Trauma

 
 Primary  Tooth  Trauma  
1)    Labial  Frenum  tear    
 Bleeding  ++    
 Pressure  over  tear  to  stop  bleeding.    
 O>en  looks  worse  than  it  is!      
 Rarely  needs  sCtches.    

2)    Concussion  injury    
 Tooth  may  turn  darken.    
 Watch  for  abscess  formaCon.    

3)    LuxaCon  
 ReposiCon  tooth  ASAP  !      

4)    Intrusion  
 Allow  to  re-­‐erupt.      

5)    Avulsion    
 Locate  tooth.  Do  NOT  replant  a  baby  tooth.    
 Concussion  
•  An  injury  to  the  tooth-­‐supporCng  structures  
without  increased  mobility  or  displacement  of  
the  tooth,  but  with  pain  to  percussion.  
 Concussion - Treatment
Guidelines  
Treatment: Monitor pulpal condition for at least 1
year.
Patient instructions: Soft food for 1 week. Good
healing following an injury to the teeth and oral
tissues depends, in part, on good oral hygiene.
Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to prevent
accumulation of plaque and debris.
Follow-up: Clinical and radiographic control at 4
weeks, 6-8 weeks and 1 year.  
 Colour  Change  
•  DiscolouraCon  =  bruising  
•  Does  not  indicate  need  for  pulpal  therapy  
•  May  lighten  over  Cme  
•  Approximately  1/3  will  require  further  treatment  
•  74%  remain  asymptomaCc  and  48%  remain  
discoloured  

•  Holan  G  Dent  Traumatol.  2004  Oct;20(5):276-­‐87.Development  of  clinical  and  radiographic  signs  
associated  with  dark  discolored  primary  incisors  following  trauma8c  injuries:  a  prospec8ve  
controlled  study.  
 SubluxaCon  
•  An  injury  to  the  tooth  supporCng  structures  
resulCng  in  increased  mobility,  but  without  
displacement  of  the  tooth.  Bleeding  from  the  
gingival  sulcus  confirms  the  diagnosis.  
 Subluxation - Treatment
Guidelines  
Treatment: A flexible splint to stabilize the tooth for
patient comfort can be used for up to 2 weeks.
Patient instructions: Soft food for 1 week. Good
healing following an injury to the teeth and oral
tissues depends, in part, on good oral hygiene.
Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to prevent
accumulation of plaque and debris.
Follow-up: Clinical and radiographic control at 4
weeks, 6-8 weeks and 1 year. Action related to
endodontic treatment may be taken after 2-3
months.  
 Extrusion  
•  ParCal  displacement  of  the  tooth  out  of  its  socket.  An  injury  to  the  tooth  
characterized  by  parCal  or  total  separaCon  of  the  periodontal  ligament  
resulCng  in  loosening  and  displacement  of  the  tooth.    
 Extrusion - Treatment
Guidelines  
Treatment: The exposed root surface of the displaced tooth is
cleansed with saline before repositioning. Reposition the tooth
by gently re-inserting it into the tooth socket with axial digital
pressure (local anesthesia is usually not necessary). Stabilize
the tooth for 2 weeks using a flexible splint. Monitoring the
pulpal condition is essential to diagnose associated root
resorption.
Patient instructions: Soft food for 1 week. Good healing following
an injury to the teeth and oral tissues depends, in part, on
good oral hygiene. Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to prevent accumulation of
plaque and debris.
Follow-up: Clinical and radiographic control and splint removal
after 2 weeks. Clinical and radiographic control at 4 weeks, 6-8
weeks, 6 months, and 1 year.
 Lateral  luxaCon  
•  Displacement  of  the  tooth  other  than  axially.  Displacement  is  usually  
accompanied  by  comminu6on  or  fracture  of  either  the  labial  or  the  
palatal/lingual  alveolar  bone.  
•  Lateral  luxa6on  injuries,  similar  to  extrusion  injuries,  are  characterized  by  
par6al  or  total  separa6on  of  the  periodontal  ligament.  However,  lateral  
luxa6ons  are  complicated  by  fracture  of  either  the  labial  or  the  palatal/
lingual  alveolar  bone  and  a  compression  zone  in  the  cervical  and  
some6mes  the  apical  area.  
•   If  both  sides  of  the  alveolar  socket  have  been  fractured,  the  injury  should  
be  classified  as  an  alveolar  fracture  (alveolar  fractures  rarely  affect  only  a  
single  tooth).    
•  In  most  cases  of  lateral  luxa6on  the  apex  of  the  tooth  has  been  forced  into  
the  bone  by  the  displacement,  and  the  tooth  is  frequently  non-­‐mobile.    
 Lateral  LuxaCon  
•  No  collision  with  permanent  tooth  bud    
 Lateral  LuxaCon  
•  Collision  with  permanent  tooth  bud  
 Lateral luxation - Treatment
Guidelines  
Same  as  for  extrusion.  
 Intrusion  -­‐  Intrusive  luxaCon  
•  Displacement  of  the  tooth  into  the  alveolar  
bone.  This  injury  is  accompanied  by  
comminu6on  or  fracture  of  the  alveolar  
socket.    
 Intrusion - Treatment
Guidelines  
Spontaneous eruption
This is the treatment of choice
for deciduous/primary teeth and
for permanent teeth with
incomplete root formation. This
treatment has been shown to
lead to significantly fewer
healing complications than
orthodontic and surgical
repositioning.  
 Intrusion  –  Treatment  Choice  
•  Spontaneous eruption
This is the treatment of choice for deciduous/primary
teeth and for permanent teeth with incomplete root
formation. This treatment has been shown to lead to
significantly fewer healing complications than
orthodontic and surgical repositioning.
•  Orthodontic repositioning
This treatment may be preferred for patients coming in
for delayed treatment. This treatment method enables
repair of marginal bone in the socket along with the
slow repositioning of the tooth.
•  Surgical repositioning
This treatment technique is preferable in the acute
phase. Intrusion with major dislocation of the tooth
(approximately more than half a crown length) may be
an indication for surgical repositioning.
 Intrusion - Treatment
Guidelines  
•  Factors determining treatment choice are
stages of root development, age and intrusion
level
•  OPEN APEX (6-11 years) Allow for spontaneous
repositioning
•  CLOSED APEX (12-17 years) AND less than 7
mm intrusion. Allow for spontaneous eruption
•  CLOSED APEX (12-17 years) AND more than 7
mm intrusion. Orthodontic or Surgical
repositioning
•  CLOSED APEX (more than 17 years)
orthodontic or surgical repositioning.  
 Avulsion  
•  The  tooth  is  completely  displaced  out  of  its  
socket.  Clinically  the  socket  is  found  empty  or  
filled  with  a  coagulum.    
 Primary  Avulsion  –  Treatment  
Guidelines  
•  NO  TREATMENT  
•  DO  NOT  REIMPLANT  THE  TOOTH  
 Avulsion  Permanent  Tooth  
•  Replant  the  tooth  with  gentle  pressure.  
•  Suture  gingival  laceraCons  if  present.  
•  Verify  normal  posiCon  of  the  replanted  tooth  clinically  
and  radiographically.  
•  Stabilize  the  tooth  for  4  weeks  using  a  flexible  splint.  
•  A/B    Tetanus  ??    
•  PaCent  instrucCons:  So>  food  for  up  to  2  weeks.  Brush  
teeth  with  a  so>  toothbrush  a>er  each  meal.  
•  Use  a  chlorhexidine  (0.1%)  mouth  rinse  twice  a  day  for  
1  week.    
•  Follow-­‐up:  Radiographic  control  
 Avulsion - First aid for avulsed
permanent teeth  
•  www.iadt-­‐
dentaltrauma.org  
 Enamel  infracCon.    
•  An  incomplete  fracture  (crack)  of  the  enamel  
without  loss  of  tooth  structure  
 Enamel  Fracture  
•  A  fracture  confined  to  the  enamel  with  loss  of  
tooth  structure.    
 Enamel-dentin fracture  
•  A fracture confined to enamel and
dentin with loss of tooth structure,
but not involving the pulp.  
 Enamel-dentin-pulp fracture
(Complicated crown fracture)  
•  A fracture involving enamel and
dentin with loss of tooth structure
and exposure of the pulp.  
 Crown-root fracture without
pulp involvement
•  A fracture involving enamel, dentin
and cementum with loss of tooth
structure, but not involving the pulp.  
 Crown root fracture with pulp
involvement  
•  A fracture involving enamel, dentin,
and cementum with loss of tooth
structure, and involving the pulp.  
 Root fracture  
•  A fracture confined to the root of the
tooth involving cementum, dentin,
and the pulp. Root fractures can be
further classified by whether the
coronal fragment is displaced (see
luxation injuries).  
 Root fracture – Primary Tooth  
•  ExtracCon:  removal  of  root  fragment  if  visible  
only.  
 Root  fracture  -­‐  Treatment  Guidelines  
Permanent  Tooth  
Treatment:  Rinse  exposed  root  surface  with  saline  before  
reposiConing.  If  displaced,  reposiCon  the  coronal  segment  of  the  
tooth  as  soon  as  possible.  Check  that  correct  posiCon  has  been  
reached  radiographically.  Stabilize  the  tooth  with  a  flexible  splint  for  
4  weeks.  Cervical  fractures  stabilizaCon  is  indicated  for  a  longer  
period  of  Cme  (up  to  4  months).  Monitor  healing  for  at  least  1  year  
to  determine  pulpal  status.  If  pulp  necrosis  develops,  then  root  
canal  treatment  of  the  coronal  tooth  segment  to  the  fracture  line  is  
indicated.    
PaCent  instrucCons:  So>  food  for  1  week.  Good  healing  following  an  
injury  to  the  teeth  and  oral  Cssues  depends,  in  part,  on  good  oral  
hygiene.  Brushing  with  a  so>  brush  and  rinsing  with  chlorhexidine  
0.1  %  is  beneficial  to  prevent  accumulaCon  of  plaque  and  debris.  
 Alveolar fracture  
•  A fracture of the alveolar process; may or may not involve
the alveolar socket. Teeth associated with alveolar fractures
are characterized by mobility of the alveolar process;
several teeth typically will move as a unit when mobility is
checked. Occlusal interference is often present.
 Alveolar  fractures  -­‐  Treatment  
Guidelines  
•  Treatment:  reposiConing  using  forceps  of  the  displaced  
segment.  Stabilize  the  segment  with  flexible  splinCng  for  4  
weeks  
•  PaCent  instrucCons:  So>  food  for  1  week.  Good  healing  
following  an  injury  to  the  teeth  and  oral  Cssues  depends,  in  
part,  on  good  oral  hygiene.  Brushing  with  a  so>  brush  and  
rinsing  with  chlorhexidine  0.1  %  is  beneficial  to  prevent  
accumulaCon  of  plaque  and  debris.  
•  Follow-­‐up:  Splint  removal  and  clinical  and  radiographic  
control  a>er  4  weeks.  Clinical  and  radiographic  control  a>er  
6-­‐8  weeks,  4  months,  6  months,  1  year  and  yearly  for  5  
years  
 PERMANENT  TOOTH  TRAUMA  
•  PREVENTION    
•  Wear  a  sports  mouthguard  for  any  contact  sport.  
•  Concussion  –  radiograph  
•  LuxaCon  –  radiograph  and  reposiCon    
•  Fractured  –  radiograph  and  if  the  fractured  piece  is  
located  it  can  be  bonded  back  on  
•  Avulsion  -­‐  locate  the  tooth.  REPLANT  IMMEDIATELY  -­‐-­‐-­‐  
DO  NOT  TOUCH  THE  ROOT  !!  Handle  the  tooth  by  the  
crown  part  and  insert  it  back  into  the  socket  ASAP!    
Radiograph  a>er  replantaCon.    
Trauma  Pathfinder  –  Tooth  is  not  
Displaced  
No   No  
displacement   displacement    
Not  loose   Loose  

Not  tender  to   Tender  to  

SUBLUXATION  
percussion   percussion  

No  fracture   Fracture   CONCUSSION  

Fracture  above   Fracture  below  

NO  TRAUMA  
gingival  margin   gingival  margin  

CROWN   CROWN  ROOT  

FRACTURE   FRACTURE  
Trauma  Pathfinder  –  Tooth  is  Displaced  
Completely  
Displaced  
displaced  

No  mobility   Mobility  

Several  mobile  
Single  mobile  
teeth  moving  
tooth  
as  a  unit  

X-­‐ray  shows  
No  sign  of  root  
sign  of  root  
fracture  
fracture  

LATERAL   ROOT   ALVEOLAR  

INTRUSION   EXTRUSION   AVULSION  
LUXATION   FRACTURE   FRACTURE