THIS IS A POWERPOINT PRESENTATION ON TRAUMATIC INJURIES TO THE TEETH AND SUPPORTING STRUCTURES

1. TRAUMATIC INJURIES TO THE
TEETH AND SUPPORTING
STRUCTURES
Dr Arun Sharma
Professor &Head
Dept of Pedodontics & Preventive Dentistry
Rama Dental College Hospital
Kanpur

2. INTRODUCTION
• Considered as an emergency situation in dentistry
• Effects the behavior and psychological well being
• Frequently occur in both primary and permanent
dentition
• Management merits special attention

3. TERMINOLOGIES
• TRAUMA: refers to injury; damage; impairment;
external violence producing injury or degeneration.
• FRACTURE: defined as sudden violent break of
continuity of bone.
• CONTUSION: injury produced by blunt trauma that
results in edema and hematoma formation in the
subcutaneous tissue.

4. • ABRASION: injury that results from friction along a
surface, removing or peeling off of superficial layer of
the skin, that results in raw, exposed or bleeding
surface.
• LACERATION: injury that causes a discontinuity in
the skin or mucosal surface.
• AVULSION: loss of tissue due to trauma.

5. ETIOLOGY
1) Iatrogenic injuries in newborns
2) Falls in infancy
3) Child physical abuse
4) Falls and collisions
5) Bicycle injuries
6) Sports
7) Horseback riding
8) Automobile injuries
9) Assaults
10) Torture
11) Mental retardation
12) Epilepsy
13) Drug related injuries
14) Dentinogenesis imperfecta

6. SEVERITY OF INJURIES TO THE TEETH
DEPENDS ON:
• Energy of impact
• Resiliency of the impacting object
• Shape of the impacting object
• Angle of direction of the impacting force

7. • DIRECT TRAUMA: occurs when the tooth itself is
hit
• INDIRECT TRAUMA: inflicted when lower dental
arch is forcefully closed against the upper
MECHANISM OF DENTAL TRAUMA
(ANDREASEN AND BENNETT)

8. INDIRECT TRAUMA

9. PREVALENCE
• 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

10. • Teeth involved- 37% upper central incisor
18% lower central incisor
6% lower lateral incisor
3% upper lateral incisor
• Facial profile: more common in:
Angle’s class II type I malocclusion
Angle’s class I type II malocclusion

11. Epidemiology
 Anterior teeth are frequently involved

12. CLASSIFICATIONS

13. ELLIS AND DAVEY CLASSIFICATION(1960)
CLASS I Simple fracture of crown, involving little or no dentin
CLASS II Extensive fracture of the crown involving considerable dentin,
but not the dental pulp
CLASS III Extensive fracture of the crown involving considerable dentin,
and exposing the pulp
CLASS IV Traumatized tooth which becomes non vital with or without
loss of crown structure
CLASS V Teeth lost as a result of trauma
CLASS VI Fracture of the root with or without loss of crown structure
CLASS VII Displacement of tooth without fracture of crown/root
CLASS VIII Fracture of the crown en mass and its replacement
CLASS IX Traumatic injuries of primary teeth

14. CLASSIFICATION BY ANDREASEN (1981)
N 873.60 Crown infraction: incomplete # (crack) of enamel
without loss of the tooth structure
Uncomplicated crown # : contained to enamel
N 873.61 Involving enamel and dentin, but not involving pulp
N 873.62 Complicated crown #: involving enamel, dentin and
exposing pulp
N 873.63 Root # : involving dentin, cementum and pulp
N 873.64 Uncomplicated crown root # : involving enamel,
dentin, and cementum but not involving pulp
Complicated crown root # : involving enamel, dentin,
and cementum and exposing pulp
A. INJURIES TO HARD DENTAL TISSUES AND PULP

15. B) INJURIES TO THE PERIODONTAL TISSUES
N 873.66 Concussion: injury to tooth supporting structure with
out abnormal loosening or displacement of tooth, but
marked reaction to percussion
Subluxation: with abnormal loosening but without
displacement o the tooth
Extrusive luxation(peripheral dislocation, partial
avulsion): partial displacement of tooth out of its
socket
Lateral luxation: displacement other than axial
direction
N 873.67 Intrusive luxation(central dislocation): displacement
into the alveolar bone. This is accompanied by
comminution or fracture of alveolar bone
N 873.68 Exarticulation (complete avulsion): complete
displacement of tooth out of its socket

16. C) INJURIES TO THE SUPPORTING BONE
N 802.20(mandible)
N 802.40(maxilla)
 Comminution of alveolar socket:
Crushing and compression of the
alveolar socket.
 # of the alveolar socket wall: a #
contained to the facial or lingual
socket wall.
 # of the alveolar process.
N802.21 (mandible)
N802.42 (maxilla)
# involves the base of mandible and
maxilla, the # may or may not involve
the alveolar process.

17. D) INJURIES TO GINGIVA OR ORAL MUCOSA
N873.69 Laceration of gingiva or oral mucosa
N902.x0 Contusion of gingiva or oral mucosa
N910.00 Abrasion of gingiva or oral mucosa

18. HISTORY:
1.Patient’s name, age, sex, address, and telephone
number.
2.When did the injury occur?
3.Where did the injury occur?
4.How did the injury occur?
5.Treatment elsewhere?
6.History of previous dental injuries?
7.General health.
EXAMINATION AND DIAGNOSIS

19. The subjective complaints can provide the examiner with
a clue to the injury. The following questions should be
asked:
8. Did the trauma cause amnesia, unconsciousness,
drowsiness, vomiting, or headache?
9. Is there spontaneous pain from the teeth?
10. Do the teeth react to the thermal changes, sweet or
sour foods?
11. Are the teeth tender to touch, or during eating?
12. Is there any disturbance in the bite?

20. CLINICAL EVALUATION OF SOFT TISSUE INJURIES
• Careful atraumatic exploration
• Use of local anesthesia, to evaluate injuries without
traumatizing the child any further
• Facial laceration may appear superficial may extend to
the bone

21. • Dirt/foreign particles should be removed, which other
wise may lead to infection or tattooing
• Involvement of facial nerve and parotid duct
• Avulsive injury may require skin grafts, local and or
regional grafts

22. CLINICAL EVALUATION OF FRACTURE OF JAW
• History: indicates mechanism and direction and vector
of force applied
• Bone injury: suggested by echymosis, edema, or
superficial contusion or abrasion
• Fractured zygoma: subconjunctival hemorrhage with
periorbital ecchymosis
• Fractured mandible: sublingual hematoma

23. Occlusion: helps in diagnosis as well as reduction of
fracture
Trismus: may indicate depressed zygomatic arch
fracture
Mobility of middle third of face: Lefort I,II&III fracture
Epistaxis: nasal or septal fracture, mid facial or
zygomatic complex fracture
Bimanual palpation of supraorbital , lateral, and inferior
orbital margins may reveal asymmetry indicating a
fracture

24. CLINICAL EVALUATION OF INJURY TO THE TEETH
- Checking for infractions
- Mobility checking
- Percussion testing
- Pulpal sensibility testing
- Radiographic examination
- Photographic registration

25. EMERGENCY CARE
• A-airway
• B-breathing
• C-circulation
• D-definitive drug therapy
• Control of bleeding: - by direct pressure
- suction
- clamping of the vessel
- ligation of vessel

26. • Tetanus prevention:
- thorough cleaning of wound
- removal of foreign body
- excision of necrotic tissue
- tetanus toxoid or antitoxin
• Anesthesia:
- local anesthesia to treat simple lacerations
- nerve block should be used to avoid distortion of
the wound

27. CLINICAL MANAGEMENT OF CROWN
FRACTURES

28. INFRACTIONS
• Common in traumatic injuries of permanent dentition
• Lines exhibit a coronal pattern depends upon the
direction of force and on the impact site location
• Visualized by transillumination
• Injury usually limited to enamel or stops at DEJ

29. TREATMENT: typically do not require definitive
treatment
- vitality test should be done
- endodontic therapy: when patient develops
symptoms of necrotic pulp (spontaneous
lancinating pain) or radiographic signs of
periapical pathosis

30. ENAMEL FRACTURES
CLINICAL RECOGNITION:
• Involves the loss of portion of coronal tooth enamel
• Usually present no threat to pulp instead it is annoying
to tongue, lip,or buccal mucosa
• Can become an esthetic concern of the patient

31. CLINICAL MANAGEMENT:
• Two methods depending on esthetic concern and extent
of tooth loss:
1) Recontouring of injured tooth, the adjacent teeth,
and/or the opposite teeth
2) Restoration or missing tooth structure with
composite
• Treatment should be performed immediately to prevent
potential drifting, tilting, or supraeruption of adjacent
and/or opposite teeth

32. ENAMEL AND DENTIN FRACTURES
• Uncomplicated crown fractures: expose large number
of open dentinal tubules to oral cavity, provide direct
communication channel to pulp

33. FRACTURE INVOLVING ENAMELAND DENTIN

34. RECOMMENDATIONS FOR RESTORATION:
- Hydrophilic restorative material should be selected
- Glass inomer liner
- GIC liner etched with 37% phosphoric acid
and composite restoration

35. CROWN FRACTURES WITH
PULP EXPOSURE (COMPLICATED)
CLINICAL RECOGNITION:
- usually presents clinically with a small amount of
bleeding from the exposed vital pulp
- sensitivity to thermal changes or mastication
- may be asymptomatic: depends upon patients pain
threshold, amount of pulpal tissue exposed, and
maturity of the tooth
- untreated cases: initial pulpal inflammation or
proliferation followed by pulpal necrosis

36. CLINICAL MANAGEMENT:
• May require: - Pulp capping
- Partial Pulpotomy
- Endodontic therapy
• Primary aim is to preserve vitality: pulp capping and
partial pulpotomy is recommended.
• Periodic recall evaluation is necessary which includes
clinical examination, vitality testing, periapical
radiographs.
• When pulp shows radiographic evidence of pathosis
or becomes symptomatic endodontic therapy is
necessary.

37. THE CROWN ROOT FRACTURE
 5% of permanent & 2% of
primary teeth
 Usually impact forces are
directed palatally
 Oblique, extending from labial
to lingual
 Crest of alveolar bone acts as
fulcrum
 # line seldom goes beyond
bone level

38. RECOMMENDED TREATMENT PROCEDURES
 Removal of crown fragment & restoration
 Gingivectomy &/or osteotomy & restoration
 Orthodontic extrusion
 Surgical extrusion
 Vital root submergence
 Intentional replantation with 1800 rotation
 Extraction when more than 1/3rd of root #

39. PROGNOSIS:
- Essential recall evaluation is necessary
- Assessed by radiographs obtained at time to time
- Success is judged by: lack of symptoms,
maintenance of pulp vitality, stable periodontal
attachment apparatus and/or pulp canal space on
radiograph
- Failure: clinical symptoms or degenerative changes
in IOPA, necessitate endodontic treatment or
extraction

40. ROOT FRACTURE

41. CLINICAL FINDINGS:
- Tooth will be slightly extruded with lingually displaced
crown
- Coronal segment may be laterally displaced
- 99% of cases the apical segment remains vital
- Coronal segment may or may not be vital and may or
may not be mobile depending on;
a. state of tooth at the time of fracture
b. extent of fracture
c. location of fracture

42. • Radiograph recommended:
- a steep occlusal exposure: ideal for fractures in
apical third
- two conventional periapical bisecting angle
exposures; better for fractures located coronally
• Direction of fracture line is oblique in the apical and
middle third and changes to more horizontal in cervical
one third

43. CLINICAL MANAGEMENT OF TRANSVERSE
ROOT FRACTURE
• Occurs in maxillary teeth commonly
• Involves dentin, cementum, pulp and periodontal
ligament
• Account for approx 6% of all trauma
• Principally occurs in adult patients where the root is
solidly supported in bone and periodontal membrane,
in younger patient teeth are more likely to be avulsed

44. NATURE OF FRACTURE HEALING
Andreasen and Hjorting-Hansen classified healing of
transverse root fractures into four categories:
1) Coronal and apical segment may have union by
hard tissue
2) Union by fibrous tissue
3) Union by bony ingrowth across the fracture line
4) Ingrowth of chronic granulation tissue

45. Healing by deposition
of cementum
Connective tissue
healing

46. Granulation tissue healing

47. CLINICAL MANAGEMENT
Factors effecting are;
1. The position of the tooth after it has been
fractured.
2. The mobility of the coronal segment.
3. The status of the pulp.
4. The position of the # ed line.
- Apical
- Middle
- Coronal

48. LUXATION INJURIES
CLASSIFICATION: ( Andreasen and Andreasen)
- Concussion
- Subluxation or loosening
- Extrusive luxation ( peripheral
displacement, partial avulsion)
- Lateral luxation
- Intrusive luxation
These injuries can range from a mild blow to a tooth to
a more severe forms that either force a tooth into, or
partially dislocate it from the alveolar socket.

49. • Least severe - involves primarily
the supporting structures
• No loosening or displacement
of the tooth
-splinting not required
• Manifestations:
-Sensitive to mastication
-Tenderness on percussion
CONCUSSION

50. MANAGEMENT
PULP TESTING: Electric pulp testing not diagnostic.
Pulp may not respond initially to vitality tests even
though the pulp may remain vital
Treatment:
• Relieving from occlusion:
- reducing the contact on the traumatized tooth
or
- reducing the contact on the opposing tooth or
teeth
Follow up care:
recall 1-2 weeks after trauma and at 6 months
interval for minimum of 1 year.

51. SUBLUXATION
• Bleeding is often seen due to damage to supporting
structures and periodontal ligament
• Manifestations:
- Tooth is slightly mobile
- Sensitive to mastication and/or to percussion

52. MANAGEMENT
VITALITY TEST: Electrical/thermal tests- not
diagnostic immediately after trauma.
TREATMENT:
If several teeth are traumatized or subluxated,
- splinting placed to stabilize
- recommended period of splinting: 7-10 days
FOLLOW-UP CARE:
- Greater potential for pulpal necrosis (6-47%)
- Endodontic treatment initiated in case of
symptoms of pulpal necrosis

53. EXTRUSIVE LUXATION

54. MANAGEMENT:
- Reposition the luxated tooth into its alveolar
socket under local anesthesia.
- if clot has formed apical to the displaced
tooth, tooth may be more difficult to reposition
and more force and pressure may be required.
- Require splinting to stabilize.
DURATION OF SPLINTING:
2-3 weeks with a flexible splint ( Andreasen and
Andreasen)

58. LATERAL LUXATION

59. LATERAL LUXATION
• More severe than extrusive luxation- because
tooth displaced laterally may also be
associated with comminution or fracture of
alveolar socket.
• Anesthesia is recommended
• Requires more forceful degree of reduction:
manipulation with thumb and index finger can
often reduce the injured tooth

60. PROCEDURE OF REDUCTION:
1. Force the displaced apex out of its locked
position with in labial bone
2. Place axial pressure in an apical direction
3. Manipulate the tooth into its natural position
SPLINTING:
Recommended duration: minimum of 14 days and
remove it when no abnormal mobility remains

62. INTRUSIVE LUXATION

63. INTRUSIVE LUXATION
• Most severe luxation, so also requires complex
treatment
• Results in severe damage to PDL, resulting in
greater incidence of external root resorption
• Patient presents with:
- completely intruded and submerged
- partially intruded into the socket

64. TREATMENT:
- spontaneous re-eruption
- orthodontically extruding the intruded tooth
over 2-4 weeks
- surgical repositioning
PROGNOSIS:
- incidence of both external root resorption and
marginal bone loss is greater in intruded teeth that are
surgically repositioned
- pulpal necrosis occurs in almost all intrusive luxations,
therefore root canal therapy should be anticipated.

65. SPONTANEOUS
RE-ERUPTION

66. ORTHODONTIC EXTRUSION

67. ORTHODONTIC EXTRUSION

68. TOOTH AVULSION

69. TOOTH AVULSION
• Complex injury affecting multiple tissue compartments
• 1-16% of all traumatic injuries to permanent dentition
• Most commonly affected: Maxillary Incisors
• Age: 8-12yrs, as loosely structured PDL offer least
resistance to extrusive forces

70. Treatment objectives:
 To minimize two main complications viz;
- attachment damage
- pulpal infection

71. Management outside the dental clinic
 Every effort should be made to replant the tooth
within 15-20mins
 Keep in suitable storage media

72. STORAGE MEDIA
Suggested storage media in order of preference:
1) Milk ( cool milk 40C is preferable to room temp. milk
230C) – upto 3hrs maintains vitality
2) Saliva, either in the vestibule of mouth / in container
into which pt. spits( upto 2hours)
3) Physiologic saline
4) Water (hypotonic environment causes rapid cell lysis
& increased inflammation on replantation) least
preferred

73. COMMERCIALLY AVAILABLE MEDIA
1) Cell Culture Media
2) Hank’s Balanced Salt Solution (HBSS)
3) Viaspan
4) Dentosafe etc.
•Presently considered to be impractical as they are not
generally available at accident sites

74. MANAGEMENT
• Depends on;
- extra oral time
- type of storage
• In emergency visit emphasis is placed on
preservation & healing of attachment apparatus
•In second visit emphasis is placed on prevention /
elimination of pulpal infection

75. EMERGENCY TREATMENT AT THE ACCIDENT SITE
•Replant if possible / place in an appropriate storage
medium
• Most important factor is the speed with which the tooth
is replanted
• Usually requires emergency personnel at the injury site
with some knowledge of protocol
• Information can also be given if consulted on phone

76. MANAGENMENT IN THE DENTAL OFFICE
Emergency visit:
• Clinical examination, diagnosis & treatment
planning
• Medical & accident history to be taken
• Inj:Tetanus toxoid
• Prepare socket / root, replant
• Functional splint
• Local & systemic antibiotics

79. PREPARATION OF THE ROOT
• Surface should be rinsed with saline if visibly
contaminated
• Better to replant with minor debris than risk destroying
PDL cells
• Examine alveolar socket

80. Extra Oral Dry Time < 60Min in Closed Apex
or 15-120Min in Wet Non-physiologic Media
• Revascularization is not possible, but chance for
PDL healing exists
• PDL healing would be expected if dry time is less
than 15-20min
• Emdogain found to be extremely valuable in the
20-60min dry period

81. Extra Oral Dry Time < 60 Min in Open Apex
/15min-6hrs in Physiologic Media (HBSS/Milk)
/15-120Min in wet Non Physiologic media (Water/Saliva)
 Soak in 1% Doxycycline for 5 min, gently rinse off
debris & replant
- reduces the chances of micro-abscesses in pulp &
significantly enhances vascularization
1% Doxycycline Soln.can be prepared by dissolving
50mg Doxycycline in 1000ml saline

82. Extra Oral Dry Time > 60 Min in Closed Apex
• Remove the PDL by placing in citric acid for 3-
5min & gently scrape using scaler
• Soak in fluoride (APF / NaF) for 20min.
• Cover the root with Emdogain & replant
• Aledronate was found to have similar resorption
slowing effects as fluoride
• Endodontics may be performed extraorally but
no advantage exists in emergency visit

83. Extra Oral Dry Time > 60 Min in Open Apex
• International Association of Dental Trauma
recommendation: Should not be replanted
• If replanted- treat as with closed apex
• Endodontic treatment may be performed
extraorally as apical seal easier to achieve

84. SPLINTING:
• Semi rigid fixation for 7-10 days
• In case of avulsion + alveolar fracture
- splinting for 4-8 weeks
• Splint removed after initiation of root canal
treatment
- e.g. Flexible wire, Monofilament, TTS etc.

85. SECOND VISIT
After 7-10 days,
- Initiate root canal treatment
- Remove the splint
- If signs of resorption- long term CaOH treatment
- CaOH changed every 3 months for 6-24 months
- Canals obturated when radiographically intact lamina
dura is seen
-In case of open apex- check for revascularization
- if infected: perform apexification

86. FOLLOW-UP CARE:
- Recall intervals at 3 months, 6 months and yearly
for at least 5 years
- If osseous replacement is identified then timely
revision of long term treatment plan
- If inflammatory root resorption is seen a new
attempt at disinfection of root canal is made
- The adjacent teeth should also be tested

87. COMPLICATIONS:
1. Surface resorption
2. Replacement resorption
3. Inflammatory resorption

88. PATIENT INSTRUCTIONS
- Soft diet for 2 weeks
- Brush teeth with a soft toothbrush after each meal
- Chlorhexidine mouthrinse (0.1%) twice a day for 1 week
- Regular follow up

89. Summary
 Treatment outside the dental office:
-replant immediately after gentle washing
-if not possible, store the tooth in media
 Treatment in the office
Emergency visit
- place tooth in HBSS while exam & history taking
- prepare socket for gentle repositioning of the tooth
- prepare the root

90.  Extra oral dry time <20mins:
closed apex – replant immediately
open apex –soak in 1mg doxycycline in 20mg saline for 5mins
 Extra oral dry time 20 to 60mins :
soak in HBSS for 30mins & replant
 Extra oral dry time >60mins:
soak in citric acid , 2% st.fluoride & doxy and replant ,
endodontics can be done extra orally
 Semi rigid splint for 7-10 days
 Antibiotics & Analgesics
 Chlorhexidine rinses and stringent oral hygiene while splint is
in place

91. Second visit after 7 to 10 days
 Endodontic treatment
 Splint removed
 Obturation visit
if RCT initiate 7 – 10days after trauma, obturate after short
term ca(OH)2
if initiated 14 days later or after inflammatory resorption ,
long term ca(OH)2 for 6- 24 months, obturated when intact
lamina dura is traced

92. Restorations
 Temporary : 4mm deep
reinforced ZOE , GIC
 Permanent : Immediately after obturation
Follow up care:
twice per yr for 3 yrs and yearly for as long as possible.

93. Stabilization Period
 Alveolar process # - 2-4 weeks
 Avulsion – 7-10 days
 Extrusion – 3 weeks
 Crown - root # - 3 weeks
 Dentoalveolar # - 3-4 weeks

94. Requirements of Splints
 Physiologic healing:
 Sufficient stability
 Allow physiologic mobility
 No damage to teeth and/ or oral tissues
 Requirements for Dentist:
 Easily constructed
 Simple to place & easy to remove
 Access available for endodontic access
 Needs for Patient:
 Comfortable
 Non interfering with occlusion and articulation
 Aesthetically acceptable
 Easy to keep clean
 Economical

95. Types of Splints
I. Depending upon tissue
coverage:
i) Splints that cover teeth & tissues:
E.g. Acrylic Splints
 Periodontal dressing Splint
 Temporary foil Splint
 Temporary crown material
Splint
ii) Splints with minimum coverage:
E.g. Composite splint

96. II. Depending upon the
Rigidity of splint:
I. Fixed Splints:
a) Rigid splint:
e.g. Maxillomand.
fixation
b) Semirigid splint:
e.g. Acid- etch
Composite
c) Flexible splint:
e.g. Titanium splint
II. Removable Splints:
• Acrylic splint
• Thermoplastic vinyl splint

97. Acrylic Splints
3 Types:
1) Lingual Cap Splint:
Indication: Marked displacement of # segments
Repositioning of # alveolar process
Complicated #s
2) Intermaxillary: E.g. Gunning Splint
Indication: # of mandibular condyle
Method of stabilization: Circummandibular / circumzygomatic
wiring / Chin Cap
Means of Stabilization : Wiring splint & teeth / Intermaxillary
fixation with arch bars

98. 3) Acrylic Cap Splint:
Resembles fenestrared splint
Indication: Permanent teeth with short crowns
Primary dentition
Incomplete eruption of deciduous teeth
Method of Fixation: Circumferential wiring

99. TRAUMATIC INJURIES TO THE
PRIMARY DENTITION
• Traumatic injuries to the primary teeth are common
• Affects 30% of the preschool children
Causes for high incidence:
1. Young children tend to be unstable on their feet
(lack of motor co-ordination)
2. Running around with new found mobility- suffer
accidents and damage the teeth

100. CONSEQUENCE OF TRAUMA TO PRIMARY
DENTITION
- Primary teeth are in close relation to their developing
permanent successors
- An acute impact can be transmitted to the developing
permanent dentition
- Infection developed subsequent to injury to primary
tooth may damage the successional tooth

102. FACTORS DETERMINING DAMAGE TO
PERMANENT DENTITION:
1. Age of the child:
- below 4 years 60% chances of damaging
permanent tooth
2. Direction of impact
3. Type of injury: Intrusive luxation- 69%
Avulsion- 52%
Extrusion-34%
Subluxation-34%

103. INCIDENCE
- 11 to 30%
- Most common age group affected: 1.5-2.5 years,
at this age child starts walking
- No sex differences in incidence as in permanent
dentition
- Owing to resilient bone surrounding the primary
teeth, injuries usually result in avulsions, luxations,
etc., rather than fractures of crown

104. ASSESSMENT
• History
• Vitality tests: unreliable and should not be
attempted
• Radiographic examination: helpful
( in case of missing tooth to determine whether
fully intruded or avulsed )
- easiest method is to take an anterior oblique
occlusal view.
• Often a child is upset at the initial visit and it may
be appropriate to postpone radiographic examination
to the review visit.

105. TREATMENT APPROACHES
The treatment strategy following injury to the primary
teeth is dictated by concern for safety of the permanent
dentition.
- Relieve pain
- Restore dentition
• In very young child – co-operation is the main problem
• Advise parents regarding - analgesia
- soft diet
- oral hygiene
• Recall the child after a week when he/she is less upset

106. LACERATION OF SOFT TISSUES
• Often the injured area is obscured by blood,
- clean up by irrigating or wiping the area
with water or normal saline
• Examine for soft tissue injury,
- if severely lacerated – suture (under LA if
cooperative or referred for GA)
• Antibiotic coverage for 5 days
• Recall or review after 7-10 days
CONTUSION AND
ABRASION

107. TOOTH FRACTURES
FACTORS TO BE CONSIDERED:
1. Any other injuries to the tooth, such as luxation-
greater chance of damage to permanent tooth
2. Patient co-operation
3. Exfoliation time of the tooth
4. Motivation of parents to keep up with the follow
up appointments

108. ENAMEL FRACTURE:
• Small chip- 1. Left as it is
2. Edge smoothened off and topical
fluoride applied
• Larger chip- composite resin restoration
ENAMEL AND DENTINE FRACTURE:
• Protect pulp- Ca(OH)2 / GIC lining followed by
composite restoration / using strip crown
TREATMENT

109. WHOLE CROWN FRACTURE:
• Coronal pulpotomy and strip crown
• Pulpectomy and strip crown
• Extraction
ROOT FRACTURES:
• Uncommon in small children
• If coronal fragment stable- leave it alone and
monitor
• If root communicates with gingiva- poor prognosis,
should be extracted
• Best to extract coronal fragment and leave the root
to resorb if not accessible to forceps

110. DISPLACEMENT INJURIES TO THE PRIMARY TEETH
AVULSION:
• Never attempt to re implant due to danger of
damaging the underlying permanent teeth
LUXATION INJURIES:
• Slight injury- left as it is, advise soft diet and oral
hygiene instructions
• Displaced palatally - less than 2mm - reposition
- more than 2mm - extraction
• If the tooth does not show an improvement in
mobility with in 2 weeks- extraction

111. INTRUSION INJURIES
• Establish where they are in the alveolus and leave
them alone
• If less than ¾ of the crown intruded- allow to re-erupt,
normally occurs in 2-4 months of injury
• If more than ¾ of the crown intruded- still can re-erupt,
careful monitoring required.
• Damage to alveolus causing pain- extraction

112. RADIOGRAPH:
• Anterior lateral radiograph should be taken to
determine the position of primary tooth in relation to
the permanent tooth
• If very close or touching the permanent tooth-
extraction
Complication: 1/3 of the re-erupted primary teeth
undergo pulpal necrosis

113. EXTRUSIVE LUXATION
•Extrusive injuries in primary dentition cause
interference in occlusion
TREATMENT:
• If extrusion is less than 1-2mm, leave them and
monitor
• If extruded more than 2mm, extract

114. FOLLOW UP CARE AFTER
INJURY TO PRIMARY TEETH
• Should be monitored- after one week, after one
month, three months, six months, one year and
yearly, until exfoliation.
• If periapical pathology occurs- extraction
• Discoluration of primary teeth is not always an
indicator of loss of vitality

115. INJURIES TO PERMANENT TEETH
RESULTING FROM TRAUMA TO PRIMARY TEETH
Can be classified as follows;
1. White or yellow-brown discolouration of enamel
2. White or yellow-brown discolouration of enamel
and horizontal enamel hypoplasia
3. Dilaceration of the crown
4. Dilaceration of the root of the tooth- causing
eruption disturbance or failure

116. 5. Odontome- like malformation
6. Root duplication
7. Vestibular root angulation
8. Lateral root angulation or dilaceration
9. Partial or complete arrest of root development
10. Sequestration of the entire tooth germ
11. Eruption disturbances

117.  Mouth guard for sports
 Seat belts
 Special car seats for infants & children
 Helmets for bike riders and passengers etc.
MANY OF THE PREVENTIVE APPROACHES ARE
BEYOND THE DENTAL PROFESSIONAL’S EXPERTISE
PRECAUTIONS