19: Problem Solving in the Management of Tooth Fractures and Traumatic Tooth Injuries

Chapter 19

Problem Solving in the Management of Tooth Fractures and Traumatic Tooth Injuries

Problem-Solving List

Problem-solving issues and challenges in the management of traumatic tooth injuries addressed in this chapter are:

Tooth Crazes, Cracks, and Fractures
Traumatic Tooth Injuries

    Extrusive luxation
    Lateral luxation
    Intrusive luxation
Sequelae to Luxation Injuries

    Pulp canal obliteration
    Marginal bone loss
    Coronal discoloration
    Transient apical breakdown
    Pulpal necrosis
Avulsion Injuries
Resorption Associated With Traumatic Tooth Injuries

    Inflammatory replacement resorption and ankylosis
Horizontal Root Fractures

    Apical-third fractures
    Middle-third fractures
    Coronal-third fractures
Healing Responses to Horizontally Fractured Teeth

    Calcified union between the segments
    Bone and connective-tissue healing
    Connective-tissue or soft-tissue union
    Failure of fracture to heal
Splinting of Traumatized Teeth

“When a Tooth is loosened by violence, but not moved out its socket, ligature alone, and astringent washes to brace the gums, are sufficient for the cure. In this case the pain ceases with the looseness of the Teeth; but if it be violent in the beginning, sedatives must be applied.”< ?xml:namespace prefix = "mbp" />11

T.G. Berdmore, 1768

Tooth Crazes, Cracks, and Fractures

The diagnosis and management of structural defects in teeth other than those caused by accidental trauma pose a unique challenge for the clinician. These defects involve posterior teeth and are usually slow to develop and manifest themselves within a variety of intertwined variables. They can be on the surface and stable, or they can migrate into the tooth, resulting in significant structural defects and clinical challenges. All defects may involve the crown, root, or both, in addition to being horizontal, vertical, or angulated.

The types of alterations in tooth structure include crazes, cracks, and fractures. Diagnosis, management, and prevention of these alterations is dependent on thorough patient assessment, identification of those factors that contribute to these defects, management of those factors when possible by the clinician, and creative measures in the overall prevention of these problems. Fractures that are the result of accidental trauma and that occur primarily in the anterior teeth are addressed in the next section of this chapter.

For purposes of clarification and clinical differentiation, the following descriptions are provided. Crazes are areas of weakness in the tooth structure where further propagation may result in a crack or facture. These are not visible radiographically but can be seen with fiberoptic transillumination. Cracks are definite breaks in the continuity of the tooth structure beginning in the enamel or cementum. No separation is evident clinically, and these are visible with fiberoptic transillumination in which light transmission is impeded across the crack line. They may often be stained due to patient diet. Fractures exhibit definite separation of the tooth structure into two or more distinct segments and are visible clinically and sometimes radiographically. They also may exhibit stain when located coronally.

Many factors that predispose to these tooth defects cannot be altered or controlled by the clinician. These include masticatory accidents, bruxism, and thermal cycling.31,34 Clinical detection of these defects can be exceedingly difficult, especially in their initial stages of development or beneath extensive restorations. Additionally, radiographs are of little value in these initial stages. In some cases, surgical intervention may actually be necessary for fracture identification. Patient symptoms may mimic many other possible diagnoses, such as temporomandibular disease, sinus problems, vague headaches, and ear pain. Efficacious management of fractured teeth is highly dependent on a complete set of variables that are often not controllable by the practitioner, such as extent and size of the defect, tooth and root anatomy, position of fracture, masticatory function, and previous dental intervention.

There is a paucity of new information regarding these types of tooth defects, and therefore the reader is referred to previous editions of this text and other supportive references that will detail the challenges of the clinician faces with these types of problems.1416,26,28,31,35 However, in the series of figures (Figs. 19-1 to 19-5), the main concepts will be highlighted for reader reference and clinical recognition. This will help differentiate these defects from those found with accidental trauma. The reader is referred to early chapters in this text that discuss many aspects of these structural defects relative to identification and management (see Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 15 Chapter 18).


FIGURE 19-1 A, Mandibular molar with crack lines on the mesial and marginal ridges (arrows). B, Mandibular molar with a crack running parallel to the buccal developmental groove (arrows).


FIGURE 19-2 A, Image shows a symptomatic molar that was excavated and stained with methylene blue on the cavity floor. Note the mesial-to-distal fracture. B, Evidence of a fracture on the distal marginal ridge often results from weakened tooth structure in that area. C, Extracted tooth shows the crack (arrows) running apically down the root in a diagonal manner. Also the periodontal ligament forms a tract as the crack is propagated. Note the lack of divergence in the occlusal preparation that is necessary for seating inlays. This was probably the contributing factor in this tooth’s demise. D, After access opening, the distal fracture line can be seen to run down the distal wall. The tooth was extracted.


FIGURE 19-3 Open anterior bites (A) and cross bites (B) contribute to excessive occlusal forces on the posterior teeth. C, Placement of multiple pins in a tooth for retention may lead to fractures. Note the fractures at the base of this pin (scanning electron microscopy photo). D, Traceable sinus tract to the midroot of this premolar. Note the size and shape of the intraradicular post. The tooth was fractured vertically.


FIGURE 19-4 A, Placement of a fiberoptic on a symptomatic maxillary premolar. Note that the light does not pass the fracture line. Transillumination can be more dramatic without the overhead light. B, Clinically deep probing in a narrow channel. C, Tissue reflection allows for visualization of the fracture (arrows).


FIGURE 19-5 Proximal view of the extracted tooth; note the oblique fracture line. Clinical view in Fig. 19-4, A.

Traumatic Tooth Injuries

The management of traumatic injuries is a constant source of difficulty for the clinician because of the complexity in diagnosing and treating these injuries properly.4 The most important concept of managing dental trauma is to feel confident in the diagnosis. By knowing the type of damage that has occurred to the dentition and supporting tissues, the clinician will be better suited to treat the affected tooth or teeth and the sequelae of these types of injuries. In the present litigious society, every clinician should know the proper guidelines for treatment of traumatized teeth to avoid the potential risk of litigation.24,23,24

The first and most important step in understanding how to treat these injuries is to determine the nature of trauma.16 This chapter will provide fundamental concepts in diagnosing and treating traumatic injuries of the more severe nature in the permanent dentition. It will also address the more common sequelae of traumatic injuries and the most appropriate methods to manage them effectively for the best outcome. Trauma ranging from luxation injuries and avulsions to horizontal root fractures will be covered in a clinically relevant manner.

Active prevention of coronal fractures in normal day-to-day living is unrealistic and a moot point. Prevention during hazardous activities such as job-related activities (e.g., during sports), however, may occur in the form of mouth protection and on-the-job training to avoid circumstances that may predispose to traumatic incidents.25 Although such incidents are uncommon, the major result of these types of fractures is dental trauma, whether direct or indirect; accidental injuries remain the predominant type reported. This implies that management of the crown fracture will usually fall into the category of a dental emergency, and principles cited in Chapters 1, 4, and 15—diagnosis, treatment planning, anesthesia, analgesics, and antibiotics—should be integrated into the total case management.

In cases in which an acute trauma accident has resulted in a crown fracture (Fig. 19-6), pulpal preservation is crucial when root formation is incomplete (see Chapter 7). Teeth with coronal and coronal-root fractures and completed root development can and should be retained, even if adjunctive treatment is indicated. The range of management may be limited to dentin protection and a bonded restoration to a root canal procedure and, in some cases, root extrusion, crown lengthening, a post, a core buildup, or acid-etched bonded core and crown (Figs. 19-7 and 19-8).


FIGURE 19-6 Enamel-dentin fractures, with the right central incisor having an angled fracture into the coronal portion of the root.


FIGURE 19-7 A, Complicated coronal fractures that are deep into the dentin with an exposed pulp. B, Clinical view.


FIGURE 19-8 Complete coronal fracture that lends itself to immediate and complete root canal treatment and appropriate restorative procedures. However, because the patient is young, a prefabricated metallic post may not be indicated, but rather a bonded type of carbon fiber post may be better.

Luxation injuries present a greater demand for the clinician in their management, as they must be diagnosed accurately.24,17,22,23 The following are the more commonly accepted definitions of luxation injuries, arranged (in order of damage to the tooth and surrounding tissues) from the least severe to the most destructive type. A luxation is defined as a dislocation of the tooth from its normal physiologic position in the socket. However, as will be seen in the specific descriptions of these injuries, a large variety of luxation injuries exist, so a number of different classifications have been suggested.4


A concussion injury is defined as a relatively minor blow to the tooth in which the affected tooth is not damaged, but the periodontium becomes inflamed. Typically, patients experience mastication sensitivity or pain on brushing or pressure on the tooth. No splinting is required in these types of luxation, and only palliative treatment is required. In most instances, reducing the occlusion is all that is required. Patients should be reevaluated within the first 2 weeks after the injury to ensure that no further treatment is required. In the vast majority of cases, root canal therapy is not indicated, because only a small percentage of these injuries become necrotic. Monitoring pulpal status for 1 year is recommended (Fig. 19-9).23


FIGURE 19-9 History of a concussion injury on the right central incisor with no signs or symptoms at the time of injury. Six-month reexamination shows a darkened tooth that does not respond to sensibility testing.


A subluxation is slightly more severe than a concussion of the tooth, because increased mobility exists that is comparable with a periodontally involved tooth (mobility +1 to +2).4,23 Although the tooth is more mobile than it was before the injury, it is at the discretion of the clinician to determine whether splinting is required. In most instances, no splint is required unless additional trauma to the tooth or the area is anticipated (e.g., young patient involved in multiple sports). If splinted, stabilization up to 2 weeks is usually indicated.23 Pulp sensibility responses are usually variable and should be monitored until a definite pulpal diagnosis can be made.

Reduction of the occlusal forces on the tooth will aid in the healing process and minimize the patient’s symptoms. Subluxations account for the most frequent type of luxation injury, although the probability of pulpal necrosis zis very small with subluxation injuries.4 Clinically it is common to see hemorrhage around the epithelial attachment (Fig. 19-10).


FIGURE 19-10 A, Subluxated tooth with the typical clinical presentation of a bleeding epithelial attachment apparatus. B, 30 months after a subluxation injury, radiograph shows ankylosis in the midroot portion. The patient is symptom free.

Extrusive Luxation

In extrusive luxation injuries, the tooth is dislocated along its long axis and can be displaced almost entirely out of the socket (Fig. 19-11). These injuries are significantly more severe than either concussion or subluxation injuries. Radiographically there may be an increased periodontal ligament space apically. Extrusive luxation injuries account for only 1% of total traumatic dental injuries. Although the use of anesthesia is not always required when dealing with younger patients, it is strongly recommended.


FIGURE 19-11 An extrusively luxated central incisor. Note that the tooth is dislocated along its long axis.

Initially the soft-tissue damage must be assessed and managed properly. The tooth is carefully and accurately repositioned in the socket. This procedure may be performed manually with gauze or with forceps (if significant dislocation has occurred) to replace the tooth gently into its original position. Keep in mind that teeth will usually realign into their original position in the socket without significant forces being required. However, the greater the post-trauma time period before treatment, the higher the likelihood of coagulation in the socket; therefore additional force may be required to accomplish the repositioning.

Sensibility testing is used initially, with variable or no responses expected, and again on reexamination to determine the pulpal status. This is especially important in teeth with immature root formation. If there is no response in the tooth with a fully formed apex, necrosis can be assumed to have occurred.22,23

In extrusive luxation injuries, the neurovascular bundle is usually disrupted, and therefore the blood supply is lost to the tooth. In adult patients and in young patients with closed apices, the likelihood of revascularization is extremely low and should not be considered a likely consequence of the healing process. Because the majority of these cases become necrotic, the patient should be notified that a root canal procedure will be necessary within a couple of weeks of the trauma or earlier at the time of splint removal. In all cases of extrusive luxation injuries, the teeth must be splinted.12

All luxation injuries require splints, using one nontraumatized tooth on either side of the traumatized tooth. For example, if only one tooth is luxated, then one healthy tooth on either side of the traumatized tooth should be included in the splint. If two teeth are luxated, then a total of six teeth should be included in the splint (two teeth on either side of the two teeth that are traumatized for a total of six). The type of splint (physiologic, rigid, or passive) is inconsequential to the healing process. However, in most instances, a nonrigid splint is easier to place and will avoid the possibility of exerting excessive pressure on the damaged periodontal ligament.37

The splint should be placed for up to 2 weeks. During this period, the periodontium will stabilize the tooth sufficiently, and minor to normal mobility will be noted following splint removal. Should the tooth be excessively mobile compared with a nontraumatized contralateral tooth, the splint may remain in place until normal mobility is noted. The use of a physiologic passive or flexible splint is indicated for any type of luxation injury.4,37 Most clinicians can use a composite-based splint, because it is the most convenient to use and place on the traumatized teeth. Should the splint remain in place for longer periods of time, no negative sequelae will result. Non-rigid splinting does not cause damage to the supporting tissues or to the tooth.

Lateral Luxation

Lateral luxation injuries are defined as a dislocation of the tooth in a mesial, distal, facial, or lingual (palatal) direction, with comminution or fracture of the bony alveolar socket. It is rare for a patient to have a pure lateral luxation. Most cases will have both a lateral and an extrusive component (Fig. 19-12). Lateral luxation injuries are considered more severe than extrusive luxation injuries because of the associated fracture or splintering of the bone in the alveolar socket.22


FIGURE 19-12 A, Lateral luxation injury. Note the lateral and extrusive component to the injury. B, Significant lateral extrusion of the mandibular incisors. Note the radiographic view and the movement in the alveolar socket.

The assessment phase is similar to that for extrusive injuries. In these instances, a blunt instrument should be inserted gently into the alveolar socket to move the fractured bony segment back to its original position before the tooth can be properly repositioned.4,23 Care should be exercised to prevent damage to the healthy periodontium remaining in the socket or on the tooth. Once the tooth is repositioned, a splint should be placed to hold the traumatized tooth (or teeth) in position for 10 to 14 days. If bony fracture is noted, the splint should remain in place for 6 to 8 weeks to allow proper healing of the alveolar socket. Whenever bone is fractured, a more rigid splint should be placed in lieu of a flexible or physiologic splint.

Because of the nature of the damage with lateral luxation injuries, the probability of pulpal damage and subsequent endodontic therapy is high.4,18,22,32 As with all luxation injuries, the older the patient (i.e., the smaller the diameter of the apical foramen), the less likely the tooth will regain its vascular supply; therefore a root canal procedure will be necessary. With both lateral and extrusive luxation injuries, external resorption (ER) or internal resorption (IR) is not a typical sequela; the patient should be informed that the long-term prognosis of these teeth is excellent.

Intrusive Luxation

Intrusive luxation injuries are the most severe type of luxation injury and therefore have the poorest prognosis.24,79,30,33 With intrusive luxation injuries, the tooth is dislocated apically into the alveolar socket. The tooth is sometimes displaced so far apically that the clinician may not be able to visualize the incisal edge. There is seldom any observable mobility because of its new position deep within the alveolar bone. These injuries cause severe damage to the neurovascular bundle, pulp, and periodontium.18 The blood supply and neurovascular tissues are crushed completely. In teeth with partially to completely closed apices, the pulpal prognosis is extremely poor, with almost a 100% probability of pulpal necrosis. Because of the severe damage to the periodontium, the probability of ER is extremely high in these injuries; therefore the patient should be warned that the prognosis of an intrusively luxated tooth is guarded.

Clinically, the tooth is usually immobile and gives a/>

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Jan 2, 2015 | Posted by in Endodontics | Comments Off on 19: Problem Solving in the Management of Tooth Fractures and Traumatic Tooth Injuries
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