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Dental Injuries

Traumatic Dental Injuries

Introduction

Traumatic dental injury (TDI) is any injury to the teeth and the surrounding periodontium and soft tissues. It is usually sudden, impactful, circumstantial and accidental. It is common in children and young adults.

Classification of traumatic dental injuries is proposed by various authors.

Ellis and Davey classification (1960):

Traumatic Dental Injuries

Class I – simple crown fracture without involving dentin

Class II – extensive crown fracture involving enamel and dentin without involving pulp

Class III – extensive crown fracture with pulp exposure

Class IV – non vital tooth (with or without any fracture)

Class V – avulsed tooth

Class VI – root fracture with or without crown fracture

Class VII – displacement of tooth without fracture

Class VIII – crown en masse

Class IX – primary tooth fracture

Andreason’s classification (1981)

  1. Injuries to the hard dental tissues and pulp

  • Enamel infraction: incomplete fracture or cracks in enamel

  • Enamel fracture: uncomplicated crown fracture

  • Enamel – dentin fracture: uncomplicated crown fracture

  • Complicated crown fracture: involving enamel and dentin with pulp exposure

  • Uncomplicated crown – root fracture: involving enamel, dentin and cementum without pulp exposure

  • Complicated crown – root fracture: involving enamel, dentin and cementum with pulp exposure

  • Root fracture: involving dentin, cementum and pulp

Traumatic Dental Injuries

Image source: Skaare & Jacobsen 2003 

  1. Injuries to periodontal tissues

  • Concussion: injury to supporting structures without abnormal loosening or displacement of tooth

  • Subluxation: injury to supporting structures abnormal loosening without displacement of tooth

  • Extrusive luxation: partial displacement of tooth out of socket

  • Lateral luxation: displacement of tooth in any direction other than axial

  • Intrusive luxation (central dislocation): displacement into the socket

  • Avulsion (exarticulation): complete displacement out of socket

Traumatic Dental Injuries

Image source: Skaare & Jacobsen 2003 

  1. Injuries to supporting bone

  • Comminution of mandibular or maxillary alveolar socket: crushing or compression of socket

  • Fracture of mandibular or maxillary socket wall: fracture of facial or lingual wall

  • Fracture of mandibular or maxillary alveolar process: involving base of mandible or maxilla

  1. Injuries to gingiva or oral mucosa

  • Laceration: shallow or deep wound leading to tear of mucosa; by a sharp object

  • Contusion: bruise due to impact of blunt object

  • Abrasion: due to rubbing of mucosa – a superficial wound 

Treatment options

  • Initial clinical examination

  • Radiographic examination

  • Pulp status evaluation

  • Stabilisation

  • Treatment 

  • Follow up

Fracture

Features

Treatment

Enamel infarction

  • Crack or crazing of enamel without loss of tooth structure

  • No treatment is required

  • In case of severe infarction, etching, sealing with restorative resins

Uncomplicated crown fracture – enamel only

  • Loss of enamel without dentin exposure

  • Search for enamel piece

  • Radiograph to check the extend of fracture

  • If tooth fragment is available, it can be bonded back or else composite restoration is done

Uncomplicated crown fracture – enamel and dentin

  • Mild sensitivity due to exposed dentin

  • Radiograph to check the extend of fracture

  • If tooth fragment is available, it is rehydrated by soaking in saline for 20 mins and bonded back.

  • If not, glass ionomer lining and tooth is built back using composite

  • If the remaining dentin is less than 0.5mm, a calcium hydroxide lining is placed

Complicated crown fracture

  • Exposed pulp is sensitive to stimuli

  • Radiograph is required.

  • For immature roots, partial pulpotomy or pulp capping is recommended

  • Conservative pulp treatment is recommended.

  • Root canal treatment is done is the pulp is necrosed.

  • Recontruction of tooth with composite or crown.

Uncomplicated crown – root fracture

  • Tender on percussion

  • Coronal fragment is mobile

  • Radiographs to find the extend of fracture

  • Removal of mobile coronal fragment and subsequent restoration with GIC lining.

Complicated crown root fracture

  • Tender on percussion

  • Coronal fragment is mobile

  • Radiographs to find the extend of fracture

  • For immature roots, partial pulpotomy or pulp capping is recommended.

  • For mature teeth, pulp removal is recommended.

  • GIC lining and subsequent restoration

Root fracture

  • Coronal segment may be mobile or displaced

  • Bleeding from gingival sulcus

  • Fracture can be horizontal, oblique, or both

  • Fracture location uysing radiograph

  • If displaced, coronal fragment is repositioned, stabilised with passive splint for 4 weeks.

  • No endodontic treatment should be started at emergency visit

Alveolar fracture

  • Fracture involving alveolar bone and may extend to adjacent bones.

  • Segment mobility, displacement

  • Occlusal disturbances

  • Reposition and stabilise the displaced segment by passive splinting for 4 weeks


Concussion

  • Tender on percussion and touch

  • No treatment is required

Subluxation

  • Injury to tooth supporting structures with abnormal loosening with no displacement.

  • Bleeding of gingiva present

  • No treatment is required

Extrusive luxation

  • Displacement of tooth out of socket in incisal direction

  • Increased mobility

  • Tooth appear to be elongated

  • Reposition and stabilisation with passive splint for 2 weeks

  • Monitor the pulp vitality

Lateral luxation

  • Displacement of tooth in any direction other than axial.

  • It may be associated with alveolar bone fracture

  • High metallic sound on percussion

  • Radiograph is required

  • Reposition and stabilisation with passive splint for 4 weeks

  • Monitor the pulp vitality

Intrusive luxation

  • Displacement of tooth in apical direction

  • CEJ shifts apically.

  • Obliterated PDL space

  • Tooth is immobile

  • High metallic sound on percussion

  • Allow spontaneous reposition if intrusion is less than 3mm. if no re-eruption after 8 weeks, surgically reposition and stabilise with passive splint for 4 weeks

  • If intruded for 3-7mm, reposition surgically or orthodontically

  • If intruded beyond 7mm, reposition surgically


Avulsion

Traumatic Dental Injuries

Traumatic Dental Injuries



 

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