TRAUMATIC INJURIES OF THE TEETH AND THEIR MANAGEMENT

CLASSIFICATIONS
Many classifications have been proposed. They include:
1. 2. 3.

Bennett classification (1963). Ellis and Davey classification (1970). World Health Organizations Application of the International Classification of Diseases to Dentistry and Stomatology (1978). Andreasens classification (1981).

4.

ANDREASENS CLASSIFICATION
Andreasen's classification (1981) is a modification of the World Health Organization's Application of the International classification of Diseases to Dentistry and Stomatology (1978).It can be applied to both the permanent and the primary teeth.

ANDREASENS CLASSIFICATION
1. Injuries to the hard dental tissues and the pulp.

2. Injuries to the periodontal tissues.

3. Injuries to the supporting bone. 4. Injuries to the gingiva or oral mucosa.

ANDREASENS CLASSIFICATION
1. Injuries to the hard dental tissues and the pulp. 2. Injuries to the periodontal tissues. 3. Injuries to the supporting bone. 4. Injuries to the gingiva or oral mucosa. Injuries to the hard dental tissues and the pulp
1.
2. 3. 4.

5.
6.

Crown infraction. Uncomplicated crown fracture. Complicated crown fracture. Uncomplicated crown-root fracture. Complicated crown-root fracture. Root fracture.

ANDREASENS CLASSIFICATION
1. Injuries to the hard dental tissues and the pulp. 2. Injuries to the periodontal tissues. 3. Injuries to the supporting bone. 4. Injuries to the gingiva or oral mucosa. Injuries to the periodontal tissues
1.
2. 3. 4. 5. 6.

Concussion. Subluxation (loosening). Intrusive luxation. Extrusive luxation. Lateral luxation. Exarticulation (Avulsion).

ANDREASENS CLASSIFICATION
1. Injuries to the hard dental tissues and the pulp. 2. Injuries to the periodontal tissues. 3. Injuries to the supporting bone. 4. Injuries to the gingiva or oral mucosa. Injuries to the supporting bone
1. 2. 3. 4.

Comminution of alveolar socket. Fracture of alveolar socket wall. Fracture of alveolar process. Fracture of mandible or maxilla.

ANDREASENS CLASSIFICATION
1. Injuries to the hard dental tissues and the pulp. 2. Injuries to the periodontal tissues. 3. Injuries to the supporting bone. 4. Injuries to the gingiva or oral mucosa. Injuries to the gingiva or oral Mucosa
1.
2. 3.

Laceration of gingiva or oral mucosa. Contusion of gingiva or oral mucosa. Abrasion of gingiva or oral mucosa.

ETIOLOGY
1.
2. 3.

4. 5. 6. 7. 8.

Falls, collisions and bumps in toddlers and young children. Bicycle accidents and falls due to unorganized playing at home or school. Sports: contact sports such as football, basketball and wrestling etc. 1.5-3.5% of children participating in contact sports sustain dental injuries. Battered child syndrome. Automobile accidents. Fight injuries. Mentally retarded children usually sustain dental injuries due to lack of motor co-ordination. Epilepsy is also a cause of dental injuries. Drug addicts may break the cusps of their teeth by violent clenching 3-4 hours after drug intake.

PREDISPOSING FACTORS
1.

2.

Incisal angulation and occlusion. Relevant medical histories:

1. Convulsive episodes in epileptic patients can result in a high frequency of dental injuries. 2. Violent tooth clenching in drug addicts usually result in fracture of cusps of posterior teeth. 3. Patients with psychiatric disorders and the LeschNyhan syndrome may inflict dental injuries themselves. Bad eye sight, slow responses, hyperactivity, physical handicap etc are also predisposing factors.

3.

Dental anomalies.
Hereditary defects of dentine (Dentinogenesis Imperfecta). Grossly carious teeth or heavily filled teeth are also predisposing factors.

EXAMINATION AND DIAGNOSIS OF DENTAL INJURIES

(Dental injuries should always be considered as an emergency)

HISTORY
Patients name, age, sex, address and telephone number. When did injury occur? Where did injury occur?

How did injury occur?

Was there a period of unconsciousness? If yes, for how long? Is there headache, nausea, vomiting, amnesia etc. Has there been previous injury to the tooth?

Has a tooth or a piece of tooth been lost? If so, where is it?

MEDICAL HISTORY
Any

heart or chest problem? Any allergies? Any bleeding tendencies? Any hospitalization? Any medicine taking at present? Any fits, i.e, epilepsy? Any G.A in the past?

PAST DENTAL HISTORY

It includes details of any earlier trauma and treatment

experience. This will give some idea of the childs likely cooperation and the parents attitude, both of which may influence treatment decisions.
Repeated injuries to the teeth can influence vitality

tests and the reparative capacity of pulp.

CLINICAL EXAMINATION
Extra-oral

Look for soft tissue bruising, hematomas or lacerations etc. Look for any asymmetry, i.e, swelling etc. Palpate the facial bones gently to investigate any abnormalities or step deformities which would indicate the presence of bone fracture. Ask the child to open and close his mouth. Any restriction or deviation to one side would indicate condylar fracture. Look for injuries on the body (if battered child syndrome is suspected.

CLINICAL EXAMINATION
Intra-oral

Record injuries to lips, frenum, tongue, gingiva, mucosa and other soft tissues. The presence of foreign matter in lips and cheeks should be ruled out. Examine the dentition for: Crown fractures and their extent. Displacement of teeth. Interference in occlusion. Mobility of teeth. Colour of injured teeth. Examine for abnormal mobility of alveolar process.

CLINICAL TESTS
Percussion test.
Vitality tests.

Thermal tests
Heated guttapercha Ethyl chloride Ice Carbon dioxide snow and dichlordifluormethane.

Electric pulp test

Unipolar Bipolar

Mechanical stimulation and cotton pellet test

Transillumination

PERCUSSION TEST
Uninjured teeth percussed first will help relax child and help in

assessing the cooperativeness and the reliability of the responses. Use finger tip.
Reaction to percussion is indicative of damage to the

periodontal ligament. If negative at the initial appointment and become positive on subsequent appointments, degenerative changes always suspected.
The sound elicited by percussion is also of diagnostic value.

Hard metallic sound tooth locked in bone. Dull sound subluxation or extrusive luxation.

VITALITY TESTS
Important for crown fractures and luxation of teeth.

Require cooperation and a relaxed attitude on part of patient.

The principle of the tests is the conduction of stimuli

to, and their registration on, the sensory receptors of the dental pulp.
Test a contralateral undamaged tooth first to obtain a

baseline of reaction.

Thermal tests
Thermal testing both heat and cold. Not reproducible in terms of graded intensity. Normal pulp tissue

may give a negative response. Positive reaction vital pulp, but may also occur in non-vital pulp especially in gaseous necroses of pulp.

Thermal tests less value for children because testing accuracy

involves not only the perception of pain but also the degree of pain.
Intensity of thermal stimulus is rarely reproducible.

Most frequently used are:

Heated guttapercha Ethyl chloride Ice Carbon dioxide snow

and dichlordifluormethane

Electric pulp test (vitalometer)

Two types:
Unipolar: Current pass through the dentist. Bipolar: Current pass through the patient. Technique of Electric Pulp Testing

Interpretation

Injured tooth responding positively to a lower than normal current hyperemic pulp or acute pulpitis. Injured tooth responding positively to a higher than normal current chronic pulpitis or degenerative changes (but not always true).

Teeth with wide open apices may not respond to electrical tests.
Electric pulp testing more reliable. Electric pulp testing reasonably reproducible. Status of the dental pulp cannot be reliably determined by vitality tests alone. Information gained from vitality testing have to be correlated very carefully with other findings.

Mechanical stimulation and cotton pellet test

Crown fracture with exposed dentine scratching

with a dental probe.

Crown fracture with exposed pulp applying a

pledget of cotton soaked in saline or distilled water.

TRANSILLUMINATION
Light source:
Mouth mirror - Fibreoptic equipment

RADIOGRAPHIC EXAMINATION
Radiographs of the traumatized area are a must as the examination is not complete without radiographs.

Information provided by the radiographs of the traumatized teeth

1. 2. 3. 4.

Stage of development of root. Will show any root fracture. Extent of displacement or dislocation of teeth. May show pathologic conditions related to previous traumatic injuries, e.g:

Periapical rarefaction. Internal or external root resorption. Calcification of pulp. Size of pulp chamber and pulp canal.

PRINCIPLES OF TREATMENT
Emergency treatment

Elimination of pain Protection of pulp Reduction and immobilization of mobile teeth Suturing of soft tissue lacerations Antibiotics? Anti-tetanus? Analgesics? Chlorhexidine mouthwash?
Pulp therapy Consider orthodontic requirements and long-term prognosis of damaged teeth Semi-permanent restorations Keep under review, usually 1 month,3 months, and then 6-monthly for 2 years. It is usually deferred until 17 years of age, to allow pulpal and gingival recession and decrease likelihood of further trauma,e.g, PJC, post and core crown etc.

Intermediate treatment

Long-term or permanent treatment

TRAUMA TO PERMANET TEETH

By the age of 6-15 years, 30% of children usually get trauma to

their permanent teeth.

Maxillary central incisors are the teeth involved in most of the

cases while maxillary lateral incisors and mandibular incisors are next on the list.
Boys appear to get injuries to the permanent dentition almost

twice as often as girls. This is because of their more active participation in games and sports.

Crown infraction
Crack may reach up to amelodentinal junction and may be

horizontal or vertical.
Can be seen only when we dry the tooth and reflect light

through it.
These do not require treatment. However, due to the frequently

associated injuries to the tooth supporting structures, vitality tests should be carried out at intervals to disclose pulp damage.
If tooth become sensitive, fluoride therapy may be required for

desensitization.

Uncomplicated crown fracture

Enamel fracture

Immediate treatment

Limited to grinding of sharp enamel edges to prevent laceration of tongue or lips. Composite repair may be done

Intermediate treatment

Review after 7-10 days or in some cases after 6-8 weeks. Corrective grinding may be undertaken with or without orthodontic extrusion of the fractured tooth.

Long-term treatment

Review after 6 months looking for necrosis of pulp, calcification, resorption etc. Pulp vitality tests continue upto 2 years.

Uncomplicated crown fracture

Enamel + dentine fracture
The aims of treatment
Pulp protection. Space maintenance. Aesthetics.

Treatment:
The immediate treatment consists of protecting the pulp from bacterial contamination or thermal stimuli by covering the exposed dentine.

Method:

Isolate and dry the tooth. Cover the exposed dentine with a calcium hydroxide lining material. Place an acid-etch composite restoration. In case of insufficient time or lack of co-operation, a composite bandage may be placed. Composite build up may be done at a future appointment. Review the patient after 1week, 1month, 3months and then at 6- monthly interval for at least 2 years. At these appointments, vitality tests should be carried out and a radiograph taken to check that root development is continuing.

Complicated crown fracture

The immediate treatment aims to preserve the vitality of the pulp. This is essential to allow continuing root development, apical closure, narrowing of the pulp cavity and thickening of the root walls.

Treatment options:
Pulp capping Partial pulpotomy Vital pulpotomy (Apexogenesis)

Review after:

1 week --- for discomfort and retention of composite. 1 month--- periapical radiograph for apical pathology. Vitality tests. 3 months--- periapical radiograph to see root development. Hard tissue barrier seen in case of vital pulpotomy (apexogenesis). 6 monthly---for at least 3 years. In case of vital pulpotomy elective root canal carried out after apical closure.

In case of non-vital pulp

Open apex - apexification Closed apex - RCT

Uncomplicated crown-root fracture

Gingivectomy + osteotomy for dentine coverage.

Crowning.

Complicated crown-root fracture

Pulp treatment. Gingivectomy + osteotomy for post and core. Crowning.

Root fracture
Classification & treatment

Fracture not communicating with gingival crevice. Fracture communicating with gingival crevice. Longitudinal root fracture.
OR

Apical root fracture. Middle root fracture. Coronal root fracture.

Splinting

Rigid splinting for 2-3 months.

Root fracture continues

Types of repair or healing

Calcific union (osteoid material) Bony union + connective tissue Fibrous repair (connective tissue) Granulation tissue interposition

Review of root fractured teeth

Should be reviewed after 1 month, then 3 months and subsequently at 6-monthly intervals for at least 2 years. Reviews should include vitality tests and radiographs.

Pulp necrosis is suggested on radiograph as:

Widening of the fracture line. Loss of lamina dura. Widening of the periodontal membrane space. Bone loss at the level of the fracture line.

Usually only coronal portion involved. Calcium hydroxide used to form a barrier for conventional root canal filling.

Splinting
Necessary functions of splint:

To immobilize the loosened teeth. To hold repositioned teeth in alignment and to protect the damaged structures from further trauma. To hold a dressing over exposed dentine.

Properties of a good splint

1.
2. 3.

4.
5. 6.

7.
8.

Should be non-toxic. Good retention (stable to last for the time needed + strength). Easy to construct, apply & cheap. Easy to remove and should not damage the enamel. Should not interfere with occlusion. Should not interfere with endodontic treatment. Should not accumulate plaque and should not cause periodontal disease and caries. Esthetics should be good.

Different types of splints

1.
2. 3. 4. 5.

Simple Acid-Etch splint.

Acid-Etch splint with wire insert. Acid-Etch splint with ortho brackets. Full coverage splint or cap splint. Foil splint.

Concussion

Usually front teeth are involved. Child may complain that the front teeth hurt when he tries to eat.
Vitality tests usually negative. May take 6-8 weeks to reverse.

Treatment:

Usually no treatment is necessary. Reassure the parents and soft diet for a few days. If vitality tests negative after 8 weeks, start pulp treatment. As vitality tests are not reliable, start pulp treatment without LA. If patient respond while touching ADJ,it means tooth is vital. Give calcium hydroxide lining & composite repair.

Subluxation
Treatment:

If slightly mobile, no active treatment. Soft diet for a few days. Not to play with the tooth and no testing for looseness. Healing take place in 1-2 weeks.
If there is marked loosening, splint the tooth for 2-3 weeks.

Intrusion
Treatment:

Re-eruption potential of immature teeth is taken into account. Leave the tooth initially to re-erupt for 1 month. If no re-eruption, then orthodontic extrusion of the tooth and simultaneous root canal treatment.

Extrusion
Treatment

Grasp the tooth with finger and thumb. Gently push the tooth back into its original position. Splint for 2-3 weeks.

Lateral displacement
Treatment:

Reposition the tooth. Splint for 3-4 weeks (because bone is involved).

Recent displacement Delayed presentation

Review of displacement injuries

Review regularly. Initially after 1 month, then after 3 months and subsequently

at 6 monthly intervals for at least 2 years.

Reviews include vitality tests and radiographs.

Pulp necrosis is the most common complication following a

displacement-type injury.

Avulsion (ex-articulation)
Avulsion is common in immature teeth because:

Root is partially formed. Alveolar bone is more elastic.

Prognosis following re-implantation

Depends upon three factors: 1. Time 2. Storage 3. handling

Emergency management outside the surgery

Attendance at the surgery

Treatment planning:
Following avulsion, three possible courses of treatment:

Re-implantation of the tooth. Maintenance of the space by a prosthesis or bridge.

Closure of the space by orthodontic means.

Factors to be considered before any decision is made about the appropriate treatment

Prognosis following re-implantation. Medical and dental history. Orthodontic status.

Method for Re-implantation

Management of Root Resorption

Loss of the incisor

Maintenance of space by a prosthesis. Closure of the space by orthodontic means.

Sequelae of displacement injuries

Greater chance of loosing vitality with intrusion, extrusion and lateral luxation. Much more chances with avulsion. Most commonly occur:
1. 2. 3.

Necrosis of pulp (loss of blood supply). Pulp canal obliteration (may be partial or full). Commonly occur in immature traumatized teeth because of more reparative capabilities. Root resorption.

External root resorption

Surface resorption Inflammatory resorption Replacement resorption Burrowing root resorption (resorption at cervical part. Retract the tissue and fill the gap). Inflammatory resorption Replacement resorption

Internal root resorption

4. 5.

Ankylosis of the tooth. Loss of marginal bone support. 10% of luxated teeth show this problem.

Fracture of maxilla, mandible, alveolar process etc need immobilization of these bones. Lacerated wound in gingiva or oral mucosa or other soft tissues need suturing.

Antibiotics and analgesics may be prescribed.

Trauma to the primary teeth

Trauma to the primary teeth

Types of injuries limited. Limited treatment. Injuries commonly occur during toddler age (1.5-3 years). Usually luxation injuries because bone is thin and elastic. Sometimes crown or root fracture. Maxillary incisors commonly involved. Radiographs (periapical) valuable especially in case of intruded teeth.

concussion

This is the simplest type of injury where a small child has walked into something or has fallen, traumatizing the anterior teeth.
Frequently no signs of the injury except for evidence of minor soft tissue damage. Child may complain that his mouth is sore or that the front teeth hurt when he tries to eat.

Treatment:

Usually no treatment is necessary.

Reassure the parents and soft diet for a few days.

Subluxation

Physiological mobility must be taken into account when diagnosing subluxation in the primary dentition. Traumatized teeth will be loose and there may be evidence of haemorrhage at the gingival margin due to the damaged periodontium. Teeth may be tender to touch and during eating.

Treatment:

Usually no treatment is necessary. Reassure the parents and soft diet for a few days. The teeth usually tighten up after about 1 week.

Remember NO splinting in primary teeth.

Displacement
Displacement occurs either labially or palatally. In palatal displacement, the displaced teeth may interfere with

occlusion.

Treatment:
Options are either to leave the traumatized teeth or to extract.

If palatal displacement and the displaced teeth do not interfere with occlusion, no treatment is required. If interfere with occlusion, then extraction. If labial displacement, extraction of the displaced teeth. If the tooth is so loose that there is danger of inhalation, then extraction. Parents advised to maintain fluid intake, soft diet and gentle brushing is recommended.

Intrusion
Intrusion is common and the tooth may not be visible.

Radiograph to confirm the presence of the tooth.

No serious discomfort to the child.

Treatment:

Wait and see policy because the intruded primary incisors commonly re-erupt and reposition themselves over a period of a few weeks. If no re-eruption, then extraction.

Extrusion
If a primary tooth is extruded, extraction. No repositioning and splinting.

Avulsion
If a primary tooth is avulsed, NO re-implantation.

Crown fracture
Coronal fracture rare unless the teeth are very carious.

Treatment:

Treatment limited by the childs cooperation. If no pulp exposure, treatment restricted to smoothening any sharp edges or composite restoration in a cooperative child. If pulp is exposed, extraction in uncooperative child and pulp treatment in a cooperative child.

Root fracture
Splinting of root-fractured primary teeth NOT practical.

Treatment:

Tooth not displaced and only slightly mobile, leave it to tighten up itself. Coronal fragment displaced or is very mobile, extraction. No removal of apical portion, as this usually undergoes physiological resorption. Removal could damage the permanent successor.

Post-trauma complications OR Sequelae of injuries to the primary teeth

1. Colour change or discolouration. The traumatized primary tooth may become bluish gray or yellow. Abscess formation, sinus formation, radiolucent area periapically. The most common complication is that the tooth becomes non-vital. 3. Tooth may become loose.

2.

Sequelae of injuries to the primary teeth continues

4.

Injury to the developing permanent teeth. Frequency is 12-69%. a.

b. c. d. e. f. g. h. i. j. k. l. White or yellow brown discolouration Enamel hypoplasia Crown dilaceration Root dilaceration Root duplication Rotation of permanent tooth germ Partial or complete arrest of development of permanent tooth germ due to infection etc. Odontome-like malformation Follicular cyst formation Dentigerous cyst formation sequestration of permanent tooth germ Disturbance in eruption or ectopic eruption of permanent tooth because of:
Retention of primary tooth Displacement of primary root apex Infection. Odontoclasts cant get access to root (very unusual). Ankylosis of primary tooth

Prevention of trauma to teeth

Primary prevention Secondary prevention

Primary prevention
Commonest cause of tooth injury in children is falling on a hard surface. So the following precautions may be taken:

Equipment in play areas for pre-school children should be designed for soft landings.
Impact absorbing safety surfacing or tree-bark chippings. Supervision of small children at play is important.

Two areas where paedodontist can help:

1. 2.

The early treatment of large overjets. The provision of well-fitting mouthguards for use in sports.

Early treatment of large overjets

Uncrowded arches
Functional appliance and extra-oral traction. Both work best during active growth periods.

Crowded arches

Extraction of primary canines and overjet reduction. Relief of crowding in the permanent dentition by extraction and arch realignment with fixed appliances.

Lengthy treatment and problems may arise. So there must be proper diagnosis, preferably by an orthodontist.

Provision of Mouthguards in sports

About 10% of the total dental injuries occur in sports. The injuries usually result from collision with opponent or a blow

from equipment,e.g; hockey sticks, cricket balls etc.

In majority of cases upper incisors are affected. Mouthguards should be used by all children involved in contact

sports (not only by those with overjet and incompetent lips).

Types of Mouthguards
1. Stock (latex rubber or Polyvinyl chloride)

2.
3.

Mouth-formed (Polyvinyl acetate polyethylene copolymer)

Custom-made (Polyvinyl acetate polyethylene copolymer)

Secondary prevention

Reducing the complications of trauma by prompt intervention can have a secondary preventive effect.
In coronal fractures, exposed dentine should be covered as soon as possible. No excuse because of advances in acid etch technique and dentine bonding agents. Apexogenesis in vital young permanent teeth and apexification in nonvital young permanent teeth with non-setting calcium hydroxide has made treatment easier for traumatized teeth. Reimplantation of the avulsed teeth should be attempted as soon as possible after the injury and carry a reasonable prognosis.

Thank You