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TRAUMATIC INJURY

Dr. Meti T. (MD)

03/20/24 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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ETIOLOGY

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

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Prevalence

•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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An average of 22,000 occur annually among children less than 18yrs.
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 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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 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 complete fracture of crown
• CLASS 9 Deciduous tooth fracture
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• Symptom

• The symptoms depends on

 whether the pulp is exposed ,
 degree of damage to the pulp
 age of the patient
 and other factor.

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• 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.

• When the pulp is exposed, pain may occur.

• In older patient, sufficient pulp recession may already have

occurred to protect the pulp against irritation from external
stimuli and tooth may be practically symptomless

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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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 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
w/in 24hrs

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• For fractured 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

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 2. Crown-Root Fracture
sometimes fractures at an angle

Angular Fracture:
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Is this 13
restorable?
 3. Vertical Root Fracture

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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 Horizontal Root Fracture

Tends to be Readily apparent –

especially after separation
Mobility a good clue
Prognosis is very poor

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 Root Fracture (Horizontal)

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
• Extrusion
• Lateral PULP NECROSIS
• Intrusive
EXTERNAL/INTERNAL
ROOT RESORPTION
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
• 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

• 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 ?
Assess vitality in 4 weeks

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 Titanium Trauma Splint
Medaris AG, Basel Switzerland

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TTS splint
•Splinting of traumatized teeth with a new device:TTS (Titanium
Trauma Splint)

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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
Increased PDL space best seen
on eccentric or occlusal
radiographs
Anesthetize & reposition
+ Flexible splint MANDATORY
4-8 weeks
 Assess vitality in 4 weeks
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 Intrusion Luxation Injury
External root resorption likely
• Most severe of luxations***
• Tooth appears shorter: displaced into
alveolar bone
• PDL destruction
• 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

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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

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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 of 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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• 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,normal saline,
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 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
 milk
 saline

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– Gently clean socket
– Replant and check occlusion
– Splint
– antibiotics

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 • 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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 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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 TMJ (TEMPOROMANDIBULAR)
DISLOCATION

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• The TMJ consists of articulation of temporal and mandibular
bones
• TMJ dislocation occur when condyle travel anteriorly along
the articular eminence and become locked in the anterior
superior aspect of eminence , preventing closure of the
mouth.
• Dislocation result in stretching of ligament and associated
with severe spasm of muscle

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 intrinsic or self induced cause
– Excessive yawning
– Vomiting
– Singing and laughing loudly
– Opening mouth too wide for eating

 muscle contraction
• due to dystonic reaction to drugs
• seizure
• tetanus

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 extrinsic cause
– blow on the chin while the mouth is opening
– Injudicious use of mouth gag during GA.
– Excessive pressure on the mouth.

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 patient prone to mandibular dislocation include
 anatomic mismatch between the fossa and articular
eminence

 weakness of capsule and temporomandibular ligament eg.

marfan syndrome

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Classifiction
• acute dislocation
• chronic recurrent dislocation
• unilateral
• Bilateral
• Subluxation /incomplete dislocation/

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Clinical feature
• unilateral or bilateral

 Unilateral
• difficulty of mastication, swallowing and speech.
• Deviation of the chin toward contralateral side.
• Mouth is partial open
• Depression in front of tragus
• Affected condyle cannot be palpated
• Lateral cross bite

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 bilateral
• Pain in temporal region
• Inability to close mouth
• Tenderness of masticatory muscle
• Excessive salivation
• Protruding chin
• Anterior open bite
• Muscle spasm
• Drooling saliva
• Mandibular movement restricted.

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Unilateral Bilateral
 Difficulty of mastication, swallowing  Pain in temporal region
and speech.  Tenderness of masticatory muscle

 Deviation of the chin toward  Protruding chin

contralateral side.  Inability to close mouth
 Mandibular movement restricted.
 Mouth is partially open  Excessive salivation, drooling saliva
 Depression in front of tragus
 Affected condyle cannot be palpated  Anterior open bite
 Muscle spasm
 Lateral cross bite  Bilateral pre auricular area depression

 Ipsilateral pre auricular area

depression

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 Diagnosis
• Diagnosis made clinically
• panaromic jaw radiographs to exclude a mandibular fracture
specially for children
• CT patient with jaw dislocation in setting of facial trauma

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 • management
• Manipulation procedure
• Patient should be given assurance and asked to relax completely
LA is injected into glenoid fossa.
• This will eliminate pain and spontaneous reduction
 Stand in front of patient and grasp mandible with both hands.
Thumbs are covered with gauze. As sudden reduction can trap
the thumbs.
 Thumbs are placed on occlusal surface of lower molars and
finger tips are placed below chin.
 Exert downward pressure on posterior teeth to depress jaw and
at the same time upward and backward pressure with fingertips

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• extraoral technique
• another option if intra oral and syringe technique fails
• requires firm pressure on mandibular angle
• usually painful

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following reduction
•avoid extreme opening of jaw for 3wk
•support the lower when yawning
•apply warm compress to TMJ area for 24 hr
•maintain a soft diet for one wk.
•NSAID PRN.
•Reevaluate after 2/3 wk.

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Complication of reduction
• Iatrogenic condyle #
• Human bite

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 Thank you

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