Trauma to teeth involves the dental pulp and the peri-odontium either directly or indirectly;

consequently, endodontic considerations are important in evaluating and treating traumatic dental
injuries. The purpose of this chapter is to describe the incidence of dental trauma, etiologic factors,
examination procedures, emergency care, treatment options, and possible sequelae in traumatized
teeth. Because injuries occur to primary teeth also, a separate section has been included for these
teeth. The recommendations for man-aging traumatic dental injuries are based on the guidelines
published by the International Association of Dental Trauma-tology, which publishes updated
guidelines on its Web site (www.iadt-dentaltrauma.org).

Epidemiologic studies have shown that the incidence of dental trauma ranges from 25% to 58%, and
the most common age group affected is children 8 to 12 years.' Sgan-Cohen and colleagues reported
a total prevalence of 29.6%.4 Severe trauma, at least involving the dentin, was found among 13.5%
and was more prevalent among children with an incisal overjet and incompetent lip. Falls were the
main cause of dental trauma (44.9%), but sports and violence also were important causes. Fractures
of enamel or enamel and dentin are the most common sequelae of dental trauma. The teeth most
often traumatized are the maxillary central incisors (88%), maxil-lary laterals (7%), and mandibular
incisors (5%). Among sports, basketball is associated with the highest injury rate, with an incidence
of 10.6 injuries per 100 athlete-seasons among men and 5 injuries per 100 athlete-seasons among
women. ' The incidence for basketball players was five times higher than that for football players, for
whom mouthguard use is mandatory.

Age is an important factor in trauma to teeth. By age 14, about 25% of children will have had an
injury involving their permanent teeth• The significance of age is a "good news/ bad news" situation.
The good news is that pulps in children's teeth have a better blood supply than those in adults and
better repair potential. The bad news is that root development is interrupted in teeth with damaged
pulps, leaving the roots thin and weak. Cervical fractures often occur either spontaneously or from
even minor injuries because of thin dentin walls. Therefore, when dental injuries occur in children,
every effort must be made to preserve pulp vitality.

Box 11.1 Classification of Dental Injuries

■ Enamel fracture: Involves the enamel only and includes enamel chipping and incomplete fractures
or enamel cracks. ■ Crown fracture without pulp exposure: An uncomplicated fracture involving the
enamel and dentin with no pulp exposure. ■ Crown fracture with pulp exposure: A complicated
fracture involving the enamel and dentin and exposure of the pulp. ■ Crown-root fracture: Tooth
fracture that includes the enamel, dentin, and root cementum and may or may not include the pulp.
■ Root fracture: Fracture of the root only involving the cementum, dentin, and pulp; also referred to
as a horizontal root fracture. ■ Luxation injuries: Tooth luxations include concussion, subluxation,
extrusive luxation, lateral luxation, and intrusive luxation. ■ Avulsion: Complete displacement of a
tooth out of its socket. ■ Fracture of the alveolar process (mandible or maxilla): Fracture or
comminution of the alveolar socket or of the alveolar process.

Classification of traumatic injuries promotes better com-munication and dissemination of

information. The system used in this chapter is based on Andreasen and Andreasen's modification of
the World Health Organization classification (Box 11.1).• Feliciano and de Franca Caldas evaluated
164 articles and 54 different classifications and concluded that, according to the literature, the
Andreasens' model was the most frequently used classification system (32%).9 Treat-ment
recommendations are based on the official guidelines of the International Association of Dental
Traumatology (1ADT).19-12

EXAMINATION AND DIAGNOSIS

Examination of a patient with dental injuries should include the history (chief complaint, history of
present illness, perti-nent medical history) and a clinical examination. The empha-sis in this chapter
is on those aspects of the examination that specifically relate to dental trauma."

Stage of Root Development and Dental Trauma

Knowledge of the developmental stages of permanent teeth is essential for clinical practice in
several dental specialties because it may influence diagnosis, treatment planning, and outcomes. In
1960 NoIla published a classification system for odontogenic development based on radiographic
interpreta-tion (Table 11.1)24 This system has been widely used,1•6 and it is particularly important
for appropriate diagnosis and treat-ment of traumatized teeth. In 1976 Fulling and Andreasen
demonstrated that the late differentiation of AS nerve fibers in the dental pulp could explain the lack
of a reliable and predictable response of erupting and undeveloped teeth to thermal and electrical
stimulation?' In young patients with immature teeth, carbon dioxide (CO2) snow and dichlorodi-
fluoromethane (DDM) are the most reliable sensitivity tests, followed by electrical pulp testing and
ethyl chloride and ice 18 Therefore, in the absence of reliable clinical tests, radio-graphic evidence of
root development and dentin maturation during follow-up examination may be critical for providing
the clinician with reliable information about the presence of a vital dental pulp.

History

Pertinent information about traumatic injuries should be obtained expeditiously by following a

system.

Chief Complaint The chief complaint is simply a statement, in the patient's (or parents') own words,
of the current problem; for example, "I broke my tooth:' or "My tooth feels loos' It may also be
unstated, as in a patient with obvious injuries.

History of Present Illness

To obtain the history of the present illness (injury), the dentist can ask a few specific questions, such
as the following.
■ When and how did the injury occur? The date and time of the accident are recorded. The record
should include how the injury took place (i.e., bicycle accident, play-ground, sports, violence, or
other). Such information is useful in the search for avulsed teeth and embedded tooth fragments,
assessment of possible contamination, determination of the time factor with respect to the choice of
treatment and the healing potential, and com-pletion of accident reports.

■ Have you had any other injuries to your mouth or teeth in the past? Individuals may have repeated
traumatic injuries if they are accident prone or participate in contact sports.I3 Crown or root
fractures may have occurred as a result of an earlier injury but are observed at a later time. A history
of previous episodes of trauma may affect the healing potential of the pulp and peri-odontium. It
should also raise concern about the possi-bility of physical abuse of a child.
• What problems are you now having with your tooth or teeth? Pain, mobility, and occlusal
interference are common symptoms. The patient's description of symp-toms aids diagnosis.

Table 11.1 Radiographic classification of odontogenic development

Classification Description

0 No crypt

1 Presence of a crypt

2 Initial calcification

3 One-third crown completed

4 Two-thirds crown complete

5 Crown almost completed

6 Crown completed

7 One-third root completed

8 Two-thirds root competed

9 Root almost open (open apex)

10 Root apex completed

Medical History

The patient's medical history is often significant. For example, the patient may have an allergy to
prescribed medication, may be taking medications that interact with proposed new medi-cations, or
may have a medical condition that affects treat-ment. The patient's tetanus immunization status
should be recorded; a booster may be indicated with contaminating inju-ries, such as avulsions and
penetrating lip and soft tissue lesions:9

The need for neurologic evaluation should always be con-sidered and ruled out. Concussion is a
disturbance in brain function caused by direct or indirect force to the head.' It is a functional, rather
than structural. injury that results from shear stress to brain tissue caused by rotational or angular
forces; direct impact to the head is not required. Headache is the most common symptom of
concussion, although a variety of clinical domains (e.g., somatic, cognitive, affective) can be affected
(Box 11.2). Signs and symptoms are nonspecific; therefore, a temporal relationship between an
appropriate mechanism of injury and the symptoms must be deter-mined.' In cases in which a head
concussion is suspected, the patient should be immediately referred for a full neurologic
examination.

Clinical Examination

The lips, oral soft tissues, and facial skeleton should be exam-ined, in addition to the teeth and
supporting structures.
Soft Tissues

The purpose of the soft tissue evaluation is to determine the extent of tissue damage and to identify
and remove foreign objects from wounds. In crown fractures with adjacent soft tissue lacerations,
wounds are examined visually and radio-graphically for tooth fragments. Lips are likely areas for a
foreign body impaction. Also, severe lacerations require suturing (Fig. 11.1).

Facial Skeleton

The facial skeleton is evaluated for possible fractures of the jaw or alveolar process. Such fractures,
when they involve tooth sockets, may produce pulpal necrosis in teeth associated with fracture
lines. 1.22 Alveolar fractures are suspected when several teeth are displaced or move as a unit;
when tooth displacement is extensive; when occlusal misalignment is present; or when there is
continuous bleeding from gingival tissues.

Teeth and Supporting Tissues

Examination of teeth and supporting tissues should provide information about damage that may
have occurred to dental hard tissues, pulps, periodontal ligaments, and bony sockets. The following
sections present guidelines for a method of collecting information systematically.

Mobility

The clinician examines the teeth (gently) for mobility, noting whether adjacent teeth also move
when one tooth is moved (indicating an alveolar fracture). The degree of horizontal mobility is
recorded: 0 for normal mobility; 1 for slight mobil-ity (less than 1 mm), 2 for marked mobility (1 to 3
mm); and 3 for severe mobility (greater than 3 mm), both horizontally and vertically. If there is no
mobility, the teeth are percussed for sounds of ankylosis (metallic sound). Absence of normal
mobility may indicate ankylosis or "locking" of the tooth in bone, such as with intrusion and lateral
luxation.

Displacement

A displaced tooth has been moved from its normal position. If this occurs as a result of a traumatic
injury, it is referred to as luxation (discussed later in the chapter).

Box 1 1 .2 Selected Symptoms of Concussion

Affective/emotional symptoms ■ Anxiety/nervousness' ■ Clinginess ■ Depression ■ Emotional

distress • Irritability' ■ Personality changes ■ Sadness

Cognitive symptoms ■ Amnesia ■ Confusion ■ Delayed verbal and other responses ■ Difficulty
concentrating' ■ Difficulty remembering' ■ Disorientation' ■ Feeling foggy' • Feeling slowed down' ■
Feeling stunned ■ Inability to focus ■ Loss of consciousness ■ Slurred speech ■ Vacant stare Sleep ■
Decreased sleep ■ Difficulty initiating sleep ■ Drowsiness' ■ Increased sleep'

Somatic/physical symptoms ■ Blurred vision ■ Convulsions ■ Dizziness/poor balance ■ Fatigue ■

Headache ■ Lightheadedness ■ Light sensitivity ■ Nausea ■ Noise sensitivity ■ Numbness/tingling ■
Tinnitus ■ Vomiting
Fig. 11.1 Laceration of soft tissues requiring sutures.

Periodontal Damage

Injury to the supporting structures of teeth may result in swell-ing and bleeding involving the
periodontal ligament. The involved teeth are sensitive to percussion, even light tapping. Apical
displacement with injury to vessels entering the apical foramen may lead to pulp necrosis if the
blood supply is compromised.r

The use of percussion can help identify periodontal injury. This testing procedure must be done
gently because trauma-tized teeth are often exquisitely painful to even light tapping. In a combined
histologic, bacteriologic, and radiographic study, Andreasen showed that only tenderness to
percussion at the time of diagnosis of pulp necrosis was related to an infected, necrotic pulp?"'
Therefore, special attention should be given to this test, especially when the tooth consistently and
reliably shows an abnormal tenderness to percussion. Uninjured teeth should be examined first to
enhance the patient's confidence and understanding of the procedures. In addition to testing the
tooth or teeth involved in the patient's complaint, it is important to include several adjacent and
opposing teeth. This permits recognition of other dental inju-ries of which the patient may not be
aware and that may not be obvious clinically. If later complications develop involving one of these
adjacent or opposing teeth, previous information aids diagnosis.

Pulpal Injury

The ideal pulpal response to injury is complete recovery after a traumatic injury. Two other potential
outcomes may occur: calcific metamorphosis, in which the pulp tissue is gradually replaced with
calcified tissue (recognized clinically as a yel-lowing effect on the crown) or pulp necrosis, which can
result in external inflammatory (infection-related) root resorption.25 Rarely, resorption may occur in
the pulp space (internal resorption). In any case, a tooth may undergo resorption without any clinical
symptoms, which emphasizes the need for follow-up controls.

The status of the pulp may be determined by the symptoms, history, and clinical tests (see Chapter
5). However, two clini-cal tests deserve consideration here because of their applica-bility to
traumatized teeth: the electrical pulp test (EPT) and the cold test with dichlorodifluoromethane
(DDM) (Endo-Ice; Hygenic Corp., Akron, Ohio). These test the neural tissue (specifically AS nerves)
within the pulp chamber and are generally reliable for evaluating and monitoring pulpal status
except in teeth with incomplete root development.' Never-theless, evaluating the vascular supply to
the pulp is the ulti-mate test to determine vitality of the tissue. Current evidence demonstrates that
pulpal blood flow can be accurately assessed with laser Doppler flowmetry (LDF)2'28 and with pulse
oxim-etry (Fig. 11.2)29-32 Gopikrishna and colleagues3' compared the efficacy of a custom-made
pulse oximeter dental probe with EPT and thermal testing for measuring the pulp vitality status of
recently traumatized permanent teeth. The results demonstrated a positive responsiveness to
thermal and electri-cal pulp tests that increased from no response on day 0 to 29.4% teeth on day
28, 82.35% of teeth at 2 months, and 94.11% teeth at 6 months. However, the pulse oximeter gave
positive vitality readings that remained constant over the study period from day 0 to 6 months in all
patients.

Radiographic Examination

Radiographs can reveal fractures of bone and teeth and the stage of root development. Horizontal
root fractures and lateral luxations are often overlooked because the conven-tional angle may miss
irregularities that are not parallel with the x-ray beam. Therefore, multiple exposures should be
routine for examination of traumatized teeth to ensure com-plete disclosure and diagnosis of the
injury.•

The film size should be such that it can accommodate two incisors without bending or distorting the
image. It is also important to use a film holder whenever possible to achieve standardized
radiographic images, especially for subsequent comparisons.

Recent improvements in three-dimensional (3D) digital radiographic imaging have introduced a new
perspective, allowing us to evaluate the anatomic structures. both hard and soft tissue, in three
spatial planes.33 The traditional projection (plain film) radiograph is a two-dimensional shadow of a
three-dimensional object; 3D imaging overcomes this major limitation by providing a true
representation of the anatomy while eliminating superimpositions. Several studies have reported
the use of computed tomography (CT) and digital radiography for differential diagnosis,m'm
assessment of treat-ment outcomes,3738 endodontics,39 oral and maxillofacial surgery,'
implantology,• and orthodontics, with reliable linear measurements for reconstruction and imaging
of dental and maxillofacial structures.45m The indications for cone beam computed tomography
(CBCT) in dental traumatology were first described in 2007." Cases that may appear straightforward
on periapical radiographs (Fig. 11.3) may reveal a different and more complex situation when
evaluated three-dimensionally (Fig. 11.4).

A thorough examination and accurate records form the basis for an appropriate treatment plan. The
information gath-ered also provides content for accident reports that may be requested either
immediately or later for legal or insurance purposes.
Fig. 11.2 Pulse oximetry unit with a commercially available sensor that fits dental tissues. (Courtesy
of Covidien.)

Fig. 11.3 Complicated crown fracture of the maxillary right central and lateral incisors and maxillary
left central incisor. A and B, Periapical radiographs at different horizontal angles.
Flg. 11.4 Complicated crown fracture of the maxillary right central and lateral incisors and maxillary
left central incisor (same case as in Fig. 11.5).