often accompanied by a root


fracture. In the permanent dentition the
crown and c;own-root fractures are usually single lesions, whereas root fractures
are often associated with subluxations or
extrusive luxatidns. Luxation injuries as
well as exarticulations are usually single
injuries, but a n exception is noted among
intrusions where crown fractures are
frequently the associated injury.
The interrelationship between injuries
to the mineralized oral tissues (i. e. hard
dental tissues and supporting bone) and
soft tissues was examined separately
(Tables 11 and 12). The results of this
analysis are listed for injuries affecting
the primary dentition and the permanent
dentition. It appears from Table 12 that
crown ftactures and root fractures, in ap-

proximately half of the cases, are accompanied by a corresponding lip injury.


Crown-root fractures generally show a
low frequency of lip injuries whereas
injuries to the chin are very common
(Fig. 2).
Intrusive luxations are characterized, in
the primary dentition, by a low frequency
of injuries to the upper lip whereas a
high frequency of injuries is recorded
affecting the lower lip or the chin.
Subluxations, extrusive luxations, and
exarticulations all show, especially in the
maxilla, a high frequency of corresponding lip injuries (Fig. 3 ) .
Fractures of the alveolar process are
apparently the hard tissue injury most
often associated with soft tissue injuries,
and the majority of these fractures show
corresponding lip lesions (Fig. 4).

ETIOLOGY A N D PATHOGENESIS OF T R A U M A T I C DENTAL IN J U R I E S

337

Table 11
Relation between hard and soft tissue injuries (primary dentition)

No. of involved

Crown
fractures
Crown-root
fractures
Root
fractures
Subluxations
Intrusive
luxations
Extrusive
luxations
Exarticulations
Fractures of
facial
bone plate
Fractures of
alveolar
process
-

teeth
Maxil- Mandilary
bular
teeth
teeth
4
1

15

53

67

135

49

19

Injuries to the
upper lip
Maxil- Mandilary
bular
teeth
teeth

Injuries to the
lower lip
Maxil- Mandilary
bular
teeth
teeth

2
50%
0
0%
10
67%
40
74%
28
42%
66
49%
25
51%
7
37 %

0
0%
1
100%
1
100%
0
0%
1
25%
1
25%
2
40%
0
0%

3
75%
0
0%
6
40%
12
22%
17
25%
28
21%
13
27 %
4
21%

0
0%
0
0%
0
0%
2
50%
2
50%
0
0%
0
0%
0
0%

6
100%

0
0%

0
0%

8
100%

[njuries to the chin


Maxillary
teeth

Mandibular
teeth

2
50%

0
0%
0
0%
0
0%
1
25%
0
0%
1
25%
1
20%
0

2
4070
1
7%
5
9%
3
5%
8
6%
2
4%
0
0%
0
0 70

0%

0
0%

Fig. 2. Indirect trauma to the chin, transferred to the dental arches, has provoked crown-root
fractures of both maxillary right premolars by forceful occlusion.

338

A N D R E ASEN
Table 12
Relation b e t w e e n hard and s o f t tissue injuries (permanent d e n t i t i o n )

No. of involved
teeth

Crown
fractures
Crown-root
fractures
Root
fractures
Subluxations
Intrusive
luxations
Extrusive
luxations
Exarticulations
Fractures of
facial
bone plate
Fractures of
alveolar
process

Maxillary
teeth

Mandibular
teeth

319

38

56

68

21

159

46

39

320

95

178

18

63

22

79

51

Injuries to the
upper lip

Injuries to the
lower lip

Mandibular
teeth

Maxillary
teeth

Mandibular
teeth

175
55%
26
4674
35
52%
96
60%
13
33%
208
65 7~
117
66%
35
567c

19
50%
1
14%
5
24 %
8
17%
1
100%
36
38%
9
50%
13
59%

85
27%
11
20%
27
40%
43
28%
16
41 7 c
104
33%
64
36%
21
33%

19
50%
2
29%
9
43%
20
44%
1
1WC/O
44
46%
6
33%
12
55%

69
87%

20
39%

10
13%

Maxillary
teeth

Discussion

Statistics concerning different types of


dental injuries may vary according to
treatment institution. T h u s a previous
study dealing with the type of dental
injuries treated by the Municipal School
Dental Service in Copenhagen (Ravn G
Rossen 1969), differs significantly from
the present hospital material, and a comparison between the two materials shows
that severe injuries, such as luxations
and bone injuries, dominate in the hospital material, in contrast to crown fractures. Apart from this discrepancy, presumably due to the selection of the present material, a number of clinical factors are in accordance with previous investigations. This applies for instance to

33
657~

Injurics to the chin


Maxillary
teeth
55

Mandibular
teeth

5
l3fh
6
X6",
10

17%
21
38%
4
6%
18
11%
8
21%
42
13%
21
12%
12
19%

20
44%
1
100%
35
3776
10
56%)
9
40%

20
25%

10
20%

48%,

the dominance of males in the sex ratio


(Abraham 1963, B u f f n e r 1968, Edward &

Nord 1967, Ellis 1960, Eickenbaum 1963,


Gelbier 1967, Grundby 1959, Gaare,
Hagen G Kansfad 1958, Hallef 1953,
Hardwick G Newman 1954, Parkin 1967,
Ravn & Rossen 1969, Sundvall-Hagland
1964, Wallenfin 1959) location of injuries (Abraham 1963, Down 1957, Ellis
1960, Gelbier 1967, Grundy 1959, Gaare,
Hagen G Kansfad 1958, Hallef 1953,
Krefer 1967, Nord 1966, 1968, Parkin
1967, Ravn G Rossen 1969, Schutzmannsky 1963, Taafz 1967, Wallenfin
1959) as well as the high frequency of
repeated traumas (Gelbier 1967, Hardwick G Newman 1954, Ravn & Rossen
1969, Sundvall-Hagland 1964).

E T I O L O G Y A N D P A T I I O G E N E S I S OF T R A U M A T I C D E N T A L IhJLKIES

339

Fig. 3. Ilirect trauma to the upper lip, T h e impact has been transmitted through the lip, resulting in extrusive luxation of maxillary right incisors a n d laceration of gingiva. T h e upper
surface of the lip shows minor lacerations in the area which was in contact with thc tooth
surfaces during transmission of the trauma (arrows).

Fig. 4 . :2 frontal impact to the lower lip (arrows) h a s been transmitted through the lip to
the mandibular incisor rcgion, resulting in a fracture of the alveolar process. T h e oral mucosa
lacerated in areas where the incisor surfaces contacted the lahial niucosa (arrows).

i5

340

ANDREASEN

Previous studies have revealed that


dental injuries usually affect only a
single tooth (Grundy 1959, Ravn & Rossen 1969, Schutzmannsky 1963). The present material showed an average of 2.3
injured teeth per individual, a figure
possibly reflecting the more complicated
injuries treated in the hospital.
W h e n comparing injuries affecting
primary and permanent teeth (Table 5 ) ,
it appears that traumas in the primary
dentition are usually confined to the
tooth-supporting structures, i. e. luxations and exarticulations. This is probably related to the resiliency of the
alveolar bone in these age groups, favoring dislocations rather than fractures.
Grouping of dental injuries according
to type of trauma yields many problems due to the complex etiology. It has
been presumed that a number of factors
are responsible for the type of inflicted
injury, such as energy of impact, resiliency? and angle of the impacting
object (Hallet 1953). Most of these factorscould not be estimated from the
records used in this study. However, the
present grouping of injury origins possibly reflects differences in energy of
impact, f o r h t a n c e , Group 5 (fall during play) p(esumab1y represents a trauma
type with less iinpact energy than Group
6 and 8 (fall with a bicycle or motor
vehicle and automobile accidents). Furthermore the factor resilience of the impacting object may be responsible for
the different distribution of injuries
within Group 7 and 9 (injuries during
fight and foreign bodies striking the
teeth).
The energy of the impact may be responsible for the higher frequency of
bone fractures in Group 3 (fall on a
staircase) as compared to Group 1 (fall
during play). W h e n Group 5 (fall) and
Group 6 (fall with bicycle or motor

vehicle) and Group 8 (automobile accident) are compared, in the mentioned


order, the probable increase in energy
of the trauma impact seems to be followed by a n increase in bone injuries
while the frequency of tooth fractures
decreases. In the latter group the high
frequency of chin injuries is probably
related to the collision between the
driver and the steering wheel or passengers hitting the dashboard.
The marked difference in injury pattern between Group 7 and 9 is possibly
related to a difference in the resiliency
of the impacting object. Possibly the
forces involved in fight injuries represent a blunt or padded impact where the
forces hitting the tooth are transferred
to the periodontal structures, resulting
in luxations and alveolar fractures. The
counterpart to this type of trauma is
possibly an impact caused by a foreign
bodys hitting the oral structures (Group
9). Most of these traumas represent a
hard unelastic impact which tends to
transmit the energy momentarily to a
limited part of the crown area, thus
favoring a crown fracture.
The relationship between injuries to
the hard dental tissues and the supporting structures, shown in Tables 11 and
12, may to some extent be explained by
certain engineering principles. Frontal
impacts to the labial aspect of anterior
teeth generate forces which tend to displace the tooth palatally. If the force
causes a crown fracture, the greater part
of the energy of the impact is expended
to create the fracture and is not transmitted to the root portion. This may explain why crown or crown-root fractures
are seldom associated with dislocations.
O n the other hand, if the impact does
not inflict a fracture, the energy is transferred to the periodontal tissues and a
dislocation of the tooth may occur, ac-

ETIOLOGY AND PATHOGENESIS OF TRAUMATIC DENTAL IN JURIES


cording t o t h e direction of t h e impact.
It appears from many case histories in
this study a n d the figures listed in Table
10 that intrusions are the result of a direct impact hitting the incisal edge in a n
axial direction. T h e tooth is thereby
forced into the supporting bone a n d the
figures show that the energy of this impact, in contrast to other luxation injuries, is al,so expended to a fracture of
the crown.
T h e location of the impact may determine the injury to the tooth a n d its
supporting structures. Thus, if the lip
is hit first by the trauma, it may possibly
act as a n impact absorber reducing the
chance of fracture a n d increasing t h e
risk of movement of the entire tooth.
This may possibly explain t h e frequent
association between lip injuries a n d traumatic lesions involving the supporting
structures, such as subluxations, extrusive luxations, exarticulations, and fractures of the alveolar process.
.Impacts may act directly or indirectly
upon t h e dental structures (Benneff
1963). Thusdirect trauma occurs when a
tooth is struck against a n object, e. g.
playground, table, chair, or a fist, whereas
an iniirect trauma is inflicted when the
mandi$ular dental arch is forcefully
closed. against the maxilla, as may result from a blow o n the chin in a fight.
T h e latter type of injury favors crownroot fractures especially in t h e premolar
and molar region. This is possibly the
explanation for the high frequency of
crown-root fractures found related to
chin injuries in this study.
Acknowledgments - This investigation was
supported by grants from the Danish State
Research Foundation and the Danish Dental
Association, Fonden ti1 statte for videnskabelige og praktiske undersagelser indenfor
tandlzgekunsten. The statistical calculations
were performed by the Northern Europe
University Computing Center.

341

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Address :
J. 0. Andreasen
Dental Department
University Hospital (Rigshospifalet)
9, Blegdamsvei
DK-2100, Copenhagen, Denmark