1. MANAGEMENT OF DENTAL
TRAUMATIC INJURIES IN
PAEDIATRIC PATIENTS
Aghimien AO
University of Benin Dental School
.

2. OUTLINE
PART 1
 introduction
 Aetiology of traumatic injuries
 Epidemiology
 Classification of traumatic injuries
PART 2
 clinical evaluation of patients
 History of the trauma
 Medical history
 Dental history

3.  Examination
general examination
extra-oral
intra-oral
 Sensibility evaluation
 Radiographic evaluation
 Clinical photography
PART 3…TREATMENT PROTOCOLS FOR VARIOUS
DENTAL TRAUMATIC INJURIES IN PRIMARY AND
YOUNG PERMANENT DENTITION

4. Hard tissue injuries
 enamel infraction
 uncomplicated crown fracture
 complicated crown fracture
 root fracture
Supporting tissue injuries
 concussion
 subluxation
 luxation; intrusive, extrusive, lateral
 avulsion

5.  FOLLOW UP
 PROGNOSIS
 COMPLICATION OF TRAUMATIC DENTAL
INJURIES
 CONCLUSION
 REFERENCES

6. INTRODUCTION
Dental trauma is one of the most common
presentation in the paediatrics clinic. The fears
and anxiety of these patients make management
difficult. If improperly managed, it could affect
the patient self-esteem and quality of life

7. AETIOLOGY
The most accident prone times include;
2-4 years for primary dentition
7-10 yrs for permanent dentition
Aetiological factors include;
1. Falls
2. Collision
3. Playing and running
4. Contact sports
5. Road traffic accident
6. Child abuse; ESPN
Emotional-Sexual-Physical-Neglect

8. PREDISPOSING FACTORS
1. Angle class 11 div 1
2. Increased overjet;
3-6mm..double the risk
>6mm….triple the risk
3. Incompetent lip closure
4. Improperly fitted mouthguard..twice the risk

9. DIRECT AND INDIRECT TRAUMA
Direct trauma;
 involves the tooth directly
 favours anterior teeth
Indirect trauma
 seen when the lower arch forcefully close against
the upper arch
 favours crown and crown-root fracture of the
premolar and molar region

10. EPIDEMIOLOGY
Dental trauma is common in childhood and
adolescence.
By 5 yrs; boys-- 31-40%
girls….16-30% and
At 12 years;
12-33% of boys and 4-19% of girls would
have suffered dental trauma
boys : girl; 2:1 in both dentitions

11. In primary dentition;
 anterior segment is commonly affected
especially the maxillary central incisor,
 concussion, subluxation, and luxation are the
commonest
In permanent dentition;
 luxation and fracture injuries are the
commonest
 Maxillary central incisor>maxillary lateral
incisor>mandibular incisor

12. CLASSIFICATION
Several classifications have been proposed for
easy diagnosis and treatment need of various
traumatic dental injuries(TDI). E.G
1. Ellis classification
2. WHO 1978
3. Garcia-Godoy 1968…for primary and
permanent dentition
4. Andreasen 1981..modification of WHO

13. ANDREASEN’S CLASSIFICATION
A. Dental Hard Tissue and Pulp Only
 Crown infraction
 Uncomplicated crown
 Complicated crown
 Uncomplicated crown-root
 Complicated crown-root
 Root fracture

14. B. Periodontium
 Concussion
 Subluxation(loosening)
 Luxation
intrusive(central dislocation)
extrusive(peripheral dislocation, partial
avulsion)
lateral
 Exarticulation(complete luxation/avulsion)

15. C. SURROUNDING BONE
 Comminution of alveolar socket
 Fractures of facial or lingual alveolar socket
wall
 Fractures of alveolar process -/+
involvement of the socket
 Fractures of the mandible or maxilla -/+
involvement of the tooth socket

16. D. SOFT TISSUE
 Laceration
 Contusion
 Abrasion

17. PART 2:
CLINICAL EVALUATION OF PATIENTS
1. History of the trauma’
HOW;
 to know extent of injury; direct or indirect
 to rule out head injury involvement
 Discrepancy between history and clinical
findings raises suspicion of physical abuse.
Where;
 whether contaminated soil or not; which may
be an indication for tetanus prophylaxis or not

18. When;
 time interval between injury and presentation
would determine treatment option and prognosis
Is the tooth fracture or not;
chest radiograph ..if not found
possible reattachment if found
Any neurological symptoms

19. 2. Medical history
 Congenital heart diseases
 Epilepsy
 Bleeding disorders
 Allergies
3.Past dental history
 Regular attenders are more likely to be cooperative
4. Immunization status.
 refer to physician for TT injection if trauma occurred
in a contaminated soil and patient had not receive a
booster dose for the past 5 yrs.

20. EXAMINATIONS
A. General exam; a quick head-to-toe
examination is done to r/o other injuries.
Signs of shock and head injury must be
excluded.
B. Extra-oral exam; observe and palpate for;
 Swelling, bruises, laceration
 Limitation of mandibular movement
 Mandibular deviation on opening and closing
 Bony step deformity
 Are wounds clean or contaminated

21. C. intra-oral exams;
 Laceration, haemorrhage and swelling
 Assess the occlusion, tooth displacement,
fractured crowns, or cracks in the enamel.
 Assess mobility;
 horizontal and vertical direction
 suspect ‘enblock alveolar process fracture
if several teeth move at the same time.
 excessive mobility…root fracture or
displacement

22. Reaction to percussion; the sensitivity and the
sound on percussion are important.
 to assess PDL inflammation
 luxated teeth are always tender
 duller note indicate a root fracture
Colour of the teeth; early colour change
associated with pulpal breakdown is visible on
the palatal surface ,in the gingival third of the
crown

23. SENSIBILITY ASSESSMENT
 Usually to ascertain nerve and blood supply
 not reliable in children
 More of a diagnostic tool in permanent
dentition
 Unreliable in erupting permanent and teeth
with open apices
 Positive response after a traumatic injury is
more valuable than negative response although
none should be trusted

24.  Commonly used are; EPT, thermal test(heat or
cold). Other include; carbon dioxide snow, laser
Doppler flowmetry

25. RADIOGRAPHIC EVALUATION
Indication for radiograph;
1. To detect root fracture
2. Ascertain extent of root development
3. To determine resorption
4. To detect foreign body in soft tissue
5. To detect jaw fracture
6. To note position and stage of development
of permanent teeth
7. To detect size of pulp chamber
8. To r/o periapical radiolucency
9. For follow-up evaluation

26.  Take two radiographs at different angles to
detect a root fracture.
 If access and co-operation are difficult then one
anterior occlusal radiograph rarely misses a root
fracture.
 Periapical films positioned behind lips can be
used to detect foreign bodies.
 Lateral anterior view with an occlusal
radiograph position by patient side could help
detect extent of intrusive luxation.
 Request for OPG if jaw injury is suspected

28. DOCUMENTATION PHOTOGRAPH
 Take a pre and post treatment photograph for
proper documentation
 To assess outcome of treatment
 For medicolegal purpose
 Always obtain a written consent

29. TREATMENT OPTIONS FOR DENTAL TRAUMATIC
INJURIES
Dental trauma to primary dentition
Most common is subluxation, intrusive luxation
and avulsion. Crown and root fracture are rare.
NB; large marrow spaces and pliability of the
alveolar bone.

30. SUBLUXATION
Diagnosis; mobile tooth -/+ sulcular bleeding
X-ray; nil abnormality
Treatment; clean associated soft tissue injury
with 0.2% chlohexidine with gauze swabs twice
daily.
Slight mobility; place on soft diet for 2 wks
Marked mobility; extract
Follow-up; after 1 month to assess mobility
Prognosis; usually good

32. INTRUSIVE LUXATION
Tooth displace towards the socket, compressing
the PDL and crushing the alveolar bone.
Diagnosis; not mobile, not tender, appear
shortened or in severe cases would seem missing
Investigation; lateral anterior radiograph.
Aim is to ascertain r/ship of apex of intruded
tooth with the permanent tooth bud

33.  Treatment;
a. if apex is displace labially, allow for
spontaneous re-eruption
b. if displaced palatally; extract the tooth
Follow-up; Review should be weekly for a month
then monthly for a maximum of 6 months. Most
re-eruption occurs between 1 and 6 months and if
this does not occur then ankylosis is likely and
extraction is necessary to prevent ectopic
eruption of the permanent successor

34. NOTE GINGIVAL DISPLACEMENT, INDICATING
INTRUSION

35. Prognosis; 90% of cases re-erupt b/w 2-6months. In
dome cases ankylosis could occur leading to a delay of
eruption of the permanent tooth.
Extrusive luxation
Partial avulsion as PDL is severely torn/damaged
Diagnosis; tooth appear elongated and mobile
X-ray; increased PDL space apically
Treatment; mild extrusion<3mm allow tooth to
reposition spontaneously and heal if tooth is immature.
when do I need to extract?
a. Severe extrusion/mobility

36. b. Tooth near exfoliation
c. Child not cooperating
d. Tooth fully mature
Follow-up; if repositioned take x-ray to determine
reduction in the PDL space apically

38. LATERAL LUXATION
Tooth displaced in any position other than axially
Diagnosis; tooth appear displace, not mobile nor
tender
X-ray; shows increased PDL space and displaced
tooth apex
Treatment; if apex is displace buccally and there
is no gagging of occlusion, allow spontaneous
realignment.
extract if apex is displaces towards the
permanent tooth bud.

39. prognosis;
If tooth is repositioned, there
is risk of pulpal necrosis
compare to spontaneous
eruption.
Note the occlusal interference

40. AVULSION
Diagnosis; Tooth is out of the socket
X-ray; do a chest x-ray if tooth can’t be accounted
for
Treatment; do not re-implant due to risk of
damaging the permanent tooth bud.
Though space maintenance is not necessary, a
fixed or removable be fabricated to allay aesthetic
concerns
Follow-up; permanent tooth eruption could be
delay for 1-2yrs due to formation of fibrotic band

41. AVULSION

42. HARD TISSUE INJURIES
UNCOMPLICATED CROWN FRCATURE;
Enamel -/+ dentine # without pulpal involvement.
Diagnosis; evidence of loss of tooth structure
X-ray; soft tissue radiograph to locate tooth fragment
Treatment;
 aim is to preserve pulp vitality and restore
aesthetics.
 small fracture: smoothen rough margins/edges
 large fracture:
for large enamel fracture restore with acid-
etch-composite resin

43. FRACTURE EDGES CAN BE DISKED

44. if dentine is involved;
protect the pulp using acid resistant calcium
hydroxide or GIC restore with acid-etch composite
COMPLICATED CROWN FRACTURE
Is uncommon in primary dentition
Diagnosis; loss of tooth structure with pulp
exposure clinically and on radiograph
X-ray; to r/o fragment in soft tissue

45. Treatment options; Depends on
 patients cooperation
 vitality of the tooth
 stages of root development
formocresol pulpotomy; if tooth is vital
pulpectomy with zinc oxide and eugenol
 non-vital tooth
 3/4th of the root must be formed
 1-2mm short of the apex
extraction; if child is uncooperative
tooth is non-vital

46. Final restoration; depends on amount of tooth
structure remaining
 composite resin if remnant can support
the composite restoration
 stainless steel crown with composite
veneering if small fragment remains
Prognosis; depends on concomitant injury to
the PDL.

47. ROOT FRACTURE;
Diagnosis; mobile coronal segment -/+
displaced
Radiograph;
 take at least 2 views
 reveal radiolucent line b/w fragment
 succedaneous tooth could obscure
root fragment
Treatment; depends on level of fracture:
at apical 1/3rd and with minimal mobility,
observe. Take serial radiograph of the tooth.

48. MIDDLE 3RD FRACTURE

49. If the coronal fragment becomes non-vital and
symptomatic then it should be removed. The
apical portion usually remains vital and
undergoes normal resorption.
At the middle and cervical 3rd, tooth should be
extracted.

50. TRAUMA TO YOUNG PERMANENT TEETH
Prompt and accurate diagnosis is invaluable in the
success of treatment.
Aims and objective of treatment;
1. Emergency/immediate; to
 retain vitality of fracture and displaced tooth
 treat exposed pulp tissue;
 reduction and immobilization of displaced
teeth
 antiseptic mouthwash, +/- antibiotics and
tetanus prophylaxis.

51. 2. Intermediate:
(a) pulp therapy;
(b) minimally invasive crown restoration.
3. Permanent:
(a) apexogenesis/apexification;
(b) root filling + root extrusion;
(c) gingival and alveolar collar modification;
(d) semi or permanent coronal restoration.

52. HARD TISSUE INJURIES AND MANAGEMENT
Enamel infraction;
Incomplete fracture in the enamel
Examination; reveal craze lines on
transillumination
Treatment; observe to ensure tooth integrity and
pulp vitality.
Uncomplicated crown fracture
Loss of enamel -/+ dentine fracture without pulp
involvement
Diagnosis; clinical and radiographic evidence of
loss of tooth structure

53. UNCOMPLICATED # E AND D

54. ,
Treatment;
 for small fracture use fine disk to smoothen
the margins
 for larger loss, protect the pulp with calcium
hydroxide or GIC then restore with acid-etch
composite.
 Enamel and dentine bonding agents have
also been used to protect the pulp from
thermal irritants and bacterial ingress.

55. COMPLICATED CROWN FRACTURE;
Factors that influence choice of treatment:
 vitality of expose pulp
 time elapse since the exposure
 degree of root maturation of the fracture
tooth
 restorability of the fracture crown
Aim of treatment; to preserve pulp vitality

56. NOTE PULP EXPOSURE, DO A CVEK

57. Treatment options;
 direct pulp capping(DPC)
 pulpotomy; partial or complete
 pulpectomy
carry out DPC ;
 when exposure is pin-point
 when exposure is just of few hours>24hrs
 when the apex is open
 as an emergency measure even pulpotomy is to
be done

58.  Review after a month, then 3 months, and eventually at 6
monthly intervals for up to 4 years to assess pulp vitality.
 Take periodic radiograph
 On the radiograph check the following:
• root is growing in length;
• root canal is maturing (narrowing);
• Compare with previous x-rays.
If growth is not occurring the pulp should be assumed to
be non-vital.

59. When to do pulpotomy:
 pulpal exposure for longer hours >24hrs
 larger pulpal exposure
 immature open apices
Aim of treatment; to eliminate inflamed pulp tissue and
preserve vital radicular pulp aiding complete root
development(apexogenesis)
Vital(full) pulpotomy or partial(Cvek) pulpotomy could be
done depending on the level of inflammation and extent of
bleeding on amputation

60.  Review after a month, 3 months, 6 monthly intervals for
up to 4 years to assess pulp vitality.
 Do periodic radiograph.
 If vitality is lost, non-vital pulp therapy should be
undertaken whether or not there is a calcific bridge
Prognosis;
success rates for partial (Cvek) pulpotomies are quoted at
97%. Those for coronal pulpotomies at 75%.

61. Pulpectomy as an option; done
 in non-vital pulp
 pulp with closed apex
 when permanent restoration need a post build up
an apical root end closure(apexification) is done, but
dentinal wall is left fragile and easily fracture

62. first month, then 3 mths, then 6 mths
Do periodic radiograph to check evidence of calcific barrier
formation. This will normally take b/w 9-24 mths
final treatment; these include
 Definitive canal obturation
 composite restoration
 porcelain veneer and crown
 post-retained crown

63. Treatment options;
1. Apexification
2. Apical barrier technique; using
 generic tricalcium phosphate(g-TCP)
 synthetic hydroxyl apatite
 bioceramic glass
 freeze-dried bone
3. Retrograde root canal filling

64. Root fracture.
Diagnosis; clinically mobile teeth and 1 or more
radiolucent lines separating fracture segments
Aims of treatment;
 to reposition and stabilise coronal segment
 encourage healing of PDL and vascular supply
 to restore aesthetics and function
Treatment;
reposition segment and immobilise for 2-3mths
(preferably fixed splint composite resin a better choice; but
why?)

66. Decision to splint;
this depend on the level of fracture and whether long term
stability of the tooth depends on it
Apical 1/3rd fracture; no need to splint except there is an
associated subluxation
Middle and cervical 1/3rd; splint if tooth is to be retained
Internal splints have ranged from hedstroem files to nickel-
chromium points, screwed and cemented into position.

68. Final treatment
1. If coronal segment is extracted for cervical fracture, root
portion is extruded surgically or via orthodontic mean
and pulp therapy done. A post-retained crown is planned
2. Both fragments could be extracted and prosthesis
planned.
follow-up
 assess pulp vitality
 assess stability of tooth

69. Prognosis
this is best for apical 3rd fracture
becomes poorer in middle and cervical fracture

70. This involve damage to supporting structures of the
teeth i.e PDL and alveolar bone.
Primary objective is to maintain vitality of the PDL
which is important in the long term prognosis of the
luxated teeth.

71. CONCUSSION
Diagnosis; tooth is firm, tender to pressure and percussion
Radiograph; usually no abnormality
Aim of treatment; to encourage healing of PDL and maintain
pulp vitality
Treatment; soft diet for 2wks, relieve it from occlusion if there
is complain of pain
Follow-up; vitality test foe 1, 3 and 6 month the yearly.
Radiograph to assess root development
Prognosis; usually good, but necrosis in 3-6% of cases

72. Subluxation
Diagnosis; tooth is mobile. Bleeding at the marginal
gingival, tender to percussion
Radiology; the PDL space is widened
Aim of treatment; allow healing of the PDL and ensure
vascular supply
Treatment; stabilize and relieve from occlusion. For
comfort use flexible splint(<2wks) if apex is fully formed
and extremely tender.

74. Prognosis;
mature teeth with closed apices are at risk of pulpal
necrosis hence, close monitoring is required.

75. LATERAL LUXATION
Diagnosis;
tooth is displaced
crown may be palatal or labially
displaced ;
not mobile nor tender
Radiology; PDL space is increased
apex is displaced labially

77. Treatment;
 reposition tooth with gentle and firm digital
pressure
 use flexible splint 3-8wks
 place on antibiotics and TT(if indicated)
 use 0.12% chlohexidine mouth wash
Follow-up; do periodic radiograph to monitor DPL re-
attachment.
Prognosis; tooth with closed apices could become
necrotic(start root canal trt) and have the canal obliterated

78. Diagnosis; teeth appear shortened, or in severe cases
could appear missing, not mobile nor tender
Radiograph; root apex is displaced apically
PDL space is non-continuous
Treatment; depends on:
1. stage of root development: open or close
2. severity of injury; mild <3 mm, moderate (3-6 mm);
or severe (>6 mm).

79. OPEN APEX ;
Mild intrusion <3 mm.
 Excellent eruptive potential.
 Treat conservatively and review.
 If no movement in 2-4 months move
orthodontically.
Moderate Intrusion 3-6 mm.
Disimpact (with forceps if necessary) and either
allow to erupt spontaneously for 2-4 months before
extruding orthodontically or apply orthodontic forces early.

80. Severe intrusion >6 mm.
Orthodontic repositioning may be impossible and
disimpaction followed by surgical repositioning under
either LA, LA/sedation, or GA is appropriate.
Functional splint for 2-3 weeks.

81. Follow-up.
 Monitor pulpal status clinically and radiographically at
regular intervals during the first 6 months after injury,
and then 6 monthly, and start endodontics if necessary:
 Non-setting calcium hydroxide in root canal does not
preclude against orthodontic movement. Once
apexification has occurred and orthodontic movement
has ceased.
 obturate canal with gutta percha.

82. CLOSED APEX ;
Mild intrusion <3 mm.
Orthodontic extrusion is probably indicated straight
away although some authors have advocated conservative
treatment.
Moderate intrusion 3-6 mm.
Orthodontic extrusion is indicated straight away.

83. Severe intrusion >6 mm.
Surgical repositioning. Functional splint for 2-3
weeks

85. Follow-up;
for closed apices carry out root canal as early as possible to
guide against external root resorption.
Prognosis;
 mature closed apex have higher risk of pulp
necrosis(96%), root resorption and ankylosis
 immature apex have 60% risk of necrosis and 56% risk of
resorption
 teeth treated early enough have better prognosis

86. Tooth displace axially from the socket
Diagnosis; clinically appear longer and is mobile
On radiograph; PDL space is increased apically
treatment; reposition tooth with gentle and firm digital
pressure
splint for 2wks
Follow-up; closed apex are at risk of necrosis hence, pulp
therapy is indicated after splinting

88. As a rule all avulsed teeth should be re-implant.
Diagnosis; clinically and radiological evidence show
absence of tooth in the socket in case complete intrusion
is been suspected.
Management;
1. Give first aid if you receive a phone call
2. On arrival in clinic the following is done;

90. Considerations;
1. Extra-oral time
2. Stage of root development

91. First aid for avulsed tooth
 1. Do not touch the root of the tooth. Handle the tooth
by the crown only.
 2. Rinse the tooth off only if there is dirt covering it. Do
not scrub or scrape the tooth.
 3. Attempt to reimplant the tooth into the socket with
gentle pressure, and hold it in position.
 4. If unable to reimplant the tooth, place it in a
protective transport solution, such as Hank's solution,
milk or saline.

93.  This will hydrate and nourish the periodontal ligament
cells which are still attached to the root. A
 small container of Hank's Balanced Salt Solution can be
purchased in dental emergency kit form at many
 drug stores. Contact lens solution is not an acceptable
storage medium.
 5. The tooth should not be wrapped in tissue or cloth.
The tooth should never be allowed to dry.

94.  6. Take the child to a dentist or hospital emergency
room for evaluation and treatment.
 7. Radiographs may need to be taken of the airway,
stomach, and mouth if the tooth cannot be found .
 8. Tetanus prophylaxis should be considered if the
dental socket is contaminated with debris.

95. 1. For A Mature Tooth With A Closed Apex:
If the extra-oral dry time is <60 minutes, reimplant as
soon as possible.
If the extra-oral dry time is >60 minutes, soak in citric
acid or curette the root; then soak in stannous
fluoride(2%) for 10 minutes.
Rinse with saline.
Perform root canal therapy one week following the
trauma.

96.  If the extra-oral dry time is <60 minutes, soak in
doxycycline (1mg/20 ml saline) for 5 minutes. If the
extra -oral dry time is >60 minutes, provide the same
treatment as for a closed apex.
 Apply a flexible, functional splint for 7 to 10 days. If
an alveolar fracture is present, provide a very rigid
splint for 4-6 weeks.

97.  suture any laceration
 place on antibiotics and analgesics
 prescribe 0.12% chlohexidine mouthwash
 check TT status

98. Open apex;
EOT < 60min; monitor for 3-4 mths, if pathosis sets in
start apexification
EOT >60min; start apexification immediately
Closed apex;
provide traditional pulp treatment and obturate
Remove splint after 7-10days
Continue review every 3-4wks

99. If tooth eventually become discoloured, noon-bleaching
could be done.

100. In primary dentition;
 Pulpitis; reversible or irreversible
 Pulp canal obliteration
 Pulp necrosis
 Resorption; inflammatory and replacement
 Injury to developing permanent teeth; hypoplasia,
hypomineralisation, crown dilacerations, arrested root
development, odontoma-like formation

101. Trauma dental injuries is common among toddlers and
adolescence. Due to the instability of children in their
developmental stage they become prone to it. Mouth
guard use in contact sport can greatly reduce the
incidence and severity.
Effort should be made if possible to preserve a
traumatise tooth considering the aesthetics and
functional role they play.

102. 1. Richard Welbury et al, 2005. paediatric dentistry
(3rd ed) Oxford University Press.
2. Cameron A and Widmer R, Handbook of paediatrics
Dentistry, 5:95-102
3. Andlaw AL and Rock WP, 1999. Manual of
Paediatrics Dentistry(4th edn)27-29:203-239
4. Pinkham JR et, Paediatrics Dentistry; infancy
through adolescence. 15:213-234, 34;531-546
5. Management of Dental Trauma in children.
Information on emergencies, Paediatrics Dental
Health,2008

103. 6. Flore MT et al , Guidelines For the Management of
Traumatic Dental injuries part II avulsion of permanent
teeth; dental traumatology 2007:130-136
7. Kapil L et al2010. A proposal for classification of tooth
fractures based on treatment need Journal of Oral Science,
Vol. 52, No. 4, 517-529
8. Elisa B. Bastone, Terry J. Freer, John R. McNamara
Epidemiology of dental trauma: A review of the
Literature; Australian Dental Journal 2000;45:(1):2-9

104. Thanks for your
time