Dental treatments

1. TRAUMA AND
MANAGEMENT
R.SARANYA
Ist Year postGraduate
Department of conservative
dentistry and endodontics

2. INTRODUCTION
• TDI occur frequently in
children and young
adults
• Luxation injuries-most
common in the
primary dentition
• crown fractures-more
common in the
permanent teeth

3. Etiology
• Trauma
• Sports accident
• Automobile accident
• Fight and assault
• Biting hard items
Chandra bs, gopikrishna v. Endodontic practice,13 th edition

4. Classification of anterior teeth trauma by
Sweets (1955)
Class I – A simple of crown exposing no dentin.
Class II – A parallel of crown involving little dentin.
Class III – Extensive fracture of crown involving more
dentin bur no pulp exposure.
Class IV – Extensive fracture of crown exposing pulp.
Class V – Complete fracture of crown exposing pulp.
Class VI – Fracture of root with or without loss of crown
structure.
Class VII – Tooth loss as a result of trauma.
Pagadala S, Tadikonda DC. An overview of classification of dental trauma.

5. Classification by Rabinowitch (1956)
1. Fractures of the enamel or slightly into the
dentin
2. Fractures into the dentin
3. Fractures into the pulp
4. Fractures of the periodontium
5. Comminuted fractures
6. Displaced teeth.

6. Benetts Classification (1963)
• Class I – Traumatized tooth without coronal or root
fracture.
a) Tooth from in alveolus.
b) Tooth subluxated in alveolus.
• Class II – Coronal fracture
a) Involving enamel
b) Involving enamel + dentin.
• Class III – Coronal fracture with pulp exposure.
• Class IV – Root fracture
a) Without coronal fracture.
b) With coronal fracture.
• Class V – Avulsion of tooth.

7. Classification by Ellis (1970)
• Class I - Simple crown fracture with little or no dentin affected
• Class II - Extensive crown fracture with considerable loss of dentin,
but with the pulp not affected.
• Class III - Extensive crown fracture with considerable loss of dentin
and pulp exposure.
• Class IV - A tooth devitalized by trauma with or without loss of
tooth structure.
• Class V - Teeth lost as a result of trauma.
• Class VI - Root fracture with or without the loss of crown structure.
• Class VII - Displacement of the tooth with neither root nor crown
fracture
• Class VIII - Complete crown fracture and its replacement.
• Class IX - Traumatic injuries of primary teeth.

8. Classification by Ellis and Davey (1970)
Class 1 - Simple fracture of the crown-involving little
or no dentin
Class 2 - Extensive fracture of the crown – involving
considerable dentin, but not the pulp
Class 3 - Extensive fracture of the crown –involving
considerable dentin, and exposing the dental pulp
Class 4 - The traumatized tooth which becomes non
vital-with or without loss of crown structure
Class 5 - Teeth lost as a trauma
Class 6 - Fracture of the root - with or without
loss of crown structure
Class 7 - Displacement of the tooth-without
fracture of crown or root
Class 8 - Fracture of the crown en masse and its
replacement.

9. ANDERSON’S CLASSIFICATION
• Injuries to hard dental tissues and pulp:
1. Enamel infraction
2. Enamel fracture
3. Enamel-Dentin fracture
4. Complicated crown fracture
5. Uncomplicated crown fracture
6. Complicated crown root fracture
7. Root fracture
• Injuries to periodontal tissues:
1. Concussion
2. Subluxation
3. Extrusive luxation
4. Lateral luxation
5. Intrusive luxation(central dislocation)
6. Avulsion(exarticulation)

10. • Injuries to supporting bone:
1.Comminution of mandibular or maxillary
alveolar socket
2.Fracture of mandibular or maxillary socket
wall
3.Fracture of mandibular or maxillary alveolar
process
• Injuries to gingiva or oral mucosa:
1.Laceration of gingiva or oral mucosa
2.Contusion of gingiva or oral mucosa
3.Abrasion of gingiva or oral mucosa

11. Classification by Garcia – Godoy (1981)
1. Enamel crack
2. Enamel fracture
3. Enamel Dentine fracture without pulp exposure
4. Enamel Dentine fracture with pulp exposure
5. Enamel- Dentine-cementum fracture without pulp
exposure
6. Enamel- Dentine-cementum fracture with pulp exposure
7. Root fracture
8. Concussion
9. Luxation
10. Lateral displacement
11. Intrusion
12. Extrusion
13. Avulsion.

12. Classification by Spinas (2002)
• It consist of 4 classes (A-B-C-D) and 3 subclasses (b1-c1-d1)
• Class A: All the simple enamel lesions, which involve a mesial
or distal crown angle, or only the incisal edge.
• Class B: All the enamel dentin lesions, which involve a mesial
or distal angle and the incisal edge. When a pulp exposition
exists defined as a subclass b1.
• Class C: All the enamel dentin lesions, which involve the
incisal edge and at least a third of the crown surface. In case
of pulp exposure defined as subclass c1
• Class D: All the enamel dentin lesions, which involve a mesial
or distal crown angle and the incisal or palatal surface, with
root involvement (crown root fracture) in case of pulpal
exposure exists defined as subclass d1.

13. Classification by McDonald (2004)
• Class 1 - Simple fracture of the crown
involving little or no dentin
• Class 2 - Extensive fracture of the crown
involving considerable dentin but not
the dental pulp
• Class 3 - Extensive fracture of the crown
with an exposure of the dental pulp
• Class 4 - Loss of the entire crown.
Pagadala S, Tadikonda DC. An overview of classification of
dental trauma. IAIM, 2015

14. TDI First Aid
• Bleeding should be controlled- positive pressure.
• Brief medical history- Tetanus immunization
• Cleansing and debridement of soft tissues
• The face and all bony margins, including the
orbit, should be palpated for signs of bone
fractures, bruising, swelling and areas of
tenderness
• Avulsion, lateral and extrusive luxations- TDI
emergencies

15. Information-Andreasen et al.
(1) When did injury occur?
(2) Where did injury occur?
(3) How did injury occur?
(4) Was a third party involved in the
accident?

16. CLINICAL EXAMINATION

17. Severe cracking can be clearly observed on the labial surface
of this central incisor by using a transilluminating device.

18. (a) Normal colour.
(b) (b) Reddish blush immediately after trauma.
(c)Purple colour some months after
trauma,responsive to sensibility testing and
assumed normal colour some years after trauma.
(d) Grey discolouration -sign of pulp necrosis.

19. e) Yellowish discolouration -sign of pulp
calcification within the crown.
f) Brown discolouration is usually a sign of pulp
necrosis. (g) Palatal view of a tooth immediately
after trauma
viewed by transillumination. This tooth became
responsive to pulp sensibility testing and
the discolouration resolved in a few years.

20. (Nellcor© OxiMax
Pulp oximeter. A view of photoelectric diode and
receptor (a). Receptor applied to a central incisor
tooth

21. CROWN FRACTURES
• Crown Infraction
• Uncomplicated Crown fracture
• Complicated Crown fracture

22. CROWN INFRACTION
•An incomplete fracture of the enamel.
•Not tender.
•Visual examination : by dyes (Methylene
Blue), transillumination.
No radiographic abnormalities.
Treatment
•Infractions- etching and sealing with resin
to prevent discoloration of the infraction
lines.
IADT treatment guidelines

23. Uncomplicated Crown fracture
A fracture confined to enamel and
dentin
• Percussion test:
Not tender
• Sensibility pulp test :Normal
• Radiographic findings
Enamel-dentin loss is visible.
periapical, occlusal - to rule out tooth
displacement or possible,
presence of root fracture.

24. Treatment
• Tooth fragment -available, it
can be bonded to the tooth
• Treatment - bonding agent
and composite resin
• RDT- within 0.5 mm (pink, no
bleeding), place calcium
hydroxide base and cover
with a material such as a
glass ionomer

25. Uncomplicated Crown fracture
Follow-up
• 6-8 weeks.
• 1 year.
Andreasen et al, reported that in cases of crown
fracture without pulp exposure, the risk of pulp
complications when a luxation injury has not occurred
is very limited
Josué Martos et al ,Management of an uncomplicated crown fracture by reattaching the fractured fragment; 06
September 2017

26. Complicated Crown fracture
• Fracture involving enamel and dentin
and exposure of the pulp.
• Normal mobility.
• Exposed pulp sensitive to stimuli.
• Radiographic findings
Enamel-dentin loss visible,
periapical, occlusal to rule out tooth
displacement or possible presence
of root fracture.

27. TREATMENT
Direct Pulp Capping Pulpotomy
• Apexification
• Pulpectomy

28. Treatment
• In immature tooth, -preserve pulp
vitality. Also, this treatment is the
choice in young patients with
completely formed teeth.
• Calcium hydroxide is a suitable material
to be placed on the pulp wound.

29. • In patients with mature apical
development, root canal treatment is
usually the treatment of choice.
• If tooth fragment is available, it can be
bonded to the tooth.
Follow-up
• 6-8 week
• 1 year

30. Crown-root fracture without pulp involvement
• A fracture involving enamel, dentin and
cementum, but not exposing the pulp.
• Crown fracture extending below
gingival margin.
Percussion test: Tender.
Coronal fragment mobile.
Sensibility pulp test :Normal response
Radiographic findings
• Apical extension of fracture usually not
visible.

31. Crown-root fracture without pulp
involvement
Treatment
• Temporary stabilization of the loose
segment to adjacent teeth can be performed
• Fragment removal
• Removal of the coronal crown-root fragment
• Restoration of the apical fragment exposed above the
gingival level.
• Endodontic treatment and restoration with a post-
retained crown. This procedure should be preceded by a
gingivectomy, and sometimes ostectomy with
osteoplasty.

32. ORTHODONTIC EXTRUSION OF APICAL FRAGMENT
The coronal fragment is unrestorable & remaining
radicular portion is partly below the gingiva
This procedure is indicated in case where C:R ratio
is not compromised
Subgingival portion is made to supra gingival
position

33. Crown-root fracture without pulp involvement
• Surgical extrusion
• surgical repositioning of the root
in a more coronal position.
• Extraction
• Extraction with immediate or
delayed implant-retained crown
restoration or a conventional
bridge.

34. Crown-root fracture with pulp involvement
• A fracture involving enamel, dentin and
cementum and exposing the pulp.
• Percussion test: tender.
• Coronal fragment mobile.
Radiographic findings
• Apical extension of fracture usually not
visible.
• Radiographs recommended: periapical
and occlusal exposure.
Treatment
• Temporary stabilization of the loose
segment to adjacent teeth.
• open apices- preserve pulp vitality

35. • Young patients with completely formed
teeth-Calcium hydroxide -pulp capping
materials.
• Mature apical development, root canal
treatment.
• Removal of the coronal fragment with
subsequent endodontic treatment and
restoration with a post-retained crown.,
preceded by a gingivectomy and sometimes
ostectomy with osteoplasty. This treatment
option is only indicated in crown-root
fractures with palatal subgingival extension.
• Orthodontic extrusion of apical fragment
• Surgical extrusion

36. Root fracture
• The coronal segment may be mobile and
may be displaced.
• Tender to percussion.
• Bleeding from the gingival sulcus may be
noted.
• Sensibility testing may give negative
results initially, indicating transient or
permanent neural damage.
• Transient crown discoloration (red or
grey) may occur.

37. Root fracture
Radiographic findings:
• Horizontal or oblique plane:
• Horizontal plane can usually be
detected in the regular
periapical 90o angle film with the
central beam through the tooth.
• Fractures in the cervical third of
the root-horizontally
• Oblique fracture which is
common with apical third
fractures.

38. Root fracture
Treatment
• If displaced- Reposition, the coronal
segment of the tooth as soon as
possible.
• Check position radiographically.
• Stabilize the tooth with a flexible
splint for 4 weeks.
• It is advisable to monitor healing for at
least 1 year to determine pulpal
status.
• pulp necrosis: Root canal treatment.

39. Root fracture
Follow-up:
• 4 weeks – Splint removal, clinical and radiographic
examination.
• 6-8 weeks .
• 6 months.
• 1 year.
• 5 years.

40. Classification
• Horizontal / transverse root fracture
• Vertical root fracture

41. Horizontal root fracture /
transverse root fracture
• Also called as: Intralveolar root fractures
• They subclassified on the basis of:
1. Location of fracture line (cervical, middle
and apical);
2. Extent of fracture (partial and total);
3. Number of fracture lines (simple, multiple
and comminuted);
4. Position of coronal fragment (displaced
and not displaced).
• Caliskan and pehlivan, in a study showed
that fracture of middle third(57%) was
the commonest than apical (34%) and
cervical (9%)

42. • Depending on the position of the
fracture line, transverse root
Fractures can also be classified
into three zones as follows:
Zone 1 – extends from the
occlusal/incisal edge to the alveolar
bone crest.
Zone 2 – extends from the alveolar
bone crest to 5 mm below.
Zone 3 – extends from 5 mm below
the alveolar bone crest to the apex
of the root.
Horizontal root fracture

43. Apical third fracture
• No mobility and asymptomatic
tooth.
• The apical segment of a
transversely fractured tooth
remains vital in most of the
cases.
• If the pulp undergoes necrosis
in the apical fragment , surgical
removal of the apical fragment
is indicated.

44. • Root fractures horizontally, the coronal
segment is displaced to a varying degree,
apical pulpal circulation is not disrupted,
pulp necrosis in the apical segment is
extremely rare.
• Pulp necrosis develops in the coronal
segment owing to its displacement but
occurs in only about 25% of cases.

45. Saroglu et al have described treatment for horizontal root fractures
located in the apical third of the roots of the teeth 11 and 21
• Teeth were gently
repositioned by finger
pressure and splinted.
• After 4 months, the splint
was removed.
• No mobility
• Teeth vitality tests: positive
response
• No sign of periapical
pathology in the radiograph.

46. Middle third fracture
• Repositioning of the
coronal fragment - semi-
rigid or rigid splint (e.g.
o r t h o d o n t i c w i r e /
composite resin splint,
acid-etch/ resin splint)
• Splint for 2–3 months.

47. The treatment
1) Repositioning the fractured segment and
splinting
• Rigid splinting
• After 45 days - the rigid fixation was removed.
sensibility test
– normal
Diastasis of
0.1 mm
No mobility
Non-
discolored
crown
No periapical
changes

48. SPLINTS

49. Disinfection and obturation of the
coronal segment only
• Apical fragment remains vital
• cervical fragment can develop
necrosis
• Coronal segment- Endodontic
treatment , apexification procedure
should be performed before
obturation of the root canal.
• Disinfection of coronal segment with
calcium hydroxide followed by
obturation with gutta-percha.

50. 3) Complete pulp necrosis- Endodontic
treatment should be performed in
both the apical and the coronal
fragments.
4) Surgical removal of the apical portion

51. 5) INTRARADICULAR SPLINTING
• It corrects the mobility
• Steel pins, titanium endodontic
implants, prefabricated titanium
dowels, posts, and ceramic, silver,
or alloy cast dowels and posts
have been used for intra radicular
splinting.
Kroncke VA. Zur Problematik der endodontalen Schienunugfrakturierter
Zahnwurzeln. Dtsch Zahnarztl Z 1969;24:49–53.

52. RIBBOND splint
Vineet Agarwal et al; A novel approach in treating horizontally fractured canine using RIBBOND
splint and MTA as an obturating material and intra-radicular splint.vol:25(1); 2012
Approximation of
fracture fragments
through H file
Splinting with
RIBBOND fibers
Light curing of RIBBOND fibers and flowable composites

53. The coronal segment is
stabilized with the use of
chrome cobalt pin as the
implant material.
• An endodontic stabilizer
was used in conjunction
with surgical intervention
and bone grafting
• Indication:
Both the fragments were
displaced wide apart
6. Removal of the apical segment and stabilization of the
coronal segment with endodontic implants.

54. CERVICAL THIRD ROOT FRACTURE
• Fracture line above the level
alveolar crest
Coronal segment intact
Coronal segment lost
• Fracture line below level of
alveolar crest

55. FRACTURE LINE ABOVE THE LEVEL ALVEOLAR
CREST
CORONAL SEGMENT INTACT
Reattachment
• coronal segment is available
and fracture occurs at or
coronal to the level of alveolar
bone crest.
• Reattachment of the fractured
segments can be done by light
transmitting or fibre-reinforced
posts and resin-based
composite material.

56. Coronal segment lost
Post crowns
• Post crowns with subgingival
margins indicated in cases where
the coronal segment is absent
• In cases where exposure of crown
margins is required, a simple
gingivoplasty or an apical
positioned flap surgery is
performed.
Owen TA, Barber M. Direct or indirect post crowns to restore compromised teeth: a review of the literature. Br
Dent J. 2018;224(6):413‐418.

57. FRACTURE LINE BELOW LEVEL OF ALVEOLAR CREST
• The remaining root structure is long enough to
support the restoration
• only the fractured portion is extracted and root
canal therapy is performed.
• Restore the fracture either with the original
fragment or composite resins.

58. Crown lengthening (periodontal surgery)
• Crown lengthening- 1–2 mm
below the alveolar bone crest.
• Periodontal and osseous
recontouring allows exposure of
the fracture margin and sufficient
root surface to give an acceptable
restorative finish line.

59. Orthodontic extrusion
• Fracture line extends deeply up
to 6 mm below the alveolar crest.
• For a successful extrusion and
post-treatment restoration, the
distance from the fracture line to
the apex should not be less than
12 mm.
Mehmet et al Surgical extrusion of a cervically root-fractured tooth after
apexification treatment. journal of endodontics;199925(7)

60. HEALING DEPENDS ON 3 CRITERIA
• Distance between fragments
• Degree & Duration of immobilization
• Presence or absence of infection
ANDREASEN & HJORTING-HANSEN
DESCRIBED 4 TYPES OF REPAIR
FOLLOWING ROOT FRACTURE
Calcified tissue
Connective tissue
Connective tissue and bone
Granulomatous tissue

61. TYPES OF REPAIR

62. Vertical root fracture
• Vertical root fractures are tooth fractures that run along
the long axis of the tooth or deviate in a mesial or distal
direction
• More centrally located running through pulp and into
periodontium
• Before any restorative or endodontic treatment its
existence has to be noticed as it affects overall success of
treatment

63. Vertical root fracture
Neeraj Malhotra et al;A Review of Root Fractures: Diagnosis, Treatment and Prognosis; 2011.

64. Prithviraj et al: International Journal of Therapeutic Applications, Volume 13, 2013, 1-16

65. Prithviraj et al: International Journal of Therapeutic Applications, Volume 13, 2013, 1-16

66. Prithviraj et al: International Journal of Therapeutic Applications, Volume 13, 2013, 1-16

67. • The buccal and palatal segments were widely
separated by as much as 2 mm and were immobile.
• Use orthodontic elastics to join the buccal and
palatal segments of vertical fractured root, which
were then sealed with a photo-cured resin liner so
as to allow the tooth for root canal treatment and
later restoration with a cast crown.
Takatsu T, Sano H, Burrow MF. Treatment and prognosis of a vertically fractured maxillary
molar with widely separated segments: a case report. Quintessence Int 1995;26:479-84.

68. • Funato et al have described
the treatment of an
incomplete vertical root
fracture by cementation with
adhesive resin intentionally
after endodontic treatment.

69. • Trope et al have described the
treatment of a vertically fractured
upper left second molar.
The two fragments were extracted
separately. The periodontal ligament was
protected from damage extraorally by
soaking it with Hanks balanced salt
solution.

70. The two segments were bonded with the use of
biocompatible glass ionomer bone cement and
replanted in conjunction with an expanded
polytetrafluoroethylene (gore-tex) membrane.
• After 1 year follow-up, the tooth was
functioning normally and was clinically and
radiographically within normal limits

71. CONCUSSION
The tooth is tender to touch or tapping;
it has not been displaced and does not
have increased mobility.
• No radiographic abnormalities.
• Treatment
No treatment is needed.
Monitor pulpal condition for at least one
year.
• Follow-up
4 weeks
6-8 weeks
1 year

72. CONCUSSION

73. SUBLUXATION
• The tooth is tender to touch increased
mobility
• Bleeding from gingival crevice may be
noted.
• Sensibility testing may be negative
initially indicating transient pulpal
damage.
• Monitor pulpal response until a
definitive pulpal diagnosis can be made.
• Radiographic abnormalities are usually
not found.

74. SUBLUXATION
Treatment
• No treatment
• Flexible splint -2 weeks.
Follow-up
• 2 weeks – Splint removal
• 4 weeks
• 6-8 weeks
• 6 months
• 1 year

75. SUBLUXATION

76. INTRUSION
• The tooth is displaced axially into the alveolar
bone.
• It is immobile and percussion may give a high,
metallic (ankylotic) sound.
• Sensibility tests -Negative results.
Radiographic findings
• The periodontal ligament space may be absent.
• The cemento-enamel junction is located more
apically in the intruded tooth than in adjacent
non-injured teeth, at times even apical to the
marginal bone level.

77. INTRUSION
Treatment
Teeth with incomplete root formation:
• Allow eruption without intervention.
• If no movement within few weeks, initiate
orthodontic repositioning.
• If the tooth is intruded more than 7 mm,
reposition surgically or orthodontically.

78. INTRUSION
Teeth with complete root formation:
• Allow eruption - intruded less than 3 mm.
• If no movement after 2-4 weeks, reposition surgically or
orthodontically before ankylosis can develop.
• If the tooth is intruded 3-7 mm, reposition surgically or
orthodontically.
• If the tooth is intruded beyond 7 mm, reposition
surgically.
• Pulp Necrotic : Root canal therapy using a temporary
filling with calcium hydroxide is recommended and
treatment should begin 2-3 weeks after repositioning.
• Repositioned surgically or orthodontically, stabilize with
a flexible splint for 4 weeks.

79. INTRUSION

80. LATERAL LUXATION
• The tooth is displaced, usually in a
palatal/lingual or labial direction.
• Immobile
• percussion -metallic (ankylotic) sound.
• Fracture of the alveolar process .
• Sensibility tests - negative results.
Radiographic findings
• The widened periodontal ligament space is
best seen on eccentric or occlusal exposures.

81. LATERAL LUXATION
Treatment
• Reposition the tooth digitally or with
forceps
• Stabilize -4 weeks using a flexible
splint.
• Monitor the pulpal condition.
• If the pulp becomes necrotic, root
canal treatment is indicated to
prevent root resorption.

82. LATERAL LUXATION

83. EXTRUSION
Treatment
Reposition -
Reinserting into the
tooth socket.
Stabilize - 2 weeks
using a flexible splint.
In mature teeth where
pulp necrosis is
anticipated, root canal
treatment is indicated.
Radiographic: Increased periodontal
ligament space apically.
The tooth appears elongated and is
excessively mobile.

84. EXTRUSION

85. Avulsion
First aid
• Find the tooth and pick it
• Wash it for 10 seconds under
running water and reposition it bite
on a handkerchief to hold it in position.
• Place the tooth in a glass of milk /
tooth can also be transported in the
mouth, keeping it inside the lip or
cheek.

86. STORAGE MEDIA

87. classifying the avulsed tooth
o The PDL cells are most likely
viable
o The PDL cells may be viable
but compromised.
o The PDL cells are non‐viable

88. Treatment guidelines for avulsed permanent
teeth with closed apex
The tooth has been replanted before the
patient’s arrival at the clinic
• Leave the tooth
• Clean the area with water spray, saline or
chlorhexidine.
• Suture gingival lacerations, if present.
• Verify normal position of the replanted tooth •
Apply a flexible splint for up to 2 weeks.
• Administer systemic antibiotics.

89. • Initiate root canal treatment 7–
10 days after replantation and
before splint removal.
• In an open apex: • The goal for
replanting in developing
(immature) teeth in children is to
allow for possible
revascularization of the pulp
space. If that does not occur,
root canal treatment may be
recommended

90. The tooth has been kept in a physiologic storage
medium ,the extraoral dry time has been less
than 60 minutes
Physiologic storage media used.
• Clean with saline and soak the
tooth in saline
• Administer local anesthesia.
• Irrigate the socket with saline.
• Examine the alveolar socket
• Replant the tooth slowly with
slight digital pressure.

91. • Verify normal position of the replanted
tooth both clinically and radiographically.
• Apply a flexible splint for up to 2 weeks,
• Initiate root canal treatment 7–10 days
after replantation and before splint
removal.
In open apex:
• Topical application of antibiotics has
been shown to enhance chances for
revascularization of the pulp.
• Remove the coagulum in the socket and
replant the tooth slowly with slight
digital pressure, allow for
revascularization of the pulp space

92. • Dry time longer than 60 minutes
or other reasons suggesting
non‐viable cells
• Delayed replantation has a poor
long‐term prognosis.
• The goal in delayed replantation is,
to restoring the tooth for aesthetic,
functional and to maintain alveolar
bone contour.
• Outcome is ankylosis and
resorption of the root and the
tooth will be lost eventually.

93. The technique for delayed replantation is:
Remove attached non‐viable soft tissue
• Root canal treatment to the tooth can be carried out
prior to replantation .
• Root canal treatment should be done either on the
tooth prior to replantation,it can be done 7–10 days later
• Administer local anesthesia.
• Irrigate the socket with saline.
• Examine the alveolar socket.
• Replant the tooth.
• Suture gingival lacerations.
• Verify normal position of the replanted tooth clinically
and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint

94. FAVORABLE OUTCOME
• Closed apex. Asymptomatic, normal mobility,
normal percussion sound. No radiographic
evidence of resorption or periradicular osteitis:
the lamina dura should appear normal.
• Open apex. Asymptomatic, normal mobility,
normal percussion sound. Radiographic
evidence of arrested or continued root
formation and eruption. Pulp canal obliteration
is to be expected.

95. UNFAVORABLE OUTCOME
Closed apex. Symptomatic,
Excessive mobility or no mobility (ankylosis)
High‐pitched percussion sound.
Radiographic : Resorption (inflammatory,
infection‐related resorption, or ankylosis‐related
replacement resorption).
Ankylosis occurs in a growing patient, infraposition
of the tooth
Open apex: Absence of continued root formation.
ankylosis occurs in a growing patient, infraposition
of the tooth is highly likely to occur leading
to disturbance of alveolar and facial growth over the
short, medium and long term.

96. Special considerations for trauma to primary
teeth
• Difficult to examine and treat due
to lack of cooperation
• Relationship between the apex of
the root of the injured primary
tooth, and the underlying
permanent tooth germ

97. Immature versus Mature Permanent Teeth
• Effort should be made to preserve pulpal
vitality in the immature permanent tooth to
ensure continuous root development.
• The immature permanent tooth has
considerable capacity for healing after
traumatic pulp exposure, luxation injury and
root fractures.

98. Instructions
• prevention of further injury
• Soft diet for up to 2 weeks.
• Rinsing with an antibacterial such as Chlorhexidine
Gluconate 0.1% alcohol free for 1‐2 weeks.
• Young child, apply Chlorhexidine Gluconate to the
affected area with a cotton swab.
• Brush teeth with a soft toothbrush after each meal
• The use of pacifiers should be restricted.

99. ANTIBIOTICS
• TOPICAL :minocycline or doxycycline,1mg per 20ml
of saline for 5 minutes soak
• SYSTEMIC : Phenoxymethylpenicillin (Pen V,)
Amoxycillin- first week.
Tetracycline- Discolouration-young
permanent tooth
• Experimental studies have however, usually shown
positive effects upon both periodontal and pulpal
healing especially when administered topically.

100. CONCLUSION
• Evidence based clinical approach should be
followed for the successful treatment of root
fractures.
• The clinician should have a thorough
knowledge of aetiological cause of fracture,
classic signs and symptoms of fracture,
availability and applicability of diagnostic
methods, differential diagnosis, and factors
determining the prognosis, so as to arrive at
an appropriate diagnosis and design a suitable
treatment protocol.

101. REFERENCES
• Pathways Of Pulp Cohen Tenth Edition
• Ingle Text Book Of Endodontics 6th Edition
• Andreasen FM, Andreasen JO, Cvek M. Root Fractures. In: Textbook And Color
Atlas
• Of Traumatic Injuries To Teeth
• Firedman S, Moshonov J, Trope M. Resistance To Vertical Fracture Of Roots,
• Previously Fractured And Bonded With Glass Ionomer Cement, Composite Resin
• And Cyanoacrylate Cement. Endod Dent Traumatol 1993 Jun;9:101-5
• Takatsu T, Sano H, Burrow MF. Treatment And Prognosis Of A Vertically
Fractured
• Maxillary Molar With Widely Separated Segments: A Case Report. Quintessence
Int
• 1995;26:479-84.
• Prithviraj, An Overview of Management of Root Fractures kathmandu
• university medical journal Vol. 12 | no. 3 | issue 47 | july- sept 2014
• Malhotra N. A Review of Root Fractures: Diagnosis, Treatment and Prognosis.
• Restorative dentistry nov 2011 615-628
• Rosen H, Partida-Rivera M. Iatrogenic fracture of roots reinforced with a

102. • Prithviraj, An Overview of Management of
Root Fractures kathmandu
• university medical journal Vol. 12 | no. 3 |
issue 47 | july- sept 2014
• Malhotra N. A Review of Root Fractures:
Diagnosis, Treatment and Prognosis.
• Restorative dentistry nov 2011 615-628
• Rosen H, Partida-Rivera M. Iatrogenic
fracture of roots reinforced with a
• cervical collar. Oper Dent 1986; 11: 46–50.
• Kroncke VA. Zur Problematik der
endodontalen Schienunugfrakturierter
• Zahnwurzeln. Dtsch Zahnarztl Z 1969;24:49–
53.

103. THANK YOU