1. Traumatic injuries in
children-Trauma to teeth and
soft tissues
Dept Of Pedodontics & Preventive
Dentistry
Christian Dental College, Ludhiana
Jeena Sara Paul 26th Aug 2009
2nd Year MDS 9 a.m.

2. • The Merriam Webster Dictionary defines trauma as an
injury (as a wound) to living tissue caused by an extrinsic
agent.
• Trauma to the oral region occurs frequently and comprises
5% of all injuries for which people seek treatment.
• In preschool children the figure is as high as 18% of all
injuries.
• Amongst all facial injuries, dental injuries are the most
common of which crown fractures and luxations occur most
frequently.

3. Incidence
• The greatest incidence of trauma to the primary dentition
occurs at 2 to 3 years of age, when motor coordination is
developing.
• The most common injuries to permanent teeth occur secondary
to falls, followed by traffic accidents, violence, and sports.
• All sporting activities have an associated risk of orofacial
injuries due to falls, collisions, and contact with hard surfaces

4. • History of trauma in both primary and permanent teeth- 46% of
children
• Boys show more frequency than girls in permanent teeth, no
significant sex difference in primary teeth
• Peak incidence in boys- 2-4 year and 9-10 year
girls- 2-3 years
• Facial injuries- common in boys of 6-12 yr of age, mandible is most
affected
• Teeth involved- 37% upper central incisor
18% lower central incisor
6% lower lateral incisor
3% upper lateral incisor
• Frequency increased with increase in over jet

5. Incidence
Molina, J. et al. Dent Trauma 24:503-509 2008
• Luxation Trauma-44%
– SUB-50%
– CON-19%
– LUX-17%
– INT-6%
– EXT=AVU-4%
• Tooth- bone trauma- 38%
– UCF- 70%
– CCF-20%
– CRF-5%
– RF-3%
– AF-2%

6. Etiology
• FALL:
- Frequent during first year of life
- peak incidence just before school age
• BATTERED CHILD SYNDROME:
- abused or neglected child who have suffered serious physical
abuse
• ACCIDENTS:
- bicycle accidents, automobile accidents, play ground
accidents
• SPORTS:
- sports like football, baseball, basketball, wrestling, kabbadi,

7. Predisposing Conditions
• Facial profile: more common in,
Angles class II type I malocclusion
• Cerebral palsy: due to,
– abnormal muscle tone and function in oral area producing
protrusion of maxillary anterior teeth
– Poor skeletal and muscle co-ordination
• Epileptic patients
• Dentinogenesis imperfecta

8. Severity of Injury
• Energy of impact
• Resiliency of the impacting object
• Shape of the impacting object
• Angle of direction of the impacting force

9. Mechanism of dental trauma
(Andreasen and Bennett)
Direct trauma: occurs when the tooth itself is hit
Indirect trauma: inflicted when lower dental arch
is forcefully closed against the upper

10. • Dental injuries could have improved outcomes if the public
were aware of first-aid measures and the need to seek
immediate treatment.
• Because optimal treatment results follow immediate
assessment and care, dentists have an ethical obligation to
ensure that reasonable arrangements for emergency dental care
are available.

11. EXAMINATION

12. • A thorough history and examination are necessary of the
patient who has suffered dental-trauma.
• Findings should be documented in the records

13. History
• A detailed history is important when the patient is first seen
after an injury.
• Questions should be asked to determine
– the cause of the injury,
– symptoms,
– possibility of concomitant injuries, and
– the medical history of the patient
before an accurate diagnosis and treatment plan can be
established.

14. Chief Complaint
• The chief complaint may include several subjective symptoms.
• These should be listed in order of importance to the patient.
• Also note the duration of each symptom.

15. History of Present Illness
(Injury)
• Obtain information about the accident in chronologic order
– Date,
– time,
– place,
– how the injury took place

16. • Has the patient noticed any other symptoms after injury-
• Signs and symptoms to watch for are dizziness; vomiting;
severe headaches; seizures or convulsions; blurred vision;
unconsciousness; loss of smell, taste, hearing, sight, or
balance; or bleeding from the nose or ears.
• Affirmative response to any of the above indicates the need
for emergency medical evaluation.

17. • Note any treatment before this examination
• Question the patient about previous injuries involving the
same area.

18. • Specific problems with the traumatized tooth/teeth
• Pain, mobility, and occlusal interference are the most
commonly reported symptoms.
• In addition, the patient should be asked about any symptoms
from adjacent soft tissues such as
tongue, lips, cheeks, gingiva, and alveolar mucosa.

19. Medical History
• Allergies,
• Disorders such as bleeding problems, epilepsy, diabetes
• Current medications
• Tetanus immunization status
– For clean wounds, no booster dose is needed if no more
than 10 years have elapsed since the last dose.
– For contaminated wounds, a booster dose should be given
if more than 5 years have elapsed since the last dose.

20. Clinical Examination
• A careful, methodical approach to the clinical examination will
reduce the possibility of overlooking or missing important
details.

21. Examination of Soft tissues
• All areas of soft tissue
injury should be noted, and
the lips, cheeks, and tongue
adjacent to any fractured
teeth should be carefully
examined and palpated.
• It is not unusual for tooth
fragments to be buried in the
lips.
• The radiographic
examination should include
specific exposures of the
lips and cheeks if
lacerations and fractured
teeth are present

22. Examination of facial bones
• The maxilla, mandible, and temporomandibular joint should be
examined visually and by palpation
• Look for distortions, malalignment, or indications of fractures.
• Indications of possible fractures should be followed up
radiographically.
• Also note possible tooth dislocation, gross occlusal
interference, and development of apical pathosis.

23. Examination of teeth
• The teeth must be examined for
fractures, mobility, displacement, injury to periodontal
ligament and alveolus, and pulpal trauma.
• Remember to examine the teeth in the opposite arch also.
They, too, may have been involved to some degree.

24. Tooth Fracture
• The crowns of the teeth should be cleaned and examined for
extent and type of injury.
• Crown infractions or enamel cracks can be detected by
changing the light beam from side to side, shining a fiber-optic
light through the crown, or using disclosing solutions.
• If tooth structure has been lost, note the extent of loss
• Check for discoloration of the crown or changes in
translucency to fiber-optic light. Both may indicate pulp
changes.

25. Mobility
• Examine the teeth for mobility in all directions.
• If adjacent teeth move along with the tooth being
tested, suspect alveolar fracture.
• Root fractures often result in crown mobility, the degree
depending on the proximity of the fracture to the crown.
• The degree of mobility can be recorded as follows:
– 0 for no mobility,
– 1 for slight mobility,
– 2 for marked mobility, and
– 3 for mobility and depressibility.

26. Displacement
• Note any displacement of the teeth that may be
intrusive, extrusive, or lateral (either labial or lingual) or
complete avulsion.
• Sometimes the change is minimal, and the patient should be
asked about any occlusal interference that developed suddenly.
• In occlusal changes, consider the possibility of jaw or root
fractures or extrusions.

27. Injury to Periodontal Ligament
and Alveolus
• The presence and extent of injury to the periodontal ligament
and supporting alveolus can be evaluated by tooth percussion.
• The results may be recorded as “normal response,” “slightly
sensitive,” or “very sensitive” to percussion.
• Careful tapping with a mirror handle is generally satisfactory.
• In cases of extensive apical periodontal damage, it may be
advisable to use no more than a fingertip for percussion.

28. • In impact trauma with no fractures or displacement, the
percussion test is very important.
• In some apparently undamaged teeth, the neurovascular
bundle, entering the apical canal, may have been damaged, and
the possibility of subsequent pulp degeneration exists.
• Such teeth are often sensitive to percussion.

29. Pulpal Trauma
• The condition of the dental pulp should be evaluated both
initially and at various times following the traumatic incident.
• The electric pulp test (EPT) has been shown as reliable in
determining pulpal status
• Discoloration, particularly a greyish hue, involving permanent
teeth is indicative of pulp necrosis, whereas a yellowish hue
means that extensive calcification has occurred.

30. Radiographic Examination
• Radiography is indispensable in the diagnosis and treatment
of dental trauma.
• Detection of dislocations, root fractures, and jaw fractures
can be made by radiographic examination.
• Extraoral radiography is indicated in jaw and condylar
fractures or when one suspects trauma to the succedaneous
permanent teeth by intruded primary teeth.
• Soft tissue radiographic evaluation is indicated when tooth
fragments or possible foreign objects may have been
displaced into the lips

31. • The size of the pulp chamber and the root canal, the apical
root development, and the appearance of the periodontal
ligament space may all be evaluated by intraoral
radiographs.
• Changes in the pulp space, both resorptive and calcific, may
suggest pulp degeneration and indicate therapeutic
intervention.
• Other radiographic views may be indicated in more
extensive injuries than those confined to the dentition.
• Finally, it is also important to carefully file all radiographs
for future references and comparisons.

32. CLINICAL
ASSESSMENT &
TREATMENT

33. Andreason- WHO 1992
A. Injuries to hard dental tissues and pulp
B. Injuries to periodontal tissues
C. Injuries to supporting bone
D. Injuries to gingiva or oral mucosa

34. Injuries to Hard dental tissues
and Pulp

35. Enamel Infraction and Fracture
• N873.60

36. Crown Fracture without Pulpal
Involvement
• N873.61

37. Crown Fracture with Pulpal
Involvement
• N873.62

38. Crown- Root Fracture
• Uncomplicated-
N873.64
• Complicated- N873.65

39. • 5% of all cases
• Injuries of
anterior region - direct trauma
posterior region - indirect trauma

40. Diagnosis
• Clinical findings usually reveal a mobile coronal fragment
attached to the gingiva with or without a pulp exposure.
• Radiographic findings may reveal a radiolucent oblique line
that comprises crown and root in a vertical direction in
primary teeth and in a direction usually perpendicular to the
central radiographic beam in permanent teeth.
• While radiographic demonstration often is difficult, root
fractures can only be diagnosed radiographically

41. Treatment
• Primary teeth: When the primary tooth cannot or should not be
restored, the entire tooth should be removed unless retrieval of
apical fragments may result in damage to the succedaneous
tooth.
• Permanent teeth: The emergency treatment objective is to
stabilize the coronal fragment.
• Definitive treatment alternatives are to remove the coronal
fragment followed by a supragingival restoration or necessary
gingivectomy; osteotomy; or surgical or orthodontic extrusion
to prepare for restoration.
• If the pulp is exposed, pulpal treatment alternatives are pulp
capping, pulpotomy, and root canal treatment.

42. Uncomplicated crown root fracture

43. • In young patients with immature, still developing teeth:
preserve pulp vitality by pulp capping or partial pulpotomy.
• This treatment is also the choice in young patients with
completely formed teeth. Calcium hydroxide and MTA (white)
are suitable materials for such procedures.
• In older patients, root canal treatment can be the treatment of
choice, although pulp capping or partial pulpotomy may also
be selected.
• If too much time elapses between accident and treatment and
the pulp becomes necrotic, root canal treatment is indicated to
preserve the tooth.

44. General prognosis
• Although the treatment of crown-root fractures can be
complex and laborious, most fractured permanent teeth can be
saved.
• Fractures extending significantly below the gingival margin
may not be restorable.

45. Root Fracture
• N873.63
• Definition: a dentin and
cementum fracture
involving the pulp.

46. • Falls are considered to be the most common cause of root
fracture (Cvek 2001).
• Other causes include fights and blows (Andreasen 1994;
Caliskan 1996; Cvek 2001;Mackie 1988).
• They are uncommon in both the permanent and primary
dentition.
• The prevalence ranges between 0.5%to 7% of all dental
injuries in the permanent dentition (Andreasen 1994).
• Most root fractures are reported in the age range of 11 to 20
years (Caliskan 1996; Cvek 2001; Welbury 2002; Yates 1992).
• Maxillary central incisors are most commonly affected
(Andreasen 1967).

47. Types
• Root fracture may be transverse (horizontal), oblique or
vertical.
• Transverse and oblique fractures are the most commonly seen
types of root fracture in previously uninjured incisors (Mackie
1988).
• Vertical root fracture occurs rarely as a primary injury in
young permanent incisors, but may result from trauma to a
tooth which has already been restored with a post-crown.

48. Types
• The fracture can be simple or complex with more than two
fragments.
• Single horizontal/oblique root fractures carry the best
prognosis.
• The site of fracture can occur at any level of the root.
Therefore root fractures are described according to the level of
the root in which they occur: apical, middle or coronal third
(the upper/top part of the root).

49. Diagnosis:
• Clinical findings reveal a
mobile coronal fragment
attached to the gingiva that
may be displaced.
• Radiographic findings may
reveal 1 or more radiolucent
lines that separate the tooth
fragments in horizontal
fractures.

50. • Multiple radiographic
exposures at different
angulations may be required
for diagnosis.
• A root fracture in a primary
tooth may be obscured by a
succedaneous tooth.

51. Treatment
• Primary teeth: Treatment alternatives include extraction of
coronal fragment without insisting on removing apical
fragment or observation.
• Permanent teeth: Reposition and stabilize the coronal
fragment.

53. • Reposition, if displaced, the coronal segment of the tooth as
soon as possible. Check position radiographically.
• Stabilize the tooth with a flexible splint for 4 weeks.
• If the root fracture is near the cervical area of the
tooth, stabilization is beneficial for a longer period of time (up
to 4 months).
• It is advisable to monitor healing for at least 1 year to
determine pulpal status.
• If pulp necrosis develops, root canal treatment of the coronal
tooth segment to the fracture line is indicated to preserve the
tooth

54. General prognosis
• Pulp necrosis in root-fractured teeth is attributed to
displacement of the coronal fragment and mature root
development.
• In permanent teeth, the location of the root fracture has not
been shown to affect pulp survival after injury.
• Therefore, preservation of teeth with root fractures
occurring in the tooth’s cervical third should be attempted.
• Young age, immature root formation, positive pulp
sensitivity at time of injury, and approximating the
dislocation within 1 mm have been found to be
advantageous to both pulpal healing and hard tissue repair
of the fracture.

55. Injuries to Periodontium

56. Concussion
• N873.66
• Definition: Injury to the
tooth-supporting
structures without
abnormal loosening or
displacement of the
tooth.

57. Diagnosis
• Because the periodontal ligament absorbs the injury and is
inflamed, clinical findings reveal a tooth tender to pressure and
percussion without mobility, displacement, or sulcular
bleeding.
• Radiographic abnormalities are not expected

58. Treatment
• objectives: to optimize healing of the periodontal ligament and
maintain pulp vitality.
• Primary teeth: For primary teeth, unless associated infection
exists, no pulpal therapy is indicated.
• Permanent teeth: Although there is a minimal risk for pulp
necrosis, mature permanent teeth with closed apices may
undergo pulpal necrosis due to associated injuries to the blood
vessels at the apex and, therefore, must be followed carefully.

59. Subluxation
• N873.66
• Definition: injury to
tooth-supporting
structures with
abnormal loosening but
without tooth
displacement.

60. Diagnosis
• Because the periodontal ligament attempts to absorb the
injury, clinical findings reveal a mobile tooth without
displacement that may or may not have sulcular bleeding.
• Radiographic abnormalities are not expected.

61. Treatment
• objectives: to optimize healing of the periodontal ligament and
neurovascular supply.
• Primary teeth: The tooth should be followed for pathology.
• Permanent teeth: Stabilize the tooth and relieve any occlusal
interferences. For comfort, a flexible splint can be used. Splint
for no more than 2 weeks.

63. General prognosis
• Prognosis is usually favorable.
• The primary tooth should return to normal within 2 weeks.
• Mature permanent teeth with closed apices may undergo
pulpal necrosis due to associated injuries to the blood vessels
at the apex and, therefore, must be followed carefully.

64. Lateral Luxation
• N873.66
• Definition: displacement of
the tooth in a direction other
than axially.
• The periodontal ligament is
torn and contusion or
fracture of the supporting
alveolar bone occurs.

65. Diagnosis
• Clinical findings reveal that a tooth is displaced laterally with
the crown usually in a palatal or lingual direction and may be
locked firmly into this new position.
• The tooth usually is not mobile or tender to touch.
• Radiographic findings reveal an increase in periodontal
ligament space and displacement of apex toward or through
the labial bone plate.

66. Treatment
• Primary teeth: allow passive repositioning or actively
reposition and splint for 1 to 2 weeks to allow for
healing, except when the injury is severe or the tooth is
nearing exfoliation.

67. • Permanent teeth: to reposition as soon as possible and then to
stabilize the tooth in its anatomically correct position to
optimize healing of the periodontal ligament and
neurovascular supply, while maintaining aesthetic and
functional integrity.
• Repositioning of the tooth is done with digital pressure and
little force. The tooth may need to be extruded to free apical
lock in the cortical bone plate.
• Splinting an additional 2 to 4 weeks may be needed with
breakdown of marginal bone.

69. General prognosis
• Primary teeth requiring repositioning have an increased risk of
developing pulp necrosis compared to teeth that are left to
spontaneously reposition.
• In mature permanent teeth with closed apices, pulp necrosis
and pulp canal obliteration are common healing complications
while progressive root resorption is less likely to occur.

70. Intrusive Luxation
• N873.67
• Definition: apical
displacement of tooth into
the alveolar bone.
• The tooth is driven into the
socket, compressing the
periodontal ligament and
commonly causes a crushing
fracture of the alveolar
socket.

71. Diagnosis
• Clinical findings reveal that the tooth appears to be shortened
or, in severe cases, it may appear missing.
• The tooth’s apex usually is displaced labially toward or
through the labial bone plate in primary teeth and driven into
the alveolar process in permanent teeth.
• The tooth is not mobile or tender to touch.
• Radiographic findings reveal that the tooth appears displaced
apically and the periodontal ligament space is not continuous.
• Determination of the relationship of an intruded primary tooth
with the follicle of the succedaneous tooth is mandatory.

72. • If the apex is displaced labially, the apical tip can be seen
radiographically with the tooth appearing shorter than its
contra lateral.
• If the apex is displaced palatally towards the permanent tooth
germ, the apical tip cannot be seen radiographically and the
tooth appears elongated.
• An extra oral lateral radiograph also can be used to detect
displacement of the apex toward or through the labial bone
plate.
• An intruded young permanent tooth may mimic an erupting
tooth.

73. Treatment
• Primary teeth: to allow spontaneous re eruption except when
displaced into the developing successor.
• Extraction is indicated when the apex is displaced toward the
permanent tooth germ

74. • Permanent teeth: to reposition passively (allowing reeruption
to its preinjury position), actively (repositioning with
traction), or surgically and then to stabilize the tooth in its
anatomically correct position to optimize healing of the
periodontal ligament and neurovascular supply while
maintaining esthetic and functional integrity.

75. • Teeth with incomplete root formation:
– Allow spontaneous repositioning to take place.
– If no movement is noted within 3 weeks, recommend rapid
orthodontic repositioning.
• Teeth with complete root formation:
– The tooth should be repositioned either orthodontically or
surgically as soon as possible.
– The pulp will likely be necrotic and root canal treatment
using a temporary filling with calcium hydroxide is
recommended to retain the tooth

76. General Prognosis
• In primary teeth, 90% of intruded teeth will reerupt
spontaneously (either partially or completely) in 2 to 6 months.
• Even in cases of complete intrusion and displacement of
primary teeth through the labial bone plate, a retrospective
study showed the reeruption and survival of most teeth for
more than 36 months.
• Ankylosis may occur, if the periodontal ligament of the
affected tooth was severely damaged, thereby delaying or
altering the eruption of the permanent successor.

77. • In mature permanent teeth with closed apices, there is
considerable risk for pulp necrosis, pulp canal obliteration, and
progressive root resorption.
• Immature permanent teeth that are allowed to reposition
spontaneously demonstrate the lowest risk for healing
complications.
• Extent of intrusion (7mm or greater) and adjacent intruded
teeth have a negative influence on healing.

78. Extrusive Luxation
• N873.66
• Definition: partial
displacement of the tooth
axially from the socket;
partial avulsion. The
periodontal ligament usually
is torn.

79. Diagnosis
• Clinical findings reveal that the tooth appears elongated and is
mobile.
• Radiographic findings reveal an increased periodontal
ligament space apically

80. Treatment
• Primary teeth: to reposition and allow for healing, except when
there are indications for an extraction (i.e., the injury is severe
or the tooth is nearing exfoliation).
• If the treatment decision is to reposition and stabilize, splint
for 1 to 2 weeks

81. • Permanent teeth: to reposition as soon as possible and then to
stabilize the tooth in its anatomically correct position
• Repositioning may be accomplished with slow and steady
apical pressure to gradually displace coagulum formed
between root apex and floor of the socket.
• Splint for up to 3 weeks using a flexible splint

83. General Prognosis
• There is a lack of clinical studies evaluating repositioning of
extruded primary teeth.
• In permanent mature teeth with closed apices, there is
considerable risk for pulp necrosis and pulp canal obliteration.
• These teeth must be followed carefully.

84. Avulsion
• N873.68
• Definition: Complete
displacement of tooth out of
socket.
• The periodontal ligament is
severed and fracture of the
alveolus may occur.

85. Diagnosis
• Clinical and radiographic findings reveal that the tooth is not
present in the socket or the tooth already has been replanted.
• Radiographic assessment will verify that the tooth is not
intruded when the tooth was not found.

86. Treatment
• Primary teeth: to prevent further injury to the developing
successor. Avulsed primary teeth should not be replanted
because of the potential for subsequent damage to developing
permanent tooth germs.
• Permanent teeth: to replant as soon as possible and then to
stabilize the replanted tooth in its anatomically correct
location.

87. • Time - Most critical factor
• Advice to patient over phone - rinse tooth gently - do not
scrub, place/hold in socket, see dentist ASAP
• Transport media - Hank’s balanced Salt Solution(HBSS), cold
milk, saline, or saliva

88. • The risk of ankylosis
increases significantly with
an extraoral dry time of 15
minutes.
• An extraoral dry time of 60
minutes is considered the
point where survival of the
root periodontal cells is
unlikely.
• Trope M. Clinical management of the
avulsed tooth: Present strategies and future
directions. Dental Traumatol
2002;18(1):1-11.
• Chappuis V, von Arx T. Replantation of 45
avulsed permanent teeth: A 1-year follow-
up study. Dental Traumatol
2005;21(5):289-96.

89. Results depend upon
• Extraoral time
• Extraoral environment
• Root surface manipulation
• Management of the socket
• Stabilization

90. Replanting within 60 min
• Keep tooth moist in saline at all times
• Radiograph: look for alveolar fracture/bone fragments
• Irrigate socket with saline/anaesthetic to remove clot
• Avoid handling root; grasp crown with forceps, splint

91. • Remove debris from root with a stream of saline
• Do not curette or vent socket; use gentle finger pressure or
patient bites on gauze
• Check tooth alignment; suture soft tissue lacerations; splint for
1-2 weeks.
• Bony fractures require splinting up to 4-8 weeks

92. • Antibiotics; tetanus booster (5 years); chlorhexidine rinses;
analgesics
• RCT for mature teeth: pulp removed after one week; Ca(OH)2
placed before splint removed
• Immature permanent teeth with wide open apices: evaluate at
2, 6, and 12 months

93. Replanting after 60 min of dry
time
• Radiograph; examine for alveolar fractures
• Remove debris & soft tissue from root(scalers & pumice);
soak tooth in 2% sodium fluoride for 5-20 min.
• Extirpate pulp; fill canal
• Remove blood clot from socket & replant tooth
• Splint for 4 weeks

94. • Replanting contraindicated by
– the child’s stage of dental development (risk for ankylosis
where considerable alveolar growth has to take place);
– compromising medical condition; or
– compromised integrity of the avulsed tooth or supporting
tissues.
• Flexible splinting for 1 week is indicated.
• Tetanus prophylaxis and antibiotic coverage should be
considered.
• Treatment strategies are directed at avoiding
inflammation that may occur as a result of the tooth’s
attachment damage and/or pulpal infection

95. Periodontal Ligament
Responses
• Surface resorption -
• Inflammatory resorption
• Replacement resorption

96. Periodontal Ligament
Responses
• Surface resorption
– Superficial resorption
cavities
– Mainly in cementum
– Complete repair of
PDL

97. Periodontal Ligament
Responses
• Replacement resorption
(Ankylosis)
– Direct union of bone and
root
– Resorption of root -
Replacement with bone
– Direct result of loss of
vital PDL

98. Periodontal Ligament
Responses
• Inflammatory resorption
– Resorption of cementum
and dentin
– Inflammatory reaction in
the periodontal ligament

99. Sequelae- Andreasen and
Hjörting-Hansen
• 1. Healing with calcified
tissue. Radiographically, the
fracture line is
discernible, but the
fragments are in close
contact
• 2. Healing with
interproximal connective
tissue. Radiographically, the
fragments appear separated
by a narrow radiolucent
line, and the fractured edges
appear rounded

100. • 3. Healing with interproximal
bone and connective tissue.
Radiographically, the fragments
are separated by a distinct bony
bridge
• 4. Interproximal inflammatory
tissue without healing.
Radiographically, a widening of
the fracture line and/or a
developing radiolucency
corresponding to the fracture line
become apparent

101. General prognosis
• Prognosis in the permanent dentition is primarily dependent
upon formation of root development and extraoral dry time.
• The tooth has the best prognosis if replanted immediately.
• If the tooth cannot be replanted within 5 minutes, it should be
stored in a medium that will help maintain vitality of the
periodontal ligament fibres.

105. Injuries of supporting bone
• Comminution/ fracture of alveolar socket or alveolar process-
a. In mandible- N802.20
b. In maxilla- N802.40
• Fracture of maxilla and mandible-
a. Mandible- N802.21
b. Maxilla- N802.42

106. Injuries to Gingiva or Oral
Mucosa

107. Lacerations
• N873.69
• Shallow or deep wound in
mucosa resulting from a tear
• Usually produced by sharp
object

108. • Provide appropriate tetanus prophylaxis and check for
associated injuries such as loose teeth, mandibular or facial
fractures .
• When only small lacerations are present and only minimal
gaping of the wound occurs, reassurance and simple aftercare
is all that is required.
• Let the patient know the wound will become somewhat
uncomfortable and covered with pus over the next 48 hours
and tell him to rinse with lukewarm water or half strength
hydrogen peroxide after meals and every one to two hours
while awake for one week.

109. • If there is continued bleeding, the wound edges gape
significantly or there is a flap or deformity when the
underlying musculature contracts, the wound should be
anesthetized using lidocaine with epinephrine, cleansed
thoroughly with saline and loosely approximated using a 4-0
or 5-0 absorbable suture.

110. Contusion
• N902.00
• Bruise produced by
impact from blunt
object
• No break in mucosa
• Sub mucosal
haemorrhage

111. Abrasion
• N910.00
• Superficial wound
produced by rubbing or
scraping of mucosa
• Raw bleeding surface

112. Follow-up Evaluation
• Trauma patients should be evaluated often
enough, and over a long enough period of time,
– To determine that complete recovery has taken place
or
– To detect as early as possible pulpal deterioration and
root resorption.
• If pulpal recovery (eg, revascularization) is to be
monitored, frequent initial re-evaluations (every 3
to 4 weeks for the first 6 months) and then yearly
are recommended.

113. Trauma Prevention
• Living and growing carry a high risk of trauma.
• A child will not learn to walk without falling, and few children
reach 4 years of age without having received a blow to the
mouth.
• We cannot totally prevent trauma.
• Moreover, the results of treatment of trauma are often less
predictable than those of other types of dental treatment.

114. • On the brighter side, there are preventive measures that have
been proved to reduce the prevalence of traumatic episodes in
certain environmental situations.
• For example, because the prevalence of fractured incisors is
higher among those with protrusive anterior teeth, many
dentists are recommending early reduction of excessive
protrusion to reduce the susceptibility of such teeth to injury.

115. • The use of car safety
seats and restraining
belts has prevented
many injuries to infants
and young children.

116. • The protective mouth guard
has prevented or reduced the
severity of countless injuries
to the teeth of youngsters
participating in organized
athletic activities; active
youngsters should be
encouraged to wear their
mouth guards during high-
risk unsupervised athletic
activities.

117. • When we have the opportunity to save a
child from pain and suffering, an ounce of
prevention is worth a pound of cure.

118. References
• Mc Donald, Avery, Dean. Dentistry for the Child and Adolescent , 8th edition.
• Andreasen JO, Andreasen F, Andersson L. Textbook and color atlas of traumatic injuries to the
teeth, 4th edition.
• Ingle JI, L K Bakland LK. Endodontics, 5th edition.
• Mitsuhiro Tsukiboshi. Treatment Planning for Traumatised Teeth.
• Guideline on Management of Acute Dental Trauma. AAPD Reference Manual 2007;Vol 30(7): 175-
183.
• Flores et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of
permanent teeth. Dental Traumatology 2007; 23: 66–71.
• Flores et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent
teeth. Dental Traumatology 2007; 23: 130–136.
• Flores et al. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dental
Traumatology 2007; 23: 196–202.