POSTER SECTIONS Coverpage Learning objectives Background Imaging findings OR Procedure details Conclusion Personal information References

2022 ASM / R-0137

Cracking the code of Dental Trauma

Congress:

2022 ASM

Poster Number:

R-0137

Type:

Educational Exhibit

Keywords:

Head and neck, Other, CT, Plain radiographic studies, Education, Education and training, Trauma

Authors:

M. Elliott, A. Reid

DOI:

10.26044/ranzcr2022/R-0137

DOI-Link:

https://dx.doi.org/10.26044/ranzcr2022/R-0137

Learning objectives

LEARNING OBJECTIVES 1. Briefly revise the radiographic anatomy of permanent teeth 2. Review the classification of traumatic dental injuries 3. Recognise the key radiographic features of specific dental injuries 4. Comprehend and communicate when urgent dental care is required

Background

BACKGROUND Many traumatic dental injuries present to medical general practitioners or hospital emergency departments as either isolated injuries or as an under recognised part of multi-trauma events [1]. Without appropriately trained dental staff present to perform a thorough assessment, it is often left to the hospital radiologist to detect traumatic injuries to the teeth and surrounding structures in these circumstances [2]. Early and accurate diagnosis has been found to have a significant effect on the prognosis of traumatised teeth, especially when early referral is required...

Imaging findings OR Procedure details

KEY RADIOGRAPHIC FEATURES DENTAL HARD TISSUE INJURIES Enamel Fracture [Fig 6] Enamel-Dentine Fracture [Fig 7] Complicated Crown Fracture [Fig 8] Crown-Root Fractures [Fig 9] Root Fractures [Fig 10] PERIODONTAL TISSUE INJURIES Concussion and Subluxation - radiographic abnormalities are not expected in these injuries and diagnosis is made clinically Extrusive Luxation Expected Imaging Findings; - Widening of periodontal space (usually apically) - Tooth may appear elevated in occlusal plane (not definitive) [Fig 11] Lateral Luxation Expected Imaging Findings; - Asymmetric widening of periodontal space (usually apically)...

Conclusion

CONCLUSION CLINICAL RELEVANCE From the injuries discussed above, identification of the following should be highlighted to the treating clinician as requiring immediate assessment/treatment by a dental specialist for best outcomes. 1. Extrusions 2. Lateral Luxations 3. Intrusions 4. Avulsions 5. Fractures of the alveolar processes or jaws Injuries that Expose the pulp also require more urgent review, but if these present overnight they can usually wait to be seen until the next day. Finally, as the evidence suggests that 90% of these injuries are missed...

Personal information

References

Meyer HJ, Schramm D, Bach AG, Eckert A, Surov A. Dental Trauma on whole Body Trauma CT-An underreported finding. Eur J Trauma Emerg Surg. 2022;48(2):1055-60. Loureiro RM, Naves EA, Zanello RF, Sumi DV, Gomes RLE, Daniel MM. Dental Emergencies: A Practical Guide. RadioGraphics. 2019;39(6):1782-95. Petrovic B, Marković D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol. 2010;26(1):52-9. Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 5th Edition ed. Hoboken: Wiley...

Fig 1: Radiographic Anatomy (Sagittal Cone-beam CT) of a normal lower molar situated...

Fig 2: Classification of Dental Hard Tissue Injuries

Fig 3: Classification of Periodontal Injuries (Luxation injuries)

Fig 4: Classification of Injuries to supporting bone NB: these injuries aren't being...

Fig 5: Schematic representation of classification of hard tissue injury by site. Note...

$Fig 6: A small fracture can be seen on the mesio-incisal aspect of the partially erupted tooth 12 (right lateral incisor), isolated to the enamel layer of the crown only. These fractures (in isolation) are of little immediate clinical concern and can be seen non-urgently by a dental practitioner. Reference: (Andreasen J et al, 2019)$

Fig 6: A small fracture can be seen on the mesio-incisal aspect of the partially...

$Fig 7: Sagittal CT (bone window) showing an uncomplicated crown fracture of an upper incisor, involving the enamel and dentine, but sparing the pulp. It can be of benefit to look for any suggestion of the lost segment of crown being embedded in the neighbouring soft tissues. Reference: (Loureiro RM et al, 2019)$

Fig 7: Sagittal CT (bone window) showing an uncomplicated crown fracture of an upper...

$Fig 8: Complicated crown fractures of both upper right incisors (11 and 12) with very likely complicated crown fracture of 21 as well (Oblique fracture line appears to intersect with the mesial pulp horn of the pulp chamber). Remember that exposure of the pulp classifies that fracture as "complicated" and increases the likelihood of a poor outcome for the tooth. Note is also made of widening of periodontal space in the apical region of 11 and 21, suggestive of possible luxation injury. Reference: (Andreasen J et al 2019)$

Fig 8: Complicated crown fractures of both upper right incisors (11 and 12) with very...

$Fig 9: Examples of Crown-Root fractures. The image on the left is a "Complicated" fracture running from the incisal edge of 11, through the pulp chamber and then to the root surface well below the cemento-enamel junction. The radiograph on the right is a more obvious crown-root fracture on the mesial half of 11, but is classified as "Uncomplicated" because it does not involve the pulp chamber. Reference: (Andreasen J et al 2019)$

Fig 9: Examples of Crown-Root fractures. The image on the left is a "Complicated"...

$Fig 10: Sagittal CT showing a root fracture of an upper incisor. These fractures always involve a pulp exposure through disruption of the root canal system (thus they aren't divided into complicated and uncomplicated). It will be helpful to report to the treating clinician any displacement of the coronal segment of the tooth beyond the fracture, as this can assist greatly in decision making during an occlusal assessment (determining chronic vs acute malposition of teeth in occlusion where the patient is unsure). References: (Andreasen J et al, 2019)$

Fig 10: Sagittal CT showing a root fracture of an upper incisor. These fractures always...

$Fig 11: CT images in 3 planes looking at lower incisors 31 + 41. The Sagittal image demonstrates the root apex clearly elevated in the alveolar socket (widened periodontal space apically), with lingual inclination of the crown as a result of the loss of periodontal attachment. No crown or root fracture can be seen. The Axial image demonstrates the much smaller cross section of the 31 and 41 roots compared to the neighbouring lateral incisors (as we are seeing the smaller apical segment that has been elevated during extrusion) PLUS the signigficant widening of the periodontal space around the roots. The Coronal image clearly demonstrates the periodontal widening in the apical region of the root, with the incisal edges of 31 and 41 sitting much higher in occlusion than the surrounding teeth. Reference: (Loureiro R et al, 2019)$

Fig 11: CT images in 3 planes looking at lower incisors 31 + 41. The Sagittal image...

$Fig 12: CT images in 3 planes looking at upper incisors 11 and 21. The sagittal image shows displacement of the root apex labially/facially through where you would expect to see the labial wall of the alveolar socket. Closer inspection reveals the labial socket wall fractured and sitting intimately against the labial root surface (likely still held in place by the periodontal ligament fibres). There is widening of the periodontal space around the ligual aspect of the root apex. The Axial image clearly demonstrates the en block fracture of a segment of alveolar bone labial to the two upper central incisors with labial displacement of the root apices as well. The coronal image shows widening of the periodontal space apically, which could be confused for extrusive luxation if this was the only image observed. A clue that this is lateral luxation is that the incisal edge of the 11 + 21 are sitting at a similar height to the neighbouring teeth, suggesting minimal extrusion in a longitudinal (axial) direction. Reference: (Loureiro R et al, 2019)$

Fig 12: CT images in 3 planes looking at upper incisors 11 and 21. The sagittal image...

$Fig 13: Plain film image of upper incisors 11 and 21, both demonstrating crown fractures. More clinically relevant with regards to treatment priority, the 21 has complete obliteration of the periodontal space, as well as significant apical intrusion into the alveolar bone compared to the 11. Clinical suspiscion of traumatic intrusion rather than long-standing root abnormality is increased when you compare the relative heights of the cemento-enamel junctions of the two teeth, with 21 being much more apically displaced (see annotated right image). Reference: (Andreasen J et al, 2019)$

Fig 13: Plain film image of upper incisors 11 and 21, both demonstrating crown...

$Fig 14: Nice and simple here, with an empty socket suggesting a likely avulsion injury. Note that traumatic avulsions are frequently associated with alveolar socket fractures. Reference: (Loureiro R et al, 2019)$

Fig 14: Nice and simple here, with an empty socket suggesting a likely avulsion injury....