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Seminar by

Dr. N. JAMINI
POST GRADUATE STUDENT

SRI RAMACHANDRA DENTAL COLLEGE AND HOSPITAL


CHENNAI
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TRAUMATIC INJURIES

CONTENTS

1. Introduction

2. Definitions and Anatomical considerations.

3. Classification, Etiology, Epidemoilogy.

4. Trauma to primary dentition

5. Examination, diagnosis and management of dental injuries

6. Crown Fracture

7. Crown – Root Fracture

8. Root Fracture

9. Concussion and Subluxation

10. Extrusive and Lateral luxation

11. Intrusive luxation .

12. Avulsion

13. Trauma to supporting structures.

14. Prevention of dental injuries.


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INTRODUCTION

• Traumatic dental injuries can be rated as second occurance compared to


limbs and other part of body. Considering all the injuries special attention
is given to traumatic dental injuries because of esthetics and the patient’s
phycologic factors involvement. In most of the traumatic dental injuries
treatment concerned is not only to the injury but also in bringing back the
lost laugh.

• Traumatic dental injuries are always caused by sudden impact force. This
impact force varies depending on the object and force.

• Traumatic dental injuries are common in children and adults (F.K.K.


kahabuka et al)

• Trauma to teeth is a common occurrence that every dental surgeon must


be prepared to asses, evaluate and treat when necessary. (Satish
chandra)

• Trauma to the oral cavity may involve soft tissues such as lips, cheeks,
tongue and floor of the mouth and hard tissues such as teeth, jaws and
temporomandibular joints. (Cohen)

• Early diagnosis, appropriate initial treatment and optimal definitive


treatment as well as reconstruction should be the goal in management
of traumatic injuries.

• There have been an increase in literature devoted to dental trauma


during the past two decades.

• Much of the credit for stimulating research in the field goes to


Dr. Jens Q. Andreasen of Denmark, a pioneer in dental traumatology.
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Definitions
 A fracture is understood to be the cracking or breaking of a tooth that has
been subjected to a force or impact greater than its resistance (Enrique
basrani)

 One important factor responsible for the loss of sound tooth structure that
is not directly associated with disease is “DENTAL TRAUMA” (Esthetics)

Anatomical Considerations
Dentoalveolar trauma involves many tissues and structures. Recognizing the
normal configuration of teeth and their supporting tissues will be helpful when
assessing the effects of trauma, planning corrective treatment and evaluating
the outcome.

A tooth consists of three hard tissues: enamel, dentin and cementum. Dentin
is formed by pulp cells and cementum is formed by periodontal ligament cells.
Embryologically, the alveolar bone is composed of the alveolar one proper
and the alveolar process. The alveolar bone proper is the compact bone within
alveolar and is formed by periotonal ligament cells.

The periodontal membrane lies between the alveolar bone and the cementum.
It is connected to the tooth and alveolar bone.

This connective tissue attachment on the alveolar bone margin is usually


about 1mmm wide and the epithelial attachment is approximately 1mm
coronally. This 2mm width is called the biologic width.

A tooth with an immature root has hertwig’s epithelial root sheath in the apical
region (Mitsuhiero Tscikibashi)
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Hertwig’s epithelial root sheath in the apical region. Hertwig’s epithelial sheath
was originally the reduced enamel epithelium separated from the enamel. The
reduced enamel is the tissue where inner and outer enamel epithelium
combine. Hertwig’s epithelial sheath plays an important role in root formation.
On the pulpal side of the Hertwig’s epithelial sheath pulpcells are induced and
differentiated to become odentoblasts, on the periodontal membrane side,
cells of the dental follicles are induced and differentiated to become
periodontal membrane cells (cementablasts, fibroblasts and osteoblasts)

CLASSIFICATION

Ellis Classification (Louis I. Grossman)

It consist of 6 groups
a. Enamel fracture
b. Dentin fracture without pulp exposure.
c. Crown fracture with pulp exposure
d. Root fracture
e. Tooth luxation
f. Tooth intrusion

Heithersay and morlie classification (Louis I. Grassman)

Class 1. : Fracture line does not extend below the level of the
attached gingiva.
Class 2 : Fracture line extend below the level of attached gingival but
not below the level of alveolar crest.
Class 3 : Fracture line extends below the level of the alveolar crest.
Class 4 : Fracture line within the coronal third of the root, but below
the level of the alveolar crest.

WHO CLASSIFICATION : (Sathish Chandra)

873.60 : Enamel fracture


873.61 : Crown fracture without pulp involvement.
873.62 : Crown fracture with pulp involvement
873.63 : Root fracture
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873.64 : Crown –Root fracture


873.66 : Tooth luxation
873.67 : Intrusion or extrusion of tooth
873.68 : Avulsion of tooth
873.69 : Other injuries such as laceration of soft tissues of oral
cavity.
802.20 : Fracture or communication of the alveolar process of
mandible
802.40 : Fracture or communication of the alveolar process of
maxilla
802.21 : Fracture of the body of the mandible
802.41 : Fracture of the body of the maxilla

ANDREASEN CLASSIFICATION: (J.O. Andreasen)

This classification includes injuries to the teeth, supporting structures, gingiva


and oral mucosa. It can be applied to both permanent and the primary
dentition.

Injuries to the hard dental tissues and the pulp

873.60 : Crown infraction


873.61 : Uncomplicated crown fracture
873.62 : Complicated crown fracture
873.63 : Root fracture
873.64 : Uncomplicated crown – root fracture
873.64 : Complicated crown- root fracture
873.66 : Concussion
873.66 : Sub luxation
873.66 : Lateral luxation
873.67 : Intrusive luxation
873.67 : Extrusive luxation
873.68 : Exarticulation (complete avulsion)
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Injuries to the supporting bone

a. Communication of alveolar socket


b. Fracture of alveolar socket wall
c. Fracture of alveolar process
d. Fracture of mandible or maxilla

Injuries to gingiva or oralmucosa

a. Laceration of gingiva or oral musoca


b. Contusion of gingiva or oral mucosa
c. Abrasion of gingiva or oral mucosa

Classification of ulfohn (Enrique Basrani)

Ulfohn examines a classification of crown fractures from a clinical endodontic


point of view based on 3 fundamental aspects:
1. The possibility of identifying the clinical state of the pulp.

2. The absolute conviction that is impossible to view the dentin and the
pulp as separate organs and that they constitute one organ.

3. Determination of treatment.

Classification of Basrani (Enrique Basrani)

A. Crown fractures

1. Fractures of the enamel


2. Fractures of the enamel and dentin
a. Without pulp exposure
b.With pulp exposure

B. Root fractures

C. Crown – root fractures


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New classification for crown fractures of teeth (Enrico spinas/ Altana)

Class A Compromises :

All the simple enamel lesions, which involve a mesial or distal coronal angle or
only the incisal edge.

Class B compromises :

All the enamel – dentin lesions, which involve a mesial or distal coronal angle
and the incisal edge.

Subclass B

When a pulp exposition exists

Class C compromises :

All the enamel – dentin lesions, which involve the incisal edge and at least a
third of crown.

Subclass C

When a pulp exposition exists

Class D Compromises :

All the enamel dentin lesions, which involve a mesial or distal coronal angle
and the incisal or palaal surface, with root involvement.

Sub Class D

When a pulp exposition exists.

Predisposing factors to traumatic injuries :


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Increased overget with protrusion of upper incisors


Insufficient lip closure (J.O. Andreasen)
Mouth breathing.

Etiology:

There are innumerable causes of tooth trauma and each causative factor
presents with unique circumstances.

Epileptic fits and cerebral palsy (Satish Chandra)


Child battered syndrome/physical abuse (Satish chandra)

 Accidents caused by falls


 Accidents caused by stones
 Traffic accidents
 Opening bottles with teeth
 Injuries in flights
 Sports
 Playground (Blows from head)
 Biting thread with the teeth
 Injuries in amusement parks (Bumper cars)
 Injuries from hitting walls, furniture doors and steps
 Biting fruit pits. (Enrique Basrani)

Epidemiology: (Sema Celenk et al)

Prevalence of dental injuries: (J.O Andreasen)

 In a prospective study where all dental injuries occurring from birth to the
age of 14 were carefully registered, it was found that 30% of children had
sustained injuries to primary dentition and 22% to the permanent dentition.

Age and Sex distribution: (Sema Celenk et al)

 9 to 11 year old group had the highest incidence of traumatic injuries.


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 Male patients had a greater number of injuries than female patients.

Location and type of injuries : (J.O Andresen Enrique basrani)

 Anterior teeth, especially maxillary central incisors commonly involved,


while the mandiular central incisors and maxillary central incisors are less
frequently involved.
 Dental injuries usually affects only a single tooth.

Type of traumatic injuries:

Fractures with indirect pulp exposure is most common type of traumatic


injuries.

Trauma to primary dentition:

The pulpal and periodontal consequences of traumatic injuries to the primary


dentition are similar to those of the permanent dentition with one important
difference. The risk of subsequent injury to the developing permanent teeth
that may occur when the primary tooth is damaged.

Any injury to children on the face affecting the appearance, speech and
functions causes much concern physically, physiologically and
psychologically.

More traumatized will be the parents, which at times requires more attention
than the child.

History taking, examinations, diagnosis and treatment should be done


carefully. All things should be properly documented with proper procedures
and skill.

There are 3 treatment goals for traumatic injuries to the primary


dentions.
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1. To protect the patient’s health


2. To protect the developing tooth bud
3. To maintain the integrity of the injured tooth.

Epidemiology:

 4 to 33% of all children


 Maxillary central incisors are involved.
 Causes- Falls, bike accidents, sports play auto accidents, child
abuse and iatrogenic injuries.

Classification:

Injuries to primary teeth only are classified as

Crown infraction
Crown fracture
Crown and root fracture
Root fracture

Injuries to the periodontal attachment are classified as

Concussion
Subluxation
Extrusion
Lateral luxation
Intrusion
Avulsion

Treatment:

Treatment of primary tooth trauma crown infraction and crown fractures that
do not involve the pulp

 Smoothing rough edges


 Placement of bonded resin restorations
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Crown fractures involving the pulp

Pulp therapy and resin restorations or full coverage, stainless steel or tooth
coloured crowns.

Crown and root fractures:

These teeth usually extracted, but pulp therapy and full coverage is an option
in some instances.

Root fractures:

Splinting mobile teeth or extraction.

Luxation and Exarticulation injuries:

Alveolarbone surrounding the primary teeth is very vesilent which yields


during the injury causing luxations & avulsions.

Another cause is resorbed roots. Most affected are the maxillary centrals.
Displacement like intrusions at times neglected as pain or injury or bleeding is
minimum. While examining the intruded teeth certain factors should be
considered as:

 Root fractures
 Alveolar bone fractures.
 Relationship of the primary teeth with developing bud after the
injury.

The developing permanent bud is normally lingual to the roots or primary


cental incisors. Because of the labial inclination of primary centrals, instrusion
causes labial displacement

Treatment :

Alignment
Realignment
Splinting is not advisable because of uncooperation of child
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Intrusion:

This is potentially for the primary tooth, root to be forced into the developing
permanent tooth follicle when this occurs, the primary tooth should be
extracted.

In most instances of intrusion, the apex of the primary tooth root will be forced
facial to the developing follicle & even through the facial plate of bone. This
results because of the more facial development location of the follicle & the
fact that the maxillary incisor roots have a slightly labial curvature in their
apical one third.

Concussion and sub luxation :

Treatment option should focus on an occlusal evaluation and alignments.

Extrusion:

Extruded primary tooth should be evaluated carefully, for any fracture of root
or alveolar bone.

Extrusion causes occlusion interfaces:

If the extrusion is minimum without much mobility of the tooth gentle


repositioning is sufficient.

If extruded with highly mobile tooth, extraction is advised.

If the tooth is missing all efforts should be made to trace it. If it could not be
traced careful examination to rule out buried tooth, swallowed tooth, aspirated
tooth or nasal intrusion.

Incase of intrusion not piercing through the vestibular bone, causes labial
displacement, in most situations further resorption take place in 6 months
time. If no reeruption extraction is indicated.
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Avulsion:
1. Replantation
2. Reaction of primary incisors to trauma

The reported frequencies of complication as:

1. Colour change
2. Pulp necrosis
3. Pulp canal obliteration
4. Gingival retraction
5. Permanent displacement
6. Surface resorption
7. Ankylosis
8. Disturbed physiologic resorption

Damage to the developing permanent tooth bud.

1. Enamel hypoplasia
2. Crown dilaceration
3. Root formation
4. Dome shaped teeth.

The extent of damage depends on the age of the patient, at the time of trauma
and the nature of the traumatic injury.

The most damage to permanent tooth bud follows -

Intrusive luxation of primary incisors:


The younger the child the greater the extent of damage to the permanent
tooth bud.

Speculative effects of trauma to the primary teeth on permanent tooth


buds-
Buccal intrusion of the primary tooth damages the enamel organ formation
resulting in hypoplasia and pigmentation. Malformation of the crown and
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hypoplasia of the enamel are due to vertical force. Bending and deformity of
the crown is caused by the tooth germ being bent due to the root of the
primary tooth being pushed against the tooth germ palatally. Bending of the
root, lack of root development is caused by damage of Hertwig’s epthelial root
sheath when the entire tooth germ is pushed apically.

Examination and diagnosis of dental injuries:

As discussed any injury may not be confirming to only dental or oral tissues.

Face injuries, head injuries and vital organs should be recognized and proper
reference should be made if necessary.

Each patient should be carefully examined and evaluated for providing


treatment.

Dental injuries should always be considered as an emergency condition and


treated immediately to relieve pain, facilitate the reduction of displaced teeth
and improve the prognosis. (J.O Andreasen)

Complete examination
[Satish chandra]

Good and Clinical Sensitivity Radiographic Other lab test like


Relevant examination tests examination BT, CT HB, etc if
history required

Good and relevant history:

Chief complaint, history of present injury, the medical history are required to
be elicited from the patient before commencing clinical examination. (Jacob G
Daniel)

1. Patient’s name, age, sex, address and telephone number


2. Chief complaint?
3. History of presenting illness
4. When did injury occur?
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5. Where did injury occur?


6. How did injury occur?
7. Treatment else where?
8. History of previous dental injuries.
9. Did the trauma cause amnesia nausea, unconsciousness headache.
10. Is there spontaneous pain from teeth?
11. Do the teeth react to thermal changes?
12. Are the teeth sore to touch (or) during eating.
13. Is there any disturbance in bite?

Medical history: (J.O Andreasen)

1. Allergic reactions to medications.


2. Disorders such as bleeding problems, diabetes and epilepsy.
3. Current medications.
4. Tetanus immunization status.

Injury to head results in the changes in movement of eyes. (Ingle)

A. Disconjugate gaze secondary to damage in brain stem.


B. Palsy of lateral rectus muscle secondary to damage to Vth Nerve.
C. Palsy of superior oblique muscle secondary to damage to IVth nerve.

Outline of initial neurologic assessment for the patient with traumatic dental
injuries.

1. Notice unusual communications.


2. Look for normal respiration.
3. Replant avulsed teeth as indicated.
4. Obtain a medical history and information on the accident.
5. Determine BP and pulse.
6. Examine for rhinorrhea and otorrhea.
7. Evaluate function of the eyes.
8. Evalute the sensitivity of the surface of facial skin.
9. Confirm that there is normal vocal function.
10. Confirm patient’s ability to protrude the tongue confirm hearing.
11. Evaluate the sense of smell.

Clinical Examination:

A correct diagnosis depends heavily on a thorough clinical examination.


Sufficient time should be spent to evaluate the patient’s injury(Jacob G.
Daniel)

Extra oral examination: (Cohen)


a. Laceration
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b. TMJ, Zygomatic arch, angle, lower border of mandible


c. Bruising of face, cheek, neck and lips.
d. Swelling
e. Areas of tenderness

Intra oral examination:


Soft tissues :

a. Lacerations of lip, cheek tongue and floor of the mouth


b. Tenderness, bruise, swelling

Hard tissues:

a. Each tooth and supporting structures must be examined with an


explorer.
b. Mobility
c. Incomplete tooth fracture
d. Tooth displacement
e. Discoloration
f. Pulp exposure

Sensitivity tests (J.O Andreasen)

a. Thermal tests a). Heated gutta-percha


b). Ethyl chloride
c). Ice 5-8 sec
d). Carbondioxide snow (Advantage - valuable in immature
tooth)
e). Dichtor – difluormethane eg. frigen.
Advantage: Consistent and reliable
Disadvantage: Infraction lines in enamel.

Elective Pulp Test:


The value and reliability of EPT have been evaluated by comparison of the
pain threshold and histologic condition of the pulp.

Test for occlusal Fracture:


A simple test for locating a fractured tooth is to have the patient bite on a
cotton roll.A tooth with an incomplete dentin fracture may respond with pain
when biting, when releasing or both.

Individual cusps can be tested for underlying fracture by having the patient
bite on a fracture detector such as tooth sloth or frac-finder (Denbur)
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Radiographic examination:

Radiography is indispensable in the diagnosis and treatment of dental


trauma.

1. Detection of discoloration
2. Root fractures
3. Jaw fractures
4. The size of the pulp chamber and root canal, the apical root
development, the appearance of the periodontal ligament space.
5. Resorption and calcifications.

Record of traumatired teeth: (Mitsuhiero tscikiboshi)

Date of birth :

Age :

Patient’s Name :

Male Female

Initial examination date : Referring dentist/ Physician

Past trauma, if any : Teeth involved

Date :

Present trauma :

Date :

Cause :
Place :

General findings:

Headache Yes No consciousness Clear Not clear

Nausea Yes No

Intra oral findings:


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Teeth involved : Primary Permanent

Spontaneous pain : Yes No

Pain to ice : Yes No

Percussion pain : Yes No

Pulp exposure : Yes No

Discoloration : Yes No

Tooth mobility : Yes No

Damage : Oralmucosa Laceration of lips

Other

Radiographic findings:

Completion of root formation : Complete Incomplete

Root fracture : Yes No

Apical lesion : Yes No

Root resorption : Yes No

Obliteratoin of pulp cavity : Yes No

Widening of periodontal membrane : Yes No

Fracture of alveolar bone : Yes No

Condition of avulsed tooth:

Duration of time out of oral cavity: __________________ (Minutes)

Stored in : dry Tap water Saliva Milk

Diagnosis:

Crown Fracture Crown –root fracture


Root fracture Concussion Subluxation
Extrusive luxation Intrusive luxation
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Avulsion

873:60 Enamel fracture

Treatment: (Jacob G. Daniel)

Management is simple and prognosis is usually very good.

Treatment Includes:

a. Smoothening of rough / sharp edges to avoid injury to lips and tongue.


b. Restoration of the using tooth structure with composite resin after acid
etching of enamel surface.
c. Periodic examination of the tooth for approximately 6 months.

873:61: Crown fracture without pulp involvement (Jacob G.Daniel)

Treatment :
a. Sealing the exposed dentin tubules.
b. Stimulating the pulp to form a layer of reparative dentin

The remaining pulpal dentin thickness over the pulp is important in managing
this type of fracture.

Stanley observed that remaining pulpal dentin more than 2mm is sufficient for
shielding the pulp from most forms of irritation.

Ca (OH)2 is applied for the following reasons : (Sathish chandra)

a. It stimulates the formation of reparative dentin.


b. It provides antimicrobial effect

Ca(OH)2 paste is very effective as a stimulant for the pulp and acid – etch
composite resin is the material of choice for holding the liner in position
restoring the appearance.
a. Proper care should be taken when restoring composite resin, composite
resin should not contact the exposed dentin.
b. Dentin should not be dried.
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c. Eugenol containing preparation should be avoided as lining agent.

If fractural crown fragment is found and is brought by the patient reattachment


of the same can be done. It may be bonded to the crown to restore original
tooth anatomy.

Treatment:

873.62: Crown fracture with pulp involvement (Cohen)

Immediate treatment increases the chances for the preservation of pulp vitality
and normal health of pulp.

Treatment planning basically depends on the following three factors.

1. The extent of fracture


2. The length of time between injury & treatment.
3. The stage of root development.

There are two treatment options:

1. Vital pulp therapy comprising pulp capping, partial pulpotomy and cervical
pulpotomy.

2. Pulpectomy.

Pulp Capping: (MC Donald)

Placing the dressing directly onto the pulp exposure.

Indications:

a. Immature, permanent teeth


b. Very recent exposure.
c. Pinpoint exposure (when the diameter of exposure is less than 1.5 mm)
d. No haemorrage is seen from the exposure site but pink healthy pulp is
visible.
e. Cases of iatrogenic exposure.
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Technique:

 A non-irritating solution such as normal saline is used to clean the


exposure site and to keep the pulp moist.

 The exposed dentin and the exposed pulp are covered with a ca (OH) 2
paste such as dycal.

 The lost tooth structure is restored with acid etch composite resin.

Follow up:

Electrical pulp testing, thermal testing, palpation tests and percussion tests
should be carried out at 3 weeks, 3,6, and 12 months. A hard tissue barrier
can be visualized as early as 6 weeks post treatment.

Partial pulpotomy : (Ingle)

Removal of coronal pulp tissue to the level of healthy pulp.

Indications:

The zone of inflammation in the pulp has extended more than 2mm in an
apical direction.

Procedure:

1. After anesthesia and rubber dam isolation, remove granulation tissue


from the exposure site using spoon excavator. This evaluates the size of
exposure.
2. Remove pulp tissue into the pulp proper to a depth of 1 or 2mm with a
water cooled round diamond stone.
3. Allow plenty of coolant water spray to irrigate and prevent heat damage
to pulp tissue.
4. After preparing pulp tissue, rinse the wound with saline and allow the
bleeding to stop then wash the wound gently with saline.
5. Apply a Ca (OH) 2 liner over the wound.
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6. An intermediate base of hard setting Znpo4 or GIC may be used before


restoration with bonded composite resins.
7. The lost tooth structure is replaced with acid-etched composite resin.

Follow up and Prognosis:

The teeth need periodic evaluation, radio graphically and clinically to


determine the status of the pulp. Prognosis – 94 to 96%.

(Teeth with incomplete apical formation: Partial Bipulpectomy: Enrique


Basrani)

Extirpation of a part of the vital pulp under anesthesia. The pulp remanent is
protected with a dressing. It is important to maintain the vitality of the healthy
pulp until apical development is complete. In this way, the normal
development of the entire length of the root will be obtained.

Indications:

1. When there is doubt that direct pulp protection will succeed.


2. When the patient comes to dental office more than 24 hrs after the injury.
3. In teeth with under developed apices that have pulp polyps.
4. In extensive pulp exposures.

Contra indications:

1. When the apex is fully developed


2. When the pulp is necrotic.

It is well to remember that a partial bipulpectomy is considered transactional


endodontic treatment, since one of the apex is completely developed and
complete endodontic treatment is carried out.

Clinical procedure:

a. Anesthesia
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b. Remove caries from the fracture site to avoid contamination of the pulp
tissue.
c. Isolate and apply an antiseptic.
d. Access opening. This is done according to the location of the fracture and
the pulp exposure following accepted techniques.
e. Pulpectomy : This cut is made at different heights. The greater pulpal
damage, the closer to the apex will be the level of the bipulpectomy.
There are 2 variations of the technique:
Use slow speed with a round bur of a diameter slightly larger than that of
the root canal, to avoid total removal of the pulp.
Use high speed with a carbide bur smaller than the diameter of the root
canal cooled with water and using an explorer.
f. Irrigate and dry the cavity.
g. Placement of Ca (OH)2: Ca (OH)2 paste is placed over the cavity. It is
continued by filling the rest of the cavity with ZnoE followed by Zn Po4.
h. Amalgam in posterior tooth or composite in anterior tooth.
i. Post operative radiograph.
j. Clincoradiographic recall examinations. This will serve to verify the
formation of a calcific barrier and degree of apical development.

FULL CERRICAL PULPOTOMY (cohen)

Pulpotomy involves removal of the entire coronal pulp to the level of the root
orifices.

INDICATIONS:

 The pulp is inflamed to the deeper levels of coronal pulp.


 Traumatic exposure [after 72 hours]

TECHNIQUE:

1. After anesthesia, rubber dam is placed and superficial


disinfections are instituted.
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2. The coronal pulp is removed but only to the level of the root
orifices.
3. Ca (OH)2 dressing and coronal restoration carried out.

Prognosis: 75%

Pulpectomy:

Removal of entire pulp upto the level of apical foramen. (Cohen)

Indications:

Complicated crown fracture of matured teeth.

Technique:

1. Rubber dam is applied and roof of the pulp chamber should be removed
to gain access to the root canals.

2. The contents of the pulp chamber and all debris from the occlusal third
of the canals should be removed.

3. A moistened pellet of camphorated monochlorophenol, with excess


moisture blotted, should be in pulp chamber. The chamber may be sealed
with ZnoE.

Prognosis : 90%

Partial pulpectomy:

Treatment of the nonvital pulp:

a. Mature tooth : RCT


b. Immature tooth : Apexification

Indications:

Teeth with open apices in which instrumentation techniques cannot create an


apical stop to facilitate effective obturation of the canal.
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Technique:

Disinfection of the canal:

1. Access to canals is achieved.

2. Working length has been confirmed radiographically, light filing is


performed with copious irrigation with 0.5% sodium hypochlorite. This is
useful in disinfecting the canals of these immature teeth.

3. The canal is dried with paper points and a soft mix of Ca (OH) 2 spun
into the canal with a lentulo spiral instrument.

Stimulation of a hard tissue barrier:

4. Pure Ca (OH)2 is mixed with sterile solution to a thick consistency.

5. The Ca (OH)2 is packed against the apical soft tissue with a plugger.

6. Ca (OH)2 meticulously removed from the access cavity and well setting
temporary filling is placed in access cavity.

7. A radiograph is taken at 3 months intervals to evaluate whether a hard


tissue barrier has formed.

8. On completion a hard tissue barrier is suspected.Ca (OH)2 should be


washed out of the canal with Naocl and a radiograph should be made to
evaluate the radiodensity of the apical stop.

Obturation of the root canal:

a. Softened gutta percha technique is indicated in these teeth.


27

b. Obturation should be completed to the level of the hard-tissue barrier and


not forced toward the radiographic apex.

Prognosis: 79% to 96% (Cohen)

873.63 Root fracture

Classification:

According to the number of fracture lines

1. Simple - When only one line of fracture divides the root in two portions.

2. Multiple - When the root is divided into more than two fragments.

3. Comminuted - When the root fractures in multiple small pieces.

According to the extension of the line of fracture:

1. Partial - The line of fracture involves a portion of the root.

2. Total - The line of fracture involves the entire root.

Position of root fragments:

Without displacement - When the segments face each other


With Displacement - When the fractured segments are not aligned.

A direction of the line of fracture with respect to the long axis of the
tooth.

1. Horizontal : When the line of fracture is perpendicular to long axis


of the tooth.

2. Oblique : When the line of fracture follows an angle in relation


to long axis of the tooth.

3. Vertical : When the line of fracture is parallel to the long axis of


the tooth.

Location of fracture:

1. The cervical third: The line of fracture is close to the cervical line of the
tooth.
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2. The middle third : The line of fracture approximately divides the root in
two halves.

3. The apical third : The line of fracture is in the apical portion of the root.

Horizontal fracture:

a. Patient experiences discomfort over the buccal portion of the affected tooth.
b. Tooth is sensitive to vertical and horizontal percussion.
c. Spontaneous pain present.
d. Slight or moderate mobility.
e. Patient feel that tooth may elongated.
f. Color change in crown.
g. Palpation provide information about the degree of tooth malposition

Radiographic examination:

Fracture is seen in radiographs as a dark line that extend across the root.

Treatment:

Immediate treatment: (Emergency Treatment)

The type of emergency Treatment depends on whether the pulp remains vital.

With pulp vitality:

a. Anesthesia.
b. Reduction and Repositioning of the segments, moving the coronal portion
apically using finger pressure. A radiograph should be taken to determine
the position of the segments.
c. Stabilize the tooth.
d. Examine the occlusion of the tooth.
e. Selective occlusal grinding done when necessary.
f. The splinting fixation should remain in place from 2 or 3 months.
g. Periodic recall examination of the involved tooth should be done.

The most popular techniques for temporary stabilization:


29

1. Orthodontic wire
2. Acrylic splint
3. Orthodontic bands and brackets
4. Composite with acid etch

Orthodontic Wire:
Stainless steel wire 0.8 to 1 mm is recommended extending at least to
adjacent tooth on each side of the fractured tooth. The wire is passed from
the buccal to the palatal area of the ends are loosely adjusted on the distal of
the last tooth on the splint. To complete the fixation, small V-shaped wires is
placed from the palatal side to buccal side of each interdental space,
engaging the palatal and buccal portion of the principle arch wire.

Once this step has been done, the free ends of ‘V’ shaped wires are twisted
with a haemostat. The excessive wire is removed, leaving about 2mm of
twisted ends which are bent into each interdental space.

Acrylic Splint:
a. Direct :
1. without a brush
2. Brush on technique
b. Indirect

Direct:
This is done in mouth with self-curing acrylic. The acrylic mass is placed on
the labial aspect of the teeth and removed before it polymerizes to avoid its
retention. Check occlusion, polish and cement with ZnoE or poly carboxylate
cement. The affected tooth and at least adjacent tooth on either side of
fractured tooth is isolated and dried. Acrylic powder and liquid are applied with
a brush to labial and lingual surfaces in middle third and in inter-dental
spaces. After the material sets, it is polished with sandpaper disc. Occlusion is
checked.
30

Indirect:
a. An impression is taken.
b. The area on the model is covered with wax to eliminate undercut
c. A splint is made of self-curing acrylic.
d. After polishing, the splint is cemented.

3. Orthodontic bands and brackets cemented and connected by wires, make a


successful splint.

4. Composite with acid etch:


The Composite and acid etch is utilized, covering of affected teeth and
adjacent teeth to the level of the contact point.

5. Intra radicular splint (Endodontic splint)


Both the segments are treated endodontically, post space is made in both
segments in which rigid [vitallium or chrom cobal ] post splint is fixed

Follow-up
With vitality: Periodic clinico radiographic examination.

Immediate and follow-up:

A. With and without vitality:

Fractures in the cervical third without coronal segments:


1. Endodontic and periodontal (Gingivoplasty and alveoloplasty)
Disadvantage: Decrease the esthetics.
2. Endodontic treatment and orthodontic extrusion of the root.
Advantage: gingival margin remains at normal level.

B. Without vitality:
31

Fracture of the cervical third with coronal segments.

Treatment:

1. Endodontic Rx and cementation of chrome-cobalt – molybdenum implant.

Fracture of the middle and apical third:


Treatment:
1. Endodontic
Total – without mobility
Coronal – With mobility
2. Endodontic and Apical segments is - small separated from coronal
segment. lesion is present and apicoeatomy
3. Endodontic , apicoectomy and implant
If coronal segment is short and apical segment is greatly displaced, it is
impossible to join them together so the apical segment is removed.

Vertical root fracture:

Clinical History:
1. Spontaneous pain.
2. Pain on mastication
3. A deep narrow pocket on lingual or buccal root surface or both surfaces.
4. A radiolucent zone from the apex to the cervical third of the root.
5. Fibro optics is useful in locating this type of injury.
6. Fractures can also be discovered when the patient bites down on an
orangewood stick.
Certain root fractures are not visible clinically nor radiographically it is
necessary to raise or flap for direct visualization and verify the existence of a
partial or total vertical fracture.

Treatment of vertical fractures:


1. Elimination of the fractured part of root.
32

2. If fracture occurs in the coronal part of a single-rooted tooth, the treatment


of choice is to reposition the root coronally by orthodontic movement after
the removal of the fractured part.
3. If fractures of the apical third of the root, the fractured part is removed
surgically.
4. In multirooted teeth, the treatment depends on the location of the fracture
line. If the fracture involves only one root, the root is removed
(Hemisection) and the tooth remain functional.

Repair: (J.O Andresen)

According to andreasen, there are four types of repair.


a. Healing with calcified tissue
b. Healing with interposition of connective tissue.
c. Healing with interposition of bone and connective tissue.
d. Interposition of granulation tissue between the segment (No healing)

a. Healing with calcified tissue:


1. A deposit of calcified tissue is formed to join the segments.
2. Four types of calcified tissue can be found histologically: Cementaoid
3. Osteodentin, osteocementum and cellular cementum.
4. The tooth maintains its vitality.

b. Healing with interposition of connective tissue:


1. Connective tissue formed between two segments. The fibres are parallel to
the line of fracture.
2. Radiographically a radiolucent zone and endings of the segments are
rounded.
3. The tooth maintains its vitality.

c. Healing with interposition of bone and connective tissue:

1. This type of healing appears when the trauma has occurred before the
complete development of alveolar process. This permits the coronal
segment to continue its euption and the apical segment remains included in
the bone.
33

2. Bone and connective tissue are seen separating both segments. These
segments are surrounded by periodontal ligament.
3. The tooth is firm and maintains its vitality.

d. Interposition of granulation tissue between the segments:

1. When the pulp tissue in the coronal fragment becomes necrotic or when
the line of fracture is close to the gingival sulcus, it causes contamination
and proliferation of chronic inflammatory tissue.
2. Wide radiolucent zone interposed between the segments and extending to
the alveolar bone at the level of the line of fracture.
3. On clinical examination, the tooth can have mobility, be extruded and be
sensitive to percussion.

Prognosis: (Enrique Basrani)

The prognosis of root fractures depends on different factors such as:

1. How soon the patient received treatment.


2. Adaptation of the segments.
3. Location of fracture
Cervical – Poor
Middle- Better
Apical – Favourable
4. Stabilization of the segments.
5. Horizontal – better or vertical fracture – very poor.
6. Absence of infection
7. Health of the patient.

Complications:

1. Root resorption
Root resorption caused by a change in normal function of the
periodontium. The distruction of periodontium would leave the root in
34

contact with the alveolar bone. Two situations can arise from this
situations: Ankylosis of the tooth or root resorption.
2. Calcification of the pulp chamber or root canal.
3. Periodontal complications

If the horizontal fracture is situated below the alveolar crest, it may


produce a periodontal abcess at the fracture site.

873.64: Crown –root fracture: (Mitsuhiero Tscikiboshi)

Uncomplicated crown-root fracture

The fracture passes through enamel, dentin and cementum without pulp
exposure.

Complicated crown-root fracture:

The fracture passes througn enamel, dentin and cementum with pulp
exposure.

Treatment Procedures:

Uncomplicated crown-root fracture:

1. Examination and diagnosis.

2. Local anesthesia.

3. Try - in of the tooth fragment.

4. Irrigation of the wound surface.

5. Pulp capping: If there is slight pulp exposure, use Ca(OH)2 cement for pulp
dressing.

6. Reattachment of the tooth fragment:

This procedure should be performed while the tooth fragment is connected


to the surrounding tissue. Do not remove the tooth fragment from the oral
cavity.
35

First, remove any pulp tissue from the pulp horn of the tooth fragment and
bevel the entire pheriphery of the fracture line of the both fragment.

Next, bevel the entire pheriphery of the fractured surface of the remaining
tooth. Fit the matrix band lightly to isolate the adhesive surface from the
exudates, then apply the etchant and bonding agent to the remaining tooth
and the tooth fragment. Apply light-curing resin to the remaining tooth and
the tooth fragment and adapt the fractured surfaces closely.Tightening the
matrix band during curing allows the tooth fragment to return to its orignal
position buccolingually & mesiodistally.

7. Reshaping and polishing

8. Followup

Complicated crown-root fracture management.

1. Examination and diagnosis


2. Removal of loose tooth fragment
3. Root canal treatment
4. Re-establishing the biologic width
5. Confirmation of healing
6. Root canal filling
7. Crown restoration : post and core
8. Follow – up

873.66 Tooth luxation: (Grossman)

WHO has classified tooth luxation (WHO classification 873.66) into:

Concussion - tooth is sensitive to percussion, but is not displaced.

Subluxation - tooth has abnormal mobility, but is not displaced.

Luxation- tooth is loose and displaced.


36

Lateral luxation -Teeth usually have their crown displaced lingually and are
often associated with fractures of the vestibalar part of the socket wall.

Management:

Concussion and subluxation, the treatment may be confined to occlusal


grinding of the opposing teeth, supplemental by repeated vitality tests during
the follow up period, minimum 1 year.

Incase of lateral luxation, repositioning is often complicated by the


associated alveolar bone fracture. Usually the apex of the displaced tooth has
been forced through the facial bone plate, thus locking the tooth in its new
position. In these cases, it is essential to disengage the apex first by pressing
over the apical area and on the lingual aspect of crown.

Displaced bone fragments can be repositioned by means of digital pressure.

Lacerated gingiva should be readapted to the neck of the tooth and sutured.
Finally, radiographs should be taken in order to verify adequate repositioning.

Immobilize the tooth with splints.

Splinting: (Andreasen)

The object of splinting is stabilization of injured tooth and prevention of further


damage to the pulp and periodontal structures during the healing period.

Requirements for an acceptable splint:

1. It should allow direct application in the mouth without delay.


2. It should not traumatize the tooth during application.
3. It should immobilize the injured tooth in a normal position.
4. It should provide adequate fixation throughout the entire period of
immobilization.
37

5. It should neither damage the gingiva nor predispose to caries.


6. It should not interface with occlusion.
7. It should not interface with endodontic therapy if needed.
8. It should preferably fulfill esthetic demands.

Acid-etch/ resin splint:

Before application of splinting material, it is important to consider that


concomitant crown fractures with exposed dentin should be covered with Ca
(OH)2 liner before etching to prevent damage to the pulp.

It is essential that the labial surfaces are as clean as possible when the
etching solution is applied to the incisal third of the labial surface. Thereafter,
etchant is removed with a water spray and the teeth air dried. After drying the
etched area it is important that the enamel is not contaminated with blood or
saliva during application of the splint.

The splint material (Epimine resins) is then applied to the incisal half of the
labial surfaces. During the curing phase, slight pressure on the incisal edge of
the involved teeth will maintain correct position.

After polymerization, it is necessary to determine that the splint does not


interface with occlusion.

Orthodontic band/brackets and resin splint:

Preformed orthrodontic bands welded together after adaptation have been


advocated for splinting.

A similar effect can be obtained by using performed orthodontic band with


brackets directly bonded to the labial surface, which are then united in
situation with cold curing resin. A variation is to unite the brackets with a steel
wire.
38

Usually one or two non-injured teeth should be included in the splint on either
side of the injured teeth.

Interdental fixation:

Thin, soft stainless wires (0.2mm, 32 gauge) are used for this type of fixation.
It is important that the ligatures are applied to several adjacent teeth on both
sides of traumtized area.

Archbar:
Metal bars fitted to the dental arch and ligated to the individual teeth are
commonly used. Semicircular soft metal bar is manually shaped to fit the
dental arch.

Resin full arch splint:

Cold-curing resin was popular as a splinting material.

Cast silver cap splint:

 Used extensively in the past


 Time consuming
 Requires impression of a traumatized teeth.

Splinting period:

Injury to periodontal ligament  2-3 weeks


Injury to bone & periodontal ligament  3-4 weeks
Injury to lateral luxation 6-8 weeks.

Patients Instructions: (M.T Flores)

 Soft diet for 10-14 days


 Brush teeth with a soft toothbrush after each meal.
 Topical use of chlorhexidine twice a day for one week follow up.
39

Follow-up period: Minimum one year.

Pathology:

1. Pulp necrosis.
a. Replacement resorption
b. Inflammatory resorption
2. Pulp canal obliteraton.
3. Root resorption, external
4. Root resorption, internal
a. Internal replacement resorption
b. Internal inflammatory resorption

Pulp necrosis:

 Most commonly occur in intrusion


 Another important factor is the stage of root development at the time of
injury.
 An age factor also seems to operate these. Increasing age seems to
favour pulp necrosis after luxation when root development is complete.
 When a tooth is forcefully displaced in the alveolus, vessels at the apical
foramen are compressed, injured or severed and circulation in the pulp
disturbed. Subsequent reactions in the pulp depend on the degree,
duration of nutritional disturbance, the stage of root development the
presence of bacterial contamination.
 A sudden complete break in circulation causes inflammation of the entire
pulp, lack of oxygen which leads to denaturation of proteins and
coagulation necrosis.

2. Pulpcanal obliteration:
40

Pulpcanal obliteration can be regarded as a response to moderate injury


consisting of an accelerated dentin deposition & is frequently encountered
after luxation injuries of permanent teeth.
 Common in severely mobile or dislocated teeth.
 A clinical manifestation is a yellow discolouration of the crown.
 Response to thermal litality test is lowered and response to EPT is
decreased.
 Radiographic finding.
Reduction in size of the coronal pulp chamber followed by gradual narrowing
of the entire pulp canal.

Root resorption:
External root resorption:
The damage to the periodontal structures and the pulp by luxation injuries can
result in various types of external root resorption.

Surface resorption:
 The root surface shows superficial resorption lacunae repaired with new
cementum. These lacunae termed as surfaced resorption.
 Self limiting and shows Spontaneous repair:
 These resorption cavities are usually confined to the lateral surface of root,
but this resorption type localized to the apical area resulting in a slight
shortening of the root.

Replacement resorption:
 Direct union between bone and root substance is seen, the tooth
substance being replaced by bone.

 Radiographic findings. Disappearance of the periodontal space and


progressive root resorption.

Inflammatory resorption:
41

 Bowl-shaped areas of resorption of both cemetum and dentin are


seen together with inflammation of adjacent periodontal tissue.
 The inflammation and resorption due to presence of infected netotic
pulp tissue in the pulpcanal.
 Radiographic findings: Root resorption with an adjacent
rediolucency.

Internal root resorption:

Internal replacement resorption:


 Radiographically characterized by an irregular enlargement of the pulp
chamber.
 The continuous rebuilding of bone at the expense of dentin is responsible
for the gradual enlargement of the pulp chamber.

Internal inflammatory resorption:


 Radiographically characterized by an oval shape increase in the size of
pulp chamber.
 Progression of internal resorption depends upon the interaction of necrotic
and vital pulp tissue at their interface.

Treatment: Root canal Treatment

873.67 Intrusion or Extrusion

Intrusion: (Cohen)

Displacement of the tooth deeper into the alveolar bone.

The tooth may be pushed into socket sometimes giving the appearance that
has been avulsed.
The tooth presents with the clinical presentation of ankylosis because the
tooth is firm in the socket, gives a metallic sound to the percussion test and
after the injury is in infra occlusion.
42

The obvious difference is the recent traumatic injury. Radiographic evaluation


is essential to evaluate the extent and the position of the intruded tooth.
Palpation of the alveolar process often reveals the position of the displaced
tooth. (Andreasen)

If a permanent central incisor is completely intruded, it should be considered


that the apex is most likely forced into the nasal cavity, resulting in bleeding
from the nose.

Examination of the floor of the nostril will reveal the protruding apex.

Radiographic findings:

The width of the periodontal space has partially or totally disappeared.

Extrusion: Partial displacement of the tooth out of its socket.

Clinical Findings:

Teeth appear elongated and most often lingual deviation of the crown there is
always bleeding from the periodontal ligament.

The percussion sound is dull.

Radiographic findings:

The width of the periodontal space is increased on radiographs of extrusion.

Management:

a. Administer local anesthesia if necessary

b. Extrusion
Reposition the tooth to normal position.

c. Intrusion:
Repositioning should be carried out orthodontically over a period of 3-4
weeks.

d. Suture gingival lacerations.

e. Check reduction radiographically.


43

f. Immobilize the tooth with one of the following:

1. Acid etch/ resin splint


2. Orthodontic band/brackets and resin splint.
g. Control the tooth radiographically

h. Splinting period.

1. Extrusion : 2-3 weeks


2. Intrusion : 6-8 weeks

i. Follow up period : Minimum 1 year

Prognosis:

a. Pulp necrosis - 15-59%


b. Pulp canal obliteration - 6-35%
c. External resorption - 1-11%
d. Internal resorption - 2%
e. Loss of supporting bone - 10%

873.68 Avulsion:

Tooth has been totally displaced out of its socket (Grossman)

The avulsed tooth is both a dental and an emotional problem. It is usually the
trauma to an anterior tooth of a child.

The shock and pain of the injury, the loss of a tooth needed for eating,
speaking and smiling often lead to emotional upheaval in-patient as well as
parent.

The situation is compounded by the need for emergency treatment, to


enhance the prognosis.

The longer the luxated tooth is out of its socket, the less likely it will remain in
a healthily functional state after replantation.
44

The following instructions should be given to the parent as soon as the dentist
has been informed of the accident and in preparation for a imminent visit.

1. Wash the tooth in running water without brushing or cleaning it.

2. Have the patient rinse mouth. Replace tooth in its socket using gentle,
steady finger pressure. If the patient is cooperative and able, have the
patient gently close the teeth together to force the tooth back into its
original position.

3. Take the patient to the dentist immediately.

If the patient or parent cannot replace the tooth in its socket then care in
transporting that tooth to the dentist becomes essential.

The tooth must be carried in a moist vehicle to maintain the viability of the torn
periodontal ligament. The most readily available vehicle is the patient mouth,
in which the tooth is bathed in saliva at body temperature.

If this cannot be done safely such as if the patient is too young then one
should place the tooth in a container of milk.

The tooth should not be wrapped in dry handkerchief or tissue because the
periodontal ligament will become dehydrated.

Several studies have shown that extra oral time for an avulsed tooth optimally
should not exceed 30 min and the patient must be taken to the dentist
immediately.

The sooner the replantation, the better the prognosis.

Factors affecting the success of replantation (Jacob G.Daniel)

Extraoral time:
45

Shorter the extraoral time, the better the prognosis for the replanted tooth.

Both the pulp and the periodontal ligament suffer extensive damage during an
extra-alveolar period and healing is almost entirely dependent upon the time
of an handling during the extra – alveolar period (Andreasen)

Storage media: (Jacob G. Daniel)

If replantation is delayed, the tooth should be stored in a physiologic medium


to preserve the vitality of the periodontal cells.

Short periods of dry storage increase both replacement and inflaminatory root
resorption.

Suggested storage media in increasing order of desirability include water,


saliva, physiologic saline, milk and cell culture media.

Water:

Least desirable because of hypotonic environment causes rapid callysis.

Vestibule:

Keeps moist but is not ideal because of incompatible osmolarity, PH and the
presence.

The tooth can be stored in saliva up to 2 hours. It decreases the speed with
which periodontal ligament tissue will die.

Milk:

Milk is considered to be the best storage media. It has a pH and osmolarity


compatible to vital calls and relatively free from bacteria. Easily available.
Effectively maintains the vitality of the periodontal ligament cells for 3 hours.
Milk may contain many antigens that could act negatively from an
immunologic standpoint on the reattachment process.

HBSS : (Franklis. S.Weine)


46

HBSS contains sodium chloride, glucose, potassium chloride, sodium


bicarbonate, sodium phosphate, calcium chloride, magnesium chloride and
magnesium sulfate.

It has been used as a tissue culture and has demonstrated the ability to
preserve and reconstitute the cells of the periodontal ligament.

Hank’s balanced salt solution to be superior to milk and comparable to


viaspan, a tissue medium for transplant. It maintains the osmolarity of
periodontal ligament cells.

Saliva:

Saliva is the best transport medium for an avulsed tooth.

Disadvantage:

If child is too young, is unreliable, there is too great a chance for swallowing
the tooth on the trip to the dentist’s office

Advantage:

Tooth is bathed in saliva at body temperature.

A commercially available storage and transport system, Save-A-Tooth, has


been developed. These containers may be purchased and kept available in
areas where accident are more likely to happen.

Diagnosis and History:

The importance of the medical history should not be compromised and must
be completed before local anesthetic is administered.

The aim of the emergency treatment is preservation of as many viable


periodontal ligament cells as possible.
47

The case history is taken with emphasis on the time interval and condition
under which the tooth has been stored.

Determination of other injuries and the extent of bony involvement may give
the clinician as how the avulsion have occurred.

When the trauma occurred, whether the tooth was dry or wet and the storage
condition are critical in formulating a treatment plan. The place of the accident
may dramatically influence the prognosis contact with foreign material and
may alter the treatment.

Treatment:
Main aim is to replant the tooth with the maximum number of periodontal
ligament cells that has potentially to regenerate. If this is not possible steps
are taken to prepare the root to slowdown the inevitable resorption.

Endodontics is not initiated at the emergency replantation- not performed


extra orally if any hope exists or vital periodontal ligament cells.

In Clinics:

Tooth should initially be placed in storage media (Hank’s Balanced salt


solution).

The socket is cleaned with saline. Thorough examination of other teeth


performed may make the clinician to note any alveolar bone fracture or soft
tissues injury.

Preparation of the root:

Extra oral dry time less than 20 minutes:

Closed apex:

Revitalization not possible, because less than 20 minutes chances of


periodontal ligament cells healing is excellent.
48

Extra oral dry time less than 20 minutes:

Open apex:

Rinsing and replanting at the earliest. The tooth is socked in storage media to
reduce ankylosis by socking debris and bacteria are reduced which reduces
inflammation. The doxycyline may help better.

Extra oral dry time more than 60 minutes.

Open & closed apex:

By this time periodontal ligament cells have died. Socking will have no effect
than physically to remove debris.

Root should be prepared. By socking in citric acid for 5 minutes and in 2%


stannous fluorides for 5 minutes then in doxycyline for 5 minutes.

• Replantation is performed
• Endodontic treatment can be preformed extra orally.

Socket Preparation:

The Socket should be left unaltered to greatest extent. If blood clot is present,
blood should be aspirated.

If the socket is collapsed because of alveolar bone fracture, a blunt instrument


along the wall repositions the socket.
Splinting:
A. splinting technique that allows physiologic movement of the tooth
decreased ankylosis.
Treatment guidelines for avulsed permanent teeth with close apex: (M.T.
Flores)
Diagnosis The tooth has already The tooth has been Extra oral drytime
49

clinical been replanted kept in special more than 60 min


situation storage media the
extraoral dry time
in less than 60 min
Treatment Clean affected area If contaminated Remove debris &
with water spray, clean the root necrotic periodontal
saline or chlorhexidine surface & apical ligament. Remove
foramen with a the coagulam from
Do not extract the stream of saline. the socket with a
tooth Removed the stream of saline.
coagulum from the Examine the
socket with a alveolar socket. If
stream of saline there is a fracture
of socket wall,
Examine the reposition it with
alveolar socket. suitable instrument

If there is a fracture Immerse the tooth


in the socket wall, in a 2.4% sodium
reposition it with a fluoride solution
suitable instrument. acidulated to a 5.5
Replant slowly with for a minimum of
digital pressure. 5minutes or if
available, fill the
socket with
emdogin.

Replant slowly
50

Suture gingival laceration, especially in the cerrical area. Verify normal position of
the replanted tooth radiographically. Apply a flexible splint for 1 week

Administer systemic antibiotics:


Doxy cycline 2 x per day for 7 days at appropriate dose for at patient age & weight.

Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come
to contact with soil or tetanus coverage is uncertain.

Initiate endodontic treatment after 7-10 days. Place ca(OH)2 as an intracanal


medicament.
Patient instructions:
Soft diet for 2 weeks
Brush teeth with a soft brush after each meal.
Use chlorhexidine mouth rinse (0.1%) twice a day for 1 week
Follow-up

Treatment guidelines for avulsed permanent teeth with open apex.

Dignosis The Tooth has The tooth has been Extra oral dry time
clinical situation already been kept in special more than 60 min
replanted storage media .
The extra oral time
is less than 60 min
Treatment Clean affected If contaminated, Replantation is not
area with water clean the root indicated
spray, saline or surface & apical
chlorhexidine rinse. foramen with a
stream of saline

Do not extract the Place the tooth in


tooth doxycycline for 5
min. Remove the
coagulam from the
socket with a
stream of saline

Examine the
alveolar socket. If
there is a fracture
to the socket wall,
51

reposition it with a
suitable instrument.

Replant slowly with


slight digital
pressure.

Suture gingival laceration, especially in the cervical area.

Verify normal position of the replanted tooth radigraphically.

Apply a flexible splint for 1 week.

Administer systemic antibiotics penicillin V 1000mg & 500mg 4xper day for 7 days
or for patients not susceptible to tetracycline staining. Doxycycline 2xper day for 7
days at appropriate dose for patient age & weight. Refer to physician to evaluate
need for a tetanus booster if avulsed tooth has come into contact with soil or
coverage is uncertain.

Patient Instruction

Soft diet for 2 weeks.

Brush teeth with a soft toothbrush after each meal.


Use a chlorhexidine mouth rinse twice a day for 1 week

Follow-up.

Splinting:

Semi-rigid splinting for 7 to 10 days is recommended with bony fracture,


longer splinting times may be necessary.

The acid-etch composite & arch-wire splint is the most commonly used splint
for traumatic injuries.

Many splints satisfy the requirements of an acceptable splint, with a new


(Titanium Trauma Splint) recently been shown to be particularly effective
and easy to use. (Matin trope)

Periodontal Healing and Resorption:

Andreasen has identified four distinct types of healing in the periodontal

ligaments.
52

1. Healing with a normal periodontal ligament


2. Healing with surface resorption
3. Healing with ankylosis
4. Healing with inflammatory resorption.

Prognosis:

External progressive root resorption 74 to 96%

1. Surface resorption
2. Replacement resorption
3. Inflammatory resorption.
Pulp Necrosis:

TRAUMA TO SUPPORTING STRUCTURES: (Mit Suhiero Tkcikiboshi)

Injuries to teeth may be combined with fractures of the alveolar bone soft
tissues and mandible as well as soft tissues trauma to the gingiva and oral
musoca.

Alveolar bone fracture:

This fracture involves the alveolar bone coronal to the apex , usually the
fracture line passes through the alveolus.

Fracture of maxilla and mandible:

This is an extensive fracture of the basal bone and mandibular ramus. Usually
the alveolar bone is also involved.

Treatment plan:

Alveolar bone fracture:

Resorption of the displaced teeth and alveolar bone at the same time. Use
teeth for splinting. Remove the splint 2 to 3 months later.

Fracture of Maxilla and Mandible:


53

1. Examination and diagnosis:


Where there is trauma to multiple teeth and post trauma malposition of
teeth, even if there is no obvious luxation, bone fracture should be
suspected and radiographs made to examine the entire jaw
pantomography.

2. Repositioning, Suturing and Splinting:


After the administration of anesthetic, reposition the teeth and alveolar
bone. Attend to any other problems related to the trauma and suture the
soft tissues and splint the teeth.

3. Endodontic treatment:
Traumatic teeth associated with alveolar bone fracture usually have apical
vascular disruption of the pulps. Perform endodontic treatment for pulp
necrosis so that it does not hinder fracture healing.

4. Removal of splint and follow-up:


Two or three months later, remove splint and confirm healing clinically as
well as radiographically. Periodically monitor the progress of healing.

Trauma to the gingiva and alveolar mucosa:

Abrasion:

An abrasion is a superficial wound in which the epithelial tissue is rubbed or


scratched.
Contusion:
A contusion is haemorrhage of subcutaneous tissue without laceration of
epithelial tissue. It is usually caused by a blunt object hitting the tissue.
Laceration:
A laceration is the tearing of tissue usually caused by a sharp object.
Treatment plan:
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For abrasions and contusions, only cleansing and observation are necessary
for lacerations, depending on their size and depth, suture the wounds after the
administration of local anesthetic.

PREVENTION OF DENTAL INJURIES: (Cohen)


Wearing a face guard or mouth guard or both is the bet way to effectively
prevent dental injuries.

FACE GUARDS:
Faceguards are usually prefabricated cage type guards that are attached to
helmets. Recently, faceguards of clear polycarbonate plastic have become
available.
Advantage:
Provide good protection to face and teeth.
Disadvantage:
Not applicable to all activities and do not protect the teeth if the individual is hit
under the chair.

MOUTH GUARDS:
Mouth guard is very effective in decreasing the severity and number of dental
injuries. There a 3 types of mouthguard in the market.
i. The stock mouth guard
ii. The mouth formed or boil and bite
mouth guard
iii. The custom-made mouth guard.

Stock Mouth Guard:


Stock mouth guard is the preformed rubber or polyvinyl-type polymer.
Advantage:
1. Inexpensive
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2. Ready to use without modification.


3. Usable by children and patients with orthodontic brackets.

Disadvantages:

1. Provides least protection


2. Uncomfortable for the wearer.

Mouth formed or Boil and Bite mouth guard:


The mouth formed mouthguard is preformed shell of semi rigid polyvinyl with
an inner lining of Silicone or plasticized acrylic gel is mixed and set in the
mouth, covering maxillary teeth.
Advantage:
1. Fit fairly well
2. The boil and bite mouth guard is preformed thermoplastic copolymer of
polyvinyl acetate and polyethylene.
3. The guard is softened for a few seconds in boiling water, then placed in the
mouth and adapted to dentition. This guard will be valuable for athletes.
Disadvantage:
Inner lining has the tendency to creep.

Custom made Mouth Guard.


 These guards are re-fabricated on a plastercast, usually of the upper
dentition and supporting tissues are made of polyvinyl acetate and
polyethylene. These are heated and then either vacuumed down on the
cast or pressed down with positive pressure.