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Traumatic
Dental Injuries

Ahmed Emad
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Causes
of
Trauma
Car accident
Blows to face
Sports activity
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Incidence of Trauma

• Boys more than girls.

• Active age ; 8-12 years & 2-3 years.

• More frequent in patient with mal-occlusion.

• Maxillary central incisor.

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Diagnosis of
traumatic
injuries
❑History of Trauma

When How where

 Soft tissue
(Lacerations, swelling,bleeding)

Extraoral
Facial bone
(deformety,fracture)
TMJ
Clinical
examination
Soft tissue
(Lacerations,swelling,bleeding)

Intraoral Alveolar bone fracture

Teeth
(Mobility,Displacement,Fracture)
 Radiographic
examination

Subgingival
Root fractures
crown fracture

Tooth Bone Foreign

displacements fractures objects
 Ellis Classification 9

• Trauma to a tooth without

Class I fracture.
• Trauma to a tooth
Class V with root fracture.
• Trauma to a tooth with
Class II chipped enamel or dentin.
• Trauma to a tooth
Class VI with displacement.
Class • Trauma to a tooth coronal
fracture with pulp
III exposure.

• Trauma to
Class • Trauma to a tooth Class VII deciduous teeth.
coronal fracture
IV subgingival.
 WHO Classification
No-873: World Health Organization of Oral Injuries
No-873.60:Enamel fracture.
A - Cracks (crown infraction)
B - Chipping of enamel

No-873.61:Crown fracture without pulp

involvement (Uncomplicated)

No-873.62:Crown fracture with pulp

involvement (Complicated)

No-873.63:Root fracture
No-873.64: Crown-Root fracture
A- Uncomplicated
B - Complicated

No-873.66:Tooth luxation
(concussion, subluxation & lateral luxation)

No-873.67: Intrusion &Extrusion

No-873.68: Complete Avulsion (Exarticulation)

No-873.69: Other injuries (Soft tissue or oral

cavity)
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Treatment ?
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Enamel Fracture
A. Crown infraction (Cracks):
▪ Incomplete fracture or crack of enamel without
loss of tooth structure.
▪ Pathway for bacteria to the pulp.
▪ Diagnosis: Transillumiation
▪ Treatment: pulp sensitivity testing
▪ Follow up: 3,6 & 12 month
▪ Prognosis: complications are rare.
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Enamel Fracture
B. Complete enamel fracture (Chipping):
▪ Fracture of enamel with loss of tooth structure.
▪ Pathway for bacteria to the pulp.
▪ Diagnosis: rough edge causes irritation
▪ Treatment:
− Smoothening the sharp edge.
− Composite resin if necessary.
▪ Follow up: 3,6 & 12 month
▪ Prognosis: complications are rare.
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B. Complete enamel fracture (Chipping):

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Uncomplicated Crown Fracture
▪ Fracture of enamel & dentin without pulp
exposure.
▪ Incidence: very common (1/3 of dental injuries).
▪ Direct ingress of noxious stimuli to the pulp
via dentinal tubules.
▪ Diagnosis:
− rough edge causes irritation
− Pt. complaint: pain with hot ,cold or even air.
− Lip bruise or lacerations.
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Uncomplicated Crown Fracture
▪ Treatment:
− Re-bonding the tooth fragment if possible or
− Ca2OH base followed by composite resin.
− Cleaning & suturing lip lacerations if present.
▪ Follow up: 3,6 & 12 month
▪ Prognosis: Good with minimal pulpal
complications.
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Uncomplicated Crown Fracture

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Complicated Crown Fracture
▪ Fracture of enamel & dentin with pulp
involvement.
▪ Incidence: 2-13% of dental injuries.
▪ Exposure ranges from minute exposure
to total deroofing of the pulp chamber .
▪ Diagnosis:
− Pulpal Hemorrhage.
− Pt. complaint: pain with hot ,cold , air or
spontaneous.
− Lip bruise or lacerations.
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Complicated Crown Fracture
▪ Diagnosis:
− Pulpal Hemorrhage.
− Pt. complaint: pain with hot ,cold , air
or spontaneous.
− Lip bruise or lacerations.
Choice of treatment depends on
Extent of the fracture

Time between accident &

treatment
Treatment Stage of root formation
(depends on(
& pulp vitality

Periodontal injury
Complicated Crown Fracture
Vital pulp
Immature Apexogenesis
tooth
Stage of root Necrotic pulp
formation & Apexification
pulp vitality

Mature Vital pulp therapy or

tooth R.C.T
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Complicated
Crown Fracture
• Treatment of exposed pulp
• A-Pulp Capping
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Complicated
Crown Fracture
• Treatment of exposed pulp
• B- Pulpotomy
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Complicated
Crown Fracture
• Treatment of
exposed pulp
• C-Apexification
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Complicated
Crown Fracture
• Treatment of exposed pulp
• C-Apexogenesis
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Complicated Crown Fracture

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Crown Root Fracture
▪ Fracture of enamel ,dentin and cementum.
▪ Pulp may or may not involved.
▪ Diagnosis:
▪ Short and chisel or long fracture.
▪ Fragments are firm or loose.
▪ Pain on pressure and biting.
▪ Treatment & prognosis :
▪ As uncomplicated and complicated crown
fracture.
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Crown Root Fracture

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Root Fracture
▪ Incidence: 7 % of dental injuries.
▪ Diagnosis:
▪ Tooth mobility.
▪ Displacement of coronal segment.
▪ Palpation tenderness over the root.
▪ Pain on biting.
▪ Bleeding from the gingival sulcus.
 Root Fracture

Usually not visible

Radiographically: Occlusal view
Multiple radiographs

Vertical fracture.
Classification Chisel fracture.
Horizontal fracture.
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Horizontal Root Fracture

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Vertical Root Fracture
 1.Root canal therapy for both coronal and
Treatment of apical segment, when they are not
separated
Root fractures: 2. Root canal therapy of coronal segment
and no treatment of apical segment, when
contains vital pulp.
3. Root canal therapy for coronal segment
and surgical removal of apical third.
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 4. Apexification type procedure of coronal
segment, i.e. inducing hard tissue barrier at
exit of coronal root canal and no treatment
of apical segment.
Treatment of 5- Intra-radicular splint in which rigid type of
post is used to stabilize the two root
Root fractures: segments
6. Root extrusion for teeth with fracture at
or near alveolar crest. Here coronal segment
is removed and apical segment is extruded
to allow restoration of missing coronal tooth
structure.
 It depends on:

PROGNOSIS
Amount of dislocation and degree
of mobility of coronal segment:
More is the dislocation, poorer is
the prognosis.

Stage of tooth development: More

immature the tooth, better the
ability of pulp to recover from
trauma.
Root fracture can show healing in following ways:

1. Healing with calcified tissue.

2. Healing with interproximal connective tissue in which radio
graphically fragments appear separated by a radiolucent line.
3. Healing with interproximal bone and connective tissues. Here
fractured fragments are seen separated by a distinct bony bridge radio
graphically.
4. Interproximal inflammatory tissue without healing, radio graphically
it shows widening of fracture line.
Tooth
luxation(Dislocation)

Types Concussion Subluxation Lateral Luxation

(30-45%)
Percussion tender tender tender
Displacement no no Displaced
horizontally
mobility normal increased mobile
Treatment No treatment Splinting 2-8 weeks −Repositioning.
−Immediate R.C.T.
−Blood clot
,manage as
avulsed tooth
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Treatment of Lateral and Extrusive Luxation
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Treatment of Lateral and Extrusive Luxation

Intrusion&Extrusion(Vertical
luxation)

Intrusion Extrusion
•The tooth is displaced •The tooth is displaced
into the alveolar bone. axially in coronal
direction.
•Treatment :
−Immature tooth: follow •Treatment :
up until re-eruption. −Repositioning and
−Mature tooth: splinting 6-8 weeks.
orthodontic repositioning. −R.C.T. calcium
hydroxide medication 6-
12 month.
Avulsion(Extra-
articulation)
▪ Complete displacement of the tooth outside
its socket.
▪ Incidence:
− 15 % of dental injuries.
− Boys > girls.
− Maxillary central incisor.
▪ Factors affecting the prognosis:
1. Extra-oral time (more or less than 30 min.)
2. Storage media: (ascending order)
− Replaced into its socket.
− Hank’s Balanced Solution ( NaCl,
KClCacl2 , MgCl2 )
− Milk
− Saline
− saliva
− water
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Avulsion ( Extra-articulation)
Avulsion(Extra-
articulation)
▪ Management:
1. examine the socket.
2. Rinse it with saline.
3. No curettage.
4. Gently sucking the blood clot.
5. Replant the tooth& splint 1 week>
6. R.C.T. after 1-2 weeks or calcium hydroxide
medication 6-12 month.
7. Revascularization.
8. Follow up: 1,3,6 & 12 month
• If the tooth has been out 15 minutes to 2
hours, soak for 30 minutes to replenish
nutrients. Local anesthesia will probably
be needed before replanting.

• If the tooth was out over two hours,

the tooth should soak 30 minutes in
5 % sodium hypochlorite and 5
minutes each in saturated citric acid,
1 % stannous fluoride and 5 %
doxycycline before replanting.
 • The splint should be removed after 7 days
unless the excessive mobility is present.
• Endodontic therapy should be started in 7-10
days except if tooth has an open apex.

POST-EMERGENCY
• Recall the patient after one month, if
radiograph is found to be satisfactory, obturate
TREATMENT the tooth. If lamina dura is not found to be
intact or if there is the evidence of external
resorption, the calcium hydroxide paste is
removed and is replaced with the fresh paste.
Avulsion(Extra-articulation)
Healing

Healing with normal periodontal ligament.

Healing with surface resorption.

Healing with replacement resorption ( Ankylosis )

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