2.

2 Trauma Trauma was an injury or a lesion either physically or psychologically that caused by physical measures with discontinuity of a normal structure. Dental trauma is injury to the mouth, including teeth, lips, gums, tongue, and jawbones. Traumas are typically quick, sudden and unexpected. The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when motor coordination is developing. Facial trauma that results in fractured, displaced, or lost teeth can have significant negative functional, esthetic, and psychological effects on children. Anterior dental trauma often happened in children because they were more active than adult person and their coordination also the assessment about their surroundings were not good enough (Eriska Ariyanti. 2011).

2.2.1 Etiology Most injuries caused by falls and accidents while playing. In general, injuries are more common in boys. Blunt trauma tends to cause great damage to the soft tissues and supporting tissues, whereas high-speed or spinning gear causing puncture wounds and fractures. (Eriska Ariyanti. 2011). Ellis and Davey differentiate the cause of the trauma into two namely (Annonymous, 2011): a. Direct, the teeth are directly exposed to the object cause of trauma. b. Indirect, teeth are not directly exposed to the object cause of trauma, such as trauma of the lower jaw which then cause tooth decay in the lower jaw. Trauma that occur directly or indirectly can be caused by (Annonymous, 2011):
a.

Accidents. These include a bad fall from a height, bicycle or motor vehicle crashes, and pedestrian and playground accidents. The highest number of accidents with dental trauma happens in children at 2 to 3 years of age.

b.

Sports injuries. These include injuries from diving, gymnastics, ice hockey, football, or horseback riding. Dental trauma may be from contact with other players or from getting hit by a hard object, such as a hockey stick.

c. d.

Street fights or other physical assaults. Especially for the trauma that occurs directly on the teeth can be caused by the action of mastication called spontaneous fractures. Fractures can occur spontaneously as a result of

mastication pressure on the tooth caries experience large, so the teeth can crack or break when biting hard objects. Trauma can be divided into two main categories (Louis H. Berman, et al. 2007):: 1. Nonintentional injury : includes domestic, recreational, sport, work, vehicular related injuries, and other such injures that are not inflicted on purpose by ones self or another person 2. Intensional injury: includes suicide, homicides, domestic abuse, war, terrorism, and other such injures that are purposefully inflicted.

In addition to the above factors there are some factor of trauma predisposes to the position of the anterior teeth and certain dental k eadaan dentofasial disorders such as type 2 malocclusion class I, class II division 1 or who have more than 3 mm overjet, circumstances that weaken the tooth ti trillionth email hypoplasia, and groups of people with cerebral palsy. (Eriska Ariyanti. 2011).

2.2.3 Classification Experts classify a wide range of disorders caused by trauma to anterior teeth. Classification of dental trauma which has been widely accepted is the classification according to Ellis and Davey (1970) and the classification recommended by the World Health Organization (WHO) in the Application of International Classification of Diseases to Dentistry and Stomatology. (Eriska Ariyanti. 2011). Table 1. Classification of Ellis and Davey (Annonymous. 2011) Class I Simple fracture of the tooth crown with open only slightly or not at all the dentin of the crown (only on the enamel) Class II A fracture that occurs in dental crown with a broad opening of dentin, but not about the pulp (only on the dentin) Class III A fracture that occurs in dental crown with a broad opening of dentin, but not about the pulp (only on the dentin) Class IV Trauma to the teeth resulting in a non-vital tooth accompanied with or without an accompanying loss of tooth crown structure Class V Trauma to the teeth that causes loss of teeth, called the avulsed

Class VI

Fracture of the root accompanied with or without an accompanying loss of tooth crown structure

Class VII

Trauma that causes displacement of the teeth (intrusion, extrusion, labial, palatal, buccal, distal, mesial, rotation) without accompanied by the crown or root fracture of tooth

Class VIII

Trauma that causes a large fracture in the tooth crown (total distraction) but the teeth still in place and tooth roots do not change

Class IX

All damage to the baby teeth due to trauma to the front teeth, the same definition for baby teeth to permanent teeth

There are basically two types on injuries to the dentition (Louis H. Berman, et al. 2007): A. Hard tissue injuries: involving the teeth, alveolar bone, and other facial bones a. Crown fracture Crown fractures are the most common type of dental trauma. The type of injury that may occur depends on the age of patient and the severity and direction of the trauma. These injuries are summarized below: Enamel infraction: present as a crack or craze line in the enamel. It is usually hairline thin in appearance and is often only noticeable when light is transilluminated through the crown. There is a tendency for these cracks to retain stains, which may create cosmetic concerns Uncomplicated crown fracture: this is a fracture of the crown that involves only the enamel or the enamel and dentin, with no pulp exposure Complicated crown fracture

b. Root fracture Occasionally, there may be an injury of the tooth that does not directly affect the crown of the tooth, but rather causes a fracture through the root. This fracture may be vertical, horizontal, or oblique in relationship to the long axis of the root. These injuries are summarized below: Crown-root fracture: A n b gabungin sama punyamu

c. Luxation injuries When a traumatic injury to a tooth seems to cause its displacement from the socket, it is termed a luxation injury. The type of luxation injury relates to the direction and severity of the injury. The luxation categories are summarized below: Concussion: when the tooth is traumatized by an impact, but does not change from its normal position Subluxation: when the tooth sustains an impact that causes slight mobility with no significant displacement from its socket Lateral luxation : implies that the tooth has been displaced within its socket in a socket in a buccal-lingual or labial-palatal direction Intrusion: when the tooth is displaced in an apical direction within the alveolus Extrusive luxation: when the tooth is displaced from its socket in a coronal direction Avulsion (or exarticulation) gabungin sama punyamu

d. Alveolar injuries There are several types of fractures that can occur to teh bone secondary to dental injuries. Comminuted fractures are multiple small fractures of the alveolar socket that can typically arise from luxation injuries. Likewise, there can be lateral, facial, or lingual fractures of teh alveolar socket. In more severe injuries, there may also be fracture of teh alveolar bone with or without any involvement of any tooth socket. B. Soft tissue injuries Concomitant with most dental injuries is trauma to teh surrounding soft tissue, including teh facial skin, lips, oral mucosa, gingival, frenum, hard and soft palate, and the tongue.

Image.. Percentage incidence of fractures 2.3 Root Resorbtion after trauma Due to the previously described inhibitory effects oorganic pre-cementum and predentin, even in teh presence of inflammation, an intact root is resistant to resorption. However, if an injury removes or alters the (protective) pre-dentin or pre-cementum, inflammation of the pulp or periodontium will induce root resorption with multinucleated clastic cells similar to those seen in bone resorption. (Martin Trope, 2002) Thus, in order for root resorption to occur, two things must happen:

A. The loss or alteration of the protective layer (pre-cementum or pre-dentin) Damage to the protective layer can occur either directly, due to the trauma of a dental injury, or indirectly, when an inflammatory response occurs as a result of a dental injury. Most traumatic injuries, however, cause surprisingly little damage to the cemental layer. Even in an avulsion injury, the greatest damage that occurs is the tearing of the periodontal ligament. With only slight damage caused to the cemental layer. Physical damage to the cemental layer will only occur at the specific points where the force of the trauma pushed the tooth directly against the bony socket. The only exception to this rule is an intrusive injury, where the forcing of the conical root apically into a similarly shaped socket will cause tremendous damage to the protective layer over the entire root surface. (Martin Trope, 2002)

image Histologic appearances the attachment apparatus of a recently avulsed tooth. Teh periodontal ligament is torn but the root surface is intact. Inflammation in reaction to the traumatic injury varies according to the stimulus it is exposed to after the injury, and has the potential to cause extensive damage to the protective layer. For example, the initial damage to the protective cementum after an avulsion injury, as described above, is limited. However, if the periodontal ligament cells remaining on the root are allowed to dry out before replantation, they will provide the stimulus for an inflammatory response over the entire root surface, which, in turn, results in extensive damage to the protective layer. (Martin Trope, 2002)

B. Inflammation must occur to the unprotected root surface. The inflammatory response caused by the dental injury can be divided into two critical phases. The first is the destructive phase where active resorption between the dried-out cells with multinucleated giant cells takes place. This destruction will continue as long as there is stimulus present to allow the inflammation to develop. In most cases, the conditions necessary to the creation of teh stimulus are due to either mechanical damage to teh root surface, or foreign materials or bacteria picked up the accident site on the root surface; therefore, the stimulus can only exist for a short period of time. Healing will, therefore, take place without intervention by the dentist. (Martin Trope, 2002)

Image Histolologic appearance of multinucleated giant cells resorbing the root. However, if the inflammatory stimulus is long standing, the destructive root resorption will continue until either no root structure remains or teh stimulus is removed by the intervention of the dentist. The destructive phase of root resorption is diagnosed primarily by the radiolucent appearance of teh root and adjacent bone on X-rays. Diagnosis is a major challenge as resorptive defects, facial or lingual/palatal, are most often missed during examination, although newer radiographic techniques, such as Tuned Aperture Computed Tomography (TACT), display significant promise in improving our ability to identify these defects in the future. The diagnosis

is also occasionally assisted by the presence of clinical symptoms which are similar to apical periodontitis. Once active root resorption has been diagnosed, the challenge to the practioner is to determine whether it will spontaneously heal, i.e. the stimulus is of short duration, or whether intervention is necessary due to the presence of a long-standing stimulus. (Martin Trope, 2002)

Image A, B. Radiographic appearance of root resorption in the destructive phase. Note the radiolucencies in the root and bone. Since most of the root destruction occurs due to the inflammatory response rather than direct physical damage, it seems logical that, if we could in some way limit this inflammation, we would also limit the root destruction and expect a more favorable outcome in terms of healing. (Martin Trope, 2002) Martin Trope. 2002. Root Resorption due to Dental Trauma. Endodontic Topics. Vol 1. Pp 79 100 Louis H. Berman, Lucia Blanco, Stephen Cohen. 2007. Dental Traumatology. China : ISBN Anonymous. 2011. Acute Dental Trauma. Available from: http://www.drugs.com/cg/acutedental-trauma.html. Accessed 6 desember 2011 Anonnymous. Trauma Pada Gigi Depan Anak. Available from:

http://ocw.usu.ac.id/course/download/611-PEDODONSIATERAPAN/pdi705_slide_trauma_pada_gigi_depan_anak.pdf. accesed 6 desember 2011