Traumatic injuries of the teeth PAEDIATRIC DENTISTRY

TRAUMATIC INJURIES OF
THE TEETH AND THEIR
MANAGEMENT

CLASSIFICATIONS
Many classifications have been proposed.
They include:
1. Bennett classification (1963).
2. Ellis and Davey classification (1970).
3. World Health Organization’s Application of the International
Classification of Diseases to Dentistry and Stomatology
(1978).
4. Andreasen’s classification (1981).

ANDREASEN’S CLASSIFICATION
 Andreasen's classification (1981) is a modification of
the World Health Organization's Application of the
International classification of Diseases to Dentistry
and Stomatology (1978).
 It can be applied to both the permanent and the
primary teeth.

1. Injuries to the hard dental tissues and the pulp.
2. Injuries to the periodontal tissues.
3. Injuries to the supporting bone.
4. Injuries to the gingiva or oral mucosa.

1. Injuries to the hard dental
tissues and the pulp.
2. Injuries to the periodontal
tissues.
3. Injuries to the supporting
bone.
4. Injuries to the gingiva or oral
mucosa.
Injuries to the hard
dental tissues and the
pulp
1. Crown infraction.
2. Uncomplicated crown fracture.
3. Complicated crown fracture.
4. Uncomplicated crown-root
fracture.
5. Complicated crown-root
fracture.
6. Root fracture.

tissues.
bone.
mucosa.
Injuries to the periodontal
tissues
1. Concussion.
2. Subluxation (loosening).
3. Intrusive luxation.
4. Extrusive luxation.
5. Lateral luxation.
6. Exarticulation (Avulsion).

tissues.
bone.
mucosa.
Injuries to the supporting bone
1. Comminution of alveolar
socket.
2. Fracture of alveolar socket
wall.
3. Fracture of alveolar process.
4. Fracture of mandible or
maxilla.

tissues.
bone.
mucosa.
Injuries to the gingiva or oral
Mucosa
1. Laceration of gingiva or oral
mucosa.
2. Contusion of gingiva or oral
mucosa.
3. Abrasion of gingiva or oral
mucosa.

Injuries to the hard dental tissues
and the pulp
 Crown Infraction: An incomplete fracture (crack) of the enamel
without loss of tooth substance.
 Uncomplicated crown fracture: A fracture confined to the
enamel or involving enamel and dentine, but not exposing the
pulp.
 Complicated crown fracture: A fracture involving enamel and
dentine, and exposing the pulp.
 Uncomplicated crown-root fracture: A fracture involving
enamel, dentine and cementum, but not exposing the pulp.
 Complicated crown-root fracture: A fracture involving enamel,
dentine and cementum, and exposing the pulp.
 Root fracture: A fracture involving dentine, cementum, and the
pulp.

Injuries to the periodontal tissues
 Concussion: An injury to the tooth supporting structures
without abnormal loosening or displacement of the tooth but with
marked reaction to percussion.
 Subluxation: An injury to the tooth supporting structures with
abnormal loosening but without displacement of the tooth.
 Intrusive luxation: (central dislocation): Displacement of the
tooth into the alveolar bone. This injury is accompanied by
comminution or fracture of the alveolar socket.
 Extrusive luxation: (peripheral dislocation or partial avulsion):
Partial displacement of the tooth out of its socket.
 Lateral luxation: Displacement of the tooth in a direction other
than axially. This is accompanied by comminution or fracture of
the alveolar socket
 Avulsion: (Exarticulation):Complete displacement of the tooth
out of its socket.

Injuries to the supporting bone
 Comminution of alveolar socket: Crushing and compression
of the alveolar socket. This condition is found together with
intrusive and lateral luxation.
 Fracture of alveolar socket wall: A fracture confined to the
facial or lingual socket wall.
 Fracture of alveolar process: A fracture of the alveolar
process which may or may not involve the alveolar socket.
 Fracture of mandible or maxilla: A fracture involving the base
of the mandible or maxilla and often the alveolar process (jaw
fracture). The fracture may or may not involve the alveolar
socket.

Injuries to the gingiva or oral mucosa
Laceration of gingiva or oral mucosa: A shallow or deep wound
in the mucosa resulting from a tear, and usually produced by a
Sharp object.
Contusion of gingiva or oral mucosa: A bruise usually produced
by impact from a blunt object and not accompanied by a break in
the mucosa, usually causing submucosal haemorrhage.
Abrasion of gingiva or oral mucosa: A superficial wound
Produced by rubbing or scraping of the mucosa leaving a raw,
bleeding surface.

ETIOLOGY
1. Falls, collisions and bumps in toddlers and young children.
2. Bicycle accidents and falls due to unorganized playing at home or
school.
3. Sports: contact sports such as football, basketball and wrestling etc.
1.5-3.5% of children participating in contact sports sustain dental
injuries.
4. Battered child syndrome.
5. Automobile accidents.
6. Fight injuries.
7. Mentally retarded children usually sustain dental injuries due to lack
of motor co-ordination. Epilepsy is also a cause of dental injuries.
8. Drug addicts may break the cusps of their teeth by violent clenching
3-4 hours after drug intake.

PREDISPOSING FACTORS
1. Incisal angulation and occlusion.
2. Relevant medical histories:
1. Convulsive episodes in epileptic patients can result
in a high frequency of dental injuries.
2. Violent tooth clenching in drug addicts usually result
in fracture of cusps of posterior teeth.
3. Patients with psychiatric disorders and the Lesch-
Nyhan syndrome may inflict dental injuries
themselves.
Bad eye sight, slow responses, hyperactivity,
physical handicap etc are also predisposing factors.
3. Dental anomalies.
Hereditary defects of dentine (Dentinogenesis Imperfecta).
Grossly carious teeth or heavily filled teeth are also predisposing
factors.

EXAMINATION AND DIAGNOSIS
OF DENTAL INJURIES
(Dental injuries should always be
considered as an emergency)

HISTORY
 Patients name, age, sex, address and telephone number.
 When did injury occur?
 Where did injury occur?
 How did injury occur?
 Was there a period of unconsciousness? If yes, for how long?
 Is there headache, nausea, vomiting, amnesia etc.
 Has there been previous injury to the tooth?
 Has a tooth or a piece of tooth been lost? If so, where is it?

MEDICAL HISTORY
 Any heart or chest problem?
 Any allergies?
 Any bleeding tendencies?
 Any hospitalization?
 Any medicine taking at present?
 Any fits, i.e, epilepsy?
 Any G.A in the past?

PAST DENTAL HISTORY
 It includes details of any earlier trauma and treatment
experience. This will give some idea of the child’s
likely cooperation and the parent’s attitude, both of
which may influence treatment decisions.
 Repeated injuries to the teeth can influence vitality
tests and the reparative capacity of pulp.

CLINICAL EXAMINATION
Extra-oral
 Look for soft tissue bruising, hematomas or lacerations etc.
 Look for any asymmetry, i.e, swelling etc.
 Palpate the facial bones gently to investigate any
abnormalities or step deformities which would indicate the
presence of bone fracture. Ask the child to open and close
his mouth. Any restriction or deviation to one side would
indicate condylar fracture.
 Look for injuries on the body (if battered child syndrome is
suspected).

CLINICAL EXAMINATION
Intra-oral
 Record injuries to lips, frenum, tongue, gingiva, mucosa and
other soft tissues. The presence of foreign matter in lips and
cheeks should be ruled out.
 Examine the dentition for:
 Crown fractures and their extent.
 Displacement of teeth.
 Interference in occlusion.
 Mobility of teeth.
 Colour of injured teeth.
 Examine for abnormal mobility of alveolar process.

CLINICAL TESTS
 Percussion test.
 Vitality tests.
 Thermal tests
• Heated guttapercha
• Ethyl chloride
• Ice
• Carbon dioxide snow and
dichlordifluormethane.
 Electric pulp test
• Unipolar
• Bipolar
 Mechanical stimulation and cotton pellet test
 Transillumination

PERCUSSION TEST
 Uninjured teeth percussed first – will help relax child and help in
assessing the cooperativeness and the reliability of the
responses. Use finger tip.
 Reaction to percussion is indicative of damage to the
periodontal ligament. If negative at the initial appointment and
become positive on subsequent appointments, degenerative
pulpal changes should almost always be suspected.
 The sound elicited by percussion is also of diagnostic value.
Hard metallic sound – tooth locked in bone. Dull sound –
subluxation or extrusive luxation.

VITALITY TESTS
 Important for – crown fractures and luxation of teeth.
Require cooperation and a relaxed attitude on part of
patient.
 The principle of the tests is the conduction of stimuli
to, and their registration on, the sensory receptors of
the dental pulp.
 Test a contralateral undamaged tooth first to obtain a
baseline of reaction.

Thermal Tests
 Thermal testing – both heat and cold.
 Not reproducible in terms of graded intensity. Normal pulp tissue
may give a negative response. Positive reaction – vital pulp, but
may also occur in non-vital pulp especially in gaseous necroses
of pulp.
 Thermal tests – less value for children because testing accuracy
involves not only the perception of pain but also the degree of
pain.
 Intensity of thermal stimulus is rarely reproducible.
 Most frequently used are:
 Heated guttapercha
 Ethyl chloride
 Ice
 Carbon dioxide snow
and dichlordifluormethane

Electric pulp test (vitalometer)
Two types:
Unipolar: Current pass through the dentist.
Bipolar: Current pass through the patient.
Technique of Electric Pulp Testing

Interpretation
 Injured tooth responding positively to a lower than normal current –
hyperemic pulp or acute pulpitis.
 Injured tooth responding positively to a higher than normal current –
chronic pulpitis or degenerative changes (but not always true).
 Teeth with wide open apices may not respond to electrical tests.
 Electric pulp testing more reliable.
 Electric pulp testing reasonably reproducible.
 Status of the dental pulp cannot be reliably determined by vitality tests
alone. Information gained from vitality testing have to be correlated very
carefully with other findings.

Mechanical stimulation and
cotton pellet test
 Crown fracture with exposed dentine – scratching
with a dental probe.
 Crown fracture with exposed pulp – applying a
pledget of cotton soaked in saline or distilled water.

TRANSILLUMINATION
Light source:
Mouth mirror - Fibreoptic equipment

RADIOGRAPHIC
EXAMINATION
Radiographs of the traumatized area
are a must as the examination is not
complete without radiographs.

Information provided by the radiographs
of the traumatized teeth
1. Stage of development of root.
2. Will show any root fracture.
3. Extent of displacement or dislocation of teeth.
4. May show pathologic conditions related to previous
traumatic injuries, e.g:
 Periapical rarefaction.
 Internal or external root resorption.
 Calcification of pulp.
 Size of pulp chamber and pulp canal.

PRINCIPLES OF TREATMENT
 Emergency treatment
 Elimination of pain
 Protection of pulp
 Reduction and immobilization of mobile teeth
 Suturing of soft tissue lacerations
 Antibiotics? Anti-tetanus? Analgesics? Chlorhexidine mouthwash?
 Intermediate treatment
 Pulp therapy
 Consider orthodontic requirements and long-term prognosis of
damaged teeth
 Semi-permanent restorations
 Keep under review, usually 1 month,3 months, and then 6-monthly for 2
years.
 Long-term or permanent treatment
 It is usually deferred until 17 years of age, to allow pulpal and gingival
recession and decrease likelihood of further trauma, e.g, PJC, post and
core crown etc.

TRAUMA TO PERMANET TEETH
 By the age of 6-15 years, 30% of children usually get trauma to
their permanent teeth.
 Maxillary central incisors are the teeth involved in most of the
cases while maxillary lateral incisors and mandibular incisors
are next on the list.
 Boys appear to get injuries to the permanent dentition almost
twice as often as girls. This is because of their more active
participation in games and sports.

Crown infraction
 Crack may reach up to amelodentinal junction and may be
horizontal or vertical.
 Can be seen only when we dry the tooth and reflect light
through it.
 These do not require treatment. However, due to the frequently
associated injuries to the tooth supporting structures, vitality
tests should be carried out at intervals to disclose pulp damage.
 If tooth become sensitive, fluoride therapy may be required for
desensitization.

Uncomplicated crown fracture
Enamel fracture
 Immediate treatment
 Limited to grinding of sharp enamel edges to prevent laceration of
tongue or lips.
 Composite repair may be done
 Intermediate treatment
 Review after 7-10 days or in some cases after 6-8 weeks.
 Corrective grinding may be undertaken with or without orthodontic
extrusion of the fractured tooth.
 Long-term treatment
 Review after 6 months looking for necrosis of pulp, calcification,
resorption etc.
 Pulp vitality tests continue upto 2 years.

Uncomplicated crown fracture
Enamel + dentine fracture
The aims of treatment
– Pulp protection.
– Space maintenance.
– Aesthetics.
Treatment:
The immediate treatment consists of protecting the pulp from bacterial
contamination or thermal stimuli by covering the exposed dentine.
Method:
 Isolate and dry the tooth.
 Cover the exposed dentine with a calcium hydroxide lining material.
 Place an acid-etch composite restoration.
 In case of insufficient time or lack of co-operation, a ‘composite bandage’
may be placed. Composite build up may be done at a future appointment.
 Review the patient after 1week, 1month, 3months and then at 6- monthly
interval for at least 2 years. At these appointments, vitality tests should be
carried out and a radiograph taken to check that root development is
continuing.

Complicated crown fracture
 The immediate treatment aims to preserve the vitality of the pulp. This
is essential to allow continuing root development, apical closure,
narrowing of the pulp cavity and thickening of the root walls.
 Treatment options:
 Pulp capping
 Partial pulpotomy
 Vital pulpotomy (Apexogenesis)
 Review after:
 1 week --- for discomfort and retention of composite.
 1 month--- periapical radiograph for apical pathology. Vitality tests.
 3 months--- periapical radiograph to see root development. Hard tissue barrier
seen in case of vital pulpotomy (apexogenesis).
 6 monthly---for at least 3 years. In case of vital pulpotomy – elective root canal
carried out after apical closure.

In case of non-vital pulp
Open apex - apexification
Closed apex - RCT

Uncomplicated crown-root fracture
 Gingivectomy + osteotomy for dentine coverage.
 Crowning.

Complicated crown-root fracture
 Pulp treatment.
 Gingivectomy + osteotomy for post and core.
 Crowning.

Root fracture
Classification & treatment
 Fracture not communicating with gingival crevice.
 Fracture communicating with gingival crevice.
 Longitudinal root fracture.
OR
 Apical root fracture.
 Middle root fracture.
 Coronal root fracture.
 Splinting
 Rigid splinting for 2-3 months.

Root fracture continues
Types of repair or healing
 Calcific union (osteoid material)
 Bony union + connective tissue
 Fibrous repair (connective tissue)
 Granulation tissue interposition
Review of root fractured teeth
Should be reviewed after 1 month, then 3 months and
subsequently at 6-monthly intervals for at least 2 years.
Reviews should include vitality tests and radiographs.
Pulp necrosis is suggested on radiograph as:
 Widening of the fracture line.
 Loss of lamina dura.
 Widening of the periodontal membrane space.
 Bone loss at the level of the fracture line.
Usually only coronal portion involved. Calcium hydroxide
used to form a barrier for conventional root canal filling.

Splinting
Necessary functions of splint:
 To immobilize the loosened teeth.
 To hold repositioned teeth in alignment and to protect the
damaged structures from further trauma.
 To hold a dressing over exposed dentine.

Properties of a good splint
1. Should be non-toxic.
2. Good retention (stable to last for the time needed +
strength).
3. Easy to construct, apply & cheap.
4. Easy to remove and should not damage the
enamel.
5. Should not interfere with occlusion.
6. Should not interfere with endodontic treatment.
7. Should not accumulate plaque and should not
cause periodontal disease and caries.
8. Esthetics should be good.

Different types of splints
1. Simple Acid-Etch splint.
2. Acid-Etch splint with wire insert.
3. Acid-Etch splint with ortho brackets.
4. Full coverage splint or cap splint.
5. Foil splint.

Concussion
 Usually front teeth are involved. Child may complain that the front teeth hurt
when he tries to eat.
 Vitality tests usually negative. May take 6-8 weeks to reverse.
Treatment:
 Usually no treatment is necessary.
 Reassure the parents and soft diet for a few days.
 If vitality tests negative after 8 weeks, start pulp treatment. As vitality tests are
not reliable, start pulp treatment without LA. If patient respond while touching
ADJ, it means tooth is vital. Give calcium hydroxide lining & composite repair.

Subluxation
Treatment:
 If slightly mobile, no active treatment. Soft diet for a few
days. Not to play with the tooth and no testing for looseness.
Healing take place in 1-2 weeks.
 If there is marked loosening, splint the tooth for 2-3 weeks.

Intrusion
Treatment:
 Re-eruption potential of immature teeth is taken into
account. Leave the tooth initially to re-erupt for 1 month.
 If no re-eruption, then orthodontic extrusion of the tooth
and simultaneous root canal treatment.

Extrusion
Treatment
 Grasp the tooth with finger and thumb.
 Gently push the tooth back into its original position.
 Splint for 2-3 weeks.

Lateral displacement
Treatment:
 Reposition the tooth.
 Splint for 3-6 weeks (because bone is involved).
 Recent displacement
 Delayed presentation

Review of displacement injuries
 Review regularly.
 Initially after 1 month, then after 3 months and subsequently
at 6 monthly intervals for at least 2 years.
 Reviews include vitality tests and radiographs.
 Pulp necrosis is the most common complication following a
displacement-type injury.

Avulsion (ex-articulation)
Avulsion is common in immature teeth because:
 Root is partially formed.
 Alveolar bone is more elastic.

Prognosis following re-implantation
Depends upon three factors:
1. Time
2. Storage
3. handling

Emergency management
outside the surgery

Attendance at the surgery
Treatment planning:
Following avulsion, three possible courses of treatment:
 Re-implantation of the tooth.
 Maintenance of the space by a prosthesis or bridge.
 Closure of the space by orthodontic means.

Factors to be considered before any decision is
made about the appropriate treatment
 Prognosis following re-implantation.
 Medical and dental history.
 Orthodontic status.

Loss of the incisor
 Maintenance of space by a prosthesis.
 Closure of the space by orthodontic means.

Sequelae of displacement injuries
Greater chance of loosing vitality with intrusion, extrusion and
lateral luxation. Much more chances with avulsion. Most commonly
occur:
1. Necrosis of pulp (loss of blood supply).
2. Pulp canal obliteration (may be partial or full). Commonly occur in immature
traumatized teeth because of more reparative capabilities.
3. Root resorption.
 External root resorption
– Surface resorption
– Inflammatory resorption
– Replacement resorption
– Burrowing root resorption
(resorption at cervical part. Retract the tissue and fill the gap).
 Internal root resorption
– Inflammatory resorption
– Replacement resorption
4. Ankylosis of the tooth.
5. Loss of marginal bone support. 10% of luxated teeth show this problem.

Fracture of maxilla, mandible, alveolar
process etc need immobilization of these
bones.
Lacerated wound in gingiva or oral
mucosa or other soft tissues need
suturing.
Antibiotics and analgesics may be
prescribed.

Trauma to the primary teeth
 Types of injuries limited.
 Limited treatment.
 Injuries commonly occur during toddler age
(1.5-3 years).
 Usually luxation injuries because bone is thin and
elastic. Sometimes crown or root fracture.
 Maxillary incisors commonly involved.
 Radiographs (periapical) valuable especially in
case of intruded teeth.

concussion
 This is the simplest type of injury where a small child has walked
into something or has fallen, traumatizing the anterior teeth.
 Frequently no signs of the injury except for evidence of minor soft
tissue damage.
 Child may complain that his mouth is sore or that the front teeth
hurt when he tries to eat.
Treatment:

Subluxation
 Physiological mobility must be taken into account when diagnosing
subluxation in the primary dentition.
 Traumatized teeth will be loose and there may be evidence of
haemorrhage at the gingival margin due to the damaged
periodontium.
 Teeth may be tender to touch and during eating.
Treatment:
 The teeth usually tighten up after about 1 week.

Displacement
 Displacement occurs either labially or palatally.
 In palatal displacement, the displaced teeth may interfere with
occlusion.
Treatment:
Options are either to leave the traumatized teeth or to extract.
 If palatal displacement and the displaced teeth do not interfere with
occlusion, no treatment is required. If interfere with occlusion, then
extraction.
 If labial displacement, extraction of the displaced teeth.
 If the tooth is so loose that there is danger of inhalation, then extraction.
 Parents advised to maintain fluid intake, soft diet and gentle brushing is
recommended.

Intrusion
 Intrusion is common and the tooth may not be visible.
Radiograph to confirm the presence of the tooth.
 No serious discomfort to the child.
Treatment:
 ‘Wait and see’ policy because the intruded primary incisors
commonly re-erupt and reposition themselves over a period of a
few weeks.
 If no re-eruption, then extraction.

Extrusion
 If a primary tooth is extruded, extraction.
 No repositioning and splinting.

Avulsion
If a primary tooth is avulsed,
NO re-implantation.

Crown fracture
Coronal fracture rare unless the teeth are very carious.
Treatment:
 Treatment limited by the child’s cooperation.
 If no pulp exposure, treatment restricted to smoothening any sharp
edges or composite restoration in a cooperative child.
 If pulp is exposed, extraction in uncooperative child and pulp treatment
in a cooperative child.

Root fracture
Splinting of root-fractured primary teeth NOT practical.
Treatment:
 Tooth not displaced and only slightly mobile, leave it to
tighten up itself.
 Coronal fragment displaced or is very mobile, extraction.
 No removal of apical portion, as this usually undergoes
physiological resorption. Removal could damage the
permanent successor.

Post-trauma complications OR
Sequelae of injuries to the primary
teeth
1. Colour change or discolouration. The traumatized primary
tooth may become bluish gray or yellow.
2. Abscess formation, sinus formation, radiolucent area
periapically. The most common complication is that the tooth
becomes non-vital.
3. Tooth may become loose.

Sequelae of injuries to the primary teeth continues
4. Injury to the developing permanent teeth. Frequency is 12-69%.
a. White or yellow brown discolouration
b. Enamel hypoplasia
c. Crown dilaceration
d. Root dilaceration
e. Root duplication
f. Rotation of permanent tooth germ
g. Partial or complete arrest of development of
permanent tooth germ due to infection etc.
h. Odontome-like malformation
i. Follicular cyst formation
j. Dentigerous cyst formation
k. sequestration of permanent tooth germ
l. Disturbance in eruption or ectopic eruption of permanent tooth
because of:
• Retention of primary tooth
• Displacement of primary root apex
• Infection. Odontoclasts can’t get access to root (very unusual).
• Ankylosis of primary tooth

Prevention of trauma to teeth
 Primary prevention
 Secondary prevention

Primary prevention
Commonest cause of tooth injury in children is falling
on a hard surface. So the following precautions may
be taken:
 Equipment in play areas for pre-school children should be
designed for soft landings.
 Impact absorbing safety surfacing or tree-bark chippings.
 Supervision of small children at play is important.

Two areas where paedodontist can help:
1. The early treatment of large overjets.
2. The provision of well-fitting mouthguards for use in
sports.

Early treatment of large overjets
 Uncrowded arches
Functional appliance and extra-oral traction.
Both work best during active growth periods.
 Crowded arches
 Extraction of primary canines and overjet reduction.
 Relief of crowding in the permanent dentition by extraction and
arch realignment with fixed appliances.
Lengthy treatment and problems may arise. So
there must be proper diagnosis, preferably by an
orthodontist.

Provision of Mouthguards in sports
 About 10% of the total dental injuries occur in sports.
 The injuries usually result from collision with opponent or a blow
from equipment,e.g; hockey sticks, cricket balls etc.
 In majority of cases upper incisors are affected.
 Mouthguards should be used by all children involved in contact
sports (not only by those with î overjet and incompetent lips).

Types of Mouthguards
1. Stock (latex rubber or Polyvinyl chloride)
2. Mouth-formed (Polyvinyl acetate polyethylene copolymer)
3. Custom-made (Polyvinyl acetate polyethylene copolymer)
Stock
Mouth-formed
Custom

Secondary prevention
 Reducing the complications of trauma by prompt intervention can have
a “secondary preventive effect”.
 In coronal fractures, exposed dentine should be covered as soon as
possible. No excuse because of advances in acid etch technique and
dentine bonding agents.
 Apexogenesis in vital young permanent teeth and apexification in non-
vital young permanent teeth with non-setting calcium hydroxide or
MTA has made treatment easier for traumatized teeth.
 Re-implantation of the avulsed teeth should be attempted as soon as
possible after the injury and carry a reasonable prognosis.

Traumatic injuries of the teeth PAEDIATRIC DENTISTRY

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