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Traumatic injuries inchildren-Trauma to teeth and soft tissues Dept Of Pedodontics & Preventive Dentistry Christian Dental College, Ludhiana Jeena Sara Paul 26th Aug 2009 2nd Year MDS 9 a.m.
• The Merriam Webster Dictionary defines trauma as an injury (as a wound) to living tissue caused by an extrinsic agent.• Trauma to the oral region occurs frequently and comprises 5% of all injuries for which people seek treatment.• In preschool children the figure is as high as 18% of all injuries.• Amongst all facial injuries, dental injuries are the most common of which crown fractures and luxations occur most frequently.
Incidence• The greatest incidence of trauma to the primary dentition occurs at 2 to 3 years of age, when motor coordination is developing.• The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports.• All sporting activities have an associated risk of orofacial injuries due to falls, collisions, and contact with hard surfaces
• History of trauma in both primary and permanent teeth- 46% of children• Boys show more frequency than girls in permanent teeth, no significant sex difference in primary teeth• Peak incidence in boys- 2-4 year and 9-10 year girls- 2-3 years• Facial injuries- common in boys of 6-12 yr of age, mandible is most affected• Teeth involved- 37% upper central incisor 18% lower central incisor 6% lower lateral incisor 3% upper lateral incisor• Frequency increased with increase in over jet
Etiology• FALL: - Frequent during first year of life - peak incidence just before school age• BATTERED CHILD SYNDROME: - abused or neglected child who have suffered serious physical abuse• ACCIDENTS: - bicycle accidents, automobile accidents, play ground accidents• SPORTS: - sports like football, baseball, basketball, wrestling, kabbadi,
Predisposing Conditions• Facial profile: more common in, Angles class II type I malocclusion• Cerebral palsy: due to, – abnormal muscle tone and function in oral area producing protrusion of maxillary anterior teeth – Poor skeletal and muscle co-ordination• Epileptic patients• Dentinogenesis imperfecta
Severity of Injury• Energy of impact• Resiliency of the impacting object• Shape of the impacting object• Angle of direction of the impacting force
Mechanism of dental trauma (Andreasen and Bennett)Direct trauma: occurs when the tooth itself is hitIndirect trauma: inflicted when lower dental arch is forcefully closed against the upper
• Dental injuries could have improved outcomes if the public were aware of first-aid measures and the need to seek immediate treatment.• Because optimal treatment results follow immediate assessment and care, dentists have an ethical obligation to ensure that reasonable arrangements for emergency dental care are available.
• A thorough history and examination are necessary of the patient who has suffered dental-trauma.• Findings should be documented in the records
History• A detailed history is important when the patient is first seen after an injury.• Questions should be asked to determine – the cause of the injury, – symptoms, – possibility of concomitant injuries, and – the medical history of the patient before an accurate diagnosis and treatment plan can be established.
Chief Complaint• The chief complaint may include several subjective symptoms.• These should be listed in order of importance to the patient.• Also note the duration of each symptom.
History of Present Illness (Injury)• Obtain information about the accident in chronologic order – Date, – time, – place, – how the injury took place
• Has the patient noticed any other symptoms after injury-• Signs and symptoms to watch for are dizziness; vomiting; severe headaches; seizures or convulsions; blurred vision; unconsciousness; loss of smell, taste, hearing, sight, or balance; or bleeding from the nose or ears.• Affirmative response to any of the above indicates the need for emergency medical evaluation.
• Note any treatment before this examination• Question the patient about previous injuries involving the same area.
• Specific problems with the traumatized tooth/teeth• Pain, mobility, and occlusal interference are the most commonly reported symptoms.• In addition, the patient should be asked about any symptoms from adjacent soft tissues such as tongue, lips, cheeks, gingiva, and alveolar mucosa.
Medical History• Allergies,• Disorders such as bleeding problems, epilepsy, diabetes• Current medications• Tetanus immunization status – For clean wounds, no booster dose is needed if no more than 10 years have elapsed since the last dose. – For contaminated wounds, a booster dose should be given if more than 5 years have elapsed since the last dose.
Clinical Examination• A careful, methodical approach to the clinical examination will reduce the possibility of overlooking or missing important details.
Examination of Soft tissues• All areas of soft tissue injury should be noted, and the lips, cheeks, and tongue adjacent to any fractured teeth should be carefully examined and palpated.• It is not unusual for tooth fragments to be buried in the lips.• The radiographic examination should include specific exposures of the lips and cheeks if lacerations and fractured teeth are present
Examination of facial bones• The maxilla, mandible, and temporomandibular joint should be examined visually and by palpation• Look for distortions, malalignment, or indications of fractures.• Indications of possible fractures should be followed up radiographically.• Also note possible tooth dislocation, gross occlusal interference, and development of apical pathosis.
Examination of teeth• The teeth must be examined for fractures, mobility, displacement, injury to periodontal ligament and alveolus, and pulpal trauma.• Remember to examine the teeth in the opposite arch also. They, too, may have been involved to some degree.
Tooth Fracture• The crowns of the teeth should be cleaned and examined for extent and type of injury.• Crown infractions or enamel cracks can be detected by changing the light beam from side to side, shining a fiber-optic light through the crown, or using disclosing solutions.• If tooth structure has been lost, note the extent of loss• Check for discoloration of the crown or changes in translucency to fiber-optic light. Both may indicate pulp changes.
Mobility• Examine the teeth for mobility in all directions.• If adjacent teeth move along with the tooth being tested, suspect alveolar fracture.• Root fractures often result in crown mobility, the degree depending on the proximity of the fracture to the crown.• The degree of mobility can be recorded as follows: – 0 for no mobility, – 1 for slight mobility, – 2 for marked mobility, and – 3 for mobility and depressibility.
Displacement• Note any displacement of the teeth that may be intrusive, extrusive, or lateral (either labial or lingual) or complete avulsion.• Sometimes the change is minimal, and the patient should be asked about any occlusal interference that developed suddenly.• In occlusal changes, consider the possibility of jaw or root fractures or extrusions.
Injury to Periodontal Ligament and Alveolus• The presence and extent of injury to the periodontal ligament and supporting alveolus can be evaluated by tooth percussion.• The results may be recorded as “normal response,” “slightly sensitive,” or “very sensitive” to percussion.• Careful tapping with a mirror handle is generally satisfactory.• In cases of extensive apical periodontal damage, it may be advisable to use no more than a fingertip for percussion.
• In impact trauma with no fractures or displacement, the percussion test is very important.• In some apparently undamaged teeth, the neurovascular bundle, entering the apical canal, may have been damaged, and the possibility of subsequent pulp degeneration exists.• Such teeth are often sensitive to percussion.
Pulpal Trauma• The condition of the dental pulp should be evaluated both initially and at various times following the traumatic incident.• The electric pulp test (EPT) has been shown as reliable in determining pulpal status• Discoloration, particularly a greyish hue, involving permanent teeth is indicative of pulp necrosis, whereas a yellowish hue means that extensive calcification has occurred.
Radiographic Examination• Radiography is indispensable in the diagnosis and treatment of dental trauma.• Detection of dislocations, root fractures, and jaw fractures can be made by radiographic examination.• Extraoral radiography is indicated in jaw and condylar fractures or when one suspects trauma to the succedaneous permanent teeth by intruded primary teeth.• Soft tissue radiographic evaluation is indicated when tooth fragments or possible foreign objects may have been displaced into the lips
• The size of the pulp chamber and the root canal, the apical root development, and the appearance of the periodontal ligament space may all be evaluated by intraoral radiographs.• Changes in the pulp space, both resorptive and calcific, may suggest pulp degeneration and indicate therapeutic intervention.• Other radiographic views may be indicated in more extensive injuries than those confined to the dentition.• Finally, it is also important to carefully file all radiographs for future references and comparisons.
• 5% of all cases• Injuries of anterior region - direct trauma posterior region - indirect trauma
Diagnosis• Clinical findings usually reveal a mobile coronal fragment attached to the gingiva with or without a pulp exposure.• Radiographic findings may reveal a radiolucent oblique line that comprises crown and root in a vertical direction in primary teeth and in a direction usually perpendicular to the central radiographic beam in permanent teeth.• While radiographic demonstration often is difficult, root fractures can only be diagnosed radiographically
Treatment• Primary teeth: When the primary tooth cannot or should not be restored, the entire tooth should be removed unless retrieval of apical fragments may result in damage to the succedaneous tooth.• Permanent teeth: The emergency treatment objective is to stabilize the coronal fragment.• Definitive treatment alternatives are to remove the coronal fragment followed by a supragingival restoration or necessary gingivectomy; osteotomy; or surgical or orthodontic extrusion to prepare for restoration.• If the pulp is exposed, pulpal treatment alternatives are pulp capping, pulpotomy, and root canal treatment.
• In young patients with immature, still developing teeth: preserve pulp vitality by pulp capping or partial pulpotomy.• This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide and MTA (white) are suitable materials for such procedures.• In older patients, root canal treatment can be the treatment of choice, although pulp capping or partial pulpotomy may also be selected.• If too much time elapses between accident and treatment and the pulp becomes necrotic, root canal treatment is indicated to preserve the tooth.
General prognosis• Although the treatment of crown-root fractures can be complex and laborious, most fractured permanent teeth can be saved.• Fractures extending significantly below the gingival margin may not be restorable.
Root Fracture• N873.63• Definition: a dentin and cementum fracture involving the pulp.
• Falls are considered to be the most common cause of root fracture (Cvek 2001).• Other causes include fights and blows (Andreasen 1994; Caliskan 1996; Cvek 2001;Mackie 1988).• They are uncommon in both the permanent and primary dentition.• The prevalence ranges between 0.5%to 7% of all dental injuries in the permanent dentition (Andreasen 1994).• Most root fractures are reported in the age range of 11 to 20 years (Caliskan 1996; Cvek 2001; Welbury 2002; Yates 1992).• Maxillary central incisors are most commonly affected (Andreasen 1967).
Types• Root fracture may be transverse (horizontal), oblique or vertical.• Transverse and oblique fractures are the most commonly seen types of root fracture in previously uninjured incisors (Mackie 1988).• Vertical root fracture occurs rarely as a primary injury in young permanent incisors, but may result from trauma to a tooth which has already been restored with a post-crown.
Types• The fracture can be simple or complex with more than two fragments.• Single horizontal/oblique root fractures carry the best prognosis.• The site of fracture can occur at any level of the root. Therefore root fractures are described according to the level of the root in which they occur: apical, middle or coronal third (the upper/top part of the root).
Diagnosis:• Clinical findings reveal a mobile coronal fragment attached to the gingiva that may be displaced.• Radiographic findings may reveal 1 or more radiolucent lines that separate the tooth fragments in horizontal fractures.
• Multiple radiographic exposures at different angulations may be required for diagnosis.• A root fracture in a primary tooth may be obscured by a succedaneous tooth.
Treatment• Primary teeth: Treatment alternatives include extraction of coronal fragment without insisting on removing apical fragment or observation.• Permanent teeth: Reposition and stabilize the coronal fragment.
• Reposition, if displaced, the coronal segment of the tooth as soon as possible. Check position radiographically.• Stabilize the tooth with a flexible splint for 4 weeks.• If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months).• It is advisable to monitor healing for at least 1 year to determine pulpal status.• If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth
General prognosis• Pulp necrosis in root-fractured teeth is attributed to displacement of the coronal fragment and mature root development.• In permanent teeth, the location of the root fracture has not been shown to affect pulp survival after injury.• Therefore, preservation of teeth with root fractures occurring in the tooth’s cervical third should be attempted.• Young age, immature root formation, positive pulp sensitivity at time of injury, and approximating the dislocation within 1 mm have been found to be advantageous to both pulpal healing and hard tissue repair of the fracture.
Concussion• N873.66• Definition: Injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth.
Diagnosis• Because the periodontal ligament absorbs the injury and is inflamed, clinical findings reveal a tooth tender to pressure and percussion without mobility, displacement, or sulcular bleeding.• Radiographic abnormalities are not expected
Treatment• objectives: to optimize healing of the periodontal ligament and maintain pulp vitality.• Primary teeth: For primary teeth, unless associated infection exists, no pulpal therapy is indicated.• Permanent teeth: Although there is a minimal risk for pulp necrosis, mature permanent teeth with closed apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be followed carefully.
Subluxation• N873.66• Definition: injury to tooth-supporting structures with abnormal loosening but without tooth displacement.
Diagnosis• Because the periodontal ligament attempts to absorb the injury, clinical findings reveal a mobile tooth without displacement that may or may not have sulcular bleeding.• Radiographic abnormalities are not expected.
Treatment• objectives: to optimize healing of the periodontal ligament and neurovascular supply.• Primary teeth: The tooth should be followed for pathology.• Permanent teeth: Stabilize the tooth and relieve any occlusal interferences. For comfort, a flexible splint can be used. Splint for no more than 2 weeks.
General prognosis• Prognosis is usually favorable.• The primary tooth should return to normal within 2 weeks.• Mature permanent teeth with closed apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be followed carefully.
Lateral Luxation• N873.66• Definition: displacement of the tooth in a direction other than axially.• The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs.
Diagnosis• Clinical findings reveal that a tooth is displaced laterally with the crown usually in a palatal or lingual direction and may be locked firmly into this new position.• The tooth usually is not mobile or tender to touch.• Radiographic findings reveal an increase in periodontal ligament space and displacement of apex toward or through the labial bone plate.
Treatment• Primary teeth: allow passive repositioning or actively reposition and splint for 1 to 2 weeks to allow for healing, except when the injury is severe or the tooth is nearing exfoliation.
• Permanent teeth: to reposition as soon as possible and then to stabilize the tooth in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply, while maintaining aesthetic and functional integrity.• Repositioning of the tooth is done with digital pressure and little force. The tooth may need to be extruded to free apical lock in the cortical bone plate.• Splinting an additional 2 to 4 weeks may be needed with breakdown of marginal bone.
General prognosis• Primary teeth requiring repositioning have an increased risk of developing pulp necrosis compared to teeth that are left to spontaneously reposition.• In mature permanent teeth with closed apices, pulp necrosis and pulp canal obliteration are common healing complications while progressive root resorption is less likely to occur.
Intrusive Luxation• N873.67• Definition: apical displacement of tooth into the alveolar bone.• The tooth is driven into the socket, compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket.
Diagnosis• Clinical findings reveal that the tooth appears to be shortened or, in severe cases, it may appear missing.• The tooth’s apex usually is displaced labially toward or through the labial bone plate in primary teeth and driven into the alveolar process in permanent teeth.• The tooth is not mobile or tender to touch.• Radiographic findings reveal that the tooth appears displaced apically and the periodontal ligament space is not continuous.• Determination of the relationship of an intruded primary tooth with the follicle of the succedaneous tooth is mandatory.
• If the apex is displaced labially, the apical tip can be seen radiographically with the tooth appearing shorter than its contra lateral.• If the apex is displaced palatally towards the permanent tooth germ, the apical tip cannot be seen radiographically and the tooth appears elongated.• An extra oral lateral radiograph also can be used to detect displacement of the apex toward or through the labial bone plate.• An intruded young permanent tooth may mimic an erupting tooth.
Treatment• Primary teeth: to allow spontaneous re eruption except when displaced into the developing successor.• Extraction is indicated when the apex is displaced toward the permanent tooth germ
• Permanent teeth: to reposition passively (allowing reeruption to its preinjury position), actively (repositioning with traction), or surgically and then to stabilize the tooth in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity.
• Teeth with incomplete root formation: – Allow spontaneous repositioning to take place. – If no movement is noted within 3 weeks, recommend rapid orthodontic repositioning.• Teeth with complete root formation: – The tooth should be repositioned either orthodontically or surgically as soon as possible. – The pulp will likely be necrotic and root canal treatment using a temporary filling with calcium hydroxide is recommended to retain the tooth
General Prognosis• In primary teeth, 90% of intruded teeth will reerupt spontaneously (either partially or completely) in 2 to 6 months.• Even in cases of complete intrusion and displacement of primary teeth through the labial bone plate, a retrospective study showed the reeruption and survival of most teeth for more than 36 months.• Ankylosis may occur, if the periodontal ligament of the affected tooth was severely damaged, thereby delaying or altering the eruption of the permanent successor.
• In mature permanent teeth with closed apices, there is considerable risk for pulp necrosis, pulp canal obliteration, and progressive root resorption.• Immature permanent teeth that are allowed to reposition spontaneously demonstrate the lowest risk for healing complications.• Extent of intrusion (7mm or greater) and adjacent intruded teeth have a negative influence on healing.
Extrusive Luxation• N873.66• Definition: partial displacement of the tooth axially from the socket; partial avulsion. The periodontal ligament usually is torn.
Diagnosis• Clinical findings reveal that the tooth appears elongated and is mobile.• Radiographic findings reveal an increased periodontal ligament space apically
Treatment• Primary teeth: to reposition and allow for healing, except when there are indications for an extraction (i.e., the injury is severe or the tooth is nearing exfoliation).• If the treatment decision is to reposition and stabilize, splint for 1 to 2 weeks
• Permanent teeth: to reposition as soon as possible and then to stabilize the tooth in its anatomically correct position• Repositioning may be accomplished with slow and steady apical pressure to gradually displace coagulum formed between root apex and floor of the socket.• Splint for up to 3 weeks using a flexible splint
General Prognosis• There is a lack of clinical studies evaluating repositioning of extruded primary teeth.• In permanent mature teeth with closed apices, there is considerable risk for pulp necrosis and pulp canal obliteration.• These teeth must be followed carefully.
Avulsion• N873.68• Definition: Complete displacement of tooth out of socket.• The periodontal ligament is severed and fracture of the alveolus may occur.
Diagnosis• Clinical and radiographic findings reveal that the tooth is not present in the socket or the tooth already has been replanted.• Radiographic assessment will verify that the tooth is not intruded when the tooth was not found.
Treatment• Primary teeth: to prevent further injury to the developing successor. Avulsed primary teeth should not be replanted because of the potential for subsequent damage to developing permanent tooth germs.• Permanent teeth: to replant as soon as possible and then to stabilize the replanted tooth in its anatomically correct location.
• Time - Most critical factor• Advice to patient over phone - rinse tooth gently - do not scrub, place/hold in socket, see dentist ASAP• Transport media - Hank’s balanced Salt Solution(HBSS), cold milk, saline, or saliva
• The risk of ankylosis increases significantly with an extraoral dry time of 15 minutes.• An extraoral dry time of 60 minutes is considered the point where survival of the root periodontal cells is unlikely.• Trope M. Clinical management of the avulsed tooth: Present strategies and future directions. Dental Traumatol 2002;18(1):1-11.• Chappuis V, von Arx T. Replantation of 45 avulsed permanent teeth: A 1-year follow- up study. Dental Traumatol 2005;21(5):289-96.
Results depend upon• Extraoral time• Extraoral environment• Root surface manipulation• Management of the socket• Stabilization
Replanting within 60 min• Keep tooth moist in saline at all times• Radiograph: look for alveolar fracture/bone fragments• Irrigate socket with saline/anaesthetic to remove clot• Avoid handling root; grasp crown with forceps, splint
• Remove debris from root with a stream of saline• Do not curette or vent socket; use gentle finger pressure or patient bites on gauze• Check tooth alignment; suture soft tissue lacerations; splint for 1-2 weeks.• Bony fractures require splinting up to 4-8 weeks
• Antibiotics; tetanus booster (5 years); chlorhexidine rinses; analgesics• RCT for mature teeth: pulp removed after one week; Ca(OH)2 placed before splint removed• Immature permanent teeth with wide open apices: evaluate at 2, 6, and 12 months
Replanting after 60 min of dry time• Radiograph; examine for alveolar fractures• Remove debris & soft tissue from root(scalers & pumice); soak tooth in 2% sodium fluoride for 5-20 min.• Extirpate pulp; fill canal• Remove blood clot from socket & replant tooth• Splint for 4 weeks
• Replanting contraindicated by – the child’s stage of dental development (risk for ankylosis where considerable alveolar growth has to take place); – compromising medical condition; or – compromised integrity of the avulsed tooth or supporting tissues.• Flexible splinting for 1 week is indicated.• Tetanus prophylaxis and antibiotic coverage should be considered.• Treatment strategies are directed at avoiding inflammation that may occur as a result of the tooth’s attachment damage and/or pulpal infection
Periodontal Ligament Responses• Surface resorption – Superficial resorption cavities – Mainly in cementum – Complete repair of PDL
Periodontal Ligament Responses• Replacement resorption (Ankylosis) – Direct union of bone and root – Resorption of root - Replacement with bone – Direct result of loss of vital PDL
Periodontal Ligament Responses• Inflammatory resorption – Resorption of cementum and dentin – Inflammatory reaction in the periodontal ligament
Sequelae- Andreasen and Hjörting-Hansen• 1. Healing with calcified tissue. Radiographically, the fracture line is discernible, but the fragments are in close contact• 2. Healing with interproximal connective tissue. Radiographically, the fragments appear separated by a narrow radiolucent line, and the fractured edges appear rounded
• 3. Healing with interproximal bone and connective tissue. Radiographically, the fragments are separated by a distinct bony bridge• 4. Interproximal inflammatory tissue without healing. Radiographically, a widening of the fracture line and/or a developing radiolucency corresponding to the fracture line become apparent
General prognosis• Prognosis in the permanent dentition is primarily dependent upon formation of root development and extraoral dry time.• The tooth has the best prognosis if replanted immediately.• If the tooth cannot be replanted within 5 minutes, it should be stored in a medium that will help maintain vitality of the periodontal ligament fibres.
Injuries of supporting bone• Comminution/ fracture of alveolar socket or alveolar process-a. In mandible- N802.20b. In maxilla- N802.40• Fracture of maxilla and mandible-a. Mandible- N802.21b. Maxilla- N802.42
Lacerations• N873.69• Shallow or deep wound in mucosa resulting from a tear• Usually produced by sharp object
• Provide appropriate tetanus prophylaxis and check for associated injuries such as loose teeth, mandibular or facial fractures .• When only small lacerations are present and only minimal gaping of the wound occurs, reassurance and simple aftercare is all that is required.• Let the patient know the wound will become somewhat uncomfortable and covered with pus over the next 48 hours and tell him to rinse with lukewarm water or half strength hydrogen peroxide after meals and every one to two hours while awake for one week.
• If there is continued bleeding, the wound edges gape significantly or there is a flap or deformity when the underlying musculature contracts, the wound should be anesthetized using lidocaine with epinephrine, cleansed thoroughly with saline and loosely approximated using a 4-0 or 5-0 absorbable suture.
Contusion• N902.00• Bruise produced by impact from blunt object• No break in mucosa• Sub mucosal haemorrhage
Abrasion• N910.00• Superficial wound produced by rubbing or scraping of mucosa• Raw bleeding surface
Follow-up Evaluation• Trauma patients should be evaluated often enough, and over a long enough period of time, – To determine that complete recovery has taken place or – To detect as early as possible pulpal deterioration and root resorption.• If pulpal recovery (eg, revascularization) is to be monitored, frequent initial re-evaluations (every 3 to 4 weeks for the first 6 months) and then yearly are recommended.
Trauma Prevention• Living and growing carry a high risk of trauma.• A child will not learn to walk without falling, and few children reach 4 years of age without having received a blow to the mouth.• We cannot totally prevent trauma.• Moreover, the results of treatment of trauma are often less predictable than those of other types of dental treatment.
• On the brighter side, there are preventive measures that have been proved to reduce the prevalence of traumatic episodes in certain environmental situations.• For example, because the prevalence of fractured incisors is higher among those with protrusive anterior teeth, many dentists are recommending early reduction of excessive protrusion to reduce the susceptibility of such teeth to injury.
• The use of car safety seats and restraining belts has prevented many injuries to infants and young children.
• The protective mouth guard has prevented or reduced the severity of countless injuries to the teeth of youngsters participating in organized athletic activities; active youngsters should be encouraged to wear their mouth guards during high- risk unsupervised athletic activities.
• When we have the opportunity to save a child from pain and suffering, an ounce of prevention is worth a pound of cure.
References• Mc Donald, Avery, Dean. Dentistry for the Child and Adolescent , 8th edition.• Andreasen JO, Andreasen F, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edition.• Ingle JI, L K Bakland LK. Endodontics, 5th edition.• Mitsuhiro Tsukiboshi. Treatment Planning for Traumatised Teeth.• Guideline on Management of Acute Dental Trauma. AAPD Reference Manual 2007;Vol 30(7): 175- 183.• Flores et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66–71.• Flores et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dental Traumatology 2007; 23: 130–136.• Flores et al. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dental Traumatology 2007; 23: 196–202.