4. ● Traumatic dental injuries (TDIs) à
5% of all injuries.
● Most common TDIs:
Ø In permanent teeth à Crown
fractures.
Ø In deciduous teeth à Luxation
injuries.
10. 1) Examination & diagnosis
2) Medical History
3) Clinical Examination
4) Teeth & supporting
structure
11. 1) DIAGNOSIS & EXAMINATION
A)INITIAL MENTAL STATE
1.The first step to examine a patient who suffered
head injury is to assess his/her mental status.
2.This can be done by asking the patient few basic
questions about his/her name, age, current date
and location.
3.If the patient can answer without confusion or
hesitation, then assumption can be made that
mental status is not affected and the examination
procedures can be proceeded.
12. 1) DIAGNOSIS & EXAMINATION
B)CHIEF COMPLAIN:
- Patient history is initiated by patient chief complain and recorded in the patient’s own
words
- Next, History of present illness should be explored as follows:
13. 1) DIAGNOSIS & EXAMINATION
B)CHIEF COMPLAIN:
Case
History
When
Where
How
1. Road traffic accidents
2. Falls
3. Sports injuries
(mechanism & force delivered
implies type of injury to expect)
Time between injury and
presentation
(influence the prognosis)
Outdoor or indoor
dirty injuries may need
(anti-tetanus)
14. 2) MEDICAL HISTORY
-
• Medical history is essential for providing information about the current medical
state ,medication taken & number of disorders such as allergic reactions or
bleeding disorders, such as hemophilia.
• The patient’s tetanus immunization status should also be determined because a
booster might be necessary in the presence of injuries that carry the potential for
contamination.
An 8-year-old boy with known hemophilia experiencing
prolonged bleeding from the periodontal ligament around
the left central incisor. The patient had suffered a
subluxation injury 22 hours earlier.
16. • Extra oral:
A- Soft tissue examination:
Ø soft tissues should be assessed for laceration
& ecchymosis.
B- Hard tissue examination (Facial Skeleton):
Ø It should be assessed for potential fracture.
This is largely done by Inspection & palpation.
3) CLINICAL EXAMINATION
17. 3) CLINICAL EXAMINATION
• Intra-Oral:
A- Soft tissue examination:
Ø Lip and tongue laceration, swelling or
bruising and entrapment of foreign
body.
Ø Anti-Tetanus booster. (contaminated)
Ø Soft tissue Radiograph before
suturing à to be sure that there is no
foreign objects.
Ø Technique: By normal-sized film /
exposed at reduced kilovoltage.
19. B- Hard tissue examination:
Ø A marked change in alignment or displacement of the teeth as a block may
indicate a fracture of the maxilla or mandible.
3) CLINICAL EXAMINATION
20. § Inspection: Clean the area with gauze soaked in water or saline.
§ Mobility.
§ Displacement (LUXATION).
§ Periodontal Damage.
§ Pulpal Injury.
§ Radiographic Evaluation.
4)Teeth & Supporting Structure:
21. 4)TEETH &
SUPPORTING
STRUCTURE:
The ideal pulpal response after traumatic injury is
complete recovery. However, two potential
outcomes may occur:
Calcific metamorphosis or Pulp necrosis due to
apical displacement of tooth which disrupts apical
blood vessels.
Pulp necrosis may cause external inflammatory
root resorption which occurs silently so follow up
is a must.
Pulp status should be assessed:
initially & during follow up visits.
• Pulpal Injury:
23. 1. Sensitivity is not reliable in traumatized teeth, because the tooth is in a state of
shock (the inflammatory edema is pressing on the nerve fibers preventing
transmission of impulses).
2. Teeth that give positive response at the initial exam cannot be assumed to be
healthy and continue to give a positive response.
3. Teeth that give a negative response cannot be assumed to have a necrotic
pulps, because they may give a positive response later.
• Pulpal Injury:
4)Teeth & Supporting Structure:
24. 4. It may take up to 9 months after trauma for normal blood flow to return to
coronal pulp.
5. The purpose of the test is to establish a base line reference for the physiologic
status of the pulps of these teeth.
• Pulpal Injury:
4)Teeth & Supporting Structure:
25. The IADT (International Association
of Dental Traumatology – British
Dental Journal) advises that:
Pulp Sensitivity Testing, should be
performed initially and at each follow
up visit to first establish baseline, and
further determine if changes occurred
over time.
• Pulpal Injury:
4)Teeth & Supporting Structure:
26. • All Anterior Teeth should be tested (Canine to
Canine) for both maxillary and mandibular
arches (Not only the tooth of the patient’s chief
complain).
• Timing:
ü at the time of initial examination (to establish a
baseline for comparison in the follow up visits)
ü at each follow up visit.
ü follow up (2 to 4 and 6 to 8 weeks, 3,6,12
months & yearly for 5 years)
• Placed on the the facial surface of the
tooth.
1- Thermal testing:
Pulp Sensitivity Testing:
27. 2- Electrical testing:
§ Limited value in young teeth. Young & immature
teeth à Absence of A-delta fibers.
Pulp Sensitivity Testing:
28. v Transition from
ü –ve to +ve response of pulp testing è healing pulp.
ü +ve to –ve response è degenerating pulp.
ü Persistent loss of response è irreversibly damaged pulp.
• Pulpal Injury:
4)Teeth & Supporting Structure:
29. IADT recommended at least 4 different
radiographs for almost every injury
90°to the long axis
2 different vertical angulation
Occlusal film
• Radiographic Evaluation:
4)Teeth & Supporting Structure:
30. • 2D imaging method has its limitations and lack of 3D information may lead to
improper diagnosis and inversely affect long term outcome.
• 3D imaging is recommended such as CBCT to enhance clinician ability to
properly diagnose luxation injuries , alveolar fracture, root fracture, root resorption
• Radiographic Evaluation:
43. 1) CROWN (ENAMEL) INFRACTION
Ø Definition:
- Incomplete fracture or crack in enamel without loss of tooth structure.
Ø Diagnosis:
- Same Process as discussed before + Transillumination.
Ø Treatment:
- Simply smoothing any rough edges may be all that is necessary to
address the chips or cracks noted.
FOLLOW UP
44. 2) ENAMEL FRACTURE
1. Treatment objects to restore aesthetics.:
2. Small fragment➡ smooth & refine.
3. Large fragments➡ restored fragment may adhered or restored by GI
or composite restoration
4. Check PDL status
45. Ø Prognosis:
•Crown infractions/ fractures are injuries that carry little danger of resulting in pulp
necrosis.
•follow-up over a 6-8 weeks, 1 year and over 5-year period is the most important
endodontic preventive measure in these cases (clinical and radiographic).
•If, at any follow-up examination, the reaction to sensitivity tests changes, or if, on
radiographic assessment, signs of apical or peri-radicular periodontitis develop or
the root appears to have stopped development or is obliterating, endodontic
intervention should be considered.
2) ENAMEL FRACTURE
46. 3) UNCOMPLICATED CROWN FRACTURE
ØDefinition:
•Involves fracture enamel only or enamel & dentin without pulp involvement.
•Majority of dental injuries {1/3-1/2}.
•Dentin is exposed; open DT (direct pathway for bacteria)
47. Ø Diagnosis:
Same Process as discussed before:
1. Examination & Diagnosis
2. Medical History
3. Clinical Examination
4. Teeth & Supporting Structure
3) UNCOMPLICATED CROWN FRACTURE
48. The main aim is to preserve pulp vitality
Concerns :
üSealing all exposed dentin (open dentinal
tubules).
üRemaining dentin thickness (< / > 0.5 mm)
ØManagement:
3) UNCOMPLICATED CROWN FRACTURE
49. • Sealing Exposed Dentin:
Emergency appointment,
- If the broken-off piece is available ➡ reattach using adhesive bonding.
- If the broken-off piece is not available and there is no time to do a full composite
restoration at the time of the emergency appointment, ➡ a temporary coverage should be
placed on all exposed dentin. This prevents any ingress of bacteria into the tubules and
reduces the patient’s discomfort.
ØManagement:
3) UNCOMPLICATED CROWN FRACTURE
51. • Remaining Dentin Thickness:
- if the remaining dentin is more than 0.5 mm thick, the tooth can be
restored with the restoration of choice, including etching and bonding, and
no special attention needs to be given to the pulp.
- However, if the remaining dentin is less than 0.5 mm , a protective
layer, (Ca(OH)), in the deepest part of the dentin exposure must be added.
ØManagement:
3) UNCOMPLICATED CROWN FRACTURE
52. • Uncomplicated crown fractures carry little danger on the pulp status.
• In fact, the biggest danger to the health of the pulp is iatrogenic, caused during
esthetic restoration of these teeth.
•follow-up over a 6-8 weeks, 1 year and over 5-year period is the most important
endodontic preventive measure in these cases (clinical and radiographic).
• If, at any follow-up examination, the reaction to sensitivity tests changes, or if, on
radiographic assessment, signs of apical or peri-radicular periodontitis develop or the root
appears to have stopped development or is obliterating, endodontic intervention should be
considered.
Ø Prognosis:
3) UNCOMPLICATED CROWN FRACTURE
53. •No tooth fragment ---- composite build-up
•Tooth fragment saved ---- reattached the fragment
•More than 0.5mm ---- no alterations
•Less than 0.5mm ---- add capping material
•Follow up to 6-8 weeks , 1 year
