Dr.

Ali Fahad Al-Fatlawi PEDODONTICS LEC: 4

Management of trauma to the teeth and supporting tissues

Traumatic injuries of the dentoalveolar region include injuries of the teeth and associated
surrounding soft and hard tissues. Trauma with accompanying fracture of a permanent incisor is a
tragic experience for the young patient and their parents, and is a problem whose management
requires experience, judgment, and skill. Tooth trauma and its management loom as a major
challenge to the dental practitioner.
Etiology
- Fall
- Accidents
- Sports
- Battered child
Predisposing factors
1. Children with convex profile like:
a- Increased over jet with protrusion of upper incisors
b- Angle class II division I
c- Angle class I
2. Children with cerebral palsy
3. Epileptic patient
4. Dentinogenesis imperfecta
Mechanism of dental trauma
1. Direct trauma: occur when tooth itself is struck, e.g. against table or chair.
2. Indirect trauma: seen when the lower dental arch is forcefully closed against upper, e.g. Blow to
chin.
Trauma to the Face
1-Tooth Fracture 2-Tooth displacement
Tooth Fracture
The first thing to occur is
Concussion: any injury to the tooth and supporting structure without loosening of the tooth but the
tooth is tender to percussion.
Subluxation: loosening of the tooth but without displacement.
Displacement of the Tooth
1- Partial displacement
2- Total displacement (avulsion)
1- Partial Displacement Caused By:
a- Direct trauma
b- Indirect trauma
1- Partial Displacement that caused by direct trauma produce:
a- Palatal or Lingual movement of the tooth with palatal fracture of the
alveolar bone.
b- Palatal movement with buccal alveolar bone fracture.
c- Displacement of the tooth from its socket without alveolar bone fracture and the tooth appear
longer (Extrusive luxation).

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2. Partial Displacement that caused by indirect trauma produce
a- Labial movement of the tooth with fracture of palatal or lingual alveolar bone.
b- Labial movement of the tooth with fracture of labial alveolar bone.
c- Intrusive luxation: displacement of the tooth into the alveolar bone, the tooth appears shorter.

Diagnosis and assessment

Firstly the dentist should determine:
1. Time of injury and subsequent arrival for cares the result of treatment are highly dependent in
the time elapsed.
2. The cause of the injury.
3. Where the injury occurred to determine need for a booster tetanus injection.
4. Whether the trauma was sever enough to cause other medical problems, such as headaches,
vomiting or other symptoms of head trauma.
5. What stimuli cause response in the injured area thermal, percussion, or chemical.

Clinical Examination
- Visually: observe the extent of the fracture to determine whether the pulp is exposed, whether
there is soft tissue laceration, and whether teeth have been avulsed or displaced.
- Radiographs: to evaluate the root fracture, any fracture of supporting alveolar bone, proximity of
the pulp tissue to the fracture, root maturity, the adjacent teeth and the opposing arch. For fracture of
the dentoalveolar region, commonly used radiographs are:
1. IOPA (intraoral periapical) X-ray.
2. OPG (orthopantomogram).
- Gently palpate the surrounding tissue and teeth to check mobility, firmness, or loose alveolar bone.
- Do not perform vitality tests at the initial appointment, because of the shock condition of the
children will give false result, and may be considered at subsequent visits.

Classification of Traumatized Anterior Teeth

The following is a modification of Ellis and Davey classification:
Class I: simple fracture of the 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 with an exposure of the dental pulp.
Class IV: loss of the entire crown.
Displacement of primary teeth can be treated by different methods:
A- Most injuries of this type occur at an age when it would be difficult to construct a splint or a
retaining appliance to stabilize the repositioned teeth.
B- By allowing the tooth or teeth to reerupt if the tooth is intruded.
C- By observation, if the involved tooth is slightly mobile.
-- In all of these situations the tooth should be observed for Subsequent color changes in the
enamel.
-- Normally the developing permanent incisor tooth buds lie lingual to the roots of tine primary
central incisors. Therefore, when an intrusive displacement occurs, the primary tooth usually remains
labial to the developing permanent tooth if the intruded primary tooth is found to be in a lingual or
encroaching relationship to the developing permanent tooth. It should be removed. Such a

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relationship may be confirmed with a lateral radiograph of the anterior segment.
-- Primary teeth that are displaced but not intruded should be repositioned by the dentist or parent as
soon as possible after the accident to prevent interference with occlusion. The prognosis for severely
loosened primary teeth is poor. Frequently the teeth remain mobile and undergo rapid root
resorption.
-- If the tooth is completely avulsed, reimplantation is not indicated.
With space maintainer may be indicated.

Emergency Treatment of Soft Tissue Injury

Open wounds of the oral tissues often accompany injury to the teeth of children. Abrasion of the
facial tissues, or even puncture wounds .the dentist must recognize the possibility of the development
of tetanus after the injury and must carry out adequate first-aid-measures.
Then the teeth and soft tissue should carefully clean of debris, Pledge of cotton moistened with
warm water or hydrogen peroxide can be used to clean the area. Beside that if soft tissue need
suturing. The treatment should perform.
Class I Fracture
Thorough examination as described before. The patient should be reexamined at 2 weeks and
again at 1 month after the injury. If the tooth appears to have recovered at that time, continued
observation at the patient's regular recall appointments should be the rule. The emergency treatment
includes:
Smoothening rough edges
Advice to parents that even though fracture is minimal. There is always the chance that the tooth
may be becomes deviate. Any color change should be noted in the tooth. If there is a color change,
the treatment needed must reevaluated.
Class II Fracture: Initial appointment should include:
-- History of trauma as before.
-- Radiograph, then covering the exposed dentinal tubules with a calcium hydroxide preparation. it
has been shown experimentally that the pulp has a dramatic increase in an inflammatory response if
dentin is left exposed to bacteria.
-- The temporary restoration is important to maintain the vitality of the teeth.
1. Fragment restoration (reattachment of tooth fragment) : Sometime the dentist may have
the opportunity to reattach the fragment of a fractured tooth using resin and bonding techniques. This
procedure seems to be the ideal method of restoring the fractured crown, it is esthetically good and
restoring its natural contour and color simply.
2. Temporary bonded resin
After the exposed dentin is protected with calcium hydroxide and the enamel adjacent to the
fracture is etched. The restorative resin material is applied as protective covering at the fracture site.
As a short-term temporary restoration .It requires little or no finishing and does not need to restore
the tooth to normal contour. After an adequate recovery period (at least 4weeks) an esthetic resin
restoration can be completed.
3. Orthodontic band
The orthodontic band will serve adequately as a retainer for a therapeutic dressing on the exposed
dentin and will maintain contact with the adjacent teeth.

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4. Stainless steel crown
This crown is one of the most stable restorations for the temporary protection of a fractured
tooth, especially if the coronal fracture is extensive with a vital pulp exposure (especially class IV).
Class III Fracture
The following points should be consider
1- The size of the pulpal exposure.
2- The root development or level of root maturity.
3- The time elapse.
There are many choice of treatment depend on many variables:
Direct pulp capping
It is dressing of the exposed pulp involves placing anhydrous setting calcium hydroxide cement
over the exposed pulp. Direct pulp capping is indicated in following condition:
1. Size of pulp exposure less than 1 mm.
2. Duration of pulp exposure is less than 24 hours.
3. Pulp showed minimal bleeding.
4. Wide open root apex or normal apex.
5. Sufficient crown remains to retain a temporary restoration support the capping material and
prevent contamination with oral fluids.
So the treatment of choice is direct pulp capping, addressing material
is calcium hydroxide (Ca(OH)2) or mineral trioxide aggregate (MTA).
Pulpotomy (vital pulpotomy)
It can be defined as removal of the inflamed coronal pulp and healthy radicular pulp helps in
physiological root end development and formation (apexogenesis). The indications of pulpotomy
1. Relatively large pulp exposure.
2. Duration of pulp exposure is within 72 hours.
3. Pulp showed moderate bleeding.
4. Immature permanent teeth if necrotic pulp tissue is evident at the exposure site.
5. Mature permanent teeth when the trauma has caused both pulp exposure and root fracture.
The successful pulpotomy allows the pulp in the root canal to maintain its vitality and also allows the
apical portion to continue to develop.