Dental Trauma Scale Instrument background and recommended use. This classification system was proposed by Ellis et al in 1970.

(Ellis RG, Davey KW. The classification and treatment of injuries to the teeth of children (5th ed.) Year Book Medical Publishers Inc. Chicago. 1970.) The instrument can be used for all teeth but is primarily used for anterior teeth, as this is the location of most dental trauma. How it is administered The instrument is administered clinically using visual inspection of the teeth. Crown Fractures. Fractures of the crown of the tooth comprise about one-third of dental injuries to the primary teeth and about 75% of injuries to the permanent teeth.1 The simplest crown fracture is a crown infraction resulting in incomplete fracture or cracks of the enamel without loss of the tooth structure. The cracks appear as craze lines running parallel with the enamel prisms and ending at the enamel dentin junction. These craze lines may be either vertical or horizontal. Crown infraction may be the only visible sign of injury. No treatment is indicated for crown infraction. Unfortunately, this trauma is often associated with displacement injuries that are detectable only on dental radiographs.6 Classification of Crown Fractures Crown Fracture Involving Enamel Only (Ellis Class I). An Ellis class I fracture involves only the enamel portion of the tooth. Crown Fracture Involving Dentin (Ellis Class II Fracture). Crown fractures exposing dentin. These fractures can be recognized by the yellow to pink color of the dentin. Crown Fracture Exposing the Pulp (Ellis Class III Fracture). Teeth that are fractured in the middle third of the clinical crown often expose vital tissue of the tooth (i.e., the pulp). The fracture site will have either a reddish tinge or will show frank blood. Exposure of the pulp eventually leads to pulpal necrosis from bacterial infection if not treated. Root Fractures Root fractures are less common than fractures of the crown and occur in only 7% or fewer of dental injuries.1 Root fractures may be further divided into horizontal or vertical. Primary teeth or developing permanent teeth usually do not sustain root fractures because of the short roots. If the root fracture communicates with the oral cavity, infection occurs, healing is impaired, and the tooth fragment must be removed. In many cases, the root can be salvaged and later placement of a post and crown will restore aesthetics. Horizontal root fractures usually occur in the anterior teeth and are caused by direct trauma. Vertical root fractures usually occur in the molars and may be caused by teeth clenching or being struck with the jaw closed.

Root fractures often are not apparent on clinical examination and can be missed if appropriate radiographs are not obtained. In most cases, dental radiographs will demonstrate this fracture. In horizontal root fractures, the fracture line may not be readily visible on normal radiographs. Angulation of the x-ray beam may show the fracture line. Rarely, the fracture line may not be visible until either hemorrhage or granulation tissue forms and displaces the coronal segment.11 The most important consideration in the success and healing of horizontal root fractures is the immediate reduction of the fractured segments and the immobilization of the coronal segment. The prognosis for complete healing is excellent if horizontal root fractures are diagnosed and the segments are rigidly splinted in place for 10-12 weeks. In order to achieve this result, root fractures must be diagnosed before repair begins and the blood clot prevents apposition of the segments. If the segments are immobilized in close proximation, healing with calcified tissue will usually occur. The pulp and tooth usually remain vital and there is often no need for root canal or other pulpal treatment. If more than 24-72 hours have elapsed, it may be impossible to get close opposition of the segments. This may preclude bony healing. Without bony healing, the prognosis for permanent retention of the tooth goes from excellent to poor and more complex dental treatment under a dentists supervision is mandatory. Vertical root fractures are more difficult to detect and may not be found until extensive tooth destruction has occurred or the tooth is extracted. The patient may complain of pain on biting or release or of sensitivity to hot or cold foods. Vertical root fractures have a worse prognosis than horizontal root fractures, probably because they are not diagnosed as easily. Extraction of all or part of the tooth is often indicated. Amputation of part of the root may be appropriate if the tooth has more than one root. If the patient develops a pulp infection, root canal therapy is required. Displaced or Loosened Teeth Many designations have been used in the literature to describe displacement of a tooth. Unfortunately, many of these terms are confusing. Generally speaking, however, the terms concussion, displacement, and avulsion are adequate to describe all forms of trauma involving injury to the periodontal attachment that do not involve loosening or loss of the tooth from the socket.

Scale Scoring and Normative Values How it is scored/calculated/summarized The various categories represent tooth-specific descriptors (nominal level) of the condition of the tooth with respect to traumatic injury. Are there subscales (if so, how are those calculated): None Scale validity (include references if available): None

Scale reliability (include reference is available): None Normative statistics. (Has this been used in definable populations and what values are considered normal/abnormal): None

Trauma

Is there trauma to the maxillary anterior teeth No

Class

Yes Is there trauma to the maxillary anterior teeth No

Yes Class 1 Simple fracture of the crown not involving dentin Class 2 Extensive fracture of the crown involving dentin Class 3 - Extensive fracture of the crown involving dentin and pulp exposure Class 4 Teeth lost as result of trauma Class 5 Fracture of the root Class 6 Displacement of tooth (without fracture of crown or root) Useful references 1. Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. St. Louis: Mosby; 1994.

2. Fountain SB, Camp JH. Traumatic injuries. In: Cohen S, Burns RC. Pathways of the Pulp. 6th ed. St. Louis: Mosby; 1994. 3. Ranalli DN, ed. Sports dentistry. Dent Clin North Am 1991;35: 609-626. 4. Gibson DE, Verono AA. Dentistry in the emergency department. J Emerg Med 1987;5:35-44. 5. Jarvinen S. Ioncisal overjet and traumatic injuries to upper permanent incisors: A retrospective study. Acta Odontol San 1978;36:359. 6. Andreasen JO. Traumatic Injuries of the Teeth. 2nd ed. Philadelphia: W.B. Saunders Co; 1981. 7. Cvek M, Lundberg M. Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing. J Endod 1983;9:8. 8. Fuks AB, et al. Partial pulpotomy as a treatment alternative for exposed pulps in crown and fractured permanent incisors. Endod Dent Traumatol 1987;3:100. 9. Heide S, Kererkes K. Delayed partial pulpotomy in permanent incisors of monkeys. Int Endod J 1986;19:78. 10. Medford HM, Curtis JW. Acute care of severe tooth fractures. Ann Emerg Med 1983;12:364-366. 11. Glickman GN, Gutman JL. Management of traumatic tooth injuries: An overview. Dentistry 1989;9:24-28. 12. Rock WP, Grundy MC. The effect of luxation and subluxation upon the prognosis of traumatized incisor teeth. J Dent 1981;9:224. 13. Gibson DE, Verono AA, Dentistry in the emergency department. J Emerg Med 1986;5:35-44. 14. Johnston D, Judd P. Primary and permanent dental trauma: Two case reports. Ontario Dent 1989;66:23-25. 15. Andreasen JO. Luxation of permanent teeth due to trauma. A clinical and radiographic follow up study of 189 injured teeth. Scan J Dent Res 1970;78:273. 16. Andreasen JO, Borum M, Jacobsen HL, et al. Replantation of 400 traumatically avulsed permanent incisors. Endod Dent Traumatol 1995. In press. 17. Medford HM. Acute care of avulsed teeth. Ann Emerg Med 1982;11:559-561.

18. Andreasen JO. Relationship between cell damage in the periodontal ligament after replantation and subsequent development of root resorption: A time related study in monkeys. Acta Odontol Scan 1981;39:15. 19. Bringhurst C, Herr RD, Alsous JA. Oral trauma in the emergency department. Am J Emerg Med 1993;11:486-490. 20. Andersson L, Bodin I, Sorensen S. Progression of root resorption following replantation of human teeth after extended extra oral storage. Endod Dent Traumatol 1989;5:38. 21. Andersson L. Dentoalveolar ankylosis and associated root resorption in replanted teeth. Experimental and clinical studies in monkeys and man. Swed Dent J 1988;56 (Suppl):1. 22. Andreasen JO, Schwarz O. The effect of saline storage before replantation upon dry damage of the periodontal ligament. Endod Dent Traumatol 1986;2:67. 23. Blomlof L, et al. Periodontal healing of replanted monkey teeth prevented from drying. Acta Odotol Scand 1983;41:11. 24. Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, milk, and Hanks balanced salt solution. Endod Dent Traumatol 1992;8:183. 25. Krasner PR. Treatment of tooth avulsion by nurses. J EmergNurs 1990;16:29-36. 26. Blomlof L, et al. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;6:912. 27. Lindskog S, Blomlof L. Influence of osmolality and composition of some storage media on human periodontal ligament cells. Acta Odotol Scand 1982;40:435. 28. Hiltz J, Trope M. Vitality of human lip fibroblasts in milk, Hanks balanced salt solution, and Viaspan storage media. Endod Dent Traumatol 1991;7:69. 29. Lindskog S, Blomlof L, Hammarstrom L. Mitosis and microorganisms in the periodontal membrane after storage in milk or saliva. Scand J Dent Res 1983;91:465. 30. Krasner PR. Treatment of tooth avulsion in the emergency department: Appropriate storage and transport media. Am J Emerg Med 1990;8:351-355. 31. Medford HM. Temporary stabilization of avulsed or luxated teeth. Ann Emerg Med 1982;11:490-492. 32. Gibson DE, Verono AA. Dentistry in the emergency department. J Emerg Med 1987;5:35.

Malocclusion
Feature Overjet Technique Place probe perpendicular to the facial surface of the mandibular central incisor and measure the point where the maxillary incisor contacts the probe. First measure More than white band Yes Second measure If Yes is it greater than white plus black band If no is there a reverse overjet If yes is it more than the white band

Yes

No

No

Yes

No Yes

Open Bite

Measure open bite at maximal point by placing the probe at the black band region along the facial/buccal surface

More than black band

Yes

No

No Displacement Measures the largest tooth displacement using the black band area of the probe. Use either the full black plus white portion for larger displacements. More than black band If yes is it more than the white band

Yes

Yes

No

No Over Bite Visually determine if maxillary incisor covers completely the mandibular incisor. Also indicate if there is palatal trauma from deep overbites. Complete If yes is there tissue damage

Yes

Yes

No

No Angles Class Class 1

Class 2

Class 3

PSR CODES Deepest probing depth in sextant Bleeding after completion of probing absent present absent present absent present

1 2 3 4 5 6

Less than 3.5 mm Less than 3.5 mm More than 3.5 mm but less than 5.5 mm More than 3.5 mm but less than 5.5 mm More than 5.5 mm More than 5.5 mm