TRAUMA DR BILAL ARJUMAND MIHS Diagnostic steps dental

TRAUMA DR. BILAL ARJUMAND MIHS

Diagnostic steps dental trauma • Medical and health history • History of the dental injury and immediate care provided • Neurologic evaluation • Clinical examination of the head and neck • Oral examination of soft and hard tissues • Radiographic examination • Photographic documentation

HISTORY • When • How • Where With time blood clots begin to form, periodontal ligaments of teeth dry out, and saliva contaminates the wound Locating specific injuries, and cause will give info about severity Prophylactic tetanus toxoid, insurance and litigation

Clinical Examination Chief Complaint • Pain and bleeding • Don't fit together now • Pain on closure Possible displacements or a bone fracture Crown, root, or bone fractures Neurologic Examination • Head and neck injuries? • Patient is communicating? • Ringing in the ears? • Paresthesia of the lips or Tongue? • Referred immediately for appropriate medical treatment. External Examination • External signs of injury • Lacerations of the head and neck • (TMJ) should be palpated externally while the patient opens and closes. • Zygomatic arch, angle, and lower border of the mandible palpated and note made of any areas of tenderness, swelling, or bruising of the face, cheek, neck, or lips for possible bone fractures.

Clinical Examination Cont…. Hard-Tissue Examination • After visual examination and abnormal findings are noted, radiographs of the injured areas should be taken Thermal and Electric Tests • Traumatized tooth vulnerable to false negative readings from these test • Conduction capability of the nerve endings or sensory receptors or both is sufficiently deranged to inhibit the nerve impulse from an electric/thermal stimulus • Teeth that yield a negative response (or no response) cannot be assumed to have necrotic pulps, because they may give a positive response later • Transition from a negative to a positive response at a subsequent test may be considered a sign of a healthy pulp • The persistence of a negative response would suggest that the pulp has been irreversibly damaged • Tests should be repeated at 3 weeks; 3, 6, and 12 months; and at yearly intervals after the accident Radiographic Examinations • Root fractures, subgingival crown fractures, tooth displacements, bone fractures, or foreign objects • Soft-tissue laceration it is advisable to radiograph the injured area before suturing to be sure that no foreign objects have been embedded

PREVENTION OF DENTAL INJURIES Face Guards • Cage-type guards attached to helmet • Face guards of clear polycarbonate plastic Mouth Guards • Stock mouth guard • Boil-and bite mouth guard • Custom-made mouth guard

CLASSIFICATION OF INJURY TO DENTAL TISSUE • Enamel Infraction Uncomplicated Crown Fracture • Enamel Dentine Fracture • • Complicated Crown Fracture Uncomplicated Crown Root Fracture Complicated Crown Root Fracture

The Ellis Classification 1. Enamel Fracture 2. Dentin Fracture without Pulp Exposure 3. Crown fracture with Pulp Exposure 4. Root Fracture 5. Tooth Luxation 6. Tooth Intrusion

INJURIES TO PERIODONTAL TISSUE • Concussion No loosening but pain on percussion • Subluxation Abnormal loosening but no displacement • Extrusive Luxation Partial displacement from socket • Lateral Luxation Displacement other than axially with communication or fracture of alveolar socket • Intrusive Luxation Displacement into alveolar bone with communication or fracture of alveolar socket • Avulsion Complete displacement of tooth from socket

Injuries to Gingiva or Oral Mucosa • Laceration Wound in mucosa resulting from Tear • Contusion Bruise not accompanied by break, causing sub mucosal haemorrhage • Abrasion Superficial wound results from rub or scrap

CROWN INFRACTION • A crown infraction is an incomplete fracture of enamel without loss of tooth structure. Biologic Consequences: • "weak points" through which bacteria and their byproducts can travel Diagnosis and Clinical Presentation: • Indirect light or transillumination • Routine examination Treatment • involves establishing a baseline pulp status with routine sensitivity testing. Follow-Up • The clinician should schedule follow-up examinations at 3, 6, and 12 months and annually thereafter.

Photograph of traumatized tooth illuminated with a resin curinglight. Enamel craze lines are clearly visible

UNCOMPLICATED CROWN FRACTURE • An uncomplicated crown fracture is a fracture of the enamel or the enamel and dentin without pulp exposure. • If the fracture involves the enamel only, the consequences are minimal • If dentin is exposed a direct pathway exists for noxious stimuli to pass through the dentinal tubules to the pulp • The reaction of the pulp depends on a number of factors, including time of treatment, distance of the fracture from the pulp, and size of the dentinal tubules

A, Uncomplicated crown fracture of the maxillary central i ncisor. B, The fractured segment is bonded to tooth after placement of a calcium hydroxide base

Maxillary right central incisor with an UNCOMPLICATED CROWN FRACTURE involving the enamel and dentin

Diagnosis and Clinical Presentation • Enamel fracture includes a superficial, rough edge that may cause irritation to the tongue or lip. Sensitivity to air or liquids (hot or cold) is not a complaint • Enamel and dentin fracture also includes a rough edge on the tooth , sensitivity to air and hot and cold liquids may be a chief complaint. • Commonly a lip bruise or laceration is present Treatment • Smooth the sharp edges and leave, if esthetically acceptable. Placing bonded composite resins may be necessary for esthetics.

Enamel and Dentin Fracture • Rx as soon as possible • A hard-setting calcium hydroxide base is placed over exposed dentinal tubules to disinfect the fractured dentinal surface and stimulate closure of the tubules, making them less permeable to noxious stimuli followed by restoration with a bonded resin technique • Fractured tooth fragment if located can be bonded to get esthetic results • If the tooth fragment is not located, a lip radiograph should be taken to ensure the fragment has not lodged in the lip Follow-Up: The clinician should schedule follow-up examinations at 3, 6, and 12 months and annually thereafter. Prognosis is good.

COMPLICATED CROWN FRACTURE • A complicated crown fracture involves the enamel, dentin, and pulp. • A crown fracture involving the pulp, if left untreated, will always result in pulp necrosis • The manner and time sequence in which the pulp becomes necrotic allows a great deal of potential for successful intervention to maintain pulp vitality

Cervical pulpotomy of an immature maxillary incisor tooth followed by pulpectomy after root formation. A, Pulpotomy is initiated. B, Six months later a hard-tissue barrier has formed and the root continues to develop. C, One year later root development is complete. D, A pulpectomy followed by a permanent root canal therapy is performed.

TREATMENT There are two treatment options (1) Vital pulp therapy comprising pulp capping, partial pulpotomy, and cervical pulpotomy (2) Pulpectomy. Choice of treatment depends on the stage of development of the tooth, time between the accident and treatment, concomitant periodontal injury, and restorative treatment plan.

CROWN AND ROOT FRACTURE • A crown and root fracture is a fracture involving enamel, dentin, and cementum. The pulp may or may not be involved • Biologic consequences of a crown root fracture are identical to an uncomplicated (if the pulp is not exposed) or complicated (if the crown is exposed) crown fracture. • Periodontal complications are also present because the fracture may encroach on the attachment apparatus

Diagnosis and Clinical Presentation • Crown root fractures are result of direct trauma that produces a chisel type of fracture • Fragments may be firm, loose • The periodontal injury causes pain on pressure and biting, and exposed dentin or pulp causes pain to air and hot or cold liquids. • Indirect light and transillumination is an effective way of diagnosing these fractures. • The "cracked tooth syndrome" in a posterior tooth is also an example of a crown root fracture

Crown and root fracture of maxillary left central incisor. A, Chisel type of fracture has resulted in multiple fragments, one of which extends below the attachment level. B, Radiograph of the same tooth.

Treatment • Injuries are treated in the same manner as uncomplicated or complicated crown fractures, with additional treatment for any attachment injury • All loose fragments are removed. • A periodontal assessment is made as to whether the tooth can be treated periodontally to allow it to be adequately restored. • Surgical access or orthodontic extrusion to the site for proper restoration of defect • Extraction if not managable

ROOT FRACTURE • A root fracture is a fracture of the cementum and dentin involving the pulp • When a root fractures horizontally, the coronal segment is displaced to a varying degree; generally the apical segment is not displaced • Pulpal circulation intact in apical segment and pulp necrosis in coronal segment • Rigid stabilization of the segments (for 2 to 4 months) will allow healing and "reattachment" of the fractured segments

Diagnosis and Clinical Presentation • Clinical presentation is similar to that of luxation injuries • Imperative to take at least three angled radiographs so that at least at one angulation the x-ray beam will pass directly through the fracture line Treatment • Repositioning of the segments in as close proximity as possible and rigidly splinting to adjacent teeth for 2 to 4 months • If a long period has elapsed between the injury and treatment, it will likely not be possible to reposition the segments

A, At this angle, no "fracture" is seen. B, The "fracture" appears complicated in nature. C, Only at this angle, the true nature of the fracture can be seen

Healing Patterns • Healing with calcified tissue-Radiographically, the fracture line is visible, but the fragments are in close contact. • Healing with interproximal connective tissue. Radiographically, the fragments appear separated by a narrow radiolucent line, and the fractured edges appear rounded. • Healing with interproximal bone and connective tissue -Radiographically, a distinct bony ridge separates the fragments • Interproximal inflammatory tissue without healing. Radiographically, a widening of the fracture line, a developing radiolucency

Healing patterns after horizontal root fractures. A, Healing with calcified tissue. B, Healing with interproximal connective tissue. C, Healing with bone and connective tissue. D, Interproximal connective tissue without healing.

Treatment of Complications 1. Coronal Root Fractures • Fractures in the coronal segment had a poor prognosis • If Reattachment of the fractured segments is not possible, extraction of the coronal segment is indicated. • The level of fracture and length of the remaining root are evaluated for restorability • If the apical root segment is long enough, forced eruption of this segment can be carried out to enable a restoration to be fabricated

2. Mid 3 rd Fracture • In almost all cases the necrosis occurs in the coronal segment with apical segment remaining vital • Endodontic treatment is indicated in the coronal root segment only unless periapical pathology • The coronal segment is obturated after a hard-tissue barrier has formed apically in the coronal segment and periradicular healing has taken place. • When both the coronal and apical pulp are necrotic, treatment is more complicated. Treatment through the fracture is extremely difficult • If healing of the fracture is completed, followed by necrosis of apical end, prognosis is much improved.

Conservative root canal treatment of the coronal and apical segments. Note the filling material in the fracture line that compromises the healing response

3. Apical root fractures • Necrotic apical segments can be surgically removed • Removal of the apical segment in midroot fractures leaves the coronal segment with a compromised attachment • Endodontic implants are used to provide additional support to the tooth

Orthodontic forced eruption of a tooth that has undergone a root fracture at the cervical bone level

INJURIES TO PERIODONTAL TISSUE • Concussion No loosening but pain on percussion • Subluxation Abnormal loosening but no displacement • Extrusive Luxation Partial displacement from socket • Lateral Luxation Displacement other than axially with communication or fracture of alveolar socket • Intrusive Luxation Displacement into alveolar bone with communication or fracture of alveolar socket • Avulsion Complete displacement of tooth from socket

Concussion • Not brought to dentist until tooth discolors • Impact force causes edema and haemorrhage in PDL • Tooth is tender to percussion (t. t. p. ) • No rupture of PDL , tooth firm in socket

Subluxation • In addition to previous findings there is rupture of some PDL fibres • Tooth is mobile in socket but not displaced

Treatment of Concussion & Subluxation • Occlusal relief • Soft diet for 7 days • Immobilisation with splint if t. t. p • CHX 0. 2% mouthwash, twice daily Little risk of pulp necrosis or resorption

Extrusive & Lateral Luxation Extrusive Luxation • Rupture of PDL and Pulp Lateral Luxation • Rupture of PDL and Pulp • Compression injury of alveolar plate Rx • LA buccal and palatal • Atraumatic repositioning of tooth with firm pressure • Functional splint 2 -3 weeks • Antibiotics age related dose of amoxicillin • CHX mouth wash • Soft diet 2 -3 weeks

Treatment • LA buccal and palatal • Atraumatic repositioning of tooth with firm pressure • Functional splint 2 -3 weeks • Antibiotics age related dose of amoxicillin • CHX mouth wash • Soft diet 2 -3 weeks • Endodontic Rx on subsequent visit depending on clinical and radio graphical examination • With severe damage more chances of resorption

Intrusive Luxation • Result of apical impact • Extensive damage to PDL and Alveolar plate • Risk of Pulp necrosis, resorption & ankylosis high 2 distinct situation exist

Open Apex: Two treatment courses for open apex intrusive luxation • Disimpact with forceps if necessary and allowed to erupt spontaniously for 2 -3 months, if no movement then start orthodontic extrusion • Disimpact and surgically reposition using functional splint for 7 -10 days , monitor pulpal status clinically and radiographically and start endo if necessary • Non setting CAOH in root canal in advocated • Once apexification is achieved obturation is done.

Closed Apex • Elective orthodontic/surgical extrusion immediately • Functional splint for 7 -10 days after extrusion • Elective RCT at 10 th day • Maintenance of Ca. OH in RC during ortho Rx • Finally obturate with GP