Dental Trauma in Permanent Dentition

Why do we want to know where the injury occurred?

• Legal implications for the patient

• Possibility of contamination

Why do we want to know how the injury occurred?

• Identification of the impact zones (i.e. a chin injury is often combined with crown or crown-root fractures in premolar and molar regions.)

• Possibility for condyle fracture

Why do we have to know when an injury occurred?

For avulsion the extent of time and the extra oral storage condition becomes very decisive for later treatment

Why do we have to know if there was a period of unconsciousness?

if yes, for how long. Amnesia, nausea and vomiting are all signs of brain damage and require medical attention

Why do we have to know if there is any occlusal interferences?

to detect luxation injury with displacement, and alveolar or jaw fracture or a fracture of the condylar region

Neurological examination, what should we check?

Cranial Nerve III (oculomotor) → pupil reaction to light/ptosis

PERRLA

PERRLA (Pupils equal, Round, Responsive to light & Accommodating)

Cranial nerve evaluation: what do we check?

• extraocular muscles (should be intact and functioning appropriately; patient can track a finger moving vertically and horizontally)

• pupils (PERRLA: Pupils equal, round, responsive to light & accommodate)

• sensory function (should be normal as measured through light contact to various areas of the face)

• symmetry of motor function (as assessed by having the patient frown, smile, move the tongue, and perform several voluntary muscular movements)

Infraction (types of trauma, hard tissues, percussion/palapation/mobility, pulp vitality tests, radiographic findings, types of treatment)

• Infraction: an incomplete fracture (crack) of the enamel

• Hard tissues (visible incomplete fracture line on the tooth surface)

• Percussion/palpation/mobility: no if tenderness, luxation injury or root fracture

• Pulp vitality tests: usually positive, transient plural damage

• Radiographic findings: none (no x-rays needed for primary teeth)

• Type of tx: severe infraction: etch and resin placement, mild-moderate infractions: no tx is needed

Enamel fracture (types of trauma, hard tissues, percussion/palapation/mobility, pulp vitality tests, radiographic findings, types of treatment)

• Type of trauma: enamel fracture: confined to the enamel with loss of tooth structure

• Hard tissues: visible loss of enamel and no exposed dentin

• Percussion/palpation/mobility: no if tenderness, possible luxation injury or root fracture

• Pulp vitality test:: usually positive, lack of response: transient pulpal damage

• Radiographic findings: visible enamel loss (no x-rays needed for primary teeth), might reveal tooth fragments inside soft injured tissues (missing fragments)

• Types of tx: depended on the extent and location of the fracture (grinding, bond tooth fragment, resin restoration)

Enamel-dentin fracture (definition, hard tissues, percussion/palapation/mobility, pulp vitality tests, radiographic findings, types of treatment)

• Type of trauma: enamel-dentin fracture: confined to enamel and dentin with loss of tooth structure

• Hard tissues: visible loss of enamel & dentin without pulp exposure

• Percussion/palpation/mobility: No if tenderness, possible luxation injury or root fracture

• Pulp vitality test: usually positive, lack of response: transient pulpal damage

• Radiographic findings: visible enamel-dentin loss. Might reveal tooth fragments inside soft injured tissues (missing fragments), evaluation of the distance between fracture and pulp, x-ray optional for primary teeth

• Types of tx: if dentin is 0,5 mm from pulp (pink but not bleeding) (calcium hydroxide lining, cover with glass ionomer), minor fractures (glass ionomer sealing), large fractures (composite restoration), if the tooth fragment is available and intact (rehydrated in saline or water for 20”, bond the fragment)

Enamel-dentin-pulp fracture (definition, hard tissues, percussion/palapation/mobility, pulp vitality tests, radiographic findings, types of treatment)

• Type of trauma: enamel-dentin-pulp fracture: confined to enamel and dentin with loss of tooth structure and pulp exposure

• Hard tissues: visible loss of enamel & dentin with pulp exposure

• Percussion/palpation/mobility: no, if tenderness, possible luxation injury or root fracture

• Pulp vitality test: positive, if negative increased risk of pulp necrosis, exposed pulp is sensitive to stimuli like air, cold, sweets

• Radiographic findings: visible enamel-dentin loss and exposed pulp, might reveal tooth fragments inside soft inured tissues (missing fragments)

• Types of tx: treatment according to the size of pulp exposures, small to moderate: pulp capping with calcium hydroxide or non-staining calcium silicate cement; large: cervical pulpotomy (1-2mm) or partial pulpotomy; cover pulp capping material with GIC; composite restoration or tooth fragment bonding if post is needed (mature tooth with complete root): RCT

What are the TDI we should refer to a specialist?

• Crown-root fracture without pulp involvement

• Criwn-root fracture with pulp involvement

• Root fracture

• Alveolar fracture

What are the diff tx options for an enamel fracture?

• grinding

• bond tooth fragment (if dray: rehydrate 20 min)

• resin restoration

Follow up - Enamel fracture

• 6-8 weeks

• 1 year

Do we use the EPT test in an 11 yo pt?

No, only cold test

Mum: is the tooth going to be ol (enamel fracture)

You: …?

Say: for now the tooth is ok, but we have to check it for the first 5 years follwing the tx. The teeth might get necrosis in 2 years (most likely in the first 2 years)

why don’t we use MTA for indirect pulp capping

might cause discoloration

Procedure enamel-dentin fracture without pulp involvement (emergency treatment)

• extra and intra oral examination

• check for brain injury

• take xray (to check if root fracture, splint if yes)

• coronal sealing of dentin with flowable composite or glass ionomer cement

enamel dentin fracture, tx option

depending on the size of the exposure and the need for a post to restore

• pulp capping <1mm

• partial pulpotomy

Material used for pulp capping

• calcium hydroxide

• Non staining calcium silicate cement

Follow up - Enamel-dentin-pulp fracture

• 6-8 weeks

• 12 weeks

• 6 months

• 1 year

Intraoral exmaination : Enamel-dentin-pulp fracture

Clinical tests:

• pulp sensibility (cold) test: positive

• palpation: tender

• mobility: normal

• tender to percussion

• Examine whole mouth: dental trauma rarely occurs in one tooth

Crown-root fracture without pulp involvement(def, hard tissues, percussion/palpation/mobility, pulp vitality test, radiographic findings, tx)

• Type of trauma: Crown-root fracture without pulp involvement

• Hard tissues: crown fracture extending below the gingival margin. Crown is split to 2 or more fragments

• Percussion/palpation/mobility: tenderness, pain during mastication, mobile

• Pulp vitality test: usually positive for the apical fragment

• Radiographic findings: visible extend of fracture in relation to the gingival margins only in laterally positioned fractures. Apical extension usually not visible. Might reveal tooth fragments inside soft inured tissues (missing fragments)

• Types of tx: referral

Crown-root fracture with pulp involvement(def, hard tissues, percussion/palpation/mobility, pulp vitality test, radiographic findings, tx)

• Type of trauma: Crown-root fracture with pulp involvement

• Hard tissues: crown fracture extending below the gingival margin with pulp involvement

• Percussion/palpation/mobility: tenderness, pain during mastication, mobile

• Pulp vitality test: usually positive

• Radiographic findings: visible extend of fracture in relation to the gingival margins only in laterally positioned fractures. Apical extension usually not visible. might reveal tooth fragments inside soft injured tissues (missing fragments)

• Types of tx: referral

Root fracture (def, hard tissues, percussion/palpation/mobility, pulp vitality test, radiographic findings, tx)

• Type of trauma: root fracture: confined to the root of the tooth involving cementum, dentin and pulp

• Hard tissues: a fracture of the root involving cement, dentin, pulp. The fracture might be horizontal, oblique or a combination of both.

• Percussion/palpation/mobility: tenderness, coronal segment is usually mobile and maybe displaced

• Pulp vitality test: usually, negative (transient or permeate neural damage). If positive better prognosis

• Radiographic findings: fracture line might be located at any level of the root. Middle or apical fractures might be undetected without additional imaging.

• Types of tx: referral

Alveolar fracture (def, hard tissues, percussion/palpation/mobility, pulp vitality test, radiographic findings, tx)

• Alveolar fracture: (which may or may not include the alveolar bone socket)

• hard tissue: complete alveolar fracture from the labial to the palatal/ lingual bony surface, and occlusal interference might occur.

• Percussion/ palpation/ mobility: tenderness, several teeth will move as a unit, Occlusal interference

• Radiographic findings: might be located at any level of the root. Vertical line of fracture might run along the PDL or in the septum may run at any level. Horizontal fracture line.

• Tx: referral to a specialist

C-R-F wo P involvement

• crown fracture extending below the gingival margin

• crown split in 2 or more fragments, at least one mobile

• Percussion: + tenderness

• Mobility: at least one fragment mobile

• pulp sensibility: + positive for the apical fragment

• pain: + during mastication

• radio: apical extension of the fracture in relation to bone level & gingival margin

C-R-F with p involved - Immature teeth tx

Partial pulpotomy

C-R-F with p involved - Mature teeth tx

RCT

C-R-F with p involved - Follow up

• 1 week

• 6-8 weeks

• 12 weeks

• 6 months

• 1 year

• yearly

RF clinical and radio exam

• percussion: + tenderness

• mobility: coronal segment (might be displaced)

• Pulp sensibility: - usually, + better prognosis, + during mastication

• Pain: transient, reddish or grayish

• radio: fracture location

RD - tx

• if coronal segment avulsed, use the instruction for avusleed

• if coronal segment displaced, reposition it as soon as possible

• check the correct placement

• splint for 4 weeks up to 4 months (cervical area)

• monitor healing

• if pulp necrotic, RCT of the coronal segment and maybe apexification

• Follow up: 4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, yearly

AF

• percussion: + tenderness

• mobility: entire segment mobile, moves as a unti

• pulp sensibility: - usually

• displacement: alveolar segment, occlusal change/ interference

• radio: a) vertical line of fracture might run along the PDL or in the septum. b) horizontal fracture line may run at any level

AF management

• clean the area with water spray, saline or chlorehexidine

• suture any gingival lacerations

• splint for 4 weeks

• monitor teeth in the fracture line

• follow up: 4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, yearly

abrasion

A superficial wound produced by rubbing or scraping of the skin or mucosa leaving a raw, bleeding surface.

contusion

A bruise without a break in the skin or mucosa. Subcutaneous

or submucosal hemorrhage in the tissue, a contusion may be isolated to the

soft tissue but may also indicate an underlying bone fracture.

laceration

A shallow or deep wound penetrating into the soft tissue,

usually produced by a sharp object. May disrupt blood vessels, nerves,

muscles, and involve salivary glands. Most frequently seen in lips, oral mucosa, and gingiva. More seldom the tongue is involved.

soft tissue avulsion

Avulsion (loss of tissue) injuries are rare but seen with bite injuries or as a result of a very deep and extended abrasion.