Tooth Trauma

Dental trauma refers to injury to the teeth and/or gums, periodontal ligament, alveolar bone, and nearby soft tissues. It is also known as Traumatic Dental Injury (TDI). Tooth trauma occurs more in the front teeth with the Maxillary central and lateral incisors in both milk and permanent teeth. Anterior TDIs poses a significant problem in adults and children alike and the occurence of trauma may exceed that of having a hole in the teeth or bleeding gums and can have significant negative effects on individuals’ affected.

There are various classifications of traumatic tooth injuries which further gives an insight into the different types with the Ellis classification (1995) being the most common and most widely used. This classification highlights nine different subclasses which are:
• Class I – Simple crown fracture with absence of yellow spots (dentine)
• Class II – Extensive crown fracture with considerable loss of dentin, but no tooth redness or bleeding.
• Class III – Extensive crown fracture with considerable loss of dentin and tooth redness and bleeding.
• Class IV – Dead tooth with greyish discolouration (Non-vital teeth).
• Class V – Complete removal of the whole tooth (Avulsion)
• Class VI – Root fracture including neck of the tooth, middle and bottom of the root fractures.
• Class VII – Displacement of the tooth including inward, outward and sideways movements. (Luxation)
• Class VIII – Fracture of a large portion of the crown.
• Class IX – Traumatic injuries of milk teeth.
These although used to categorize dental trauma types in general also apply to specific anterior traumatic dental injuries.

The cause of anterior tooth trauma varies with the age of the individual. At age one and two years, it is mainly caused by falls when learning to walk. At preschool age, between two and six years, many such injuries are caused by falls resulting from lack of attention when engaging in physical play as these children are left in the care of those who are only a few years older. The highest occurrences of anterior dental trauma occurs between seven and twelve years of age with most of the cases due to sporting activities, collision, contact with hard surfaces, and physical assaults. Among the earliest causes of traumatic dental injuries (TDI) are tooth protrusion and inadequate lip coverage. Anterior teeth trauma from motor vehicle and motor bike accidents are said to be more common in adults than children. Other causes that may be unrelated to the age include tooth trauma during treatment and lip piercings.
Risk factors for development of anterior teeth trauma include teeth with proclined or protruded teeth, presence of partial or no lip coverage, forward upper or lower jaws.

These may include adjoining soft tissue trauma presenting as bleeding from the gums, tongue, lips etc., mobility of a tooth segment or the entire tooth, sharp edges of the remainder of the tooth segments, shocking sensation from dentine exposure, Tooth ache, and inability to chew with that side of the mouth.

Management of Anterior TDIs depend on the severity of the fracture after a thorough assessment of individuals affected by a trained dental practitioner which will take the details of events leading to the fracture and examination the mouth. X-rays would also be taken and is important in treatment and determination of outcome after treatment.

The treatment of Anterior TDI is dependent on the particular type of anterior teeth trauma and is divided into:
• Immediate treatment
• Short-term treatment
• Long-term treatment

Immediate Treatment
These are practices employed following the event of injury and can be done by parents or guardians. Gentle rinsing of the surrounding area with warm water to remove dirt should be done regardless of type of teeth trauma. In the event of swelling and pain, cold compress using ice wrapped in a handkerchief should be applied to the site, also visiting the health centre for administration of tetanus toxoid (TT) or Anti-tetanus Serum (ATS) as applies to the individual’s vaccination status. In the case of Class II fractures, preservation of fractured tooth segment is important in the short term treatment of this type of injury by the dentist. The immediate management of Avulsion injuries involving permanent teeth will immensely affect the treatment outcome as the avulsed teeth should be held at the crown, rinse under running water and stored in a suitable transport medium like saliva, placing teeth in the cheek or normal saline.

Short term Treatment
Usually done by a trained dentist. This entails smoothing rough edges and building up using tooth-coloured restorative materials or reattachment of detached tooth segment in cases of class I and II types of Anterior TDIs. In class III anterior TDIs where there is tooth redness or bleeding, a root canal treatment or Apexification procedure is done. Root canal treatments are also implicated in cases of Class IV and VIII, with the use of an age appropriate crown/tooth covering (either Acrylic or Porcelain or PFM crowns) important for the success of Treatment. Avulsion injuries are managed short term by reattaching the permanent teeth and splinting the tooth with the success of treatment dependent on the time taken to get to the clinic following injury.Class VI anterior tooth fracture management depend on the level of the root fracture as various treatment approaches such as splinting, orthodontic tooth extrusion and sometimes tooth extraction. Luxation injuries/Class VI including concussion, lateral luxation, intrusion and extrusion management ranges from keeping the tooth under observation to tooth repositioning and splinting. It is also noteworthy to include vertically fractured tooth not covered by the Ellis classification have poor treatment outcome therefore tooth extraction is usually required.

Long term Treatment
This usually entail periodic monitoring and follow-up to determine successful of treatment. Root canal treatment of a tooth following splinting after avulsion or luxation injury should be done if imperative after which teeth with fractured segments are restored or crowned to restore aesthetics and function after management of the luxation or avulsion injury. Long-term management of individuals with anterior tooth trauma may also include tooth replacement in individuals following extraction in cases implicated which may include Removable partial dentures, conventional bridges, resin-bonded bridges and implants.


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