Trauma Cases

Trauma cases
Case 1
• A 10-year-old male patient had dentoalveolar trauma after a fall from his
own height in a water park.
• He went to the dental office 2 hours after the trauma, as referred by the
hospital, where he received medication (analgesic). The child had lateral
luxation and displacement of teeth 11 and 21 in labial direction, as well as
enamel dentin-pulp fracture in both teeth. There was not a fracture in the
alveolar bone
• The diagnosis revealed that the patient did not feel pain, had no systemic
impairment and had the immunization updated. With his collaboration, the
region was cleaned with 2% chlorhexidine, bone and dental fragments were
removed and suture of the soft tissues with silk thread was performed.
• The teeth were then repositioned into their original location and stabilized
using a semi-rigid splint with orthodontic wire.
• Both the parents and the patient were advised regarding meticulous oral
hygiene, rinsing with alcohol free chlorhexidine gluconate 0.2% for 2 weeks
and administration of systemic antibiotic.
• In the next day, a panoramic radiograph was performed that revealed adequate dental
repositioning.
• Two weeks later, good tissue healing was observed, and the suture was removed. The
splint was removed after 4 weeks.
• Eight weeks after trauma, endodontic treatment of teeth 11 and 21 was performed with
calcium hydroxide.
• It is possible to observe radiographically external radicular resorption in both teeth,
possibly caused by large tooth dislocation because of trauma and delayed endodontic
treatment.
• The reanatomization was performed after 6 months of trauma with a fiberglass pin and
composite resin.
• The final restoration satisfactorily restored the aesthetic and dental function.
After 1-year follow-up, a periapical radiography was taken, and stability of the
external root resorption was verified. The restoration was clinically adequate
Case 2
• A 21 year old healthy patient sought treatment for TDI caused by a bicycle
fall. Lesions included compound crown fracture in teeth numbers 12, 11 and
21. Injury happened 48hours ealier
• The patient suffered pain and inflammation.
• Intraoral exploration revealed pulp exposure of involved teeth and
emergency treatment to be instated in order to decrease pain and
inflammation.
Case 2
Compound fracture of tooth number 21.
Compound fracture of tooth 12 at cervical level.
Compound fracture of root and crown of tooth 11.
• The patient exhibited gingival smile, he suffered the following fractures:
• compound fracture in the crown of tooth 21 at the crown's middle third
(Figure 3) and of tooth 12 at the cervical third (Figure 4),
• compound fracture of crown and root in tooth 11 (Figure 5), gingivitis
induced by dental plaque (Figure 7),
• Transposition of teeth 13 and 14,
Treatment plan
Root canal treatment, post and core

Crown lengthening for endodontic and restorative purposes
Final restoration
Case 3
• A 15-year-old female patient was referred due to traumatic avulsion of her

right upper central incisor that occurred during a volleyball game (Figure 1)
• This tooth had been kept in an extraoral dry environment for two hours and
had a mature apex
Treatment plan
• nonviable soft tissues were removed from the root with a gauze and
endodontic therapy was carried out prior to replantation.
• After local anesthesia administration, the socket was irrigated with saline
solution and carefully checked to exclude the presence of bony fractures.
• The tooth was then replanted applying slight but firm pressure. The correct
position of the tooth was verified clinically and radiographically, and it was
stabilized through a passive flexible splint made by a 0.4 mm diameter metal
wire bonded to the tooth and to adjacent teeth .
• Postoperative instructions included antibiotic therapy with amoxicillin, soft
diet for 2 weeks, and soft-bristle toothbrush and chlorhexidine 0.12%
mouth rinses, twice a day for 2 weeks. The splint was kept in place for 2
weeks, and the patient was visited after 2, 3, and 6 months and yearly. At
the 3-year follow-up visit, the tooth appeared asymptomatic, with
physiological mobility, no sensitivity to percussion, and normal percussion
sound. No radiotransparency and no radiographic evidence of root
resorption were detected
• At the 8-year follow-up visit , the tooth presented no mobility, metallic
percussion sound, and clinical infraposition. Radiographically, there was
evidence of ankylosis-related resorption
Case 4
• A 20-year-old male patient was referred due to traumatic root fracture of

his left upper central incisor after a bike accident .
• A passive and flexible buccal splint with metal stainless steel wire and
composite patches was immediately performed and kept for 4 weeks, aimed at
stabilizing the mobile coronal segment and maintaining the vitality of the tooth.
Soft diet was suggested for 1 week and oral hygiene instructions were
delivered, brushing with a soft-bristle toothbrush and rinsing with chlorhexidine
0.12% mouthwash to prevent accumulation of plaque and biofilm.
• However, after one month, the tooth still did not respond to electrometric and
thermal pulp testing, due to plausible pulp necrosis development. For this
reason, an endodontic treatment of the coronal tooth segment to the fracture
line had to be performed (
• After a further 4 weeks, the patient still referred pain and discomfort of the
area, and the decision for a surgical approach had to be taken. An
apicectomy with a retrograde canal obturation was performed in order to
remove the symptomatology and obtain a complete healing of the area
Postsurgical instructions included prevention of further injury by avoidance of contact sports, meticulous oral hygiene,
and rinsing with an antibacterial agent such as chlorhexidine gluconate 0.12%.
Healing was uneventful, and the patient did not refer pain nor swelling. At the 4-year follow-up visit, clinical and
radiographic analysis showed a healed area with a good ossification of the periradicular bone
Case 5
• A 40-year-old female patient reported with the chief complaint of pain,

mobility & extrusion of teeth in lower front region of jaw for the last 2
months. Patient had history of frontal impact due to fall from bike about 2
month back.
• On clinical examination teeth 31, 41 & 42 showed grade II mobility with
extrusion[ fig1a ]. Teeth were tender on percussion; probing depth was
2mm & demonstrated no response to vitality test (thermal & electrical test).
Intraoral periapical radiograph showed transverse radiolucent line at the
apical one third of the root with gap in between two segments was seen
• On basis of clinical and radiographic finding, diagnosis of irreversible pulpitis
with horizontal root fracture in relation to 31, 41 & 42 was made.
Treatment plan
• Comprised of reduction, semi rigid splinting and endodontic treatment of

only the coronal fragment in relation to 31, 41 & 42, as the fracture
fragments were not approximated and the possibility of the apical fragment
retaining pulp vitality as well. Teeth 31, 41 & 42 were splinted labially[ fig1c]
with fiber splint which was bonded to tooth surface with composite resin.
• Endodontic therapy was initiated access was gained through lingual surface
of teeth 31, 41 & 42, pulp chamber was irrigated with 2.5 % NaOCl & Saline.
• Working length was determined [ fig1d ] , cleaning and shaping was
completed. Calcium hydroxide Intracanal medicament was placed. Patient
was recalled after two week. MTA plug was placed into apical 4 mm of the
coronal fragment. After 24 hours rest of canal was obturated with warm
vertical compaction of gutta-percha (Calamus, Denstply).
• Access cavity was sealed with composite resin. Patient post operative
course was uneventful. Splint was removed after 4 week & mobility was
within normal limits.
Case 6
• A 16-year-old male patient reported with the chief complaint of pain and
broken tooth in upper front region of jaw since 2 month. Clinical
examination revealed Ellis class 3 fracture & grade I mobility with 11[ fig2a].
• Sinus opening was seen buccally in relation with 11. Tooth was tender on
percussion with the history of root canal treatment having been attempted
in private clinic about 3 days back.
• Intraoral periapical radiograph showed horizontal mid-root fracture with
radiolucency around fracture line and radiopaque root canal filling with
11[ fig2b ].
Treatment plan
• Treatment plan comprised of re-root canal treatment of apical and coronal

fragments followed by
• fiberpost and core by holding both fracture fragments. Old obturation
material was removed with RC solve and H files. Cleaning and shaping was
done upto working length determined by intraoral periapical radiograph. 1%
• Sodium hypochlorite and saline was used as irrigating solution during
preparation. The root canal was finally irrigated with 2% chlorhexidine.
Calcium hydroxide intracanal medicament was placed for 2 weeks. At next
• appointment tooth was asymptomatic and sinus was healed. Root canal was
irrigated with EDTA liquid and
• obturation was done with gutta-percha & resinoseal sealer [ fig2c ]. The
post space was prepared with pessoreamer. Selected fibre post was luted
into the root canal holding both coronal and apical fragment of root with
dual cure resin cement (Luxacore, DMG) [ fig2d ]. The core build up was
done with composite resin [ fig2e ].
In follow up visit tooth mobility was reduced and tooth was clinically asymptomatic. The
patient was
reviewed at 3 months [ fig2f ], 6 months [ fig 2g ], 1 year [ fig 2h ], and 2 year [ fig 2i ] with no
signs or symptom
Case 7
• A 10-year-old Caucasian girl suffered combined injuries to both maxillary

central incisors while skiing. At the moment of the traumatic event, her
mother was able to collect the extruded portions of the two teeth and to
perform the immediate repositioning of both segments. The patient was
then taken to a general dentist to assess the status of the teeth involved in
the accident
• Following the clinical examination, the dentist reported that teeth #1.1 and
#2.1 had suffered extrusive luxation, had been replanted correctly, and that
tooth #1.1 also had an enamel–dentin uncomplicated crown fracture, while
tooth #2.1 exhibited a fracture limited to the enamel.
• Damages to the alveolar bone, or to the soft tissues, were not observed.
• The dentist applied a passive and flexible splint for 4 weeks; wire and
composite stabilization were chosen so as to favor oral hygiene and because
they are well tolerated.
• The dentist monitored the teeth, which remained asymptomatic, and nine
months after the trauma the dentist referred the patient to an endodontist to
check the pulpal status of the traumatized elements.
Diagnosis
• . During the consultation, the girl reported a mild tenderness to pressure on

tooth #2.1. The soft tissues appeared healthy; the extruded teeth showed no
signs of discoloration, grade 1 mobility, and a coronal fracture on both teeth.
• Tooth #2.1 was tender to percussion and palpation and did not respond to pulp
sensitivity tests,
• Tooth #1.1 was slightly tender to percussion and did respond to sensitivity
tests. Interestingly, the periapical radiographs showed the presence of a
horizontal fracture of the apical third in both the teeth.
• The periapical area of the coronal fragment of tooth #2.1 showed a defined
radiolucency, while no clear radiolucency was visible on the fractured portion of
tooth #1.1 (Figure 1B).
• Clinical photograph showing the uncomplicated crown fracture of the incisal
third of teeth #1.1 and #2.1. (B) Periapical radiograph showing the apical
root fracture of teeth #1.1 and #2.1 (arrowed) and the radiolucency at the
fracture line of #2.1 (small arrow).
• The diagnosis was as follows:
• apical horizontal root fractures of teeth #1.1 and #2.1; severe extrusive
luxation of the coronal fragment of both central incisors, which were
successfully repositioned
• Pulp necrosis and apical periodontitis 2.1
• Uncomplicated crown fracture of both teeth
Treatment plan
• The prognosis was considered guarded. The proposed treatment was

apexification on tooth #2.1 (as the fractured portion of the coronal
fragment mimicked an open apex),
• restoration of the access cavity and of the crown fractures with bonded
composite resin, and follow-up of the overall case.
• Access , cleaning shaping then application of CaOH for 4 weeks
• Obturation with MTA
• 6 months later #1.1 was symptomatic and the same procedure was
repeated for it

Trauma Cases

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Trauma Cases

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Trauma cases

Root canal treatment, post and core

• A 15-year-old female patient was referred due to traumatic avulsion of her

• A 20-year-old male patient was referred due to traumatic root fracture of

• A 40-year-old female patient reported with the chief complaint of pain,

• Comprised of reduction, semi rigid splinting and endodontic treatment of

• Treatment plan comprised of re-root canal treatment of apical and coronal

• A 10-year-old Caucasian girl suffered combined injuries to both maxillary

• . During the consultation, the girl reported a mild tenderness to pressure on

• The prognosis was considered guarded. The proposed treatment was

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