ISSN:

Printed version: 1806-7727

Electronic version: 1984-5685
RSBO. 2011 Jan-Mar;8(1):e1-18

Dentistry Topics

Dentoalveolar trauma in the primary dentition

Estela Maris Losso1
Maria Cristina dos Reis Tavares1
Fernanda Mara de Paiva Bertoli1
Flares Baratto-Filho1
Corresponding author:
Estela Maris Losso
5300, Prof. Pedro Viriato Parigot de Sousa, St. Campo Comprido
ZIP code 81280-330 Curitiba PR
E-mail: emlosso@up.edu.br
1

School of Dentistry, Positivo University Curitiba PR Brazil.

Keywords: trauma;
deciduous teeth;
prevention.

Abstract
The treatment of children presenting dental trauma in the primary
dentition requires a different approach from that used in the permanent
dentition, because there is a very close relation between the apex
of the traumatized primary tooth and the successor permanent
bud. The possible consequences on the permanent teeth should be
considered when performing early treatment in order to prevent
further damage. Also, the probable traumas late sequelae should
be taken into account both for primary and permanent dentition.
Given the subjects importance, this chapter aimed to report this
issue broadly. This comprises the anamnesis, general, intraoral,
and radiographic examination and the comprehensive treatment
of the patient. Additionally to the classification of dental injuries,
we highlighted the diagnosis, required treatment, prognosis, and
follow-up of each clinical situation. A topic on soft tissue lesion was
included, because it has a great impact on both the child and family.
Moreover, it could be associated with other trauma types. Since the
analysis of the childs vaccination status is suggested, in face of cases
demanding that tetanus vaccine be valid, the recommendation of
the Brazilian Ministry of Health was also informed. Furthermore,
there is an item on dental splinting, parenting advice, and trauma
consequences on primary and successor permanent teeth. At the
end of the chapter, two tables summarize the early and delayed
treatment of trauma involving primary tooths enamel, dentin, pulp,
and supportive tissues.

Losso et al.

e Dentoalveolar trauma in the primary dentition

Introduction
Trauma management in primary dentition is different from that required by permanent dentition,
because there is a very close relationship between the primary tooth affected by the trauma and its
permanent tooth successor (figure 1).

Figure 1 Frontal computed tomography evidencing the primary tooth root proximity to its permanent successor

The possible consequences on the permanent

tooth should be taken into account when early
treatment is performed, aiming to prevent further
damage. For treatment selection, childs maturity,
cooperation during an emergency situation, and
occlusion should be considerate.
The lack of labial sealing and excessive overjet
are predisposing factors to trauma at primary
dentition (figure 2). Children presenting an overjet
of between 3 and 6 mm and more than 6 mm,
respectively show twice to three times more traumas
in comparison to those presenting an overjet of 0
to 3 mm. In these cases, it is recommended that
non nutritive suction habit be rationally used or
removed.

Figure 2 Patient presenting anterior openbite and

accentuated overjet risk factor for dental traumas
occurrence

There is a childs phase where oral trauma

is predominant: when the child begins to stand
up, walk, and run. At this period, there is lack
of motor coordination due to little age (figure 3
and 4). Concerning to the traumas type, the most
common is the fall from the childs own height,
reaching about 80% of the cases. From the children
between 1 and 3 years-old, 11 to 30% show any
dental trauma, without differences between boys
and girls. Upper anterior teeth have been the most
affected, generally one of them, except when the
cause is due to sports or car accident.

Figure 3 One-year old patient exploring the

environment

RSBO. 2011 Jan-Mar;8(1):e1-18

Figure 4 Photograph of the upper incisors of the child

of Figure 3. A enamel fracture of tooth # 51 due to fall
from hers own height

Oral trauma is a stressing situation for the

child and parents. For this reason, first of all, it is
necessary to calm them down in order to continue
the treatment.

Appointment

e

treatment. This aims to assure the childrens

general health.
Considering the current trauma, it must be
considered
how dental and oral trauma happened and
if the history is compatible with the clinical
condition, because about 50 to 65% of the
lesions provoked by child abuse are located
in the head, face, and oral cavity;
when the trauma occurred, since the time
elapsed will define the best management to be
performed;
where the trauma occurred, in order to know
if the traumas place was contaminated. If this
is the case, the childs vaccination should be
checked, mainly the tetanus vaccine.
Besides this information, it is important to know
if there is a previous history of trauma, because this
may justify the clinical and radiographic findings.
Previous dental history will provide information on
the possible childs behavior during treatment.

General examination

Anamnesis
The anamnesis is important since several
factors w ill define t he best t reat ment to be
performed, as well as, which information about
t he childs systemic condit ion w ill assure a
safe treatment. There are situations in which
t he ch i lds doctor shou ld be cont acted for
obtaining more information. Children presenting
cardiopathies and clotting problems will maybe
requ i re t hei r m a n a g ement pr ior to dent a l

When the patients general examination is

performed, it should be observed:

Extra-oral lesions (chin, face, head): in case that

the patient presents lesions in these areas, the
child must be referred to medical evaluation.
Trauma in the chins area may result in tooths
longitudinal fracture, being capable of affecting
the tooths crown or involving tooths crown
and root (figure 5);

A
Figure 5 A: Patient suffered trauma in the chins area; B: Fracture in the buccal cusp of tooth #85

Losso et al.

e Dentoalveolar trauma in the primary dentition

Lesions in skin and face: patient must be

referred to a plastic surgeon.

Radiographic examination
When a radiograph is seen, it is necessary to
consider the childs age and traumas type. Therefore,
it should be verified:

Stage of tooth eruption;

Degree of physiologic root resorption of primary
teeth;
Rizogenesis degree of permanent tooth;
Presence of fragments within soft tissue;
Presence of bone or tooth fractures;
Thickness of the dentin remanent between
the fracture line and crow n pulp (crow n
fractures);
Root resorptions;
Size of pulp chamber;
Intrusive and extrusive displacements;
Relationship between the intrusive displacement
of the primary tooth and the permanent bud
successor;
Presence of other pathologic alterations in the
area.

jeopardize the development of the permanent tooth

are contraindicated.

Brazilian Ministry of Health

recommendation concerning to
tetanus vaccine
In cases of dentoalveolar trauma, regarding
to tetanus prophylaxis, the Brazilian Ministry of
Health recommends that the lesion be cleaned and
disinfected through saline solution and an oxidant
solution, as well as, the wound debridement,
when necessary.

Injury presenting low risk of tetanus

It is i mport a nt t he accurate radiog raph

processing and storage in order to be able of
comparing it with future following-up radiographs.
If possible, photographs should comprise the cases
documentation and follow-up.

Intraoral clinical examination

In this phase, soft tissue should be cleaned
and examined. Also, it should be verified:
if soft tissues are affected by trauma and which
is the extension;
if the teeth present fracture, mobility, or
displacement;
if the bone is fractured;
if the occlusion is within normal patterns,
because this will be indicative of tooth and
bone fracture;
percussion and vitality tests should not be
performed.
Only after clarifying these aforementioned
aspects, the treatment to be performed is chosen,
for each situation, defining the recommended
early treatment of each lesion type; if possible
the consequences of the adopted management
should be predicted. Heroic treatments that may

Complete basic vaccines and tetanus vaccine

reinforcing dose performed less than 10 years:
no management.
Complete basic vaccines and tetanus vaccine
reinforcing dose performed less than 10
years: it is necessary a reinforcing dose of
the tetanus vaccine.
Uncertain or incomplete vaccinal state, or
lack of vaccines: DTP vaccine (diphtheria,
tetanus, and pertussis) in children with 6
years-old or less; tetravalent vaccine (DTP
+ H ib [men i n g it is a nd ot her i n fect ions
caused by Haemophilus influenza type B])
or dT (diphtheria and tetanus) + complete
immunization series in children with 7 yearsold or more.

Injury presenting high risk of tetanus

Complete basic vaccines and tetanus vaccine

reinforcing dose performed less than five
years: no management.
Last dose received more than five years
and less than ten years: reinforcing dose
of dT.
Uncertain or incomplete vaccinal state, lack of
vaccines, or last dose received more than ten
years: DTP (or dT) vaccine followed by complete
immunization + 250 UI of hyperimmune
hu ma n tet a nus i m mu nog lobu l i n (HHTI)
intramuscular route different from that used
for the tetanus vaccine. If HHTI is not available,
5000 UI of anti tetanus serum (ATS flask
with 5.0 ml), intramuscular route different
from t hat used for t he tet a nus vacci ne,
informing the parents of the possibility of
immediate hypersensibility reaction.

RSBO. 2011 Jan-Mar;8(1):e1-18

e

Classification of the traumatic lesions

Table I Traumatic lesions of dental tissues

Enamel cleavage
Enamel cleavage

Without tooth structure loss

Tooth structure loss restricted to enamel
Tooth structure loss restricted to enamel and dentin, without pulp
Enamel and dentin fracture
exposure
Enamel and dentin fracture with Tooth structure loss restricted to enamel and dentin, with pulp
pulp exposure
exposure
Continuity solution involving enamel, dentin, and cement, without pulp
Crown-root fracture
involvement
Root fracture
Continuity solution involving enamel, dentin, and cement, and pulp
Table II Traumatic lesions of supporting tissues

Concussion
Subluxation
Lateral luxation
Intrusive luxation
Extrusive luxation
Avulsion

Small intensity trauma on the supporting tissues without fibers rupture. There
is no tooth displacement and mobility
Small to mild intensity trauma on supporting tissues, in which the tooth
presents mobility, but it is not displaced from its socket. Gingival sulcus
bleeding may be present.
Higher intensity trauma which leads to tooth displacement at palatine, buccal/
labial, mesial or distal direction.
Tooth displacement into its socket.
Tooth partial displacement out of its socket.
Tooth total displacement out of its socket.

Treatment of traumatic lesions of dental

tissues
Enamel cleavage without structure loss
a. Examination: visual clinical examination of the
clean, dry, and well illuminated tooth surface,
in order to examine cleavages on tooth crown,
generally perpendicular to tooths long axis.
Radiographic examination must be always
performed when there is a report of tooth
trauma, however, enamel cleavages are not
seen in periapical radiographs;
b. Treatment: fluoride therapy;
c. Prognosis: favorable;
d. Proservation: all teeth with report of trauma
must be clinically and radiographically followedup. In this case, this can be performed in
patients routine appointments.

and to serve as parameter for the next followup examinations;

b. Treatment: for fractures involving only the
enamel, an eventual abrasion and polishing
of the tooth are performed, aiming to avoid
lacerations on soft tissues (lips and tongue).
Fluoride application on the fractured tooth is
recommended. Also, the tooth could be restored
to its original morphology, in case that there
is a parents concern on aesthetics; however,
generally, additional abrasions are avoided;
c. Prognosis: favorable;
d. Proservation: patients routine appointments.

Uncomplicated crown fractures

Enamel cleavage: structure loss restricted to enamel
(figures 6 and 9A)
a. Examination: visual clinical examination of the
clean, dry, and well illuminated tooth surface,
in order to confirm the structure loss restricted
to enamel. Radiographic examination should
be performed to evaluate the fracture extension

Figure 6 Enamel fracture on tooth #61

Losso et al.

e Dentoalveolar trauma in the primary dentition

Fracture of enamel and dentin without pulp

exposure: structure loss of enamel, dentin, and pulp
preservation (figures 7, 8, and 9B)
a. Examination: visual clinical examination of
the clean, dry, and well illuminated tooth
surface, in order to confirm the extension of
tooth structure loss and discard pulp exposure
possibility. Radiographic examination should be
performed to evaluate the relationship of the
fracture with pulp chamber and the stage of
rizogenesis or root resorption of the affected
tooth, besides to serve as parameter for the
next follow-up examinations;

b. Treat ment: t he relat ionship bet ween t he

fracture and the pulp chamber should be
radiographically observed for deciding on the
necessity of dentinopulpar complex protection
by calcium hydroxide. In cooperative children,
such fractures should be restored by composite
resin. For non-cooperative children, the fracture
can be provisionally restored by glass ionomer
cement (GIC);
c. Prognosis: favorable;
d. Proservation: it is important to clinically
follow-up the tooth after seven days; clinical
and radiographic follow-up must be carried out
after 30 and 90 days, and the next following
years until tooth exfoliation.

Figure 7 A: tooth trauma leading to fracture of enamel and dentin on teeth # 51 and #61; B: teeth restored by
composite resin

Figure 8 A: Upper anterior teeth trauma showing enamel and dentin fracture on tooth #51; B: radiograph showing
structure loss extension and lack of periapical and root alterations

Complicated crown fractures

Fracture of enamel and dentin with pulp exposure:
structure loss involving enamel, dentin, with pulp
tissue exposure (figures 9C)
a. Examination: visual clinical examination of the
clean, dry, and well illuminated tooth surface, in

order to confirm the extension of tooth structure

loss and presence of small hemorrhages or red
spots indicating pulp involvement. Radiographic
examination should be performed to evaluate
the pulp chamber and the stage of rizogenesis
or root resorption of the affected tooth, besides
to serve as parameter for the next follow-up
examinations;

RSBO. 2011 Jan-Mar;8(1):e1-18

b. Treatment: If there is a pulp involvement, the

treatment will depend on a series of factors,
such as: fracture extension, degree of tooth
development (degree of rizogenesis or root
resorption), moment at which the trauma
occu r red (ea rly or late t reat ment), a nd
degree of childs cooperation. Concerning
to t he deg ree of toot h development, t he
younger the tooth (while the rizogenesis is
incomplete) the better the pulp response
will be. Therefore, if a small extension tooth
fracture is present and an early treatment
can be performed, it is recommended the
direct pulp protection followed by restoration
with composite resin or fragment bonding.
In primary teeth presenting complete roots
or initial physiological root resorption, early
t reat ment w ill comprise pulpotomy, a nd
late treatment pulpectomy. In teeth showing
advanced root resorption, tooth extraction
is indicated;
c. Prognosis: favorable, if the ideal conditions
are observed;
d. Proser vat ion: clinica l follow-up must be
c a r r ie d out a f t er s e ven d ay s; cl i n ic a lradiographic follow-up must be performed
after 30 and 90 days, and the next following
years until tooth exfoliation.

Figure 9 Schematic drawing (A: enamel fracture;

B: enamel and dentin fracture; C: enamel and dentin
fracture with pulp exposure)

Crown-root fracture (enamel-dentin-cement)

without pulp exposure (figure 10A)
a. Examination: visual clinical examination,
aiming to evaluate the subgingival fracture
extension. Frequently, the fragment is secured
by the periodontal ligament fibers; therefore,
the presence of mobility of the fractured
fragment should be observed. Radiographic

e

examination may not show the fracture, since

the fracture line is generally perpendicular
to x-ray beam; this will serve as parameter
for the next follow-up examinations;
b. Treatment: it depends on the subgingival
e x tension. T he f ra g ment i s removed to
verify such extension. When the fracture is
extending 2 mm beyond the gingival limit,
tooth extraction is the treatment of choice.
However, in cooperative child and fractures
extending below gingival limit, it is possible
to restore the tooth with composite resin;
c. P r o g n o s i s : f a v o r a b l e , i f r e s t o r a t i o ns
indications a nd /or cont raindications a re
observed;
d. Proservation: it is important the clinical followup after seven days; clinical-radiographic
follow-up must be performed after 60, 90,
and 180 days, and the next following years
until tooth exfoliation.

Crown-root fracture (enamel-dentin-cement)

with pulp exposure (figure 10B and 11)
a. Examination: visual clinical examination,
aiming to evaluate the subgingival fracture
e x ten sion. F requent ly, t he f ra g ment i s
secured by the periodontal ligament fibers;
therefore, the presence of mobility of the
fract ured fra g ment should be obser ved.
Radiographic examination may not present
t he f ract u re, si nce t he f ract u re l i ne i s
generally perpendicular to x-ray beam; this
will serve as parameter for the next followup examinations;
b. Treatment: it also depends on the subgingival
extension, follow ing t he sa me principles
of t he crow n-root fract ure w it hout pulp
exposure. However, in this case, pulp therapy
is necessary and the approach is similar to
the management of the crown facture with
pulp involvement;
c. Prognosis: favorable, if the indications and/or
contraindications of the restoration (2 mm
below gingival margin) and pulp treatment
(stage of tooth development) are observed;
d. Proservation: it is important the clinical followup after seven days; clinical-radiographic
follow-up must be performed after 60, 90,
and 180 days, and the next following years
until tooth exfoliation.

Losso et al.

e Dentoalveolar trauma in the primary dentition

Figure 10 Schematic drawing of crown-root fracture

(A: without pulp exposure; B: with pulp exposure)

Figure 11 Photograph showing tooth #61 with crowroot fracture

Root fracture
a. Examination: visual clinical examination, when a slight crown displacement associated with little
extrusion can be seen. Palpation on the affected area is performed for verifying the presence of
pain and/or mobility and for discarding bone fracture. Generally, mobility due to bone fracture is in
block, i.e., by testing one tooth, the adjacent teeth also show mobility. Radiographic examination will
determine if the tooth mobility is due to luxation or root fracture (figure 12). In such cases, additional
radiographic shots at several angulation are suggested;

Figure 12 A: root fracture at tooth #61; B: physiologic root resorption and root fragment resorption after one
year and four months

b. Treatment: it depends on the fracture line

localization (apical, medium or cervical thirds)
and direction (transversal or longitudinal);
Transversal fractures at apical and medium
thirds: repositioning by finger pressure for
fragments approximation, when performing
early treatment. If late treatment is carried
out, there is the clot interposition, making this
approach difficult to be performed. Apical third
fractures normally undergo recovering without
treatment, however, in medium third fractures

and mainly those displaying tooth mobility,

a rigid splinting is necessary for 90 to 120
days. The repair formation is followed-up by
radiographs for splinting removal;
Transversal fractures at cervical third: tooth
extraction, since crown fragment mobility hinders
the splinting. Literature stated that there is no
need of removing the root fragment because it
may undergo the physiologic root resorption;
Longitudina l or oblique fractures: toot h
extraction is the treatment of choice.

RSBO. 2011 Jan-Mar;8(1):e1-18

c. Prognosis: apical third transversal fractures

has a more favorable prognosis than the other
types;
d. Proservation: clinical and radiographic follow-up
for one, three, four and six months, and the
next following years until tooth exfoliation.

Traumatic lesions of the supporting tissues

The supporting tissues lesions are involved in
most of primary teeth traumas, since there is a
high prevalence of tooth displacements due to both
the greater alveolar bone resilience in children of
little age, and the root morphology, which is smaller
and more tapered.

Concussion
It is a trauma of small intensity involving
hemorrhage and edema of the periodontal ligament,
however, without fibers rupture. There is no
displacement, tooth mobility, or gingival sulcus
bleeding.
a. Examination: visual clinical examination.
Clinically, the affected tooth does no present
alterations, however, it may present sensibility
to palpation and discomfort during mastication.
The clinician is almost not sought for in these
cases; there are only reports in following routine
appointments. Percussion and sensibility
tests are not recommended in children, since
these will not result in a reliable outcome, as
well as the probability of resulting in a noncooperative behavior. A radiographic exam must
be performed for future follow-up appointments,
although alterations are not seen;
b. Treatment: dietary guidance. A softer and more
liquid diet is offered, mainly in the first 48
hours, and the use of pacifiers and bottles is
restricted. Parents must be oriented to seek for
treatment if anything strange factor is observed,
such as local edema or presence of fistula;
c. Prog nosis: favorable, w it h possibi lit y of
presenting transitory or permanent color
alteration due to pulp hemorrhage. A late color
change must be closely followed-up in order to
discard pulp necrosis;
d. Proservation: seven days after trauma and
during patients routine appointments.

Subluxation
Trauma of low to mild intensity that provokes
the rupture of some periodontal ligament fibers and

e

leads to tooth mobility, without resulting, therefore,

in tooth displacement. Bleeding on gingival sulcus
may be present.
a. Examination: visual clinical examination.
Although the tooth suffering sublu xation
does not show displacement, it is possible
to have horizontal mobility (mild to severe).
When the examination is immediately after
the trauma, gingival sulcus bleeding can be
seen. There is report of sensibility to palpation
a nd du r i n g m a st ic at ion. A s prev iou sly
mentioned, thermic or percussion tests are
not recommended. Likely to concussion,
although the radiographic exam does not show
any alteration, it will be performed for future
follow-up appointments;
b. Treatment: as the same as in concussion,
the dietary guidance and the restricted use
of pacifiers and bottles should be performed.
If there is accentuated mobility, a flexible or
semirigid splinting should be used for ten to
14 days;
c. Prognosis: favorable, with possibility of presenting
color alteration and pulpar calcification;
d. Proservation: clinical evaluation seven days after
trauma and clinical-radiographic follow-up after
30 and 120 days; after that, during patients
routine appointments.

Lateral luxation
It is a higher intensity trauma leading to tooth
displacements at palatine, buccal/labial, mesial, or
distal directions (figure 13).
a. Examination: in the visual clinical examination,
the tooth displacement is noted, with presence
or not of mobility, bleeding, and gingival
tissue laceration. Palpation of the adjacent
tissues is necessary to find the root apexs
bulges. Occlusion should be checked because
eventual premature contacts may exist due
to t he toot hs new posit ion on t he a rch.
Radiographic exam shows tooth displacement
by the increasing of the periodontal ligament
space. It is very important to evaluate the
relation of the affect primary tooth with the
permanent bud successor, comparing this bud
to its homologous for diagnosing possible bud
displacement;
b. Treatment: it will depend on several factors,
such as: magnitude of displacement, degree of
tooth development and its relationship with the
permanent bud successor, early or late seeking
for treatment, and degree of cooperation of the

Losso et al.

e10 Dentoalveolar trauma in the primary dentition

child to the proposed treatment. Very small

displacements without occlusal interference
tend to be repositioned by tongue and lips,
without any other intervention. In cases of
not very large displacements, in favorable
conditions (i.e., teeth presenting initial stage
of physiological rot resorption [less than 1/3 of
resorption], displacement direction opposite to
the permanent tooth [crown at palatal direction
root at buccal/labial direction], early treatment,
cooperative child), reposition is performed under
local anesthesia, by two-finger pressuring the
tooth. In case of mobility, flexible or semirigid
splinting is indicated for ten to 14 days. If the
occlusal interference persists, incisal abrasion
is performed. If the tooth displacement is of
great intensity or towards the permanent bud
successor, extraction is the treatment of choice.
In al situations, the parents should be guided
concerning to a offer a soft diet, restriction of
the use of pacifiers and bottles, and to perform
the mechanical and chemical (0.12% digluconate
of chlorhexidine) control of oral biofilms;
c. Prognosis: favorable for permanent tooth,
although there would be a possibility of necrosis
of the affected tooth;
d. Proservation: clinical evaluation and removal of
the splinting after 15 days, clinical-radiographic
follow-up after 30, 60, and 120 days, and every
year until tooth exfoliation.

is still visible, degree II (moderate) when less

than 50% of the crown can be seen, and degree
III (severe) when there is the total intrusion of the
crown. Generally, the tooth is intruded towards
the buccal/ labial direction in relation to the
permanent bud, but the tooth may be intruded
towards the bud direction.
a. Examination: visual clinical exam. Eventual
volume increase is verified, at buccal/labial
area, indicating the intrusion direction. The
area of the bottom of the vestibule should
undergo palpation in order to verify if the
intrusion is not very severe so that the alveolar
bone is disrupted. If that occurs, during
palpation the tooth will move. For radiographic
examination, intra- and extraoral radiographs
are suggested. For intraoral radiographs, the
periapical technique or modified occlusal
technique is employed (figure 14 and 16).
In these images, if the root of the primary
toot h is shortened in compa rison to its
homologous tooth, the affected tooth does not
reach the permanent bud; if the root image
is elongated, the affect tooth moved towards
the permanent bud direction. Extraoral shots
may be performed using occlusal films (5 x
7 film) or periapical (3 x 4 film), placed into
patients profile, perpendicular to patients
labia l sulcus (fig ure 15). If t he prima r y
tooth does not move towards the permanent
bud, its root apex appears at buccal/labial
direction;

Figure 13 Schematic drawing of lateral luxation of

tooth #51

Intrusive luxation
A lso so-ca lled i nt rusion, it is t he toot h
displacement within its socket. It is considered as
degree I (mild) when more than 50% of the crown

Figure 14 Anterior periapical radiograph modified

shot

RSBO. 2011 Jan-Mar;8(1):e1-18

Figure 15 Extraoral radiograph shot, by using 5 x 7

film, used in cases of tooth intrusion

Figure 16 Anterior periapical radiograph of the

intrusion of tooth #51 and #61

b. Treatment: it will depend on the intrusion

direction and the association or not with
bone cortical fracture. Teeth intruded towards
their permanent buds (radiographic image of
a elongated affected tooth compared to its

e11

homologous tooth), extraction is the treatment

of choice, in order to relieve the pressure on
the permanent bud. Unlikely, that is, if the
radiographic image of the affected tooth is
shortened, suggesting a labial direction of the
intrusion, it is necessary to wait the tooths
re-eruption, for 6 months. In the follow-up
appointments, the presence of infection is
evaluated; in that case, antibiotic therapy
must be instituted. When the bone cortical is
fractured, the re-eruption process difficultly
occurs, and tooth extraction is necessary.
In order to prevent further damages to the
permanent bud, the use of apical elevators
must be avoided. Tooth extraction should be
performed by using dental forceps, because
their apprehension is made at the mesiodistal
direction. The recommendations on soft diet,
pacifiers and bottles usage, and mechanical
and chemical control of biofilms follow the
same principles of lateral luxation;
c. Prognosis: for primary tooth is favorable when
it presents a labial displacement direction,
and the re-eruption onset occurs within two
months (figure 17). It may be unfavorable
when the displacement direction is towards
palatine, or when the re-eruption process does
not occur within two months. For permanent
successor tooth, it is a trauma type that
provoke most da ma ges, i.e., t he sma ller
the permanents Nolla stage, the higher the
probability of damage;
d. P roser vat ion: cl i n ica l a nd rad iog raph ic
evaluation after seven, 30, 60 and 120 days,
and every year until tooth exfoliation.

Figure 17 A: lateral photograph showing labial edema due to teeth #51 and #61 intrusion; B: edema reduction
after one week; C: lateral radiograph of teeth #51 and #61 intrusion; D: one month after, re-eruption of the intruded
tooth (kindly provided by DDS. Sheila C Stroppa)

Losso et al.

e12 Dentoalveolar trauma in the primary dentition

Extrusive luxation
So-called extrusion, it is the partial displacement
of the tooth out of its socket (figure 18).
a. Examination: clinically, the tooth seems to be
elongated compared to its contralateral, presenting
local bleeding. During radiographic examination,
it can be seen the increase of the apical periodontal
space. Generally, trauma affects more than one
tooth, and the affected teeth show high degree
of mobility;
b. Treatment: it depends on the same factors
aforementioned analysed for lateral luxation,
such as: magnitude of displacement, degree of
tooth development and its relationship with the
permanent bud successor, early or late seeking
for treatment, and degree of cooperation of the
child to the proposed treatment. In cases of small
displacements, it should be observed if occlusal
interferences are not caused by the new tooth
position, because if this occurred, small abrasions
are indicated. Early treatment permits an attempt
for repositioning. In late treatment, it is present
a reduction of mobility and clot formation; in
such case, the best option is allowed the tooth
to heal at this new position. In excessive mobility
degrees, and severe extrusions (more than 3 mm),
tooth extraction is the recommended option;
c. Prognosis: unfavorable, because it seems to be
the injure type that mostly lead to tooth loss.
Likely to other displacements, the possibility of
pulp necrosis is high, and follow-up appointments
are necessary;
d. Proservation: proservation approach should be
carried out by clinical examination after two or three
weeks, clinical and radiographic examination after
six to eight weeks, and clinical and radiographic
examination following one year.

Avulsion
So-called total luxation, it is the complete
displacement of the tooth out of its socket.
a. Examination: clinically, it is seen the absence of
the tooth suffering trauma (figure 19) and often,
lesions in surrounding soft tissues. Periapical
radiograph shot should be performed in order
to assure that the tooth is not intruded and that
there is not the presence of a foreign body within
the area (figure 19B);
b. Treatment: unlikely to permanent dentition, tooth
replant is not indicated for primary dentition due
to be a procedure involving very specific conditions
for its success, and due to the possibility of damage
of the permanent bud, because the clot may be
forced towards the bud area. The best option is
prosthetic rehabilitation, which can be complicated
in little age children, but it is important due to
aesthetical and functional aspects;
c. Prognosis: unfavorable for the permanent
successor tooth. The most common findings are
hypocalcifications and hypoplasias;
d. Proservation: clinical examination after one week
and radiographic and clinical examination every
six months until permanent tooth eruption.
A

Figure 18 Schematic drawing of extrusive luxation of

tooth # 51

Figure 19 A: photograph of the absence of tooth # 61; B:

radiograph of the avulsion of tooth #61 and calcification
of tooth #51 as a consequence of trauma (kindly provided
by DDS. Sheila C Stroppa).

RSBO. 2011 Jan-Mar;8(1):e1-18

Alveolar fracture
This type of fracture involves alveolar bone,
and the teeth inside this fragment generally present
mobility.
a. Examination: during clinical exam, the teeth
within the fragment frequently are displaced and
with high mobility. Therefore, it is necessary to
verify if there are occlusal interferences. The
mucosa of the area may present discontinuity.
Radiographically, the horizontal fracture
passes through the primary tooth apex and
the permanent bud is observed. It is possible
that a lateral radiograph shows the relationship
between both dentitions and if the segment is
displaced to labial or palatine direction;
b. Treatment: the repositioning of the fractured
area must be performed by two-finger pressure.
Due to the childs faster healing, immobilization
is not necessary, but in cases of large extension
fractures, tooth splinting is executed for
reaching stability; moreover, some teeth may be
extracted with this purpose. Such procedures
must be performed under local anesthesia or,
in larger traumas, under general anesthesia.
Generally, tooth splinting is removed after four
weeks. At the following-up appointments, the
presence of fistula or mobility is verified;
c. Prognosis: bone healing in children commonly
occurred without complications, however,
A

e13

during the following-up period, root resorptions

may be seen;
d. Proservation: follow-up appointments should
comprise clinical and radiographic examinations
after four, six, and eight weeks, after one year,
and after every year until permanent tooth
eruption.

Tooth splinting
It is an auxiliary method for maintaining the
teeth at rest position to help the repair of the
vascular-nervous bundle and periodontal fibers.
It is necessary to keep tissues integrity and allow
proper conditions of dental hygiene in order to
avoid bacterial plaque accumulation. When tooth
splinting is recommended, it should be installed
on the medium third of the labial surface of the
traumatized and adjacent teeth, involving two
abutment teeth at each side.
The most common splints are those employing
nylon line or steel wire bonded to teeth with
composite resin (figure 20). Tooth splints may
be: f lexible, employing the nylon line, ranging
from n #70 to #80, and are generally used when
there is damage to supporting tissues; semirigid,
constructed with 0.2 or 0.4 mm, or twist f lex
orthodontic wires, indicated for bone fractures;
and rigid, constructed with 0.5 mm orthodontic
wires, when there is root fractures.
C

Figure 20 Model of the tooth splints used in cases of trauma (A: twist flex wire; 0.5 mm stainless steel wire; C:
#70 nylon spring)

Soft tissue lesions

Trauma occurring in children is often followed
by soft tissue lesions, such as: gingiva, alveolar
mucosa, frenulum and bridles, lips, and skin. These
lesion types can be classified into:
Laceration: perforation by cutting objects
showing continuity solution;
Contusion: hematoma provoked by impacts
of rhombus objects leading to bleeding and
edemas, with intact mucosas (figure 21);
Abrasion: injure in which there is the removal
of the superficial layer of the tissue, resulting
in a rough and bleeding gingiva.

The treatment of these lesions must follow a

sequence of procedures that begins by trauma severity
evaluation and possibility of site contamination, for
assessing the childs vaccine state and the need of
antibiotic therapy. Next, the injure cleaning and
debridement are carried out, aiming to remove
foreign bodies, microorganisms, and damaged
tissues. For this purpose, a high pressure syringe
or gauze embedded in saline solution can be
used. If there is very much damaged, ischemic
or necrotic tissues, these should be removed by
the aid of scalpel blades (number #11 or #15) or
curettes, because they allow infection installation.
After the wound cleaning, the necessity of suture

Losso et al.

e14 Dentoalveolar trauma in the primary dentition

is evaluated; if necessary, they are performed with

silk or poly-vicryl suture thread 4/0 or 5/0, removed
after three or four days.

Parents guidance

Figure 21 Photograph of the anterior area, in which it is
observed an accentuated edema of the upper lip (kindly
provided by DDS. Sheila C Stroppa)

Local hygiene should be recommended in order

to allow better healing. Such hygiene must be
performed employing a soft toothbrush and
application of 0.12% chlorhexidine by swab on the
injured area twice a day, for one week, to prevent
plaque accumulation;
If lips are injured, it is necessary to apply a lip balm
during healing process for avoiding dehydration;
To keep the area at rest by employing soft, warm
diet for seven to ten days to improve the supporting
tissues recovering;
To avoid the use of bottles and pacifiers, mainly
in cases of intrusion, to allow spontaneous reeruption;
Parents are alerted to observe eventual alterations
in primary teeth, such as: prolonged retention,
darkening, increase of mobility of the affected tooth,
and possibility of appearance of a buccal/labial
fistula;
Possible sequela to permanent teeth associated to
primary teeth trauma should also be informed,
mainly in cases of intrusion, avulsion, and alveolar
bone fracture, in children under 4 years-old;
Following-up appointments are important according
to the trauma type;
All data should be registered in patients file, and the
parents should be told that follow-up appointments
are necessary. We suggested that they sign a clarified
consent form that they received the information.

Effects of trauma on primary teeth

A

B
Figure 22 A: gingival edema caused by trauma; B:
clinical follow-up after 60 days

Several sequelas may affect the primary teeth after

trauma, varying according to the traumas intensity
and type.
Pulp hyperemia is the first reaction of the pulp in
response to trauma and it is present even in low intensity
traumas. Blood congestion within pulp chamber is
frequently seen during clinical examination.
Tooth crown discoloration is the most common
sequela in primary dentition and may be transitory
or permanent. Shades of yellow or opaque white
are generally related to root canal obliterations
(calcifications), characterized by deposition of
mineralized tissue within root canal. Despite of root
canal obliteration presence, it is normal that these teeth
undergo physiologic root resorption. Shades of grey or
blue occurring just after a trauma are consequence of
pulp bleeding, caused by capillaries rupture, leading
to extravasation of erythrocytes, and consequently to
pigmentation (figure 23). However, if this color change
occurs months or years after trauma, it is possible that
such bleeding has developed into pulp necrosis.

RSBO. 2011 Jan-Mar;8(1):e1-18

e15

Color change alone does not suggest the need

of endodontic treatment of the primary teeth; this
will only be executed in cases of pulp necrosis or
associated infections.
Tooth resorptions have been divided into
internal and external (figure 25) and they are or
are not linked to other alterations, such as pulp
necrosis. Mild resorptions demand only radiographic
follow-up. In more severe cases, tooth extraction is
the treatment of choice.

Figure 25 Pathologic external root resorption of

primary central incisors

Figure 23 Color change of tooth #51 due to tooth

trauma

Ot her cli nica l f i ndi ng due to t rau ma is

prolonged retention of primary tooth, because
the physiologic root resorption does not occur;
in this case, tooth extraction must be performed
(figure 24).

Tooth ankylosis (substitutive resorption) may

also occur due to the progressive substitution of
dental tissue by bone tissue. Clinically, the tooth is
presented in infraocclusion in relation to its adjacent
teeth. Radiographically, it may be lack of continuity
of periodontal ligament space at the cements area
of fusion. In most of the cases, tooth extraction is
necessary, because this tooth will not undergo the
physiologic root resorption, resulting in the successor
permanent tooth delayed or ectopic eruption.

Effects of trauma on successor permanent

teeth

Figure 24 Patient showing prolonged retention and

darkening of tooth #51 due to trauma

Due to the anatomical proximity of primary

tooths root to the permanent tooth bud, trauma to
primary dentition may damage the permanent tooth
bud. This leads to alterations ranging according to
the type of trauma and the development stage of the
permanent tooth; the initial stages of mineralization
are more susceptible to sequela.
Enamel hypoplasia is clinically shown as a
structural defect associated to a white or yellowbrown discoloration, evidence of ameloblasts
destruction before enamel deposition (figure 26).

Losso et al.

e16 Dentoalveolar trauma in the primary dentition

Dilaceration is another type of consequence

occurring when the already formed portion of
the tooth is twisted or bent over itself and it
continues its development at this new position.
It may a f fect t he crow n (f i g u re 27), at t he
earlier stages of dental formation, or the root
(figure 28).

Figure 26 Enamel hypoplasia of tooth #11 due to

intrusion of tooth # 51 in a child of about 2 years-old

Sometimes, the trauma is severe enough to

remove the enamel layer still in formation and
make the adjacent odontoblasts to produce a type
of reparative dentin.

Figure 27 Photographs of anterior area at two time periods,

in which it is observed the tooth #11 presenting crown
dilacerations due to intrusion of tooth #51, in a child under
1 year-old (kindly provided by DDS. Sheila C Stroppa)

Figure 28 A absence of tooth #21 in oral cavity

due to its dilaceration, as a consequence of trauma
during primary dentition; B: radiographic image of the
dilaceration of tooth #21

RSBO. 2011 Jan-Mar;8(1):e1-18

e17

Table III Treatment of lesions traumatic to tooth and pulp tissues: primary dentition
Trauma type

Early treatment

Late treatment

Enamel cleavage

Dental prophylaxis + fluoride + x-ray (if

possible)

Dental prophylaxis + fluoride + x-ray (if

possible)

Enamel fracture

Small: polishing + fluoride (x-ray, if

possible)
Large: restoration

Small: polishing + fluoride (x-ray, if

possible)
Large: restoration

Enamel + dentin
fracture

X-ray + dentin protection (when necessary)

+ restoration + proservation

Without pain: x-ray + dentin protection

(when necessary) + restoration +
proservation
With pain: pulpectomy + restoration

Enamel + dentin
+ pulp fracture

Open apex: x-ray + pulpotomy +

restoration
Close apex: x-ray + pulpectomy +
restoration

X-ray + pulpectomy + restoration

Enamel +
dentin + cement
fracture

Recoverable remanent: x-ray + pulpectomy

+ restoration
Unrecoverable remanent: x-ray +
extraction + space maintainer

Recoverable remanent: x-ray + pulpectomy

+ restoration
Unrecoverable remanent: x-ray +
extraction + space maintainer

Root fracture

apical or medium third: rigid splint

cervical third: extraction

Little mobility: x-ray + rigid splint

Much mobility: x-ray + extraction

Table IV Treatment of the trauma to supporting tissues: primary dentition

Trauma type

Early treatment

Late treatment

Concussion

X-ray + observation + following-up + removal

of non-nutritive habits + soft diet

X-ray + observation + following-up +

removal of non-nutritive habits + soft diet

Subluxation

X-ray + semirigid splint + removal of nonnutritive habits + soft diet

With mobility: x-ray + semirigid splint

Without mobility x-ray + observation

Intrusive
luxation

Primary tooth intruded against permanent

tooth or bone cortical rupture with root
exposure at labial surface: x-ray (lateral) +
extraction
Primary tooth intruded towards labial
direction, without bone cortical ruptures or
root exposure: x-ray + following-up of reeruption + medication

Primary tooth intruded against permanent

tooth or bone cortical rupture with root
exposure at labial surface: x-ray (lateral) +
extraction
Primary tooth intruded towards labial
direction, without bone cortical ruptures or
root exposure: x-ray + following-up of reeruption + medication (if necessary)

Extrusive
luxation

Up to 2 mm: x-ray + tooth repositioning +

splint + medication
More than 2 mm: x-ray + extraction

X-ray + extraction

Lateral
luxation

X-ray + tooth repositioning + splint +

medication

X-ray + extraction

Avulsion

X-ray + suture (if necessary)

NO REPLANTATION

X-ray + evaluation of space maintainer

necessity

Alveolar
fracture

X-ray + repositioning + splint + medication

X-ray + extraction (teeth presenting severe

root resorption)

Obs.: Always evaluate patients vaccinal state

Losso et al.

e18 Dentoalveolar trauma in the primary dentition

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How to cite this article:

Losso EM, Tavares MCR, Bertoli FMP, Baratto-Filho F. Dentoalveolar trauma in the primary dentition.
RSBO. 2011 Jan-Mar;8(1):e1-18.