Dental traumatology: essential diagnosis and treatment planning

2004, Endodontic Topics

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21 pages

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Traumatic dental injuries are for the most part unanticipated events that, if not managed appropriately, can have serious consequences for the patient. The purpose of this review is to describe the current concepts in establishing diagnosis descriptive of specific traumatic entities, and to delineate recommended treatment approaches for these injuries based on available evidence.

Figures (19)

Fig. 1. Basic types of dental traumatic injuries: Separation injury (a) and crushing injury (b). (a) Displacement of the tooth away from the socket wall, such as in extrusive luxations and avulsions, results in separation of the periodontal ligament fibers. (b) When a tooth is forced against the socket wall, such as in intrusive and lateral luxation injuries, the periodontal ligament fibers and associated cells are crushed, causing extensive damage. (From Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Traumatic Dental Injuries. A Manual, 2nd edn, Oxford, UK: Blackwell Munksgaard, 2000: 10)

Fig. 2. Penetrating lip wound containing foreign object (tooth fragment). (a) When a tooth fractures, pieces of it may penetrate soft tissue such as lips. (b) Ifa soft tissue wound is present, a radiograph of the area should be taken (reduce the expose to about 25% of normal). (c) Ifa foreign object is noted (such as a piece of tooth), it should be removed as soon as possible to prevent it from becoming encapsulated in fibrotic tissue. during examination because the typical single exposure fails to demonstrate diagonal root frac- tures (Fig. 3). Another application of radiography is to examine for the presence of impacted foreign bodies in penetrating soft tissue wounds. It is not possible to detect by Another application of radiography is to examine for

Fig. 3. Radiographic examination for possible root fractures should include at least one steep occlusal exposure in addition to the conventional 90° angulation exposure. The following illustrations demonstrate the importance of this concept. (a) A tooth with a diagonal midroot fracture was extracted. The fracture line on the labial root surface can be seen (arrow). (b) The diagonal nature of the fracture can be seen on the lateral surface of the root (arrow). (c) Radiographic film exposed at 90° angulation fails to show any fracture line. (d) Lateral view of the root shows the fracture (because the X-rays are parallel to the fracture). Such an angulation is not possible, however, in a clinical setting. (e). By changing the angulation, to simulate a steep occlusal one, the fracture line is readily noted.

Fig. 4. Failure to treat. The maxillary right central incisor had been avulsed in a sports accident and replanted within 15min about 18 months prior to radiographic examination shown in this image. Note the extensive resorption (infection-related) of the root and the apical lesion. Timely endodontic treatment could have prevented the resorption and subsequent loss of this tooth. period for traumatic dental injuries; some may require

Fig. 5. Healed root fractured teeth in risk of extraction. A 12-year-old boy visited a dentist for the first time. All the teeth were examined radiographically, including the maxillary central incisors, which, according to his mother, had been injured 3 years earlier in an accident. The teeth were asymptomatic, functional and acceptable in appearance, yet both the examining dentist and a subsequent consulting oral and maxillofacial surgeon recommended extraction of both teeth based on the radiographic appearance. Fortunately for the boy, his mother sought additional consultation and was advised by a dentist more familiar with dental trauma that neither tooth should be extracted. (a) The photographs show central incisors. (b) The radiograph indicates that the root fractures have healed satisfactorily.

Fig.6. Examples of pulp necrosis as a result of trauma severing the blood supply to the pulp. (a) Coagulation necrosis occurs when the pulp is deprived of blood. The tissue gradually disintegrates. This photomicrograph shows pulp tissue undergoing coagulation necrosis. (H&E x 100) (b) When pulp tissue which has undergone coagulation necrosis is exposed to bacteria, gangrenous necrosis results. Such necrosis can result in rapid proliferation of bacteria in the tissue lacking any defense capability (as a result of the severed blood supply). A colony of bacteria can be seen growing on a piece of pulp tissue removed for experimental purposes (H&E x 100).

Fig. 7. Cervical root fracture. (a) The preoperative radiograph of the right lateral incisor in a 12-year-old boy at the beginning of orthodontic treatment. The tooth had been luxated about 4 years earlier and had received no previous treatment. The pulp is now necrotic and a large periradicular lesion is present. Apexification procedure using calcium hydroxide was started. (b) Fifteen months later the lesion has filled in with new bone and there is evidence of apical closure. The patient was scheduled for completion of root canal treatment. (c) Before the appointment to fill the canal, the boy was in a ‘pillow fight’ with a sibling and the tooth received a mild injury, resulting in cervical fracture, even though the tooth was in part protected by the orthodontic appliance. This case illustrates how susceptible teeth, such as this, are to cervical fracture. Repair-related resorption (also described as surface resorption) is a transient process involving small areas on the root surface following luxation and avulsion injuries and can also be observed associated with root fracture injuries (23). Typically, diagnosis can be made within 4 weeks after injury. As long as conditions are right for healing, that is, absence of bacteria in the root (inflammatory) root resorption (23). This risk empha-

Fig.9. Replacement ankylosis-related resorption. (a) Replacement resorption and ankylosis occurring shortly aftes replantation of a left maxillary central incisor which had been dry for more than 1h prior to replantation. Note th« disappearance of PDL, indicating bony fusion with tooth structure. (b) The same tooth 20 months later shows almost complete loss of root structure.

Fig. 10. Reorganization of disrupted PDL fibers. (a) Photomicrograph of PDL after orthodontic extrusion of a tooth in a dog. Note the disarray of fibers (H&E x 100). (b) Photomicrograph of another tooth that also had been extruded, taken after 6 weeks of stabilization. Note the regular arrangement of fibers (H&E x 100).

Fig. 11. Bonding fractured crown. (a) Photo showing maxillary left central incisor of an 8-year-old boy who fractured the tooth in an accident. (b) His mother saved the broken fragment allowing it to be rebonded. (c) Radiograph shows development stage of the tooth; protecting the pulp by bonding the crown fragment is desirable. (d) Photo shows result of bonding. The fracture line can be additionally covered with composite resin. (e) Radiograph 8 months later shows continued root development with apical closure, indicating normal pulpal function. (Courtesy of Dr Todd Milledge, pediatric dentistry, Loma Linda University, Loma Linda, CA, USA.)

Fig. 12. The use of mineral trioxide aggregate (MTA) for vital pulp therapy. (a) Two fractured central incisors in an 8- year-old boy who suffered a traumatic accident. The pulps in both teeth were exposed. (b) Radiograph shows initial treatment with MTA in the right incisor; the same procedure was performed on the left incisor. (c) Radiograph of the two incisors 3 years post-treatment. Note the continued root development indicating normal pulpal function in both teeth.

Fig. 13. Crown-root fracture of maxillary left central incisor in a 6-year-old boy who fell off a swing and hit the tooth on a rock. (a) Photo shows the appearance typical of crown-root fractures: Broken, loose crown pieces still attached to PDL. (b) The radiograph shows early development stage of the tooth. Crown root fractures are a severe challenge to manage in young patients with developing roots. The goal is to make every effort to protect the pulp to allow continued root development.

Fig. 14. Ankylosis-related resorption of intruded maxillary left central incisor. (a) Note the extensive infraocclusion as a result of ankylosis at the time of significant growth including the alveolar processes and eruption of adjacent teeth. (b) Radiograph of the tooth pictured in A; interestingly, the pulp survived the traumatic injury, but the PDL and cementum were damaged, allowing ankylosis-related resorption.

Fig. 15. Intrusive luxation of developing tooth in a 6-year-old boy. (a) Photo taken immediately after intrusion of maxillary left central incisor. (b) Radiograph taken at the time of examination showing very early stages of development of the incisors. Re-eruption is the ideal outcome. (c) Photo taken 6 weeks after intrusion showing satisfactory re- eruption of the intruded tooth, which in time reached the same level of eruption as the adjacent incisor.

Clinical examination form for the time of injury and follow-up examinations Each column represents an examination of a given tooth. The first column for each tooth gives the values from the time of injury. Only the parameters listed in the top half of the form (“Time of injury’) are to be recorded at the time of injury. The information from this examination as well as the information collected on the emergency record are used to determine the final diagnoses for the injured teeth. Those parameters avd the last four (fistula, gingivitis, gingival retraction, abnormal pocketing) are to be registered at all follow-up controls.