Traumatic Injuries

to the Teeth

Traumatic Injuries to the Teeth

Crown Fractures
Crown-Root Fractures
Root Fractures
Luxation Injuries
Avulsion

Traumatic Injuries to the Teeth

Root Fracture Update

Traumatic Injuries to the Teeth

Root Fracture Update

Management of the
Avulsed Tooth

Root Fracture Update

Clinical examination
Tooth usually slightly extruded
Tooth frequently displaced lingually

Root Fracture Update

Clinical examination
Tooth usually slightly extruded
Tooth frequently displaced lingually

Root Fracture Update

Clinical examination
Diagnosis entirely
dependent upon
radiographic
examination

Emergency Management

Periapical radiographs
Standard XCP radiograph
Increased vertical angulation

Emergency Management

Periapical radiographs
Standard XCP radiograph
Increased vertical angulation

Emergency Management

Reposition coronal
fragment

Emergency Management

Previous
recommendation
Rigid splinting for 2-3
months

Emergency Management

Previous
recommendation
Rigid splinting for 2-3
months

New recommendation
Splinting for 3 weeks

Root Fracture Healing

Root Fracture Complications

Pulp necrosis
Coronal segment 20 to
44%

Root Fracture Complications

Pulp necrosis
Coronal segment 20 to
44%
Apical segment 0%

Root Fracture Complications

Pulp necrosis
Coronal segment 20 to
44%
Apical segment 0%

Root Fracture Complications

Pulp necrosis
Coronal segment 20 to
44%
Apical segment 0%

Pulp canal obliteration

69%

Root Fracture Complications

Pulp necrosis
Coronal segment 20 to
44%
Apical segment 0%

Pulp canal obliteration

69%
Root resorption 60%

Root Fracture Treatment

Summary
Reposition and splint for 3 weeks !!

Root Fracture Treatment

Summary
Reposition and splint for 3 weeks !!
Monitor with pulp tests and
radiographs

Root Fracture Treatment

Summary
Reposition and splint for 3 weeks !!
Monitor with pulp tests and
radiographs
Do not initiate endodontic treatment
unless there are signs of pulp
necrosis

Management of the Avulsed

Tooth

Management of the
Avulsed Tooth

Overview
Periodontal Ligament Responses
Treatment Considerations
Pulpal Prognosis/ Endodontic Rationale
Treatment Regimen

Avulsed Permanent Teeth

Incidence
0.5% to 16% of
traumatic injuries

Main etiologic
factors

Fights
Sports injuries
Automobile
accidents

Avulsed Permanent Teeth

Maxillary central incisor

Most commonly avulsed
tooth

Mandibular teeth
Seldom affected

Most frequently involves a

single tooth

Avulsed Permanent Teeth

Most common age - 7 to 11

Permanent incisors erupting
Loosely structured PDL

Avulsed Permanent Teeth

Associated injuries
Fracture of alveolar
socket wall

Avulsed Permanent Teeth

Associated injuries
Fracture of alveolar
socket wall
Injuries to the lips
and gingiva

Management of the
Avulsed Tooth

What tissue should

be our primary
concern?
Pulp?

Management of the
Avulsed Tooth

What tissue should

be our primary
concern?
Pulp?
Socket?

Management of the
Avulsed Tooth

What tissue should

be our primary
concern?

Pulp?
Socket?
PDL?

Management of the
Avulsed Tooth

Ultimate goal
PDL healing without
root resorption

Management of the
Avulsed Tooth

Ultimate goal
PDL healing without
root resorption

Most critical factor

Maintaining an intact
and viable PDL on
the root surface

Periodontal Ligament
Responses

Surface Resorption
Replacement Resorption (Ankylosis)
Inflammatory Resorption

Andreasen JO, Hjorting-Hansen E.

Replantation of teeth II. Histological study
anterior teeth in humans.
Acta Odontol Scand 1966;24:287-306.

of 22 replanted

Periodontal Ligament
Responses

Surface resorption
Superficial resorption
cavities
Mainly in cementum
Complete repair of
PDL

Periodontal Ligament
Responses

Replacement
resorption
(Ankylosis)
Direct union of bone
and root
Resorption of root Replacement with
bone
Direct result of loss of
vital PDL

Periodontal Ligament
Responses

Inflammatory resorption
Resorption of cementum
and dentin
Inflammatory reaction in
the periodontal ligament

Etiology

Inflammatory
resorption
Surface resorption of
cementum exposing
dentinal tubules

Etiology

Inflammatory
resorption
Surface resorption of
cementum exposing
dentinal tubules
Pulp necrosis

Etiology

Inflammatory
resorption
Surface resorption of
cementum exposing
dentinal tubules
Pulp necrosis
Toxic products from
the pulp provoke an
inflammatory
response in the PDL

Periodontal Ligament Responses

Surface resorption

Periodontal Ligament Responses

Surface resorption
Replacement resorption (Ankylosis)

Periodontal Ligament Responses

Surface resorption
Replacement resorption (Ankylosis)
Inflammatory resorption

Treatment Considerations

Extraoral time
Extraoral environment
Root surface manipulation
Management of the socket
Stabilization

Extraoral Time

Shorter time = Better prognosis*

< 30 min 10% resorption
> 90 min 90% resorption

Andreasen JO, Hjorting-Hansen E.

Replantation of teeth I. Radiographic and clinical study
of 110 human teeth replanted after accidental loss.
Acta Odontol Scand 1966;24:263-86.

Extraoral Time

Shorter time = Better prognosis*

< 30 min 10% resorption
> 90 min 90% resorption
*depending on storage medium
Andreasen JO, Hjorting-Hansen E.
Replantation of teeth I. Radiographic and clinical study
of 110 human teeth replanted after accidental loss.
Acta Odontol Scand 1966;24:263-86.

Extraoral Environment

Viability of PDL cells is

critical

Storage Media

Tap Water
Dry
Saliva
Saline

Poor
results

Andreasen JO.
Effect of extra-alveolar period and storage media
upon periodontal and pulpal healing after replantation
of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43-53.

Storage Media

Tap Water
Poor results
Dry
Saliva
Good
protection for
Saline
2 hrs
Andreasen JO.
Effect of extra-alveolar period and storage media upon
periodontal and pulpal healing after replantation
of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43-53.

Milk As A Storage Medium

Physiologic
osmolality
Markedly fewer
bacteria than saliva
Readily available

Storage Media - Milk vs. Saliva

Storage for 2 hrs

Periodontal healing almost as good as immediate
replantation

Blomlof L, et al.
Storage of experimentally avulsed teeth in milk
replantation.
J Dent Res 1983;62:912-6.

prior to

Storage Media - Milk vs. Saliva

Storage for 2 hrs

Periodontal healing almost as good as immediate
replantation

Storage for 6 hrs

Saliva extensive replacement resorption
Milk healing almost as good as immediate replant
Blomlof L, et al.
Storage of experimentally avulsed teeth in milk
replantation.
J Dent Res 1983;62:912-6.

prior to

Cell Culture Media

Eagles Medium
Hanks Balanced Salt Solution

Hanks Balanced Salt Solution

Proper pH and osmolality

Reconstitutes depleted cellular metabolites
Washes toxic breakdown products from the
root surface

Organ Transplant Storage Media

Viaspan
Dramatically prolongs the storage of human
organs
Expensive
Not readily available

Storage Media Comparison

Viaspan

Complete healing after 6 and 12 hrs

Good for extended storage periods (72 and 96 hrs)

Trope M, Friedman S.
Periodontal healing of replanted dog teeth stored
Viaspan, milk and Hanks balanced salt solution.
Endod Dent Traumatol 1992;8:183-8.

in

Storage Media Comparison

Viaspan

Complete healing after 6 and 12 hrs

Good for extended storage periods (72 and 96 hrs)

Hanks balanced salt solution

Healing results similar to Viaspan
Trope M, Friedman S.
Periodontal healing of replanted dog teeth stored
Viaspan, milk and Hanks balanced salt solution.
Endod Dent Traumatol 1992;8:183-8.

in

Recommended Storage Media

1. Socket (immediate
replantation)
2. Cell culture
medium
3. Milk
4. Physiologic saline
5. Saliva

Root Surface Manipulation

Attempt to retain PDL cell viability

Do not curette root surface
Avoid caustic chemicals

Van Hassel HJ, Oswald RJ, Harrington GW.

Replantation 2. The role of the periodontal
ligament.
J Endodon 1980;6:506-8.

Root Surface Manipulation

Extraoral dry time determines handling

Root Surface Manipulation

Extraoral dry time < 1 hr

PDL healing is still possible
Handling recommendations
Keep root moist
Do not handle root surface
Gentle debridement

Root Surface Manipulation

Extraoral dry time > 1 hr

Loss of PDL cell viability
inevitable
Treatment recommendations
Remove tissue tags
Soak in accepted dental
fluoride solution for 20 min

Fluoride Treatment

1.0-2.4% topical
fluoride solution
Sodium fluoride
(Andreasen)
Stannous fluoride
(Krasner)

20 minute soak

Management of the Socket

Remove contaminated coagulum in

socket
Irrigate with sterile saline

Management of the Socket

Examine socket If fracture is evident

Reposition fractured bone with a blunt
instrument

Management of the Socket

Replant using light digital pressure

Stabilization

Splint
Definition a rigid or flexible device used to
support, protect, or immobilize teeth, preventing
further injury
Types
Acid etch composite
Cross-suture

Acid Etch Composite Splints

Interproximal composite

Acid Etch Composite Splints

Composite with arch wire

Acid Etch Composite Splints

Composite with monofilament nylon

Acid Etch Composite Splints

Functional Splint
20-30 lb
monofilament nylon
Bonded with
composite
Allows physiologic
movement
Antrim DD, Ostrowski JS.
A functional splint for traumatized teeth.
J Endodon 1982;8:328-31.

Cross-Suture Splint

Indications
No adjacent teeth to
splint to
Unmanageable
traumatized children

Cross-Suture Splint

Splinting Time

Effect of splinting time

7 days
30 days

Nasjleti CE, Castelli WA,

Caffesse RG.
The effects of different splinting
times on replantation of teeth in
monkeys.
Oral Surg 1982;53:557-66.

Splinting Time

Recommended time
7 to 10 days

Nasjleti CE, Castelli WA,

Caffesse RG.
The effects of different splinting
times on replantation of teeth in
monkeys.
Oral Surg 1982;53:557-66.

Pulpal Prognosis

Stage of root development

Dry storage time
Storage media
Antibiotics

Stage of Root Development

Mature roots (< 1.0 mm)

Revascularization 0%

Kling M, et al. Endod Dent Traumatol 1986;2:83-9.

Andreasen JO, et al. Endod Dent Traumatol
1995;11:51-8.

Stage of Root Development

Mature roots (< 1.0 mm)

Revascularization 0%

Immature roots (> 1.0 mm)

Revascularization 18-34%

Kling M, et al. Endod Dent Traumatol 1986;2:83-9.

Andreasen JO, et al. Endod Dent Traumatol
1995;11:51-8.

Revascularization

Loss of blood
supply to pulp

Revascularization Day 4

Coronal pulp
Extensive ischemic
injury

Revascularization Day 4

Coronal pulp
Extensive ischemic
injury

Apical pulp
Initial revascularization

Revascularization 4 Weeks

Pulp status

Revascularization
Reinnervation
New odontoblastic layer

Revascularization

Typical sequela
Pulp canal obliteration

Dry Storage Time

As dry storage time increases

Pulp survival decreases

Andreasen JO, Borum MK, Jacobsen HL,

Endod Dent Traumatol 1995;11;59-68.

Andreasen FM.

Storage Media

Nonphysiologic storage
Minimal chance of pulp
revascularization

Andreasen JO, Borum MK, Jacobsen HL,

Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.

Storage Media

Nonphysiologic storage
Minimal chance of pulp
revascularization

Physiologic storage
HBSS, milk, saline, saliva
Improved chance of pulp
revascularization

Andreasen JO, Borum MK, Jacobsen HL,

Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.

Pulpal Prognosis - Antibiotics

Systemic antibiotics
Pulp
revascularization is
not increased

Cvek M, Cleaton-Jones P, Austin J, Lowni J,

Kling M, Fatti P.
Endod Dent Traumatol 1990;6:157-69.

Pulpal Prognosis - Antibiotics

Systemic antibiotics
Pulp
revascularization is
not increased

Topical antibiotics
Beneficial effect

Cvek M, Cleaton-Jones P, Austin J, Kling M,

Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.

Pulpal Prognosis - Antibiotics

Topical Doxycycline
Decreased microorganisms in
pulpal lumen
Increased pulp
revascularization

Cvek M, Cleaton-Jones P, Austin J, Kling M,

Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.

Pulpal Prognosis - Antibiotics

Recommendation
Topical Doxycycline
1 mg in 20 ml physiologic saline
5 minute soak

Cvek M, Cleaton-Jones P, Austin J, Kling M,

Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.

Endodontic Rationale

Mature root - 4 weeks

Very limited
revascularization

Endodontic Rationale

Mature root - 4 weeks

Very limited
revascularization
Ischemic coronal pulp with
great risk of infection !!!

Endodontic Rationale Mature

Root

Pulpectomy 7-14 days

Endodontic Rationale Mature

Root

Calcium hydroxide
placement

Endodontic Rationale Mature

Root

Calcium hydroxide

Antibacterial
Increases pH in dentin
Favors mineralization over resorption

Tronstad L, Andreasen JO, et al.

pH changes in dental tissues after
calcium
hydroxide.
J Endodon 1981;7:17-21.

root canal filling with

Endodontic Rationale Mature

Root
Treatment recommendation

Ca(OH)2 therapy for as long as

practical, usually 6-12 months

Treatment of the Avulsed

Permanent Tooth.
Recommended Guidelines of the
American Association of
Endodontists, 1995.

Specific Treatment Regimen

Treatment of the Avulsed Permanent Tooth.

Recommended Guidelines of the American
Association of Endodontists, 1995.

Specific Treatment Regimen

Root Development

Closed apex
Open apex

Extraoral Dry Time

One hour or less

More than one hour

Treatment of the Avulsed

Permanent Tooth.
Recommended Guidelines of the
American Association of
Endodontists, 1995.

Treatment Flowchart
Extraoral Dry Time
< 1 hr

Closed
Pulpecto
my7-14
days

> 1 hr

Apex Maturity

Open
Observ
e

Open or Closed
Pulpecto
my 7-14
days
Option:
Extraoral
RCT

Emergency Treatment

Replantation
technique
Local anesthetic, if
necessary
Radiograph to verify
position
Check occlusion
Physiologic splint

Emergency Treatment

Additional
Considerations
Analgesics

Emergency Treatment

Additional
Considerations
Analgesics
Chlorhexidine

Emergency Treatment

Additional Considerations

Analgesics
Chlorhexidine
Tetanus
Refer to physician for tetanus prophylaxis prn

Rothstein RJ, Baker FJ.

Tetanus: Prevention and
treatment.
J Am Med Assoc 1978;240:6756.

Emergency Treatment

Additional Considerations

Analgesics
Chlorhexidine
Tetanus
Antibiotics

Antibiotics

Penicillin
500 mg qid for 4-7 days

Andreasen JO.
Atlas of replantation and transplantation of
Philadelphia: W.B. Saunders Co., 1992;57-

teeth.
92.

Antibiotics

Tetracycline vs. amoxicillin

replacement resorption model

in a

Tetracycline had better anti-resorptive properties

Sae-Lim V, Wang CY, Choi GW, Trope M.

The effect of systemic tetracycline on resorption of
dried replanted dogs teeth.
Endod Dent Traumatol 1998;14:127-32.

Antibiotics

Tetracycline vs. amoxicillin

root resorption model

in an inflammatory

Tetracycline had better anti-bacterial properties

Sae-Lim V, Wang CY, Trope M.

Effect of systemic tetracycline and amoxicillin on inflammatory root
resorption of replanted dogs teeth.
Endod Dent Traumatol 1998;14:216-20.

Antibiotics

Recommendation
Tetracycline could be considered as an alternative
to amoxicillin after avulsion injuries.

Sae-Lim V, Wang CY, Trope M.

Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs teeth.
Endod Dent Traumatol 1998;14:216-20.

Tetracycline Use In Young

Children

Tetracycline staining
Not a problem since avulsed maxillary anteriors
have already erupted and are not susceptible to
staining
At worst, posterior teeth might be stained
Remote possibility with 7-10 day prescription
Sae-Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs teeth.
Endod Dent Traumatol 1998;14:216-20.

Avulsion Sequelae

Closed Apex
Extraoral dry time
1 hour or less

Avulsion Sequelae

Closed Apex
Extraoral dry time
more than 1 hour

Avulsion Sequelae

Open Apex
Extraoral dry time
1 hour or less

Avulsion Sequelae

Open Apex
Extraoral dry time
more than 1 hour

Avulsion Management

Be prepared Dental Trauma Kit

Immerse tooth in a
physiologic storage medium
to buy time
Determine extraoral dry time
Follow AAE Guidelines