very detailed presentation, added my own clinical cases of trauma to permanent maxillary central incisors.

1. Dental Trauma to Permanent Teeth
By:
Dr. A.K.Zalan
PGR MDS
Pediatric dentistry
Children Hospital, PIMS,
Islamabad.

2. Dental traumatology is the branch of dentistry that
encompasses the epidemiology, etiology, prevention,
assessment, diagnosis, and management of trauma to
the
jaws and surrounding tissues.
• It also embraces posttraumatic sequelae, such as root
resorption and its treatment

3. CLASSIFICATION OF INJURIES
Basically two types:
Hard tissue injuries: involving the teeth, alveolar bone,
and other facial bones.
Soft tissue injuries: involving the facial skin,
lips,mucosa
(cheeks and periodontium), soft tissues of the hard and
soft palate, and tongue

4. Crown fracture
• Crown fractures are the most common type of dental
trauma. The type of injury that may occur depends on
the age of the patient and the severity and direction of
the
trauma.
Enamel infraction:
craze line
Can be seen with transilumination or dye.
Uncomplicated crown fracture:

5. Schematic presentation

6. ENAMEL FRACTURE

7. • UN-COMPLICATED Crown Fracture

8. Root fractures
Crown-root fracture: this fracture involves both the
crown and the root at the same time.
• May be complicated or un-complicated.
• Always take multiple radiographs for fracture
delineation.
Intraalveolar root fractures:
Maybe horizontal or diagonal.
Divides roots into two fragments. Coronal and apical.

9. • Crown-root fracture

10. Root fracture

11. Luxation injuries:
When a traumatic injury to a tooth seems to cause its
displacement from the socket, it is termed a luxation
injury.
The type of luxation injury relates to the direction and
severity of the injury.
Concussion: when the tooth is traumatized by an
impact,
but does not change from its normal position.

12. Subluxation: when the tooth sustains an impact that
causes slight mobility with no significant displacement
from its socket
Lateral luxation: implies that the tooth has been displaced
within its socket in a buccal-lingual or labialpalatal
direction.
Intrusion: when the tooth is displaced in an apical
direction within the alveolus.

13. Extrusive luxation: when the tooth is displaced from its
socket in a coronal direction.
Luxations in early age or primary dentition
Fractures in later age
Avulsion (or exarticulation): when the tooth has been
completely dislodged out of its alveolar socket

14. Usually more then one type of dental injury will be present .
Careful observation

16. Alveolar fractures:
Secondary to dental injury
Almost always associated with luxation injuries
Soft tissue injuries:

17. • Patient assessment
• The medical status of the patient plays a vital role in the
comprehensive management of traumatic injuries.
• The clinician should be aware of the general medical
issues that may affect emergency dental care.
• Details regarding systemic diseases, allergies, and recent
hospitalizations are good screening questions

18. • Pulse rate and blood pressure should be recorded. Cool,
pale skin, perspiration, hypotension, tachycardia, and
mental status changes are reliable indicators of shock.
• Decreased pulse rate along with hypertension may
indicate a rise in intracranial pressure.
• Common findings of foreign body aspiration are
coughing, cyanosis, dyspnea, and fever.
• Any patient suspected of having partial airway
obstruction should have chest radiographs taken as
quickly as possible to rule out a foreign body within the
lungs.

20. • With regards to the posttrauma evaluation, questions
pertaining to loss of consciousness, dizziness, headache,
nausea, and vomiting should be discussed since their
presence could indicate possible intracranial injury
requiring immediate medical attention.
• The inability of patients to open their eyes may also
indicate an underlying neurological injury.
• Both pupils should be equal in size and reactive to light,
otherwise underlying brain injury should be suspected.
• Discomfort or paresthesia of the extremities during head
movement may indicate cervical vertebral fractures.

21. • Inability of the patient to protrude the tongue suggests
possible damage to the hypoglossal nerve.
• Once confirmed that there are no major medical
issues, the patient can be evaluated for injuries to the
dentition.

22. • Patient History
WHERE
WHEN
HOW

23. • SOFT TISSUE CLINICAL EXAMINATION
• Extraoral Examination
• When injury present, wash gently with mild detegent
• For hemorrhage, apply finger pressure
• For extensive hemorrhage, a suture may be necessary.
• Ecchymosis seen behind the ear (Battle’s sign) or
bilaterally in the periorbital areas (raccoon eyes),
concomitant with rhinorrhea or otorrhea, may indicate a
basal skull fracture that requires immediate medical
attention

24. • Intraoral Examination:
• visual observation
• Careful irrigation and suctioning of the intraoral tissues will
allow better viewing of these tissues without provoking
pain from potentially injured teeth.
• Administer local anesthesia and suture the bleeding
vessels.
• Unless bleeding is controlled, diagnosis of the extent of
the injury will be difficult to assess.

25. • Bleeding from the sulcus may indicate a crown-root
fracture ,tooth displacement or an alveolar fracture.
• The sublingual area should be examined for signs of
ecchymosis suggesting a mandibular fracture.
SOFT TISSUE RADIOGRAPHIC
EXAMINATION
very important

26. • HARD TISSUE CLINICAL EXAMINATION
• Alveolar Bone
• Bone usually protrudes from mucosa.
• Malocclusion and mobility of fracture segment provide
additional signs .

27. Teeth:
• Observation :
• Fractured , displaced, missing
• Change of color and its manifestations
• If tooth damage, then with or without pulp
exposure.
• Size of exposure?
• Preserve vitality esp. immature tooth with vital pulp
therapies.

28. Mobility
• Tooth mobility is observed by objectively moving the tooth,
using two instruments (typically the back ends of dental
mirror handles), with one instrument on the facial and the
other on the palatal of the tooth.
• Mobility indicates:
subl-luxation
lateral luxation
alveolar segment fracture
root fracture
Complete lack of mobility indicates intrusive luxations
Replacement resorption?? If presented late after trauma.

30. Percussion
• Tooth percussion should initially be performed using a
gentle touch with the fingertip( palpation) , followed by a
light percussion with the fingertip.
• Sensitivity to percussion is an indication of damage to the
periodontal ligament
• alveolar fracture
• root fracture
• pulpal necrosis with an acute periradicular abscess.

31. Pulp vitality/ sensibility tests:
vitality blood supply
sensory nerve fibres.
Reliability in immature teeth?
Do not rely completely on pulp tests… co-relate
clinically and radiographically .
initially negative then positive
initially positive then negative

32. Laser doppler flowmetry

33. HARD TISSUE RADIOGRAPHIC EXAMINATION
• Periapical / occlusal radiographs
• To detect a root fracture,the central x-ray beam must be
directed through the fracture line. ( within 15 – 20 degrees)
• Multiple radiographs should be taken from several different
angles to be more predictable in visualizing fractures.

34. • The following should be considered by the clinician during
the radiographic examination of a traumatic injury:
• stage of root development
• possible crown and/or root fractures
• relative proximity of the distance between a fractured
crown and the pulp
• Radiographic abnormalities of the pulp, including pulp
calcification or internal resorption
• possible intraalveolar root fractures

35. • fracture of the alveolar bone
• degree of dislodgment of a luxated tooth from
its dental alveolus
• Variations in thickness of the periodontal
ligament
• signs of root resorption

36. Crown fractures:
Classifications:
• Enamel infraction and enamel fracture only
• Fracture of enamel and dentin (uncomplicated
crown
Fractures)
• Fracture of crown of the tooth with pulp
involvement
(complicated crown fracture)

37. • Enamel infractions and Enamel Fractures:
• Enamel infractions are very common but frequently
overlooked.
• Infractions are frequently the only evidence of trauma, but
they can also be associated with other injuries. (
periodontal).
• Disclosed by directing the light beam perpendicular to the
long axis of the tooth from the incisal edge
(transillumination).
• Differential diagnosis should exclude cracks caused by
wide, rapid thermal changes (from hot coffee to cold ice

38. • Fibre optic

39. • Enamel fractures can be diagnosed by direct clinical
examination of the missing tooth structure.
• pulp testing can be temporarily negative or there might be
a change in color.

40. Treatment:
Enamel infraction, Generally do not require treatment.
Seal the enamel surface with an adhesive to prevent
taking up stains from tobacco, food, drinks (tea, red wine,
cola), or other liquids like chlorhexidine mouthwashes.
Sealing of cracked teeth may be performed with any
adhesive system after appropriate cleaning and acid
etching.
Crown fractures confined to the enamel , only recontouring
if fracture is small, or restoration .

42. • Concomitant periodontal injuries and their
consequences are usually overlooked with these
fractures…

43. ENAMEL-DENTIN FRACTURE WITHOUT PULP
INVOLVEMENT(UNCOMPLICATED CROWN
FRACTURES)
The fractured tooth should be cleaned with water spray or
a wet cotton roll before examination.
The tooth is generally sensitive to variations in temperature,
dehydration, and pressure because of the exposure
of sectioned dentinal tubules.
Sensitivity is greater in younger teeth…. Why????
Pulp shock and change of color might be present.

44. HISTOPATHOLOGY:
Bacteria and bacterial byproducts have been proven to be
the most important etiological factors in inflammatory
reactions of the human dental pulp.
The pulp has the potential to defend itself by means of
two defensive mechanisms:
1- Passive mechanism
2- Active mechanism

45. •
• Treatment:
• Restoration ( composite Resin):
• Technique that offers the most predictable results
recommends the use of a silicone reference guide.
• Reattachment of coronal Segment:
• With the new dentin bonding agents available , fragment
reattachment is becoming more and more attractive.
• Laminate veneers:

46. Composite Resin Restoration

48. Fracture reattachment

61. • Advantages of re-attachment:
• Psychological acceptance by the patient and/or
• Parents
• Reduced chair time
• Accurate restoration of tooth
• Morphology and texture
• Abrasion would be similar to that of the contralateral and
opposing teeth.

62. • The proposed technique involves the use of a groove in
the fragment to improve its retention.
• Making a small groove with a round diamond bur within
the dentin at the fractured interface.
• A resin composite is applied into the groove of the
fragment ( after acid etch and conditioning)and fitted
against the fractured surface.
• Excess is removed before curing the composite for 40
seconds, both buccal and lingual

65. Dental Trauma to Permanent Teeth
By:
Dr. A.K.Zalan
PGR MDS
Pediatric dentistry
Children Hospital, PIMS,
Islamabad.

66. • Dentine bonding agents on exposed dentine?

67. ENAMEL-DENTIN FRACTURE WITH PULP
INVOLVEMENT (COMPLICATED CROWN FRACTURES):
• clinical examination of the missing tooth structure of the
crown and the presence of a pulp exposure.
• slight hemorrhage from the exposed part.
• Proliferation of pulp tissue occurs when treatment in young
teeth is delayed.
• Tooth is generally sensitive to variations of temperature,
dehydration, and pressure caused by the sectioning of the
dentinal tubules and of the exposed pulp.

69. Radiographic examination:
Stage of root development ( type of treatment)
Concomitant root fracture
As a baseline radiograph
Histopathology:
Inflammatory response followed by the subsequent
formation
of granulation tissue.
Bacterial colonization is impeded if pulpal vascularity is

70. FACTORS INFLUENCING CHOICE OF TREATMENT
Teeth have the potential to form a hard tissue barrier
subsequent to a pulp exposure when a biocompatible pulp-
capping agent is placed.
The stage of root development, the size of the exposure,
and the time elapsed between the injury and the
emergency
treatment seem to be the most important factors.
Other factors are : health of the pulp before the trauma, the
age of the patient, the presence of a concomitant luxation
injury, the effect of the surgical procedures, and the type of

71. • Stage of root development:
• Size of the exposure: larger the exposure, the lower the
chance of healing through the formation of a dentin bridge.
• Presence or absence of concomitant luxation injuries:
• Pulpal health before trauma:
• Age of the tooth:

72. Two different Treatment modalities

73. TREATMENT: MATURE AND IMMATURE TEETH
• Pulp capping and pulpotomy procedures should be
attempted whenever possible in teeth having immature
apices with crown fractures that expose the pulp.
• Calcium hydroxide
• MTA

74. Direct Pulp Capping
• Small exposures.
• Performed within the first 24 hours after injury.
TECHNIQUE:
The fracture surface and the pulpal wound should be
cleaned with saline or diluted in 2.5% sodium hypochlorite to
disinfect the cavity and remove any blood clot that might be
present.
When bleeding has stopped, the exposed pulp is covered
with the selected pulp dressing.
What if bleeding continues after wet cotton pellet pressure?

75. • Pulp capping agent is then covered with GIC and
restored with leak free composite restoration.
• Any leakage will compromise the pulp and results in
treatment failure.

76. Partial pulpotomy:
With longer periods of time subsequent to the trauma, or
with larger exposures, a partial pulpotomy (Cvek technique)
or coronal pulpotomy should be performed.
Involves the removal of damaged and inflamed tissue to
the
level of a clinically healthy pulp, followed by a pulp dressing
(calcium hydroxide or MTA).

77. Procedure:
The tooth should be anesthetised… with or without
epinephrine?
Isolation… ( rubber dam or cotton rolls)
only tissue judged to be inflamed is removed—usually
approximately 1 to 2 mm below the level of the pulp
exposure.
Pulp amputation… what should be used for amputation?
Hemorrhage is controlled by placing sterile moistened
cotton pellets and apply dry cottons over them.

78. • If hemorrhage persists, ensure complete removal of pulp
tissue remnants coronal to pulp stumps.
• Bleeding can be also controlled by flushing continuously
with sterile solution to prevent clot formation.
• Once hemorrhage is controlled, a dressing of calcium
hydroxide is gently placed over the amputation site or,
alternatively, the pulp can be covered with a layer of MTA.
The teeth must be examined clinically and radiographically
every
3 months to assess healing.

79. • Radiographically the formation of a hard tissue barrier
should be observed, and root development, especially
the immature root.
• After 3 months, Cvek proposes that the hard tissue
dentinal barrier must be clinically monitored and the final
restoration placed in a timely manner……. ?
• How to carry MTA to the amputation site ?
• MTA depth – 1 mm
• A thin layer of “flowable” glass ionomer or composite
resin is placed over the MTA and light cured and restored

80. • Coronal Pulpotomy:
• inflammation deeper than 2mm from the exposure site, a
coronal pulpotomy is performed to allow completion of root
development.
• it may be regarded as an apexogenesis procedure.
• Care should be taken to remove the blood clot before
placement of a calcium hydroxide paste over the pulp
stumps
• Why??????

81. • Clinical and radiographic follow-up of these teeth is
essential to ensure that pulpal or periapical pathosis is not
developing.
Deep pulpotomy:
This treatment should be considered in teeth with immature
apices with pulp exposures in which treatment was delayed,
and it became necessary to extend into the coronal third of
the radicular space to reach healthier tissue.
Calcium hydroxide should be used instead of MTA….
WHY??

82. • It is difficult to determine the status of the pulp deep in
the root canal, the outcome may be unpredictable.
• If non-healing present…. Apexification or
Regenerative endodontics.

83. TREATMENT TECHNIQUES FOR NONVITAL TEETH
MATURE TEETH:
• Conventional endodontics.
IMMATURE TEETH
Apexification
• Conventional root canal procedures cannot be used for
these teeth with open apices.
• weaker roots that are much more prone to fracture.

84. Apex of immature teeth may present in two variations:
1- divergent and flaring apical foramen (blunderbuss apex)
2- parallel to convergent.
• In both types conventional endo treatment cannot be
done.
• The most common complication is cervical crown or root
fracture because the cervical portion of the tooth is very
thin and may fracture easily. ( also the role of calcium
hydroxide).
• 2 types of apexification….. They are ???

85. • Apexification:
• Access opening.
• Gates glidden to remove lingual eminence.
• Debridements / irrigations . NAOCL, CHX follower by N/S.
• Minimal instrumentations…. Why?
• Calcium hydroxide paste delivery with?
• Next appointment should be after 2 weeks to remove all the
denatured granulation tissue.
• Radiographic determination of working length .
• Calcium hydroxide placement and should reach the apex.
Why?

86. • Follow up:
• Clinical and radiographically.
• When calcific barrier noticed radiographically, open
the chamber, irrigation
• Use large gutta percha or paper point to check the
apical stop.
• If not formed, again pack it with calcium hydroxide.
• Appropriate time for changing calcium hydroxide???
• If seal formed.. Use gutta percha .. ( heated end of
gutta percha to get complete seal at the apex)

87. Apical barrier (PLUG) Formation:
Although apexification procedures with calcium
hydroxide and other materials have been highly
successful, many problems exist.
Treatment duration may reach upto 3 years with calcium
hydroxide apexification.
Weakening effect of Caoh
Patient’s compliance ( Tx duration and number of
appointments)

88. MTA HAS TAKEN THE
ENDODONTIC WORLD BY
STORM

89. • With the development of an apical barrier technique using
MTA, along with root strengthening restorations of bonded
composite, a more predictable outcome is now possible.
PROCEDURE:
• Access opening
• Canal irrigations
• Sonic or ultrasonic device to flush the apical divergent
canal.
• Working length measurement
• Copious irrigation and drying the canals
• Thick paste ( T/P) consistency Calcium hydroxide
• Sealed with temporary but tight filling.

90. •
• Second appointment:
Examine the tooth C AND R. ( very important)
• Rubber dam isolation
• Cleansed and dried the canal
• Apical placement of MTA plug.
• MAP system or amalgam carrier is used. ????
• Remove MTA from dentinal walls with damp paper point
• Blunted plugger for MTA compaction.
• Thicknes of MTA plug should be atleast 4 mm…. Why?

91. MTA Apexification

92. • MTA Apexification

93. • Wet cotton placed in the canal but should not contact MTA,
above which dry cotton pellet should be placed.
• Temporarily seal
• After 6 hours, the cotton removed , MTA hardness should be
checked with endo file and fill the canal with permanent
restoration.
• Strength of a tooth after MTA plug placement and treated with
newer dentin bonding agents….or Placement of an acid
• etched, bonded composite resin in the ???
• Its strength with non endo treated tooth??

94. Crown-root Fracture:
• fracture involving enamel, dentin, and cementum
• Maybe complicated / uncomplicated
• Crown-root fractures in the anterior region are usually
caused by direct trauma.
• Posteriorly, premolar / molars C-R-F is because of indirect
trauma.
• The fracture line begins a few millimeters incisal to the
marginal gingiva facially and follows an oblique course
below the gingival crevice orally.

96. • Radiographic findings:
• Oblique fracture line is almost perpendicular to the central
beam and hence usually missed.
• Radiographic examination should be done with atleast 3
periapical radiographs in different vertical angulations.

99. Pathology and healing:
• Pulpal inflammation adjacent to fracture site because of
bacterial invasion.
• Proliferation of marginal gingival epithelium into the pulp
chamber.
• Removal of coronal fragment and treatment of the
segment should be done.

100. Four different treatment alternatives are present :
1- Removal of coronal fragment and supragingival
restoration:
This is to allow gingival healing (presumably with formation
of a long junctional epithelium), whereafter the coronal
portion can be restored.
Indications:
This procedure should be limited to superficial fractures
that
do not involve the pulp (i.e. chisel fractures).

101. Procedure:
• Remove loose fragment
• Rough edges along the fracture surface below the gingiva
may be smoothed.
• Temporarily Restoration of remaining crown .
• Maintenance of oral hygiene and wait for gingival healing.
• Restoration with dentin and enamel bonded composite.

104. • Reattachment of the C-R fragment is same as that was
for crown fracture but the gingival margins should be
sharp and should end at the free gingival margin.

105. •
Surgical exposure of fracture surface:
• To convert the subgingival fracture to a supragingival
fracture with the help of gingivectomy and osteotomy.
• Shouldn’t compromise the esthetics
Procedure
• Local anesthesia
• Remove coronal fragment and examine surface carefully
• Axial fracture lines running from the pulp chamber to the
root

106. • Despite good marginal adaptation, re-growth of the
gingiva often takes place, leading to development of a
pathologic pocket palatally and inflammation of the
surrounding gingiva.
• labial migration of the restored teeth.

110. Orthodontic extrusion of apical fragment:
• To move the fracture to a supragingival position
orthodontically.
Indication:
For uncomplicated Crown-root fracture.
Also used for complicated C-R-F
To reconstruct osseous and/or gingival defects, slow
orthodontic extrusion can be used to guide downgrowth of
these tissues.
The cervical diameter should be analyzed before extrusion.

113. • Endodontic therapy can be performed prior to removal of
the coronal fragment.
• In teeth with incomplete root formation, pulp capping or
pulpotomy may be performed. Thereafter, orthodontic
traction
is initiated.
How much can a tooth be extruded and still maintain
reasonable periodontal support?

117. Surgical extrusion of apical fragment :
• To surgically move the fracture to a supragingival position.
Indicated in completed root development and the apical
fragment is long enough to accommodate a post-retained
crown.
Post-ponement of surgical procedure results in atraumatic
extraction?

118. PROCEDURE :
• Apical fragment is luxated with a thin periosteal elevator.
• Root is moved into a more coronal position and stabilized
in the new position with interproximal sutures and/or a
splint.
In case of palatally inclined fractures, 180° rotation can often
imply that only slight extrusion is necessary to accommodate
crown preparation due to the difference in position of the
cemento-enamel junction labially and palatally.

125. Root Fractures:
• Unusual sequelae
• wide variety of presentations as to the location,
angulation, and severity of these fractures.
• Maybe vertical or horizontal along the long axis of the
tooth.
• when the traumatic injury results in a root fracture that is
oriented more horizontally—and completely encased in
bone—often there is a favorable prognosis

126. • Maybe horizontal (transverse) or diagonal (oblique).
• May occur at different axial levels of the root.
• Coronal third, middle third and apical third.

128. Clinical Presentation:
• Slightly extruded
• coronal fragment of the tooth typically being displaced
more lingually.
• Mobility ( depends on fracture location)
• Gingival sulcus bleeding
• Discoloration
• Coronal fragment does become nonvital, the apical
fragment tends to remain vital.

130. • Radiographic presentation:
• Often difficult to visualize.
• When the x-ray beam is directed at approximately the
same angulation as the fracture, the fracture will
become visible.
• However, most intra-alveolar fractures are oblique,
easily obscured.
• Two or three radiographs should be exposed at various
vertical angulations.
• Overlap fragments may appear comminuted or elliptical.

133. Healing classification
Calcific fusing of the fragments
Connective tissue band between the fragments
Bone between the fragments
Granulation tissue between the fragments

135. SEQUELAE :
Pulp canal obliteration
Internal resorption ( transient / progressive)
External resorption
Loss of crestal bone

138. • Healing parameters
• Fracture location
• Diastasis
• Young teeth
• Gender

141. Management
• Just as bone fracture …. Reduction and fixation
Splinting:
Difficult to generalize as to when and how long it is
necessary
to splint a case of an intraalveolar root fracture.
Repositioning
Semi-rigid splinting
Duration?

142. Endodontic treatment:
usually vital
what if vitality is questionable?

143. •
Several options exist
• Endodontically treat the coronal fragment
• Endodontically treat the coronal fragment and surgically
remove the apical fragment
• Endodontically treat both the coronal and apical fragments
• Remove the coronal fragment and endodontically treat the
apical fragment.

150. • luxation injuries
• Clinical situations in which the common presentation is a
severance or disruption between the tooth and its
surrounding tissues secondary to trauma.
• Concussion
• Subluxation
• Lateral luxation
• Extrusive luxation
• Intrusive luxation
• avulsion

151. • Radiographic evaluation is always necessary
• Number of radiographs depends on the clinical
presentation of dental injury

152. Concussion
Only tender to percussion
Should not bleed from gingival sulcus
Still needs thorough clinical evaluation and multiple
radiographs to rule out intra-alveolar root fracture.
Pulp will usually not response to sensitivity tests
immediately post-trauma

153. • Subluxation:
• Similar to concussion, but some mobility will be present.
• Tender to percussion
• Slight bleed from gingival sulcus
• Thorough clinical and radiographic evaluation
• Non-responsive to pulp test immediately after trauma

154. • Lateral Luxation
• in many instances, lateral luxation is accompanied by
some component of vertical displacement as well (i.e.,
extrusion or intrusion of the affected tooth).
• The most important factor in determining the treatment
plan for luxated teeth is the presence or absence of
significant apical displacement at the time of injury

156. Lateral Luxation Without Apical Displacement
• These teeth are pushed only in a facial or lingual direction
with the apical root remaining in its original location within
the socket.
• Digital force is enough to reposition.
• Sulcular bleed will be present
• Good likelihood that neurovasular bundle will be intact in
slight luxation with no apical displacement
• Pulp test negative initially and for few weeks

158. Lateral Luxation With Apical Displacement
• The tooth is frequently pushed palatally or lingually and is
firmly located in its new position.
• Dull metalic sound , different from adjacent teeth
• This occurs because the apex has broken into the facial
cortical plate and wedged the tooth in there.
• Proper radiographic evaluation – PDL widening and
obliteration
• Requires endo treatment but should give a chance to
immature tooth before endodontic intervention.

159. Extrusive Luxation
Tooth will be loose and markedly extended out of its socket
in comparison with adjacent teeth.
It has been stated that if a tooth moves more than 2 mm in
an axial direction, there is little hope for pulp survival,
particularly if
the involved tooth displays a fully formed apex.
Radiographic examination to see if only the coronal part is
extruded in intra-alveolar root fracture and to see the
widened PDL

160. • Intrusive Luxation
• Tooth is firmly locked into the alveolar bone.
• Complete disappearance of the PDL space
radiographically
• Will not response to pulp sensitivity tests.
• Percussion will give a metallic sound like an ankylosed
tooth.
• A completely intruded tooth may also be mistaken for an
avulsed tooth or a subgingival crown-root fracture.

163. • The degree of intrusion should be recorded i-e
• Measure the distance from the intruded tooth’s new
location to the incisal edge of adjacent teeth.
• If the tooth does not spontaneously move towards its
original position over a period of 3 to 5 weeks, then
immediate treatment is indicated.

164. •
Treatment
Emergency treatment:
The main objective of the emergency treatment of luxation
injuries is to reposition the tooth using minimal additional
trauma to the PDL.

165. Repositioning
• Lateral luxation:
• Without apical displacement
• should be gradually moved back to its original position,
using local anesthetic.
• If there is any resistance, the associated alveolar bone
socket should be carefully evaluated.

167. • With apical displacement:
• Tooth is nearly always firmly lodged in its new location and
it is almost impossible to push it directly forward to its
original position
• The explanation for this is that the apex has broken
through the cortical bone plate and stays wedged in there.
• To reposition the tooth back to its original location, the apex
needs to be released from the cortical plate by pulling or
pushing it slightly in a coronal direction.
• while concomitantly applying a gentle pressure to the
palatal side of the crown with the index finger.

171. • Repositioning extruded tooth
• If a few hours have elapsed since the traumatic injury,
there may be some apical resistance to repositioning the
tooth.
• The tooth should be gradually manipulated into the socket
with digital pressure.
• Holding it securely in place with a formed pink wax plate,
while the splint is being attached, is an easy way to
counter the tendency of the tooth to drift out of the socket.

173. • Repositioning intruded teeth:
• most severe of all luxations injuries.
• Four main treatment options:
• Allow for spontaneous eruption.
• Perform surgical crown uncovering.
• Perform orthodontic extrusion.
•
• Perform surgical extrusion.

174. • Spontaneous re-eruption
• Further the permanent tooth has been intruded, especially
if it has a fully formed apex, the less likely it is to erupt on
its own without complications.
• Replacement resorption may occur while waiting for
spontaneous re-eruption
• Less than 3 millimeters, there is some indication that it can
survive and reerupt on its own.
• 6 mm or more then that ?

176. Orthodontic extrusion
It should be initiated as soon as possible, delaying no
more than 3 to 4 weeks posttrauma.
An intruded tooth should first be gently luxated before the
placement of an orthodontic appliance.
Retention period?

177. •
• Surgical extrusion:
• Careful immediate surgical repositioning of a severely
intruded permanent tooth with complete root formation has
many advantages with few disadvantages.

179. • Splinting
• Splint should be flexible, should allow some tooth mobility,
and should be removed within 7 to 10 days.
• But if alveolar bone is involved and if severe luxation??
• Soft wire attached to the teeth with composite or with direct
composite.
• Ribbond, a polyethylene fiber mesh, which is applied on
the teeth and reinforced with composite.
• Titanium trauma splint

180. • Splinting the tooth while having the patient bite into a
warm pink wax plate during the procedure allows for a
very stable platform to work on.
• Check radiographically after splinting.

184. • Additional considerations:
if indeed necessary, endodontic treatment should not be
initiated at the emergency visit, but rather at a follow-up
appointment 7 to 10 days later. WHY???
The pulp of immature luxated (displaced or nondisplaced)
teeth may survive, heal, or revascularize after the
injury.

185. POSTTRAUMA FOLLOW-UP EVALUATIONS AND
TREATMENT
• Clinical and radiographic examination along with pulp
tests.
Endodontic Evaluation and Treatment:
The type of luxation injury and the stage of root
development
will be the two key factors.
Mild concussion or subluxation injury, and even in the case
of a slight lateral or extrusive luxation, there is a good
chance that the pulp will survive.

186. SEQUELAE OF LUXATION INJURIES:
PULPAL
• Pulp necrosis and pulp canal obliteration…. Depends upon
the severity of trauma.
• Internal root resorption and its radiographic diagnosis and
management?

188. Peri-radicular:
• 1- periapical changes
• 2- external root resorption
A – surface resorption
B- replacement resorption
C- root resorption
and cervical resorption

189. THANK YOU