Tooth Trauma pediatric dental practical examination

Pediatric dental practical examination

1. Traumatic Injuries Traumatic Injuries
to the Anterior Teethto the Anterior Teeth
Presented by:Presented by:
Dr. Navroop KaurDr. Navroop Kaur
MDS (Pedodontics)MDS (Pedodontics)

2. IntroductionIntroduction

Traumatic episodes, depending on the energy of the impact, Traumatic episodes, depending on the energy of the impact,
can result in injuries which may range in severity from can result in injuries which may range in severity from
enamel fractures to complex dental injuries involving the enamel fractures to complex dental injuries involving the
pulp and the periodontium.pulp and the periodontium. The extent of injury is influenced The extent of injury is influenced
by the severity of the traumatic event, direction of force by the severity of the traumatic event, direction of force
against the teeth and supporting structures and the type of against the teeth and supporting structures and the type of
impact—blunt or sharp.impact—blunt or sharp. The injury may remain limited to the The injury may remain limited to the
dental tissues or may involve the supporting structures dental tissues or may involve the supporting structures
including the periodontal ligament and the alveolar bone. including the periodontal ligament and the alveolar bone.

Majority of dental injuries occur unexpectedly during daily life Majority of dental injuries occur unexpectedly during daily life
activities and mostly involve the anterior teeth, thus affecting activities and mostly involve the anterior teeth, thus affecting
their function. their function.

3. Incidence-Incidence- In the deciduous dentition, there In the deciduous dentition, there
are 5% new cases of dental trauma every year. are 5% new cases of dental trauma every year.
There is an increase in incidence of traumatic There is an increase in incidence of traumatic
injuries from 1 year of age with a peak of 10% injuries from 1 year of age with a peak of 10%
at 3 years of age because by 1 year of age at 3 years of age because by 1 year of age
most of the children learn to walk and by the most of the children learn to walk and by the
age of three they can indulge in riding a bicycle/ age of three they can indulge in riding a bicycle/
tricycle making them prone to falls and injuries. tricycle making them prone to falls and injuries.

4. Etiology- Traumatic injuriesEtiology- Traumatic injuries

Motor incontrol- Motor incontrol- especially at 2-3 years of age leads especially at 2-3 years of age leads
to falls and collisions and hence increased incidence to falls and collisions and hence increased incidence
of dental trauma.of dental trauma.

Medical ailments- Medical ailments- like isolated convulsions and like isolated convulsions and
epilepsy also predispose a child to traumatic injuries epilepsy also predispose a child to traumatic injuries
especially complicated crown fractures.especially complicated crown fractures.

Contact sports- Contact sports- injuries due to contact sports are injuries due to contact sports are
generally seen in older age group when children start generally seen in older age group when children start
to indulge in outdoor sports activities. to indulge in outdoor sports activities.

5. Automobile accidents- Automobile accidents- injuries due to road injuries due to road
side accidents may be seen in children of side accidents may be seen in children of
any age group but most common in teenage any age group but most common in teenage
children and especially in boys.children and especially in boys.
Fights- Fights- commonly leads to complex oro-commonly leads to complex oro-
maxillofacial injuries along with associated maxillofacial injuries along with associated
dental trauma which may be luxation injuries dental trauma which may be luxation injuries
or crown fractures.or crown fractures.

6. 
Risk factors- Risk factors- 1. 1. Anteroposterior molar relation- Anteroposterior molar relation- Studies Studies
have reported that increased prevalence of dental trauma have reported that increased prevalence of dental trauma
is seen in children with Angle’s Class II div I malocclusion is seen in children with Angle’s Class II div I malocclusion
and also in children with an Angle’s Class I molar relation.and also in children with an Angle’s Class I molar relation.

2. Lip incompetency- 2. Lip incompetency- Lips form a natural barrier against Lips form a natural barrier against
trauma to the teeth. Reduction of cushioning effect in the trauma to the teeth. Reduction of cushioning effect in the
presence of incompetent lips predisposes to dental presence of incompetent lips predisposes to dental
trauma. trauma.

33. Incisal overjet- . Incisal overjet- Children with greater than 5 mm overjet Children with greater than 5 mm overjet
are considered to be 1.5 times more susceptible than are considered to be 1.5 times more susceptible than
children with an overjet of less than 5 mm. The incidence children with an overjet of less than 5 mm. The incidence
increases to twofold when the overjet is greater than 9 increases to twofold when the overjet is greater than 9
mm. mm.

7. Traumatic Injuries to the TeethTraumatic Injuries to the Teeth

Classification of traumatic injuries to anterior teeth- Ellis and Davey (1970)Classification of traumatic injuries to anterior teeth- Ellis and Davey (1970)

Cl-1Cl-1- Simple fracture of crown involving only enamel with little or no dentin.- Simple fracture of crown involving only enamel with little or no dentin.

Cl-2Cl-2- Extensive fracture of crown involving considerable dentin but not exposing - Extensive fracture of crown involving considerable dentin but not exposing
dental pulp.dental pulp.

Cl-3Cl-3- Extensive fracture of crown involving considerable dentin and exposing - Extensive fracture of crown involving considerable dentin and exposing
pulp.pulp.

Cl-4Cl-4- Traumatized tooth which becomes non- vital with/ without loss of crown - Traumatized tooth which becomes non- vital with/ without loss of crown
structure.structure.

Cl-5Cl-5- Tooth loss- avulsion.- Tooth loss- avulsion.

Cl-6Cl-6- Root fracture with/ without loss of crown structure.- Root fracture with/ without loss of crown structure.

Cl-7Cl-7- Displacement of tooth without fracture of crown or root.- Displacement of tooth without fracture of crown or root.

Cl-8Cl-8- Fracture of crown en masse and its displacement.- Fracture of crown en masse and its displacement.

Cl-9Cl-9- Traumatic injuries of primary teeth- Traumatic injuries of primary teeth

8. Traumatic Injuries to the TeethTraumatic Injuries to the Teeth

Clinical examination-Clinical examination-

Medical history- Medical history- Assess the need for SBE Assess the need for SBE
prophylaxis. Determine if the child has a prophylaxis. Determine if the child has a
bleeding disorder, or is immune compromised. bleeding disorder, or is immune compromised.
Record any current medications. Question the Record any current medications. Question the
parent about allergies to medications. parent about allergies to medications.
Determine if the child’s tetanus immunization Determine if the child’s tetanus immunization
is up-to-date. Determine if the child lost is up-to-date. Determine if the child lost
consciousness due to the injury.consciousness due to the injury.

9. Dental and trauma history- Dental and trauma history- The clinician should determine how, The clinician should determine how,
when and where the injury occurred. when and where the injury occurred.
“How” is important because it provides information on the “How” is important because it provides information on the
severity of the injury. “When” is important, because the severity of the injury. “When” is important, because the
prognosis for the injured tooth worsens with every minute of prognosis for the injured tooth worsens with every minute of
delay in treatment. “Where” is important, because it may delay in treatment. “Where” is important, because it may
determine whether or not tetanus prophylaxis is warranted.determine whether or not tetanus prophylaxis is warranted.
Extra oral examination- Extra oral examination- It is important to rule out head injury, It is important to rule out head injury,
ocular damage, and cervical spine injury. An evaluation of pupil ocular damage, and cervical spine injury. An evaluation of pupil
size and reaction to light may establish the presence of head size and reaction to light may establish the presence of head
injury.injury.
Palpate the mandible, zygoma, TMJ, and mastoid region. Palpate the mandible, zygoma, TMJ, and mastoid region.
Ensure that no mandibular or maxillary fractures are present. Ensure that no mandibular or maxillary fractures are present.
Record any extraoral lacerations, bruises, or swelling. Record any extraoral lacerations, bruises, or swelling.

10. Intra oral examination- Intra oral examination- Each tooth should be Each tooth should be
examined for damage or mobility.examined for damage or mobility.
The labial mucosa, maxillary frenum, gingival The labial mucosa, maxillary frenum, gingival
tissues, and tongue should be examined for tissues, and tongue should be examined for
bruising or lacerations. bruising or lacerations.
Radiographic examinationRadiographic examination
Photographic documentationPhotographic documentation
Vitality testing- Vitality testing- Recently traumatized teeth fail to Recently traumatized teeth fail to
respond to conventional vitality testing but a respond to conventional vitality testing but a
baseline measurement is important for future baseline measurement is important for future
interpretation. It may take several months for the interpretation. It may take several months for the
tooth to gain its ability to respond to vitality tests. tooth to gain its ability to respond to vitality tests.
Undamaged adjacent teeth and teeth in the Undamaged adjacent teeth and teeth in the
opposite arch are used as controls. opposite arch are used as controls.

11. Ellis class 1 fractureEllis class 1 fracture

Ellis class 1 fractures can be of two types-Ellis class 1 fractures can be of two types-

1. Crown infractions- Infraction lines are 1. Crown infractions- Infraction lines are
visualized easily with trans- illumination and visualized easily with trans- illumination and
their presence indicates a significant force, their presence indicates a significant force,
hence the status of the pulpal and supporting hence the status of the pulpal and supporting
periodontal structures should be evaluated.periodontal structures should be evaluated.

Treatment- Treatment- Sealing the infraction line with an Sealing the infraction line with an
unfilled resin following an acid etch technique unfilled resin following an acid etch technique
may prevent stains from becoming an esthetic may prevent stains from becoming an esthetic
problem. problem.

12. RECONTOURING FOR ELLIS CLASS I FRACTURE

13. 2. Enamel fractures- Management-2. Enamel fractures- Management-
a. a. Recontouring-Recontouring- Recontouring of the Recontouring of the
injured or adjacent opposing tooth may be injured or adjacent opposing tooth may be
done. Recontouring eliminates the sharp done. Recontouring eliminates the sharp
enamel edges associated with minor enamel edges associated with minor
injuries and prevents laceration of the injuries and prevents laceration of the
tongue, lips oral mucosa. tongue, lips oral mucosa.
b. b. Composite resin restorationComposite resin restoration- The - The
missing tooth structure can be restored missing tooth structure can be restored
with composite resin after acid etching of with composite resin after acid etching of
the enamel surface. the enamel surface.

14. Ellis class 2 fracturesEllis class 2 fractures

The tooth should be examined for minor pulp The tooth should be examined for minor pulp
exposures. Vitality testing should be done immediately exposures. Vitality testing should be done immediately
and regularly at periodic recall visits for a minimum and regularly at periodic recall visits for a minimum
time period of six months and symptoms like thermal time period of six months and symptoms like thermal
sensitivity and pain on mastication should be noted. sensitivity and pain on mastication should be noted.

Intra oral peri apical radiograph of the tooth should Intra oral peri apical radiograph of the tooth should
reveal an intact periodontal ligament space and solid reveal an intact periodontal ligament space and solid
cortical bone associated with the tooth. cortical bone associated with the tooth.

15. Clinical managementClinical management

1. 1. Indirect pulp capping and composite Indirect pulp capping and composite
resin build up-resin build up- If the thickness of remaining If the thickness of remaining
dentin is within 0.5 mm of the dental pulp, dentin is within 0.5 mm of the dental pulp,
application of hard setting calcium hydroxide application of hard setting calcium hydroxide
cement as a liner over the exposed dentinal cement as a liner over the exposed dentinal
tubules and restoration with a composite tubules and restoration with a composite
resin is done.resin is done.

2. 2. Reattachment of the fractured segmentReattachment of the fractured segment

16. ELLIS CLASS II FRACTURE
BEVEL MARGIN
BEFORE COMPOSITE
RESTORATION
APPLICATION OF CALCIUM HYDROXIDE
FOLLOWED BY ACID ETCHING AND
COMPOSITE RESTORATION

17. Reattachment procedure

18. ELLIS CLASS 3 FRACTURESELLIS CLASS 3 FRACTURES

Ellis class 3 fractures are defined as crown fractures Ellis class 3 fractures are defined as crown fractures
involving enamel, dentin and pulp. involving enamel, dentin and pulp.

Radiographic evaluation and sensitivity testing is mandatoryRadiographic evaluation and sensitivity testing is mandatory

Sensitivity testing is usually not indicated initially since Sensitivity testing is usually not indicated initially since
vitality of the pulp can be visualized clinically. vitality of the pulp can be visualized clinically.

Clinical management-Clinical management-

A. Teeth with immature root apices and vital pulpal A. Teeth with immature root apices and vital pulpal
exposures require:exposures require:

1. Pulp capping- 1. Pulp capping- Capping of the pulpCapping of the pulp is to be done only for is to be done only for
small exposures that can be treated immediately after the small exposures that can be treated immediately after the
injury.injury.

19. 
2. Partial pulpotomy or 2. Partial pulpotomy or

3. Pulpotomy depending on the individual case- 3. Pulpotomy depending on the individual case-
Studies indicate that it may be safe to proceed with Studies indicate that it may be safe to proceed with
shallow pulpotomies up to 1 week post fracture. shallow pulpotomies up to 1 week post fracture.
After that, it is questionable in mature, fully formed After that, it is questionable in mature, fully formed
teeth. Although in young, developing teeth with teeth. Although in young, developing teeth with
wide-open apices, pulpotomy can be tried even wide-open apices, pulpotomy can be tried even
when the tooth has been exposed for more than a when the tooth has been exposed for more than a
week. week.

20. TREATMENT PLAN FOR ELLIS CLASS3 FRACTURES

21. B. Fractured crown with mature apex- B. Fractured crown with mature apex- In In
case of teeth with closed apex, vital pulp case of teeth with closed apex, vital pulp
procedures are performed according to procedures are performed according to
individual case. If on follow up, signs of failure individual case. If on follow up, signs of failure
of therapy are seen, for instance, periapical of therapy are seen, for instance, periapical
radiolucency, pain or tenderness on percussion radiolucency, pain or tenderness on percussion
is seen, extirpation of pulp and conventional is seen, extirpation of pulp and conventional
endodontic treatment are carried out. endodontic treatment are carried out.
Instructions to the patient and follow up-Instructions to the patient and follow up-
1. Brushing with a soft brush and rinsing with 1. Brushing with a soft brush and rinsing with
chlorhexidine 0.1%.chlorhexidine 0.1%.
2. The intervals for recall evaluation are 2 2. The intervals for recall evaluation are 2
weeks, 1 month, 3 months, 6 months, 12 weeks, 1 month, 3 months, 6 months, 12
months and yearly for atleast 3 years. months and yearly for atleast 3 years.

22. ELLIS CLASS 3 FRACTURE MANAGEMENT
REMOVAL OF CORONAL PULP
APPLICATION OF
CALCUM HYDROXIDE
PULPOTOMY
PROCEDURE

23. ELLIS CLASS 4 FRACTURESELLIS CLASS 4 FRACTURES

In Ellis class 4 fracture, the tooth becomes non vital In Ellis class 4 fracture, the tooth becomes non vital
with/ without loss of tooth structure.with/ without loss of tooth structure.

Management of Ellis class 4 fracture- Management of Ellis class 4 fracture- depends on depends on
the status of root completion of the tooth.the status of root completion of the tooth.

In case of a tooth with an incomplete/ open apex In case of a tooth with an incomplete/ open apex
and a non vital pulp, the process of apexification and a non vital pulp, the process of apexification
is used to induce the completion of the root apex. is used to induce the completion of the root apex.

In case of a tooth with mature apexIn case of a tooth with mature apex and a necrotic and a necrotic
pulp the line of treatment is pulp the line of treatment is pulpectomy and pulpectomy and
obturation of the canal.obturation of the canal.

24. TREAMENT PLAN FOR ELLIS CLASS 4 FRACTURES

25. A. In case of a tooth with an incomplete/ open A. In case of a tooth with an incomplete/ open
apex and a non vital pulp: apex and a non vital pulp: Two treatment options Two treatment options
can be considered in such cases.can be considered in such cases.
1. Apexification procedure is used to induce apex 1. Apexification procedure is used to induce apex
completion- can be done in one ormultiple visits completion- can be done in one ormultiple visits
depending on the material used.depending on the material used.
Materials for apexificationMaterials for apexification- -
1. calcium hydroxide1. calcium hydroxide
2. MTA2. MTA
3. Metacresylacetate camphorated 3. Metacresylacetate camphorated
parachlorophenolparachlorophenol
4. Resorbable tricalcium phosphate gel.4. Resorbable tricalcium phosphate gel.
5. Tricalcium phosphate + β tri calcium phosphate.5. Tricalcium phosphate + β tri calcium phosphate.
6. Collagen + calcium phosphate gel.6. Collagen + calcium phosphate gel.
7. Biodentine.7. Biodentine.

26. APEXIFICATION PROCEDURE
Discolored non vital tooth- access opening, working
length measurement and CA(OH)2 placement

27. 2. Revascularization of the pulp- Indications2. Revascularization of the pulp- Indications--
Pulp revascularization is indicated as a Pulp revascularization is indicated as a
procedure in cases with immature permanent procedure in cases with immature permanent
teeth where disinfection of the canal can be teeth where disinfection of the canal can be
achieved.achieved.
The necrotic infected pulp may act as a scaffold The necrotic infected pulp may act as a scaffold
for the in growth of new tissue from the for the in growth of new tissue from the
periapical area. This process is called pulp periapical area. This process is called pulp
revascularization. The absence of bacteria is revascularization. The absence of bacteria is
important for successful revascularization important for successful revascularization
hence the canal is disinfected with NaOCl and hence the canal is disinfected with NaOCl and
tri antibiotic paste(metronidazole, tri antibiotic paste(metronidazole,
minocycline and ciprofloxacin ). minocycline and ciprofloxacin ).

28. B. In case of a tooth with mature apex and a B. In case of a tooth with mature apex and a
necrotic pulp:necrotic pulp: pulpectomy followed by pulpectomy followed by
obturation of the root canal is the recommended obturation of the root canal is the recommended
treatment.treatment.
Reattachment of the fragment- Reattachment of the fragment- Reattachment Reattachment
of the fragment is carried out in a similar way as of the fragment is carried out in a similar way as
for an uncomplicated fracture except that an for an uncomplicated fracture except that an
internal groove is made in the dentin of the internal groove is made in the dentin of the
fractured fragment for the coronal part of the fractured fragment for the coronal part of the
post to fit in. post to fit in.

29. Management of crown discolorationManagement of crown discoloration- - In cases In cases
where crown discoloration occurs due to seepage where crown discoloration occurs due to seepage
of necrotic pulp remnants into the dentinal of necrotic pulp remnants into the dentinal
tubules- tubules-
1. Non vital bleaching- 1. Non vital bleaching- thermocatalytic techniquethermocatalytic technique
light bleach light bleach
walking bleach. walking bleach.
2. Veneers2. Veneers
3. Acrylic crowns3. Acrylic crowns

30. ELLIS CLASS 5 FRACTURESELLIS CLASS 5 FRACTURES
Dental avulsion occurs when a tooth is Dental avulsion occurs when a tooth is
completely displaced or knocked out of the completely displaced or knocked out of the
dental socket.dental socket.

Incidence Incidence
–0.5% to 16% of 0.5% to 16% of
traumatic injuriestraumatic injuries

Main etiologic Main etiologic
factorsfactors
–FightsFights
–Sports injuriesSports injuries
–Automobile Automobile
accidentsaccidents

31. Avulsed Permanent TeethAvulsed Permanent Teeth

Maxillary central incisor Maxillary central incisor
–Most commonly avulsed toothMost commonly avulsed tooth

Mandibular teethMandibular teeth
–Seldom affectedSeldom affected

Most frequently involves a Most frequently involves a
single toothsingle tooth

Most common age - 7 to 11Most common age - 7 to 11
–Permanent incisors eruptingPermanent incisors erupting
–Loosely structured PDLLoosely structured PDL

32. Avulsed Permanent TeethAvulsed Permanent Teeth

Associated injuriesAssociated injuries
–Fracture of alveolar Fracture of alveolar
socket wallsocket wall
–Injuries to the lips Injuries to the lips
and gingivaand gingiva

33. Periodontal Ligament Periodontal Ligament
ResponsesResponses

Surface ResorptionSurface Resorption

Replacement Resorption (Ankylosis)Replacement Resorption (Ankylosis)
Inflammatory ResorptionInflammatory Resorption

34. Periodontal Ligament Periodontal Ligament
ResponsesResponses

Surface resorptionSurface resorption
–Superficial resorption Superficial resorption
cavitiescavities
–Mainly in cementumMainly in cementum
–Complete repair of Complete repair of
PDLPDL

35. Periodontal Ligament Periodontal Ligament
ResponsesResponses

Replacement Replacement
resorption resorption
(Ankylosis)(Ankylosis)
–Direct union of bone Direct union of bone
and rootand root
–Resorption of root - Resorption of root -
Replacement with Replacement with
bonebone
–Direct result of loss of Direct result of loss of
vital PDLvital PDL

36. Periodontal Ligament Periodontal Ligament
ResponsesResponses

Inflammatory resorptionInflammatory resorption
–Resorption of cementum Resorption of cementum
and dentinand dentin
–Inflammatory reaction in the Inflammatory reaction in the
periodontal ligamentperiodontal ligament

37. TYPES OF HARD TISSUE BARRIERS FORMEDTYPES OF HARD TISSUE BARRIERS FORMED
The hard tissue barrier has been described by Ghose The hard tissue barrier has been described by Ghose
et al as et al as
1) A cap, 1) A cap,
2) Bridge or 2) Bridge or
3) Ingrown wedge 3) Ingrown wedge
AND MAY BE COMPOSED OF AND MAY BE COMPOSED OF
Cementum,Cementum,
Dentin,Dentin,
Bone Bone
or or
‘Osteodentin’. ‘Osteodentin’.

38. Treatment ConsiderationsTreatment Considerations

Extraoral time- Shorter time = Better Extraoral time- Shorter time = Better
prognosisprognosis**
< 30 min < 30 min  10% resorption 10% resorption
> 90 min > 90 min  90% resorption 90% resorption
Extra oral environmentExtra oral environment

Root surface manipulationRoot surface manipulation

Management of the socketManagement of the socket

StabilizationStabilization

39. Recommended Storage Media- physiological Recommended Storage Media- physiological
storage media are recommended which storage media are recommended which
maintain the environment conducive to vitality maintain the environment conducive to vitality
of PDL cellsof PDL cells
1. Socket (immediate 1. Socket (immediate
replantation)replantation)
2. Cell culture 2. Cell culture
mediummedium
3. Milk3. Milk
4. Physiologic saline4. Physiologic saline
5.5.SalivaSaliva
6.6.Tap waterTap water

40. Milk As A Storage MediumMilk As A Storage Medium

Physiologic osmolalityPhysiologic osmolality

Markedly fewer bacteria than salivaMarkedly fewer bacteria than saliva

Readily availableReadily available

Storage for 2 hrsStorage for 2 hrs
–Periodontal healing almost as good as Periodontal healing almost as good as
immediate replantationimmediate replantation
Storage for 6 hrsStorage for 6 hrs
–Saliva Saliva  extensive replacement resorption extensive replacement resorption
–Milk Milk  healing almost as good as immediate healing almost as good as immediate
replantreplant

41. Hank’s Balanced Salt Solution- Hank’s Balanced Salt Solution-
ideal storage mediumideal storage medium

Proper pH and osmolalityProper pH and osmolality

Reconstitutes depleted cellular metabolitesReconstitutes depleted cellular metabolites

Washes toxic breakdown products from the Washes toxic breakdown products from the
root surfaceroot surface

42. EMERGENCY TREATMENT AT THE TIME EMERGENCY TREATMENT AT THE TIME
AND SITE OF INJURYAND SITE OF INJURY
1. Replant the tooth as soon as possible after 1. Replant the tooth as soon as possible after
the avulsion. the avulsion.
2. If it is not possible to reinsert the tooth, place 2. If it is not possible to reinsert the tooth, place
it in a suitable transport medium.it in a suitable transport medium.

43. EMERGENCY TREATMENT AT THE EMERGENCY TREATMENT AT THE
DENTAL OFFICEDENTAL OFFICE
1. Place the tooth in normal saline. Take 1. Place the tooth in normal saline. Take
relevant history, examine the area andrelevant history, examine the area and
take radiographs as thoroughly and as quickly take radiographs as thoroughly and as quickly
as possible. as possible.
2. Any gross debris should be wiped away 2. Any gross debris should be wiped away
gently from the root surface with a wet sponge. gently from the root surface with a wet sponge.
3. The socket should be irrigated with saline.3. The socket should be irrigated with saline.
4. As soon as possible, the tooth should be 4. As soon as possible, the tooth should be
replanted back into the socket holding it with a replanted back into the socket holding it with a
wet sponge. wet sponge.
5. A radiograph will confirm the right position of 5. A radiograph will confirm the right position of
the tooth. the tooth.

44. Replantation guidelinesReplantation guidelines

For a mature tooth with a closed apex: For a mature tooth with a closed apex:

1. 1. If the tooth has already been replantedIf the tooth has already been replanted- Clean - Clean
affected area with water spray, saline or chlorhexidine.affected area with water spray, saline or chlorhexidine.

2.2. If the extraoral dry time is <60 minutes If the extraoral dry time is <60 minutes and the and the
tooth has been kept in suitable transport mediumtooth has been kept in suitable transport medium- -
Clean the contaminated root surface and apical foramen Clean the contaminated root surface and apical foramen
with a stream of saline. Remove the coagulum from the with a stream of saline. Remove the coagulum from the
socket with a stream of saline. Examine the alveolar socket with a stream of saline. Examine the alveolar
socket. If there is a fracture in the socket wall, reposition socket. If there is a fracture in the socket wall, reposition
it. Replant the tooth slowly with slight digital pressure. it. Replant the tooth slowly with slight digital pressure.

45. Root Surface ManipulationRoot Surface Manipulation

Extraoral Extraoral drydry time > 1 hr time > 1 hr
–Loss of PDL cell viability Loss of PDL cell viability
inevitable inevitable
–Treatment recommendationsTreatment recommendations
»Remove tissue tagsRemove tissue tags
»Soak in accepted dental Soak in accepted dental
fluoride solution for 20 minfluoride solution for 20 min

1.0-2.4% topical fluoride 1.0-2.4% topical fluoride
solutionsolution
–Sodium fluorideSodium fluoride(Andreasen)(Andreasen)
Stannous fluoride (Krasner)- Fluoride is used because fluoroapatite
formed is more resistant to resorption.

46. MANAGEMENT OF A TOOTH WITH A NON VITAL PERIODONTAL LIGAMENT-

curettage of
PDLremnants
followed by
extraoral root canal
treatment,
replantation and
splinting

47. MATERIALS USED TO PREVENT FAILURE MATERIALS USED TO PREVENT FAILURE
OF REIMPLANTED TOOTH- OF REIMPLANTED TOOTH-
1. Emdogain- 1. Emdogain- Emdogain consists of Emdogain consists of
hydrophobic enamel matrix proteins extracted hydrophobic enamel matrix proteins extracted
from porcine developing embryonic enamel. It from porcine developing embryonic enamel. It
can be used for treating avulsed teeth prior to can be used for treating avulsed teeth prior to
replantation to prevent or delay replacement replantation to prevent or delay replacement
root resorption by regenerating a healthy root resorption by regenerating a healthy
periodontium because of its ability to produce periodontium because of its ability to produce
new periodontal ligament from the viable cells new periodontal ligament from the viable cells
on the socket wall.on the socket wall.
2. Hydroxyapatite2. Hydroxyapatite
3. Acetazolamide3. Acetazolamide
4. Bis- phosphonates4. Bis- phosphonates

48. For an immature tooth with an open apex: For an immature tooth with an open apex:
A. If the tooth has already been replanted-A. If the tooth has already been replanted-
Clean affected area with water spray, saline or Clean affected area with water spray, saline or
chlorhexidine rinse.chlorhexidine rinse.
B. The tooth has been kept in special B. The tooth has been kept in special
storage media, milk, saline or saliva. The storage media, milk, saline or saliva. The
extra-oral dry time is <60 minutes- extra-oral dry time is <60 minutes-
If contaminated, the root surface and apical If contaminated, the root surface and apical
foramen are cleaned with a stream of saline.foramen are cleaned with a stream of saline.
Place the tooth in doxycycline (~100 mg/20 ml Place the tooth in doxycycline (~100 mg/20 ml
saline) for 5 minutes or soak in minocycline- saline) for 5 minutes or soak in minocycline-
These antibiotics have shown to increase the These antibiotics have shown to increase the
chances of maintainance of vitality of PDL cells. chances of maintainance of vitality of PDL cells.

49. MANAGEMENT OF A TOOTH WITH INCOMPLETE APEX FORMATION BY
INTRA CANAL CALCIUM HYDROXIDE DRESSING- APEXIFICATION PROCEDURE

50. For cases with extra oral time of 20 to 60 For cases with extra oral time of 20 to 60
minutes-minutes-
IntracanalIntracanal placement of Ledermix paste has placement of Ledermix paste has
been shown to produce promising results in been shown to produce promising results in
such cases. Ledermix paste consists of such cases. Ledermix paste consists of
triamcinolone (steroid) and demeclocycline triamcinolone (steroid) and demeclocycline
(tetracycline). (tetracycline).
Bryson et al proved that Ledermix paste was Bryson et al proved that Ledermix paste was
more useful in healing and less resorption more useful in healing and less resorption
occurred in comparison to cases where calcium occurred in comparison to cases where calcium
hydroxide was used as the intracanal hydroxide was used as the intracanal
medicament as it disinfects the root canal space medicament as it disinfects the root canal space
and hence discourages external resorption and hence discourages external resorption
caused by necrotic canal contents. caused by necrotic canal contents.

51. Management of the SocketManagement of the Socket

Remove contaminated coagulum in Remove contaminated coagulum in
socketsocket
–Irrigate with sterile saline Irrigate with sterile saline

52. Management of the SocketManagement of the Socket

Examine socket Examine socket  If fracture is evidentIf fracture is evident
–Reposition fractured bone with a blunt Reposition fractured bone with a blunt
instrumentinstrument

53. Management of the SocketManagement of the Socket

Replant using light digital pressureReplant using light digital pressure

54. StabilizationStabilization

Splint Splint
–Definition Definition  a a rigidrigid or or flexibleflexible device used to device used to
support, protect, or immobilize teeth, preventing support, protect, or immobilize teeth, preventing
further injury for 7 to 10 days.further injury for 7 to 10 days.
–TypesTypes
•Acid etch compositeAcid etch composite
•Cross-sutureCross-suture
•Titanium trauma splintTitanium trauma splint
•Acid etch wire composite splint Acid etch wire composite splint
•RibbondRibbond

55. Acid Etch Composite SplintsAcid Etch Composite Splints

Interproximal compositeInterproximal composite

56. Acid Etch Composite SplintsAcid Etch Composite Splints

Composite with arch wireComposite with arch wire

57. Acid Etch Composite SplintsAcid Etch Composite Splints

Composite with monofilament nylonComposite with monofilament nylon

58. Cross-Suture SplintCross-Suture Splint
Indications
No adjacent teeth to splint to
Unmanageable traumatized children

59. Titanium trauma
splint
Splinting with
Ribbond

60. Pulpal PrognosisPulpal Prognosis

Stage of root development- as the maturity Stage of root development- as the maturity
increases, the chances of revascularization increases, the chances of revascularization
decreases.decreases.

Dry storage time- Dry storage time- if more, decreases chances if more, decreases chances
of pulp survivalof pulp survival

Storage media- Storage media- physiological media favor physiological media favor
pulp survivalpulp survival

Antibiotics-Antibiotics-topical antibiotics have a beneficial topical antibiotics have a beneficial
effecteffect

61. Endodontic Rationale – Mature Endodontic Rationale – Mature
RootRoot

Pulpectomy Pulpectomy  7-14 days 7-14 days

62. Endodontic Rationale – Mature Endodontic Rationale – Mature
RootRoot

Calcium hydroxideCalcium hydroxide
placement placement
–AntibacterialAntibacterial
–Increases pH in dentinIncreases pH in dentin
–Favors mineralization over resorptionFavors mineralization over resorption
–Ca(OH)Ca(OH)
22 therapy for as long as practical, therapy for as long as practical,
usually 6-12 months to stop external usually 6-12 months to stop external
resorption.resorption.

63. Treatment FlowchartTreatment Flowchart
<< 1 hr 1 hr > 1 hr> 1 hr
ExtraoralExtraoral Dry Dry TimeTime
Apex MaturityApex Maturity
ClosedClosedOpenOpen Open or ClosedOpen or Closed
PulpectomPulpectom
y7-14 daysy7-14 days
ObserveObserve
OptionOption: :
Extraoral Extraoral
RCTRCT
PulpectomPulpectom
y 7-14 y 7-14
daysdays

64. 
Additional ConsiderationsAdditional Considerations
–Analgesics- Paracetamol or NSAID based Analgesics- Paracetamol or NSAID based
analgesics are generally prescribed like analgesics are generally prescribed like
paracetamol and codeine combination or paracetamol and codeine combination or
ibuprofen.ibuprofen.
–Chlorhexidine mouthwash (0.12%) to Chlorhexidine mouthwash (0.12%) to
maintain oral hygienemaintain oral hygiene
–Tetanus- History of prophylaxis should be Tetanus- History of prophylaxis should be
taken and toxoid injection advised if taken and toxoid injection advised if
required.required.

Antibiotics- PenicillinAntibiotics- Penicillin
–500 mg qid for 4-7 days500 mg qid for 4-7 days

65. In case the avulsed tooth cannot be locatedIn case the avulsed tooth cannot be located- -
There are two treatment options:There are two treatment options:
1. A provisional removable partial denture.1. A provisional removable partial denture.
2. Autotransplantation-2. Autotransplantation-
Autotransplantation is defined as the extraction Autotransplantation is defined as the extraction
of a tooth from one location and its replantation of a tooth from one location and its replantation
in a different location in the same individual. in a different location in the same individual.
Autotransplantation can be done in cases Autotransplantation can be done in cases
where a suitable graft is available and treatment where a suitable graft is available and treatment
needs of the patient indicate extraction of the needs of the patient indicate extraction of the
graft.graft.

66. AUTOTRANSPLANTATION
OF SECOND
PREMOLAR IN PLACE
OF MAXILAARY
CENTRAL INCISOR
FOLLOWED BY
CONTOURING AND
FULL COVERAGE
ALL CERAMIC
CROWN PLACEMENT

67. ELLIS CLASS 6 FRACTURESELLIS CLASS 6 FRACTURES
Root fractures can be in two planes- Root fractures can be in two planes-
1. Horizontal plane.1. Horizontal plane.
2. Vertical plane. 2. Vertical plane.
Horizontal fractures are further classified Horizontal fractures are further classified
depending on the level of fracturedepending on the level of fracture
• Apical 1/3• Apical 1/3
rdrd
fracture: zone I fracture: zone I
• Middle 1/3• Middle 1/3
rdrd
fracture: zone II fracture: zone II
• Cervical 1/3• Cervical 1/3
rdrd
fracture: zone III fracture: zone III

68. 1. 1. Root fractures are often not apparent during Root fractures are often not apparent during
a clinical examination and can usually be a clinical examination and can usually be
diagnosed using appropriate radiographs. diagnosed using appropriate radiographs.
2. 2. Clinical features when present are mobility of Clinical features when present are mobility of
the coronal fragment. The level of fracture can the coronal fragment. The level of fracture can
be discerned by arc of mobility of the mobile be discerned by arc of mobility of the mobile
fragment. The greater the arc, the coronal is the fragment. The greater the arc, the coronal is the
level of fracture. level of fracture.

69. Treatment of horizontal fractures-Treatment of horizontal fractures-
The definitive treatment of a horizontal root The definitive treatment of a horizontal root
fracture is the immediate reduction of the fracture is the immediate reduction of the
fractured segments and complete immobilization fractured segments and complete immobilization
of the coronal segment. If more than 24-72 hours of the coronal segment. If more than 24-72 hours
have elapsed, close apposition of the segments is have elapsed, close apposition of the segments is
generally impossible.generally impossible.
Splinting time-Splinting time- Root fracture (middle third) - 4 Root fracture (middle third) - 4
weeks.weeks.
Root fracture (cervical third) - 4
 months.
Root fracture (cervical third) - 4
 months.
Splinting is not needed in cases of apical third Splinting is not needed in cases of apical third
fractures because the coronal fragment is fractures because the coronal fragment is
sufficiently stable.sufficiently stable.

70. MANAGEMENT OF ELLIS CLASS 6 FRACTURE BY SPLINTING

71. 3. Endodontic treatment-3. Endodontic treatment- Healing is monitored Healing is monitored
for at least 1
 year to determine pulpal status. If
for at least 1
 year to determine pulpal status. If
pulp necrosis develops, root canal treatment of pulp necrosis develops, root canal treatment of
the coronal tooth segment to the fracture line is the coronal tooth segment to the fracture line is
indicated to preserve the tooth. Endodontic indicated to preserve the tooth. Endodontic
treatment of both or the coronal fragment may treatment of both or the coronal fragment may
be carried out. be carried out.
In case of coronal third fractures where the In case of coronal third fractures where the
coronal fragment is lost-coronal fragment is lost-
1. Orthodontic extrusion of root1. Orthodontic extrusion of root
2. Intra alveolar reimplantation of fractured tooth 2. Intra alveolar reimplantation of fractured tooth
can be done.can be done.

72. ACCESS OPENING FOLLOWED BY INTRA CANAL CALCIUM
HYDROXIDE DRESSING TILL THE FRACTURE LINE AND THEN
FINALLY OBTURATION WITH GUTTA PERCHA

73. Vertical fractures-Vertical fractures- The fracture runs lengthwise The fracture runs lengthwise
from the crown towards the apex. from the crown towards the apex.
Clinical recognitionClinical recognition- - 1. Persistent dull pain of long 1. Persistent dull pain of long
standing origin.standing origin.
2. Pain is elicited by applying pressure.2. Pain is elicited by applying pressure.
3. A chronically non healing pocket that is not 3. A chronically non healing pocket that is not
present around the tooth but localized to one side present around the tooth but localized to one side
and is isolated. and is isolated.
4. Radiographically, thickening of periodontal 4. Radiographically, thickening of periodontal
ligament, separation of the root fragments is seen.ligament, separation of the root fragments is seen.
5. Pulpal sensitivity testing should be done to 5. Pulpal sensitivity testing should be done to
confirm pulpal necrosis which is inevitable in these confirm pulpal necrosis which is inevitable in these
cases. cases.
  
  

74. Treatment- Treatment- In general, prognosis for single In general, prognosis for single
rooted teeth is poor and extraction is generally rooted teeth is poor and extraction is generally
the suggested treatment. However innovative the suggested treatment. However innovative
methods like bonding the fragments using a methods like bonding the fragments using a
biocompatible material have also been biocompatible material have also been
reported. reported.

75. ELLIS CLASS 7 FRACTURESELLIS CLASS 7 FRACTURES
This class of fractures includes:This class of fractures includes:
1. Concussion1. Concussion- - Injury to tooth supporting structures Injury to tooth supporting structures
without abnormal loosening or displacement of tooth.without abnormal loosening or displacement of tooth.
2. Subluxation2. Subluxation- - Injury to tooth supporting structures Injury to tooth supporting structures
with abnormal loosening but without displacement of with abnormal loosening but without displacement of
tooth.tooth.
3. Extrusive luxation3. Extrusive luxation- - Partial displacement of tooth Partial displacement of tooth
out of the socket.out of the socket.
4. Lateral luxation4. Lateral luxation- - Displacement of tooth in a Displacement of tooth in a
direction other than axially.direction other than axially.
5. Intrusion-5. Intrusion- Apical displacement of tooth into Apical displacement of tooth into
alveolar bone, accompanied by comminution or alveolar bone, accompanied by comminution or
fracture of alveolar socket.fracture of alveolar socket.

76. SUBLUXATION AND DENTAL CONCUSSIONSUBLUXATION AND DENTAL CONCUSSION
These injuries represent minor injuries to the These injuries represent minor injuries to the
periodontal ligament and pulp caused by an periodontal ligament and pulp caused by an
acute impact. acute impact.
RadiographicallyRadiographically, there are no pathological , there are no pathological
changes in the supporting tissues. changes in the supporting tissues.
Treatment consists of:Treatment consists of:
- Occlusal relief - Occlusal relief (e.g. by selective grinding of (e.g. by selective grinding of
opposing teeth) and a soft diet is advised for opposing teeth) and a soft diet is advised for
two weeks.two weeks.
- Immobilization- - Immobilization- If the tooth is very mobile, and If the tooth is very mobile, and
can be moved more than 2mm, a flexible wire can be moved more than 2mm, a flexible wire
and composite splint may be placed. The and composite splint may be placed. The
fixation period is 2 weeks.fixation period is 2 weeks.

77. CONCUSSION AND SUBLUXATION
CLINICAL AND RADIOGRAPHIC PICTURE


MANAGEMENT- REMOVAL OF OCCLUSAL INTERFERENCE
FOR CONCUSSION AND SPLINTING FOR SUBLUXATION

78. EXTRUSIVE LUXATIONEXTRUSIVE LUXATION
An extrusion occurs when a tooth is only An extrusion occurs when a tooth is only
partially removed from the socket.partially removed from the socket.
Clinical recognition- Clinical recognition- 1. The tooth appears 1. The tooth appears
elongated and is excessively mobile.elongated and is excessively mobile.
2. Sensitivity tests will likely give negative 2. Sensitivity tests will likely give negative
results.results.
Clinical management- Clinical management- 1.1. Reposition the tooth Reposition the tooth
by gently re-inserting it into the socket. by gently re-inserting it into the socket.
2. Stabilize the tooth for 2 weeks using a 2. Stabilize the tooth for 2 weeks using a
flexible splint. flexible splint.

79. 3. 3. Orthodontic intrusion Orthodontic intrusion may also be carried out by may also be carried out by
fixed appliance therapy. fixed appliance therapy.
4. 4. Endodontic treatment Endodontic treatment is certain in cases of is certain in cases of
significant extrusion (more than 2 mm) of mature significant extrusion (more than 2 mm) of mature
teeth. In such cases, pulpectomy should be teeth. In such cases, pulpectomy should be
performed and root canal space obturated with gutta performed and root canal space obturated with gutta
percha.percha.
5. 5. Crown discoloration Crown discoloration in such cases may be treated in such cases may be treated
with non vital bleaching methods, veneers or full with non vital bleaching methods, veneers or full
coverage all ceramic crowns.coverage all ceramic crowns.
6. In cases with incomplete root formation or open 6. In cases with incomplete root formation or open
apex and pulp necrosis, apex and pulp necrosis, apexificationapexification is done to is done to
induce complete root formation. induce complete root formation.

80. MANAGEMENT OF EXTRUSION BY MANUAL REPOSITIONING
AND SUTURING TO SECURE THE TOOTH

81. INTRUSIONINTRUSION
An intrusion injury is the most severe type of An intrusion injury is the most severe type of
luxation injury. The intruded tooth is impacted luxation injury. The intruded tooth is impacted
into the alveolar bone, and the alveolar socket into the alveolar bone, and the alveolar socket
is fractured.is fractured.
Clinical recognition- Clinical recognition-
1. In many cases, the tooth may not be visible.1. In many cases, the tooth may not be visible.
2. The tooth is displaced axially into the alveolar 2. The tooth is displaced axially into the alveolar
bone.bone.
3. It is immobile and percussion may give a 3. It is immobile and percussion may give a
high, metallic (ankylotic) sound.high, metallic (ankylotic) sound.
4. Sensitivity tests will likely give negative 4. Sensitivity tests will likely give negative
results.results.

82. Clinical managementClinical management- Management strategies: - Management strategies:
1. surgical reduction (immediate repositioning), 1. surgical reduction (immediate repositioning),
2. repositioning with traction (active repositioning), 2. repositioning with traction (active repositioning),
3. waiting for the tooth to return to its pre-injury 3. waiting for the tooth to return to its pre-injury
position (passive repositioning).position (passive repositioning).
Incisors intruded less than 3mm may be allowed to reposition
themselves.
Prognosis of incisors intruded between 3 –6 mm is unpredictable,
but they may be orthodontically extruded within 3-6 weeks.
Incisors that have been intruded beyond 6 mm should be
immediately repositioned (surgically) to their normal
– followed by root canal treatment.

83. MANAGEMENT OF INTRUSION

SPONTANEOUS ERUPTION
ORTHODONTIC
EXTRUSION

84. LATERAL LUXATIONLATERAL LUXATION
In lateral luaxation, a horizontal impact forces In lateral luaxation, a horizontal impact forces
the crown palatally and the apex labially.the crown palatally and the apex labially.
Clinical recognition- Clinical recognition- 1. 1. The tooth is displaced, The tooth is displaced,
usually in a palatal/lingual or labial direction. usually in a palatal/lingual or labial direction.
2. It will be immobile and percussion usually 2. It will be immobile and percussion usually
gives a high, metallic (ankylotic) sound.gives a high, metallic (ankylotic) sound.
3. Sensitivity tests will likely give negative 3. Sensitivity tests will likely give negative
results.results.

85. Clinical managementClinical management--
1. 1. An anti-inflammatory agent, an analgesic and an An anti-inflammatory agent, an analgesic and an
antibiotic are prescribed.antibiotic are prescribed.
2. Repositioning 2. Repositioning after local anesthesia, and applying a after local anesthesia, and applying a
semi-rigid splint for 4 weeks. A post-treatment semi-rigid splint for 4 weeks. A post-treatment
radiograph should be performed to assure proper radiograph should be performed to assure proper
position of the tooth in the socket. position of the tooth in the socket.
4. Stabilize 4. Stabilize the tooth for 4 weeks using a flexible splint. the tooth for 4 weeks using a flexible splint.
5. Monitor the pulpal condition. 5. Monitor the pulpal condition. If the pulp becomes If the pulp becomes
necrotic, root canal treatment is indicated to prevent necrotic, root canal treatment is indicated to prevent
root resorption. root resorption.
6. In immature, developing teeth, 6. In immature, developing teeth, revascularization can revascularization can
be a possibility.be a possibility.

86. ELLIS CLASS 8 FRACTURESELLIS CLASS 8 FRACTURES
It is the fracture of the crown enmasse and its It is the fracture of the crown enmasse and its
displacement. displacement.
  
Clinical examination-Clinical examination- 1. Hemorrhage or 1. Hemorrhage or
swelling are seen in the related area.swelling are seen in the related area.
2. Pulpal exposure will be observed in the 2. Pulpal exposure will be observed in the
affected tooth.affected tooth.
3. Vitality of the tooth should be checked by an 3. Vitality of the tooth should be checked by an
electrical pulp tester.electrical pulp tester.

87. Clinical management- Clinical management-
1. Reattachment-1. Reattachment-
Fractured fragment is removed and kept in Fractured fragment is removed and kept in
saline.saline.
Obturation of the canal carried out followed by Obturation of the canal carried out followed by
post space preparation.post space preparation.
Fiber reinforced post is cemented into the Fiber reinforced post is cemented into the
canal. canal.
The fractured fragment is cemented to the The fractured fragment is cemented to the
coronal portion of the fiber post by using self coronal portion of the fiber post by using self
cure resin cement.cure resin cement.
The palatal access cavity is filled with a The palatal access cavity is filled with a
composite resin.composite resin.

88. MANAGEMENT OF ELLIS CLASS 8 FRACTURE BY SURGICAL
EXTRUSION AND POST AND CORE BUILD UP FOLLOWED BY
FULL COVERAGE CROWN

89. MANAGEMENT BY ORTHODONTIC EXTRUSION

90. ELLIS CLASS 9 FRACTURESELLIS CLASS 9 FRACTURES
Ellis class 9 fractures include all the injuries to Ellis class 9 fractures include all the injuries to
the primary teeth and the supporting tissues.the primary teeth and the supporting tissues.
Trauma to the primary dentition presents Trauma to the primary dentition presents
special problems and the management is often special problems and the management is often
difficult and different as compared to the difficult and different as compared to the
permanent dentition. As much as 18% of all the permanent dentition. As much as 18% of all the
injuries are seen in the oral region in children, injuries are seen in the oral region in children,
0-6 years old. The teeth most commonly 0-6 years old. The teeth most commonly
affected are the maxillary incisors, and the affected are the maxillary incisors, and the
average age for the highest incidence of trauma average age for the highest incidence of trauma
is between 1 and 3 years.is between 1 and 3 years.

91. In the primary dentition, small coronal
fractures may be observed in primary teeth
but luxations are more common. This is
because of the pliability of the facial skeleton
and of the periodontal ligament, the large
volume of teeth in relation to the bone in
primary and mixed dentition period and
finally, the shorter roots of primary teeth.

92. Sequelae for permanent dentition after traumatic
injuries to primary dentition-
1.Hypoplastic defects- may range from white opacities to brown
spots or pits on the labial surface.
2.Turner’s hypoplaisa is another example marked by discoloration of
teeth or structural alteration in the crown.
3. Structural alterations associated with enamel hypoplasia, crown
dilaceration and white, yellow or brown discoloration.
4. Root duplication, root dilaceration and partial or complete arrest of
root formation.
5. Alterations to the process of eruption of the permanent tooth, or
malformation of the permanent tooth germ.

93. Sequelae to injury to permanent teeth due to trauma to primary teeth

94. Clinical examinationClinical examination- - A detailed history about A detailed history about
the accident causing the trauma and the time the accident causing the trauma and the time
elapsed since the accident are important elapsed since the accident are important
components to be evaluated. Thorough extra components to be evaluated. Thorough extra
oral and intra oral examination must be carried oral and intra oral examination must be carried
out to discern any associated injuries. out to discern any associated injuries.
Radiographic examinationRadiographic examination- - Radiographs with Radiographs with
the following three angulations are the following three angulations are
recommended:recommended:
9090
oo
horizontal angle, with central beam through horizontal angle, with central beam through
the tooth in question.the tooth in question.
• Occlusal view.• Occlusal view.
• Lateral view from the mesial or distal aspect of • Lateral view from the mesial or distal aspect of
the tooth in question.the tooth in question.

95. 1. Uncomplicated crown fracture- Fracture
involves enamel or dentin and
enamel; the pulp is not exposed.
 
Radiographic findings- An intra oral periapical
view will show the relation between the fracture line
and the pulp chamber.
 
Treatment -1. Smoothen sharp edges if possible the
tooth can be restored with glass ionomer cement or
resin composite.
 

96. 2. 2. Complicated crown fractureComplicated crown fracture- - Fracture involves enamel Fracture involves enamel
and dentin and the pulp is exposed.and dentin and the pulp is exposed.
Radiographic examination- Radiographic examination- A periapical view is used to A periapical view is used to
discern the extent of fracture and the stage of root discern the extent of fracture and the stage of root
development.development.
  
Treatment-Treatment- In very young children with immature, still In very young children with immature, still
developing roots, it is advantageous to preserve pulp vitality developing roots, it is advantageous to preserve pulp vitality
by pulp capping or partial pulpotomy. Calcium hydroxide is by pulp capping or partial pulpotomy. Calcium hydroxide is
the material of choice. In cases where these treatments are the material of choice. In cases where these treatments are
not feasible, extraction is indicated. not feasible, extraction is indicated.
Coronal pulpotomy is the most widely advocated treatment Coronal pulpotomy is the most widely advocated treatment
for exposed primary pulps because of its consistently for exposed primary pulps because of its consistently
reported higher success rates when compared with direct reported higher success rates when compared with direct
pulp capping.pulp capping.

97. MANAGEMENT OF A CROWN ROOT FRACTURE BY EITHER
EXTRACTION OR
ROOT CANAL TREATMENT IF THE PROGNOSIS IS FAVORABLE

98. 3. 3. Crown root fractureCrown root fracture- - Fracture involves enamel, dentin and Fracture involves enamel, dentin and
root structure; the pulp may or may not be exposed. Additional root structure; the pulp may or may not be exposed. Additional
findings may be loose but still attached fragments of the tooth. findings may be loose but still attached fragments of the tooth.
There is minimal to moderate tooth displacement.There is minimal to moderate tooth displacement.
Radiographic examination- Radiographic examination- InIn laterally positioned i.e. oblique laterally positioned i.e. oblique
fractures, the extent of the fracture line in relation to the fractures, the extent of the fracture line in relation to the
gingival margins can be seengingival margins can be seen..
Treatment- Treatment- Extraction is the only recommended treatment Extraction is the only recommended treatment
unless pulp therapy procedures can be implemented. Root unless pulp therapy procedures can be implemented. Root
canal treatment should be initiated only if protection against canal treatment should be initiated only if protection against
bacterial leakage can be achieved and the tooth adequately bacterial leakage can be achieved and the tooth adequately
restored thereafter. Care must be taken to avoid injury to the restored thereafter. Care must be taken to avoid injury to the
adjacent tooth bud.adjacent tooth bud.

99. 4. Root fracture- 4. Root fracture- The coronal fragment is generally The coronal fragment is generally
mobile and may be displaced.mobile and may be displaced.
Radiographic examination- Radiographic examination- Generally, the fracture is Generally, the fracture is
located in the middle or the apical third.located in the middle or the apical third.
Treatment-Treatment- Root fracturesRoot fractures 
in primary teeth,
 
in primary teeth,
particularly those occurring in the apical third of the particularly those occurring in the apical third of the
root, can be monitored if there is no mobility. If there is root, can be monitored if there is no mobility. If there is
mobility or if the fracture occurs in the coronal third of mobility or if the fracture occurs in the coronal third of
the root, extraction is the treatment of choicethe root, extraction is the treatment of choice..

100. 4. 4. Alveolar fractureAlveolar fracture- - The fracture involves the alveolar The fracture involves the alveolar
bone supporting the primary teeth and permanent tooth bone supporting the primary teeth and permanent tooth
germs.germs.
The tooth containing segment is mobile and usually The tooth containing segment is mobile and usually
displaced. displaced.
Occlusal interference is usually noted.Occlusal interference is usually noted.
  
Radiographic examination- Radiographic examination- TheThe fracture line close to fracture line close to
the apices of the primary teeth and their permanent the apices of the primary teeth and their permanent
successors will be disclosed. A lateral radiograph may successors will be disclosed. A lateral radiograph may
also be taken to discern the relation between the two also be taken to discern the relation between the two
dentitions and also if the segment is displaced in the dentitions and also if the segment is displaced in the
labial direction.labial direction.
  
TreatmentTreatment- - Reposition any displaced segment and then Reposition any displaced segment and then
splint. General anesthesia may be indicated in splint. General anesthesia may be indicated in
complicated cases. Teeth in the fracture line are complicated cases. Teeth in the fracture line are
monitored for loss of vitality of pulp.monitored for loss of vitality of pulp.

101. LUXATION INJURIES IN THE PRIMARY LUXATION INJURIES IN THE PRIMARY
DENTITIONDENTITION
1. Concussion- 1. Concussion- The tooth is tender to touch; it The tooth is tender to touch; it
has no increased mobility or sulcular bleeding.has no increased mobility or sulcular bleeding.
  
Radiographic examination- Radiographic examination- No radiographic No radiographic
abnormalities are visible. The periodontal space abnormalities are visible. The periodontal space
is normal in width.is normal in width.
  
Treatment- Treatment- No treatment is needed except No treatment is needed except
repeated observation.repeated observation.

102. 2. Subluxation- 2. Subluxation- The tooth has increased mobility but The tooth has increased mobility but
has not been displaced. has not been displaced.
Radiographic examination- Radiographic examination- No radiographic No radiographic
abnormalities are visible. The periodontal space is abnormalities are visible. The periodontal space is
normal in width.normal in width.
Treatment-Treatment-  Monitoring of afflicted teeth should be Monitoring of afflicted teeth should be
done on a regular basis for the first year as opposed to done on a regular basis for the first year as opposed to
immediately instituting invasive treatment. In instances immediately instituting invasive treatment. In instances
of excessive mobility, short-term splinting of 7 to 10 of excessive mobility, short-term splinting of 7 to 10
days using acid-etched resin attachment of a light days using acid-etched resin attachment of a light
orthodontic wire should be considered. Equilibrating orthodontic wire should be considered. Equilibrating
opposing teeth to reduce repeated hyperocclusion opposing teeth to reduce repeated hyperocclusion
trauma to the afflicted teeth can also enhance trauma to the afflicted teeth can also enhance
stabilization.stabilization.

103. Extrusive LuxationExtrusive Luxation- - The tooth appears elongated The tooth appears elongated
and is excessively mobileand is excessively mobile..
  
Radiographic examination- Radiographic examination- Increased periodontal Increased periodontal
ligament space apically.ligament space apically.
Treatment- Treatment- Treatment depends upon the degree of Treatment depends upon the degree of
displacement, mobility, root formation and the ability displacement, mobility, root formation and the ability
of the child to cope with the emergency situation. of the child to cope with the emergency situation.
For minor extrusion (>3 mm) in an immature For minor extrusion (>3 mm) in an immature
developing tooth- Careful repositioning and developing tooth- Careful repositioning and
stabilization is an acceptable treatment option. stabilization is an acceptable treatment option.
Extraction is the treatment of choice for a severe Extraction is the treatment of choice for a severe
extrusion in a fully matured primary tooth.extrusion in a fully matured primary tooth.

104. Lateral luxation- Lateral luxation- The tooth is displaced usually in a The tooth is displaced usually in a
palatal/ lingual direction. It will often be immobilepalatal/ lingual direction. It will often be immobile..
Radiographic examination- Radiographic examination- Increased periodontal Increased periodontal
ligament space apically is best seen on an occlusal ligament space apically is best seen on an occlusal
view.view.
Treatment- Treatment- If there is no occlusal interference as is If there is no occlusal interference as is
often the case in anterior open bite, the tooth is often the case in anterior open bite, the tooth is
allowed to reposition spontaneously. When there is allowed to reposition spontaneously. When there is
occlusal interference with the use of local anesthesia, occlusal interference with the use of local anesthesia,
the tooth can be gently repositioned by combined the tooth can be gently repositioned by combined
labial and palatal pressure.labial and palatal pressure.
In severe displacement, when the crown is dislocated In severe displacement, when the crown is dislocated
in a labial direction, extraction is the treatment of in a labial direction, extraction is the treatment of
choice. choice.

105. Intrusive luxation- Intrusive luxation- The tooth is usually The tooth is usually
displaced through the labial bone plate or can displaced through the labial bone plate or can
impinge upon the succedaneous tooth bud.impinge upon the succedaneous tooth bud.
Clinical examination- Clinical examination- Clinically, the tooth may Clinically, the tooth may
disappear completely into the surrounding disappear completely into the surrounding
tissues.tissues.
Percussion on an intruded tooth produces a Percussion on an intruded tooth produces a
metallic sound and does not provoke pain.metallic sound and does not provoke pain.

106. It is extremely important to determine after the injury whether It is extremely important to determine after the injury whether
the primary tooth is in contact with the permanent tooth germ the primary tooth is in contact with the permanent tooth germ
or has been pushed away in the labial direction. or has been pushed away in the labial direction.
Several clinical and radiographic signs support the diagnosis Several clinical and radiographic signs support the diagnosis
of labial alignment of the root:of labial alignment of the root:
1. Palatal inclination of the crown.1. Palatal inclination of the crown.
2. Hemorrhage and hard swelling palpated in the vestibule 2. Hemorrhage and hard swelling palpated in the vestibule
due to fracture of the labial cortical plate by the root of the due to fracture of the labial cortical plate by the root of the
primary incisor.primary incisor.
3. A shortened and more opaque image of the primary incisor 3. A shortened and more opaque image of the primary incisor
as compared to an adjacent non intruded tooth.as compared to an adjacent non intruded tooth.
4. Proper alignment of the permanent successor as seen on a 4. Proper alignment of the permanent successor as seen on a
periapical radiograph.periapical radiograph.
  

107. Radiographic examination- Radiographic examination- When the apex is When the apex is
displaced toward or through the labial bone plate, displaced toward or through the labial bone plate,
the apex can be visualized and appears shorter the apex can be visualized and appears shorter
than the contra lateral tooth.than the contra lateral tooth.
When the apex is displaced towards the permanent When the apex is displaced towards the permanent
tooth germ, the apex cannot be visualized and the tooth germ, the apex cannot be visualized and the
root appears elongated.root appears elongated.
Treatment- Treatment- If the apex is displaced toward or If the apex is displaced toward or
through the labial bone plate, the tooth is left for through the labial bone plate, the tooth is left for
spontaneous repositioning. If the apex is displaced spontaneous repositioning. If the apex is displaced
into the developing tooth germ, extraction of the into the developing tooth germ, extraction of the
tooth is indicated. tooth is indicated.

108. INTRUSION FOLLOWED BY SPONTANEOUS
ERUPTION
INTRUSION- PRIMARY TOOTH INTRUDING INTO THE
PERMANENT TOOTH FOLLICLE
SHOULD BE TREATED BY EXTRACTION OF THE PRIMARY
TOOTH

109. Avulsion- Avulsion- The tooth is displaced completely out of the socket.The tooth is displaced completely out of the socket.
Radiographic examination- Radiographic examination- A radiographic examination is A radiographic examination is
essential to ensure that the missing tooth is not intruded.essential to ensure that the missing tooth is not intruded.
Treatment- Treatment- It is generally not recommended to replant an It is generally not recommended to replant an
avulsed primary tooth because of the elevated potential for avulsed primary tooth because of the elevated potential for
chronic infection and subsequent dystrophic changes that could chronic infection and subsequent dystrophic changes that could
occur within the developing teeth.occur within the developing teeth.
  
Reimplantation of avulsed primary teeth Reimplantation of avulsed primary teeth - - Case selection Case selection
criteria include teeth with an extraoral dry time of less than 30 criteria include teeth with an extraoral dry time of less than 30
minutes and periodontal ligament cell maintenance through an minutes and periodontal ligament cell maintenance through an
appropriate tooth storage medium. appropriate tooth storage medium.
Functional space maintainers after exarticulation of Functional space maintainers after exarticulation of
primary teeth- primary teeth- In case the primary tooth/ teeth are extracted, a In case the primary tooth/ teeth are extracted, a
removable or a fixed functional space maintainer should be removable or a fixed functional space maintainer should be
given to the patient till the time the permanent teeth erupt. given to the patient till the time the permanent teeth erupt.

110. To conclude- To conclude- The majority of dental and oral The majority of dental and oral
injuries are unexpected which makes their injuries are unexpected which makes their
prevention difficultprevention difficult. . Hence, education is the best Hence, education is the best
method of prevention of such injuries. method of prevention of such injuries.
Altogether, 7- 25% of dental injuries appear to Altogether, 7- 25% of dental injuries appear to
be preventable by means of preventive devices be preventable by means of preventive devices
like helmets, mouth guards and face guards etc.like helmets, mouth guards and face guards etc.

111. Thank you