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Dental Traumatology

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CROWN FRACTURE

NOTES EXTRACTED FROM UK DENTAL EXAMS MASTERCLASS
Type of Trauma Details Treatment
Crown Infraction Also known as Greenstick Fracture. A simple crack in enamel without tooth structure loss.
Diagnosed via transillumination or indirect light.		 No specific treatment required. Long-term follow-up (up to 5 years) to monitor pulp condition.
Uncomplicated Crown Fracture (Ellis Class I & II) Enamel and dentin exposed, pulp is intact.
Most common dental injury among all crown fractures.
Treatment depends on Remaining Dentin Thickness (RDT):
  • RDT > 2 mm: Restoration of choice.
  • RDT < 0.5 mm: Composite Bandage needed to protect underlying dentinal tubules.
  • RDT < 0.5 mm with deep dentinal tubules: Protection with Ca(OH)₂ or MTA liner, followed by restoration.
Complicated Crown Fracture (Ellis Class III) Pulp is exposed.
In 24 hours, only 2 mm of pulp will be inflamed.
Incidence: 0.9% – 13%.
Treatment depends on:
  • Time between trauma & treatment
  • Maturity status of tooth:
    • Open Apex
    • Closed Apex
  • Concomitant attachment damage (PDL & alveolar bone damage)
Time Tooth Treatment
<8 hours Mature Apex, No attachment damage, Superficial inflammation (1.5 – 2 mm of pulp) Partial pulpotomy, Direct pulp capping with Ca(OH)₂ or MTA.
<8 hours Immature Apex, No attachment damage, Superficial inflammation Partial pulpotomy (CVEK pulpotomy) followed by apexogenesis.
>8 hours Mature Apex, PDL damage, Deep pulpal inflammation Root canal treatment required.
>8 hours Immature tooth, No PDL damage Conventional treatment: Apexification or recent/contemporary pulp revascularization.
>8 hours Immature tooth, Damage to PDL/Bone Semi-rigid splinting for 2 weeks.
Dental Trauma Table
Type of Trauma Clinical Presentation Treatment Point to Note
Uncomplicated Crown Fracture (Ellies 1 & II) Most common. Enamel and/or dentin are exposed. Composite restoration. If remaining dentin is less than 0.5 mm, calcium hydroxide liner is given before composite.
Complicated Crown Fracture (Ellies Class III) Pulp is exposed. In 24 hrs, only 2 mm pulp will be inflamed. Immature Teeth:
  • Less than 24 hrs: Pulp capping – Partial pulpotomy.
  • More than 72 hrs: Full pulpotomy (less success).
  • If Pulp is Nonvital: Apexification – Revascularization.
Mature Teeth:
  • Less than 24 hrs: Pulp capping – Partial pulpotomy.
  • If pulp therapy is not possible: Pulpectomy (More predictable).
Pulp Capping Success Rate:
  • Lower success because inflamed pulp is not removed.
  • Partial pulpotomy has high success.
  • In mature teeth, full pulpotomy is contraindicated.
Ca(OH)₂ Apexification Disadvantages:
  • Long treatment time (3-8 months).
  • Weakens root dentin.
  • Possible fracture of tooth.
  • Irregular “swiss cheese” dentin bridge.
Crown-Root Fracture Usually oblique fracture.
  • Removal or reattachment of fractured fragment.
  • Removal of coronal fragment.
  • Surgical or orthodontic extrusion of root fragment or simple gingivectomy.
 RCT is required if pulp is involved.
Vertical Fracture

Vertical fracture of posterior teeth is not as amenable to conservative endodontic treatment as horizontal fracture.

If the fracture occurs in a buccolingual plane in multi-rooted teeth through furcation:

  • Endodontic therapy followed by hemisection.
  • Full crown coverage of mesial and distal segments.

If the vertical fracture occurs through the crown furcation of a maxillary molar in a mesiodistal plane, extraction is indicated.
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ROOT FRACTURES

Root Fractures

Root Fractures

Type Clinical Presentation Treatment Points to Note
Cervical, Middle third, Apical
  • Infrequent
  • Coronal fragment displacement varies
  • Three-angle radiography needed for diagnosis
  • Repositioning and semi-rigid splinting for 2-4 weeks
  • Cervical fracture: Extraction or orthodontic extrusion if repositioning fails
  • Mid root: If coronal segment is necrotic, treat like apexification
  • If both segments are necrotic: Surgical removal or endodontic implants
  • Apical root: Excellent prognosis

Healing patterns of the fracture site:

  1. Healing with calcified tissue
  2. Healing with interproximal connective tissues
  3. Healing with interproximal bone
  4. Interproximal inflammatory tissue without healing

First three patterns are considered successful.

LUXATION

Luxation Injuries
Type Clinical Features Treatment Notes
Concussion
  • Sensitive to percussion
  • No displacement
  • No mobility
  • No treatment
  • Repeat vitality tests
 Least damage to periodontal ligament and cemental layer.
Subluxation
  • Sensitive to percussion
  • Increased mobility
  • No displacement
  • Monitor with periodic vitality tests
 Minimal risk of root resorption.
Lateral Luxation

Displacement labially, lingually, distally, or incisally. May perforate the cortical plate.
  • Immediate repositioning
  • Semi-rigid splinting for 4 weeks
  • In mature apex: Initiate RCT within 7-10 days
  • In immature apex: Wait for revascularization, perform apexification if necessary

Risk of external and internal root resorption:

  • Surface resorption: Common in concussion and subluxation, spontaneous repair.
  • Replacement resorption: Occurs in intrusive luxation, leading to bone formation.
  • Inflammatory resorption: Most damaging, occurs with necrotic pulp.
Intrusion

Displacement in an apical direction into the alveolus.
  • Orthodontic extrusion or surgical repositioning
  • Semi-rigid splinting for 4 weeks
 Highest risk of ankylosis and root resorption.
Luxation Injuries
Features Concussion Subluxation Lateral Luxation Extrusion Intrusion
Displacement No displacement of tooth No displacement of tooth Present Present Present
Mobility No mobility Present No mobility Present No mobility
Pain on Percussion Present Present *High Pitched metallic sound on percussion or Ankylotic sound* Can be Present / Absent Present *High Pitched metallic sound on percussion*
Treatment No treatment needed Splinting for 2 weeks Splinting for 2 weeks Splinting for 2 weeks Splinting for 4 weeks
📌 Important: Splinting depends on the depth of luxation injury and maturity status of tooth.
Depth Mature Tooth Immature Tooth
< 7 mm Ortho repositioning Wait and watch. Spontaneous eruption
> 7 mm Surgical repositioning Surgical repositioning
📌 Treatment for mature tooth should be carried out within 2-3 weeks, else ankylosis will occur.
Injury Diagnosis Table

Injury Diagnosis Table

Type of Injury Abnormal Mobility Tenderness to Percussion Percussion Sound Response to Pulp Testing Clinical Radiologic
Concussion – + Normal ± – –
Subluxation + + Dull ± – –
Extrusive Luxation + ± Dull – + +
Lateral Luxation – – Metallic – + +
Intrusive Luxation – – Metallic – + +

AVULSION

Avulsion Treatment

Avulsion is also known as Exarticulation.

Pulp necrosis is 100%.

Treatment

  • Replantation is the first treatment to be considered.
  • Treatment depends upon time & maturity status of tooth.
Time Maturity Treatment
<60 min Mature
  • Hold the tooth with forceps at crown or above CEJ.
  • Use warm saline: Rinse soft debris.
  • Use warm saline: Rinse socket.
  • Gently replant the tooth and splint for 1-2 weeks (7 days).
<60 min Immature Pulp-less tooth.
  • Pulp Regeneration is the treatment of choice.
  • Place the tooth into freshly prepared 2% Doxycycline solution or sprinkle with minocycline powder.
  • Replant + splinting (1-2 weeks).
>60 min Mature tooth
  • PDL survival is unlikely, so removal is needed.
  • Place tooth in organic acid – 5 min, remove PDL, then place into 2% SnF2 for 5 min.
  • Condition root surface.
  • Replant + splinting (1-2 weeks).
>60 min Immature tooth
  • Worst prognosis.
  • Endotherapy done after 1-2 weeks.
  • Adjacent with antibiotics.
  • Tetracycline 100mg 1 – 1 × 7 days.

🔍 Replantation within 15-20 min is optional/ideal because it has maximum survival probability.

  • Maximum time – 60 min is also better for replantation.
  • Beyond 60 min → PDL becomes dead, initiating inflammatory root resorption.

Oxford Handbook:

Saline > Milk > Water > Air

IADT Guidelines

Replantation > Milk > HBSS > Saliva (spit in a Cup) > Saline > water > Air

Splint Duration Guide

Splint Duration Guide

Type of Splinting Splint Duration
Subluxation 2 Weeks
Extrusive Luxation 2 Weeks
Lateral Luxation 4 Weeks
Intrusive Luxation 4 Weeks
Root Fracture 4 Weeks
Root Fracture Cervical 1/3rd 4 Months
Avulsion 2 Weeks
Avulsion > 60 Mins 4 Weeks
Alveolar Fracture 4 Weeks

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