Dental Trauma

Definition

Dental trauma is injury to the mouth, including teeth, lips, gums, tongue, and
jawbones. The most common dental traumais a broken or lost tooth.
Epidemiology: Dental trauma in children is common. At 5 years of age 31-40% of
boys and 16 – 30% of girls and at 12 years of age 13 – 33 % of boys and 4 – 19 %
of girls will have suffered some dental trauma. The majority of dental injuries in the
primary and permanent dentition involve the anterior teeth, especially the maxillary
central incisors. Many factors affect the severity of trauma; researches showed that
there was relation between the severity of trauma and the protrusion of maxillary
incisors and the amount of lip coverage.

Etiology

Children are most accident prone between 2 and 4 years for the primary dentition and
between 7 and 10 years for the permanent dentition. Coordination and judgement are
incompletely developed in children with primary dentition, and the majority of
injuries are due to:
1. falls in and around the home as the child becomes more adventurous and
explores his/her surroundings. In the permanent dentition most injuries are caused by
falls and collisions while playing and running, although bicycles are a common
accessory. The place of injury varies in different countries according to local
customs, but accidents in the school playground remain common.
2. Sports injuries usually occur in the teenage years and are commonly associated
with contact sports.
3. Injuries due to road traffic accidents and assaults are most commonly associated
with the late teenage years and adulthood.

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 Accidental injuries can be the result of either direct or indirect trauma. Direct
trauma occurs when the tooth itself is struck. Indirect trauma is seen when the lower
dental arch is forcefully closed against the upper, for example by a blow to the chin.
Direct trauma implies injuries to the anterior region, while indirect trauma favours
crown or crown-root fractures in the premolar and molar regions as well as the
possibility of jaw fractures in the condylar regions and symphysis. The factors that
influence the outcome or type of injury are a combination of energy impact, the
resilience of the impacting object, the shape of the impacting object, and the angle of
direction of the impacting force.
4. Increased overjet with protrusion of upper incisors and insufficient lip closure
are significant predisposing factors to traumatic dental injuries. Injuries are almost
twice as frequent among children with protruding incisors, and the number of teeth
affected in a particular incident for an individual patient also increase.
5. Dental trauma may be inflicted in a number of ways: fights, eating hardfoods,
drinking hot liquids, and other such mishaps. As oral tissues are highly sensitive,
injuries to the mouth are typicallyvery painful. Dental trauma should receive promt
treatment from a dentist.

Injuries to hard dental tissues and pulp

a. Enamel infraction: Incomplete fracture(crack) of enamel without loss of tooth
substance.
b. Enamel fracture: loss of tooth substance confined to enamel.
c. Enamel-dentine fracture: loss of tooth substance confined to enamel and dentine not
involving the pulp.
d. Complicated crown fracture: fracture of enamel , dentine exposing the pulp.
e. Uncomplicated crown-root fracture: fracture of enamel , dentine and cement but not
exposing the pulp.
f. complicated crown-root fracture: fracture of enamel , dentine and cement exposing
the pulp.
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g. Root fracture: fracture of dentine and cement and the pulp. can be sub-classified into
apical, middle and coronal (gingival ) part.
Injuries to the periodontal tissues
a. Concusion: no abnormal loosening or displacement but marked reaction to
percussion.
b. Subluxation (loosening): abnormal loosening but no displacement.
c. Extrusive luxation ( partial avulsion):partial displacement of tooth from socket.
d. Lateral luxation: displacement other than axially with comminution or fracture of
alverolar socket.
e. Intrusive luxation: displacement into alveolar bone with comminution or fracture of
alverolar socket.
f. Avulsion: complete displacement of tooth from socket.
Injuries to supporting bone
a. Comminution of mandibular or maxillary alveolar socket wall: crushing and
compression of alveolar socket. found in intrusive and lateral luxation injuries.
b. Fract ure of mandibular or maxillary alveolar socket wall: fracture confined to facial
or lingual / palatel socket wall.
c. Fracture of mandibular or maxillary alveolar process: fracture of alveolar process
which may or may not involve the tooth socket.
d. Fracture of mandible or maxilla: may or may not involve the alveolar socket.
Injuries to gingiva or oral mucosa
a. Laceration of gingiva or oral mucosa: wound in the mucosa resulting from a tear.
b. Contusion of gingiva or oral mucosa: bruise not accompanied by a break in the
mucosa. Usually causes sub mucosal hemorrhage.
c. abrasion of gingiva or oral mucosa: superficial wound produced by rubbing or
scraping the mucosal surface.

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 A history of the injury followed by a thorough examination should be completed in
any situation.

1. When did injury occur? The time interval between injury and treatment significantly
influences the prognosis of avulsions, luxations, crown fractures with or without
pulpal exposures, and dento-alveolar fractures.
2. Where did injury occur? This may indicate the need for tetanus prophylaxis.
3. How did injury occur? The nature of the accident can yield information on the type
of injury expected. Discrepancy between history and clinical findings raises suspicion
of physical abuse.
4. Lost teeth/fragments? If a tooth or fractured piece cannot be accounted for when
there has been, a history of loss of consciousness, a chest radiograph should be
obtained to exclude inhalation.
5. . Previous dental history? Previous trauma can affect pulpal sensibility tests and the
reparative capacity of the pulp and/or periodon-tium. Previous treatment experience,
age, and parental/child attitude will affect the choice of treatment.

1. Congenital heart disease, a history of rheumatic fever, or severe immunosuppression?

These may be contraindications to any procedure that is likely to require prolonged
endodontic treatment with a persistent necrotic/infected focus. Not all congenital
heart defects carry the same risks of bacterial endocarditis, and the child‟s
pediatrician/cardiologist should be consulted before a decision regarding endodontic
treatment is made.
2. Bleeding disorders? Very important if soft tissues are lacerated or teeth are to be
extracted.
3. Allergies? Penicillin allergy requires alternative antibiotics.

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4. Tetanus immunization status? Referral for tetanus toxoid injection is necessary if
there is soil contamination of the wound and the child has not had a „booster‟
injection within the last 5 years.

When there are associated severe injuries a general examination is made with respect
to signs of shock (pallor, cold skin, irregular pulse, hypotension), symptoms of head
injury suggesting brain concussion, or maxillofacial fractures.
Facial swelling, bruises, or lacerations may indicate underlying bony and tooth
injury. Lacerations will require careful debridement to remove all foreign material
and suturing. Antibiotics and/or tetanus toxoid may be required if wounds are
contaminated. Limitation of mandibular movement or mandibular deviation on
opening or closing the mouth indicate either jaw fracture or dislocation.
Crown fracture with associated swollen lip and evidence of a penetrating wound
suggests retention of tooth fragments within the lip. Clinical and radiographic
examinations should be undertaken (Fig1).

Figure 1 (a) A 12-year-old child presented with an enamel and dentine fracture of the
upper right permanent central incisor. (b) The lower lip was swollen with a mucosal
laceration. (c) A lateral radiograph confirmed the presence of tooth fragments in the
lip. (d) Fragments were retrieved from the lip under local anaesthesia.
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 This must be systematic and the following should be recorded:
1. Laceration, hemorrhage, and swelling of the oral mucosa and gingiva (Fig. 2). Any
lacerations should be examined for tooth fragments or other foreign material.
Lacerations of lips or tongue require suturing, but those of the oral mucosa heal very
quickly and may not need suturing.
2. Abnormalities of occlusion, tooth displacement, fractured crowns, or cracks in the
enamel.

The following signs and reactions to tests are particularly helpful:

1. Mobility. Degree of mobility is estimated in a horizontal and a vertical direction.
When several teeth move together en bloc, a fracture of the alveolar process is
suspected. Excessive mobility may also suggest root fracture or tooth displacement.
2. Reaction to percussion in a horizontal and vertical direction compared with a
contralateral uninjured tooth. A duller note may indicate root fracture.
3. Color of tooth. Early color change associated with pulp breakdown is visible on the
palatal surface of the gingival third of the crown.
4. Reaction to sensitivity tests. Thermal tests with warm gutta percha (GP) or
ethyl chloride (EC) are widely used. However, an electric pulp tester (EPT) in
the hands of an experienced operator is more reliable. Vitality test, immediately
after trauma it does not give response to vitality test because the tooth is in state
of shock, re – examine in the next appointment after 6 weeks, if the child does
not give response then the tooth is dead. The vitality test needs cooperation and
relaxed child, (child anxiety result in false response).

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Figure 2 Degloving injury to the lower labial sulcus that required exploration to
remove grit.
Radiographic examination
1. To approximate the size of pulp chamber.
2. The stage of apical development; indicate the type of treatment.
3. To see root fracture.
4. To check alveolar bone.
5. Any dislocation of the tooth.
6. Periodontal condition.
7. For comparing with record in the future.
Periapical
Reproducible periapicals are the best for accurate diagnosis and clinical audit. Two
radiographs at different angles may be essential to detect a root fracture. However, if
access and cooperation are difficult, a single anterior occlusal radiograph rarely
misses a root fracture. Periapical films positioned behind the lips can be used to
detect foreign bodies.
Occlusal
This view detects root fractures when used inta-orally and foreign bodies within the
soft tissues when held by the patient/helper at the side of the mouth in a lateral view.
Orthopantomogram
This is essential in all trauma cases where underlying bony injury is suspected.

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6. Photographic records
Good clinical photographs are useful for assessing the outcome of treatment and for
medico-legal purposes. Written consent must be obtained.

General management consideration:

Immunization: if the child is not fully immunized then a tetanus booster is

required: Tetanus toxoid 0.5 ml by immediate intramuscular injection.

Antibiotics: unless there are significant soft – tissue or dento – alveolar

injuries, antibiotics are not normally required. Antibiotics are prescribed
empirically as a prophylaxis against infection, but are not a substitute for
proper debridement of wounds. All drugs should be prescribed according to
the child‟s weight.

During its early development the permanent incisor is located palatally to and
in close proximity with the apex of the primary incisor. With any injury to a
primary tooth, there is risk of damage to the underlying permanent successor.
Most accidents in the primary dentition occur between 2 and 4 years of age.
Realistically, this means that few restorative procedures will be possible and in
the majority of cases the decision is between extraction or maintenance
without performing extensive treatment.

Unlike the permanent dentition, primary teeth are more commonly displaced
rather than fractured. Enamel and dentin may be smoothed with a disk and if
possible cover the dentin with glass – ionomer cement or composite resin if co
–operation is satisfactory.

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 If the root is in the process of resorbing, the suggested treatment is extraction.
If the pulp tissue is vital, a pulpotomy is performed. Pulp capping is not a
recommended procedure for primary teeth. If the pulp is non vital and the root
structure is intact, a pulpectomy is performed. Follow up treatment consists of
a clinical examination after one week and a radiographic examination at six to
eight weeks and one year intervals.

The pulp is usually exposed and any restorative treatment is very difficult. It is
best to extract the tooth.
If there is no displacement and only a small amount of mobility, the tooth
should be kept under observation. If the coronal fragment becomes non-vital
and symptomatic, it should be removed. The apical portion usually remains
vital and undergoes normal resorption. Similarly, with marked displacement
and mobility only the coronal portion should be removed.

Associated soft tissue damage should be cleaned by the parent twice daily with
0.2% chlorhexidine solution using cotton buds or gauze swabs until it heals.
Concussion is an injury to the tooth and ligament without displacement or
mobility of the tooth and the tooth firm in the socket. Subluxation occurs when
the tooth is mobile but is not displaced. Both involve minor damage to the
periodontal ligament. All these teeth are tender to percussion. Marked mobility
requires extraction.

Management:

 Periapical radiograph as baseline.

 Soft diet for 1 - 2 weeks, analgesic and antibiotics and keep the traumatized
area as clean as possible.

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 Advice to the parents of possible sequelae, such as pulp necrosis.
 Individualized follow up.

Treatment Spontaneous repositioning If there is no occlusal interference, as

is often the case in anterior open bites, the tooth should be allowed to
reposition spontaneously. Repositioning When there is occlusal interference
local anesthesia should be applied where after the tooth should be repositioned
by gentle combined labial and palatal pressure. Extraction For teeth with
severe displacement in a labial direction, extraction is the treatment of choice.
Extraction is indicated in these cases because of the collision between the
primary tooth and the permanent tooth germ. Slight grinding In cases with
minor occlusal interference, slight grinding is indicated.

It is common condition injuries to upper primary incisors in children in the

first 3 years because of spongy bone. Falls and striking of teeth on hard object
may force the tooth into the alveolar process to the extent that the entire
clinical crown becomes buried in bone soft tissue.

Management: The aim of investigation is to establish the direction of

displacement by thorough radiographical examination. If the root is displaced
palatally towards the permanent successor then the primary tooth should be
extracted to minimize the possible damage to the developing permanent
successor. If the root is displaced buccally then periodic review to monitor
spontaneous re – eruption should be allowed.. If the tooth exhibits no evidence
of re-eruption after a four week period, extraction of the tooth is recommended
to avoid ankylosis and possible injury to the developing permanent tooth.

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Treatment depends on the degree of displacement, occlusal interferences and
time to exfoliation. If the injury is not severe ( less than 3mm extrusion), the
tooth may be repositioned or allowed to spontaneously align. When the injury
is severe, the tooth is nearing exfoliation, or the patient is uncooperative,
extraction should be considered.

Replantation of avulsed primary incisors is not recommended due to the risk of

damage to the permanent tooth germs. The other main reason is lack of patient
cooperation, and most of such injuries occur at age when it would be difficult
to construct a splint or appliance to stabilize the repositioned tooth. Space
maintainer is not necessary immediately following the loss of a primary incisor
as only minor drifting of adjacent teeth occurs. The eruption of the permanent
successor may be delayed for about 1 year as a result of abnormal thickening
of connective tissue overlying the tooth germ.

If the tooth is stable and causing no discomfort to the patient, the tooth needs
only to be monitored by clinical and radiographic examination post trauma. If
the tooth is mobile and the patient expresses discomfort, the coronal fragment
should be extracted. If the apical fragment is too difficult to retrieve, it should
be left to resorb so as not to disturb the developing permanent tooth. The
tooth is monitored for apical pathology or normal resorption

This is more common in the mandible with the anterior teeth displaced
anteriorly with the labial plate. It is often desirable to reposition the teeth with
the bone to maintain the alveolar contour. this can be achieved with thick
nylon suture passed through the labial and lingual plates of the bone.

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Complications following traumatic injuries to primary teeth may appear
shortly after the injury (e.g., infection of the PDL or dark discoloration of the
crown) or after several months (e.g., yellow discoloration of the crown and
external root resorption).
 Pulpitis
The pulp's initial response to trauma is pulpitis. Capillaries in the tooth
become congested, Teeth with reversible pulpitis may be tender to percussion
if the PDL is inflamed (e.g., following a luxation injury). Pulpitis may be
totally reversible if the condition causing it is addressed, or it may progress to
an irreversible state with necrosis of the pulp.

 Infection of the Periodontal Ligament

Infection of the PDL becomes possible when detachment of the gingival fibers
from the tooth in a luxation injury allows invasion of microorganisms from the
oral cavity along the root to infect the PDL. Loss of alveolar bone support can
be seen on a periapical radiograph . This diminishes the healing potential of
the supporting tissues. Subsequently, increased tooth mobility accompanied by
exudation of pus from the gingival crevice will require extraction of the
injured tooth.
 Pulp Necrosis and Infection
Two main mechanisms can explain how the pulp of injured primary teeth
becomes necrotic: (1) infection of the pulp in cases of untreated crown fracture
with pulp exposure, and (2) interrupted blood supply to the pulp through the
apex in cases of luxation injury leading to ischemia. Periapical radiolucencies
indicative of a granuloma or cyst are frequently evident radiographically in
necrotic anterior teeth.

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  Coronal Discoloration
As a result of trauma, the capillaries in the pulp occasionally hemorrhage,
leaving blood pigments deposited in the dentinal tubules. In mild cases, the
blood is resorbed and very little discoloration occurs, or that which is present
becomes lighter in several weeks. In more severe cases, the discoloration
persists for the life of the tooth .
From a diagnostic standpoint, discoloration of primary teeth does not
necessarily mean that the tooth is nonvital, particularly when the discoloration
occurs 1 or 2 days after the injury.
Pink discoloration that is observed shortly after the injury may represent
intrapulpal hemorrhage.
Yellow discoloration of primary incisors can be seen when the dentin is thick
and the pulp chamber narrower than usual. This condition is termed pulp canal
obliteration
Dark discoloration of primary teeth is the most controversial posttraumatic
complication in terms of the significance of the change in tooth color. The
term “dark” refers to a variety of shades, including black, gray, brown.
When the pulp becomes necrotic or when pulpal hemorrhage occurs, red blood
cells lyse and release hemoglobin. Hemoglobin and its derivatives, such as
hematin molecules that contain iron ions, invade the dentin tubules and stain
the tooth dark. If the pulp remains vital and eliminates the pigments, the dark
discoloration may fade with subsequent restoration of the original color. If the
pulp loses its vitality and cannot eliminate the iron-containing molecules, the
tooth may remain discolored.
 Inflammatory Resorption
Inflammatory resorption can occur either on the external root surface or
internally in the pulp chamber or canal .It occurs subsequent to luxation
injuries and is related to a necrotic pulp and an inflamed PDL.
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Internal Resorption
The predentin, an unmineralized layer of organic material, covers the inner
aspect of the dentin and protects it against access of osteoclasts. When the pulp
becomes inflamed, as in cases of traumatic injury, the odontoblastic layer may
lose its integrity and expose the dentin to odontoclastic activity, which is then
seen on radiographs as radiolucent expansion of the pulp space. Eventually
this process reaches the outer surface of the root, causing root perforation.
External Resorption
The cementoblast layer and the precementum serve as a shield protecting the
root from involvement in the perpetual remodeling process of the surrounding
bone. In nontraumatized primary teeth, external root resorption is part of the
physiologic process of replacing the primary dentition with permanent teeth. In
primary incisors sustaining traumatic injuries, external root resorption may
appear as an accelerated unfavorable pathologic reaction.
 Pulp Canal Obliteration
Pulp canal obliteration is the result of intensified activity of the odontoblasts
that results in accelerated dentin apposition. Gradually, the pulp space narrows
to a state in which it cannot be seen on a radiograph. PCO is a common finding
in primary incisors following traumatic injuries and is often associated with
yellow coronal discoloration
 Replacement Resorption
Replacement resorption, also known as ankylosis, results after irreversible
injury to the PDL. Alveolar bone directly contacts and fuses with the root
surface. As the alveolar bone undergoes normal physiologic osteoclastic and
osteoblastic activity, the root is resorbed and replaced with bone). Ankylosis
occurs more often in intruded primary teeth, and they eventually become
infraoccluded

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Injuries to the permanent successor tooth can be expected in 12-69% of
primary tooth trauma and 19-68% of jaw fractures. Intrusive luxation causes
most disturbances. Most damage to the permanent tooth bud occurs under 3
years of age during its developmental stage. However, the type and severity of
disturbance are closely related to the age at the time of injury. Changes in the
mineralization and morphology of the crown of the permanent incisor are most
common, but later injuries can cause radicular anomalies. Injuries to
developing teeth can be classified as follows:
1. White or yellow-brown hypomineralization of enamel.
2. Crown dilaceration.
3. Odontoma-like malformation.
4. Root duplication.
5. Vestibular or lateral root angulation and dilacerations.
6. Partial or complete arrest of root formation.
7. Sequestration of permanent tooth-germs.
8. Disturbance in eruption: Eruption disturbances may involve delay because
of thickening of connective tissue over a permanent tooth-germ, ectopic
eruption due to lack of eruptive guidance, and impaction in teeth with
malformations of crown or root.
The term dilaceration describes an abrupt deviation of the long axis of the
crown or root portion of the tooth. This deviation results from the traumatic
displacement of hard tissue, which has already been formed, relative to
developing soft tissue.
The term angulation describes a curvature of the root resulting from a gradual
change in the direction of root development, without evidence of abrupt
displacement of the tooth-germ during odon-togenesis. This may be vestibular
(i.e. labiopalatal) or lateral (i.e. mesiodistal).

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Evaluation of the full extent of complications following injuries must await
complete eruption of all permanent teeth involved. However, most serious
sequelae (disturbances in tooth morphology) can usually be diagnosed
radiographically within the first year post-trauma.

(a) Investigation of delayed eruption of the permanent upper central incisors

revealed (b) an intruded upper left primary central incisor on radiograph. (c)
Following removal of the retained primary incisor, the permanent successor
erupted spontaneously with a white hypoplastic spot on the labial surface.

Brown hypoplastic area on the lower left permanent central incisor

Treatment of injuries to the permanent dentition

Yellow-brown hypomineralization of enamel with or without hypoplasia
1. Acid–pumice micro–abrasion.
2. Composite resin restoration: localized, veneer, or crown.
3. Porcelain restoration: veneer or crown . Conservative approaches are
preferred whenever possible.

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Crown dilaceration
1. Surgical exposure + orthodontic realignment.
2. Removal of dilacerated part of crown.
3. Temporary crown until root formation complete.
4. Semi-permanent or permanent restoration.
Vestibular root angulation
Combined surgical and orthodontic realignment.

Trauma cases require follow-up to identify any complications and institute the
correct treatment. In the review period the following schedule is a guide: 1
week; 1, 3, 6, and 12 months; then annually for 4–5 years.

Infraction is defined as an incomplete fracture (crack) of the enamel without

loss of tooth structure. Clinical examination reveals normal gross anatomic and
radiographic appearance: however, upon closer examination, craze lines are
apparent in the enamel, especially with transillumination. A periapical
radiograph of the involved area is taken to rule out root fracture and injuries to
the supporting tooth structure. Pulp sensibility testing is recommended in adult
teeth to monitor pulpal changes, however, results in primary teeth may be
unreliable. Test results may be negative initially indicating transient pulpal
damage.
These incomplete fractures without loss of tooth substance and without proper
illumination are easily overlooked. Review is necessary, as above, as the
energy of the blow may have been transmitted to the periodontal tissues or the
pulp.

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In some cases, minor enamel fractures can be smoothed with fine disks. Larger
fractures should be restored using an acid-etch/composite resin technique.

1. The primary issue in managing fractures that expose dentin is to prevent

bacterial irritants from reaching the pulp. Standard care in the past called for
covering exposed dentin with calcium hydroxide (CaOH) or glass ionomer
cement to seal out oral flora. Recent research indicates that sealing exposed
dentin with a bonding agent enables the unexposed pulp to form reparative
dentin. Some clinicians are thus advocating simultaneous acid etching of dentin
and enamel followed by dentin and enamel bonding without placement of CaOH
or glass ionomer. However, a recent review of pulp capping with dentin adhesive
systems reported that these systems are not indicated owing to increased
inflammatory reactions, delay in pulp healing, and failure of dentin bridge
formation. Its recommends covering the deepest portion of dentin fractures with
glass ionomer cement, followed by a dentin-bonding agent . The tooth can then
be restored with an acid-etch/composite resin technique .If adequate time is not
available to restore the tooth completely, an interim covering of resin material (a
resin “patch”) can temporize the tooth until a final restoration can be placed.
Some dentists routinely place such a partial restoration to ensure an appropriate
post-treatment evaluation when the patient returns for the final restoration. This
is a reasonable strategy, provided that care is taken to ensure an adequate seal.

2. Reattachment of crown fragment. Few long-term studies have been reported

and the longevity of this type of restoration is uncertain. In addition, there is a
tendency for the distal fragment to become opaque or require further
restorative intervention in the form of a veneer or full-coverage crown . If the
fracture line through dentine is not very close to the pulp, the fragment can be
reattached immediately. However, if it runs close to the pulp, it is advisable to

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place a suitably protected calcium hydroxide dressing over the exposed
dentine for at least a month while storing the fragment in saline, which should
be renewed weekly.
Technique
1. Check the fit of the fragment and the vitality of the tooth.
2. Clean fragment and tooth with pumice-water slurry.
3. Isolate the tooth with rubber dam.
4. Attach fragment to a piece of sticky wax to facilitate handling.
5. Etch enamel for 30 seconds on both fracture surfaces and extend for 2mm
from fracture line on tooth and fragment. Wash for 15 seconds and dry for 15
seconds.
6. Apply bonding agent ± dentine primer according to the manufacturer‟s
instructions and light cure for 10 seconds.
7. Place appropriate shade of composite resin over both surfaces and position
fragment. Remove gross excess and cure for 60 seconds labially and palatally.
8. Remove any excess composite resin with sandpaper discs.
9. Remove a 1mm gutter of enamel on each side of the fracture line both
labially and palatally to a depth of 0.5mm using a small round or pear-shaped
bur. The finishing line should be irregular in outline.
10. Etch the newly prepared enamel, wash, dry, apply composite, cure, and
finish.

Management of crown fractures that expose the pulp is particularly

challenging .Pertinent clinical findings that dictate treatment include the
following:
1Vitality of the exposed pulp
2Time elapsed since the exposure
3Degree of root maturation of the fractured tooth
4Restorability of the fractured crown

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The objective of treatment in managing these injuries is to preserve a vital pulp in
the entire tooth. It is not always possible to maintain vital tissue throughout the
tooth. Three treatment alternatives are available, based on the clinical findings just
noted:

1. Direct pulp cap

2. Pulpotomy
3. Pulpectomy
The direct pulp cap is only indicated in small exposures that can be treated within
a few hours of the injury. The chances for pulp healing decrease if the tissue is
inflamed, has formed a clot, or is contaminated with foreign materials..

A rubber dam is applied, and the tooth is gently cleaned with water. Commercially
available CaOH paste or mineral trioxide aggregate (MTA) is applied directly to the
pulp tissue and to surrounding dentin. It is essential that a restoration be placed that
is capable of thoroughly sealing the exposure to prevent further contamination by
oral bacteria. As in the management of dentin fractures, it is acceptable to use an
acid-etch/composite resin system for an initial restoration. A calcific bridge
stimulated by the capping material should be evident radiographically in 2 to 3
months.
In fractures exposing pulps of immature permanent teeth with incomplete root
development, a direct cap is no longer the treatment of choice. Failure in these cases
leads to total pulpal necrosis and a fragile, immature root with thin dentinal walls.
Thus the preferred treatment in pulp exposures of immature permanent teeth is
pulpotomy.
Vital pulp therapy: pulpotomy
In pulpotomy a portion of exposed vital pulp is removed to preserve the radicular
vitality and allow completion of apical root development (apexogenesis) and further
deposition of dentine on the walls of the root. This procedure is the treatment of
choice following trauma where the pulp has been exposed to the mouth for more

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than 24 hours. The amount of pulp that is removed depends on the time since
exposure, which will also determine the depth of contamination of the pulp.
Attempts must be made to remove only the pulp that is deemed to be contaminated.
If the patient presents within 24–48 hours of the incident, it is safe to assume that
the contaminated zone is no more than 2-4mm around the exposure site and only
the pulp in the immediate vicinity of the exposure is removed, in a procedure also
termed partial pulpotomy (Cvek‟s technique). For more extensive exposures all
coronal pulp can be removed down to the cervical constriction of the tooth .
A pulpectomy involves complete pulp tissue removal from the crown and root and
is indicated when no vital tissue remains. It is also indicated when root maturation
is complete and the permanent restoration requires a post buildup. In the absence of
inflammatory root resorption, treatment is to obturate the canal with gutta-percha.
One of the greatest challenges facing the clinician is the treatment of a nonvital
immature permanent tooth with an open apex. Physiologic root maturation cannot
occur without the presence of vital pulp tissue, apical papilla stem cells,
odontoblasts, and Hertwig epithelial root sheath. Traditional treatment for these
cases was an apexification procedure wherein CaOH was carried to the root apex
to contact vital tissues directly. The CaOH stimulated the formation of a cementoid
barrier against which gutta-percha could subsequently be condensed. Multiple visits
over a period of 9 to 18 months were required, however, and the outcome was a
shortened root with thin walls. Additionally, long-term CaOH therapy has been
shown to weaken the tooth root and increase the likelihood of root fractures.
An alternative to the CaOH apexification technique for managing devitalized
immature incisors is the apical barrier technique using MTA. The material is
condensed into the apical area, and allowed to set. Gutta-percha is then condensed
against the MTA barrier at a subsequent appointment. Though overall treatment
time is greatly reduced, the shortened root and thin walls continue to place the tooth
at risk for subsequent cervical root fracture.
Regenerative Endodontics

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An alternative to apexification of necrotic immature teeth termed
revascularization or “regenerative” endodontics. These procedures seek to
replace damaged dentin, root structures, and pulp cells with live tissues that
restore normal physiologic function. The concept is to thoroughly disinfect the
root canal system and then stimulate bleeding from the apical papilla to fill the
root chamber with a blood clot. A host of growth factors in the area then act on
dental stem cells, primarily from the apical papilla, to use the clot as a scaffold
and differentiate into healthy cells of the pulp-dentin complex that can
complete physiologic root maturation.
The technique is to first cleanse the canal by copious irrigation with sodium
hypochlorite or Ethylenediaminetetraacetic acid (EDTA). Owing to the
immature status of the root and thin radicular walls, instrumentation is kept to
a minimum and used mainly to agitate the irrigant. The irrigant is also
activated by placing an ultrasonic tip about 3 mm short of the working length
in the canal to facilitate better debridement of the pulp tissue remnants and to
minimize the substrate for microbial proliferation. The canal space is then
dried using sterile paper points. A triple antibiotic mix of 250 mg
ciprofloxacin, 250 mg metronidazole, and 150 mg clindamycin is prepared to a
creamy paste with propylene glycol as a vehicle. The antibiotic paste is
carefully placed into the root canal system using a Lentulo spiral up to the
cementoenamel junction (CEJ). The access cavity is sealed with a sterile
cotton pellet and glass ionomer cement.
The patient is scheduled for follow-up appointments after 3 to 4 weeks. At the
follow-up appointment, the area is anesthetized with local anesthetic
containing no epinephrine. The antibiotic paste is rinsed out, and a sterile
endodontic file is placed beyond the apex to initiate bleeding. A clot is allowed
to form as close to the CEJ as possible to facilitate root thickening at the tooth
cervix. MTA is then placed against the clot, and the tooth is temporarily sealed
with glass ionomer cement. The final restoration is placed at a subsequent

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appointment. Root maturation should be apparent radiographically within
several months
5.
Without pulp exposure:
fragment removal with or without gingivectomy and restore.
With pulpal exposure and immature roots:
Perform a partial pulpotomy to preserve pulp vitality.
Pulp exposure with mature roots:
Perform endodontic treatment then restore with a postretained crown.
Orthodontic or surgical extrusion of apical fragment may be indicated to
expose the margins prior to permanent restoration.
Extraction with immediate or delayed implant-retained crown restoration or a
conventional bridge. Extraction is inevitable in crown root fractures with a
severe apical extension, the extreme being a vertical fracture

If the coronal fragment is stable and immobile (high apical root fracture), no
treatment is indicated. If the coronal fragment is mobile, reposition and
stabilize the fragment with rigid splinting of composite resin and wire or
orthodontic appliances for four weeks; If the root fracture is near the cervical
area of the tooth, stabilization is beneficial for a longer period of time (up to 4
months).. Root canal therapy should not be initiated until clinical and
radiographic signs of necrosis or resorption are apparent. Even in those cases,
treatment can often be limited to the coronal fragment, because in most
instances the apical fragments maintain their vitality.

Reposition any displaced segment and then splint the involved teeth with a
flexible splint for 4 weeks. Suture gingival laceration if present

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8.
Monitor pulpal response until a definitive pulpal diagnosis can be made
9.
Extruded permanent teeth should be repositioned as soon as possible and
splinted for 2 to 3 weeks. It normally takes the PDL fibers this period of time
to reanastomose. Extruded permanent teeth with closed apices will undergo
pulpal necrosis; therefore root canal therapy should be initiated after the teeth
are splinted. Extruded teeth with open apices have a chance to revascularize
and maintain their vitality, so the decision to initiate therapy should be delayed
until clinical or radiographic signs indicate necrosis.

Alveolar bone fractures frequently occur in lateral luxation injuries and can
complicate their management. In the most severe cases, PDL and marginal
bone loss occur. Treatment is to reposition the teeth and alveolar fragments as
soon as possible. A splint should then be applied for 3 to 6 weeks, depending
on the degree of bone involvement. If the apices are closed, the pulps will
likely become necrotic. Again, teeth with open apices should be monitored
until signs of necrosis are evident.

Teeth with incomplete root formation:

Teeth with incomplete root formation:
If the crown remain visible and there is very wide immature apex (>2mm ) the
tooth may be allowed to re-erupt spontaneously . If no movement is noted
within 3 weeks, orthodontic repositioning using light forces should be
employed.

Teeth with complete root formation:

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Mature permanent teeth intruded less than 3 mm should be allowed to
reemerge without intervention. If no movement is noted within 3 weeks they
should be repositioned surgically or orthodontically before they
ankylose.Those teeth intruded beyond 7 mm should be repositioned surgically

Soft Tissue Trauma

The soft tissues are often involved during traumatic injuries to the orofacial
area and maybe bruised or lacerated by the impact of teeth against the tissue.
Usually application of pressure with gauze to the injured site should provide
adequate hemostasis. If hemostasis cannot be obtained or the laceration is so
severe the edges are not well opposed, sutures are recommended.

Lips often cushion the teeth during a fall, bearing the brunt of the injury and
resulting in bruises and lacerations. If a laceration is present, it should be
carefully examined to determine whether a foreign object such as a tooth
fragment or gravel has been introduced into the wound.

The maxillary labial frena may tear as a result of a fall. This type of injury is
common during falls experienced while learning to walk. However, such an

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injury occurring in infants who do not walk or crawl is probably due to an
object being forced into the child‟s mouth.

Trauma to the tongue can result in laceration or puncture. Careful examination

of the injury is important since the necessity for suturing is dependent on the
extent of injury.

Impalement of the soft palate is commonly found in the child who falls while
holding an object in the mouth, i.e., a stick, pencil or pen, straw or toothbrush.
Most impalement injuries heal spontaneously and do not require treatment,
however the area should be thoroughly explored for foreign body objects and a
prophylactic antibiotic should be prescribed to avoid infection complications.

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