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Restorations
Primary teeth
Important points:
1. Caries risk
2. Developmental stage
3. Status of pulp prior to determine choice of restorative material.
Steps:
1. Restore damage by caries
2. Protect and preserve remaining Choice of material:
Age ● Ability to cooperate such as rubber dam & LA
● How long restoration is required eg older child doesn't need same durability as younger

● High risk - stainless steel crown

Caries risk
(tooth prep involved but it eliminate need for future retreatment)
● Rampant caries, initial caries control - GIC

● 2 yrs - GIC is best for primary anterior teeth (slows

Cooperation of child
carious process + temporarily restore aesthetic)
● 3-4 yrs - composite and strip crown
(more definite treatment)

Uncooperative child ● Due to Age OR Physical disability

● Stainless steel crowns are must
(to reduce future treatment for these high need children)

Restoring Posterior teeth:

GIC ● Indication:
○ Small occlusal & interproximal
○ Young child
● Avoid -
○ large cavities Or if tooth to be retained for 3yrs or more
● Survival rate -
○ 33 months over 5 yrs ● Procedure:
○ La and ubberdam used where needed
○ Remove caries using slow speed or hand instrument
○ Place GIC
○ Final restor protected from moisture contamination via either
■ Thin layer of Unfilled resin OR

advantage disadvantage

● Aesthetic ● Susceptible to erosion and wear

● Fluoride leaching ( secondary caries ● Brittle
reduced) ● Technique sensitive
■ Vaseline ( in young children with behaviour issue)
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Composite ● Indication:
○ Small - moderate occlusal & proximal cavity
(Best material in primary molar provided Cooperative child & good moisture control (tech
sensitive & expensive)
● Success rate = < 40 % after 6 yrs

Advantage Disadvantage

● Aesthetic ● Technique sensitive

● Reasonable wear ● require rubber dam and LA
● Expensive

Stainless steel crown ● Indication:

○ High caries mouth (done under GA)
○ Grossly broken teeth
○ Pulp treated tooth
○ hypoplastic/ hypomineralized primary or permanent teeth
● Survival rate
○ 3 ½ yrs (40 months)
● Procedure
○ Give LA ( irrespective if tooth is vital or not vital, due to soft tissue manipulation)
○ Give rubber dam where possible
○ Restore tooth with GIC or compomer and then prep the tooth
○ Crown selected and then cement with GIC
○ Excess cement wiped away and layer of vaseline placed around margin while
cement is setting

Advantage Disadvantage

Most durable ( provides excellent ○ Unaesthetic

○ coronal seal)
○ Relatively expensive short term but
economical long term. (rate of
○ Protect & support remaining replacement is low)
tooth structure (covers the entire ○ Tooth prep and LA is always used
crown so recurrent and
○ further caries unlikely)
will last lifetime of tooth

Hall crown technique
● Involves
(not suitable for all cases)
molars, with little or no tooth prep or caries removal ● Indication:
Success rate:
Procedure:
Restoring Anterior teeth
GIC, Compomers
Composite strip crown
Interproximal stripping
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○ placement of stainless steel crown, directly over carious lesions in primary
○ Children with limited cooperation (doesn't accept LA)
○ Only used for primary molar teeth that has moderate decay, symptom free
and without sign or symptom of pulpal pathology
○ Technique of choice in high caries mouth ●
○ 5 yrs ●
○ Pre op radiograph and examination to exclude pulpal pathology
○ Ortho separators placed at prior appointment (to ease placement of crown)
○ Tooth clean with toothbrush Or Can remove gross caries with hand excavator
○ Stainless steel Crown selected ( No prep of LA given)
○ Crown cemented on tooth using GIC which is bitten into place by child ○
Excess cement maybe washed or wiped away, before it has set.
➔ any occlusal disruption following crown placement will self correct within few
weeks
● Advantage: Good aesthetic
● Disadvantage: Prep must be caries free otherwise sec caries will form
Durability is questionable
● Material of choice
● Advantage: aesthetic and durable
● Procedure:
○ LA and rubber dam if possible, alternative is GA
○ Select celluloid crown
○ Remove caries
○ Trim the crown and make two holes in incisal edge, fill it with filling, cure
and then remove the crown and finish the resto
● Indication:
○ Used occasionally for minimal caries in ant primary teeth
● Advantage: opening contact
○ allows saliva and flouride to arrest caries, even if dentine is involved.
○ Open access for toothbrush aid removal of cariogenic biofilm.
● Disadvantage:
○ Unaesthetic
● Procedure:
○ Open the contact
○ Apply high % topical fluoride varnish (duraphat or clinpro) to enamel and
dentine
○ Repeat upto 4 times/ year in high risk children
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Permanent teeth
Amalgam ● No longer used, chance of weakening marginal ridge, cusp fracture, pulp exposure,
teeth would often require longer resto in future.
Fissure sealant ● Most appropriate used in
○ Medium or high risk of caries = all permanent Molars
○ High risk = Premolar (permanent) Primary
post teeth
○ Low risk = only deep and retentive fissures
● Material used
○ Resin based for fully erupted molar/ premolar
○ GIC for partially erupted, hypomineralized in high risk cases
● Procedure:
1. Isolate tooth, clean the surface, minimal widening of occlusal fissure, apply
thin coat of sealant
2. If tooth cant be isolate - use fluoride varnish or GIC, review eruption in
following months, once tooth is fully erupted, place fissure sealant.
● Advantage: Simple and economical way to prevent pit and fissure caries (majority
caries occur in pits & fissure of 1st permanent molars)
PRR/ occlusal ●
restoration ● Composite is material of choice Indication:
○ Enamel only lesion
○ Incipient occlusal lesion just into dentine
○ Small class 1 lesions
● Advantage: Durability as good as amalgam, less tooth prep

● Disadvantage: Technique sensitive

Pulp Therapy

Primary teeth ● Early extraction of post teeth has profound effect than anterior teeth
● Early loss can lead to:
○ Localised Space loss, arch collapse, delayed/ premature/ ectopic
eruption of permanent.
● Pulp therapy will create favourable environment for normal exfoliation of
primary tooth

Immature permanent teeth ● Roots take 3 yrs to complete their growth ( root short & wide apices)
● Open apex is good for healing response - high pulpal vascularity

● Dentine is thin - high permeability to bacteria

● Retention of compromised permanent tooth with long term prognosis may

still be beneficial for arch integrity.

Sign And Symptom

Acute Chronic
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● Pain ● Persistent infection

● Mobility ● Discharging sinus
● Periapical or intra radicular abscess ● Inflammatory follicular cyst
● Facial cellulitis ● Failure of exfoliation of primary teeth
(including spread of infection into tissue ● Apical fenestration
planes around airway - ludwig
● Ectopic permanent teeth
angina)

Diagnostic test:
1. Pulp sensibility test
● Limited value
● In immature permanent tooth, raised response is observed, decrease to normal as root mature
2. Radiograph
● Essential If clinical S&S suggest pulp involvement and before proceeding with endo procedure,
3. Clinical signs
Pain
● If severe, prolong, spontaneous/ nocturnal = irreversible pulpitis or dental
abscess ( Young patient will only complain if pain is severe & prolong)
● History of repeated need for analgesic = suggest pulp necrosis
(pain resolves once sinus tract is formed, it will drain and relieve pressure. If chronic infection in primary
not resolved, it can cause Disturbance to enamel formation in permanent teeth and malocclusion

● Most of pain is due to food impacting into cavity ( pulp is usually involved in big
cavity)

Swelling
Alveolar, Facial swelling, coronal discolouration and presence of sinus are indicator of
pulp necrosis and abscess.

Clinical ● can be due to

Mobility 1. Imminent exfoliation
2. Infection
● Inappropriate mobility, TTP suggest abscess formation
Suggest pulp necrosis
Coronal
discolouration

Fracture ●
Marginal ridge fracture in primary tooth suggest pulpal involvement in contact
point caries.
● Fracture of occlusal triangular ridges or carious undermining of cusp in pit &
fissure caries also suggest carious involvement

Restoration ● Persistent symptoms soon after resto placement indicate pulpal pathology
● Lack of coronal seal can lead to pulpal pathology

● Radio is essential

Antibiotic can temporarily resolve acute infection but will not reduce underlying pathology

Primary tooth that cannot be saved or endo is contraindicated, should be extracted due to future
problems
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1. Presence of caries in furcation

2. Root resorption - internal/ external, physiological root resorption
3. Periapical or furcation bone lesions
4. If floor of pulp chamber is perforated during pulpotomy.
5. Severe infection including acute facial cellulitis
6. Congenital cardiac disease
7. Severely immunocompromised with poor healing potential

To retain or to extract
○ Bleeding disorders - consult childs haematologist
○ Hypodontia - decision will be influenced by overall ortho strategy
○ Behavioural - if cooperation is problem, elective use of GA or elective extraction is preferred
( endo require effective pain control, child will still feel pain, inhalation sedation along with LA can help give comfort and

compliance)

○ Dental factors -
■ Primary teeth life is (Elective extraction considered within 3 yrs of exfoliation )
○ Incisor = 5-8 yrs
○ Cuspid or molar = 8-10 yrs
■ If tooth is not restorable, better to extract (coronal seal is imp for success)
■ In general full coverage resto with metal crown or composite resin crown is recommended.

Pulp capping
Indirect pulp capping
● It seals residual caries from oral environment and Promote pulpal healing with formation of reactionary
dentine in primary and permanent teeth. Also known as caries control ● Indication:
1. Large carious lesion
2. Asymptomatic tooth/ mild transient symptom
3. Pre op radio confirm absence of radicular pathology
● Indirect pulp capping will require Preformed metal crown in
○ primary lower 1st molar
○ Permanent 1st molar, severely broken ( stabilized with metal crown to allow maturation of pulp & dentine prior
to definitive resto)

● Procedure:
○ LA + Rubber Dam
○ Remove superficial caries, all peripheral caries & leaving deep caries over pulp
○ Finalise cavity prep & restore with adequate coronal seal Direct
pulp capping:
1. Primary teeth: can be due to
a. Caries = pulpotomy is better ( pulp capping can fail as a result of internal root resorption)
b. Iatrogenic = CAOH maybe but
➢ Ideally pulpotomy is better than direct pulp capping in primary, if pulp is not necrotic.
2. Immature permanent teeth:
● Pinpoint exposure due to mechanical or caries
○ CAOH & hard setting CAOH cement
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Pulpotomy
(partial removal of coronal pulp, tooth has to be caries free, and no necrotic pulp) Primary:
● Aim is to amputate inflamed coronal pulp & preserve vitality of radicular pulp to facilitate normal
exfoliation of primary.
● Extract the tooth is floor is perforated during the procedure
● Indications
1. Carious pulp exposure
2. Tooth asymptomatic or mild transient pain
3. Restorable tooth
4. Radio confirms absence of radicular pathology
● Procedure
○ LA + Rubber Dam
○ Remove caries from roof of pulp chamber ○
Amputate coronal pulp, arrest bleeding,
■ If bleeding stops in 5 min - apply therapeutic agent MTA (avoid CAOH), place cavit to seal,
and then restore with core buildup.
■ If bleeding >5 min or cannot be stopped - pulpectomy or extract ( as bleeding is a sign/ hyperaemic
pulp means infection has spread to the roots and poor prognosis)

○ Finally restore with

■ preformed metal in molar
■ Composite resin strip crown in anterior
○ Regular radio assessment

Immature Permanent tooth:

● Aim is to amputate inflamed coronal pulp & preserve vitality of remaining pulp to promote apexogenesis.
It allows normal growth of pulp below pulpotomy site, leading to normal root length and apex closure ●
Apexogenesis:
○ Allows root to develop normally
○ Main risk is dystrophic pulp calcification, which would require pulpectomy ●
Apexification:
○ Only option once pulp necrosis occurred in immature permanent tooth.
● Pulpotomy
○ Small exposure of pulp - CVEK pulpotomy (its superficial pulpotomy of 1-2 mm)
○ Large exposure or multiple exposure site - deep pulpotomy by opening canal or level of CEJ in ant
tooth.
● Indication:
○ Same as for primary
○ Preop radio confirms immature roots with open apices ●
Procedure
○ Same as primary, only difference is amputation, which can be superficial or deep ○
Material used:
■ CAOH - powder or paste
■ MTA
■ antibiotic/ corticosteroid (ledermix) paste
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Pulpectomy
(complete removal of all pulpal tissue) Primary:
● Indication: (only if it has intact roots)
○ Pulp necrosis of any tooth or carious exposure of vital incisor
○ Restorable tooth
○ Retention of tooth is required ○
Intact non resorbed root.
● RCT of incisor is simple, multirooted teeth is complex and overinstrumentation has potential to damage
underlying permanent tooth.
● Procedure:
○ LA + Rubber Dam
○ Complete removal of caries
○ Cleaning canal, prep, shape, taking care not to force anything beyond apex. Obturate with
resorbable paste ( resorbable material used inside canal like Zno eugenol cement, CAOH & iodoform paste. Only exception is

when it is planned to retain primary that does not have permanent successor)

○ Restore with coronal seal

○ Regular radio assessment

Immature Permanent tooth: ( immaturity is defined by lack of apical closure)

● Often preferable to extract 1st permanent molar and allow second molar to drift mesially, done before 10
yrs.
● Long term prognosis in molars is poor and is eventually removed (as endo will further weaken tooth)
● Retention is mainly imp due to alveolar development, holding space for ortho until optimal time for
extraction
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Extraction
● Pre op assessment:
○ Medical history & consent
○ Radio to Assess root morpho & proximity
○ Explain LA and feeling of numbness & sensation associated with luxation of tooth.
○ If child unable to cope
■ Sedation or GA (decision made in pre op appointment) ●
Discuss complications:
○ Small apical root fragment of primary after extraction maybe left to resorb, as attempted removal
may damage permanent
○ Second primary molar often difficult to remove due to divergent roots, section tooth and remove
○ If it appears impossible to take tooth out without root fracture, then perform surgical removal,
assessment done prior to procedure ● Following extraction:
○ Examine socket
○ Stop bleeding & suture any areas of gingiva/ mucosa that may have been torn or damaged
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● Post op instructions:
○ Avoid rinsing on the day of extraction to allow blood clot to stabilize
○ Next day - gently rinse mouth with mouth
○ Good oral hygiene is essential & gentle tooth brushing can start day after extraction
○ Halitosis often occur following extraction/ oral surgery
○ Prescribe analgesic & antibiotic if required
○ No sport or excessive play for remainder of day ○
Careful not to bite on lips as its anesthetized

.
Nursing bottle syndrome
( early childhood caries, rampant caries)
● Cause:
1. Long periods of exposure to cariogenic substrate.
a. sleeping with bottle containing fermentable carbohydrates eg milk,drink, juices
containing vitamin C, for upto 8 hours. Bottle used as pacifier to get infant to sleep (esp who are
difficult sleepers or have colic)
b. Also occur with prolonged at- will breast feeding in conjunction with cariogenic diet eg
grazing snacks constantly, feeding cups and sipper bottles filled with sugary fluids

2. Low salivary flow rate at night ( reduce time for remineralisation and acid buffering)
3. Parental history of active and untreated caries - esp mothers
4. Parents in situation of social stress
● Prevalence -
○ 2.5- 15% ● Site:
○ Maxillary anterior teeth
○ Later on maxillary and mandibular 1st primary molars ( as teeth erupt)
○ Canines are less affected as it erupts later
○ Mandibular ant teeth usually unaffected (due to salivary flow and position of tongue). If it is
affected, it indicates extremely high risk.
● Reasons for offering feed during night (quick fix)
○ Parental or infant illness
○ Maternal guilt, stress, anxiety, depression
○ Marital discord ○
Domestic violence.
● Management:
○ Advice about early childhood caries and Cessation of dietary habit (Important to understand
normal feeding routines)
■ All infant wake once at least overnight and often resettle them self. If parent offer milk,
than this behaviour will be reinforced and infant will learn the reward. Also babies that fill
up with milk overnight will refuse solid meals during the day. Best to settle with comfort
like patting, cuddling and reassurance.
○ Dietary advice and modification
■ gradually reducing amount of sugar in bottle by diluting with water, which maybe done over
several weeks. OR
■ Remove the bottle and offer sips of water only.
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■ Not recommended that children fall asleep with bottle at night, only dentally safe fluid in a
feeding bottle is water.
○ Fluoride and/ or CPP-ACP application
○ Use of biofilm/ antimicrobial products (disclosing agents)
○ Restoration of teeth
■ Small lesions - tooth colour restoration
■ Extensive lesions - composite resin strip crowns for anterior
Stainless steel crown for posterior ○
Extraction if required.
■ If canines have erupted, no space loss after removal of ant teeth.
■ If post teeth to be extracted - parents informed about possible space loss, assessment
should be carried out if space maintainer is required.
○ Treatment under GA often required for small children.
● Arrested caries: Once habit is ceases and/ or areas of decay become self cleansing, caries arrest and lesion
appear darker.

Trauma
● Initial reassurance is very imp + discuss various possible sequelae eg
○ Pulp necrosis
○ Resorption
○ Infection ○
Facial swelling ●
Aetiology:
○ Luxation injuries is very common in toddlers.
■ Blunt injury = high damage to soft tissues and supporting structures
■ sharp/ high velocity injury = luxation and fracture of teeth
➔ Chin point trauma - imp to check mandibular condyle ●
Incidence:
○ Peak incidence = 2-4 yrs and 8-10 yrs
○ Upper central (both dentition commonly involved
○ Usually single tooth involved except sport injury or motor accident.
● History:
○ when , where and how did trauma occur?
○ Were there any other injury?
○ What initial treatment was given?
○ Have there been any other dental injuries in past?
○ Are current immunizations up to date?
(tetanus, if child has completed their normal schedule, booster not required) ●
Examination:
○ Extra oral:
■ for wounds & palpation of facial bone ○
Intra oral:
■ Soft tissue injury + palpation of alveolus
■ Teeth for displacement, occlusion abnormality, extent of tooth fracture and tooth mobility
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■ Pulp sensibility + percussion ●

Baseline test:
Radiograph ● As baseline, All traumatised tooth should be radiographed to assess
○ Stage of root development
○ Injuries - root and supporting structures
○ Degree and direction - luxation or displacement

● Important to take subsequent radio within 2 weeks (for all traumatised teeth) ●
Dentoalveolar injury:
○ Several PA at different angles for each traumatised tooth +
○ Occlusal of ant maxilla or mandible (imp as it will determine root fracture & luxation)
○ OPG - esp very young/ upset/ difficult child
○ True lateral maxilla - intrusive luxation of primary anterior

Pulp sensibility test ● To assess pulp status via thermal and electric pulp test
● Initial response - inaccurate but
○ Useful for later comparison
○ Useful predictor of prognosis of traumatised teeth (teeth that respond is
more likely to recover)
➔ If a tooth doesn't respond, it may still have intact blood supply. Imp for
treatment planning.
➔ Cold test is more reliable in children (Cao2 or dry pencil ice)

Percussion Two reason to percuss

1. TTP:
❖ Show extent of damage to PA & PDL
❖ Also if tooth has been concussed or subluxated
( luxated tooth will be painful on percussion, so avoid it)
2. Sound:
❖ Imp indicator of presence of ankylosis esp during follow up

Transillumination ● Presence of crack and/ or fracture

● Subtle alteration in crown colour indicate change in pulp status.

Treatment of maxillofacial injury:

● With accurate reduction of fracture, fixation and immobilisation, fracture will unite within 3 weeks.
● Prophylactic Antibiotic + strict oral care must be maintained.

Luxations in primary
Most common injury in toddlers, involve displacement of teeth in alveolar bone. General
management:
● Treatment option:
○ Leave & observe ( Mostly heal without sequelae.) OR
○ Extract the tooth
● If child is not fully immunised - tetanus booster required
● Antibiotic
○ not required unless significant soft tissue/ dentoalveolar injuries
○ Given prophylactically to avoid infection
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●
Concussion & Concussion: injury to tooth & ligament without displacement or mobility, no gingival
subluxation bleeding
● Subluxation: tooth is mobile, but not displaced and bleeding.

● Pathophysiology: minor damage to PDL

● S&S: TTP
Haemorrhage & oedema within ligament
● Management:
○ PA radio as baseline
○ Soft diet for 1 week
○ Advice about possible sequelae - pulp necrosis and infection

○ Individualised follow up.

●
Intrusive luxation Most common injury to upper primary incisors.
● Site: usually palatal & superior displacement of crown, apex of tooth is forced away
from permanent follicle.
● Management:
○ Crown visible - leave tooth to re-erupt
○ Extract if
■ Whole tooth intruded
■ Apex perforate labial alveolar cortical plate
■ Severe injuries involving alveolar bone & gingiva
➔ (decision depends on degree & direction of displacement & amount
of alveolar bone & gingival damage)
Extrusive & ● Treatment depends on
lateral luxation ○ Mobility
○ Extent of displacement
➔ If severe - extract the tooth
Avulsion ● Never replant - risk of damage to permanent tooth.
○ It may force blood clot in socket OR
○ root apex into permanent follicle
○ Lack of patient co-operation
● If parent replanted tooth - splint, to prevent inhalation/ swallowing. Splint must be
removed later when child maybe less compliant.
● Antibiotic not required unless ○
Significant soft tissue injury
● Radiograph - if tooth cant be found

Sequelae of ●
25% risk of disturbance to development of permanent tooth in very young child (esp
trauma with luxation or avulsion)
(luxated or avulsed) ● Warn about sequelae & reassure that minor defects are easily repaired
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● Primary
○ Necrosis of pulp causing grey discolouration with possible infection, followed
by abscess formation
○ Internal resorption of primary tooth
○ Ankylosis - fail to fully erupt,
■ but will exfoliate normally.
■ If not - extract prior to eruption of permanent
● Permanent
○ hypoplasia/ hypomineralization
○ Dilaceration of crown/ root
○ Resorption of permanent tooth germ
Treatment options ● Primary:
○ Discoloured, but asymptomatic - no treatment
○ If aesthetic concern - mask with composite
○ If abscess - Pulpectomy
Extraction
● Permanent:
○ Hypoplasia & hypomineralisation - composite
○
Dilaceration - Ortho extrusion
Extraction (in severe case)

Fractures of primary Incisors

Crown fracture of enamel &
dentine
More commonly displaced than fracture
Complicated crown/ root
fracture
If extend below gumline = extract
● Treatment:
○ Smooth with disc,
○ Cover dentine with GIC or composite strip crown Possible
● sequelae:
○ Pulp necrosis and/ or grey discolouration
( can subsequently become infected - apical abscess.
●
Site:
○ mostly involve pulp, extend below gingival margin & often
● multiple fracture in same tooth - extract tooth S&S:
○ not evident immediately often, child may present several days after
trauma with pulp polyp that causes separation of fragments
- not painful. (protective mechanism) - extract tooth
● Management:
○ In emergency - remove loose tooth fragment (cause discomfort as
its held by gums)
○ Later under sedation or GA - extract remaining tooth
○ If small piece remain - leave as it will resorb as permanent erupts
and inform parents.
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Root fracture ● No treatment with horizontal or transverse fracture

● Regular review and if
Uncommon = isolated root fracture ○ Sign of necrosis & infection
○ Excessive mobility
○ Sinus formation
➔ Extract coronal portion,
➔ leave apical part, it will resorb as permanent erupts

Crown/ root Fractures of permanent Incisors

Crown infraction/ ● Usually do not cross DEJ, but it's impossible to know extent if it involves dentine or
crack of enamel not
● Investigation
○ Transillumination - to identify crack
○ Pulp sensibility test
○ Radio - PA from several angles
Occlusal - to exclude other injuries
● Treatment:
○ Cover with two coats of resin bonding liquid as temporary mean to protect
against bacterial penetration during healing phase.
● Review:
○ Pulp sensibility test - every 3,6,12 months
○ Radio - PA each visit
Uncomplicated ● Types:
crown fracture ○ Enamel only

○ enamel/ dentine
NO PULP involvement ● Investigation
○ Pulp sensibility test
(usually oblique fracture
○ Radio - PA + Occlusal ( to exclude other injuries)
of mesial or distal
corner) ● Treatment
○ Enamel only -
■ smooth sharp edge & restore with composite ○
enamel/dentine -
■ cover dentine with GIC ( imp to cover asap to prevent direct irritation of pulp due
to entry of bacteria)

■ crown restored with composite either immediately or at review

■ If parent bring fractured piece - bond it back with composite
○ If pulp exposure questionable & tooth very immature
■ Elective CVEK pulpotomy indicated (allow normal development of apex)
● Review
○ Pulp sensibility test - every 3,6,12 months
○ Radio - PA each visit ●
Prognosis:
○ Pulp necrosis - more likely if dentine is not covered.
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Complicated crown ● Pulp is exposed and healing doesn't occur spontaneously. Untreated will result in
fracture ○ Pulp necrosis and subsequent infection of root canal, leading to
■ Apical periodontitis & possible apical abscess
Enamel, dentine, pulp ● Time of injury & stage of root development is important
exposed
○ Within several hours - conservative management
○ Within several days - radical pulp amputation (as microabscess may form within pulp)
● Investigation:
○ Pulp sensibility test - to assess adjacent teeth for possible injury
○ Radio - PA + Occlusal - ( to exclude other injuries)
● Treatment:
(Aim for treating exposed pulp is to Preserve non inflamed pulp rather than RCT, by using CaoH that
forms dentine bridge)

1. Incomplete root apex

with normal pulp - CVEK PULPOTOMY (apexogenesis)
● Procedure
○ LA + Rubber Dam
○ Remove 1-2 mm of contaminated pulp tissue
○ Wash and once bleeding stops, cover it directly with CaoH ( over
uncontaminated pulp)

○ Place GIC on top of CaoH

○ Restore with composite
➔ This technique is not limited to coronal pulp only, Partial pulpotomy
maybe performed at any level of pulp space, Imp to preserve apical part
of pulp in traumatised incisor
● Review
○ Pulp sensibility - 6-8 week, then 6 & 12 month
○ Radio - PA each visit
to check Continued root development + narrowing of root canal space as root develops
● Prognosis
○ Favourable healing in 80-90%

with necrotic pulp (apexification)

● Unlikely to occur immediately, mostly diagnosed at follow up.
● Treatment: RCT required , It can be complicated due to ➢ Inability to create
apical seal

➢ Thin dentinal wall

➢ Difficult to fill canal by lateral condensation
● Prognosis
○ no difference in prognosis of RCT in mature & immature tooth but long term
survival of tooth with open apex maybe low due to
■ Thin dentine walls of root esp at cervical third.
■ Shortened root - susceptible to fracture during function Or
Further trauma to tooth
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● I. agement: Apexification
● Aim: to create apical hard tissue barrier against which root canal filling can
be placed, by using long term intracanal CaoH dressing

● Procedure
○ LA + Rubber Dam
○ Remove necrotic pulp, disinfect canal & dissolve remaining pulp
tissue remnants
○ Place ledermix paste as initial dressing, followed by CaoH (50:50
mix). It
■ Reduces PA inflammation, pain & control infection within
canal.
○ Cover coronal pulp with small cotton wool & place temporary
filling (cavit)
○ Review:
■ After 4-6 weeks, if no symptom, Remove temporary
filling + previous dressing, dry & redressed with
CaoH, compress with cotton wool so that it reaches
apex, cover with temporary resto
■ Every 3 month - Change CaoH each time.

○ Formation of apical hard tissue barrier may take 12-18 months.

Once formed
■ RCT with GP + cement ( don't leave GP & cement in access cavity - cause
discolouration of tooth)

■ Place cavit on base (to facilitate any further access to RC)

■ GIC to replace dentine & finally composite
■ Review -
● 6 month after root filling completed &
● Annually for 5 yrs - to monitor tooth & PA tissue
● PA at each review
● Adjacent teeth should also be monitored
following trauma.
II. MTA - filling open ended RC
III. Pulp regeneration, revascularization of RC

2. Mature root apex

● If short period of exposure -
○ CVEK pulpotomy (to preserve pulp, regardless of apical development)
○ If restorative consideration - remove pulp & RCT immediately
Root fracture ● To identify
○ Horizontal fracture - PA, alter vertical angulation
○ Vertical fracture - PA, alter horizontal angulation
○ Occlusal - indicated in all cases
➔ Take subsequent radiograph within 2 weeks (imp for all traumatised teeth) ●
Treatment:
○ Reposition coronal fragment
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■ Place rigid splint with composite & wire OR

■ Ortho appliance for 3-4 months - if coronal fragment is mobile.
● Review:
○ Pulp sensibility = 4,8,12 week
○ Remove splint after 3-4 month ○
Review at 6,12 & annually for 5 yrs ○
Take PA at each visit.

Pulp necrosis & infection

coronal fragment
● If an apical fragment few mm -
○ no treatment ( it will undergo pulp calcification, uncommon to develop pulp necrosis)
● If coronal fragment -
○ There will be radiographic signs of bone loss at level of fracture
○ Symptom - pain, excessive mobility, gingival swelling or draining sinus
(signs that coronal pulp has necrosed & infected)
➔ These problems will be evident in follow up appointment after several
months or longer in case of root fracture and won't be visible straight
after trauma, so no need to do endo straight away after trauma. If it
occurs
○ Treatment:
■ Remove pulp from coronal segment
■ Take PA to determine working length, 1 mm coronal to fracture
line ( never pass file through fracture line)
■ Prepare canal, place 50:50 ledermix + CaoH as initial dressing to
control infection & inflammation in fracture line and place
temporary resto.
○ Review:
■ In 4 weeks - remove initial dressing & place Caoh to induce
formation of hard barrier at the end of coronal section. Replace
Caoh every 3 months. It may take upto 18 months. ■ Once barrier
is formed - perform RCT and restore

Both apical and coronal

● Poor prognosis
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Crown/ root 1. Uncomplicated fracture - Fracture extend below gingival margin

fracture ● Initially Cover dentine with GIC and then restore with composite or crown
(do not restore root portion, only crown to allow new cementum formation)

2. Complicated fracture (with pulp exposure) - root development is complete

Always remove coronal
fragment to fully assess
extent of fracture
Luxation in permanent
● Fracture extend below crestal bone
○ Remove coronal portion to assess
○ RCT required, ledermix or CaoH placed as initial dressing.
● Fracture does not extend below crestal bone
○ CVEK pulpotomy performed
○ Restore with
■ composite or
■ cast resto (deeper fractures) or
■ Surgical to expose margin of resto
○ Prognosis - Poor
○ Management: gingivectomy ( if fracture is just below gingival margin, restore root
with GIC and crown buildup with composite), cast crown, ortho extrusion,
extraction, root burial (good for implant)

Concussion & ● Concussion : marked response to percussion, tooth firm in socket

subluxation ● Subluxation: high mobility, but no displacement or radio abnormality. TTP
● Investigation:
○ Pulp sensibility + radio (PA & occlusal)
● Treatment
○ Relief from occlusion, no splinting
○ Soft diet for 2 weeks
● Review
○ Pulp sensibility - 1,3,6 and 12 month
○ Radio - each visit ( to assess size of pulp chamber & root development)
➔ Follow up for at least 12 month to check - pulp status, colour, mobility and radio, it
will indicate if pulp recovered.
● Prognosis
○ Pulp necrosis in 3-6% of cases
Lateral & ● Procedure:e luxated in any position and require repositioning & splinting
extrusive ● ○
luxation Under LA, early tooth reposition with digital pressure
■ Difficult after 24 hr as blood clots in original socket
■ avoid forcep, can damage root surface, causing root resorption
○ Suture gingival laceration

○ Place flexible splint with composite & fishing line/ ortho

appliance ■ 10-14 days - extrusive
■ 4-6 weeks - lateral luxation (more rigid splint)
○ Prescribe antibiotic, tetanus prophylaxis, 0.2% chlorhexidine mouthwash if
required
○ Lateral luxation always have fracture of socket wall - imp to mould bone back
into correct position
➔ No need for RCT, unless there is sign of infection.
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○ Review:
■ Every 2 weeks while splint is there, then 1,3,6, & 12 months
■ Annual review upto 5 yrs
■ Take pulp sensibility + radio at each review
○ Prognosis:
■ Depends on degree of displacement, apical development and any
concurrent injuries eg crown fracture
■ Immature teeth - excellent healing, pulp canal calcification often occur
■ Closed apices - 15-85% chance of pulp necrosis & infection
Intrusion ● Caused by
(worst injury)
○ Pushing or forcing tooth into alveolar bone
● Key issue - Extensive damage to
○ supporting structures eg PDL & bone and neurovascular bundle of pulp
● General rule
○ Reposition and splint
○ Incompletely developed teeth - can be left to see spontaneous re eruption.
● Aim of early repositioning
○ To avoid ankylosis
○ Minimise pressure necrosis of PDL
○ Allow Access to palatal surface of tooth to remove pulp immediately ( highly unlikely
pulp will survive, removal is imp to reduce possibility of external inflammatory resorption)
● Management
1. Repositioning
a. Incomplete root formation
● If crown visible >2 mm immature apex
○ Allow to re erupt spontaneously
○ If no improvement after 3-4 weeks, than rapid ortho

repositioning is required
b. Complete root formation
● Immediate repositioning with fingers or forceps
(apply only to crown & avoid rotating tooth in socket)
● Fixed ortho to apply traction over 2 week
(extrusion should be rapid so palatal surface is exposed & start RCT asap)
2. Endo treatment
○ Removal of pulp is essential in all cases except
■ Partially intruded
■ Extremely immature teeth - left to re erupt with regular monitoring
○ Initial 3 month - ledermix, change every 6 weeks to reduce chance of external
resorption

○ Another 2-3 months - 50:50 mixture ledermix paste & CaoH

○ If immature apex - furthur period of CaoH for apexification ○
If mature apex - RCT
● Review ( imp as external inflammatory resorption occur rapidly & tooth maybe lost within weeks)
○ Every 2 weeks - during splinting phase
○ 6-8 weeks
○ 6,12 month & yearly for 5 yrs
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● Prognosis
○ Mature teeth - pulp necrosis in >96% of cases ( esp with concurrent crown fracture)
Replacement resorption & ankylosis (high risk)
○ Immature teeth - pulp necrosis in 60%
Ankylosis in upto 50%
➔ Teeth treated earlier has better prognosis
DENTOALVEOL ● Laterally luxated, intruded & avulsed always have alveolar bone fracture +/ -
AR FRACTURE displacement
● Alveolar fracture can occur without significant dental involvement.

● Management:
○ Reposition with firm finger pressure on buccal & lingual plate
○ Splint - ( can be rigid or semi rigid, depends on injury & no. of teeth)
■ 4 weeks in children ■
6-8 weeks in adults
● Investigations:
○ Pulp sensibility test
■ Only test nerves, not blood supply
■ In luxated permanent teeth, can give false result as nerve damage may take
1 yr or never to respond.
○ Radiograph regularly to assess
■ crown/ root fracture ( possible if tooth luxated)
■ Root development & growth
■ Root resorption (external or internal)
■ Change in size of pulp chamber
○ Clinically: important diagnostic sign for infected root canal
■ Change in colour
■ Excess mobility
■ TTP
■ Draining sinus
➔ Necrotic pulp doesn't cause periodontitis, only when its infected, PA tissues respond. So
IMPORTANT TO ASSESS WHETHER ROOT CANAL SYSTEM IS INFECTED OR NOT.
Avulsion ● As general, all teeth should be REPLANTED, WHETHER WET OR DRY , even if they have
poor prognosis ( although prognosis of dry is poor, still preferable to have tooth during growth, than not
at all)

○ Tooth may ultimately be lost by progressive replacement resorption, but will retain
space, occlusion & aesthetic, preserve alveolar bone height ( good for ortho & prostho)

○ Only exception of replantation is very immature roots, where ankylosis will

■ prevent alveolar bone growth
■ May complicate further ortho or prostho treatment
● Prognosis: poor if tooth is out for > 30min

●
First Aid advice:
○ TIMING IS ESSENTIAL , >10 min - poor prognosis, replant straight away
○ Keep child calm
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○ Do Not allow to eat ( incase anesthesia of sedation required)

○ Locate tooth (check pt clothing, if thought to be lost)

○ Hold by crown only ■

Replant:
● If clean - immediate
● If dirty - wash with milk (preferable) Or saline/ pt saliva/ brief rinse
under cold water (last option)
● Hold tooth in place by
○ Biting gently on handkerchief/ clean cloth OR
○ Aluminium foil OR
○ Seek urgent dental treatment ■
Unable to replant:
● Store in isotonic media to prevent dehydration & death of PDL
cells, use
○ Milk (preferred)
○ Saline
○ Saliva
○ Wrap in cling film ( with some saliva to keep it moist)
● DO NOT USE WATER - hypotonic lysis of PDL cells
●
Management in dental clinic:
1. Tooth replanted prior to arrival:
➢ Do not extract the tooth
➢ Debride mouth
2. Tooth in storage solution/ extraoral time < 60 min
➢ Hold teeth by crown with wet gauze (can be slippery)
➢ Debride & irrigate root surface under
○ Copious saline
○ Milk
○ Tissue culture media (hanks balanced salt solution)
➢ Give LA & debride tooth socket (saline)
○ To remove any blood clot
○ DO NOT curette bone or remaining PDL
➢ Replant tooth gently with finger pressure
3. Tooth is dry/ extraoral time > 30 min
➢ Remove necrotic PDL by
○ Soak tooth in saline & gently debriding root surface with saline
soaked gauze
➢ Then rehydrate tooth prior to replantation
○ Soak in sodium fluoride for 20 min
➢ Give LA, debride tooth socket with saline ○ Do not curette
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➢ Replant tooth gently with finger pressure.

● Management following replantation:

1. Splint for 14 days:
➢ Material: (any archwire placed for splinting should be passive and not
move adjacent teeth) ○ Ortho brackets with light
archwire ( preferable as it takes less time to apply). ○ Composite
resin & nylon fibre i.e fishing line
➢ Type:
○ Flexible - mostly preferred as it reduce risk of ankylosis & replacement resorption
○ Rigid - if bone or root fracture (so that teeth and bone dont move)
➢ Time frame:
○ 10-14 days = No complicating factor like alveolar or root fracture
○ 4-6 weeks = Bone fracture
○ 3 months = Root fracture
○ 4 weeks = Avulsed teeth with immature apices & kept dry prior to
replantation
➢ Occlusion:
○ May need to be relieved ( tooth does not receive unwanted forces) via
■ Minimal removal of enamel OR
■ Construction of upper removable appliance OR
■ Composite on molar to open bite
2. Reposition and suture - any degloved gingival tissue or lacerations
3. Rubber dam and start endo
● Remove pulp, irrigate canal with sodium hypochlorite and dry it.
● Place ledermix dressing in canal - to reduce chance of external root resorption ●

Continue RCT as for intruded teeth.

4. Prescribe antibiotic (high dose & broad spectrum eg tetracycline)

5. Check current immunisation status
6. Check for any missing teeth - chest radio may be required
7. Normal diet & strict oral hygiene including chlorhexidine 0.2% mouthwash.

Root canal treatment:

1. Immature root apex
● Tooth avulsed, replanted within short period, apex extremely immature
> 2 mm & child < 8yrs
○ RCT only if symptoms & c;incal sign indicate pulp is infected.
○ Dont commence RCT immediately after replantation
○ Teeth should be monitored to see if pulp revascularization
● If canal becomes infected
○ Canal dressed with ledermix initially for 6 months
○ Followed by another ledermix for further 6 weeks (total period 3
months)
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○ CaoH then used to induce apexification, changed 3 monthly until apical

hard tissue barrier has formed and RCT possible (usually takes 12 months
to form)

● Long term survival of immature teeth

○ 30 %, even if replanted early

2. Mature root apex

● Apex of avulsed tooth is <2mm open or closed
○ RCT commenced immediately after replantation - to prevent external
root resorption
○ Initial dressing of ledermix for two periods of 6 weeks each (total 3
months)
○ Followed by 50:50 mixture ofl edermix and CaoH or just CaoH alone
○ RC filling completed after 5-6 months
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Complications in endo management of avulsed teeth

1. External inflammatory root resorption
● Defined as, “ progressive loss of tooth structure by an inflammatory process
caused by the presence of bacteria in the root canal system and damage to
root surface.
● Management:
○ Prophylactic antibiotic - broadspectrum (eg tetracycline, amoxicillin, penicillin V)

■ given asap after avulsion and continued for 1 week

■ Tetracycline avoided in children, staining of other teeth can occur
○ Pulp removal
■ Done on the day on injury, Asap after tooth replanted and
stabilized with splint
■ Not done outside the mouth
■ Any delay in RCT can lead to inflammatory resorption ●
Prevention:
○ Avoid medicament that cause inflammation eg CaoH in first 3 month of
trauma
○ Ledermix is ideal first dressing medicament, as it ■
prevents inflammatory root resorption & ■
Inhibit action of clastic cells.
● If inflammatory resorption detected:
○ Canal re-instrumented, irrigated and dressed with ledermix for 3
months, changing dressing every 6 weeks
○ CaoH placed for further 3 months
○ If no further progression of resorption, root canal can be filled.

2. External replacement root resorption

● Defined as, “ progressive resorption of tooth structure and replacement with
bone as part of continual bone remodelling”
● Cause:due to
○ damage to cementum and/ or PDL or replantation of dry teeth.
● Treatment:
○ Cant be treated, Aim is to prevent it and subsequent ankylosis
○ Extra oral time
■ Prognosis decreases after 15 min if tooth is dry.
■ 50% PDL cells die after 30 min and
■ All dead after 60 min ○
Storage media:
■ Milk - best medium (keep cell viable for upto 6 hr),
● Advantage: it is pasteurized with few bacteria, readily
available and cold.
■ Saliva - upto 2 hour
■ Saline & plastic cling wrap - 1 hour
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■ Tissue culture media such as Hanks balanced salt solution - upto 24 hr cell survival
■ Avoid
● Water - its hypotonic & causes cell lysis.
● Avoid yogurt and sour milk due to low pH
○ Mechanical damaged:
■ Ankylosis occur if cementum removed or damaged
■ Risk increases during transport and replantation
○ Splinting:
■ Flexible splinting allows physiological movement, so less replacement resorption

○ Extra oral RCT:

■ Avoided, will increase likelihood of replacement resorption and ankylosis due to
● prolong extraoral time
● Damage during treatment
● Effects of toxic substance such as irrigating solution and RC cements.