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TRAUMATIC INJURIES OF TEETH LUXATION

 This is a condition where the tooth is dislocated


TREATING A PATIENT WITH ORAL FACIAL TRAUMA: within the socket but maintains some attachment.
 One should record the patient’s medical & dental
history.  It is caused by a trauma that affects tooth nerves,
 This will include neurological signs, vital signs, and blood, cementum & surrounding bone.
changes in speech pattern.
 Tests involved are percussion, mobility test & pulp Subluxation
vitality test.  Injury to the tooth supporting structures with
 High quality radiographs are of great importance abnormal loosening.
for diagnosis & prognosis.
 Subluxated teeth exhibit mild to moderate
3 MAIN OBJECTIVES WHEN TREATING A PX FOR A horizontal mobility or vertical mobility or both.
DENTAL TRAUMA EMERGENCY:
1. Preserve the pulp vitality  No radiographic changes.
2. Control pain & bleeding
3. Look for radiographic changes, changes in  Hemorrhage is usually evident around the neck of
tooth color, and changes in pain. the tooth at the gingival margin.
- Rate the pain from 1 to 10
 If minimal, leave alone, monitor tooth with vitality
IN HUMAN DENTISTRY, THERE ARE 6 CLASSIFICATION tests, and adjust occlusion if necessary.
OF INJURIES THAT RESULT WHEN FORCES APPLIED
TO THE TOOTH IS GREATER THAN THE PHYSICAL  If extensive, place a flexible splint (monofilament
LIMITS OF THE PDL, NEUROVASCULAR SUPPLY & nylon or light orthodontic wire) bonded to the
BONE: tooth with acid etch resin for one to two weeks.

Concussion Extrusive luxation


 It is an alteration of consciousness, disturbance in  This type of injury is characterized by partial
vision & equilibrium caused by a direct blow to the displacement of the tooth out of its socket.
head, rapid acceleration and/or deceleration of the
head, or direct blow to the base of the skull from a  Extruded teeth appear elongated; there is always
vertical impact to the chin. (BRAIN CONCUSSION) hemorrhage from PDL.

 In dentistry, results to mild injury to the tooth &  Complete disruption of the PDL fibers.
PDL without displacement from its position in the
alveolus.  There is wider PDL space on radiographs.

 Tooth mobility may be present with no abnormal  This type of injury requires immediate treatment.
loosening.
 Therapy is directed at reduction (repositioning the
 Most noticeable clinical finding is a markedly tooth) & fixation (splints) for 2 to 3 weeks.
increased sensitivity to percussion.
Lateral & extrusive luxation is an angular displacement
 No radiographic changes are observed. of the tooth while it remains within the socket. There is
usually an associated fracture of the supporting
 May cause bleeding in the PDL & pulpal edema. alveolar bone, especially with labial & palatal luxation.

 For concussive tooth injuries in human dentistry, Lateral luxation


no immediate treatment is necessary, the px  This type of injury is characterized by eccentric
should allow the tooth to rest until sensitivity has displacement of tooth from its socket.
subsided.
 The tooth is usually displaced lingually, buccally,
 Px is instructed a soft diet for 2 weeks with close mesially, or distally, that is out of its normal
monitoring of pulp vitality at 1, 3, 6, & 12 months. position and away from its long axis, with fracture
of the wall of the alveolar socket.
 This type of injury usually requires no therapy &
usually resolves without complications.  There is fracture & rupture of the PDL fibers.
 There is little mobility w/ the apex locked.  RCT is performed within 1 to 2 weeks

 There is increased PDL space observed on The goal of the tooth reimplantation is complete
radiographs. redevelopment of the PDL.

 These teeth need immediate treatment; the longer Avulsed primariy teeth are not reimplanted due to
the delay, the more likely the tooth will consolidate possible injury to the developing permanent tooth.
in its ectopic position.
PX CONFRONTED WITH EMERGENCY SITUATION CAN
 Therapy is directed at reduction (repositioning BE INSTRUCTED TO:
tooth) & fixation (splints) 1. Find the tooth

 In addition, many such teeth become necrotic & 2. Rinse the tooth
require endodontic therapy. - Do not scrub the tooth. Do not touch the root. After
plugging the sink drain, hold the tooth by the crown
Intrusive luxation and rinse it under running tap water.
 Displacement of the tooth deep into the alveolar
bone in an axial (apical) direction, at times to the 3. Insert the tooth into the socket
point of being buried & not visible. - Gently place it back into its normal position.
- To protect the vitality of the PDL cells on the root
 Fracture of the alveolus. surface, an appropriate transport medium must be
used. (Milk is an excellent transport medium)
 All vessels are smashed and treatment results are
unpredictable. 4. Go directly to the dentist
- Hold the tooth in place with gentle finger pressure.
 An intrusion injury is the most severe type of - Apply an acid etch retained splint
luxation injury. The intruded tooth is impacted into - Complications include root surface resorption (no
the alveolar bone, & alveolar socket is fractured. treatment), replacement resorption (extraction if
The forces that drive the tooth into the socket wall progressive, otherwise root canal therapy) and
crush the PDL, & rupture blood and nerve supply to inflammatory resorption (root canal therapy)
the teeth. The tooth may not be visible, and can be
mistaken for an avulsion. TOOTH REPLANTATION
Success rate:
 This type of injury is rare in the permanent Less than 30 min – 90% success
dentition but is a common injury to primary 30 to 90 min – 43% success
dentition. More than 90 min – 7& success

 Immediate care is required & usual sequela is Successful replantation of a developing tooth recal
ankylosis. radiograph taken 1 year after replantation. The
continued root development proves that the pulp was
 Teeth may normally re-erupt spontaneously. saved.
 Surgical repositioning has been shown to
increase complications such as external root Filling material surrounded by bone. This tooth was
resorption & loss of marginal bone. allowed to dry for several hours before it was
 Repositioning can be carried out presented. The dentist removed the remaining
orthodontically over a period of 3 to 4 weeks. periodontal membrane, and performed RCT from the
root apex before replanting.
Exarticulation/avulsion
 The most extreme luxation injury. FRACTURE
WHAT CAUSES TEETH TO CRACK?
 Complete displacement/loss of tooth out of its 1. From repetitive chewing on your teeth, day
socket. after day.
2. A history of clenching or grinding (bruxism)
 An avulsed tooth can be generally be preserved & teeth.
maximize treatment successful, provided 2 steps 3. Chewing on hard substances or foods such as
are taken: ice, popcorn kernels or candy.
4. Trauma to the mouth such as a blow the chin
 The tooth is replanted as soon as possible. or lower jaw.
Preferably within 15 min of trauma, or 30 min
at the latest.
5. Large fillings that are deep or that involve the Ellis class III
contacts bet. teeth.  These fractures involve enamel, dentin and
6. Bone loss associated with PDL disease can be pulp layers. These teeth are typically tender
predispose a tooth to root fracture because of and have visible area of pink, red, or even
decreased support. blood at the center of the tooth.

WHAT ARE THE SIGNS AND SYMPTOMS OF A CRACKED Cracked tooth syndrome
TOOTH? - It is exactly what the name implies, a tooth
1. History of erratic pain upon chewing with crack. This is a very common problem
(shock/jolt), especially upon release of biting that affects teeth that have large fillings in
pressure (disclusion) them. Decay and large fillings cause a
2. Discomfort with extreme temperatures, weakening in the remaining tooth structure
especially cold over time. A hairline fracture often
3. If the crack involves the root there may be a develops at the bottom corner of the filling.
localized periodontal pocket/defect The longer people keep their teeth, the
4. If the crack extends to the nerve, there may more likely they are to have necessary
be signs of irreversible inflammation dental procedures (fillings, RCT) that leave
(irreversible pulpitis) which will lead to pulpal the tooth more susceptible to cracking.
death & ultimately an abscessed tooth
5. Sensitivity to sweets with lack of detectable TYPES OF CRACKS
decay clinically or on an xray. Craze lines
 These are tiny cracks that affect only the outer
DIAGNOSIS: enamel of the tooth. They are common in all
Crown fracture adult teeth and cause no pain. Craze lines
 Comprise about 33% of injuries to primary need no treatment. They do not extend into
teeth, and about 75% of injuries to permanent the dentin. They are the result of wear and
teeth. It is classified based on the location of tear on teeth.
the fracture in relation to the enamel, dentin or
pulp tissue of the tooth. Fractured cusp
 When a cusp becomes weakened, a fracture
Root fracture may result. A fractured cusp rarely damages
 It occur in only 7% of dental injuries. the pulp. This tooth will need to be restored
Horizontal root fractures occur in anterior with a full a crown.
teeth, and are caused by direct trauma.
Vertical root fractures usually occur in molars, Cracked tooth
and may be caused by clenching or trauma to  This type of crack extends from the chewing
the mandible. Vertical root fractures are more surface of the tooth and vertically migrates
difficult to detect, and may not be found until towards the root.
extensive tooth destruction has occurred.
 Tooth is not completely split into 2 distinct
CLASSIFICATION OF DENTAL FRACTURES movable segments.
Dental fractures are divided into the following
categories, based on the Ellis classification system:  Damage to the pulp is common.

Ellis class I  A root canal treatment is usually necessary


 These fractures involve the crown and extend and a full crown is needed to hold the tooth
through the enamel only. These teeth are together.
usually non tender and without visible color
change but have rough edges.  A cracked tooth that is not treated will worsen,
resulting in the loss of the tooth.
Ellis class II
 These fractures involve the enamel as well as
the dentin layer. These teeth are typically Split tooth
tender to touch and to an exposure. A yellow  It is usually the result of an untreated cracked
layer of dentin may be visible. tooth in which the crack has progressed so that
there are 2 distinct segments that can be
separated from one another.

 A split tooth can never be saved intact.


 In rare instances RCT, possible some gum
surgery, and a crown may be used to retain a
portion of the tooth.

Vertical root fracture


 It begins at the root and extends towards the
chewing surface of the tooth. Treatment may
involve root surgery, if a portion of the tooth
can’t be saved, tooth is extracted.

TOOTH FRACTURE
Management:
A fracture will probably not improve and will eventually
need to be treated. Teeth do have a limited ability to
heal themselves. Unfortunately, fractured teeth do not
heal themselves like other bones in your body. The
only real solution to hold the tooth together and to
prevent the tooth from breaking is with a crown. A
crown will allow chewing forces to move the whole
tooth rather than splitting it apart. This full crown is
bonded over the entire tooth to seal all the small
cracks and prevent bacterial leakage thus allowing the
nerve to recover and stabilize.

Considerations:
About 10% of cracked teeth have nerves that can still
die and need root canal treatment. Early treatment can
help to minimize this from happening. If you decide to
refuse treatment for this condition remember that the
tooth is like a ticking time bomb that will suddenly
flare up and cause severe pain, swelling, pus, and
possible bone loss that will put stress on your immune
system and may affect your overall health.

HOW CAN YOU CHECK TO SEE IF A TOOTH HAS A


CRACK AND/OR FRACTURE?
 No single test or technique provides the correct
diagnosis 100 of the time.

Transillumination
 Most of the time we use a transilluminating
light and see if the light transmits from one
side of the tooth to the other.

Tooth slooth biting test on each cusp


 A biting test can be performed. We concentrate
the biting forces commonly using an
instrument. This can isolate specific areas of
the tooth that might be sensitive to bite, but
does not tell us the underlying cause of
discomfort.

Stained cracked tooth (blue stain can be fully


removed after diagnosis)
 Sometimes, some dye might be used to
temporarily stain the tooth and check to see if
a tooth is fractured. It is then washed off and
evaluated. This is most commonly done once
access to root canals if obtained.