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Traumatic Injuries Traumatic Injuries

As part of growing up any child gets
increasingly involved in physical activities,
progressing from crawling to walking on
unsteady legs, climbing over objects,
graduating to bicycles, skate boards and
contact sports.
Physical activities and exercise are important
but they also present inherent potential
danger of injury to the face and teeth.
The emotional impact of such an accident
over the child and parents is very strong.
It is important that the dental team dealing
with such a situation show a calm, confident
and reassuring attitude to alleviate the anxiety
created by the situation.
Accurate and speedy diagnosis, followed by
definitive therapy must be undertaken
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Epidemiology:
.Upper anterior teeth are the most commonly
affected by trauma.
.Boys are more susceptible than girls.
.With deciduous teeth, luxation injuries are
common.
.In permanent teeth, fractures are common.
etiology
.Falling.
.Automobile injuries.
.Bicycle injuries.
.Sport injuries.
.Patients with Angle class II malocclusion. (Trauma
prone profile)
The trauma is either direct to the tooth or it is
transmitted from the lower dental arch to the
upper arch.
ELLIS Classification:
class I: Simple fracture of the crown involving
little or no dentin.
class II: Extensive fracture of the crown
involving considerable dentin but not exposing
the dental pulp.
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class III: Extensive fracture of crown involving

considerable dentin and exposing the dental
pulp.
class IV: Traumatized tooth becomes non vital
with or without loss of crown structure.
class V: Total tooth loss.
Class VI: Fracture of root
with or without loss of the
crown.
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class VII: Displacement of tooth

without fracture of crown or root.
class VIII: Fracture of crown
en masse
class IX: Trauma to deciduous teeth
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Modified Ellis Classification for crown fractures

Class I: Simple crown fracture involving little or
no dentin.
Class II: Extensive fracture of the crown involving
considerable dentin but not the dental pulp.
Class III: Extensive fracture of the crown with an
exposure of the dental pulp.
Class IV: Loss of the entire crown.
Descriptive Classification
(Non Numerical)
Trauma To Teeth:
Fracture Crown;
Enamel craze or fracture , enamel and dentin
fracture with or without pulp involvement and
posterior crown fracture.
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This can be further divided to non

complicated or complicated which means
root or pulp involvement.
Fracture Root;
This could be vertical, oblique or
horizontal at apical, middle or coronal
thirds.
Trauma to the supporting
structures (Luxation injuries);
Concussion, subluxation, Intrusion, Extrusion,
lateral luxation and avulsion.
As a rule:
Before treating a child with dental
trauma proper quick medical and
dental history should be obtained
followed by clinical examination.
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A-MEDICAL HISTORY
-Bleeding disorders.
-Cardiac disorders
-Allergies to medication.
-Seizure disorders.
-Special medications.
VERY IMPORTANT
Serious head injuries may cause central nervous
system injury which could be
manifested by:-
-Nausea
-Vomiting
-Disorientation
- Amnesia
-Loss of consciousness.
- Diplopea.
- Headache
- Neck stiffness cervical spine injury
Status of tetanus prophylaxis.
*If the patient has not received an immunization
, anti-tetanic serum is administered.
*If the child had already received the vaccine
but did not receive a booster dose in the last
years, the tetanus toxoid is given.
B- History of dental injury
Three main questions should be asked:
.When has the trauma occurred ?
( time is a major factor )
.Where has the trauma occurred ?
(tetanus prophylaxis.)
.How did the trauma occur ?
( severity )
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Determine whether the tooth had been

injured previously or whether the injury had
first been treated elsewhere.
Teeth which have received previous blows
have poor prognosis.
C- CLINICAL EXAMINATION
A) Extra-oral Examination:-
-Facial bones.
-T.M.J. and mandibular function
-Wounds and bruises.
Visual extraoral examination to identify any
bleeding:
Subconjunctival hemorrhage of the eyes
Bleeding or cerebrospinal rhinorrhea from the
nose
Bleeding from or bruising around the external
auditory canal.
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A blow to the chin can cause, in addition to

posterior crown fracture, mandibular
symphisis fracture.
B) Intra-oral Examination
) Visual-Examination
to determine:
Extent of injury.
Soft tissue injury.
Any lacerations should be explored to make
sure they do not contain fragments of teeth,
bone, glass, dirt, grass, or other foreign
material.
Thorough exploration can be performed after
the wound is anesthetized
A cotton pellet moistened with warm water or
hydrogen peroxide may be used to clean the
area.
- The integrity of the dental arch is assessed.
The occlusion should be checked.
Maxillary, mandibular, or alveolar-process
fractures may affect the occlusion
Manipulation of teeth and alveolar process to
determine mobility (multiple tooth mobility
may denote alveolar bone fracture).
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With the aid of a good light (transillumiation) ,

the clinical crown should be examined
carefully for cracks and craze lines.
With light transmitted through the teeth in
the area, the color of the injured tooth should
be carefully compared with that of adjacent
uninjured teeth.
Pulpal hyperemia is manifested by a darker
and reddish appearance .
) Percussion can give an idea about periodontal
membrane injury.
* Usually done with the handle of mirror.
) Vitality test:
Initial results may be inconclusive .
It establishes a baseline that can be compared
with follow-up examinations in subsequent
months
The electrode is placed upon the incisal edge
or the most incisal aspect of enamel in the
case of crown fractures.
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Permanent teeth in a state of shock may not

respond to vitality tests.
It only indicates a transient lack of pulpal
response.
The test can be repeated after - days of
trauma.
Thermal testing
More reliable in testing primary incisors in
young children than the electric pulp testing.
Failure of a tooth to respond to heat or cold is
indicative of pulpal necrosis.
C) Radiographic Examination:
Although this may show nothing at the time of
trauma.
It could serve as a valuable base line record.
It also shows:
Size of pulp.
Root resorption.
Amount of root development.
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Position of unerupted teeth.

Root fractures.
Alveolar fractures.
Degree of tooth displacement.
Jaw fractures.
Any X-ray film that will show properly the
affected area can be done:-
Periapicals.
Panoramic film.
Lateral films.
Occlusal films.
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Occlusal radiographs
. Give an excellent view of most lateral
luxations, apical and mid-root fractures and
alveolar fractures.
. To check the integrity of the arch.
The orbicularis oris muscle closes tightly
around foreign bodies in the lip, making them
impossible to palpate.
Films of soft tissue of the lips can be made to
detect any foreign body or tooth fragments in
lips.
This is accomplished by placing a dental film
between the lips and the dental arch and
using % of the normal exposure time.
Follow up radiographs after,& months up
to months to detect periapical radiolucency
and root resorption.
After - weeks ankylosis can be seen.
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Photographic registration of the trauma is

also recommended.
It offers an exact documentation of the extent
of injury which can be used in later treatment
planning, legal claims, or for clinical research.