By: Dr.Mostafa kareem B.D.S

1. By:
Dr. Mustafa Kareem
B.D.S

2. Is an injury to the mouth , including teeth, lips, gum and
tongue and the most common dental trauma is a broken or lost
tooth .
Traumatic dental injury is
consider to be one of the
serious dental accidents
affecting children and young
adults.

3. The most important classifications are :-
1) Ellis classifications
2) WHO classifications
3) Garcia-Godoy classification
Class I : Enamel fracture
Class II: Enamel and Dentine
fracture
Class III: Enamel & Dentine
fracture with pulp exposure
Class IV: Root fracture
Class V: Tooth luxation
Class VI: Tooth avulsion

4. Crown :
1) Crack or craze of the enamel without loss of tooth structure.
2) Fracture of the crown involving enamel , dentine and pulp.
3)Fracture of the crown and root involving cementum.
Root:
1) Apical 1/3 fracture (horizontal or oblique)
2) Middle 1/3 fracture (horizontal or oblique)
3) Coronal 1/3 fracture (horizontal or oblique)
Involving the whole tooth:
1) Concussion
2) Subluxation
3) Displacement (Luxation)
a) Intrusion
b) Extrusion
c) Labial/Lingual/ palatal luxation:
d) Lateral luxation
4) Avulsion

5. 1) Fracture of alveolar socket due to tooth intrusion.
2) Socket wall fracture (labial or lingual fracture)
3) Fracture of alveolar process
4) Fracture of maxilla
5) Fracture of mandible
1) Contusion
2) Abrasion
3) Laceration
4) Deep puncture wound
5) Wide tissue loss

6. May be categorized into:
1) Domestic violence , child abuse and neglect.
2) Sporting activities like football and contact sports like
rugby, hockey and judo.
3) Other causes like struck by an object, falls, collision,
assaults , RTA , fights and eating hard foods.
Mechanism of trauma occurrence:
A) Direct trauma: which produce
1) palatal or lingual movement of tooth with palatal
fracture of alveolar bone
2) palatal or lingual movement of the tooth with buccal
fracture of alveolar bone.
3) Extrusion.
B) Indirect trauma : which produce
1) Labial movement of tooth with fracture of the labial
alveolar bone.
2) Labial movement of the tooth with fracture of palatal or
lingual alveolar bone
3) Intrusion

8. Take complete medical history.
Assess the need for antibiotic prophylaxis.
Determine if the child is immunocompromised or has
congenital heart disease and bleeding disorder
Determine if the child’s tetanus immunization is up to date
Determine if the child lost consciousness due to the injury.
The clinician should determine How , When and Where the
injury occurred.
“How” is important because it provides information on the
severity of injury.
“When” is important because the prognosis for the injured
tooth worsen with every minute of delay in treatment.
“Where” is important because it may determine whether or
not tetanus prophylaxis is warranted.
“Pain” is important in determine the extent of injury.

9.  Vital signs
 Head and neck examination and accident information
 Rule out head injury
 An evaluation of pupil size and reaction to light may
establish the presence of head injury
 Extra oral Examination.
 Intraoral Examination.
 Radio graphical Examination.
 Photographic Documentation.

10. Require either smoothening the sharp edges or restore with
an acid etch restoration.
Require extraction or pulp care , while in majority of cases like
concussion, subluxation and luxation the decision is between
extraction or maintenance without performing extensive
treatment.

11. Should be repositioned by the dentist or parent as soon
as possible after the accident.
Give the child soft diet , analgesic and antibiotic .
Observe at one week , one month radio graphically.
The prognosis of severely loosened primary teeth is poor.
If traumatized teeth are so loose that they are in a
danger of being aspirated or if they interfere with normal
occlusion, immediate referral to a dentist for extraction is
required.

12.  it is generally agreed that immediate attention should be
given to soft tissue damage.
Intruded primary tooth should be observed with few
exceptions, no attempt should be made to reposition them .
Primary anterior teeth intruded as a result of a blow may
often re-erupt within 3 to 4 weeks after the injury.
Normally the developing permanent incisor tooth bud lie
lingual to the roots of primary central incisors ;therefore,
when an intrusive displacement occur , the primary tooth
remain labial to the developing permanent tooth
If the intruded primary tooth is found to be in a lingual or
encroaching relationship to the developing permanent
tooth, It should be removed
Intruded primary tooth may cause:
1) Localized hypoplasia
2) Dilaceration

13. Root fracture of primary teeth is usually uncommon because
the more pliable alveolar bone allows displacement of the
tooth .
NOTE:-
Replantation of avulsion of primary tooth is not
recommended due to risk of damage to the permanent
tooth bud.

14. No restoration is needed and the treatment is limited to
smoothing of any rough edge.
The child should be reexamined at 2 weeks and again at
one month after the injury to check the vitality.

15.  Require pulp protection against thermal , chemical and
osmotic and from bacteria via dentinal tubules ,and
restoration of crown morphology to prevent drifting of tooth.
 The dentist may have the opportunity to reattach the
fragment of fracture tooth using resin and bonding technique.
For cases in which considerable dentine is exposed, an
indirect pulp capping is indicated if the patient come
immediately after trauma but if the patient come latter on,
the probability of being non vital increase.
If enough part is missing to compromised the entire tooth
structure but the pulp not permanently damaged and no
tooth fragment is present ,the tooth will require immediate
temporary restoration.
Pulp vitality should be checked for 4-6 weeks.

16.  If the patient is seen within an hour or two after injury and
the vital exposure is small, and if sufficient crown remains
to retain temporary restoration to support the capping
material and prevent the ingress of oral fluids, direct pulp
capping is indicated.
 If the pulp exposure large and the child did not seek
treatment until several hours or days after the injury or if
insufficient crown remains to retain temporary restoration
to support the capping material as well as if the tooth
immature (open apex). The tooth will require pulp care
(vital pulpotomy or apexogenesis)
Another indication for vital
pulpotomy is trauma to a
mature permanent (closed
apex) tooth that has caused
both a pulp exposure and root
fracture.

17. Therapy to stimulate root growth and apical repair subsequent
to pulpal necrosis in anterior permanent teeth.
The apexification procedure should precede conventional root
canal therapy in the management of teeth with irreversible
(necrotic) diseased pulps and open apices.
Procedure :-
1) The affected tooth is isolated with rubber dam, and an
access opening is made into the pulp chamber.
2) A file is placed in the root canal and a radiograph is made
to establish the root length accurately.
3) The remnants of the pulp are removed using barbed
broaches and files , then the canal is flooded with H2O2 to
aid in the removal of debris. Then the canal is irrigated
with sodium hypochlorite and saline.
4) The canal is dried with large paper points and loose cotton
5) A thick paste of calcium hydroxide and CMCP is transferred
to the canal with the aid of amalgam carrier.

18. 6) A cotton pledge is placed over the calcium hydroxide and
the seal is complete with a layer of reinforced zinc oxide
eugenol cement for 1 week.
7) As a general rule the treatment paste is allowed to remain
6 months. The root canal then reopened to determine if the
tooth is ready for conventional gutta-percha filling.
Frank’s four successful results of apexification :
• Continued closure of the canal and apex to normal
appearance.
•A dome shaped apical closure with the canal
retaining a blunderbuss appearance.
•No apparent radiogrphic change but a positive stop
in the apical area
•A positive stop and radiographic evidence of a
barrier coronal to the anatomic apex of the tooth.
8) If the apical closure has not occur in 6 month, the root
canal is retreated with Ca(oh)2 paste
9)If weeping in the canal was not controlled before filling, re-
treatment is recommended 2 or 3 months after first
treatment.

19. Mineral trioxide aggregate (MTA)
 The root canals were rinsed with 5% sodium
hypochlorite.
Calcium hydroxide was then placed in the canals for
1 week.
The apical portion of the canal (4 mm) is filled with
MTA ,and the remaining portion of the root canal is
closed with thermoplastic gutta-percha
Fellow up at 6-month and 1-year clinically and radio
graphically.

20. A tooth that is vertically fractured or fractured below the
gum line will require root canal treatment when there is
closed apex , or apexification and root canal treatment when
there is open apex before protective restoration.
A tooth that no longer has enough remaining structure to
retain restoration may have to be extracted.
Require long term follow up and / or root canal restoration.

21. Require repositioning, splinting
along with long term follow up.
If the tooth do not responded
to the pulp test within 2-3
weeks, endodontic treatment is
indicated before there’s evidence
of root resorption.
If the tooth not mobile just
reduce little bite of the incisal
edge.

22. Teeth subject to intrusive luxation have been intruded into
the alveolar bone , which may occur to the point that the
teeth are not visible.
It can be treated by:
 Immediate surgical correction.
Intruded immature permanent teeth may be left to re
erupt spontaneously within 1-2 weeks.
If the tooth does not show early spontaneous re-eruption
or if the intrusion is sever, orthodontic repositioning should
be initiated .
A palatal gingivectomy and endodontic treatment 10
days after the injury should be considered rather than
orthodontic repositioning.

23. Management include :
 Careful repositioning and stabilizing of the tooth for 2-
3 weeks
If mature repositioned tooth do not respond to vitality
test within 2-3 weeks after reposition, endodontic
treatment is indicated.
With extruded immature tooth, the clinician should
monitor the situation and be prepared to intervene with
endodontic therapy if the condition warranted

24. Avulsion of permanent tooth is the
most serious of all dental injuries
and replantation is the treatment of
choice.
The prognosis depends on:
1) The measures taken at the place
of accident (contamination) and
extra oral dry time.
2) Stage of root development.
3) The condition of tooth and the
condition of PDL remaining on
the root surface.

25. Treatment:-
The tooth should be immediately
reimplanted with simple finger
pressure and secured by a splint.
Rinsing with normal saline if
required.
If the tooth cannot be reimplanted
within 5 minutes, it should be stored
in a medium that will maintain
vitality of PDL.
If the tooth is visibly
contaminated, it should be gently
rinsed in cold running tap water.
Care should be taken not to touch,
rub or clean the root.
The socket should not scrap.
Emdogain has been shown to
increase the incidence of healed PDL
Antibiotic prophylaxis (penicillin)
Tetanus vaccine should be
administered

26. After replantation of avulsed tooth , a splint is required to
stabilize it during at least the first week of healing.
Type of splint:
1) The bonded resin and wire splint
2) Bonded brackets and arch wire
3) Suture and a bonded resin splint
4) Orthodontic arch wire
5) Fiber-filled acrylic
6) Titanium trauma splint

27. Coronal or cervical fracture:
We usually remove the crown and if the remaining root is
long enough we do RCT. Some time we need orthodontic
extrusion of remaining apical fragment and then we do post
and core permanent restoration. If remaining tooth is short
do extraction.
Middle 3rd fracture:
Treated by RCT involving both the coronal and apical
fragments and obturated with silver point that act as a splint.
Apical 3rd fracture:
Fracture in the apical third are often
repaired without treatment. Some
time RCT of the coronal fragments
and apical fragment removed
surgically.