2. introduction-
• Dentoalveolar injuries are those injuries
involving the teeth, the alveolar portion of
the maxilla and mandible, and the adjacent
soft tissues. They are among the most
serious dental conditions.
Examples of such injuries include the avulsion
of teeth, fractures of the teeth, fractures of the
alveolar process, and lacerations of the soft
tissue.
3. HISTORY
Hippocrates of Cos , was the first to
document
treatment regiemes for dentoalveolar
traumas in
his writings . He was the one who alluded
various
splinting techniques as well as to expedit
healing
process.
4. ETIOLOGY AND INCIDENCE :
Common in
Pediatric-Falls during 1st years of life
Teenage-contact sports ,background activity ,
Adults - motor vehicle accidents, contact sports, altercations,assaults,
industrial accidents and iatrogenic medical and dental misadventures
Child abuse is one of the significant etiology causing dentoalveolar
trauma.
PREVALANCE:
Primary dentition – 11 – 30 %
Permanent dentition – 5 to 20 %
SEX RATIO:
Mem :women – 2:1
5. Other groups at increased risk :
• Seizure disorders
• Mental disorders
•Congenital abnormalities
Trauma can be
•Direct – most commonly affected teeth is Maxillary centrals
(class II division 1 is more prone for such trauma)
Primary dentition – Luxation occurs more
commonly(75%)
Permanent dentiton – Crown/crown-root fracture
(39%)
•Indirect –Forceful impact in the chin may trasmit the forces
to
the posterior teeth
6. HISTORY :
•Preinjury data – biographic
-
demographic
•Past Medical History
•Time of incident
•Occlusion
•Location of incident
•Loss of consiousness
•Nature of incident
PHYSICAL EXAMINATION:
Check for
- potential for aspiration
-Airway compromise
-Neurosensory deficit
9. CLASSIFICATIONS:
Two commonly used classifications are
-Ellis and Davey’s classification
-Andersons classification- Adopted by WHO
Ellis and Davey’s classification(1960):
Class I - Simple fracture of the crown involving only enamel with little
or no
dentin.
Class II - Extensive Fracture of crown involving considerable dentin but
not
exposing dental pulp.
ClassIII - Extensive fracture of crown involving considerable dentin and
exposing dental pulp.
Class IV - Traumatized tooth that becomes non-vital.
Class V - Total tooth loss-Avulsion.
Class VI - Fracture of the root with or with out loss of crown structure.
Class VII - Displacement of tooth with neither crown or root fracture.
ClassVIII - Fracture of crown en masse and its displacement.
Class IX - Traumatic injuries of primary teeth.
10. Anderson’s classification:
• Injuries to hard dental tissues and Pulp:
1. Enamel infarction
2. Enamel fracture
3. Enamel-Dentin fracture(uncomplicated crown fracture
4. Complicated crown fracture
5. Uncomplicated crown root fracture
6. Complicated crown root fracture
7. Root fracture
• Injuries to periodontal tissues:
1. Concussion
2. Subluxation
3. Extrusive luxation(peripheral dislocation,partial avulsion)
4. Lateral luxation
5. Intrusive luxation(central dislocation)
6. Avulsion (exarticulation)
• Injuries to supporting bone:
1. Comminution of mandibular or maxillary alveolar socket
2. Fracture of maxillary or mandibular socket wall
3. Fracture of maxillary or mandibular alveolar process
• Injuries to gingiva or oral mucosa:
1. Laceration of gingiva or oral mucosa
2. Contusion of gingiva or oral mucosa
3. Abrasion of gingiva or oral mucosa
11. MANAGEMENT OF DENTOALVEOLAR
INJURIES
ENAMEL INFARCTIONS:
• Very common
• Appear as crazing within the enamel which do not
cross the dentino-enamel junction and appear with
or without loss of tooth substance.
• Caused by direct impact
• Patterns of infarction lines depends on direction and
location of trauma
• Seen by – visualizing along the long axis of the tooth from
the incisal edge
- Fiberoptic light sources
- Transillumination
12. ENAMEL FRACTURE:
Clinical feature:
•More common in both primary and permanentdentition
then the complicated fracture
•Confined to a single tooth
•Common in maxillary region
Treatment:
•Restoration with composite resin after corrective grinding and
removal of sharp edges
13. UNCOMPLICATED CROWN FRACTURE:
Clinical feature:
•Dentin exposed after crown fracture often gives rise
to sensitivity to thermal changes and mastication
•Careful search for any minute pulp exposure to be
done during examination .
Treatment:
•Immediate provisional treatment :
Placement of calcium hydroxide paste on the exposed
dentin and restore
•Permanent treatment:
Restoration with composite resin or full coverage crown
14. COMPLICATED CROWN FRACTURE:
Clinical fracture:
•Occurs when there is a fracture of enamel ,dentin
along with exposure of pulp .
•Usuallypresents as a fractured segment of the tooth
with frank bleeding from exposed pulp.
Treatment:
Treatment depends upon the extent and time of pulp exposure
• When the exposure is small , which is not exposed for more than
4-5 minutes then it is advisable to do pulp capping .
• When the exposure is large , and is exposed for
more than 5 minutes – pulpotomy(pulp is vital)
Apexification(pulp is necrotic)
Endodontic treatment(pulpectomy)
15. CROWN –ROOT FRACTURE:
It is defined as the fracture involving enamel,dentin
and cementum .Can be either complicated or
uncomplicated fracture.
Anterior crown fracture – direct trauma
Posterior crown fracture- indirect trauma
Clinical feature:
•Fracture lines begins few millimeters incisal to marginal
gingiva or to the facial aspect of the crown (in an oblique
course below the gingival crevice )
Treatment :
Emergency treatment- acid etch split
Definitive treatment-( Before deciding the treatment the fractured fragment
to be removed to evaluate the apical extent of the
fracture)
Uncomplicated with out pulp exposure – restorable
Complicated fracture – may require RCT or extraction of root fragment
16. ROOT FRACTURE
It is the fractures involving dentin,cementum and pulp.
Mechanism of Root fracture – Frontal impact.
Clinical feature:
• Commonly seen in maxillary central incisor region
in age group of 11 to 20 years
• Coronal fragments are displaced lingually or slightly extruded
• Temporary loss of sensitivity.
Radiographically:
1. Radiolucent oblique line which is most often visible only if the
central beam is directed with in maximum range of 15-20°
CLASSIFICATION:
1.CORONAL THIRD ROOT FRACTURE
2.MIDROOT FRACTURE
3.APICAL THIRD ROOT FRACTURE
17. Coronal root fracture
Fracture in the
cervical segment
were considered to
have poor prognosis .
Treatment –
extraction of tooth
18. Mid root fracture
Prognosis and treatment plan depends on follo
wing factors
1.Position of the tooth after root fracture
2.Mobility of the coronal segment
3.Ststus of the pulp
4.Position of the fracture line.
Treatment options-1.root canal therapy of both
segments,when the segments are not separated
2.Root canal therapy of coronal segment and
removal of apical segment,when the segments are
separated.
3.Use of intra-radicular splint,eg-rigid type post to
stabilize the two root segments.
4.Root canal treatment of the coronal segment and
no treatment of apical one,when the apical segment
is vital
19. Apical third root fracture
Prognosis is favorable becouse pulp
in apical segment usually remains
vital.
If pulp of coronal segment is non
vital –rct can be done.
If tooth fails to recover,apical,
segment can be removed
surgically.
20. VERTICAL ROOT FRACTURE( Cracked tooth syndrome )
It runs lengthvise from crown towards the apex .
Etiology – mostly iatrogenic.
Clinical Features:
•Persistant dull pain of long standing origin .
•Pain is elicited by applying pressure
Radiographic Feature:
•If the central beam lies in the line of fracture it is visible
as a radiolucent line
•Widening of PDL
Treatment:
•Single rooted teeth- extraction
•Multiple rooted teeth- Hemisection and remaining tooth is
endodontically treated and restored with crown.
21. Healing patterns
1.Healing with calcified tissue-fracture line is discernible on
radiograph.
2.Healing with interproximal connective tissue-fracture
fragments appear
Separated but fracture edges appear rounded
3.Healing with interproximal connective tissue and bone-
fragments are separated by a distinct ridge.
4.Interproximal inflmmatory tissue without healing
(granulomatous tissue)
-widening of fracture line
22. CONCUSSION (Sensitivity)
An injury to the tooth supporting structure,when there
is some crushing injury to apical vasculature
periodontal ligament with resultant inflammatory edema
with marked reaction to percussion but no abnormal
loosening or displacement.
Clinical feature:
•Traumatized tooth has pain on percussion
•Sensitivity during masitication.
Radiographically :
•Widening of periodontal ligamen space apically.
•Reduction in size of pulp after a few months
Treatment:
•Sensitivity – symtomatic relief
- relieving the tooth from occlusal contact.
23. SUBLUXATION (MOBILITY, LOOSENESS)
An injury to tooth supporting structures with abnormal
loosening but with out clinically or radiographically
demonstrable displacement of the teeth.
Clinical feature:
• Tooth is tender on palpation
• Mobility
• Evidence of hemorrhage at gingival margin
Radiographically:
• Widening of PDL space
• Reduction in the size of the pulp after few months
Treatment:
• Adjustment of occlusion
• Splinting for 10 days
24. INTRUSIVE LUXATION
Displacement of the tooth into alveolar bone.
Clinical feature:
•Displacement with fracture or crushing of alveolar bone.
•Mobile tooth
•Gingival bleeding
•Metallic sound with pain on percussion
•Pain on mastication
•Clinically crown appeas shorter.
Radiographic feature:
•Obliteration of apical portion of PDL space
•Crushiong of lamina dura
Treatment:
• Mostly involves orthodontic or surgical repositioning of the
tooth
• Stabilization using splits for 2-3 weeks after
tooth has come to normal or original position
25. EXTRUSIVE LUXATION:
It is also called peripheral displacement or partial avulsion.
It is partial dispacement of tooth out of its socket.
Clinical feature:
•Crown appears longer
•Mobile tooth
•Gingival bleeding
•Pain on percussion.
Radiographically:
•Widwning of PDL
Treatment :
•Repositioning of tooth in normal position using digital
pressure.
•Splint the tooth for 2-3 weeks
26. LATERAL LUXATION
Displacement of the tooth in any direction other than axial.
Clinical features:
•Tooth is mobile and displaced
•Gingival bleeding
•Pain on percussion and mastication
Radiographically:
•Widening of the PDL space on one side and crushing of lamina dura on
other side
Treatment:
1. Repositioning of tooth followed by splinting for 2-3 weeks
27. AVULSION: (Exarticulation)
Complete displacement of tooth from its alveolus .
Clinical features:
•Bleeding socket with missing tooth
Radiographic features:
•Empty socket
•Associated bone fractures
•If the wound is recent then lamina dura is visible
Treatment:
The factors most important for determining the prognosis of the treatment ar
- the length of time the tooth has been out of the socket(sooner the better)
-Periodontal tissues
-The manner in which the tooth is preserved
28. REIMPLANTATION
The following conditions should be considered before reimplanting a
permanent tooth:
•The alveolar socket should be reasonably intact in order to provide
seat for the avulsed tooth .
•The extra alveolar period
-Short
- Long
Storage medium:
•Hank’s balanced salt solution(HBSS)
•Milk
•Saliva
•Saline
Follow up: Minimum of 1 year
Complication : Root resorption
Prognosis:
1. Tooth survival -51 to 89 %
2. PDL healing - 9 to 50 %
3. Pulp healing - 4 to 15 %
29. PROCEDURE:
The tooth is placed in saline
If contaminated ,the root surface is cleansed with stream of saline
The socket is examined for evidence of fracture.The alveolus is also cleansed
with a flow of saline to remove contaminated coagulum
Tooth to be reimplanted using slight digital pressure with light pressure. The
reimplanted tooth should fit loosely in the alveolus
Suture gingival laceration
Apply splint for 1 week only as prolonged splinting of replanted tooth
causes root resorption
Proper repositioning can now be evaluvated by the occlusion of tooth
Verify position radiographically
Tetanus prophylaxis is important
and tetracycline twice a day for
2 week
If apical foramen is closed then perform endodontic therapy after one week
prior to removal of splint
30. STABILIZATION PERIODS FOR DENTOALVEOLAR
INJURIES
DENTOALVEOLAR
INJURY
DURATION OF
IMMOBILIZATION
Mobile tooth
Tooth displacement
Root fracture
Replanted tooth (mature)
Replanted tooth(immature)
7-10 days
2-3 weeks
2-4 months
7-10days
3-4 weeks
31. METHODS OF IMMOBILISATION
SPLINTING:
It is the method of fixation is the best for treating both
dentoalveolar fracture and subluxed teeth .
Splints provide excellent immobilization and have additional
advantage that when teeth have had their crown fractured , the
splint is able to retain sedative dressing in place and provide good
protection for the traumatized tooth.
Types splinting:
•Foil /cement splint:
It is an emergency procedure , it is possible to mould a splint
using either protective lead foil from an xray pack or thin tinfoil.
It can be gently manipulated over both the subluxed tooth
and adjuscent firm tooth.
Rigidity can be gained using double thickness foil and
cemented using cold cure resin.
32. Cold-cure acrylic splint:
The material is moulded in situ with fingers to provide
temporary splinting of the subluxed tooth .
Enamel bound composite resin splint:
Hall in 1983 recommends for fixation of dentoalveolar
fracture of maxilla or mandible following repositioning
or reimplatation of the teeth.
Composite resin/acrylic resin and wire splint:
This technique is used as a rigid splint by incorporating two
adjuscent healthy teech on either side of injured teeth.
Orthodontic brackets and wires:
Used for displacement injuries and exarticulation .
They have an advantage of allowing more accurate
reduction of injury ny gentle forces .
33. Interdental Wiring:
Interdental wiring on a arch wire ligated to the teeth
with ligature wire should not be used except as
temporary measure , as it compromises gingival health.
Wiring techniques that can be followed are:
•Arch bars
•Loop wiring
•Figure of eight wiring
Thermoplastic splint:
Constructed from polyvinylacetate-poly ethylene in the
same way like a mouth caurd
34. Conclusion:
Dentoalveolar trauma being very common in dental practice
requires prompt treatment which aids in saving a tooth.
Treatment modalites in this modern world are very simple and very
effective provided the management is done on time .
After all “We can make a difference when it comes to teeth as well”
35. Reference:
.
• Contemporary Oral and maxillo facial surgery
- James.R.Hupp, Edward Ellis III, Myron R.Tucker.
• Text book of oral and Maxillo facial surgery
-Neelima Anil Malik
• Grossman’s endodontic practice(12th edition)
