INJURIES TO PERMANENT

DENTITION
DR SHUJA ASLAM MEMON
BDS.FCPS.MFD
Assistant Professor operative dentistry
Incharge peadododontics department
1. Emergency:
(a) retain vitality of fractured or displaced tooth
(b) treat exposed pulp tissue
(c) immobilization of displaced teeth
(d) antiseptic mouthwash ± antibiotics and tetanus
prophylaxis.

2. Intermediate:
(a) pulp therapy
(b) minimally invasive crown restoration.

3. Permanent:
(a) apexogenesis/apexification/regeneration for teeth
that have lost vitality
(b) root canal filling + root extrusion
Enamel infraction
Monitoring is necessary.

Enamel fracture
smoothing of any rough edges.
No restoration is needed unless there are
aesthetic concerns
ENAMEL-DENTINE FRACTURE:
 Emergency protection of the exposed dentine can be achieved by

the following.
1. A bonded composite resin or compomer.
2. Glass ionomer cement within an orthodontic band

 Final restoration of most enamel–dentine fractures can be achieved

by the following.
1. Resin-bonded composite applied either freehand or utilizing a
celluloid crown-former
2. 2. Reattachment of crown fragment
If the fracture line is not very close to the pulp, the fragment can be
reattached immediately. However, if it is close to the pulp, it is
advisable to place calcium hydroxide or calcium silicate cement
dressing over the exposed dentine for a month while storing the
fragment in saline
Technique for fragment attachment
1. Check the fit of the fragment and the vitality of the tooth
2. Clean the fragment and tooth with pumice–water slurry.
3. Isolate the tooth with rubber dam.
4. Attach the 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 the 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 the appropriate shade of composite resin over both
surfaces and position the fragment. Remove gross excess
and cure for 60 seconds labially and palatally.
8. Remove any excess composite resin with sandpaper discs.
 Complicated crown fracture

Newly erupted teeth have short roots, their

apices are wide and often diverging, and the
dentine walls of the entire tooth are thin and
relatively weak. Provided that the pulp remains
healthy, dentine deposition and normal root
development will continue for 3-5 years after
eruption in permanent teeth.
Vital pulp therapy
1.Direct Pulp capping
2. pulpotomy: partial or complete

Non vital therapy:

1.Root canal treatment
2.Apexification(either by MTA or CAOH)
3.Regenerative endodontics
Within 24 hrs: direct pulp capping
24-48 hrs: partial pulpotomy
48-72 hrs: complete pulpotomy
If large exposure involving pulp: Root canal
treatment
DIRECT PULP CAPPING:
 isolate with rubber dam.

 Preparation if needed

 Any bleeding should be controlled with sterile

cotton wool, which may be moistened with

saline or sodium hypochlorite
 Then layer of setting calcium hydroxide or

calcium silicate cement(MTA or Biodentine) is

gently flowed onto the exposed pulp and
surrounding dentine and quickly overlaid with a
‘bandage’ of adhesive material (e.g. composite).
 Success is determined on the radiograph by the

following:
• root is growing in length
• root canal is maturing (narrowing )
PULPOTOMY:

 Under local anaesthesia and rubber dam, pulp tissue is

excised with a diamond bur via high speed handpiece
under constant water cooling.
 Gently rinse the wound with sterile saline or sodium
hypochlorite (1–2%) to stop bleeding.
 Apply a calcium hydroxide or calcium silicate cement
dressing to the pulp.
 For partial pulpotomy, a setting calcium hydroxide
cement may be gently flowed onto the pulp surface, but
for complete pulpotomy,stiff mixture of calcium
hydroxide powder in sterile saline which is carried to
the canal in an amalgam carrier and gently packed into
place with pluggers.
 Then composite
 Composite resin
Non-setting
calcium Hard setting cement
hydroxide
cement

Calcific barrier form

Root formation is comp

 Non-vital pulp therapy: pulpectomy or root
canal treatment
Challenges in pulpectomy if apex is open:
 the root has thin dentine walls liable to

fracture
 a wide open apex
 there is no natural apical constriction or stop

against which a suitable root filling material

can be placed
 Apexification
 local anaesthesia and rubber dam isolation
 determine a provisional working length by estimating from an
undistorted preoperative radiograph.
 Little canal shaping is usually needed. Instead, the canal should be
thoroughly cleaned with sodium hypochlorite marked to stay 2–
3mm short of working length.
 MTA is then mixed to a clay-like consistency. It is carried to the
canal in small increments with a dedicated MTA gun, or with an
amalgam carrier, and is carefully walked up the canal with pluggers
set 2mm short of working length to prevent over-extension.
 take a radiograph to confirm its position. If you are happy,
continue to build increments until an apical plug of 4mm thickness
has been achieved
 seal moist cotton wool in the canal for at least 24 hours before
bringing the patient back
 Then obturation.
APEXIFICATION WITH CAOH
Only difference is that CaOH is placed for 3
months and then changed. Barrier forms in
approximately 18 months

Advantages of MTA apexification:

Single visit
Less patient compliance needed
More cost effective than multiple visit procedures
of caoh
 Disadvantages of Caoh

 Brittle barrier formed

 It takes 18 months for barrier to form
 expensive
Obturation
Manual obturation
 backfill with thermoplastic gp
Regenerative endodontic treatment
First treatment visit
• Isolate the tooth using rubber dam.
• Access the tooth and extirpate the pulp using barbed
broaches.
• Negotiate the canal with minimal or no filing to prevent
further weakening of the existing dentinal walls.
• Irrigate the root canal system with:
– copious amounts of 1.5% sodium hypochlorite (NaOCl)
– 5mL sterile saline.
• Dry the canal using paper points.
• Mix metronidazole (100mg) and ciprofloxacin (100mg)
with distilled water.
• Inject the mixture of the two antibiotics into the root canal
system.
• Place a cotton pellet to cover the root canal orifice and
 Second treatment visit
 If clinical signs or symptoms persist, the procedures
performed in the first appointment should be repeated.
 Administer plain local anaesthetic solution (no
vasoconstrictor, e.g. 3% mepivicaine), isolate the tooth, and
re-access as described above.
 Flush the antibiotic mixture out of the root canal by irrigation

with copious amounts of normal saline.

 Irrigate the root with 10mL 17% EDTA.
 Dry the root canal thoroughly with paper points.

 Insert a sterile sharp instrument (25 mm k file or finger

spreader) with a length of 2mm beyond the working length to
intentionally induce bleeding into the root canal. Allow the
bleeding to fill the root canal.
 Once the root canal is filled with blood, place a sterile cotton-
wool pledget in the pulp chamber and allow a clot to form in
the root canal.
 Hermetically seal the access cavity with these material to
prevent coronal leakage and contamination:
Uncomplicated crown–root fracture
After removal of the fractured piece of tooth
these vertical fractures are commonly a few
millimetres incisal to the gingival margin on
the labial surface but down to the cemento-
enamel junction palatally. Prior to placement of
a restoration the fracture margin has to be
brought supra-gingival by either gingivoplasty
or extrusion (orthodontically or surgically) of
the root portion.
 Complicated crown–root fracture

Same as above plus endodontic treatment

Complicated crown root fracture
 Root fracture
It is divided into coronal,middle and apical fracture.

Coronal fracture:
If displacement has occurred, the coronal fragment should be
repositioned as soon as possible by gentle digital manipulation .Splint
for 4 months.
Fractures in the cervical third of the root will repair as long as no
communication exists between the fracture line and the gingival
crevice. If there is communication, splinting is not recommended and
an early decision must be made to extract the coronal fragment and
retain the remaining root, internally splint the root fracture with H
files to nickel–chromium points , or extract the two fragments

 Extraction of coronal fragment and root retention

The remaining radicular pulp should be removed and the canal
temporarily dressed prior to obturating with gutta percha. Three
options are now available
1. Post, core, and crown restoration if access is adequate.
2. Extrusion of the root either surgically or orthodontically if the fracture
extends too subgingivally for adequate access.
3. Cover the root with a mucoperiosteal flap. This will maintain the
 Middle and apical third root fracture:
In apical and middle third fractures any
endodontic treatment is usually confined to the
coronal fragment only. A barrier is achieved on
the coronal aspect of the fracture line by
preparation of a stop with MTA, and the
coronal canal is obturated with gutta percha.
The apical fragment almost always contains
viable pulp tissue After completion of
endodontic treatment, repair and union
between the two fragments with connective
tissue is a consistent finding. Splint for 4
weeks.
Three main categories of repair are
recognized.
1. Repair with calcified tissue: invisible fracture
line
2. Repair with connective tissue: narrow
radiolucent fracture line
3.Repair with bone and connective tissue: the
two fragments are separated by a bony
bridge
Middle third root fracture
Middle third root fracture of both
permanent central incisors with bony
repair and sclerosis of the apical
fragments
Initial presentation of a high coronal root fracture
which extended palatally below alveolar bone. (b), (c)
Post, core, and diaphragm after root extrusion. (d)
Final ceramic crown
Splinting
 A functional splint involves one, and a rigid
splint two, abutment teeth on either side of
the injured tooth
Dento-alveolar fractures
These require 3–4 weeks of rigid splinting
For Root fractures ,functional splint is done
 Types and methods of constructing splints

 Composite/acrylic resin and wire splint

 Bend a flexible orthodontic wire to fit the middle third of the labial
surface of the injured tooth and one abutment tooth either side.
 Stabilize the injured tooth in the correct position palatally with soft
red wax.
 Clean the labial surfaces. Isolate, dry, and etch the middle of the
crown of the teeth with 37% phosphoric acid for 30 seconds, wash,
and dry.
 Apply a 3mm diameter circle of either flowable or filled composite
resin or acrylic resin to the centre of the crowns.
 Position the wire into the filling material and then apply more
composite or acrylic resin.
 Mould and smooth the composite. Acrylic resin is more difficult to
handle, and smoothing and excess removal can be done with a flat
plastic instrument.
 Cure the composite for 60 seconds. Wait for the acrylic resin to cure.
 Smooth any sharp edges with sandpaper discs.
Composite resin and wire splint for
a luxation injury.
Prefabricated titanium trauma splint

This splint has a number of advantages,

including ease of adaptation owing to its
flexibility. It is also easy to apply with
composite resin, easy to remove, and allows
the tooth to retain the physiological mobility
which is essential for healing the PDL
Titanium trauma splint
 Orthodontic brackets and wire

 Foil–cement splint
A temporary splint made of soft metal (cooking
foil) and cemented with quick-setting zinc
oxide–eugenol cement is an effective
temporary measure either during the night
when it is difficult to fit a composite wire
splint as a single-handed operator or while
awaiting construction of a laboratory-made
splint
 Laboratory splints

INDICATIONS:traumatized maxillary incisors,

unerupted lateral incisors, and either carious or
absent primary canines. Both methods require
alginate impressions

 Acrylic splint: There is full palatal coverage and the

acrylic is extended over the incisal edges for 2–3mm
of the labial surfaces of the anterior teeth. The splint
should be removed for cleaning after meals and at
bedtime.

 Thermoplastic splint The splint is constructed from

polyvinylacetate– polyethylene (PVAC–PE) copolymer
Like the acrylic splint, it should be removed after
meals and at bedtime.
 Concussion
The tooth is tender to percussion (TTP).
 Subluxation

In addition to the above there is rupture of

some PDL fibres and the tooth is mobile in the
socket, although not displaced. The treatment
for both concussion and subluxation is as
follows:
 occlusal relief
 soft diet for 7 days
 immobilization with a functional splint for 2

weeks
 chlorhexidine 0.2% mouthwash twice daily
Extrusive Luxation:
There is a rupture of PDL and pulp. Treatment is a
functional splint for 2 weeks.

 Lateral luxation
 There is a rupture of PDL, pulp, and the alveolar plate
 The treatment for both extrusive and lateral luxation
is as follows:
 atraumatic repositioning with gentle but firm digital
pressure
 non-rigid functional splint for 4 weeks
 antibiotics, e.g. amoxicillin 250mg three times daily
(<10 years old, 125mg three times daily) for 5 days
 chlorhexidine 0.2% mouthwash twice daily while
splint is in position
 soft diet for 2–3 weeks
 the prognosis is significantly better for open
apex teeth
Five-year pulpal survival after injuries involving
the periodontal ligament

 Type of injury Open apex (%) Closed apex

 Concussion 100 96
 Subluxation 100 85
 Extrusive luxation 95 45
 Lateral luxation 95 25
 Intrusive luxation 40 0
 INTRUSIVE LUXATION:
There is extensive damage to the PDL, pulp, and alveolar
plate(s).
 There are two distinct treatment categories: the open

apex and the closed apex. Both categories can be

discussed depending on whether the intrusive injury is
<7mm or >7mm.

 Open apex

 <7mm: There is eruptive potential which may be

improved by disimpaction with forceps. If no movement
in 2–4 weeks, move orthodontically
 >7mm :

surgical repositioning under local anaesthetic, local

anaesthetic/sedation, or general anaesthetic is
appropriate. Functional splint for 4–8 weeks.
 Closed apex
 <7mm: Orthodontic extrusion is probably
indicated straight away. The danger of a tooth
ankylosing in an intruded position should
always be borne in mind
 >7mm Surgical repositioning and functional

splint for 4–8 weeks

Monitor pulpal status clinically and
radiographically and start endodontics if
necessary. Elective pulp extirpation will be
necessary for all significant intrusive luxation
injuries in closed apex teeth at about 10 days.
The risk of pulpal necrosis in these injuries is
high, especially in the closed apex. The
incidence of resorption and ankylosis sequelae
is also high
Also prescribe antibiotics, chlorhexidine
mouthwash, and soft diet.
 Avulsion and replantation

Successful healing after replantation can only

occur if there is minimal damage to the pulp
and PDL. The extra-alveolar dry time (EADT),
the type of extra-alveolar storage medium, and
the total extra-alveolar time (EAT), i.e. the time
that the tooth has been out of the mouth, open
or close apex,minimal damage to PDL,condition
of socket,necrosed pulp,splinting time are
critical factors
Advice on phone (to teacher, parent, etc.)
1. Don’t touch the root—hold by the crown.
2. If the tooth is dirty, wash briefly (10 seconds)
under cold running water.
3. Replace in the socket or transport in milk to
the surgery.
4. If replaced, bite gently on a handkerchief to
retain it and come to the surgery.
The best transport medium is the tooth’s own
socket. Milk, saliva, the patient’s buccal sulcus,
or normal saline are alternatives
 Replantation of teeth with a dry storage time less than 1
hour

 Immediate surgery treatment

1. Do not handle the root. If replanted, remove tooth from
socket.
2. Rinse the tooth with normal saline. Note the state of root
development. Store in saline.
3. Local analgesia.
4. Irrigate the socket with saline. Remove clot and any foreign
material.
5. Push the tooth gently but firmly into the socket.
6. Non-rigid functional splint for 14 days.
7. Check occlusion.
8. Baseline radiographs: periapical or anterior occlusal. Any
other teeth injured?
9 Systemic antibiotics, chlorhexidine mouthwash, soft diet as
previously.
10. Check tetanus immunization status.
 Antibiotics
Tetracycline is first choice for age >12 years for 1 week
post replantation. Phenoxymethylpenicillin (Pen V) or
amoxicillin are suitable for children <12 years.

Review
1. Radiograph prior to splint removal at 14 days.
2. Remove splint at 14 days.
3. Endodontics—commence prior to splint removal for
categories (b) and (c).
(a) Open apex, EAT <30–45 minutes. Observe.
(b) Open apex, EAT >30–45 minutes. Endodontics:
(i) subsequent intracanal dressings: non-setting calcium
hydroxide paste
(ii) replace calcium hydroxide every 3 months until apical
barrier or place MTA plug
(iii) obturate canal with gutta percha and sealer.
c) Closed apex. Endodontics:
(i) subsequent intracanal dressing: non-setting
calcium hydroxide paste
(ii) obturate with gutta percha and sealer as soon
as possible as long as there is no progressive
resorption.
2.Radiographic review: 1 month; 3 months; every 6
months for 2 years; then annually.
3. If resorption is progressing unhalted, keep non-
setting calcium hydroxide in the tooth until
exfoliation, changing it every 6 months.
 The immature tooth with an EAT <30–45 minutes

may undergo pulp revascularization. However,

these teeth require regular clinical and
radiographic review because once EIR occurs it
progresses rapidly.
 Replantation of teeth with a dry storage time
longer than 1 hour
 Teeth with very immature apices should not be
replanted. The incidence of resorption, ankylosis,
and subsequent loss is high because of the high
rate of bone remodelling in this age group.
 Mature teeth with a dry storage time of more than
1 hour will have a non-vital PDL. The necrotic PDL
and pulp should be removed at chairside with
pumice and water on a bristle brush prior to
rinsing with normal saline. The root canal is then
obturated with gutta percha and sealer, and the
tooth is replanted and splinted for 4 weeks. The
aim of this treatment is to produce ankylosis,
allowing the tooth to be retained as a natural
space maintainer, perhaps for a limited period
only.