Braz Oral Res 2008;22(3):229-34 229

Oral and Maxillofacial

Surgery
Dental trauma involving root fracture
and periodontal ligament injury: a
10-year retrospective study
Abstract: The purpose of this retrospective study was to analyze the cases
of traumatic dental injuries involving root fracture and/or periodontal
ligament injury (except avulsion) treated at the Discipline of Integrated
Clinic, School of Dentistry of Araatuba, So Paulo State University
(UNESP), Brazil, from January 1992 to December 2002. Clinical and radiographic
records from 161 patients with 287 traumatized teeth that had
sustained root fracture and/or injuries to the periodontal ligament were
examined. The results of this survey revealed that subluxation (25.09%)
was the most common type of periodontal ligament injury, followed by
extrusive luxation (19.86%). There was a predominance of young male
patients and most of them did not present systemic alterations. Among
the etiologic factors, the most frequent causes were falls and bicycle accidents.
Injuries on extraoral soft tissues were mostly laceration and abrasion,
while gingival and lip mucosa lacerations prevailed on intraoral soft
tissues injuries. Radiographically, the most common finding was an increase
of the periodontal ligament space. The most commonly performed
treatment was root canal therapy. Within the limits of this study, it can be
concluded that traumatic dental injuries occur more frequently in young
male individuals, due to falls and bicycle accidents. Subluxation was the
most common type of periodontal ligament injury. Root canal therapy
was the type of treatment most commonly planned and performed.
Descriptors: Tooth injuries; Periodontal ligament; Comprehensive
dental care; Soft tissue injuries; Facial injuries.
Snia Regina Panzarini(b)
Denise Pedrini(a)
Wilson Roberto Poi(b)
Celso Koogi Sonoda(b)
Daniela Atili Brandini(a)
Jos Carlos Monteiro de Castro(a)
PhDs, Assistant Professors; (b)PhDs, Adjunct
(a)

Professors Department of Surgery and

Integrated Clinic, School of Dentistry of
Araatuba, So Paulo State University
(UNESP), Araatuba, SP, Brazil.
Oral and Maxillofacial Surgery
Corresponding author:
Snia Regina Panzarini
Departamento de Cirurgia e Clnica
Integrada
Disciplina de Clnica Integrada
Faculdade de Odontologia do Campus
de Araatuba (UNESP)
Rua Jos Bonifcio, 1193
Araatuba - SP - Brazil
CEP: 16015-050
E-mail: panzarin@foa.unesp.br
Received for publication on Mar 01, 2007
Accepted for publication on Jun 20, 2007
Dental trauma involving root fracture and periodontal ligament injury: a 10-year retrospective study
Braz Oral Res 230 2008;22(3):229-34
Introduction
Current Dentistry presents high scientific and
technological standards, and, in most cases, it is
capable of reestablishing esthetics and function to
patients. Nevertheless, traumatic dental injuries are
still a great challenge inasmuch as they usually injure
teeth and their supporting tissues in a precocious
phase and frequently with an unfavorable
prognosis that can lead to tooth loss.
Statistical data underscore the magnitude of this
problem and indicate that one out of ten individuals
had sustained dental trauma during childhood
or adolescence. These data also highlight that some
conditions, such as an increased incisal overjet and
resulting inadequate lip coverage, are important predisposing
factors to be considered.1-4
Dental traumatisms may be classified according
to several factors. Andreasens1 classification is based
on the classification proposed by the World Health
Organization (WHO) in 1992 and can be applied
for both primary and permanent dentitions.
Regarding occurrence and etiology, it is observed
that traumatic dental injuries are less common
during the first years of childhood. Occurrence
increases when the child starts walking alone due
to his/her lack of experience and coordination in
movements. This occurrence reaches its apex during
school years, mainly as a result of falls.2-10
During adolescence, most of the traumatic dental
injuries are attributable to accidents in sports activities.
Some authors have described that approximately
1.5% to 3.5% of all adolescents practicing sports activities
undergo traumatic dental injuries annually. In
late adolescence and early adulthood, these injuries
associated to automotive accidents are prevalent.11
Traumatic dental injuries related to fights are
usually more common in older individuals. Other
groups that present high incidences of traumatisms
in the orofacial region are epileptics, alcoholics and
drug users.1,12
Knowledge of the different factors related to dental
trauma, such as its etiology and types of treatment,
is essential for a better understanding of the
biological mechanisms involved in wound healing.
Therefore, it allows a better selection of therapeutic
measures.13-15
The purpose of this retrospective study was to
analyze the cases of traumatic dental injuries involving
root fracture and periodontal ligament injury
(except avulsion) treated at the Discipline of Integrated
Clinic, School of Dentistry of Araatuba, So
Paulo State University (UNESP), during a 10-year
period.
Material and Methods
Clinical and radiographic records of 161 young
and adult patients with 287 traumatized teeth in the
permanent dentition were examined. The patients
had been treated at the Discipline of Integrated
Clinic, School of Dentistry of Araatuba (UNESP),
Brazil, from January 1992 to December 2002. Only
cases of trauma involving root fracture and/or injuries
to the periodontal ligament (except avulsion),
according to Andreasens1 classification, were included
in this survey.
Data were compiled from the case report forms
used at the Discipline of Integrated Clinic. The following
information was available: identification
of the patient, medical history, former and current
history of dental trauma, extraoral and intraoral
physical examination including both soft and hard
tissues, radiographic findings, diagnosis based on
Andreasens1 classification and treatment plan as
well as the treatment currently performed.
Results
From 1992 to 2002, 346 patients with traumatic
dental injuries were referred for treatment at the Discipline
of Integrated Clinic, School of Dentistry of
Araatuba. Of these 346 patients, 161 had sustained
a trauma involving root fracture and/or periodontal
ligament injury in 287 teeth, which were the scope
of this survey.
Review of the records showed a predominance of
male patients, most of them belonging to the 12-18
year-old group.
In response to the medical history item, 64 patients
(40%) reported no systemic alterations and 57
(35%) left this item blank. Among the 40 patients
(25%) who reported any systemic problem, the alterations
mentioned were: allergic reaction to drugs
(6), controlled hypertension (4), epilepsy (2), bronPanzarini
SR, Pedrini D, Poi WR, Sonoda CK, Brandini DA, Castro JCM
Braz Oral Res 2008;22(3):229-34 231
chitis (7), frequent tonsillitis (2), adenoids (1), pneumonia
(1), mycosis (1), anemia (1), type A hepatitis
(1), cardiac surgery (1), nervousness (1), allergic reaction
to other substances (4), asthma (1), Hansens
disease (1), depression (2), HIV positive (1), convulsion
(1), diabetes (1) and rheumatism (1).
From the 161 case report forms evaluated, 12
(7.5%) mentioned previous traumatic dental injuries.
The most frequently reported accident site was
the street, corresponding to 91 cases (57%), followed
by 23 cases of home accidents (14%). Other
39 (25%) sites were distributed among clubs (10),
schools (7), highways (5), outskirts (8), soccer fields
(2), parks (1), gyms (1), working places (4) and gas
stations (1). In 8 case report forms (5%), this information
was missing.
Direct impact was the type of trauma that resulted
in the largest number of traumatic dental injuries
(133, corresponding to 82.60% of the cases), while
indirect impact was the cause of injury in only 3 patients
(1.86%). In 25 forms (16%), this information
was missing. The etiologic factors responsible for
the traumatisms in the surveyed population were bicycle
accidents (42), falls (42), motorcycle accidents
(28), car accidents (13), aggressions (13), sports (8),
work accidents (4), collisions (4) and epilepsy episodes
(1). In 6 case report forms, this information
was missing.
Regarding the first-aid sites, 67 patients were
taken to hospitals and emergency rooms (42%), 19
were first treated at private dental offices (12%) and
14 were directly referred to the School of Dentistry
of Araatuba (9%). However, in a large number of
forms (61, corresponding to 37% of the cases), this
information was not available. The procedures performed
at first-aid care included suture (37), dental
splint therapy (36), pulp capping (1), tooth repositioning
(16), tooth extraction (4) and pulpectomy
(2). In 65 case report forms, this information was
missing. The most frequently administered medications
were antibiotics (55), anti-inflammatories
(43), analgesics (18), antitetanic vaccines (13) and
mouthwashes (2). In 4 cases, no drugs were administered
and in 84 case report forms this item was
left blank.
The findings from intraoral and extraoral examinations
are summarized in Tables 1 and 2.
Complementary tests performed for diagnosis included
166 percussion tests, 20 heat sensitivity tests,
60 cold sensitivity tests, 29 occlusal exams and 2
mobility assessments.
Injury
Site
Total (n = 161)
Face Lip Mentum Nose
Laceration 6 (3.7%) 28 (17.4%) 7 (4.3%) 0 41 (25.4%)
Abrasion 14 (8.7%) 9 (5.6%) 6 (3.7%) 4 (2.5%) 33 (20.7%)
Contusion 10 (6.2%) 18 (11.1%) 3 (1.8%) 3 (1.8%) 34 (21%)
No injury 02 (1.2%)
No answer 51 (31.7%)
Table 1 - Types of extraoral
injuries (Andreasens1
classification).
Injury
Site
Total
Lip mucosa Gingiva (n = 161)
Alveolar
mucosa
Cheek
Mucosa
Tongue
Laceration 29 (18%) 28 (17.4%) 3 (1.8%) 2 (1.2%) 2 (1.2%) 64 (39.6%)
Abrasion 3 (1.8%) 1 (0.6%) 0 0 0 4 (2.4%)
Contusion 9 (5.6%) 18 (11.1%) 1 (0.6%) 2 (1.2%) 0 30 (18.5%)
No injury 5 (3.1%)
No answer 58 (36.4%)
Table 2 - Types of intraoral
injuries (Andreasens1
classification).
Dental trauma involving root fracture and periodontal ligament injury: a 10-year retrospective study
Braz Oral Res 232 2008;22(3):229-34
Radiographic findings obtained from the patients
case report forms are presented in Table 3.
Data regarding to periodontal ligament injuries
(except avulsion) and root fracture for both maxillary
and mandibular arches are shown in Tables 4 and 5.
The treatment plans varied according to the
type of dental traumatism. Treatment plans reported
were root canal therapy (40%), dental splint
therapy (17%), surveillance (14%), composite resin
restoration (10%), tooth repositioning (7%), tooth
extraction (6%) and others (6%). Treatments actually
performed were root canal therapy (6%), dental
splint therapy (15%), surveillance (12%), composite
resin restoration (7%), tooth repositioning
(6%), tooth extraction (6%), intracanal calcium
hydroxide dressing changes (41%), occlusal adjustment
(2%), temporary partial prosthesis (2%) and
others (3%).
Discussion
The great convenience of such a retrospective
study is that it gives an overview of the traumatic
dental injuries with respect to the profile of the most
affected patients, the etiologic factors involved and
the most frequently adopted treatment plans. Putting
the information all together leads to a better
knowledge of the different types of injuries. It also
allows the choice of the most effective and long-lasting
therapeutic procedures.3,4,10-16
The Discipline of Integrated Clinic of the School
of Dentistry of Araatuba has a clinical service for
patients who have suffered traumatic dental injuries.
The patients are treated by a fourth-year dental
student and a graduate student from the Oral and
Maxillofacial Surgery course together. This multidisciplinary
approach is essential for the treatment
of traumatic dental injuries.
In this study, the finding of a greater frequency
of traumatic dental injuries in 12-18 year-old male
Table 3 - Radiographic findings.
Finding
Number
of cases
%
Thickening of the periodontal ligament space 34 11.8
Increase of the periodontal ligament space
- tooth dislodgment
40 13.9
Root fracture - cervical third 1 0.3
Root fracture - middle third 25 8.7
Root fracture - apical third 5 1.7
Fracture of the alveolar process 8 2.7
Bone loss 3 1.0
External root resorption 10 3.4
Internal root resorption 3 1.0
Tooth dislodgement 3 1.0
Root canal obliteration 3 1.0
Periapical radiolucent area 11 3.8
Crown fracture 10 3.4
Absence of periodontal ligament space 4 1.3
Maxillary or mandibular fracture 1 0.3
Empty alveolus 3 1.0
No visible alteration 123 42.8
Total 287 100
Table 4 - Classification and incidence of periodontal ligament
injuries and root fractures in the maxillary arch (Andreasens 1
classification).
Classification
Tooth
13 12 11 21 22 23
Root fracture (n = 32) 1 1 17 11 2
Concussion (n = 31) 2 3 13 7 5 1
Subluxation (n = 63) 17 23 14 7 2
Extrusive luxation (n = 41) 1 6 15 12 7
Lateral luxation (n = 34) 4 12 12 4 2
Intrusion (n = 24) 2 1 7 10 4
Total (n = 225) 6 32 87 66 29 5
Table 5 - Classification and incidence of periodontal ligament
injuries and root fractures in the mandibular arch (Andreasens1
classification).
Classification
Tooth
33 32 31 41 42 43
Root fracture (n = 10) 2 2 2 2 2
Concussion (n = 17) 3 4 5 3 2
Subluxation (n = 9) 1 2 3 2 1
Extrusive luxation (n = 16) 1 5 6 4
Lateral luxation (n = 10) 1 2 4 3
Intrusion (n = 0)
Total (n = 62) 3 9 16 19 13 2
Panzarini SR, Pedrini D, Poi WR, Sonoda CK, Brandini DA, Castro JCM
Braz Oral Res 2008;22(3):229-34 233
patients is supported by the majority of the previous
studies.1-4,6-11,16-18
The first and foremost steps in treating a traumatized
patient should be physical examination and
medical history review. Data obtained from this survey
showed that 40% of the patients denied systemic
alterations, which is consistent with their mean age.
Regarding etiology, falls and bicycle accidents
were the most common causes of traumatisms,
which is in agreement with the findings of previous
studies.2-10
Laceration was the most common extraoral injury.
This is easily explained since most of the traumas
were caused by direct impacts, in which lips act as
a shield.1 Intraoral examinations revealed that gingival
and lip laceration were the most common soft
tissue injuries due to tooth dislodgement, mainly in
cases of luxation.1
Among the complementary tests, percussion and
thermal sensitivity tests were largely performed to
obtain information regarding damage to periodontal
ligament and pulp tissue, respectively.1,15,19 Pulp
sensitivity tests require the patients cooperation,
which is frequently not achieved during first-aid
care. Therefore, the validity of these tests is controversial.
Andreasen19 (1989) postulated that sensitivity
responses may be temporarily reduced, especially
in traumatic luxations. Consequently, sensitivity
tests should be postponed to a subsequent visit.
All traumatized teeth should be radiographed to
investigate the existence of root fracture and/or injuries
to periodontal structures as well as to assess
root development stage. These are important factors
accounting for the establishment of the treatment
plan.1,15
Following Andreasens1 classification, 72 out of
287 teeth involved in this study had subluxation.
This finding is in agreement with the patients age,
type of impact (direct) and soft tissue injuries (lip
lacerations).
The therapeutic approach for traumatic dental
injuries varies according to the dentition affected
(primary or permanent) and to the type of damage
for both the teeth and supporting structures.1,15,18 In
this context, it should be kept in mind that the treatment
plan must be carefully elaborated. This would
avoid new traumas that would worsen the prognosis,
which is not so favorable in many cases.
Root canal therapy is advised mainly for luxations
(extrusive, lateral and intrusive) in which pulp
neurovascular supply is disrupted. This would avoid
pulp necrosis leading to external inflammatory root
resorption.1,14,15,19-21 Intracanal calcium hydroxide
dressing placement and changes are widely employed
procedures due to the well-recognized anti-bacterial
and healing properties of calcium hydroxide. 22
It also has the ability of preventing and/or arresting
the process in cases of ongoing external inflammatory
root resorption.21,22
Occlusal adjustment is another key step of the
treatment plan because tooth repositioning does not
necessarily return it to its original position. Even
small dislodgements may provide premature contacts
that cause undesirable additional traumas.1
Follow-up of any type of traumatism is of paramount
importance because it is not possible to know
exactly the extent of damage for both the tooth and
the supporting tissues or predict future consequences.
1 However, this is difficult to be achieved since it
depends on the patients compliance on a long-term
basis.
Management of traumatic dental injuries usually
requires a multidisciplinary approach for long
periods of time. Therefore, general dentists should
be prepared to treat properly the cases of dental injuries
since they are the professionals more likely to
face them in clinical practice.
Conclusion
Within the limits of this study, it can be concluded
that traumatic dental injuries occur more frequently
in young male individuals, due to falls and
bicycle accidents. Subluxation was the most common
type of periodontal ligament injury. Root canal
therapy was the type of treatment most commonly
planned and performed.
Dental trauma involving root fracture and periodontal ligament injury: a 10-year retrospective study
Braz Oral Res 234 2008;22(3):229-34
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