(1)
Department of Endodontics, Nova Southeastern University College of Dental Medicine, Fort Lauderdale, FL, USA
Traumatic Dental Injuries
Traumatic dental injuries (TDIs) are caused by sudden impact forces to teeth generated by falls, fights, sports-related injuries, and traffic accidents. School children have a 25 % risk of suffering TDIs and 33 % of all adults will suffer TDIs [1]. The most common TDIs in adult teeth are crown fractures [2], while children are most likely to suffer a protrusion or retrusion of a tooth causing lateral luxation [3]. All TDIs, even if apparently mild, require a dental exam. Sometimes, the neighboring teeth can suffer an additional, unnoticed injury that can only be detected by a thorough dental exam.
Patient Care Immediately Following Traumatic Dental Injuries
When the patient or their parent/guardian telephones and describes tooth trauma, arrange to see the patient immediately. Check that the trauma is limited to the teeth; if the injuries to the face are more extensive, the patient must be directed to visit an accident and emergency center for treatment prior to seeking dental treatment. If the patient has an avulsed tooth, tell them to wash it and replant it quickly. When the patient arrives at your office following an accident, you should wash blood and dirt from their face with soapy water. Tell the patient to rinse their mouth with mouthwash or saline.
Differential Diagnosis of Traumatic Dental Injuries
An accurate diagnosis of the type of TDI is needed to ensure the tooth is given the most appropriate treatment. The diagnosis of trauma should use the following criteria [4]:
1.
Subjective information
2.
Objective information
3.
Assessment
4.
Plan
Subjective Information About the Traumatic Dental Injuries
Subjective information should be gathered by talking with the patient about their injury. The types of questions to ask patients are:
1.
How do you feel? Did you become unconscious or confused?—Judge if the patient appears confused and needs medical assistance, or if their condition is stable and they are healthy enough for dental trauma care.
2.
How long ago did the injury occur?—Knowing the amount of elapsed time is important for replanting teeth and treatment planning.
3.
How did you get injured?—Crashing in a car or bicycle will likely cause greater injury forces than those associated with a fall onto the pavement or being punched to the mouth.
4.
Have you taken any pain killers for the pain?—Assess if the trauma symptoms are being masked by pain killers.
5.
Have you had any previous difficulty to control pain with local anesthesia? With taken any pain killers for the pain?—This will help determine if a longer waiting time or supplemental anesthesia is needed before you can start treatment.
Objective Information About the Traumatic Dental Injuries
Objective information should be gathered about the patient’s condition from the following criteria:
1.
Palpation tenderness and swelling.
2.
Examination of the injured tooth.
3.
Radiographs taken from different angulations or a cone beam computed tomography image of the root canal of an injured tooth.
4.
Cold, hot, electric, and percussion sensibility test results.
5.
Asking the patient to point to the painful tooth, if it is not obviously injured.
6.
Identification of trauma type.
7.
Dental and medical history.
8.
Soft tissue lesions should be palpated to identify any tooth fragments or foreign bodies. If the lip is lacerated, a radiograph of the lip is needed to identify any tooth fragments or foreign bodies.
Assessing Information to Reach a Differential Diagnosis
The assessment of objective information should be used to reach a differential diagnosis of the type of dental trauma. The assessment should include the following criteria:
1.
Avulsion of the tooth from its socket
2.
Displacement and loosening of the tooth
3.
Mobility of a single tooth or several teeth as a unit
4.
Intrusion, protrusion, and retrusion of the tooth
5.
Tenderness to percussion
6.
Signs of root and crown fracture
Plan/Procedure
The differential diagnosis of dental trauma and assessment criteria are used for treatment planning:
1.
Regenerative endodontic treatment for teeth with immature roots, which have symptoms of a traumatized irreversibly injured pulp.
2.
Antibiotics can protect the patient from infection following TDIs. There is none or limited evidence that antibiotics are beneficial for saving teeth or for healing TDIs.
3.
Discarding teeth which should not be replanted, replanting avulsed teeth, and repositioning loose and luxated teeth back into their sockets using splinting to neighboring teeth. Splinting should reposition a loose tooth in its correct position and be comfortable.
4.
Apexification treatment for teeth with mature roots which have symptoms of a traumatized irreversibly injured pulp.
5.
Root amputation, hemisection, bicuspidization.
6.
Surgical intervention needed to restore facial appearance and function.
Root and Crown Fractures
Root or crown fractures should not condemn the tooth so that it should automatically be considered for extraction. Root fractures can be vertical or horizontal and can occur at any level. Many teeth with root fractures can be saved by endodontic treatment and restoration of the crown. The type of and amount of treatment needed to save the injured tooth are dependent on the type and severity of TDI. If the extent of the fracture is linear from the crown to the root, replanting the tooth is not recommended because of the high risk of treatment failure caused by infection through the fracture.
Tooth Fracture Diagnosis by Radiographic Examination
Several angulated radiographs are needed to identify root fractures, particularly in the mesiodistal plane, and incomplete or oblique fractures. These fractures are the most difficult to identify. Radiographs should be carefully examined for the following information if a fracture is suspected:
1.
Degree of fragment separation
2.
Apex and root development
3.
Root resorption, fracture lines, and presence and location of radiolucencies
4.
Evaluation of periodontal tissues
Tooth Fracture Diagnosis by Clinical Examination
The dental examination should identify the movement of a tooth following TDI, such as coronal displacement, tooth discoloration, and mobility. It may include the following criteria:
1.
Soft tissue evaluation
2.
Periodontal probing
3.
Occlusal evaluation
4.
Responsive testing
5.
Exploration by lifting a surgical flap
Tooth Fracture Diagnosis by Patient Report
The patients’ description of their TDI will help diagnose the type and severity of the injury. It may include the following criteria:
1.
Swelling and treatment history
2.
Pain history
3.
Injury description
4.
Time elapsed since injury
Identification of the Type of Traumatic Dental Injury
The SOAP, PERCACIDS, ADMITS, RADARS, DARE, SPORE, and SPIT criteria are used to differentially diagnose the type and severity of TDI. The starting point is always to assess if the tooth has been completely avulsed from its socket and replanted. If the tooth has not been avulsed, the displacement of the tooth and its mobility beyond normal limits should be tested. If several teeth move as one unit, it is characteristic of an alveolar fracture. If a single tooth moves and a fracture can been seen in a radiograph, it is characteristic of a root fracture. If no root fracture can be identified in a radiograph, it suggests that the tooth has had an extrusion. A tooth which appears to be in an abnormal position because of protrusion or retrusion has suffered from lateral luxation. A tooth which is abnormally located by intrusion out of its socket into alveolar bone has suffered from intrusion. If the tooth has not been displaced, but is loose, it has suffered from subluxation. If the tooth has not been displaced, but is not loose, and has percussion tenderness, it has suffered concussion. If the tooth has not been displaced, is not loose, and has no percussion tenderness, it has suffered concussion. If the tooth has not been displaced, is not loose, has no percussion tenderness, and has suffered a fracture above the gingiva which exposed the pulp, the tooth has suffered a complicated crown fracture. If a tooth has a crown-root fracture that has not exposed the pulp, it has suffered an uncomplicated crown fracture. If a tooth has a crown-root fracture that has exposed the pulp, it has suffered a complicated crown fracture. If the extent of the fracture is so minimal that no tooth structure has been lost, the tooth has suffered an infraction. If the tooth has no discernible symptoms of trauma, then it can be assumed that the tooth has no injury. A diagnostic flowchart to classify TDI is shown in Fig. 2.1.
Fig. 2.1
A diagnostic flowchart to classify traumatic dental injuries
Types of Traumatic Dental Injuries
The accurate use of TDI terminology is essential to communicate in dental records and between dentists. The TDI terminology can vary slightly among organizations and authors [5–13]. The six types of luxation injuries are:
-
Avulsion—The complete displacement of the tooth out of its socket.
-
Concussion—An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion.
-
Extrusion—Partial displacement of the tooth out of its alveolar socket. Characterized by a partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone is intact in an extrusion injury as opposed to a lateral luxation injury. Apart from axial displacement, the tooth will usually have an element of protrusion or retrusion. In severe extrusion injuries, the retrusion/protrusion element can be very pronounced. In some cases, it can be more pronounced than the extrusive element.
-
Lateral luxation—Displacement of the tooth other than axially. Displacement accompanied by crushing or fracture of either the labial or the palatal/lingual alveolar bone. Lateral luxation injuries, similar to extrusion injuries, are characterized by partial or total separation of the periodontal ligament. However, lateral luxations are complicated by a fracture of either the labial or the palatal alveolar bone and a compression zone in the cervical and sometimes the apical area. If both sides of the alveolar socket have been fractured, the injury should be classified as an alveolar fracture (alveolar fractures rarely affect only a single tooth). In most cases of lateral luxation, the apex of the tooth has been forced into the bone by the displacement, and the tooth is frequently nonmobile.
-
Intrusion—Displacement of the tooth into the alveolar bone. This injury is accompanied by crushing or a fracture of the alveolar socket.
-
Subluxation—An injury to the tooth-supporting structures with increased mobility, but without displacement of the tooth. In acute trauma, bleeding from the gingival sulcus confirms the diagnosis.
The eight types of tooth and bone fracture injuries are:
-
Alveolar fracture—A fracture of the alveolar process, which could involve the alveolar socket. Teeth with alveolar fractures are characterized by mobility of the alveolar process; several teeth typically will move as a unit when mobility is checked.
-
Complicated crown fracture—A fracture through enamel and dentin which caused a loss of tooth structure, but which exposed the dental pulp.
-
Complicated crown and root fracture—A fracture through the enamel, dentin, and cementum which caused a loss of tooth structure, but which did not expose the dental pulp.
-
Enamel fracture—A fracture confined to the enamel with loss of tooth structure.
-
Enamel infraction—An incomplete fracture or crack in the enamel without a loss of tooth structure.
-
Root fracture—A fracture through the dentin and cementum which exposed the dental pulp.
-
Uncomplicated crown and root fracture—A fracture through the enamel, dentin, and cementum which caused a loss of tooth structure, but which did not expose the dental pulp.
-
Uncomplicated crown fracture—A fracture through the enamel and dentin which caused a loss of tooth structure, but which did not expose the dental pulp.
The three main types of injuries to the gingival or oral mucosa are:
-
Abrasion—A superficial bleeding wound caused by the rubbing or scraping of tissues with an object or surface
-
Contusion—A bruise of the gingiva or oral mucosa caused by a blunt object often associated with an adjacent bone fracture
-
Laceration—A wound in the gingiva or oral mucosa caused by a penetrating sharp object
Diagnosis of Traumatic Dental Injuries
-
Avulsion—The displacement of the tooth from its normal position in the socket is an indicator of the direction and amount of injury sustained by the tooth. If the tooth has been completely avulsed, the percussion test and sensibility tests are not used to diagnose pulp sensibility since these tests are unreliable for replanted teeth. It is important to check radiographs of the involved socket for intrusion and alveolar fracture.
-
Alveolar fracture—The displacement of several teeth from their normal position, or the movement of several teeth as a unit when mobility has been checked, is a symptom of fractured alveolar bone across the periodontal ligaments or septum. These teeth will be tender to the percussion response and usually have no response to the pulp sensibility test.
-
Concussion—A tooth which has no visible or radiographic abnormalities, except that the percussion test causes a pain response, is probably suffering from concussion. If there is a normal response to the pulp sensibility test, the pulp has a lower risk of becoming necrotic.
-
Crown fracture—A tooth with a visible fracture through the enamel and dentin above the gingiva which caused a loss of tooth structure. Uncomplicated—a fracture which did not expose the dental pulp and has a lack of response to the percussion test. The pulp responds normally to the pulp sensibility test. Complicated—a fracture which exposed the dental pulp and has a tender or painful response to the percussion test, and also an abnormal response to the pulp sensibility test.
-
Crown–root fracture—A tooth with a visible fracture through the enamel, dentin, and cementum, below the gingiva which caused a loss of tooth structure. Uncomplicated—a fracture which did not expose the dental pulp and has a lack of response to the percussion test. The pulp responds normally to the pulp sensibility test. Complicated—a fracture which exposed the dental pulp and has a tender or painful response to the percussion test, and also an abnormal response to the pulp sensibility test.
-
Extrusion—A tooth which is partially displaced out of its alveolar socket. The tooth is loose and has greater than normal mobility. The radiograph shows there is an increased periodontal ligament space at the root apex. The involved tooth is tender in response to percussion and is likely to have an abnormal response to the sensibility test.
-
Infraction—A small fracture contained within the tooth enamel without any loss of tooth structure. The involved tooth has a no pain response to percussion and no increased mobility and a normal sensibility response is an indicator for a low risk of necrosis.
-
Intrusion—A displacement of the tooth into the alveolar bone accompanied by a fracture of the alveolar socket. This involved tooth causes no pain in response to percussion, but it creates a metallic sound. The tooth has no increased mobility and no response to the sensibility test. The radiograph shows a reduced periodontal ligament space.
-
Lateral luxation—A displacement of the tooth other than axially accompanied by a fracture of either the labial or the palatal/lingual alveolar bone. This involved tooth causes no pain in response to percussion, but it creates a metallic sound. The tooth has no increased mobility and no response to the sensibility test. The radiograph shows an increased periodontal ligament space.
-
Root fracture—A root fracture is seen on the radiograph of the tooth. The involved tooth evokes a pain or tender response to percussion; it has more mobility above the site of the fracture. A normal sensibility response indicates a low risk of pulp necrosis.
-
Subluxation—A tooth with injured supporting structures and often bleeding from the gingival sulcus. The involved tooth evokes a pain or tender response to percussion; it has increased mobility. A normal sensibility response indicates a low risk of pulp necrosis.
The diagnoses for traumatic dental injuries are summarized in Table 2.1.
Table 2.1
Diagnosis of traumatic dental injuries
|
Description
|
Representation
|
Symptoms
|
Percussion response?
|
Increased mobility?
|
Pulp sensibility?
|
Radiographic observations
|
|---|---|---|---|---|---|---|
|
Avulsion
|
 |
Teeth are completely displaced out of their socket
|
Not indicated
|
Yes
|
Not indicated
|
Check socket for intrusion and alveolar fracture
|
|
Alveolar fracture
|
 |
Several teeth move as a unit when mobility is checked
|
Tender
|
Several teeth move as a unit
|
Abnormal
|
A fracture can be seen along the periodontal ligaments or septum
|
|
Concussion
|
 |
Injured tooth is not displaced
|
Pain
|
No
|
A normal response indicates a low risk of necrosis
|
No abnormalities
|
|
Crown fracture (uncomplicated)
|
 |
Lost crown structure without an exposed dental pulp
|
None
|
Crown—yes
|
Normal
|
Fracture visible in crown
|
|
Root—no
|
||||||
|
Crown fracture (complicated)
|
 |
Fractured crown structure with an exposed dental pulp
|
Tender
|
Crown—yes
|
Abnormal
|
Fracture visible in crown
|
|
Root—no
|
||||||
|
Crown-root fracture (uncomplicated)
|
 |
Fractured crown-root structure without an exposed dental pulp
|
None
|
Crown-root—yes
|
Normal for apical pulp
|
Fracture not visible in apical area
|
|
Apical root—no
|
||||||
|
Crown-root fracture
(complicated)
|
 |
Lost crown-root structure with an exposed dental pulp
|
Tender
|
Crown-root—yes
|
Abnormal
|
Fracture not visible in apical area
|
|
Apical root—no
|
||||||
|
Extrusion
|
 |
Injured tooth is partially displaced out of its socket
|
Tender
|
Yes
|
A normal response indicates a low risk of necrosis
|
Increased periodontal ligament space at root apex
|
|
Infraction
|
 |
An enamel fracture without any loss of tooth structure
|
None
|
No
|
A normal response indicates a low risk of necrosis
|
None
|
|
Intrusion
|
 |
Intrusion of the tooth axially into alveolar bone
|
None, metallic sound
|
No
|
Abnormal
|
Reduced periodontal ligament space
|
|
Lateral luxation
|
 |
Injured tooth is displaced other than axially and fractures alveolar bone
|
None, metallic sound
|
No
|
Abnormal
|
Increased periodontal ligament space
|
|
Root fracture
|
 |
Injured tooth has a root fracture
|
Tender
|
Yes—above fracture
|
A normal response indicates a low risk of necrosis
|
A root fracture is visible
|
|
Subluxation
|
 |
Bleeding from gingival sulcus but no tooth displacement
|
Tender
|
Yes
|
A normal response indicates a low risk of necrosis
|
None
|
Emergency Care for a Traumatic Dental Injury
The priority of emergency care is to relieve pain and provide evidence-based treatment to save the tooth. This involves giving anesthetics, suturing soft tissue lacerations, and the repositioning and stabilizing of bone and the involved teeth. If pain and mobility are not present, a definitive diagnosis and treatment plan should be delayed until healing has had a chance to occur. The immediate lack of pulp sensibility response should not indicate that the pulp is necrotic and root canal treatment is needed, since the test may be unreliable owing to the temporary neural paresthesia. The patient should be recalled immediately if they experience pain or after 3 months have elapsed and be evaluated for the following criteria:
1.
Change in tooth color.
2.
History of pain and swelling.
3.
A radiographic evaluation should also be performed.
4.
Mobility beyond normal limits.
5.
Pulp sensibility response.
6.
Soft tissue changes.
Diagnosis and Treatment Modalities for Dental Trauma
The steps to diagnose and deliver treatment for dental trauma are:
1.
Clean and inspect all aspects of the TDI.
2.
The SOAP, PERCACIDS, ADMITS, DARE, SPORE, and SPIT criteria are used to differentially diagnose the type and severity of TDI.
3.
Give local anesthesia to relieve pain at the site of the TDI and make the patient comfortable.
5.
Use RADARS criteria to plan the treatment.
6.
Use CHAMPS criteria to monitor the healing and success of the treatment.
Treatment Planning for Dental Traumatic Injuries
The treatment decision-making steps for dental traumatic injuries using the criteria are:
1.
Decide to give immediate treatment with appropriate pain relief or delay treatment and monitor the tooth until a treatment is indicated and necessary. Check the pulp sensibility; if the pulp sensibility response is altered to cold and electric pulp testing, or the tooth is painful, suggesting a necrotic pulp or a pulp with irreversible pulpitis, then root canal treatment is indicated.
2.
Reimplant avulsed teeth if they will be able to heal or discard the tooth.
3.
Examine all lacerations and abrasions, to ensure that all tooth fragments, dirt, and foreign material have been removed.
4.
Suture any lacerations after checking the wound is clean and disinfected with saline or chlorhexidine.
5.
Splint loose teeth with resin to immobilize them in their correct position to neighboring teeth for 2 or 4 weeks.
Treatment for Dental Traumatic Injuries
Avulsed Tooth Replantation
Avulsion injuries are considered one of the most complicated and detrimental displacement injuries of teeth. The maxillary central incisors are the most frequently avulsed teeth. Avulsion frequently involves a single tooth; but multiple avulsions are occasionally encountered. The most common age group for avulsion injuries is children between the age of 7 and 10 years, when the permanent incisors are erupting. The loose structure of the periodontal ligament favors complete detachment and avulsion of the tooth as opposed to a crown or root fracture. Damage to both the pulpal and periodontal tissues is a common sequel of tooth avulsion injuries. Immediate replantation of a permanent avulsed tooth is the most critical of all factors that impact the prognosis of that tooth. Failure to properly handle, transport, and store the avulsed tooth in addition to delaying its replantation may lead to permanent irreversible destruction of both the pulpal and periodontal tissues and inevitably reduce the success of any replantation attempts.
The replantation of avulsed permanent teeth has been the subject of several in vivo research studies using animals. Normal healing is characterized by complete repair of the periodontal ligament (PDL) and is radiographically characterized by no signs of resorption. In a clinical study of 110 replanted teeth, 90 % of teeth replanted in less than 30 min showed no resorption [10]. The replantation of avulsed teeth can be a very successful therapy over the long term; however, many replanted teeth fail. Replacement resorption is the most detrimental of the periodontal ligament responses that occur following replantation of an avulsed tooth with long extra-alveolar time [14].
Avulsed baby teeth should not be replanted. The following are considerations for replanting avulsed permanent teeth:
1.
Replant the avulsed teeth as quickly as possible, preferably within 30 min. The longer the teeth are outside the oral cavity, the less favorable is the prognosis.
2.
Alveolar fractures can complicate healing. Avulsed teeth with an extensive root and crown fracture should not be replanted.
3.
Intact periodontium is essential for replant success.
4.
Necrosis of the pulp is likely because of the interruption in blood flow. A fully mature tooth will need a root canal treatment no later than 2 weeks following its replantation. An immature tooth with an apex open more than 1.1 mm will need a regeneration treatment if the root canal walls are thin and will be prone to fracture. An immature tooth with thick walls will need an apexification treatment. These treatments are discussed in the next chapter.
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