TRAUMATIC
I N J U R I E S O F
TEETH
Prepared by:
Group B

➢Case History
✓Chief complaint
✓History of present illness
✓Medical History
Traumatic Injuries of
Teeth

➢Clinical Examination
✓External Examination
✓Soft Tissues
✓Facial Skeleton
✓Teeth and Supporting Structures
Traumatic Injuries of
Teeth

➢Radiographic Examination
✓Periapical
✓Occlusal
✓Panoramic
Traumatic Injuries of
Teeth

➢(1) Concussion
➢(2) Luxation
➢(3) Fracture
Traumatic Injuries of
Teeth

➢tooth is not mobile
➢not displaced
➢periodontal ligament (PDL)
absorbs injury + inflammed
✓leaves tooth tender to
biting pressure + percussion
Concussion

➢Visual sign:
✓not displaced
➢Percussion test:
✓tender to touch or tapping
➢Mobility test:
✓no increased mobility
Concussion

➢Pulp Sensibility Test:
✓positive result
✓it is important in assessing
future risk of healing
complications
✓lack of response to the test
indicates an increased risk
of later pulp necrosis
Concussion

➢Radiographic findings:
✓no radiographic
abnormalities
➢Radiographs:
✓occlusal
✓periapical
✓lateral view from mesial +
distal aspect of tooth in
question
Concussion

➢Treatment Objectives:
✓usually there is no
treatment
➢Treatment:
✓monitor pulpal condition
for at least 1 year
Concussion

➢Patient Instructions:
✓soft food for 1 week
✓brush with soft bristle
✓rinse with chlorhexidine
0.1% to prevent plaque
accumulation
Concussion

➢tooth is displaced in
a labial, lingual or lateral
direction
➢PDL is usually torn
➢fractures of supporting
alveolus may occur
Luxation

➢similar to extrusion injuries
✓partial or total separation
of periodontal ligament
Luxation

➢Visual sign:
✓displaced, usually in a
palatal/lingual or labial
direction
➢Percussion test:
✓usually gives a metallic
(ankylotic) sound
➢Mobility test:
Luxation

➢Pulp Sensibility Test:
✓likely give a lack of
response except for teeth
with minor displacement
✓test is important in assessing
risk of healing complications
✓positive result at the initial
examination indicates a reduced
risk of future pulp necrosis
Luxation

➢Radiographic findings:
✓widened periapical ligament
space best seen on occlusal
or eccentric exposures
➢Radiographs:
✓occlusal
✓periapical
✓lateral view from mesial +
distal aspect of tooth in
question
Luxation

➢Treatment Objective:
✓reposition + splint a displaced
tooth to facilitate pulp +
periodontal ligament healing
Luxation

➢Treatment:
✓rinse the exposed part of root
surface with saline before
repositioning
✓apply local anesthesia
✓reposition tooth with forceps
or with digital pressure to
disengage it from its bony
socket
Luxation

➢Treatment:
✓gently reposition it into
its original position
✓stabilize the tooth for 4 weeks
using a flexible splint
✓4 weeks is indicated due to
associated bone fracture
Luxation

➢Patient Instructions:
✓soft food for 1 week
✓brush with soft bristle
✓rinse with chlorhexidine
0.1% to prevent plaque
accumulation
Luxation

➢Ellis and Davey classification
of crown fracture is useful in
recording extent of damage to
crown
✓ Class I – simple
fracture of crown
involving little or no
dentin
✓Class II – extensive fracture
of crown involving considerable
Fracture

✓ Class III – extensive fracture
of crown with an exposure of
dental pulp
✓Class IV – loss of entire crown
Fracture

➢Enamel Fracture
➢Enamel-Dentin Fracture
➢Enamel-Dentin-Pulp Fracture
➢Root Fracture
Fracture

➢fracture confined to the
enamel with loss of tooth
structure
Enamel Fracture

➢Visual sign:
✓visible loss of enamel
✓no visible sign of exposed
dentin
➢Percussion test:
✓not tender
✓if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Enamel Fracture

➢Mobility test:
✓normal mobility
➢Sensibility test:
✓usually positive
✓test may be negative initially
indicating transient pulpal
damage
Enamel Fracture

➢Sensibility test:
✓monitor pulpal response
until definitive pulpal
diagnosis can be made
✓test is important in assessing
risk of future healing
complications
✓lack of response at initial
examination indicates an increased
risk of later pulpal necrosis
Enamel Fracture

➢Radiographic findings:
✓enamel lost is visible
➢Radiographs:
✓occlusal
✓periapical
✓recommended to rule out
possible presence of root
fracture or a luxation injury
Enamel Fracture

➢Treatment:
✓if tooth fragment is available,
it can be bonded to the tooth
✓grinding or restoration with
composite resin depending on
extent + location of fracture
Enamel Fracture

➢fracture confined to enamel
+ dentin with loss of tooth
structure, but not involving
pulp
Enamel-Dentin Fracture

➢Visual sign:
✓visible loss of enamel
+ dentin
✓no visible sign of exposed
pulp tissue
➢Percussion test:
✓not tender
✓if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Enamel-Dentin Fracture

➢Mobility test:
✓normal mobility
➢Sensibility test:
✓usually positive
✓test may be negative initially
indicating transient pulpal
damage
Enamel-Dentin Fracture

➢Sensibility test:
✓monitor pulpal response
until definitive pulpal
diagnosis can be made
✓test is important in assessing
risk of future healing
complications
✓lack of response at initial
examination indicates an increased
risk of later pulpal necrosis
Enamel-Dentin Fracture

➢Radiographic findings:
✓enamel-dentin lost
is visible
➢Radiographs:
✓occlusal
✓periapical
✓recommended to rule out
displacement or possible
presence of root fracture
Enamel-Dentin Fracture

➢Treatment:
✓if tooth fragment is available,
it can be bonded to the tooth
✓otherwise perform provisional
treatment by covering exposed
dentin with glass ionomer
or a permanent restoration
using a bonding agent +
composite resin
Enamel-Dentin Fracture

➢(Complicated Crown Fracture)
➢a fracture involving enamel +
dentin with loss of tooth
structure + exposure of pulp
Enamel-Dentin-Pulp
Fracture

➢Visual sign:
✓visible loss of enamel
+ dentin
✓exposed pulp tissue
➢Percussion test:
✓not tender
✓if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Enamel-Dentin-Pulp
Fracture

➢Mobility test:
✓normal mobility
➢Sensibility test:
✓usually positive
Enamel-Dentin-Pulp
Fracture

➢Sensibility test:
✓test is important in assessing
risk of future healing
complications
✓lack of response at initial
examination indicates an increased
risk of later pulpal necrosis
Enamel-Dentin-Pulp
Fracture

➢Radiographic findings:
✓lost of tooth substance
is visible
➢Radiographs:
✓occlusal
✓periapical
✓recommended to rule out
displacement or possible
presence of luxation or root
fracture
Enamel-Dentin-Pulp
Fracture

➢Treatment:
✓if young patients with open
apices, it is very important to
preserve pulp vitality by
pulp capping or partial
pulpotomy in order to secure
further root development
✓this treatment is also
treatment of choice in patients
with closed apices
Enamel-Dentin-Pulp
Fracture

➢Treatment:
✓Calcium hydroxide compunds
+ MTA are suitable materials
for such procedures
✓in older patients with closed
apices + luxation injury with
displacement, root canal
treatment is usually
treatment of choice
Enamel-Dentin-Pulp
Fracture

➢fracture involving:
✓enamel
✓dentin
✓cementum
✓with loss of tooth structure
✓but not exposing pulp
Crown-Root Fracture
without pulp involvement

➢Visual sign:
✓crown fracture extending
below gingival margin
➢Percussion test:
✓tender
Crown-Root Fracture
without pulp involvement

➢Mobility test:
✓coronal fragment mobile
➢Sensibility test:
✓usually positive for apical
fragment
Crown-Root Fracture
without pulp involvement

➢Radiographic findings:
✓apical extension of fracture
usually not visible
➢Radiographs:
✓occlusal
✓periapical
✓recommended to detect fracture
lines in root
✓cone beam exposure can reveal
whole fracture extension
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Fragment removal only
• removal of superficial
coronal crown-root fragment
• subsequent restoration of
exposed dentin above gingival
level
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Fragment removal + gingivectomy
(sometimes ostectomy)
• removal of coronal segment
with subsequent endodontic
treatment + restoration with
a post-retained crown
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Orthodontic extrusion of
apical fragment
• removal of coronal segment
with subsequent endodontic
treatment + orthodontic
extrusion of remaining root
with sufficient length after
extrusion to support a post-
retained crown
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Surgical extrusion
• removal of mobile
fractured fragment
• subsequent surgical
repositioning of root in a more
coronal position
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Decoronation (root submergence)
• implant solution is planned,
root fragment may be left in
situ after in order to avoid
alveolar bone resorption
• thereby maintaining volume of
alveolar process for later
implant installation
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Extraction
• with immediate or delayed
implant-retained crown
restoration or a coventional
bridge
• fractures with severe apical
extension, the extreme being
a vertical fracture
Crown-Root Fracture
without pulp involvement

➢fracture involving:
✓enamel
✓dentin
✓cementum
✓with loss of tooth structure
✓exposure of pulp
Crown-Root Fracture
with pulp involvement

➢Visual sign:
✓crown fracture extending
below gingival margin
➢Percussion test:
✓tender
Crown-Root Fracture
with pulp involvement

➢Mobility test:
✓coronal fragment mobile
➢Sensibility test:
✓usually positive for apical
fragment
Crown-Root Fracture
with pulp involvement

➢Radiographic findings:
✓apical extension of fracture
usually not visible
➢Radiographs:
✓occlusal
✓periapical
✓cone beam exposure can reveal
whole fracture extension
Crown-Root Fracture
without pulp involvement

➢Treatment:
✓Fragment removal + gingivectomy
(sometimes ostectomy)
• removal of coronal segment
with subsequent endodontic
treatment + restoration with
a post-retained crown
Crown-Root Fracture
with pulp involvement

➢Treatment:
✓Orthodontic extrusion of
apical fragment
• removal of coronal segment
with subsequent endodontic
treatment + orthodontic
extrusion of remaining root
with sufficient length after
extrusion to support a post-
retained crown
Crown-Root Fracture
with pulp involvement

➢Treatment:
✓Surgical extrusion
• removal of mobile
fractured fragment
• subsequent surgical
repositioning of root in a more
coronal position
Crown-Root Fracture
with pulp involvement

➢Treatment:
✓Decoronation (root submergence)
• implant solution is planned,
root fragment may be left in
situ after in order to avoid
alveolar bone resorption
• thereby maintaining volume of
alveolar process for later
implant installation
Crown-Root Fracture
with pulp involvement

➢Treatment:
✓Extraction
• with immediate or delayed
implant-retained crown
restoration or a coventional
bridge
• fractures with severe apical
extension, the extreme being
a vertical fracture
Crown-Root Fracture
with pulp involvement

➢fracture confined to the
root of tooth involving:
✓cementum
✓dentin
✓pulp
Root Fracture

➢Visual sign:
✓coronal segment may be
mobile
✓some cases displaced
✓transient crown discoloration
(red or gray) may occur
✓bleeding from gingival sulcus
may be noted
Root Fracture

➢Percussion test:
✓tooth may be tender
➢Mobility test:
✓coronal segment may be
mobile
Root Fracture

➢Sensibility test:
✓the test is important in assessing
risk of healing complications
✓a positive sensibility test
at the initial examination
indicates a significantly
reduced risk of later pulpal
necrosis
Root Fracture

➢Sensibility test:
✓may give negative results
initially
✓indicating transient or permanent
neural damage
✓pulp sensibility test is usually
negative for root fractures
except for teeth with minor
displacements
Root Fracture

➢Radiographic findings:
✓root fracture line is
usually visible
✓fracture involves root of
the tooth in a horizontal
or diagonal plane
Root Fracture

➢Treatment:
✓rinse exposed root surface
with saline before repositioning
✓if displaced, reposition the
coronal segment of the tooth as
soon as possible
✓check that correct position
has been reached radiographically
Root Fracture

➢Treatment:
✓stabilize the tooth with flexible
splint for 4 weeks
✓if the root fracture is near
cervical area of the tooth
stabilization is beneficial for
a longer period of time (upto 4
months)
Root Fracture

➢Treatment:
✓monitor healing for at least
1 year to determine pulpal
status
✓if pulp necrosis develops, then
root canal treatment of the
coronal tooth segment to
the fracture is indicated
Root Fracture

References:
❖ Books
➢ McDonald, Avery et al: Dentistry for
the Child and Adolescent
• (pages 458-459)
❖ Internet
➢http://www.dentaltraumaguide.org