This document provides information on the management and treatment of traumatic dental injuries in children. It discusses the diagnosis process, which involves taking a medical and dental history, performing a clinical examination, conducting sensitivity tests, and getting radiographs. The clinical exam evaluates soft tissues, hard tissues, tooth displacement, mobility, fractures, and color changes. Treatment depends on the specific injury and may include protecting soft tissues, monitoring concussed teeth, splinting subluxated teeth, restoring tooth fractures with calcium hydroxide, crowns, or composite resins, and reattaching tooth fragments when possible. The goal is to restore function and aesthetics while protecting the pulp.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
3

2. College of Dentistry
Pedodontic III
MANAGEMENT OF TRAUMATIC
INJURIES IN CHILDREN - 2 -
Dr. Hazem El Ajrami

3. Trauma to the supporting bone
• Involves alveolar bone fractures.
Diagnosis:
I. History.
II. Clinical Examination.
III. Sensitivity or Vitality test.
IV. Radiographic Examination.

4. I. History:
1. Personal History:
It should include the patient's
name, age, sex, address, source of referral
if any, and reason for attendance.

5. 2. Medical History:
Routine data on the patient's general health
should be obtained particularly those relevant
to dental injuries.
 Cardiac disease which would necessitate
prophylaxis against subacute bacterial
endocarditis.
 Bleeding disorders.
 Allergies to medication.

6. Seizure disorders.
Current medications.
The child's current immunization status which
is particularly important if the child suffers
from a dirty wound.

7. • Children acquire active immunity through a
series of injections of heat-denatured tetanus
toxoid in their first 18 months of life. They
should then receive a booster dose at 4-6 years
of age. Boosters are recommended every 10
years or in cases of an accident in a dirty
environment.

8. 3. Dental History:
 Previous dental history:
Information can be obtained on the
frequency of dental visits, type of treatment
performed such as extraction or
conservative procedures. The type of
anesthesia used for the procedures and the
cooperation of the child can be determined.

9. History of the injury:
Histories should be short and to the point.
Only three questions need to be asked to obtain
maximum information: When, Where, and
How?

10. When did the accident occur?
In cases of oral trauma with damage to the
teeth, time elapsed since trauma is very
important. If there is avulsion of the tooth the
need to reposition, or treat a fractured crown
with pulp involvement, the shorter the time
between accident and treatment the better the
prognosis.

11. Where did the accident occur?
If the accident occurred in a particularly dirty
environment, prophylactic tetanus treatment is
indicated.
How did the injury happen?
A direct blow under the chin may cause a
fracture in the condyle and fracture of crowns
of molars and premolars.
For young children, when there is a marked
discrepancy in clinical findings and the history
given, the child abuse should be suspected.

12. II. Clinical Examination:
1. Extra-oral Examination:
The extra-oral examination begins
immediately when the patient enters the
office.
 Lacerations, abrasions, and contusions on
the face, head, neck and exposed limbs can
be noted visually.
 Any asymmetries including any deviation
in mandibular path during mouth opening.
Extra-oral wounds should be inspected for
foreign bodies.

13. 2. Intraoral Examination:
It includes: (A) the soft tissues, (B) the
hard tissues.
A. Soft-tissue Examination:
Note any laceration of the tongue, gingiva,
labial and buccal mucosa or penetrating
wounds. The presence of embedded tooth
fragments should always be suspected in this
case. A hematoma in the floor of the mouth
indicates mandibular fracture.

14. B. Hard-tissue Examination:
1) Displacement:
Teeth may suffer labial, lingual,
palatal, or lateral displacement as well as
intrusion, extrusion or avulsion. Visually
determine and note any displacement.
2) Mobility:
If two or more teeth are seen to
move, an alveolar fracture should be
suspected.

15. 3) Tooth fracture:
A modification of Ellis and Davey
classification of crown fracture is useful in
recording the extent of damage involving
young permanent incisors.
 Class I: Traumatized teeth with fracture
involving enamel only or enamel and little
dentine.
 Class II: Traumatized teeth with fracture of
enamel and considerable amount of dentine.

16. Class III: Traumatized teeth with fracture of
enamel and dentine with pulp exposure.
Class IV: Traumatized teeth where amputation
of the crown en-mass occurs.
Class V: Traumatized teeth where there is root
fracture accompanied with or without crown
fracture.

18. 4) Color change:
Non-vital teeth often appear discolored.
This is due to an interruption in the blood
supply of the tooth. The blood already
present in the pulp chamber undergoes a
normal breakdown process, but the products
are unable to dissipate. This results in tooth
discoloration varying from gray-brown to
black.

19. III. Sensitivity or Vitality test:
In order to obtain a full evaluation of
injury, vitality testing of the teeth must be
performed. Vitality testing just following
traumatic injury is of little value because
false responses often occur. Further testing
should be performed at subsequent visits.

20. • There are many types of vitality tests:
Thermal pulp testing.
Electrical pulp testing.
Laser Doppler flow-meter.
Test cavity.

21. IV. Radiographic Examination:
All traumatized teeth should be
radiographed to investigate the following:
1. The stage of root formation.
2. The presence of any root fracture.
3. The presence of periapical radiolucencies.

22. 4. Injuries to the supporting periodontal
membrane, such as the degree of intrusion or
extrusion of the tooth.
5. The size of the pulp chamber.
6. Presence of tooth fragments or foreign bodies
in the soft tissue.

23. • If teeth are missing and no accurate history of
their whereabouts, it is advisable to refer the
patient to a hospital for chest radiographs.
• If a jaw fracture is suspected, extra-oral
radiographs are indicated (panoramic and
lateral oblique views).

24. Treatment of Traumatic Dental Injuries
(Permanent Dentition)
I. Soft tissue injuries.
II. Concussion.
III. Subluxation.
IV. Tooth Fracture.
V. Displacement of permanent anterior teeth.

25. I. Soft tissue injuries:
a) Determination of child immunization
status:
If the child had received a primary
immunization the antibody forming
mechanism may be activated with booster
injection of toxoid. Un-immunized child
can be protected through passive
immunization or serotherapy with tetanus
antitoxin (tetanus immunoglobulin).

26. b) Debridement, suturing and/or hemorrhage
control of open soft tissue wounds, and when
indicated refer the child to family physician.

27. II. Concussion:
A mild blow to the tooth resulting in
mild sensitivity requires little or no
treatment. Examination with regular vitality
testing at subsequent visits is required.

28. III. Subluxation:
With mobility of the tooth but no
displacement, there is often hemorrhage
around the gingival margin of the tooth, and
the tooth may be sensitive to percussion.
The treatment is similar to that of the
concussed tooth. If mobility is extensive,
splint the tooth using the acid-etch splinting
technique. Periodic reviews every 3 to 4
weeks are essential to monitor for abscess
formation and loss of vitality.

29. IV. Tooth Fracture:
Class I:
 A crack or craze of the enamel without loss
of tooth structure:
Horizontal or vertical crack or craze
lines in enamel do not require immediate
treatment. Injury to the blood supply and
supporting structures may have occurred;
therefore vitality testing should be
performed at regular intervals to monitor
any changes.

30. Fracture of enamel only:
Horizontal, vertical, and oblique fractures of
the crown involving enamel only or enamel
and a very small amount of dentine can be
treated either by leaving them alone or
smoothing down any sharp edges to prevent
irritation of the lips or tongue.
The patient should be re-examined at 2
weeks and again at 1 month and periodic
vitality testing is important.

31. Class II:
Immediate treatment of horizontal, vertical,
or oblique fracture of the crown is required
to:
1) Protect the pulp from chemical or thermal
insult and bacterial contamination.
2) Restore esthetics and function.
3) Maintain the integrity of the arch by
restoring normal contact with adjacent
teeth.

32. • Emergency treatment: .
Cover the exposed dentine by a layer of hard
setting calcium hydroxide. This is to
encourage reparative dentine formation and
reduce the possibility of further trauma to the
pulp. Protection for this dressing can be
achieved temporarily by use of an acrylic or
polycarbonate crowns, stainless steel crown,
orthodontic band, fragment restoration
(reattachment of tooth fragment) or more
permanently by acid-etch composite resin.

33. • Fragment Restoration (Reattachment of
Tooth Fragment)
Occasionally the dentist may have the
opportunity to reattach the fragment of a
fractured tooth using resin and bonding
techniques. This procedure is atraumatic and
seems to be the ideal method of restoring the
fractured crown.

34. • The tooth requires no mechanical preparation
because retention is provided by enamel
etching and bonding techniques. If little or no
dentine is exposed, the fragment and the
fractured tooth enamel are etched and
reattached with a resin or glass ionomer
bonding material. If only a small amount of
dentin is exposed (well away from the pulp), it
should be protected with calcium hydroxide
before being etched, but the dressing is
removed before the fragment is reattached.

35. • If considerable dentine is exposed or a direct
pulp cap is indicated, a thin protective dressing
of calcium hydroxide should remain over the
exposed dentine and pulp of the tooth. In this
case the inside portion of the fragment must be
modified with a bur to accommodate the
thickness of the calcium hydroxide dressing
when the fragment is repositioned on the tooth.

36. • The removal of a small amount of the
remaining dentine on the inner surface of the
fragment must be done carefully so that the
outer enamel margins are undisturbed (the
outer enamel is important to provide guidance
for the exact repositioning of the fragment on
the fractured tooth).

37. Acid-etch Composite Resin Restoration
The excellent marginal seal and retention
derived from applying esthetic restorative
materials to etched enamel surfaces have
revolutionized the approach to restoring
fractured anterior teeth. These bonding
techniques are highly successful and versatile
in many situations involving anterior trauma.

38. • It may not be advisable to restore an extensive
crown fracture with a finished esthetic resin
restoration on the day of the injury, since it is
usually best not to manipulate the tooth more
than is absolutely necessary to make a
diagnosis and provide emergency treatment.

39. • After the exposed dentine is protected with
calcium hydroxide and the enamel adjacent to
the fracture is etched, the restorative resin
material is applied as a protective covering at
the fracture site. However, the restoration
should cover the fractured surfaces and
maintain any natural proximal contacts the
patient may have had before the injury. After
an adequate recovery period (at least 4 weeks),
an esthetic resin restoration may be completed,
often without removing all the temporary resin
material.

40. • However, the surfaces of the temporary
restoration should be freshened with a bur
before the new material is applied. The
margins of the new restoration should extend
beyond the margins of the temporary
restoration and onto newly etched enamel.

41. Thank You