Traumatic Injuries, Cracked Teeth and
vertical root fractures (VRF)
Fact
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Most dental trauma occurs in 7_12 age range
And most trauma occurs in the anterior region
of the mouth, maxilla>mandible
1. Crown FX without Pulp exposure
NO PROBLEM,
RELAX AND RESTORE
Complicated Crown FX with Pulp
Exposure
@80% IF
w/in 24hrs
Pulp Cap?
Partial Pulpotomy@95%
Full pulpotomy @75%
OR:
EXTIRPATION if
root is fully formed
2. Crown-Root Fracture
sometimes fractures at an angle
Angular Fracture:
Is this
restorable?
Remember,

In all trauma, the primary purpose of our
treatment is to keep the pulp vital, if at all
possible, ESPECIALLY if apex is open

WHY?
Pulpotomy – Immature Apex
If Vital = “Apexogenesis”*
Apexogenesis vs Apexification
Dealing with the immature root
Apexogenesis
(Vital Pulp) best to treat w pulpotomy. The idea is to
allow the vital pulp to remain vital and complete the
development of the root apex
as well as thickening of the RC walls
RCT maybe needed later BUT not if tooth remains
asymptomatic AND vital
Apexification
(Necrotic Pulp) Hoping to get closure of the apex (&
there is NO wall thickening) to be able to later do a
proper RC seal via obturation. CaOH + time is
proper tx over 3-18mo
RCT ALWAYS NEEDED HERE* and is less
predictable due to thinner walls
Object of either treatment is to allow for roofing over
of apex and allow RCT to be done at a later date.
And now, Regeneration?

Revascularization of immature permanent teeth
utilizing a mixture of antibiotics(3 weeks), creating
a blood clot w/in the RCS which produces
development of the tooth structure
3.Horizontal Root Fracture
Root FX (Horizontal)
What do you do here? Try to reposition and
splint 2-4 wks, check for vitality q 30 days
4. Luxation Injuries
(MOST COMMON OF ALL DENTAL INJURIES)
30-44%
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Concussion
Subluxation
Extrusion
Lateral
Intrusion
AVULSION
WORST CASE SEQUELAE?
PULP NECROSIS
EXTERNAL/INTERNAL
ROOT RESORPTION
Possible tooth loss
Concussion Luxation Injury
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Least severe of
Luxation injuries
No displacement of
tooth nor excessive
mobility
Tooth tender to
touch “Bruised PDL”
No radiographic
abnormalities
Assess vitality in 4
wks
Subluxation Luxation Injury
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Tooth tender to touch &
slightly mobile (1+) but not
displaced
Possible hemorrhage from
gingival crevice
No radiographic
abnormalities
Damage to supporting
structures?
Assess vitality in 4 weeks
Extrusion Luxation Injury

Elongated mobile tooth
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Cl. II mobility or greater
Radiographs show
increased apical
periodontal space
Manually reposition
Reposition tooth +
Flexible splint (2 weeks)
Assess vitality in 4 weeks
What is a flexible splint?
-Allows physiologic movement of the teeth in
order to minimize ankylosis
-In the past, .028 gauge ortho wire bonded to
tooth for 7-10 days unless alveolar FX had
occurred. Then 4-8 wks
OR: 4-6# fishing line bonded to teeth
-Currently, titanium trauma splint (TTS) is
recommended
Semi-rigid or flexible splinting


Experimental studies in non-human primates have
demonstrated that rigid splinting ,especially for
prolonged periods, leads to ankylosis &/or external
resorption.
Maintaining a slight degree of tooth mobility appears to
be beneficial to PDL healing
Titanium Trauma Splint
Medaris AG, Basel Switzerland
TTS splint
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Insert picture of same
Splinting of traumatized teeth with a new
device:TTS (Titanium Trauma Splint)
Medartis AG, Basel, Switzerland
Von arx T, etal Dent Traumatol, ’01;17:180-84
Lateral Luxation Injury
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Displaced laterally & often
locked in bone
Not tender to touch, not
mobile
Alveolus fractured
Percussion test: high metallic
sound (ankylosis)
Increased PDL space best
seen on eccentric or occlusal
radiographs
Anesthetize & reposition
+ Flexible splint (4 weeks)
Assess vitality in 4 weeks
Intrusion Luxation Injury
External root resorption likely

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Most severe of
luxations***
Tooth appears shorter: displaced into
alveolar bone
PDL destruction/alveolar crushing)
Beware of ankylosis/resorption/

pulp necrosis is all but certain in
mature teeth***

Not tender to touch, not mobile
Percussion test: high metallic sound
Radiographs not always conclusive
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Slightly luxate with forceps or band and
move orthodontically.
Splinting is not usually necessary (>4
weeks)
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Tooth with open apex may
spontaneously re-erupt.
Treatment of intrusion luxation

Closed apex needs ortho. or surgical
repositioning and probable RCT in 1-3 weeks
In all LUXATION and especially INTRUSION injuries,
the apical neurovascular bundle and attachment
apparatus will be affected to some degree>>>loss
of vitality & internal/external resorption
5. Avulsion
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Tooth is knocked completely out of
mouth
Viability of the PDL must be
preserved for success
Extra-oral dry time is CRITICAL 3060”***
Must be replaced in socket ASAP
(15-20”) in order to..
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Prevent ankylosis
Prevent external root resorption
To replant or not? should be “decent tooth”: No point in replanting THIS one
Replant?
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TX is aimed at minimizing the inflammation
from the two main consequences of avulsion,
namely; attachment damage and pulpal infection
that inevitably results
The SINGLE most VIP factor in achieving a
favorable outcome is the SPEED at which a
clean tooth is properly replanted
Keeping the attached PDL moist is VIP!!*
Replantation guidelines
HOW FAST IS FAST? 5”, 30” 60”, TAKE YOUR PICK, it depends on whose book you read!
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If tooth is out of the mouth less than 15-20”,
replant according to guidelines
If tooth was out and placed in cold milk or other
physiological solution w/in 15-20” & available for
replantation w/in 30”, replant and follow
guidelines
If tooth is out > 60” and not stored, there is usually
one outcome: resorption and probable loss
If the pt is pre adolescent, the tooth may become
infraoccluded (ankylosed) as he/she grows older
To replant or not
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If the root of the avulsed tooth is not completely formed,
the prognosis for survival and revascularization is possible
if not left out>60”
If root is incompletely formed and replantation is rapid,
vitality may be maintained but is not predictable
First Aid Instructions
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Handle by crown only
Pick off debris with tweezers
Replant tooth if possible
_________________________________
If not, transport in appropriate medium:
“HBSS (Hank’s Balanced Salt solution)
 OR “Via Span” (if available)
 OR milk if above not available
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 OR
place in vestibule (saliva) & Report to
dental office ASAP
Once in Dental office:

Take films to make sure there is no alveolar FX
& that adjacent teeth are OK
“Save-a-tooth” (Hank’s Balanced Salt solution)
 OR “Via Span”, milk, saline
 Gently clean socket
 Replant and check occlusion
 Splint (7-10 days)
 RX antibiotics

Avulsion Injury
What NOT to do!
 Do
Not
Handle by root
 Scrub root
 Allow tooth to dry
 Submerge the tooth in water
(tap water is hypotonic>
and will cause cell rupture)
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AAE has a Flow Chart Outlining Current Treatment Management Protocols of
both Luxation and Avulsion cases ..www. aae.org.
If over 60” “dry time”
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Remove remnants ofPDL by soaking in acid for 1”
Soak in Stannous Fl for 5”
No harm done to go ahead and complete endo ASAP
Splint
Immature Tooth: Open Apex, revascularization
is possible if out less than 30-60”
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Replant as above EXCEPT different
Soak tooth in Doxycycline (1mg/20cc
saline)<replantation for 5”
Monitor pulp vitality closely (q 30 d or until root
development is confirmed)
Vital Open apex will NOT necessarily require RCT
UNLESS pulp becomes necrotic.
What if it does? Do we do apexogenesis then?
Ankylosis
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A problem following trauma and
long term rigid splinting
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Tooth is solidly fixed and has a high
metallic ring when percussing. Does
not erupt with other teeth
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May lead to massive external
resorption & loss of tooth
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Internal= appearance of
“aneurysm” w/in canal.
Complications with Replanted
avulsed teeth & Possibly with Rigid
Long-Term Splinting
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Ankylosis (Replacement Resorption)
Vertical Root Fracture
Look for ‘J’-Shaped apical lesion
Look for Drop-off Pocket if . . . .
VRF difficult to confirm
radiographically –UNLESS
separation of segments occurs
Transillumination
Restoration Removal + Staining
Other methods of discovering VERTICAL ROOT FRACTURE
A surgical exploration is usually the only other way to
confirm presence of VRF*
Flare-ups
Flare-ups
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A flare-up is an acute exacerbation of an
asymptomatic pulp/or periapical pathosis after
the initiation or continuation of root canal
treatment.
Patient Presentation
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Pain
Pain and swelling
Factors
 Mechanical
chemical
 Emotional state
 Gender
 Microbial
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• Immunological
• Psychological
•
state
Regulation of
periapical
inflammation
Incidence
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1.4 to 19%
20 to 40%
Age of Patient?
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There is a lack of agreement concerning the
influence of age on the incidence of flare-up.
40_59 year(most)
Under the age of 20(least)
Gender and Flare-ups
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Women(most)
Systemic conditions
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Host resistance
Allergy
Anatomic Location
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Mandibular teeth
premolars
Anxiety
Preoperative History of the Tooth
Number of Treatment Visits
Causes of Inter-Appointment
Pain
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Mechanical
Chemical
Microbial injury
Re-Treatment Cases
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13.6% flare-up
Strategies to Prevent Flare-ups
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Anxiety Reduction
Behavioral Intervention
Occlusal Reduction
Pharmacologic Strategies for
Flare-up
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Antibiotic
NSAIDs and Acetaminophen
Long-acting Local Anesthetics
Patient Instructions
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By the Clock
NOT
PRN
Indications for
Antibiotic Therapy
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Systemic involvement
Compromised host resistance
Fascial space involvement
Treatment of Endodontic Flareups
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Diagnosis and Definitive Treatment
Drainage Through the Coronal Access Opening
I&D
Instrumentation
Trephination( For severe pain without visible
swelling)