1

Dr. Akash Ardeshana

Department of paedodontics and preventive dentistry

MANAGEMENT OF TRAUMATIC
INJURY OF PRIMARY DENTITION
contents

 Introduction
 Objective of management
 Management of traumatic dental injury of the
primary teeth
 Injuries to the hard dental tissues and the
pulp:
 Infraction
 Enamel fracture
 Enamel dentine fracture
 Enamel dentine pulp fracture
 Injuries to the hard dental tissues, the pulp, and the alveolar
process:
 Crown-root fracture without pulpal involvement
 Root fracture with without pulpal involvement
 Alveolar fracture

 Injuries to the periodontal tissues:

 Concussion
 Subluxation
 Luxation injuries:
 Lateral luxation
 I ntrusive luxation
 Extrusive luxation
 Avulsion
 sequelae of acute dental trauma in the
primary dentition.
 sequelae in permanent dentition after trauma
in primary dentition.
 Conclusion
 Bibiliography
 In preschool children, head and facial nonoral
injuries make up as much as 40% of all
somatic injuries .

 In the age group 0–6 years, oral injuries are

ranked as the second most common injury
covering 18% of all somatic injuries (1–3).
Introduction

 Traumatic injuries to the primary dentition

present special problems and the
management is often different as compared
with the permanent dentition.

 Trauma to the oral region occurs frequently

and comprises 5% of all injuries for which
people seek treatment .
Objectives……

1. Recognize the various trauma entities.

2. Recognize the risk of concomitant to the permanent

dentition.

3. Determine treatment option that will reduce the risk of

developmental disturbances of permanent dentition.

4. Determine risk profile for primary tooth that present a

significant risk for the permanent dentition.
Treatment principle
 The primary goal is to optimize periodontal
and pulpal healing in the primary dentition
provided that no further injury is transmitted
to the developing permanent successors.
Factors influence on selection of treatment plane
Infraction
Treatment
 No treatment necessary

Follow-up
 No follow-up is needed for infraction injuries unless they
are associated with a luxation injury or other fracture
types involving the same tooth.
Enamel fracture
Treatment
 Smooth sharp edges.
 In patients with lip or cheek lesions it is
advisable to search for tooth fragments or
foreign material.

Follow-up
 No followup required.
Enamel-dentin fracture
Treatment
 If possible, seal completely the involved dentin with glass
ionomer to prevent micro leakage.
 In case of large lost tooth structure, the tooth can be
restored with composite.

Follow-up
 Clinical control at 3-4 weeks.
Enamel-dentin-pulp fracture
(Complicated crown fracture)
 Treatment
 If possible, preserve pulp vitality by partial
pulpotomy.
 Calcium hydroxide is a suitable material for such
procedures. A well-condensed layer of pure calcium
hydroxide paste can be applied over the pulp,
covered with a lining such as reinforced glass
ionomer. Restore the tooth with composite.

The treatment is depending on the child's maturity

and ability to cope. Extraction is usually the
alternative option.
 Partial pulpotomy

 Cervical pulpotomy

 Pulpectomy

 Extraction
 Follow-up
 Clinical after 1 week.
 Clinical and radiographic after 6-8 weeks and
1 year.
radiograph of the maxillary primary Three-month follow-up radiograph showing
incisors of a 3-year-old child, 3 hours after injury. the development of a dentin bridge at the site
of the partial pulpotomy.

Two-year follow-up
Clinical photograph of a 27-month-old child who had sustained a
complicated crown fracture that was not treated. The child
appeared 6 weeks later with a parulis above the involved tooth. The
tooth was extremely mobile
Crown-root fracture without pulp
involvement
 Localization of fracture line
 The fracture involves the crown and root of
the tooth and is in a horizontal or diagonal
plane.
 A radiographic examination usually only
reveals the coronal part of the fracture and
not the apical portion
 treatment
 Depending on the clinical findings, two
treatment scenarios may be considered. Most of
these may be deferred to later treatment.
 Fragment removal only
If the fracture involves only a small part of the
root and the stable fragment is large enough to
allow coronal restoration, remove the mobile
fragment.
 Extraction
Extraction in all other instances.
 Patient instructions
 Soft food for 10-14 days.

Good healing following an injury to the teeth and

oral tissues depends, in part, on good oral hygiene.
Brush with a soft brush after every meal and apply
chlorhexidine 0.1 % topically to the affected area
with cotton swabs twice a day for one week.

 This is beneficial to prevent accumulation of plaque

and debris along with recommending a soft diet.
 Parents should be further advised about possible
complications that may occur, like swelling, increased
mobility or fistula.

 Children may not complain about pain; however,

infection may be present and parents should watch for
signs of swelling of the gums and bring the child in for
treatment.
 Follow-up
 In case of fragment removal only: Clinical :after 1 week.
 Clinical and radiographic :after 3-4 weeks.
 Clinical : after 1 year.

In case of tooth extration: Clinical and radiographic

control at 1 year and every year until eruption of the
permanent successor.
 Crown-root fracture with pulp
involvement (Complicated crown-root
fracture)
 Treatment
 Depending on the clinical findings, two treatment
scenarios may be considered.
 Fragment removal only if the fracture involves only a
small part of the root and the stable fragment is large
enough to allow coronal restoration.
 Extration in all other instances.
 Follow-up
 In case of fragment removal only: Clinical and
radiographic control at 1 year and every year
until eruption of the permanent successor.

In case of tooth extration: Clinical and

radiographic control at 1 year and every year
until eruption of the permanent successor.
Root fracture
 In the primary dentition, root fractures are as
rare as about 2-4% (1, 4, 5), due to the
plasticity of the developing alveolar bone.

 They are most frequent at the age of 3-4

years where physiologic root resorption has
begun, thereby weakening the root
Treatment
 No treatment
If the coronal fragment is not displaced no
treatment is required.
 Extraction
If the coronal fragment is displaced,
repositioning and splinting might be considered.
 Otherwise extract only that fragment.
 The apical fragment should be left to be
resorbed.
 These root fractures occurred at the
age of 4 years. Due to severe displacement,
both coronal fragments were extracted. The
root tips remained in situ and where resorbed
normally
 Patient instructions
 Soft food for 10-14 days.
 Follow-up
 Clinical control after 1 week. Clinical and
radiographic control after 6-8 weeks and 1
year.

In case of tooth extration: Clinical and

radiographic control at 1 year and every year
until eruption of the permanent successor.
Title Conservation of root-fractured primary teeth--report of a case.

Author Liu X1, Huang J, BaiY, Wang X, Baker A, Chen F, Wu LA.

Journal Dent Traumatol. 2013 Dec;29(6):498-501.

Level of Iv
evidence
abstract A 3.5-year-old girl presented to our clinic experiencing pain in her maxillary
central incisors following traumatic injury during a fall. Radiographic
examination revealed both primary maxillary central incisors with mid-root
and apical third horizontal root fractures, respectively. Splinting with
orthodontic brackets and stainless steel wire was performed. At 2 weeks,
resorption of the apical fragments in both injured teeth was observed, and
after 3 months, almost complete resorption was noted on radiographs. Tooth
mobility at this point was back to physiologic levels and the splint was
removed. After 2.5 years, the primary maxillary incisors were replaced by
permanent incisors demonstrating normal tooth color, position, and root
development. Although this case illustrated the favorable prognosis of two
primary teeth with root fractures and severely mobile coronal fragments by a
conservative approach, more scientific evidences are needed and frequent recalls
are necessary when primary root fractures are attempted to be managed with
splinting.
Radiograph taken 2 weeks after injury
showing root resorption of the apical After 10 month
fragments
Concussion
treatment objectives
 There is no need for treatment.

Treatment
 No treatment is needed only observation.

Patient instructions
 Soft food for 1 week.
 In a clinical study, endodontic treatment was
performed on 48 primary incisors with dark-
gray discoloration of the crowns.
 Pulp necrosis was found in 37 discolored
teeth, without presenting tenderness to
percussion, increased mobility, and periapical
osteitis
Title Long-term effect of different treatment modalities for traumatized primary incisors
presenting dark coronal discoloration with no other signs of injury.

Author Holan G1.

Journal Dent Traumatol. 2006 Feb;22(1):14-7.
Level of IIB
evidence
aim The aim was to compare the long-term outcomes of root canal treatment with that of
follow-up-only in traumatized primary incisors in which dark discoloration is the only sign of
injury.
Method Root canal treatment was performed in 48 dark discolored asymptomatic primary incisors
following trauma. Twenty-five of them [root canal treatment (RCT) group] were followed till
eruption of their permanent successors. Ninety-seven dark discolored asymptomatic
primary incisors were left untreated and invited for periodic clinical and radiographic
examination. Of these, 28 [follow-up (FU) group] were followed till eruption of their
permanent successors.
Result Chi-square test was used for statistical analysis. Seven of 25 (28%) of the RCT group and
32% (nine of 28) of the FU group required early extraction. Five of 25 (20%) of the RCT group
and 21% (six of 28) of the FU group showed early or delayed eruption of the permanent
successors. Sixteen of 25 (64%) of the RCT group and 79% (22 of 28) of the FU group showed
ectopic eruption of the permanent successors. Enamel hypopcalcification or hypoplasia in
the permanent successors was equally found (36%) in both groups (nine of 25 in the RCT
group and 10 of 28 in the FU group). None of differences was statistically significant.
Conclusion It can be concluded that more than 50% of the primary incisors that retain their dark
coronal discoloration acquired after dental injuries remain clinically asymptomatic till
the eruption of the permanent successor even if they present accelerated root
resorption. Asymptomatic traumatized primary incisors that retain their dark coronal
discoloration may develop a sinus tract and inflammatory root resorption years after the
injury. There is still a dilemma: which treatment is better for dark discolored primary
incisors: early endodontic treatment or follow-up with the risk of development of
infection and root resorption that may require extraction?
Title Development of clinical and radiographic signs associated with dark discolored primary
incisors following traumatic injuries: a prospective controlled study.
Author Holan G1.

Journal Dent Traumatol. 2004Oct;20(5):276-87.

Level of III
evidence
aim The purpose was to evaluate late complications of asymptomatic traumatized primary
incisors with dark coronal discoloration.

Method The clinical and radiographic signs of 97 teeth of the study group were recorded along a
follow-up period that ranged between 12 and 75 months (mean >36 months). Children's age
at time of injury ranged between 18 and 72 months (mean 40). The control group consisted
of 102 non-discolored maxillary primary central incisors in 51 children older than 54 months
with no history of dental trauma.
Result In 50 teeth (52%) the color faded or became yellowish and in 47 (48%) it remained dark.
Clinical signs of infection, that were diagnosed 5-58 months after the injury, were associated
significantly more with dark than yellowish hues (83 and 17%, respectively). Teeth that had
changed their color to become yellow presented more PCO than teeth with
black/gray/brown coronal discoloration (78 and 6%, respectively). Arrest of dentine
apposition was found in 15 teeth, one had yellow coronal discoloration and the remaining 14
had a dark shade. Eleven teeth showed inflammatory root resorption all with dark
discoloration. Two atypical types of root resorption were observed: a surface resorption
restricted to the lateral aspects of the apical half of the root while the root length remained
unchanged and in the other expansion of the follicle of the permanent successor was
Conclusion Root canal treatment of primary incisors that had change their color into a dark-gray hue
following trauma with no other clinical or radiographic symptom is not necessary as it
does not result in better outcomes in the primary teeth and their permanent successors.
Unfavorable Outcome
 Dark discoloration of crown.
 No treatment is needed unless apical
periodontitis develops
Subluxation
 Meadowet al. reported subluxations to occur
at an incidence of 40% of all trauma.

 Andreasen noted this type of injury to occur

at a frequency of 12% in all traumatized
primary teeth.
Treatment objective
 No treatment is needed.

Patient instructions
 Soft food for 1 week.
 Unfavorable Outcome
 Transient red/ gray discoloration or yellow
discoloration indicates pulp obliteration and
has a good prognosis
Lateral luxation
Treatment
 Spontaneous repositioning
If there is no occlusal interference, as is often the case in anterior open
bites, the tooth should be allowed to reposition spontaneously.
 Repositioning
When there is occlusal interference local anesthesia should be applied
where after the tooth should be repositioned by gentle combined labial
and palatal pressure.
 Extraction
For teeth with severe displacement in a labial direction, extraction is the
treatment of choice. Extraction is indicated in these cases because of
the collision between the primary tooth and the permanent tooth germ.
 Slight grinding
In cases with minor occlusal interference, slight grinding is indicated.
 From a prospective study of 104 lateral Luxated
teeth,99%were realigned within the 1st year.
 In an observational study, it was found that of 52 teeth
that were left for spontaneous reposition, almost 60%did
not disclose any complication.
 However, repositioning of lateral luxation was associated
with an increased risk of developing pulp necrosis.
 Patient instructions
 Soft food for 10-14 days.

 Follow-up
 Clinical control after 1 and 2-3 weeks. Clinical
and radiographic control at 6-8 weeks and 1
year.
intrusion

 Intrusive luxation has been defined as dislocation of a

tooth in an axial direction into the alveolar bone.

 This dislocation is considered complete when the tooth

is enveloped by surrounding tissues or partial when the
incisal border of the crown is visible

-(Andreasen, 1984).
intrusion
 Intrusion comprises 8–22% of all luxation injuries of
primary anterior teeth (Andreasen and Ravn, 1972).

 Other authors have reported prevalence rates as 15.3%

(Soporowski et al., 1994), 21% (Onetto et al., 1994), 34%
(Garcia-Godoy et al., 1987), and 54% (Robertson et al.,
1997).
The degree of intrusion can be divided into 3 grades (Von
Arx, 1995)

 Grade I. Mild partial intrusion in which more than 50% of

the crown is visible.

 Grade II. Moderate partial intrusion in which less than

50% of the crown is visible.

 Grade III. Severe or complete intrusion of the crown

 Management of an intruded primary incisor depends on
the following variables:

1. Direction of intrusion,

2. Degree of intrusion,

3. Presence of alveolar bone fracture.

 In a retrospective study of 172 intruded teeth, the apices
of more than 80% of the teeth were pushed labially.

 It was found that most of them re-erupted and survived

with no complications for more than 36months post
trauma, even in cases of complete intrusion and fracture
of the labial bone plate.
 Whenever the intrusion is moderate or severe (grade II or
III), the tooth rarely reerupts and may become necrotic,
indicating the need for extraction (Ravn, 1968; Wilson,
1995).

 If signs of reeruption are not evident after 4–8 weeks,

ankylosis should be suspected, and extraction should be
considered (Harding and Camp, 1995; Borum and
Andreasen, 1998).
(A) Complete intrusion of tooth 61in a1-year-old girl.
(B) The intruded tooth appears shorter than its contralateral in the periapicalX-ray.
(C) In the lateralX-ray, the apex of the intruded tooth is displaced
through the labial bone plate.
(D) Clinical appearance 1month later.
(E) Re-eruption at 3months. (F) One year later.
Follow-up
 1 week C
 3–4 weeks C + R
 6–8 weeks C
 6 months C+R
 1 year C+R and (C*)
Extrusion
Extrusion
 Partial displacement of the tooth out of its
socket. An injury to the tooth characterized
by partial or total separation of the
periodontal ligament resulting in loosening
and displacement of the tooth.
 The alveolar socket bone remains intact. In
addition to axial displacement, the tooth
usually will have some protrusive or retrusive
orientation.
 Treatment
 The treatment choice should be based on the degree
of displacement, mobility, root formation and the
ability of the child to cope with the emergency
situation.

For minor extrusion (< 3mm) in an immature

developing tooth, either careful reposition the tooth
or leave the tooth for spontaneous alignment.

Extraction is the treatment of choice for severe

extrusion in a fully formed primary tooth.
Patient instructions
 Soft food for 1 week.

 Follow-up
 Clinical control after 1 weeks. Clinical and
radiographic control at 6-8 weeks, 6 months,
and 1 year.
Avulsion
 Replacement of avulsed tooth….
 May displace a coagulum in to the follicular
space of developing incisor.

 Periapical inflammation

 External root resorption

 Treatment
 It's not recommended to replant avulsed primary
teeth.
A the initial examination make sure that all avulsed
teeth are accounted for.
 If not it is highly recommended to make a
radiographic examination in order to ensure that the
missing tooth is not a case of complete intrusion or
root fracture with loss of the coronal fragment.

 If the avulsed tooth has not been found refer the

child to the paediatrician to exclude aspiration.
Tsukibosi M. treatment planing for traumatize teeth 1st edition , quintessence boo, 2000.
Title Replantation of an avulsed maxillary primary central incisor and management of
dilaceration as a sequel on the permanent successor.

Author Sakai VT1, Moretti AB, Oliveira TM, Silva TC, Abdo RC, Santos CF, Machado MA.
Author information
Journal Dent Traumatol. 2008 Oct;24(5):569-73.
Level of IVa
evidence
Abstract This case report outlines the sequel and possible management of a permanent tooth
traumatized through the predecessor, a maxillary right primary central incisor that was
avulsed and replanted by a dentist 1 h after the trauma in a 3-year-old girl. Three years later,
discoloration and fistula were present, so the primary tooth was extracted. The patient did
not come to the scheduled follow-ups to perform a clinical and radiographic control of the
succeeding permanent incisor, and only returned when she was 10 years old. At that
moment, the impaction and dilaceration of the maxillary right permanent central incisor
were observed through radiographic examination. The dilacerated permanent tooth was
then surgically removed, and an esthetic fixed appliance was constructed with the crown of
the extracted tooth. Positive psychological influence of the treatment on this patient was
also observed.
Alveolar fracture
 A fracture of the alveolar process which may
or may not involve the alveolar bone socket.

 Teeth associated with alveolar fractures are

characterized by mobility of the alveolar
process; several teeth typically will move as a
unit when mobility is checked.
 Occlusal interference is often present.
Radiographic findings:

 The vertical line of the fracture may run along the PDL or
in the septum.
 The horizontal line may be located apical at the apex or
coronal to the apex.
 An associated root fracture may be present. The
horizontal fracture line may run at any level in regard to
the permanent tooth germs.
 Treatment

 Treatment of fracture of the alveolar process

includes reduction and immobilization
 After administration of local anesthesia, the
alveolar fragment is repositioned with digital
pressure.
 In this type of fracture, apices of involved
teeth can often be locked in position by the
vestibular bone plate.
Andreasen J O, Andreasen F M, Andersson L. Textbook and Color Atlas of Traumatic Injuries
to the Teeth. 4th ed. Munksgaard: Blackwell publication Co. 2007.
  Splinting of alveolar fracture can be achieved
by means of acid-etch/ resin splint or arch
bars.
 Intermaxillary fixation is not required
provided that a stable splint is used.
 Fixation period of 4 week is usually
recommended.
 In child this period can be reduced to 3 weeks.
Andreasen J O, Andreasen F M, Andersson L. Textbook and Color Atlas of Traumatic
Injuries to the Teeth. 4th ed. Munksgaard: Blackwell publication Co. 2007.
Follow-up
 Splint removal and clinical and radiographic
control after 4 weeks.
 Clinical control after 1 week.
 Clinical and radiographic control and splint
removal after 3-4 weeks.
 Clinical and radiographic control after 6-8
weeks and
 1 year then yearly untill exfoliationh.
Sequele Of Acute Dental Trauma In
The Primary Dentition.
Pulpitis:
 Pulpitis is the initial response of the tooth to
trauma and it accompanies almost every injury.
 Signs include sensitivity to percussion and
capillary congestion, which may be clinically
apparent from the lingual surface of the tooth
using transillumination.
 Pulpitis may be reversible in minor injuries or
may progress to irreversible pulpitis and pulp
necrosis.
Pulp Necrosis

 Injured pulps may lose their vitality either

because of damage to the vascular tissue at
the apex and the resulting ischemia or
because of necrosis of exposed coronal pulp
tissue.
 If the necrotic pulp becomes infected with
oral microorganisms either because of
luxation of the root and ingress through the
lacerated PDL or via an exposed pulp, pain
and root resorption can occur.
McTigue DJ. Managing injuries to the primary dentition. Dent Clin North Am. 2009
Oct;53(4):627-38.
Tooth Discoloration

 Injuries to the primary incisors frequently

cause tooth discoloration .
 Blood vessels within the pulp chamber can
rupture, depositing blood pigment in the
dentinal tubules.
 This blood may desorbed completely or can
persist to some degree throughout the life of
the tooth.

McTigue DJ. Managing injuries to the primary dentition. Dent Clin North Am. 2009
Oct;53(4):627-38.
 Teeth that discolor are not necessarily
necrotic, particularly when the color change
occurs within a few days of the injury.
 A yellowish discoloration of both primary and
permanent teeth may occur if they undergo
pulp canal obliteration
pulp canal obliteration

 The entire pulp chamber and canal appear

radiopaque in radiographs and the crown
may have a yellowish color.
 The process of accelerated dentinal
apposition in PCO is not well understood, but
primary teeth with PCO tend to resorb
normally.
 Pulp necrosis is rare in teeth with PCO and
root canal treatment is rarely indicated in
either the primary or permanent dentitions.
McTigue DJ. Managing injuries to the primary dentition. Dent Clin North Am. 2009
Oct;53(4):627-38.
Sequelae In Permanent Dentition
After Trauma In Primary Dentition.
Enamel hypoplasia:
 This includes discoloration of the enamel and
or defects of the enamel surface.
 Discoloration usually ranges from white to
yellowish-brown staining.
 The hypoplasia normally affects the labial
crown surface and ranges from tiny spots to
large areas.
Fig. 1.-Enamel discoloration of 31 and 32 in a 9-year-old boy after trauma to their predecessors at 2.5 years of age.
Fig. 2.-Buccal enamel defect of 1 1 in an 8-year-old boy after partial luxation of 51 at 1.5 years of age.
Fig. 3.-Combined enamel defect and discoloration of 12 in a 9-year-old boy after partial luxation of 52 at 2 years of
age.
Fig. 4.-Extended enamel hypoplasia of 41 in a 7-year-old boy after partial luxation of 81 at 11 months of age.
form
Crown dilaceration

 A traumatic displacement of already formed hard tooth

substance in relation to the developing soft tissues leads to
a deviation of the crown in relation to the long axis of the
tooth.

 A minor dilaceration consists of a circular enamel defect.

 The severe type includes a complete palatal deviation of

the crown with additional enamel hypoplasia
Fig. 5a.-Crown dilacerations of 21 and 22 in a 9-year-old boy after partial luxations
of 61 and 62 at 2 years of age.

Fig. 5b.-Palatal deviations of the crowns of 21 and 22.

Odontome-like teeth
 Heavy trauma to the permanent tooth germ at an early stage
of odontogenesis may lead to complete tooth deformation.

 Odontome-like disturbances of permanent teeth may develop

especially after intrusive or luxation of primary teeth.

 On radiographs such malformed teeth present as a

conglomeration of hard tissues resembling a complex
odontome.

 As a rule such malformed teeth do not erupt and must be

removed surgically.
Root malformation

 Trauma to the epithelial root sheath of Hertwig

during root development may lead to root
dilaceration or to an arrest of root formation

 In the latter case a very short root may develop and

tooth eruption will be delayed or completely
disturbed.
 Other, but very rare, malformations include root
duplication and lateral or vestibular root angulation
root dilaceration of 11 with pulpal calcification in a
7-year-old girl after partial luxation of 51 at 5 years of age.
Summary…
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