This document discusses the management and treatment of traumatic dental injuries in children and permanent dentition. It covers different classes of injuries including tooth fractures, displacements, and avulsions. The main objectives of treatment are to retain the tooth and maintain its vitality. Depending on factors like the size of exposure, root development, and time since injury, direct pulp capping, pulpotomy, apexification, or pulpectomy may be used. Displaced teeth require repositioning and splinting. Avulsed teeth should be replanted immediately if possible. The document also discusses potential pulp and root reactions to trauma like necrosis, resorption, and discoloration.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
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2. College of Dentistry
Pedodontic III
MANAGEMENT OF TRAUMATIC
INJURIES IN CHILDREN - 3 -
Dr. Hazem El Ajrami
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3. Class III:
The treatment depends on many factors such
as:
1. Vitality of the exposed pulp (Vital or Non
vital). Size of the exposure (Small or Large).
2. Time elapsed since the exposure (Early, within
6 hours or Late).
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4. 3. Degree of root maturation (Open apex or close
apex).
4. Restorability of the fractured crown (Restorable
or not).
5. Physical condition of the patient (Medically
compromised or not).
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5. The main objective of treatment in managing
these injuries is to retain the tooth and
maintain its vitality. This allow for physiologic
closure of the root apex in immature teeth.
The following procedures may be adopted to
accomplish the preceding objective:
Direct Pulp capping.
Calcium hydroxide pulpotomy.
Apexification.
Pulpectomy.
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6. Management of Class III
Small exposure
Early Late
Open Closed Open Closed
Direct pulp
capping
Pulpotomy
(transient
procedure) →
Pulpectomy
Pulpectomy
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7. Management of Class III
Large exposure
Early Late
Open Closed Open Closed
Pulpotomy
(transient
procedure)
→Pulpecto
my
Pulpectomy Apexificatio
n →
Pulpectomy
Pulpectomy
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8. Class IV:
Crown fracture where the fracture line
passes beneath the gingival margin. This may be
a vertical or oblique fracture. Treatment will
usually involve removing the loose fragment
which is often held in a close position to the rest
of the tooth by the periodontal ligament fibers.
Then it can be decided if the remaining part of
the tooth can be extruded orthodontically or
whether a surgical approach will be required to
gain access to the apical part of the fracture line
prior pulp therapy and placement of a
restoration.
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9. Class V:
In the permanent dentition root fractures
mainly affect the maxillary central incisors and
are most common at 11 to 20 years of age.
Below 11 years of age, the root is in its
formative stage and more resilient to the
effects of trauma. Fracture may occur in the
cervical third, middle third or apical third of
root.
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10. A. Apical third root fracture:
No treatment is needed follow up with x-
ray should be continued up to six weeks.
B. Middle third root fracture:
With this type of fracture there will be
displacement of the fractured crown-root
segment, usually palataly or lingualy.
Under local anesthesia, achieve
reduction into position by digital pressure,
and stabilize the tooth or teeth in this position
by splinting (4-6 weeks). After reduction
check the position radiographically.
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11. • Splinting:
The purpose of splinting is to stabilize the
tooth in the arch in order to prevent further
damage to the pulpal and periodontal tissues.
Splints can be fixed or removable.
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12. • Types of fixed splints:
1. Acid-etched resin composite splint.
2. Orthodontic brackets and wire splint.
3. Interdental wiring.
4. Arch wire and resin splint.
5. Full arch, vacuum molded acrylic splint.
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13. 13

14. C. Coronal (Cervical) third root fracture:
 Remove the coronal segment. If the fracture
is 1-2mm infra-bony a possible osteoplasty
to expose the root or orthodontic root
extrusion may be required.
 Root canal treatment with post and crown
restoration can be accomplished. Otherwise
extraction is the treatment of choice.
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15. Treatment of Traumatic Dental Injuries
(Permanent Dentition)
I. Soft tissue injuries.
II. Concussion.
III. Subluxation.
IV. Tooth Fracture.
V. Displacement of permanent anterior teeth.
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16. V. Displacement of permanent anterior teeth:
• Intrusion:
An intruded permanent tooth can be treated
in one of three ways:
1) In case of intruded tooth with incomplete
root formation, the tooth will erupt
spontaneously.
2) Immediate surgical repositioning,
splinting, and endodontic therapy.
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17. 3) Orthodontic extrusion and repositioning.
Complications such as external root
resorption and loss of marginal bony support
do occur in surgically repositioned teeth. A
far better success rate has been achieved with
orthodontic repositioning which occurs
slowly over 3 to 4 weeks. Endodontic
therapy can be performed when there is
adequate crown available.
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18. • Extrusion:
Reposition an extruded tooth by digital
pressure on the incisal edge, returning the
tooth to its original position. Delay in treating
the tooth may result in its being fixed in its
extruded position. After repositioning,
maintenance of position is by splinting. If
vitality of the tooth is lost, begin root treatment
immediately, placing calcium hydroxide in the
canal for 6 months to 1 year followed by a
more permanent filling.
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19. • Avulsion:
In the permanent dentition avulsion of the
maxillary central incisors is most common in
the age of 7 to 10 years.
There are two important factors to be
considered in cases of avulsion:
Time, interval between injury and treatment.
Conditions under which the tooth or teeth have
been stored.
The treatment of choice, for permanent teeth,
is immediate re-plantation within 30-60
minutes of injury.19

20. The tooth must be kept moist to prevent
irreversible damage to the periodontal
membrane.
Storage media may be: Saliva, Saline, Milk.
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21.  In many cases the initial patient/dentist
contact is by phone. It is essential to advise
the parent to follow these procedures:
1) The tooth should be handled by the crown
only.
2) The tooth should be rinsed under running
tap water (soap and alcohol as cleaning
agents are contraindicated).
3) Insert the tooth back into its socket if
possible.
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22. 4) Let the child gently occlude on a gauze or
handkerchief for stability and present to the
dental office as soon as possible.
5) If re-plantation is not possible, the tooth
should be placed in a suitable storage
medium as milk, saliva, contact lenses
solution or unsalted water.
6) If no storage medium is available, the tooth
should be placed in the mouth between cheek
and gum or under the tongue.
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23.  At the dental office
A. Information on current tetanus
immunization should be obtained.
B. Stabilization of the tooth in the socket is
obtained by acid etch composite resin
splint (One week is sufficient to obtain
adequate periodontal support).
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24. C. Calcium hydroxide should be placed in the
tooth after 1 week. This will prevent the
initiation of inflammatory root resorption.
D. Root canal therapy.
E. In immature teeth with open apices, the tooth
should be splinted for approximately 2
weeks. This will give the neurovascular
tissues an opportunity to re-anastomose.
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25. Treatment of Traumatic Dental Injuries
(Primary Dentition)
Primary teeth are more likely to be displaced
than fractured because of:
The thinner and more elastic alveolar bone.
Physiological resorption, which reduces the
root length.
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26. The effect of injury in the deciduous dentition
falls into two categories:
Immediate effect on the primary teeth:
Displacement: Intrusion, extrusion or
avulsion.
Fracture: Crown-root fracture (very rare).
Indirect effect on the unerupted permanent
teeth:
Hypoplasia: Turner's hypoplasia.
Hypomineralization.
Dilaceration.
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27. Treatment of fractured primary teeth:
Enamel fractures: smooth sharp edges,
Enamel and dentin fractures: acid etch
composite.
Fractures involving pulp: pulp therapy or
extraction.
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28. Traumatized anterior teeth that have become
non-vital: no treatment is required unless there
are signs of a pathological condition (i.e. pain,
abscess and fistula). Treatment can be either
pulpectomy then filing with resorbable paste or
extraction.
Fractures of root of primary tooth: extraction.
N.B.
Children below 4 years of age are usually
treated under general anesthesia.
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29. Treatment of displaced primary teeth:
Intrusion:
In almost all instances of intrusion,
reassurance and observation is required. Most
intruded primary teeth will re-erupt over a
period of few months. Only if there is clear
evidence that the intruded tooth is in contact
with the underlying successor consideration
should be taken for removing the intruded
tooth. Infection is unusual complication, in
which the intruded tooth should be extracted.
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30. • Extrusion:
The extruded primary tooth is usually
extracted if severely loose.
Repositioning such tooth may result in
damage to the underlying permanent
successor. In addition, providing adequate
splint to support the repositioned tooth may be
difficult in a very young child.
• Avulsion:
Avulsed primary teeth are not replanted.
The tooth should be discarded.
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31. Reaction of the tooth to trauma:
Pulp Hyperemia:
A trauma of even a so-called minor
nature is immediately followed by a condition
of pulpal hyperemia. The hyperemic condition
with a single outlet of veins leads to an
increased danger of strangulation of the
vessels.
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32.  Congestion of the blood within the pulp
chamber a short time after the injury can often
be detected in the clinical examination (the
coronal portion of the tooth will often appear
reddish as compared with the adjacent teeth).
The color change may be evident for several
weeks after the accident and is often indicative
of a poor prognosis.
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33. Internal Hemorrhage:
The dentist will occasionally observe
temporary discoloration of a tooth after injury.
Hyperemia and increased pressure may cause
the rupture of capillaries and the escape of red
blood cells with subsequent breakdown and
pigment formation. The extravasated blood
may be reabsorbed before gaining access to the
dentinal tubules, color change is noticeable
and it is temporary in nature. In more severe
cases there is pigment formation in the
dentinal tubules.
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34. • The change in color is evident within 2 to 3
weeks after injury, and the reaction is
reversible to a degree that the crown of the
injured tooth retains some of the discoloration
for an indefinite period of time.
• Discoloration that becomes evident for the first
time months or years after an accident,
however, is evidence of a necrotic pulp.
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35. Calcific Metamorphosis (Dystrophic
Calcification):
Calcific metamorphosis is a degenerative
pathologic process that ultimately leads to
obliteration of the pulp chamber and root canal.
The reaction is considered to be a physiologic
repair response of the pulp and once initiated, it
may continue until the pulp is completely
replaced with a dentine like calcified tissue.
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36. • Such teeth, their clinical crowns may have a
yellowish, opaque color and will not show any
response to various pulp tests. Primary teeth will
undergo normal physiologic resorption, and
permanent teeth will often be retained
indefinitely.
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37. Inflammatory resorption:
Inflammatory resorption can occur
externally and/or internally (pink spot). It
commonly arises following luxation injuries
when the periodontal ligament is inflamed and
the pulp is necrotic. Odontoclastic activity can
occur so rapidly that the teeth are destroyed in
a matter of weeks.
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38. • Immediate treatment of inflammatory resorption
is essential. As soon as this process is detected
radiographically, the pulp tissue in the tooth is
thoroughly extirpated. Copious irrigation with
sodium hypochlorite assists in the dissolution of
organic debris in the canal. In permanent teeth,
calcium hydroxide is placed in the canal; here
the objective is not to induce apical closure but
to create an environment unfavorable for the
resorption process.
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39. • Depending upon the severity of the
inflammatory resorption, calcium hydroxide
may need to be retained in the tooth for 6-24
months. Repeated applications may be
necessary if the resorption progresses. When
radiographs confirm that the process is not
continuing, gutta percha is placed as the final
filling material.
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40. Replacement Resorption (Ankylosis):
Replacement resorption occurs most
commonly following severe luxation injuries
like avulsion or intrusion, in which periodontal
ligament cells are destroyed. Alveolar bone
directly contacts cementum of the involved
tooth and becomes fused with it.
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41. • Then as the bone undergoes its normal,
physiologic, osteoclastic, and osteoblastic
activity, the root is resorbed or replaced with
bone, which may cause a mechanical lock or
fusion between alveolar bone and root
surfaces. Clinically ankylosed tooth appear at a
lower incisal plane than its adjacent teeth, as
they continue to erupt while the ankylosed
tooth remain fixed to surrounding structures.
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42. • This type of resorption cannot be treated once
the tooth is firmly immobilized by the process.
In young children with rapid bone turnover,
teeth are completely resorbed in 3-4 years. In
adults, the process may take up to 10 years.
Replacement resorption can be prevented only
by prompt and appropriate treatment of
luxation injuries.
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43. Pulp Necrosis:
• Little relationship exists between the type of
injury to the tooth and the reaction of the pulp
and supporting tissues. A severe blow to a
tooth causing displacement often results in
pulp necrosis; the blow may cause a severance
of the apical vessels, in which case the pulp
undergoes autolysis and necrosis.
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44. • In a less severe type of injury the hyperemia
and slowing of blood flow through the pulpal
tissue may cause eventual necrosis of the pulp.
In some cases the necrosis may not occur until
several months after the injury.
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45. Thank You
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