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FRACTURE Or TRAUMATIC INJURY

Dr. YIBELTAL M. (DMD)

09/22/21 1
 INTRODUCTION
• Trauma may result into damage to the pulp,
crown, root, displacement and exfoliation to
the teeth from the socket.
• Sometime at the time of trauma nothing is
noticed and felt by patient but after couple of
month thermal hypersensitivity or pain is felt.

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 Outline:
1. Crown Fracture
2. Crown-root fractures
3. Vertical/Horizontal Root Fracture
4. Luxation
5. Avulsion
6. Resorption
7. Prevention

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 ETIOLOGY
• Falls in infancy
• Child abuse
• Falls and collision
• Sports injury
• Road traffic accident
• Epileptic fits

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 Fact
• Most dental trauma occurs in 7_10 age range
• And most trauma occurs in the anterior region
of the mouth, maxilla>mandible
• Prevalence 1) primary dentition BOYS 31-40%
GIRLS 16-30%

2) secondary dentition BOYS 12-35%

GIRLS 4-16%
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 DENTAL TRAUMA

An average of 22,000 occur annually among children less

than 18 years of age.
Over 80% of all dental injuries involve the upper teeth.
30% of preschoolers have had a dental injury of some kind.
Of all sports, baseball and basketball were associated with
the largest number of dental injuries.
Children with primary teeth, less than 7 years old, sustained
over half of the dental injuries in activities associated with
home furniture.
Outdoor recreational products and activities were
associated with the largest number of dental injuries among
children ages 7-12 years of age.

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 CLASSIFICATION
ELLIES CLASSIFICATION
• CLASS 1 Enamel fracture
• CLASS 2 Dentin fracture without pulp exposure
• CLASS 3 Crown fracture with pulp exposure
• CLASS 4 Non –vital tooth
• CLASS 5 Avulsion
• CLASS 6 Root fracture with or without crown fracture
• class 7 Subluxation ,luxation,
• CLASS 8 Fracture of crown enmasse
• Class 9 Deciduous tooth fracture
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SYMPTOMS
The symptoms depends on whether the pulp is
exposed , degree of damage to the pulp, age of the
patient and other factor. In a young patient even
though pulp is not exposed , if the break has bared the
dentin, the tooth will become sensitive to temperature
changes and to sweet and sour because the pulp
chamber is larger, the pulp horn are still extensive and
the dentinal tubules are relatively larger contain tissue
and fluid that are susceptible for noxious stimuli. When
the pulp is exposed, pain may occur. In some cases
patient is free of pain. In older patient, sufficient pulp
recession may already have occurred to protect…….

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…the pulp against irritation from external stimuli
and tooth may be practically symptomless.
Calcification of the root canal from trauma has
a small chance but it can occur. Many times
pulp pathos's is accompanied by internal or
external root resorption.

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 DIAGNOSIS
• It is made from complete examination of the
patient.
• Complete examination is done by
• A) Good and relevant history
• B) Clinical examination
• C) Sensitivity test
• D) Radiographic examination

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 1. Crown Fracture without Pulp
exposure

NO PROBLEM,
RELAX AND RESTORE

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 Complicated Crown fracture with Pulp
Exposure=vital pulp therapy

@80% IF Partial
w/in 24hrs Pulpotomy@95%
Full pulpotomy @75%
OR:
EXTIRPATION if
root is fully formed

Pulp Cap?
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 FRACTURE CROWN WITH PULP
EXPOSURE
• Four kind of treatment are possible:
• 1) pulpotomy (pulp is vital)…apexogenesis (capping
the inflamed dental pulp of an incompletely
developed tooth.)
• 2) apexification (pulp is necrotic)….If apex was not
closed
• 3)pulpectomy or endodontic treatment(RCT)….if apex
was already closed
• 4)root resection (apisectomy)

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 2. Crown-Root Fracture
sometimes fractures at an angle

Angular Fracture:
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Is this 14
restorable?
 Vertical Fracture of Crown>Root
@ 3% of all dental injuries
Generally if crack extends to the pulpal floor (molar), the tooth will be
lost
Most commonly cracked tooth – Distal of Mandibular second molar –

– May need to STAIN crown to see crack

WHY?
Look for
“Drop-Off”
Pocket at
base of
Crack site

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Insert occlusal view of MMR/DMR fracture
to supplement previous slide
• Because, endo/perio lesion can mimic VRF
radiogragraph

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If untreated, a crack will widen into a split

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 3. Vertical Root Fracture

Look for ‘J’-Shaped apical lesion

Look for Drop-off Pocket if . . . .

Vertical root fracture difficult to

confirm radiographically –
UNLESS separation of segments
occurs

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 Transillumination Restoration Removal + Staining
Other methods of discovering VERTICAL ROOT FRACTURE
A surgical exploration is usually the only other way to
confirm presence of VRF*

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09/22/21 20
09/22/21 21
 Horizontal Root Fracture
Tends to be Readily
apparent – especially
after separation
Mobility a good clue
Is this salvageable?
Prognosis is very poor

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 Root Fracture (Horizontal)

What do you do here? Try to reposition and

splint 2-4 wks, check for vitality q 30 days
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 4. Luxation Injuries
(MOST COMMON OF ALL DENTAL INJURIES)
30-44%

• Concussion WORST CASE SEQUELAE?

• Subluxation
PULP NECROSIS
• Extrusion
• Lateral EXTERNAL/INTERNAL
ROOT RESORPTION
• Intrusive
Possible tooth loss
AVULSION
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 Concussion Luxation Injury

• Least severe of
Luxation injuries
• No displacement of
tooth nor excessive
mobility
• Tooth tender to touch
“Bruised Periodontal
ligament”
• No radiographic
abnormalities
• VIP!!! Assess vitality
in 4 wks
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 Subluxation Luxation Injury

• Tooth tender to touch &

slightly mobile (1+) but not
displaced
• Possible hemorrhage from
gingival crevice
• No radiographic
abnormalities
• Damage to supporting
structures?

• VIP!!! Assess vitality in 4

weeks
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 Extrusion Luxation Injury

Elongated mobile tooth

 Class .II mobility or greater
Radiographs show
increased apical
periodontal space
Manually reposition
Reposition tooth + Flexible
splint MANDATORY 7-10
days ?
VIP!!! Assess vitality in 4
weeks

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Titanium Trauma Splint
Medaris AG, Basel Switzerland

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09/22/21 29
 TTS splint
• Insert picture of same
• Splinting of traumatized teeth with a new
device:TTS (Titanium Trauma Splint)
• Medartis AG, Basel, Switzerland
• Von arx T, etal Dent Traumatol, ’01;17:180-84

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 Lateral Luxation Injury
Displaced laterally & often
locked in bone
Not tender to touch, not
mobile
Alveolus fractured
Percussion test: high metallic
sound (ankylosis)
Increased PDL space best seen
on eccentric or occlusal
radiographs
Anesthetize & reposition
+ Flexible splint MANDATORY
4-8 weeks
VIP!!! Assess vitality in 4
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weeks 31
 Intrusion Luxation Injury
External root resorption likely
• Most severe of luxations***
• Tooth appears shorter: displaced into
alveolar bone
• PDL destruction/alveolar crushing) Beware
of ankylosis/resorption/
• pulp necrosis is all but certain in mature
teeth***
• Not tender to touch, not mobile
• Percussion test: high metallic sound
• Radiographs not always conclusive
• Slightly luxate with forceps or band and
move orthodontically.
• Splinting is not usually necessary
– Tooth with open apex may spontaneously re-
erupt.

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 Treatment of intrusion luxation

• Closed apex needs ortho. or surgical repositioning

and probable RCT ( root canal therapy) in 1-3 weeks

– In all LUXATION and especially INTRUSION injuries,

the apical neurovascular bundle and attachment
apparatus will be affected to some degree>>>loss
of vitality & internal/external resorption

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 5. Avulsion
• Tooth is knocked completely out of mouth
• Viability of the PDL( periodontal ligament)
must be preserved for success
• Extra-oral dry time is CRITICAL 30-60”***
• Must be replaced in socket as soon as possible
in order to..
– Prevent ankylosis
– Prevent external root resorption

To replant or not? should be “decent tooth”: No point in replanting THIS one

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 REPLANTATION
• Also refer as Reimplantation- is the insertion
of a tooth in its socket after complete avulsion
resulting from traumatic injury.

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 FACTORS AFFECTING SUCCESS RATE IN REPLANT

1. Extra oral time

2. Storage media and transportation of avulsed teeth
3. Management of socket- preservation of periodontal ligament and
resorption

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 Replant?
• Treatment is aimed at minimizing the inflammation from the
two main consequences of avulsion, namely; attachment
damage and pulpal infection that inevitably results
• The SINGLE most very important factor in achieving a
favorable outcome is the SPEED at which a clean tooth is
properly replanted
• Keeping the attached periodontal ligament moist is very
important!!*

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 EXTRA ORAL TIME

• One of the most critical factors affecting

prognosis. The avulsed tooth should be
replanted as soon as possible. Shorter the
extra oral time ,the better the prognosis for
retention of the replanted tooth. When replant
within 30 min only showed 10% resorption
whereas the 95% resorbed when replanted
more than 2 hrs after avulsion.

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 STORAGE MEDIA
1. Preferably in the socket
2. Other media patient saliva, milk, ice cold,
normal saline, liquid used to clean the
contact lens
3. Recently developed and marketed storage
media is HBSS (hank’s balanced salt solution)

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 First Aid Instructions

• Handle by crown only

• Pick off debris with tweezers
• Replant tooth if possible
_________________________________
• If not, transport in appropriate medium:“Save-a-
tooth”
• Hank’s Balanced Salt solution)
– or “Via Span” (if available)
– or milk if above not available
– or place in vestibule (saliva) & Report to dental
office as soon as possible
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 ONCE IN DENTAL OFFICE:
• Take films to make sure if there is:
- no alveolar fracture
- that adjacent teeth are OK
• “Save-a-tooth” in
 Hank’s Balanced Salt solution
 Via Span
 milk
 saline
– Gently clean socket
– Replant and check occlusion
– Splint
– antibiotics

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 Avulsion Injury What NOT to do!

• Do Not:
1. Handle by root
2. Scrub root
3. Allow tooth to dry
4. Submerge the tooth in water
(tap water is hypotonic>
and will cause cell rupture)

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 What if a baby tooth is completely knocked out?
• Primary teeth (baby) are different than adult teeth and
the treatment is different.
• Primary teeth are generally not replanted into the socket.
• The reason for not replanting is that the primary tooth
may cause an infection to spread to the permanent
tooth. It may also affect the eruption pattern of the
permanent tooth.

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 Complications with Replanted avulsed teeth &
Possibly with Rigid Long-Term Splinting

• Ankylosis (Replacement Resorption)

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 Plug for Prevention
• Mouth guards***
• Many of the injuries we discussed could be prevented
through the aggressive promotion and use of mouth
guards.
• Every child should wear one for most active play.
• Every adult involved in sports should wear one.
• Become Involved in your Community!
Begin the Service if not available in
your area.

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 Plug for Prevention
Mouthguards Protect teeth!

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 Plug for Prevention
Mouth guards

 Mouth guard are design to absorb and distribute the

forces of impact received while participating in athletic
activities.
Properly fitted mouth guards help to protect the soft tissues
of the lip, cheeks, gums, and tongue by covering the sharp
surfaces of the teeth.
They can also reduce the potential for jaw joint fractures
and displacement by cushioning against the impact.
They can reduce the force upon impact helping to protect
the jaws from fracture.

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 THANKS

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