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Dento-
alveolar
trauma
Dento-alveolar trauma:
In children is distressing for both child and
parent.
Often difficult for the dentis.
It is important that the dentist (all members
of the dental team) are well prepared to
meet the many complex and challenging
problems in the care of dental
emergencies.
Is one of the most common reason young
children to visit a pediatric dentist.
This concerns especially for cases whit little
children \toddler\.
History
When the patient is received for treatment, the first step is to get an initial impression of the extent of the injury.
Has a tooth been knocked out?
Is the patient’s general condition affected?
Is there a need for immediate medical care?
History of
the
Dental Injury
Three important questions are asked in gathering the dental history:
When?
Where?
How did the accident occur?
Dental history
When did the injury occur?
The time interval between injury and treatment can influence both the treatment procedure and the expected outcome.
Optimal repositioning of an extruded permanent tooth is difficult if treatment is delayed.
The time factor is also very critical for the prognosis of replanted teeth.
Dental
history
Where did the injury occur ?
This information is important for insurance and social security purposes.
The place of accident also provides information on the need for tetanus prophylaxis in replantation cases.
Dental history
How did the injury occur?
The nature of the blow may provide
information about the type of injury,
which can be expected.
When a blow hits the chin, the
mandibular arch is forced against
the maxillary arch.
As possible resulting injuries:
Jaw fracture
Сrown-root fracture in the
premolar or molar regions
Dental history
Was there a period of unconsciousness?
If so, for how long?
Is there а headache? Amnesia? Nausea? Vomiting?
Excitation or difficulties in focusing the eyes?
These are all signs of brain concussion and require medical attention.
Head injury
Between 25% and 50% of all
accidents in children up to 14 years
involve the head.
If there is any suggestion that a
head injury has been sustained, the
child should be immediately
medically assessed.
Signs of closed head injury
● Altered or loss of consciousness.
● Bleeding from the head or ears.
● Disorientation.
● Prolonged headache.
● Nausea, vomiting, amnesia.
● Altered vision or unilateral
dilated pupil.
● Seizures or convulsions.
● Speech difficulties.
Dental history
Is there any disturbance in the bite?
Disturbance in the occlusion can imply:
luxation injury
alveolar fracture
jaw fracture or luxation
or fracture of the temporomandibular
joint.
Limitations of mandibular movement or
mandibular deviation on opening or
closing the mouth indicate that the jaw
might be fractured.
Medical history
A short medical history should
reveal
Possible allergies
Blood disorders – very important if
soft tissues are lacerated or teeth
are to be extracted
Congenital heart disease
Other information about
conditions that could interfere
with treatment.
Clinical
examination
Extraoral
examination
The facial skeleton should be palpated to determinediscontinuities of facial bones.
Extraoral wounds and bruises should be recorded.
Deep lip wounds are examined closely with respect to tooth fragments or other foreign bodies.
Extraoral examination
The temporomandibular joints should be palpated, and any swelling, clicking, or crepitus should be noted.
Mandibular function in all excursive movements should be checked.
Any stiffness or pain in the child's neck necessitates immediate referral to a physician to rule out cervical spine injury.
Intraoral examination
All soft tissues should be examined and any injuries
recorded.
The presence of foreign matter in lacerations of the
lips and cheeks, such as tooth fragments or soil,
should be identified.
Removal at the initial appointment will eliminate
chronic infection and disfiguring fibrosis.
Intraoral examination
It is important to examine all teeth within a
traumatized area;
In close bite situations;
Also teeth in the opposite jaw;
Each tooth in the mouth should be examined
Particular note is taken of the following
factors:
Intraoral
examination
Displacement.
The direction as well as the extent (in mm) of displacement should be recorded.
Minor displacement can be difficult to detect.
In such cases it is helpful to examine the occlusion as well as radiographs taken at various angulations.
Intraoral examination
Mobility
The degree of mobility is assessed
in a horizontal and vertical
direction
keeping in mind that immature
permanent teeth and primary
teeth undergoing root
resorption have quite extensive
physiologic mobility.
When several teeth move
together en bloc, a fracture of
the alveolar process is suspected.
Intraoral examination
Reaction to percussion.
The handle of a mouth mirror is
tapped gently against the
teeth in a horizontal and
vertical direction.
Tenderness to percussion
indicates damage to the
periodontal ligament.
A high metallic tone implies
that the injured tooth is locked
in bone.
Intraoral
examination
Color of the tooth
Discoloration may appear
almost immediately after the
injury.
Special attention should be
paid to the palatal surface in
the gingival third of the crown.
Intraoral examination
Reaction to sensibility tests
It is usually not possible to obtain reliable information from a young, frightened child.
In the permanent dentition electrometric sensibility testing should be performed whenever possible.
It gives important information about the neurovascular supply to the pulp.
Provides a baseline value for comparison at follow-up examination.
Reaction to sensibility tests
The contralateral uninjured tooth or another comparable tooth serves as a control.
The most reliable response is obtained when the electrode is placed upon the incisal edge.
It is important to explain the purpose of the test and the type of reaction to be expected.
Radiographic
examination
Is mandatory in order to get an
impression:
Of the injury to the supporting
tissues
The stage of root development
In the case of primary tooth
injuries, the relation to
permanent successors
The injury site should be viewed
from different angulations.
Diagnosis
A diagnosis is based on
information from the
clinical and radiographic
examination.
The injury is classified as a
guide to the treatment
required.
We use the classification,
recommended by the
World Health Organization
(WHO).
Classification of dento-alveolar injuries (WHO)
Injuries to hard dental tissues and pulp
Enamel infraction
Enamel fracture
Enamel – dentine fracture
Complicated crown fracture
Uncomplicated crown-root fracture
Complicated crown-root fracture
Root fracture
Classification of dento-alveolar injuries (WHO)
Injuries to the periodonal tissues
Concussion
Subluxation
Extrusive luxation (partial avulsion)
Lateral luxation
Intrusive luxation
Avulsion
Classification of dento-alveolar injuries (WHO)
Injuries to supporting bone
Comminution of mandibular or
maxillary alveolar socket wall
Fracture of mandibular or maxillary
alveolar socket wall
Fracture of mandible and maxilla
Classification of dento-alveolar injuries (WHO)
Injuries to gingiva or oral
mucosa
Laceration of gingiva or oral
mucosa
Contusion of gingiva or oral
mucosa
Abrasion of gingiva or oral
mucosa
Injuries to primary teeth. Clinical features, diagnosis and treatment
Epidemiology in primary dentition:
At 5 years of age
11 – 30 % of children suffer trauma to
primary dentition (31 – 40 % of boys and
16 – 30 % of girls)
The incidence of injuries to primary
teeth increases from 1 year of age –
peak incidence is at 2 – 4 years
Most traumas involve children younger
than 4 years of age.
In preschool children, trauma in
boys is more common than in girls.
Epidemiology:
Depending on the affected teeth:
The most frequently injured teeth in the primary
dentition are the maxillary incisors.
Primary molars are rarely injured - when injury
occurs it is usually due to indirect trauma
blows to the underside of the chin causing
the mandible to close forcefully against the
maxilla.
Epidemiology:
Depending on the kind of injury:
In the primary dentition luxation injuries are
more common than fractures due:
to the spongy nature of the bone in young children
to the lower root/crown ratio in comparison with
that of permanent teeth.
Concussion and subluxation – are the next
most injuries
Aetiology: In a young child learning to walk and to
run, muscle coordination and judgmentare incompletely developed and fallinginjuries frequently occur.
Predisposing factors:
Malocclusion – protrusion
Most injuries are caused by falls and play accidents.
Another major cause of dental injuries in young children is automobile accidents.
Child abuse is serious cause of dental injuries to young children.
- Physical abuse. - Emotional abuse.
- Neglect. - Sexual abuse.
Important!
The permanent incisor is located palatally during its early development and in close proximity to the apex of the primary incisor.
With any injury to primary teeth, the dentist must always be aware of possible damage to the underlying permanent teeth.
A primary incisor should always be removed if its maintenance will jeopardize the developing tooth bud.
Important!
A traumatized, retained primary tooth should
be assessed regularly for clinical and
radiographic sings of pulpal or periodontal
complications.
Every 3-4 months – for the 1. year
Then annually until tooth exfoliation
Soft tissue injuries should be assessed weekly
until healed
Injuries to
the
periodonal
tissues
Concussion – description:
An injury to the tooth-supporting structures:
without increased mobility
tooth is not displaced
but with pain to percussion
without gingival bleeding.
Concussion – etiology:
The neurovascular supply is usually intact
In a few areas bleeding edema
In most areas the periodontal ligament is without
damage
No damage to the follicle or permanent tooth
germ
Diagnostic signs
➢ The signs of concussion are transient. It is not possible to
diagnose concussion if the examination is done several days after
injury.
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs
recommended
Not displaced.
Tender to touch or tapping.
No increased mobility.
Not reliable in primary teeth. Inconsistent results
No radiographic abnormalities. Normal
periodontal space.
An occlusal exposure is recommended in order
to screen for possible signs of displacement or
the presence of a root fracture. The radiograph
can be used as a reference point in case of
future complications.
Treatment Guidelines
There is no need for treatment.
Only observation is needed
Clinical control at 1 week, 6-8 weeks.
PATIENT
INSTRUCTIONS
Soft food for 1 week.
as far as possible - children do not bite with teeth
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
PATIENT
INSTRUCTIONS
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
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.
Subluxation
An injury to the tooth supporting structures
resulting in:
➢ increased mobility
➢ pain to percussion
➢ without displacement of the tooth.
Bleeding from the gingival sulcus is evident if the
child is seen shortly after the accident.
Subluxation – etiology:
Damage may have happened to the
neurovascular supply
In many areas separation of periodontal
ligament with interstitial bleeding and edema
Some areas have undamaged periodontal
ligament
No damage to the follicle or permanent tooth
germ
Diagnostic signs
➢ The signs of subluxation are transient. It is not possible to
diagnose it if the examination is done several days after injury.
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs
recommended
Not displaced.
Tender to touch or tapping.
Increased mobility.
Not reliable in primary teeth. Inconsistent results
Normal periodontal space.
An occlusal exposure is recommended in order
to screen for possible signs of displacement or
the presence of a root fracture. The radiograph
can be used as a reference point in case of
future complications.
Treatment Guidelines
There is no need for treatment.
Only observation is needed
Clinical control at 1 week, 6-8
weeks.
Treatment GuidelinesPATIENT INSTRUCTIONS
Soft food for 1 week.
as far as possible - children do not bite with teeth
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
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
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.
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.
Extrusion
Severance of neurovascular pulp supply
Separation of periodontal ligament and
coronal exposure of root surface
Usually no damage to the follicle or
permanent tooth germ
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
Appears elongated.
Tenderness to percussion.
Excessively mobile
Not reliable in primary teeth. Inconsistent results
Increased periodontal ligament space apically
An occlusal exposure is recommended in order to evaluate the size of the displacement and rule out the presence of a root fracture. The radiograph can be used as a reference point in case of late complications.
Treatment
The treatment choice should be based on the:
degree of displacement
mobility
root formation
the ability of the child to cope with the emergency situation.
For minor extrusion (< 3 mm) 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.
Extrusion - repositioning
The area must be cleaned with water spray,
saline
Reposition tooth with finger
Extrusion - extraction
• The area must be cleaned with water spray,
saline
• Apply local anesthesia (if necessary)
• Extract tooth
Treatment Guidelines
PATIENT INSTRUCTIONS
Soft food for 1 week.
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
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
increased mobility or fistula.
Treatment Guidelines
PATIENT INSTRUCTIONS
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
Clinical control after 1 week.
Clinical and radiographic control at 6-8 weeks, 6 months, and 1 year.
Once per year until physical exfoliation of the tooth
Lateral luxation
Displacement of the tooth other than
axially.
Labial, lingual, lateral direction
Displacement is accompanied by
comminution or fracture of either the
labial or the palatal/lingual alveolar
bone.
Palatal/lingual luxation of the maxillary
incisors may result in occlusal interference
expressed by premature contact with the
opponent teeth.
Lateral luxation
No collision with permanent
tooth bud
Collision with permanent tooth
bud
Lateral luxation - Retrusion
Rupture of the periodontal ligament
Rupture of the neurovascular supply and
entrapment of the apex in the bone
Possible damage to the permanent tooth
germ
Lateral luxation - Protrusion
Rupture of the periodontal ligament
Rupture of the neurovascular supply
and entrapment of the apex in the
bone
High risk of damage to the permanent
tooth germ
Diagnostic signs Lateral luxations are complicated by fracture of either
the labial or the palatal/lingual alveolar bone and a
compression zone in the cervical and sometimes the
apical area.
If both sides of the alveolar socket have been
fractured, the injury should be classified as an alveolar
fracture (alveolar fractures rarely affect only a single
tooth).
In most cases of lateral luxation the apex of the tooth
has been forced into the bone by the displacement,
and the tooth is frequently non-mobile.
Diagnostic signs
Visual signs
Percussion test
Mobility test
Sensibility test
Radiographic findings
Radiographs recommended
Displaced, usually in a palatal/lingual or labial direction
Usually gives a high metallic (ankylotic) sound
Usually non-mobile.
Not reliable in primary teeth. Inconsistent results
Increased periodontal ligament space apically is best seen on the occlusal exposure
An occlusal exposure can sometimes show the position of the displaced tooth and its relation to the permanent successor.
Treatment
• If there is no occlusal interference, as is often the case in anterior open bites, the tooth should be allowed to reposition spontaneously.
Spontaneous repositioning
• Clinical control after 1 and 2-3 weeks.
• Clinical and radiographic control at 6-8 weeks and 1 year.
• Once per year until physical exfoliation of the tooth
Follow-up
Treatment
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.
Follow-up
Clinical control after 1 and 2-3 weeks.
Clinical and radiographic control at 6-8 weeks and 1
year.
Once per year until physical exfoliation of the tooth
Treatment
Extraction (protrusion)
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.
Treatment Guidelines
PATIENT INSTRUCTIONS
Soft food for 10 – 14 days.
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
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
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.
Intrusion - Intrusive luxation
Displacement of the tooth into
the alveolar bone.
This injury is accompanied by
comminution or fracture of the
alveolar socket.
Intrusion - Intrusive luxation
No collision with permanent
tooth bud
Collision with permanent tooth
bud
Intrusion
Contusion of the periodontal
ligament and bone
Rupture of the neurovascular supply
and fracture of the labial bone
Damage to the permanent tooth
germ is frequent
Diagnostic signs
The tooth is displaced axially into the alveolar
bone and frequently penetrating the labial bone
plate where it can be palpated.
The tooth may disappear completely in the tissues
resembling avulsion and root fracture with
complete extrusion of the coronal fragment.
In this case diagnosis is based on an occlusal
radiograph.
Penetration of the tooth into the nasal cavity can
be diagnosed by bleeding from the nose or simple
observation of the nostril.
Diagnostic signs
Percussion test
Mobility test
Sensibility test
Radiographic findings
Usually give a high metallic (ankylotic) sound; in severe intrusion cases - not always possible to perform.
The tooth is non-mobile.
Not reliable in primary teeth.
When the apex is displaced toward or through the labial bone plate the apical tip can be visualized and appears shorter than the unaffected contralateral tooth.When the apex is displaced toward the permanent tooth germ, the apical tip cannot be visualized, and the tooth appears elongated.
Treatment
Spontaneous re-eruption
Follow-up
Clinical control after 1 week.
Clinical and radiographic control at 3-4 weeks, 6-8 weeks, 6-month, 1 year and yearly clinical and radiographic control until eruption of the permanent successor.
If eruption has not yet begun after 4 weeks an ankylosis may be present
Indication for extraction at a later day
Treatment
Extraction
If the apex is displaced into the
developing tooth germ.
Other indications are:
signs of swelling, spontaneous
bleeding, abscess and fever
Follow-up
Clinical and radiographic control
at 1 year
Yearly until eruption of the
permanent successor.
Treatment Guidelines
PATIENT INSTRUCTIONS
Soft food for 10 – 14 days.
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
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
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.
Intrusive LuxationPrimary Teeth
One of the most dangerous
injuries to the developing
tooth bud
Management: Minimize
damage by assessing
displacement of permanent
bud
Discoloration of Primary ToothPost Trauma
Color may change 2-4 weeks
after trauma
May retain/regain vitality
and return to near normal
color within 6 months
Monitor. Esthetics may be a
concern if color does not
resolve
Color may be pink, purple,
grey or brown
Pulpal Obliteration
History of Trauma
Tooth darker-usually yellowish
Radiograph shows pulpal space
narrowing or obliterated
Radiographic
Abscess
Note:
resorption
post trauma.
Avulsion
The tooth is completely
displaced out of its
socket.
Clinically the socket is
found empty or filled
with a coagulum.
Damage to the follicle
of the permanent tooth
germ is frequent
Diagnostic signs
• Visual signs
Radiographic
findings
Radiographs
recommended
The tooth is removed from its socket.
The alveolar socket will be empty. If the
avulsed tooth is not present a
radiographic examination is essential to
ensure that the missing tooth is not
intruded.
An occlusal exposure is recommended
in order to screen for the presence of
root fragments and to make sure that
the missing tooth is not intruded.
TreatmentReplantation is contraindicated
In the initial examination all avulsed teeth are accounted for.
If not, it is 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 pediatrician to exclude aspiration.
TreatmentPatient instructions
Soft food for 1 week.
Good oral hygiene.
Inform the parent about possible complications in the development of the permanent successor
especially following avulsion injuries sustained in children under 3 years of age.
Follow-up
Clinical control after 1 week
Clinical and radiographic control after 6 months and 1 year.
Yearly clinical and radiographic controls until eruption of the permanent successor.
Injuries to
hard
dental
tissues and
pulp
Enamel infraction
An incomplete fracture
(crack) of the enamel without
loss of tooth structure.
Fracture lines in the enamel
No damage to the permanent
tooth germ
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
A visible fracture line on the surface of the tooth
Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.
Normal mobility.
Not reliable in primary teeth.
No radiographic abnormalities.
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
A fracture confined to the
enamel with loss of tooth
structure.
Fracture restricted to enamel
No damage to the
neurovascular supply
No damage to the permanent
tooth germ
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
Visible loss of enamel. No visible sign of exposed dentin.
Not tender. If tenderness is observed evaluate the tooth for a possible luxation or a root fracture.
Normal mobility.
Not reliable in primary teeth.
The enamel loss is visible
Treatment
Smooth sharp edges.
In patients with lip or cheek
lesions it is advisable to search
for tooth fragments or foreign
material.
Clinical and radiographic
controls after 3-4 weeks
Follow-up
No follow up required.
Enamel-
dentin fracture
A fracture confined to enamel
and dentin
with loss of tooth structure
not involving the pulp.
No damage to the
neurovascular supply
No damage to the permanent
tooth germ
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Visible loss of enamel. No visible sign of exposed pulp tissue.
Not tender. If tenderness is observed evaluate the tooth for a possible luxation or a root fracture.
Normal mobility.
Not reliable in primary teeth.
The enamel loss is visible. The distance between the fracture and the pulp chamber can be evaluated.
Treatment
Clean the area with water spray,
saline
As an emergency treatment GIC can
be applied as temporary coverage
Restore with composite after 1 month
(GIC must be removed)
Follow up
Clinical and radiographic controls
after 6-8 weeks and 1 year
Complicated
crown fracture
A fracture involving enamel and dentin
with loss of tooth structure and exposure
of the pulp.
No damage to the neurovascular supply
No damage to the permanent tooth
germ
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
Visible loss of enamel and dentin and exposed pulp tissue
Not tender. If tenderness is observed evaluate the tooth for a possible luxationinjury or a root fracture.
Normal mobility.
Not reliable in primary teeth.
The loss of tooth structure is visible.
An occlusal exposure is recommended in order to screen for possible signs of displacement or the presence of a root fracture. The radiograph can be used as a reference point in case of future complications.
Treatment
Pulp capping
Partial pulpotomy
Extraction
❑ The treatment is depending on the child's maturity and ability to cope.
❑ Extraction is usually the alternative option.
Follow-up
➢ Clinical after 1 week.
➢ Clinical and radiographic control after 6-8 weeks and 1 year.
Crown-root fracture without pulp involvement
A fracture involving enamel, dentin and
cementum with loss of tooth structure
but not involving the pulp.
Enamel-dentin fracture extending below
the gingival margin
No damage to the neurovascular supply
No damage to the permanent tooth
germ
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
Crown fracture extending below gingival margin. The crown is split into two or more fragments, one of which is mobile.
Tenderness to percussion.
At least one coronal fragment is mobile. Because of mobility during mastication there might be transitory pain.
Not reliable in primary teeth.
Apical extension of fracture usually not visible. In laterally positioned fractures, the extent in relation to the gingivalmargin can be seen.
An occlusal exposure.
Treatment
• Most of these may be redirected to later treatment.
Depends on the clinical
findings - two treatment
scenarios may be considered.
• If the fracture involves only a small part of the root
• The stable fragment is large enough to allow coronal restoration,
• Remove the mobile fragment.
Fragment removal only
• Extraction in all other instances.Extraction
Treatment
PATIENT INSTRUCTIONS
Soft food for 10 – 14 days.
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
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
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.
Treatment
Follow-up
❑ In case of fragment removal only:
Clinical control after 1 week.
Clinical and radiographic control after 3-4 wks.
Clinical control after 1 year.
❑ In case of tooth extraction:
Clinical and radiographic control at 1 year
Every year until eruption of the permanent successor.
Crown-root
fracture with
pulp involvement
Enamel-dentin fracture with pulp
involvement extending below the
gingival margin
No damage to the neurovascular supply
No damage to the permanent tooth
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
Crown fracture extending below gingival margin. The crown is split into two or more fragments, one of which is mobile.
Tenderness to percussion.
At least one coronal fragment is mobile. Because of mobility during mastication there might be transitory pain.
Not reliable in primary teeth.
Apical extension of fracture usually not visible. In laterally positioned fractures, the extent in relation to the gingival margin can be seen.
An occlusal exposure.
Treatment
Extration:
Follow-up
Clinical and radiographic control at 1 year
Every year until eruption of the permanent successor.
Root fracture
A fracture confined to the root of the
tooth involving cementum, dentin, and
the pulp.
The neurovascular supply is usually intact
at tooth apex
No damage to the permanent tooth
germ
Rupture of neurovascular supply at
fracture line
Separation of PDL and exposure of root
surface
Diagnostic signs
Visual signs
Percussion test
Mobility test
Pulp sensibility test
Radiographic findings
Radiographs recommended
The coronal segment is usually mobile and may be displaced. Transient crown discoloration (red or grey) may occur.
The tooth may be tender.
The coronal segment is usually mobile
Not reliable in primary teeth.
The fracture is usually located mid-root or in the apical third.
An occlusal or periapical exposure.
Treatment
No treatment
If the coronal fragment is not displaced no treatment is required.
Extraction
If the coronal fragment is displaced - extract only that fragment.
The apical fragment should be left to be resorbed.
Root FracturesPrimary Teeth
Apical 1/3
Most teeth maintain vitality and are
minimally mobile
Apical fragment should
resorb normally
Monitor with radiographs
Root FracturesPrimary Teeth
Middle or Cervical 1/3
Most teeth mobile.
Extraction indicated
Gently attempt to retrieve apical
fragment
If not successful, monitor
Don’t disrupt permanent tooth
bud
Treatment
PATIENT INSTRUCTIONS
Soft food for 10 – 14 days.
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
Parents should be further advised about possible complications that may occur, like:
swelling,
dark discoloration of the crown,
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.
Treatment
Follow-up
Clinical control after 1 week.
Clinical and radiographic control after 6-8 weeks and 1 year.
In case of tooth extraction:
Clinical and radiographic control at 1 year
Every year until eruption of the permanent successor.
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.
Recommended