Trauma and nerve damage to teeth (Part II)

TRAUMATIC INJURIES OF TEETH

CONCUSSION

• Concussion refers to vascular structures at the tooth apex and periodontal ligament resulting in inflammatory edema
• No displacement, only minimal loosening of tooth occurs
• May result in mild avulsion of the tooth from its socket causing occlusal surface to make premature contact with an opposing tooth

Clinical features

• Tenderness on gentle horizontal or vertical percussion
• Tooth sensitive to biting forces
• Patients usually try to modify occlusion to avoid traumatized tooth

Management

• Soft diet
• Relief of occlusal interferences
• Flexible splinting
• Periodic monitoring with repeated vitality testing and radiographs

Prognosis

• Pulp necrosis
• Root resorption is very rare

LUXATION

• Dislocation of the tooth from its socket after severing of the periodontal attachment
• Usually two or more teeth involved
• Teeth mostly affected: deciduous and permanent maxillary incisors
• Mandibular teeth seldom affected
• Vitality testing: temporarily decreased or undetectable
• Vitality may return after weeks or several months
• Depending on magnitude and direction of traumatic force
• Subluxation
• Extrusive luxation
• Lateral luxation
• Intrusive luxation

SUBLUXATION

Subluxation denotes an injury to supporting structures of the tooth that results in abnormal loosening of the tooth without frank dislocation.

Clinical features

• Teeth are in normal location or limited elevation of tooth from its socket
• Abnormally mobile
• Extravasated blood emanating from gingival crevice depicts PDL damage
• Tenderness to percussion and masticatory forces

EXTRUSION

• Partial displacement of a tooth out of its socket
• Often found in deciduous teeth

Clinical features:

• Tooth appears elongated
• Usually displaced palatally
• Bleeding from gingival sulcus
• Mobile

LATERAL LUXATION

Movement of tooth in a direction other than intrusive or extrusive displacement

Clinical features

• Comminution or crushing of alveolar process accompany tooth dislocation
• Movement direction depends on:
• Orientation and magnitude of the force
• Root shape
• Tooth may be pushed through buccal or less commonly lingual cortical plate
• Root apex palpable insulcus area

Management (Subluxation, Extrusion, Lateral luxation)

• Restoring teeth to normal position by digital pressure under LA
• Comminuted pieces of alveolar bone to be repositioned by digital pressure
• Removal of occlusal interferences if necessary
• Immobilization for 2-3 weeks using flexible splints
• Root canal therapy prior to splint removal
• Extraction of the traumatized teeth should be the last resort
• Periodic follow up clinically and radiographically

Prognosis

• Pulp necrosis: Open apex -9%, Closed apex -55%
• Chances of surface resorption
• Inflammatory resorption can be seen in association with pulp necrosis
• Due to compression to the PDL, both inflammatory and replacement resorption may occur

INTRUSION

• Displacement of tooth into alveolar process
• Comminution or crushing of alveolar process accompany tooth dislocation
• Often seen with deciduous dentition, less in permanent dentition

Clinical features

• Reduced height of clinical crown
• Gingival bleeding evident
• High metallic sound on percussion
• Maxillary incisors may be intruded into the alveolar process
• Damage to adjacent teeth especially underlying permanent teeth

Management for intrusion:

Depends entirely upon the stage of root development

Immature root formation

• Spontaneous eruption can be anticipated
• Luxation of tooth slightly with the forceps done if no signs of re-eruption after 10 days
• Pulpal healing is monitored during the period of re-eruption at 3, 4, 6 weeks after injury
• In case of negative response of the pulp or periapical radiolucency
• Endodontic therapy with calcium hydroxide dressing is done

Completed root development

• Spontaneous re-eruption is unpredictable
• Orthodontic extrusion is indicated over a period of 2-3 weeks
• Prophylactic endodontic therapy is indicated as frequency of pulp necrosis

Prognosis

• Pulpal necrosis-Open apex-63%, Closed apex –100%
• External surface, inflammatory and replacement resorption are very frequent findings, especially in teeth with complete root development
• Severe complication can be seen as late as 5-10 years after trauma

AVULSION

• Complete displacement of a tooth from the alveolar process
• Can occur due to direct or indirect trauma 

Clinical features

• Seen in relatively younger age group
• Maxillary central incisors-most commonly avulsed teeth in both dentitions
• Affects single tooth mostly
• Socket is found empty or filled with coagulum
• Lip laceration
• Fracture of alveolar process may occur 

Management

• If avulsed tooth is not found clinically or radiologically, chest or abdominal radiograph to locate it
• Reimplantation of permanent teeth. The prognosis depends on:
• Condition of tooth
• Time out of socket
• Viability of residual PDL fibres
• Splinting
• Endodontic therapy after reimplantation
• Follow up

DISCLAIMER : “Views expressed above are the author’s own.”