Traumatic Dental Injury

in Children

drg. Septriyani Kaswindiarti, MDSc

FKG UMS
 Epidemiology and Etiology
• The most frequently injured teeth in primary
dentition  maxillary incisors
• Primary dentition >> luxation
Permanent dentition >> crown fracture
 spongy nature of the bone in young children and lower
root/crown ratio in permanent teeth
• Children with protruding incisors (Class II
malocclusion)  2-3x suffer dental trauma
• 11-30% of children suffer trauma to primary
dentition, up to 20% in preschool children
• 22% of children suffer trauma to permanent
dentition by age 14 years
• Male : female  2 : 1ears
• Peak incidence  Age 2-4 years developing
mobility skills, rise again at 8-10 years
• Primary dentition:
Automobile accident, chronic seizure disorder,
child abuse (up to 50% suffer injuries to the head
and neck  clinical presentation is not consistent
with the history presented by the parent)
• Young Permanent Dentition:
Falls during play, sport, automobile
accident, children with seizure disorders
Sequelae of Trauma to Primary Teeth

• Disturbance of the permanent tooth,

depends on:
– Direction and displacement of the primary root
apex
– Degree of alveolar damage
– Stage of formation of the permanent tooth
• Possible damage:
– Necrosis pulp of primary tooth (abscess)
– Internal resoprtion of primary tooth
– Ankylosis of the primary tooh
– Hyplopasia or hypomineralization of
succedaneous teeth
– Dilaceration of the crown, or root
– Resorption of permanent tooth germ
 HISTORY
• Medical History
– Cardiac disease  prophylaxis against
infectious endocarditis
– Bleeding disorder
– Allergies to medications
– Seizure disorder
– Medications
– Status of tetanus prophylaxis
• History of The Dental Injury
WHEN
Time elapsed  determine the type of
treatment
WHERE
Determine the need for tetanus prophylaxis
HOW
Severity of injury
 CLINICAL EXAMINATION
• Extraoral examination
• Intraoral examination
• Radiographic examination
 Luxation
Soft Tissue
(Displacement)

Tooth Fracture Maxillofacial/Jaw

INJURY
 Tooth Fracture
Ellis 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 involving considerable dentin
and exposing the dental pulp.
Class IV - The traumatized teeth that become non-vital with (or) without
loss of crown structure.
Class V - Teeth lost as a result of trauma.
Class VI - Fracture of the root with or without a loss of crown structure.
Class VII - Displacement of a tooth without fracture of crown (or) root.
Class VIII - Fracture of crown.
Class IX - Injuries to primary dentition
Treatment
Primary Dentition
• Not involving pulp  may be smoothed with a
disc, restoration with GIC or composite resin
• Involving pulp  if it is not possible to restore, it
should be removed
• If a small piece of root remains in socket  may
be safely left (it will be resorb)
Young Permanent Dentition
• Baseline periapical radiographs and pulp
sensibility test
• Not involving pulp  restoration with composite
resin (with/without GIC) or reattachement
• Involving pulp:
– Complete root apex with vital pulp  direct pulp
capping
– Incomplete root apex with vital pulp  cvek
pulpotomy (apexogenesis)
– Incomplete root apex with necrotic pulp  extirpation
and RCT (apexification)
Reattachment
Direct Pulp Capping
• Objective  preserve pulp vitality by calcific
barrier/bridge
• Only indicated in small exposure that can be treated
within few hours of the injury
• Prognosis <<  tissue is inflamed, has formed a clot, or
is contamined with foreign materials
• CaOH or MTA  2-3 months
• Not a choice for immature permanent teeth
Pulpotomy Cvek/ Apexogenesis
• Local anesthesia
• The use of rubber dam
• Removal of contamined pulp tissue  round high speed
diamond bur  The pulp is washed with saline until the
haemorrhage stop
• Non-setting Ca(OH)2 placed over the pulp  covered
with a setting Ca(OH)2
• GIC base is placed over the dressing, tooth is restored
with composite resin
• Follow up 6-8 weeks and then 12 months with pulp
sensibility tests and radiographs examination (to check
hard-tissue barrier formation and continued root
development)
• Prognosis: success rate 80-96%
Apexification
• Create access cavity under rubber dam
• Extirpate the necrotic pulp tissue
• Mechanically prepare the canal 1mm short of the
radiographic apex (should be really carefully)
• Irrigate thoroughly with 1% NaOCl
• Ledermix paste should be placed as the initial dressing
followed by CaOH
• Re-dress with non-setting CaOH after 1-2 weeks,
compress with cotton pellet
• Place GIC / ZnOE for temporary filling
• Follow-up 3-6 monthly
• Calcific bridge may take up to 18 months  may be
obturated with gutta percha
• CaOH should be changed 2-3 months (for adequate
concentration and reduces the chance of infection)
• Development of a small root apex although the pulp
otherwise appears necrotic  surviving remnants of
Hertwig’s epithelial root sheath (HERS)
 Luxation/Displacement
Concussion

Subluxation

Intrusion

Extrusion

Lateral Luxation

Avulsion
Concussion
• The tooth is not mobile
and is not displaced.
The PDL absorbs the
injury and is inflamed,
which leaves the tooth
tender to biting
pressure and
percussion.
Subluxation

• The tooth is loosened

but it is not displaced
from the socket
• No treatment is required
• Soft diet instruction (±1 week)
• Oral Hygiene instruction (CHX rinse)  to
prevent contamination of the damaged
PDL
• Recall if a late complication develop 
tooth discoloration
Intrusion
• The tooth is driven into
its socket. This
compresses the PDL
and commonly causes
a crushing fracture of
the alveolar socket
Primary Dentition

• One of the most complicated injuries to the

primary incisors
• Tooth may disappear complete or remain incisal
part (shorter than adjacent teeth)
• Mobility <<, percussion (-), bleeding (+),
swollen/hemorrhage
• May severely damage the developing tooth bud
 extraction
• Do not risk the permanent teeth  can be left 
spontaneously re-erupt
Permanent Dentition

• The prognosis is not good  root resorption, pulpal

necrosis, alveolar bone loss
• Mature teeth  pulp necrotic 96%, >> ankyloses and
root resorption
Immature teeth  pulp necrotic 60%, ankyloses 50%
• Immature teeth intrude < 7 mm  allow reemerge
spontaneously  no movement in 3 weeks 
orthodontic repositioning (light force)
• > 7 mm  orthodontically/ surgically repositioned
• Mature teeth:
< 3mm  reemerge spontaneously
3 – 7 mm  orthodontic/surgical
repositioning
> 7 mm  surgical repositioning
• Endodontic  non-vital
RCT or apexification (immature teeth)
• Follow-up every 2 weeks during mobilization phase, then
6-8 weeks, 6 months, 12 months, and yearly for 5 years
Surgical repositioning
Extrusion
• This is a central
dislocation of the tooth
from its socket. The
PDL is usually torn in
this injury
• Clinically elongated relative to adjacent un
affected teeth.
• Mobility >>, percussion (+), bleeding (+)
• Treatment in primary dentition is
dependent on the mobility and extent of
displacement excessive mobility 
should be removed
• Permanent tooth  repositioned as soon
as possible and splinted for 2-3 weeks
• Closed apices  pulpal necrosis  RCT
should be initiated after splinting
• Open apices  have a chance to
revascularize and maintain vitality 
initiate therapy should be delayed
Lateral Luxation
• The tooth is displaced
in a labial, lingual, or
lateral direction. The
PDL is torn, and
contusion or fracture of
supporting alveolar
bone occurs
• Mobility >>, percussion (+), bleeding (+)
• Severely luxation  potentially damage
the succeeding permanent incisor 
extraction
• Before the formation of a coagulum 
repositioning  splinting 7-14 days 
RCT
• Cost/benefit ratio must be explained to the
parents
A. Subluxation, B. Palatal luxation, C. Extrusive
luxation, D. Gross Displacement
• In permanent teeth:
reposition of the teeth and alveolar
fragments  splinting 3-6 weeks and
prescribing 0,12% CHX mouth rinse
• Close apices  necrotic pulp  RCT
a.s.a.p after splinting
• Open apices  monitoring
Avulsion
• The tooth completely
displaced from the
alveolus. The PDL is
severed, and fractures
of the alveolus may
occur.
• Common outcome of dental trauma in
young children  high crown/root ratio of
primary incisors
• Should not be replanted  the permanent
tooth may be damaged during insertion of
the root back to its socket
• Shortening of the root by 2-3 mm before
replantation  risk/benefit??
Permanent teeth:
• Prognosis for long-term retention worsens the longer that
the tooth is out of socket
• Primary therapeutic  maintain vitality of PDL fibers
• Culture media: ViaSpan, Hanks Balanced Salt Survivor,
etc
• Alternative  milk, saline solution, saliva (in patient
mouth!!!)
• WATER  hypotonic solution  PDL cells swell an
rupture
• Dry > 1 hour  necrotic PDL
• Soaking in fluoride ± 20 minutes before reimplantation 
<< resorption
• Reimplant tooth in its socket a.s.a.p
Reimplantation
• Hold the tooth by the crown to prevent damage to the
PDL
• Gently rinse the tooth with tap water (no scrubbing)
• Manually reimplant the tooth in its socket a.s.a.p
• Apply a light, functional splint for 1-2 weeks
• Complete CaOH pulpectomy after 1 week and then
remove splint (non-vital)

*immature teeth spontaneous revascularization

*prescribing systemic ab  ??  board spectrum ab (doxycycline)
*OH instruction
Ideal Splinting:
• Be passive and not cause trauma
• Be flexible and allow functional movement
of the tooth
• Allow for vitality testing and endodontic
access
• Be easy to apply and remove
 Soft Tissue Injuries
• Alveolar mucosa and skin bruising
– Treatment  symptomatic
• Lacerations
– Lip suturing  within first 24 hours (preferably
within 6 hours)
– Debris removal  2,5% pov. Iodine or 0,5%
chx acetate
• Attached gingival tissue degloving
 Suturing is required
 Injury Prevention
• Seat belts and child restrains
• Helmets for bike riding
• Mouthguards
• Supervision of pet esp. dog
 References
• Cameron, A.C., and Widmer, R.P., 2008,
Handbook of Pediatric Dentistry, 3rd ed., Mosby
Elsevier, Sydney.
• Cassamasimo, P.S., Fields, H.W., McTigue, D.J.,
Nowak, A.J., 2013, Pediatric Dentistry: Infancy
through Adolescence, 5th ed., Elsevier Saunders,
Missouri.

American Academy of Pediatric Dentistry, 2013, Guidelines

for the Management of Traumatic Dental Injuries 1-3.