·
Introduction.
·
Etiology
·
Incidence
·
Classification.
·
Diagnosis
·
Management of traumatic
injuries
o Crown
fractures
o Uncomplicated
crown fracture
o Complicated
crown fracture
o Crown
root fracture
o Root
fracture
·
Luxation injuries
o Subluxation
o Concussion
o Extrusive
luxation
o Intrusive
luxation
o Avulsion
·
Conclusion
·
References
Introduction
Injuries to the teeth can have
devastating consequences to the victims and to the parents, if they involve
minors. They also often present complex diagnostic and treatment planning
problems for clinicians.
Traumas
that affect the hard tissues and cause pulpal and periodontal lesions are of
great relevance to present day dentistry, because of their frequency, the
functional and esthetic disturbances that accompany them and the rapidity with which
these problems must be treated.
Dental injuries often
involve damage not only to the tooth, but also to the supporting tissues., If
treatment is to be completely successful, an examination of a patient with
dental injuries must pay attention to both components jointly.
Fracture:
is understood to be the cracking or breaking of a tooth that has been subjected
to a force or impact greater than its resistance.
Even though endodontic techniques used
by the specialist can resolve the pulpal complications caused by the fractured
teeth, the fundamental aspect of prevention must be understood and practiced by
the general dentist who will have a complete understanding of the value of
rapid action to save the vitality of the pulp.
Etiology:
1) First
year of life – Although infrequent injuries at this age may occur due to fall
from a baby carriage.
2) Before
school age – Incidence of dental injuries reaches its peak. Occurs due to
falls, collisions and bumps.
3) Small
children – Child abuse, as seen in battered child syndrome, Playground
accidents, bicycle accidents.
4) Teen
age – Sports such as hockey, football, basketball, wrestling and Horse riding.
5) Late
teens – Automobile accidents.
6) Older
age group – Rights (related to alcohol abuse), wife abuse.
7) Mentally
retarded patients – due to lack of motor coordination.
8) Epileptic
patients – Mainly due to fall during seizures.
9) Drug
addicts - From violent with clenching.
10) Dentinogenesis
imperfecta – Root fracture due to reduce hardness of dentin.
Predisposing factors:
Increased
overjet with protrusion of upper incisors and insufficient lip closure are
significant predisposing factors to traumatic dental injuries.
Mechanisms of dental injury:
The exact mechanisms of dental
injuries are unknown, and without experimental evidence. Injuries can be Direct
or Indirect.
FACTORS
THAT CHARACTERIZE THE IMPACT AND EXTENT OF INJURY
1) Energy
of impact:
-
This factor includes both
mass and velocity.
-
Low velocity blows causes
more damage to surrounding tissues rather than tooth.
-
High velocity impacts –
crown fractures are not associated with damage to the supporting structure.
2) Resiliency
of impact force:
When the blow to the tooth absorbed by
surrounding tissues and less forces act on the tooth luxation results rather
than a fracture of tooth.
3) Shape
of impacting object:
-
Sharp object – Clean crown
fracture with minimal displacement because energy is spread rapidly over a
limited area.
-
Blunt impact – area of
resistance in crown portion is increased, impact is transmitted to apical
portion causing luxation or root fractures.
4) Direction
of impacting force:
-
Impact can meet the tooth at
different angles. Most often tilting the tooth facially perpendicular to long
axis of the root.
-
Depending on different
angles, different fracture lines are seen.
Due
to frontal impacts four categories of fracture appear:
-
Horizontal crown fracture.
-
Horizontal fracture at the
neck of tooth.
-
Oblique crown root fracture.
-
Oblique root fractures.
EPIDEMIOLOGY
1. Prevalence
of dental injuries:
-
Primary dentition – 11-30%.
-
Permanent dentition – 5-29%.
2.
Sex and Age distribution:
Sex – Boys
affected almost twice as often as girls.
Age – Peak
incidence at 2-4 and 8-10 years of age.
3.
Location of injuries:
-
Most commonly involved are
maxillary central incisors.
-
Least involved are
mandibular central and maxillary lateral incisors.
4. Type of dental injuries:
-
Permanent dentition à
Uncomplicated crown fractures mostly.
-
Primary dentition à
Luxation mostly.
CLASSIFICATION
OF FRACTURES
A) W.H.O. CLASSIFICATION
The World Health Organization
adopted the following classification in 1978 with a code number corresponding
to the international classification of disease:
873.60
à
Enamel fracture.
873.61
à
Crown fracture involving enamel / dentin without pulp exposure.
873.62
à
Crown fracture with pulp exposure.
873.63
à
Root fracture.
873.64
à
Crown root fracture.
873.66
à
Luxation.
873.67
à
Intrusion or extrusion.
873.68
à
Avulsion.
873.69
à
Other injuries such as soft tissues.
B) BY ANDREASEN
1) Classification
of trauma in injury of hard tissues and pulp.
This
is based on W.H.O. classification.
873.60
à
Incomplete fracture.
873.61
à
Uncomplicated crown fracture.
873.62
à
Complicated crown fracture.
873.64
à
Uncomplicated crown and root fracture.
873.64
à
Complicated crown and root fracture.
873.63
à
Root fracture.
2) Injuries
to the periodontal tissues:
873.66
à
Concussion.
873.66
à
Subluxation (loosening).
873.67
à
Intrusive luxation (central dislocation).
873.67
à
Extrusive luxation (peripheral dislocation, partial avulsion).
873.66
à
Lateral luxation.
873.68
à
Exarticulation (Avulsed tooth).
3) Injuries
to the supporting bone:
Mandible No. 802.20, maxilla No. 8.2.40 –
comminution of alveolar socket.
Mandible No. 802.20, Maxilla No. 802.40 –
Failure of alveolar socket wall.
Mandible No. 802.20, Maxilla No. 802.40 –
Fracture of alveolar process.
Mandible No. 802.21, Maxilla No. 802.42 –
Fracture of mandible / maxilla.
4) Injuries
to Gingiva/ Oral mucosa:
873.69
à
Laceration of gingiva/oral mucosa.
920.X0
à
Contusion of gingiva/oral mucosa.
910.00
à
Abrasion of gingiva or oral mucosa.
C) ELLIS CLASSIFICATION
Class I – Simple crown fracture with little or
no dentine affected.
Class
II – Extensive crown fracture with considerable loss of dentin, but
with the pulp not affected.
Class III – Extensive crown fracture with
considerable loss of dentin and pulp exposure.
Class IV –
A tooth devitalized by trauma with
or without loss of tooth structure.
Class V –
Tooth lost as a result of trauma.
Class VI –
Root fracture with or without the
loss of crown fracture.
Class VII – Displacement of the tooth with neither
root nor crown fracture.
Class VIII –
Complete crown fracture and its
replacement.
Class IX –
Traumatic injuries of primary teeth.
D) BY HEITHERSAY AND MORILE
They classified subgingival
fractures based on the level of tooth fracture in relation to various
horizontal planes of periodontium.
Class
I à
Fracture line does not extend below the level of attached gingiva.
Class
II à
Fracture line below the level of attached gingiva but not below the level of
alveolar crest.
Class
III à
Fracture line extends below the level of alveolar crest.
Class
IV à
Fracture line is within the coronal third of root, but below the level of
alveolar crest.
E)
BY ULFOHN
His classification is based on
clinical endodontics and does not reveal the extent of fracture or amount of
dentin exposed.
He based his classification on 3 aspects:
i)
Clinical state of the pulp.
ii)
Pulp and dentin as one
organ.
iii)
Determination of treatment.
Crown fractures:
a) Of
enamel.
b) With
indirect pulp exposure through dentine.
c) With
direct pulp exposure.
F) BASRANI CLASSIFICATION
1) Crown
fractures.
a) Fracture
of enamel.
b) Fracture
of enamel and dentin.
i.
Without pulp exposure.
ii.
With pulp exposure.
2) Root
fractures.
3) Crown
root fractures.
Diagnosis
•
A patient who has suffered a
traumatic injury is always distraught.
•
The clinician should take
time to calm the patient and carry out a good evaluation of the patients’
injuries and formulate a treatment plan depending on the immediate needs of the
patient.
•
A proper history recording
and thorough clinical examination is must.
History Taking:
•
This includes primarily the
subjective statement by the patient.
•
It includes the chief
complaint, history of present illness and pertinent medical history.
History of present illness
•
When and where did the
injury happen?
•
How did the injury happen?
•
Have you had treatment
elsewhere for the same?
•
Have you had similar
injuries before?
•
Have you noticed any
symptoms since the injury?
•
What specific symptoms have
you had with the traumatized tooth/teeth?
Medical
history
•
Allergic reactions to any
medication.
•
Disorders such as bleeding
problems, diabetes and epilepsy.
•
Current medications.
•
Tetanus immunization status.
•
Clinical Examination
•
A careful methodical
approach should be followed.
Extra oral examination
•
The maxilla, mandible and
TMJ should be examined visually and also palpated to look for distortions,
malalignment, or indications of fractures.
•
Tooth dislocation, gross
occlusal interference and development of apical pathosis should be duly noted.
Soft tissue examination
•
Examine soft tissues for the
presence of tooth fragments buried inside the lips after trauma.
•
All areas of soft tissue
injury should be noted, and the lips, cheeks and tongue adjacent to any
fractured teeth should be carefully examined and palpated.
Hard
tissue examination: Teeth should be examined for
- Mobility.
- Displacement:
[Intrusion or Extrusion]
- Fracture:
by shining fiber optic light through the tooth or by using disclosing
solution. Root fracture can be felt by placing a finger on the patients
mucosa and moving the crown.
- Injury
to periodontal ligament & alveolus: Can be evaluated by tooth
percussion. The results may be normal, slightly sensitive or highly
sensitive.
- Pulpal
trauma: Condition of the pulp must be noted at the time of injury and at
regular intervals of 3 weeks, 3, 6 and 9 months hence forth. After a blow to the tooth, the pulp does not
respond to any of the vitality tests normally [“stunned state”].
Radiographic examination
•
It is indispensable in the
diagnosis and treatment of dental trauma.
•
Many angulated radiographs
must be taken in order to properly detect and assess the presence or absence of
fracture.
•
While viewing films of
traumatized teeth, special attention should be directed to:
1.
The dimension of the root canal space.
2.
Degree of apical closure.
3.
The proximity of fracture to the pulp.
4.
Relation of the root fracture to the alveolar crest.
The following modified principles of
“PRINZ” fulfill the necessary requisites for obtaining a correct diagnosis of
the pulp, whatever the cause.
A. Subjective symptoms:
1. Case
history: Thorough history about the occurrence of injury is necessary.
2. Pain:
Intensity, duration, specificity, cause, spontaneity, localization, radiation.
B. Objective symptoms:
1. Exploration:
Consistency (dentin: hard-soft) depth, dentinal sensitivity, pulp exposure.
Inspection: Tooth structure, adjacent soft
tissues.
2. Colour:
Localized spots, diffuse area of white, gray, brown.
3. Transillumination.
4. Pulp
vitality tests - Thermal
-
Electrical
5. Radiograph
– Pulp canal, periapical region, root fracture.
6. Percussion
– Degree of periapical involvement.
Palpation
: Changes in form, size, consistency and mobility of teeth.
Management of Traumatic
Injuries
CROWN FRACTURES:
1) Fractures of enamel:
These are fractures of the crown of the
tooth involving only the enamel which may be accompanied by a crack that
affects the dentin.
This can be classified into three:
Horizontal – Line of fracture
perpendicular to long axis of the tooth.
Oblique – Inclined to long axis.
Vertical – Parallel to long axis.
According
to Ingle:
This involves chips and cracks
confined to the enamel, did not cross DEJ but terminate at it. Also known as
“crown infractions” by Andreasen.
Diagnosis:
-
Transillumination.
-
Dyes.
-
Vitality. Both immediately
and after 6-8 weeks – concussion to apical neuro vascular bundle. Mainly
involve children and majority of cases go unnoticed.
Treatment:
1) Smoothening
of rough edges.
2) Composite
resin using acid-etch technique.
Prognosis:
Good
Sequlae: -
Pulp necrosis.
-
Internal resorption.
-
Calcification.
-
Trauma to primary may result
in malformation of permanent successors.
2) Crown fracture involving enamel and dentin without
pulp exposure.
Description:
Also known as “uncomplicated crown fractures”
by Andreasen and Class II by “Ellis”.
1. Anterior teeth (more
common).
Site:
-
Incisal proximal corners.
-
Incisal edges.
-
Lingual chisel type
fractures.
2. Posterior teeth à cusps.
Incidence:
The enamel / dentin fracture is very
common accounting for about one third of dental injuries.
Diagnosis:
-
As the tooth fracture
involves dentin, dentinal tubules are exposed through which harmful bacteria
and other substances have a direct pathway to pulp.
-
Thus along with the extent
and degree of fracture, pulp vitality should be checked.
-
Electric pulp test is more
reliable than a cold thermal test for vitality. If non-vital appropriate
endodontic therapy should be provided.
Percussion à Tenderness on percussion should be
check.
Mobility à This dictate the periodontal ligament
status.
Treatment à Emergency / immediate follow up
Objective
of treating a tooth without pulp exposure is three fold:
- Elimination
of discomfort.
- Preservation
of vital pulp.
- Restoration
of fractured crown.
Emergency
-
Primary goal of treatment is
to protect the pulp.
1. Most
effective method is placement of a protective material over exposed dentin to
allow the pulp to form a protective barrier e.g. Ca(OH)2 placement (Dycal).
2. The
fracture site must be covered with a restoration material such as acid-etch
composite restoration.
The
advantages are:
No
additional tooth structure is removed.
Protects
the dressing material.
Provides
for function and esthetics.
Permanent:
-
This begins at 6-8 weeks
after the injury.
-
Acid-etch – composite is the
treatment of choice.
-
Because of the extent of
fracture and because of esthetics reason – crown may be required.
3) Crown fracture with pulp exposure:
-
Crown fracture involving
enamel, dentin and pulp are called “complicated crown fractures” by Andreasen
and Class 3 fractures by Ellis.
-
Degree of pulp exposure
varies from a pinpoint exposure to a total unroofing of coronal pulp.
-
Pulp exposure complicates
the treatment as healing and repair are harmed.
-
Traumatic exposure of the
pulp lacerates the tissues and exposes the pulp to the oral environment.
-
Initial reaction is
hemorrhage followed by an inflammatory response which is either distructive
(necrotic) or prolifeative (polyp) reaction.
Incidence:
-
Crown fractures are less
than those not involving the pulp.
-
Range à
2-13%.
Diagnosis:
The condition of the exposed pulp
will affect the treatment choice and must be carefully evaluated.
This
depends on four factors:
- Length
of time the pulp has been exposed.
- Maturity
of tooth – Apex formed or not formed.
-
Check Radiographically.
- Age
of the patient.
- Extent
of crown fracture – dictates pulp treatment along with maturity.
Treatment:
-
Depends on maturity of the
tooth can be divided into two:
1. Treatment
of pulp exposure with incomplete root formation.
a) Pulp
cap with Ca(OH)2 if treatment performed within 3-4 hours after
injury.
b) Pulpotomy
- Massive pulp exposure.
-
Exposure > 3-4 hours.
Aim:
To maintain the vitality and allow root completion.
After
root completion, perform root canal filling.
c) If
pulp is necrotic, apexification is done to induce apical closure (use Ca(OH)2).
After root completion fill canal with gutta-percha as permanent filling.
2. Treatment
of pulp exposure with completely formed roots:
a) Pulpectomy
– if pulp is necrotic.
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