trauma hossam khalifa

8/3/2019 Trauma Hossam Khalifa

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Trauma to the oral cavity is a common dental

problem, where

Trauma to the oral cavity is a common dental

problem, where

Early diagnosis.

Appropriate initial treatment.

Optimal definite treatment.

Should be a goal in the management of

traumatic injuries.


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Sudden impact involving the face or head

may result in trauma to the teeth and

supporting structures.

I- frequent causes :

a-falling while running, b-

traffic accidents,

c-acts of violence, and d-

sports.

Automobile accidents are often very

destructive.

One estimate suggests that 20 to 60% of all

traffic accidents


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1)1) Age:

Deciduous most common (2-5

years).

Permanent (8-12 years).2) Sex:

Boys > girls 2:1.

3) Site:

80% upper central.

Maxillary lateral incisors.

II- Incidence of traumatic injury:II- Incidence of traumatic injury:


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Numerous studies indicate that mal-occlusion predisposes to dental

injuries.

Numerous studies indicate that mal-occlusion predisposes to dental

injuries.


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** Old ClassificationOld Classification::Ellis ClassificationEllis ClassificationClass IClass ITraumatized -crown and Root are intact .Traumatized -crown and Root are intact .

a- Devitalized pulp .a- Devitalized pulp .

b- Devitalized pulp with incomplete rootb- Devitalized pulp with incomplete root

formation.formation.c- Internal and External resorption.c- Internal and External resorption.

d- Calcification- Concussion.d- Calcification- Concussion.

ClassIIClassII Coronal fracture - Pulp not exposed (EnamelCoronal fracture - Pulp not exposed (Enamelfracture)fracture)

ClassIIIClassIII Coronal fracture pulp exposed (DentinCoronal fracture pulp exposed (Dentinfracture)fracture)

ClassIVClassIVCoronal fracture extending subgingivally .Coronal fracture extending subgingivally .

ClassVClassV Root fracture with or without loss of crownRoot fracture with or without loss of crown

structure.structure. Division I :Division I : Horizontal fractureHorizontal fracture

Division 2:Division 2: Vertical and chisel fracture.Vertical and chisel fracture.

Class VIClass VI Displacement of tooth with or withoutDisplacement of tooth with or withoutfracturefracture

Division I:Division I: Partial displacementPartial displacement


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New Classification W H ONew Classification W H ONo-873No-873 World Health Organization of Oral InjuriWorld Health Organization of Oral Injuri

873.60873.60 Enamel fracture.Enamel fracture.

873.61873.61 Crown fracture without pulpCrown fracture without pulpinvolvement.involvement.

873.62873.62 Crown fracture with pulp involvemenCrown fracture with pulp involvement

873.63873.63 Root Fracture.Root Fracture.

873.64873.64 Crown - Root fracture.Crown - Root fracture.873.66873.66 Tooth Luxation (dislocation, concussiTooth Luxation (dislocation, concussi

sublaxation).sublaxation).

873.67873.67 Intrusion and Extrusion.Intrusion and Extrusion.

873.68873.68 Complete Avulsion.Complete Avulsion.873.69873.69 Other injuries (Soft tissue or oral caviOther injuries (Soft tissue or oral cavi

802.20802.20 Fracture or communication of alveolaFracture or communication of alveolaprocess of mandibleprocess of mandible

and Maxilla.and Maxilla.


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WHO classificationWHO classification::WHO classificationWHO classification::

1) Enamel fracture:

(A) Enamel infraction (cracks).

(B) Complete

(chipping). 2) Crown fracture withoutpulpal involvement

(uncomplicated).


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3) Crown fracture with pulpalinvolvement (complicated).

4) Root fracture.

5) Crown root fracture.


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6) Tooth luxation:6) Tooth luxation:

(A) Concussion

(B) Subluxation.

(C) Luxation.


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7) Extrusion.8) Intrusion.

9) Avulsion.10) Alveola

bone

injury


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I. Case history.

II. Clinical examination.

III.Vitality test.

IV.Radiograph.

Examination & Diagnosis


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(A) Chief complaint:in patients own words.(B) History of the injury:

1. When?1. When? did the injury occur The prognosis of injured teeth is

logically often dependent, to a great

extent on the time that has elapsed

between the accident & when the

emergency treatment is provided.

2. Where? did the injury occur Necessity of tetanus vaccination is

influenced by the location of the

accident.

1) Case history:1) Case history:1) Case history:1) Case history:


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3. How ? did the injury occur?

Hard blow coronal fracture.

Padded blow root fracture.

4.Have you had similar injuries before?

Repeated injuries to teeth affect

the pulp & their ability to

recover from the trauma.


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5.5. Have you noticed any other

symptoms since the injury?

Signs & symptoms to be

watched: dizziness, vomiting &

blurred vision.

Affirmative response to any of

the above indications needs


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(C) Medical history::

Allergic reaction.

Current medication.

Tetanus immunization status.


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2) Clinical examination:2) Clinical examination:2) Clinical examination:2) Clinical examination:

(A) Extra-oral examination:

Laceration of head & neck.

Deviation from normal bonycontour.

TMJ.

(B) Intra-oral examination: Soft tissue examination.

Hard tissue examination.


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Soft tissue examination

Laceration of lips & tongue must be

radiographically examined for embeddedforei n bodies.


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Hard tissue examination

Check occlusion.

Several teeth are out of

alignement

fracture of mandible or maxilla.

Tooth discolouration.

Crown fracture.

Tooth displacement.


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Palpation


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PERCUSION.


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PROBING.

MOBILITY.


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3) Vitality test:3) Vitality test:3) Vitality test:3) Vitality test:

Thermal.Thermal.

Electrical.Electrical.

Cavity test.Cavity test.

They are in reality sensitivity testsThey are in reality sensitivity tests

for nervefor nervefunctions & do not indicate thefunctions & do not indicate the

presence orpresence or

absence of blood circulation withinabsence of blood circulation within

Thermal.Thermal.

Electrical.Electrical.

Cavity test.Cavity test.

They are in reality sensitivity testsThey are in reality sensitivity tests

for nervefor nervefunctions & do not indicate thefunctions & do not indicate the

presence orpresence or

absence of blood circulation withinabsence of blood circulation within


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A THERMAL TEST

HEAT TESTHEAT TEST1 Warm gutta percha.2 Warm Instrument.

3 Heated ball burnishes.

4 Frictional heat from rubber

polishing disk.


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COLD TEST

1 Co2 Snow.

2 Ethyl chloride.

3 Ice in dental carpule.

4 Endo Ice.


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B Vitality Tests:

ELECTRIC PULP TESTER

(E.P.T):

A variety of devices are available fortesting pulp vitality:

1 Battery operated device.2 Constricted in the dental unit.


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1.Mild to moderate degree of

awareness of slight pain thatsubsides within 1-2 seconds after

the stimulus has been removed

(normal limits).

2.Strong momentary painful response

that subsides within 1-2 seconds

after the stimulus has beenremoved (reversible pulpitis).

3.Moderate to strong painful

response that lingers for some

Response to vitality tests:

Necrotic pulp.Recent trauma.

Excessive


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Controversy has for decades

surrounded the validity of

thermal & electrical tests on

traumatized teeth.

A negative response is not a

reliable evidence of pulpdeath, because the teeth may

be in a state of shock & may


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1) Radiographic examination:

The examination of

traumatized teeth

cannot be considered

complete without a

radiograph of the injured

tooth & the adjacent

teeth.

Multiple radiographs at

different angulations are


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New Classification W H ONew Classification W H ONo-873 World Health Organization of Oral InjuriNo-873 World Health Organization of Oral Injuri

873.60 Enamel fracture.


873.62873.62 Crown fracture with pulp involvementCrown fracture with pulp involvement









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1) Enamel fracture

Diagnosis:

Transillumination

Chief complaint: sharp or


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Scheduled follow up is needed.

Very good prognosis.


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873.60 Enamel fracture.873.60 Enamel fracture.

873.61 Crown fracture without pulpinvolvement..









2)Crown fracture without pulpal involvemen


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2)Crown fracture without pulpal involvemen

(Uncomplicated fracture)

Diagnosis:Determine the state of the pulp &

periradicular tissue

by usual examination procedure.


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Treatment:Treatment:A) Primary goal of treatment is to

protect the pulp by sealing

dentinal tubules with Ca(OH)2.


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B) Restoration with composite

resin.


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C) If the tooth fragment is

available, attempt toreattach it.


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Follow up is done periodically to determine the

state of the pulp.

The prognosis & reaction of the pulp depends on:A) Proximity of the fracture to

the pulp.

B) Surface of dentin exposed.

C) Length of time between

trauma & treatment.


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873.62 Crown fracture with pulp involvement









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3) Crown fracture with pulp involvement(Complicated fracture)


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A.Degree of root maturity.

B.Size of the exposure.

C.Time elapsed between trauma

treatment.

Choice of treatment & prognosis depends on:Choice of treatment & prognosis depends on:


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(1) EXPOSURE WITHIN 24(1) EXPOSURE WITHIN 24

HOURSHOURS::

-- Pulp still vital means:Pulp still vital means:

1-The exposed pulp red in colour.1-The exposed pulp red in colour.

2-Bleed freely when picked with2-Bleed freely when picked with

explorer.explorer.

mature apex


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TREATMENT:TREATMENT:1-Should involve pulpotomy or pulp1-Should involve pulpotomy or pulp

capping.capping.2-Pulpotomy is best then pulp capping2-Pulpotomy is best then pulp capping

because:because:

a-bacterial contamination occurred ina-bacterial contamination occurred in

traumatic exposure, it is likely removed intraumatic exposure, it is likely removed inpulpotomy but it remain in pulp capping.pulpotomy but it remain in pulp capping.

b-It is difficult to restore a pulp capped toothb-It is difficult to restore a pulp capped toothwithout distributing the capping, that is notwithout distributing the capping, that is nottrue in pulpotomy.true in pulpotomy.

c-It is difficult to obtain retention in pulpc-It is difficult to obtain retention in pulpcapping, while easy in pulpotomy.capping, while easy in pulpotomy.

d-The success of pulpotomy proceduresd-The success of pulpotomy procedurescom re f vor l with the s ccess of

A) Vital pulp therapy (apexogenesis)


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A) Vital pulp therapy (apexogenesis):

a-Pulp capping:

Involves application of dressing

Ca(OH)2 to exposed pulp in attempt

to preserve its vitality.


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b-Cervical pulpotomy:

Removal of pulp tissue till cervical level & application

of capping agent to promote healing.


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c-Shallow pulpotomy

(Cvek pulpotomy)

Removal of pulp tissue

to depth

of about 2 mm &

application of

capping agent.


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Follow up is needed.

The feature for successful vital pulptherapy:1. Pulp vitality is preserved.

1. No clinical signs or symptoms.2. No radiographic evidence of

peri-radicular

pathologic changes.

4. Immature root continues its

formation.


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N.B.: Apexogenesis is a

temporary treatment until the

root is completely formed, then

conservative root canal treatment

is done.


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(2) EXPOSURE AFTER LONG(2) EXPOSURE AFTER LONGPEROIDPEROID::

In this case the pulp should beIn this case the pulp should be

devitalized in this the pulp should bedevitalized in this the pulp should be

completely removed pulpectomycompletely removed pulpectomy


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Immature apex

(Necrotic pulp)

The conventional treatment of

pulpless teeth was apical surgery.


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Condensing pressure of amalgam may lead

to root fracture.

Retro-filling of apices of immature teeth,

often means packing of amalgam into the

preparation with paper-thin walls. (Frank

1966).

Procedure involves young children and can

Disadvantages of surgery:Disadvantages of surgery:

APEXIFICATION


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APEXIFICATION:APEXIFICATION:

It is biologic phenomena ofIt is biologic phenomena ofcementificationcementification

which lead towhich lead to apical closure.apical closure.

Believes that thisBelieves that thisprocess is natural but it mustprocess is natural but it muststimulatedlystimulatedly

biologic activatorbiologic activator (Calcium(Calcium

Hydroxide) +Hydroxide) +

intracanalintracanal medicamentmedicament

a- initial appointment


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1-Rubber dam and access cavity opened .1-Rubber dam and access cavity opened .

2-Large blunted file (H-Type) remove2-Large blunted file (H-Type) remove

necrotic canal content then irrigation.necrotic canal content then irrigation.3-Enlargement the canal until clear dentin.3-Enlargement the canal until clear dentin.

b-Material:

1-Calcium Hydroxide with Compherated1-Calcium Hydroxide with CompheratedPara Chloro Phenol mixed to a thick, dryPara Chloro Phenol mixed to a thick, dryputty-like consistency.putty-like consistency.

2-With long plugger insert the mixture2-With long plugger insert the mixturegently to the space to apex and fill thegently to the space to apex and fill thecanal completely.canal completely.

3-Place a dry cotton pellet over the mixture,3-Place a dry cotton pellet over the mixture,

and then cover with ZOEand then cover with ZOE

--


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c- Subsequent appointment:c- Subsequent appointment:

Four to six months after firstFour to six months after first

appointment and by radiographicappointment and by radiographicexaminationexamination ..

a-If there is no response (apex appeara-If there is no response (apex appear

to be opened), the initialto be opened), the initial

appointment repeated. These mayappointment repeated. These may

be done from 6 months to 2 ears.be done from 6 months to 2 ears.

b-If there is a response. There are fourb-If there is a response. There are four


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b If there is a response. There are fourb If there is a response. There are four

appearance that may be seen in theappearance that may be seen in the

radiograph:radiograph:

1-The root end formed and sealed,1-The root end formed and sealed,the canal shape not changed.the canal shape not changed.

2-The root end formed and sealed but2-The root end formed and sealed but

the canal fill in with blunderbussthe canal fill in with blunderbussapex.apex.

3-The root end blunderbuss in shape3-The root end blunderbuss in shape

and closed with thin calcifiedand closed with thin calcified


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New Classification W H ONew Classification W H O


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873.63 Root Fracture..








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4) Root fracture

Root fracture constitutes

3% or less of all traumatic

dental injuries.


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Root fracture could be:

1- A) Complete (21- A) Complete (2separate parts)separate parts)

B) Incomplete (crackB) Incomplete (crackin root withoutin root without

separationseparation

of the 2of the 2

parts).parts).

2- A) Single line of2- A) Single line of


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Horizontal.Horizontal.

A- Cervical thirdA- Cervical third

B- Middle thirdB- Middle third

C- Apical thirdC- Apical third

Vertical.Vertical.

Chisel (diagonal) fracture.Chisel (diagonal) fracture.


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1.Mobility of the tooth.

2.Displacement of coronal

segment.

3.Pain on biting.

4.Radiograph:Root fractures are not always horizontal,

so root fracture is often missed byradiograph unless x-ray beam passes

directly through the fracture line.

Diagnosis of root fractureDiagnosis of root fractureDiagnosis of root fractureDiagnosis of root fracture


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Additionalfilms mustbe taken(45, 90, 110)

degree.

Root fracturesare not always

horizontal, soroot fracture isoften missed by

radiograph

unless x-ray beampasses directlythrough thefracture line.

E (i iti l) t t tE (i iti l) t t t


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Emergency (initial) treatment

for root fracture

Emergency (initial) treatment

for root fracture

1) Apical 1/3 withno mobility ordisplacement no treatment &healing will occur

follow-up.


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2)2) Mobility of the coronal segment.Mobility of the coronal segment.


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Prognosis depends on:

A.A.Amount of dislocation.Amount of dislocation.

B.B.Comunication between fractureComunication between fracture

site &site &

gingival sulcus.gingival sulcus.

C.C.Location & direction of fracture.Location & direction of fracture.

D.D.The quality of the treatment.The quality of the treatment.

* The healing of the fractured segments may


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take one of this form:

1- CALCIFIED HEALING : (CALLUS1- CALCIFIED HEALING : (CALLUSFORMATION):FORMATION):

If the fragments are in close positionIf the fragments are in close positionwith little mobility of the part andwith little mobility of the part andtooth with root. It is possible to get atooth with root. It is possible to get acalcified callus formation at fracturecalcified callus formation at fracture

site, both externally or the rootsite, both externally or the rootsurface and internally on the rootsurface and internally on the rootcanalcanal..

Mobility :Mobility : within limitswithin limits..


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2- CONNECTIVE TISSUE HEALING:

--If the fragments are separated orIf the fragments are separated or

some mobility of the tooth, formationsome mobility of the tooth, formation

of fibrosis attachment similar toof fibrosis attachment similar to

periodontal ligament , the fractureperiodontal ligament , the fracture

dentin surface may be lined bydentin surface may be lined bycementum.cementum.

-The sharp edges of fractured was-The sharp edges of fractured was

rounded by surface resorption.rounded by surface resorption.MobilityMobility :: little mobilitylittle mobility..

Vitality :Vitality : reduce level of responsereduce level of response


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3- COMBINATION BONE AND


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3 COMBINATION BONE ANDCONNECTIVE TISSUE HEALING:

-If the fragments are with further-If the fragments are with further

separation and possible mobility ofseparation and possible mobility of

broken part growth of new bonebroken part growth of new bonebetween fracture segments, thebetween fracture segments, the

fracture surface will be lined byfracture surface will be lined by

cementum with periodontal ligamentscementum with periodontal ligaments

between tooth and new bonebetween tooth and new bone..

Mobility :Mobility :quite firm.quite firm.


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4-HEALING WITH NON UNION ANDGRANULATION TISSUE FORMATION


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GRANULATION TISSUE FORMATION:

1-When there is severe dislocation of1-When there is severe dislocation of

fractured fragment and possiblefractured fragment and possible

contamination of the pulp with oralcontamination of the pulp with oral

fluids.fluids.

2-The incisal portion of the pulp undergo2-The incisal portion of the pulp undergo

necrosis and apical portion still vital.necrosis and apical portion still vital.

3- The necrotic pulp stimulate3- The necrotic pulp stimulateinflammation and granulation tissue ininflammation and granulation tissue in

the fracture line causing resorption ofthe fracture line causing resorption of

bone which may be extend to adjacentbone which may be extend to adjacent


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TREATMENT PHILOSOPHY OF


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TEETH WITH FRACTURED

ROOT.Horizontal Fracture

1-CERVICAL THIRD FRACTURE:


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A, Root fracture at or belowcrestal bone.

C,Cementation of a

B, Root canal therapy completed.B, Root canal therapy complete

D, Occlusal view; horizontal wireis bent tocross midline of the tooth to be

extruded.Wire


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Elastic is attached to activate extrusion.

F,When satisfactory extrusion

been completed, the tooth isstabilized until periodontal andbony repair are complete

eriodontal and bony repair completed. H, Permanent restoration.


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A- Crown-root fracture of a right central incisornecessitating orthodontic extrusion owing topalatal extension of fracture.

Note that the loose palatal segment (arrow)


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B-Adequate remaining tooth length allows useof the technique.


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C- One-visit root canal therapyperformed after removal of loose palatal

fragement.


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D -Extrusion hook cemented inprepared post space.


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E -Extrusion hookcemented in prepared


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F- Horizontal wire attached toadjacent teeth at desired positionby acid-etched composite.


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G-Activation elastic placed overhook and wire


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H- Two weeks later, the toothhas extruded the

desired distance.


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I- It is now stabilized for 8weeks by use of

ligature wire.

2- MIDDLE THIRD FRACTURE


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2 MIDDLE THIRD FRACTURE

I-in case of treated apical half.

first appointment:first appointment:

1- Rubber dam + intracoronal cavity1- Rubber dam + intracoronal cavitypreparation + Pulpectomy.preparation + Pulpectomy.

2- Enlargement the canal till size 70 -2- Enlargement the canal till size 70 -100100

3- Close with cotton + Zinc Oxide and3- Close with cotton + Zinc Oxide and

Eugenol.Eugenol.Second appointment:Second appointment:

1-Removal of Zinc Oxide and Eugenol.1-Removal of Zinc Oxide and Eugenol.

2- Obturate the canal .2- Obturate the canal .


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II-in case of Non-treated apical


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phalf.

1- Rubber dam + intra coronal cavity1- Rubber dam + intra coronal cavitypreparation +preparation +

pulpectomypulpectomy

2- Root canal enlargement till 70- 100 of2- Root canal enlargement till 70- 100 ofcervical portion.cervical portion.

3- Apicectomy and remove apical half.3- Apicectomy and remove apical half.

4- Select the4- Select the chrome- cobalt pinchrome- cobalt pin ((EndossiasEndossiaspinpin) smaller) smaller

than last file.than last file.

--


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3 APICAL THIRD FRACTURE:


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3- APICAL THIRD FRACTURE:

1- Root canal treatment .1- Root canal treatment .

2- Apicectomy.2- Apicectomy.

3- Retrograde amalgam.3- Retrograde amalgam.

4- Closed the cavity.4- Closed the cavity.

**Vertical root fracture.**Vertical root fracture.


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Vertical root fracture.

Extraction.Extraction.

New Classification W H ONew Classification W H ON 873 W ld H l h O i i f O l I j iN 873 W ld H lth O i ti f O l I j i


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No-873 World Health Organization of Oral InjuriNo-873 World Health Organization of Oral Injuri





873.64 Crown - Root fracture.873.66873.66 Tooth Luxation (dislocation, concussiTooth Luxation (dislocation, concussi



873.68873.68 Complete Avulsion.Complete Avulsion.

873.69873.69 Other injuries (Soft tissue or oral caviOther injuries (Soft tissue or oral cavi



5) Crown - root fracture:


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5) Crown root fracture:

C/R fracture may be:C/R fracture may be:A- Complicated

(pulp involvement).

B- Uncomplicated

(without pulp

involvement).


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Causes of C/R fracture

A.Trauma.

B.During obturation, due to

excessive force.

C.During post placement.

D.Large sized restoration.

Diagnosis of C/R fractureDiagnosis of C/R fracture


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Diagnosis of C/R fractureg /

1. Fragments may be loose & attached

only to the periodontal ligament.

2. Pain when loose fragments are

manipulated.

3. The fragments are easy to remove

& bleeding from the periodontal

ligament often fills the fracture

Treatment:


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Treatment:

1) All loose fragments must be removed1) All loose fragments must be removed

before the definite ttt can bebefore the definite ttt can bestarted.started.

2) If the fracture is incomplete &2) If the fracture is incomplete &

involves the crowninvolves the crown the crown isthe crown ismade to prevent the fracture frommade to prevent the fracture from

roceedin to involve the root.proceedin to involve the root.

The treatment is the same asThe treatment is the same as

li t d li t dli t d li t d


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complicated or uncomplicated crowncomplicated or uncomplicated crown

fracture.fracture.

The seriousness of the complicationsThe seriousness of the complications

depends on the apical extent of thedepends on the apical extent of the

attachment injury.attachment injury.


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If the apical extent of the fracture is

within 4 mm of the gingival crevice crown lengthening (gingivectomy &

alveoplasty).

If more than that & root is not too

short extrusion.


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New Classification W H ONew Classification W H ONo 873 World Health Organization of Oral InjuriNo 873 World Health Organization of Oral Injuri


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No-873 World Health Organization of Oral InjuriNo-873 World Health Organization of Oral Injuri





873.64873.64 Crown - Root fracture.Crown - Root fracture.873.66 Tooth Luxation (dislocation, concussisublaxation).


873.68873.68 Complete Avulsion.Complete Avulsion.

873.69873.69 Other injuries (Soft tissue or oral caviOther injuries (Soft tissue or oral cavi




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6- Tooth luxation

The goal in treatment of luxation

injuries is to promote the

recovery of both the pulp &

periodontal health, but

realistically except in young,

immature teeth, pulp recovery

is not likely to occur as

(a) Concussion:


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(a) Concussion:--The blowThe blow

(Trauma) to the(Trauma) to thetooth may betooth may besufficient tosufficient tocause bleedingcause bleeding

in periodontalin periodontalligament andligament andpulpal edema.pulpal edema.

-The increased-The increasedfluid influid inperiodontalperiodontalligamentligamentpressure ofpressure of

masticationmastication

DIAGNOSIS:E.P.T: positive response


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p pMobility: Normal mobility.

Percussion: Tooth tender to percussion

TREATMENT :- adjusting the tooth slightly out of- adjusting the tooth slightly out of

occlusion.occlusion.

FOLLOW UP :

- E.P.T for vitality should be repeated at1,3,6,12 monthintervals.

-If tooth initially respond positive


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(B) Subluxation:


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( )

When a tooth, as a

result oftrauma, is sensitive topercussionand has increasedmobility, it isclassified assubluxated.

Electric pulp testresults may be eitherno response orpositive; if they are the

former, damage to the

DIAGNOSIS:E P T: Negative or positive response


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E.P.T: Negative or positive responseMobility: Increase mobility.

Percussion: Tooth tender to percussion

TREATMENT :1. Treatment initially may be none, except to

allow tooth to rest.2. Sometimes it is necessary to stabilize toothfor a short period of time (2-3 weeks) topromote periodontal ligament recovery.

3. Needs long term follow up.

FOLLOW UP :- E.P.T for vitality should be repeated at 1,3,6,12

month intervals.-


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(C) Lateral luxation.


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Traumatic injuries may result inTraumatic injuries may result in

displacement of a tooth labially, lingually,displacement of a tooth labially, lingually,

distally, or mesially Such displacement isdistally, or mesially Such displacement is

called lateral luxation, and it is often verycalled lateral luxation, and it is often very

painful, particularly when thepainful, particularly when thedisplacement results in the tooth beingdisplacement results in the tooth being

moved into a position of prematuremoved into a position of premature

occlusion.occlusion.An example of such lateral luxation is whenAn example of such lateral luxation is when

a maxillary incisor is pushed palatally. Thea maxillary incisor is pushed palatally. The

crown makes occlusal contact long beforecrown makes occlusal contact long before

DIAGNOSIS:


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E.P.T: Negative orpositive responseMobil ity:

Increase mobility.

Percussion:Tender to percussion

Displacement:Horizontaldisplacement

Treatment:


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A) Immediate repositioning of the

teeth, then splinting for 2-6weeks.

B) Definite treatment is root canalB) Definite treatment is root canal


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B) Definite treatment is root canalB) Definite treatment is root canal

treatment &treatment & Ca(OH)Ca(OH)22 is put in 1-2is put in 1-2

weeks after theweeks after theinjury for a period of 6-12 monthinjury for a period of 6-12 month

New Classification W H ONew Classification W H O

No-873 World Health Organization of OralNo-873 World Health Organization of Oral


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No 873 World Health Organization of OralNo 873 World Health Organization of OralInjuries.Injuries.

873.60 Enamel fracture.873.60 Enamel fracture.873.61873.61 Crown fracture without pulpCrown fracture without pulp

involvement.involvement.

873.62873.62 Crown fracture with pulp involvemCrown fracture with pulp involvem

873.63873.63 Root Fracture.Root Fracture.873.64873.64 Crown - Root fracture.Crown - Root fracture.

873.66873.66 Tooth Luxation (dislocation,Tooth Luxation (dislocation,concussion, sublaxation).concussion, sublaxation).

873.67873.67 Intrusion and Extrusion.Intrusion and Extrusion.873.68873.68 Complete Avulsion.Complete Avulsion.

873.69873.69 Other injuries (Soft tissue or oralOther injuries (Soft tissue or oralcavity).cavity).

802.20802.20 Fracture or communication of alveFracture or communication of alve

1-Extrusion1-Extrusion


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DIAGNOSIS:IAGNOSIS:


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E.P.T.:.P.T.:response.response.

Radiography:adiography:Exhibit marked increase periodontal ligaments apically.Exhibit marked increase periodontal ligaments apically.

Clinical Examination :linical Examination :1- There is difference in the incisal level with adjacent .1- There is difference in the incisal level with adjacent .

2-2- Mobilityobility : It is slightly mobile.It is slightly mobile.3-3- Percussionercussion : Sensitive to percussionSensitive to percussion.4- There is some bleeding from socket (due to injury4- There is some bleeding from socket (due to injury

of periodontal ligaments).of periodontal ligaments).

TREATMENT :TREATMENT :


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I- Minor (Slight) Extrusion: (less than 5mm).- Minor (Slight) Extrusion: (less than 5mm).-slight grinding of insical edge to restore-slight grinding of insical edge to restore

the incisal levelthe incisal levelII- Major (Great) Extrusion : (more thanI- Major (Great) Extrusion : (more than5mm).mm). 1-Small semilunar incision is made an1-Small semilunar incision is made an

opening through alveolar cortical plateopening through alveolar cortical plateof the bone at level of root apex with Nof the bone at level of root apex with Noo6 round bur.6 round bur.

2- The blood is related and Tooth is2- The blood is related and Tooth is

pushed into normal positionpushed into normal positionN.B. Sometimes when pushing the tooth itN.B. Sometimes when pushing the tooth it

resist the push due to formation ofresist the push due to formation ofblood clot in the socket.blood clot in the socket.

-3-S lintin the offendin tooth for six


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2) Intrusion.2) Intrusion.


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Intrusion of teeth ranges from slight infr-Intrusion of teeth ranges from slight infr-

occlusion to total disappearance.occlusion to total disappearance.

DIAGNOSIS:DIAGNOSIS:

1 Vi l i i1 Vi l i ti h i


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1-Visual examination1-Visual examination ::There isThere isdifference in incisal level withdifference in incisal level with

adjacent.adjacent.

2-Mobility :2-Mobility :It is firmly wedged in bone,It is firmly wedged in bone,that is not mobilethat is not mobile

3-Percussion:3-Percussion:give hard and harshgive hard and harshsound in compared to normal tooth.sound in compared to normal tooth.

4-Radiograph4-Radiograph :: May show loss ofMay show loss of

periodontal space.periodontal space.

N.B. Sometimes central incisor isN.B. Sometimes central incisor is

completely intruded and it maycompletely intruded and it may

TREATMENT:TREATMENT:


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TREATMENT:TREATMENT:

A-Minor (Slight) Intrusion:A-Minor (Slight) Intrusion:

1- After period of time it may erupted to1- After period of time it may erupted to

its normal position.its normal position.

2- If not, by applying finger spring2- If not, by applying finger spring

cemented to labial surfaces.cemented to labial surfaces.

B- Major (Great) Intrusion:B- Major (Great) Intrusion:

-By retract the tooth by forceps.-By retract the tooth by forceps.

ENDODONTIC TREATMENT:ENDODONTIC TREATMENT:I-TOOTH WITH COMPLETE ROOT FORMATIONI-TOOTH WITH COMPLETE ROOT FORMATION::


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There are several factor may beThere are several factor may be

helpful in deciding whether or nothelpful in deciding whether or notto enter the canal, the primaryto enter the canal, the primaryfactor is to determine pulpalfactor is to determine pulpalnecrosis.necrosis.

1-In Major displacement1-In Major displacement (over 5mm) or(over 5mm) or

intrusive injuries , pulpal necrosisintrusive injuries , pulpal necrosis

therefore root canal treatment istherefore root canal treatment is

indicated, and applying Coat asindicated, and applying Coat astemporary filling to prevent roottemporary filling to prevent root

rosorption.rosorption.

2-While2-While in Minor displacementin Minor displacement (under(under

5mm need no emer enc root canal5mm need no emer enc root canal


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II- TOOTH WITH INCOMPLETE ROOT FORMATION:II- TOOTH WITH INCOMPLETE ROOT FORMATION:


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1-A displaced tooth with incomplete1-A displaced tooth with incomplete

developed root has better prognosisdeveloped root has better prognosis

for pulpal survival, Retention of vitalfor pulpal survival, Retention of vital

pulp enhance normal development ofpulp enhance normal development ofroot.root.

2-On the other hand, inflammation root2-On the other hand, inflammation root

resorption in immature tooth progressresorption in immature tooth progressmore rapidly.more rapidly.

3-When decision is made that pulp3-When decision is made that pulp

3) Avulsion.3) Avulsion.


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1-It is occurs when traumatic injury1-It is occurs when traumatic injury

totally displace tooth from sockettotally displace tooth from socket


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totally displace tooth from socket.totally displace tooth from socket.

2-Permanent dentition 1-16% ,2-Permanent dentition 1-16% ,Deciduous 7 - 13%.Deciduous 7 - 13%.

3-Age: 7 - 11 years.3-Age: 7 - 11 years.

4-Sex: Male >3 females.4-Sex: Male >3 females.5-Tooth : central incisors.5-Tooth : central incisors.

6-Jaws : Maxilla > mandible.6-Jaws : Maxilla > mandible.

7-The prognosis of replanted tooth still7-The prognosis of replanted tooth stillvery poor.very poor.

8-The sooner the implantation is carried8-The sooner the implantation is carried

out after accident the more favorableout after accident the more favorable

FACTORS AFFECTING THE SUCCESS OF REPLANTATIONFACTORS AFFECTING THE SUCCESS OF REPLANTATION ::


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1- EXTRA - ORAL TIME.- EXTRA - ORAL TIME.1-The shorter the extra-oral time the1-The shorter the extra-oral time the

better the prognosis.better the prognosis.

2-90% of teeth replanted before 302-90% of teeth replanted before 30

minutes give no root resorption.minutes give no root resorption.

3- While 95% of teeth replanted after3- While 95% of teeth replanted after

2 hours ,lead to root resorption.2 hours ,lead to root resorption.

4-The critical time for dry storage 304-The critical time for dry storage 30minutes.minutes.

5-Replantation after 60 minute in dry5-Replantation after 60 minute in dry

2-STORAGE MEDIA:2-STORAGE MEDIA:


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1-The storage media is critical if1-The storage media is critical if

immediate replanation is impossibleimmediate replanation is impossible

2-The tooth should be stored in2-The tooth should be stored in

physiologic medium ,to prevent furtherphysiologic medium ,to prevent furtherinjury to periodontal ligaments cells.injury to periodontal ligaments cells.

3-Under no circumstance the tooth3-Under no circumstance the tooth

allowed to dry because, drynessallowed to dry because, dryness

accelerate cellular necrosis.accelerate cellular necrosis.

4-The importance of storage media to4-The importance of storage media to

5- The storage media include:5- The storage media include:

a-Milk:a-Milk:is the best storage media superioris the best storage media superior


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a Milk:a Milk:is the best storage media superioris the best storage media superiorthan saliva because Physiologicthan saliva because Physiologic

osmolality, Composition, and availability.osmolality, Composition, and availability.mitotic activity of periodontal cellmitotic activity of periodontal cellmaintained for 6 hours in Milk.maintained for 6 hours in Milk.

b-Normal saline:b-Normal saline: is best storage media thanis best storage media than

saliva - but it is less available than milk.saliva - but it is less available than milk.some investigators, storage of tooth insome investigators, storage of tooth in

saline give much more resorption thansaline give much more resorption thanmilk.milk.

c-Saliva:c-Saliva: is the last choice when other areis the last choice when other arenot available.not available.

some investigators: storage of tooth insome investigators: storage of tooth insaliva for 2 - 3 hour cases swelling andsaliva for 2 - 3 hour cases swelling and

Storage media in ascending order ofStorage media in ascending order of


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A.A. Water.Water.

B.B. Saliva.Saliva.

C.C. Saline.Saline.

D.D. Milk.Milk.

g gg g

desirabilitydesirability


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E.E. Hanks balanced salt solutionHanks balanced salt solution

(HBSS) (cell culture media)(HBSS) (cell culture media)

F.F. Via-span:Via-span: Media used forMedia used for

transplantation operation.transplantation operation.

3-PRESERVATION OF THE-PRESERVATION OF THEPERIODONTAL LIGAMENTS ANDERIODONTAL LIGAMENTS AND


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RESORPTION :ESORPTION :1- Healing with normal periodontal1- Healing with normal periodontal

ligaments is not achieved when itligaments is not achieved when it

replanted with necrotic periodontalreplanted with necrotic periodontal

membrane , ankylosis develop as themembrane , ankylosis develop as the

necrotic tissue are replaced by bonenecrotic tissue are replaced by boneformation.formation.

2-If the periodontal ligaments replaced2-If the periodontal ligaments replaced

before replantation, extensivebefore replantation, extensivereplacement resorption.replacement resorption.

3- Following replantation a clot formed in3- Following replantation a clot formed in

periodontal ligaments healing beginsperiodontal ligaments healing begins

TREATMENT:TREATMENT:A- Tooth with Incomplete root formationA- Tooth with Incomp

lete root formation


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1-Revascularization may occur following1-Revascularization may occur following

replantation, pulp removal should bereplantation, pulp removal should bedelayed until pulpal necrosis are evident.delayed until pulpal necrosis are evident.

2-If signs of pulpal necrosis occur2-If signs of pulpal necrosis occur

immediate root canal treatment followingimmediate root canal treatment followingreplantation and splinting.replantation and splinting.

3- It is possible that root formed following3- It is possible that root formed following

revascularization.revascularization.4- In some cases, root formation ceases and4- In some cases, root formation ceases and

obliteration of the canal by dentin orobliteration of the canal by dentin or

bonebone

The immature tooth might revascularize, soThe immature tooth might revascularize, so

l i li i & l f ll i


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replantation, splinting & long term follow up isreplantation, splinting & long term follow up is

necessarynecessary..

B- Tooth with Complete Root Formation:B- Tooth with Comp

lete Root Formation:


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-There are 2 theories about root-There are 2 theories about root

canal treatmentcanal treatment beforebefore oror afterafterreplantation:replantation:

First Theory : R C T beforeFirst Theory : R C T beforereplantation.replantation.

1-The tooth should be endodontically1-The tooth should be endodonticallytreated (pulpectomy) beforetreated (pulpectomy) before

replantation because,if the tooth notreplantation because,if the tooth nottreated the usual sequel are pulptreated the usual sequel are pulpnecrosis of inflammation resorption.necrosis of inflammation resorption.

N B i ti t b li d th t itN B i ti t b li d th t it


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N.B. :some investigators believed that itsN.B. :some investigators believed that its

wrong because:wrong because:

a- Further damage to periodontal ligamenta- Further damage to periodontal ligament

from handling the tooth.from handling the tooth.

b- Exposure to chemical during theb- Exposure to chemical during the

procedures.procedures.

c- Bacterial contamination.c- Bacterial contamination.

d- Prolonged extra- oral time.d- Prolonged extra- oral time.

Second Theory : R C T afterSecond Theory

: R C T afterreplantation.rep

lantation.


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pp

1-The tooth should be endodontically1-The tooth should be endodonticallytreated (pulpectomy) aftertreated (pulpectomy) after

replantation to prevent inflammationreplantation to prevent inflammation

root resorption within 1-2 weekroot resorption within 1-2 weekfollowing resorption.following resorption.

2-This achieved through the splint2-This achieved through the splint

placed during emergency treatmentplaced during emergency treatment

appointment, thus the tooth will notappointment, thus the tooth will not

be firmly attached, extirpation duebe firmly attached, extirpation due


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Under favorable conditions, manyUnder favorable conditions, many

replanted teeth are retained for 5-10replanted teeth are retained for 5-10

years & few for a lifetime, othersyears & few for a lifetime, others

however fail soon after replantation.however fail soon after replantation.

*REPLANTATION TECHNIQUE*REPLANTATION TECHNIQUE

1 Clean the socket to remo e the clotted1 Clean the socket to remove the clotted


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1-Clean the socket to remove the clotted1-Clean the socket to remove the clotted

blood and any foreign materials byblood and any foreign materials bygentile curettage:gentile curettage:

A- within 30 minutes-2h irrigationA- within 30 minutes-2h irrigationwith normal saline.with normal saline.

B- More than 2h the toothB- More than 2h the toothimmersed for 20 minute at 2.4%immersed for 20 minute at 2.4%phosphate solution fluoridephosphate solution fluoride

(P.H.5.5) for prevent root(P.H.5.5) for prevent rootresorption or ankylosis.resorption or ankylosis.

2-Make a small surgical vent (opening) to2-Make a small surgical vent (opening) to

Handling of tooth during extra-oral time:Handling of tooth during extra-oral time:


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Avoid scrubbing the tooth & handleAvoid scrubbing the tooth & handle

the tooth by holding the crown.the tooth by holding the crown.


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Examination of the socket.Examination of the socket.

4-The alveolar plate should be4-The alveolar plate should be

squeezed firmly against the toothsqueezed firmly against the tooth


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squeezed firmly against the toothsqueezed firmly against the tooth

with digital pressure.with digital pressure.

5-A radiograph should be exposed5-A radiograph should be exposed

to verify the adequacy ofto verify the adequacy of

resorption.resorption.

6-Any soft tissue lacerations are6-Any soft tissue lacerations are

sutured to arrest seepage ofsutured to arrest seepage of

hemorrhage prior to splinting.hemorrhage prior to splinting.

7-The affecting tooth should be out7-The affecting tooth should be out

of occlusion by grinding theof occlusion by grinding the

opposite tooth.opposite tooth.

Replantation of the tooth & splintingReplantation of the tooth & splinting


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p p gp p g

for 1-2 weeks.for 1-2 weeks.

8-ANTIBIOTICS :8-ANTIBIOTICS :

The systemic administration ofThe systemic administration of


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The systemic administration ofThe systemic administration of

antibiotic at the time of and during theantibiotic at the time of and during the

first week following replantation hasfirst week following replantation has

been shown to prevent invasion of thebeen shown to prevent invasion of the

necrotic pulp.necrotic pulp.

9-TETANUS PROPHYLAXASIS:9-TETANUS PROPHYLAXASIS:

if the wound or avulsed teeth has beenif the wound or avulsed teeth has been

contaminated with soil, the patient mustcontaminated with soil, the patient must

receive tetanus injection.receive tetanus injection.

10-The Patient asked to avoid using the10-The Patient asked to avoid using the

offending tooth for 2-3 weeksoffending tooth for 2-3 weeks

FOLLOW UP:FOLLOW UP:


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1-Radiograph :1-Radiograph :Carefully for anyCarefully for anypathosis.pathosis.

2-Discoloration:2-Discoloration:Checked by oralChecked by oralexamination for colour change.examination for colour change.

3-E.P.T:3-E.P.T:Unreliable in teeth withUnreliable in teeth withincompletely formed root.incompletely formed root.

4-Mobility:4-Mobility:Negative response.Negative response.

5-Percussion :5-Percussion :Negative response.Negative response.6-Repair:6-Repair:Functional repair of pulpFunctional repair of pulp

nerve fiber are re-established within 35nerve fiber are re-established within 35

daysdays

HEALING OF THE AVULSEDHEALING OF THE AVULSED

TOOTH :TOOTH :


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TOOTH :TOOTH :

1-HEALING WITH A NORMAL PERIODONTAL1-HEALING WITH A NORMAL PERIODONTALLIGAMENT :LIGAMENT :

1-Complete repair of periodontal1-Complete repair of periodontal

ligament occur with this type ofligament occur with this type ofhealing, without significanthealing, without significantinflammation change.inflammation change.

2-Small area of resorption2-Small area of resorptionrepresenting localized areas ofrepresenting localized areas ofdamage to periodontal ligamentdamage to periodontal ligamenttermed surface resorption, thesetermed surface resorption, theseusually involve cementum butusually involve cementum but

Healing with normal periodontal ligament.Healing with normal periodontal ligament.


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2-HEALING WITH ANKYLOSIS OR2-HEALING WITH ANKYLOSIS OR

REPLACEMENT RESORPTION:REPLACEMENT RESORPTION:


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1-Ankylosis occurs when areas of root1-Ankylosis occurs when areas of rootresorption are repaired by deposition ofresorption are repaired by deposition ofbone, resulting in fusion of root surfacebone, resulting in fusion of root surfaceand alveolar bone.and alveolar bone.

2-Etiology :2-Etiology : related to observe of vitalrelated to observe of vitalperiodontal ligament or root surface,periodontal ligament or root surface,Progenitor cells (UndifferentiatedProgenitor cells (UndifferentiatedMesencymle Cell) with osteogenicMesencymle Cell) with osteogenic

potential from adjacent bone marrowpotential from adjacent bone marrowmigrate into damaged area and formedmigrate into damaged area and formedankylosis.ankylosis.

3-In minor injuries to periodontal ligament3-In minor injuries to periodontal ligament

4-Observed histologically after 2 weeks4-Observed histologically after 2 weeks


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and radiographically after 2 months.and radiographically after 2 months.

55-Radiographically show-Radiographically show::

Absence of normal R.L of periapicalAbsence of normal R.L of periapical

space.space.

Surface resorption:Surface resorption:


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Small superficial cavities in cementum andSmall superficial cavities in cementum and

outermost dentin.outermost dentin.

(B) Resorption of cementum & dentin, until(B) Resorption of cementum & dentin, until


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loss of the tooth.loss of the tooth.

3- INFLAMMATORY RESORPTION3- INFLAMMATORY RESORPTION::


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1-Granulation tissue in the1-Granulation tissue in the

periodontal ligament adjacent toperiodontal ligament adjacent tolarge areas of root resorption.large areas of root resorption.

2-Occur on root surface adjacent to2-Occur on root surface adjacent to

areas of damage to periodontalareas of damage to periodontalligaments or drying ofligaments or drying of

periodontal ligament beforeperiodontal ligament before

replantation.replantation.3-Etiology:3-Etiology: A toxic products andA toxic products and

bacteria penetrating from rootbacteria penetrating from root

canal throu h dentinal tubule intocanal throu h dentinal tubule into

4-If these teeth is not endodontically4-If these teeth is not endodonticallytreatment immediately, it will be apicallytreatment immediately, it will be apicallyresorped resulting in loss of toothresorped resulting in loss of tooth


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resorped resulting in loss of tooth.resorped resulting in loss of tooth.

5-They can be demonstrated 1 week after5-They can be demonstrated 1 week afterreplantation and it will be progressive ifreplantation and it will be progressive ifit not endodontically treatment.it not endodontically treatment.

6-The inflammation resorption dependent6-The inflammation resorption dependentin four condition :in four condition :

a-Injury of periodontal ligaments.a-Injury of periodontal ligaments.b- Exposure of dentinal tubule.b- Exposure of dentinal tubule.

c-Communication of exposed tubulesc-Communication of exposed tubules

with necrotic ul or with leaka ewith necrotic ul or with leaka e

7-The inflammation resorption a the7-The inflammation resorption a the

mechanism of elimination infectedmechanism of elimination infectedl ifi d i f h b d b


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calcified tissue from the body bycalcified tissue from the body by

action of osteoclasts, which isaction of osteoclasts, which isspecialized macrophage activityspecialized macrophage activity

participate in the healing process toparticipate in the healing process to

repair traumatized tooth and bone.repair traumatized tooth and bone.

8-These inflammation resorption is8-These inflammation resorption is

difficult to eliminate once it begins, ifdifficult to eliminate once it begins, ifendodontically treatment delayedendodontically treatment delayed

more than 3 weeks followingmore than 3 weeks following

replantation.replantation.

Inflammatory resorption:Inflammatory resorption:


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Root canal therapy can be expected to arrest inflammatoryRoot canal therapy can be expected to arrest inflammatory

resorption that involves replanted teeth.resorption that involves replanted teeth.


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trauma hossam khalifa

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