TRAUMATIC INJURIES 2.

Pulpal hemorrhage
3. Calcific metamorphosis
A. Prevalence of Injuries 4. Pulpal necrosis
1. falls during play 5. Inflammatory resorption
2. contact sports 6. Replacement resorption
3. automobile accidents 7. Injuries to developing permanent teeth
4. starting to walk  enamel hypoplasia
5. seizure disorder  ectopic eruption
 root dilaceration
If Not Treated:
1. discoloration C. Clinical Management of Traumatic Injuries to the Primary Dentition
2. malformation 1. Trauma to Teeth
3. possible loss a. Enamel Fracture
 Small > grinding of sharp edges / recontour
Types:  Large > acid-etch composite resin technique
1. Concussion b. Enamel & Dentin Fracture
2. Mobility  base, bonding agent & composite
3. Intrusion c. Fractures involving the pulp
4. Extrusion  Depends on the vitality of the pulp
5. Lateral Luxation  formocresol pulpotomy
6. Avulsion
 pulpectomy w/ ZOE
 extraction
B. Diagnostic Procedures:
d. Root Fractures
1. Case History
 Splinting is preferred if possible (fracture on apical third – best
a. Medical
prognosis)
1.) cardiac diseases
 Extraction - cervical or middle third of the root
2.) bleeding disorder
3.) allergies
Trauma to Supporting Structures
4.) seizure disorder
a. Concussion
5.) medications
 Tooth should be taken out of occlusion
6.) status of tetanus prophylaxis
b. Mobility
 Prognosis is good
b. Dental
 Avoid eating w/ the tooth involved
1.) when, where & how did the accident occur
 follow-up after a month
2.) time elapsed since the injury
c. Lateral Luxation
3.) any previous injury to the tooth
 If occlusion dictates, treat the teeth, otherwise it is left untreated
4.) is the injury treated elsewhere
d. Intrusion Injuries
5.) direction of force to teeth
 Minor cases: allow tooth to reerupt ( 2 – 6 months)
6.) history of pain
 follow-up should be done every month until it re-erupts, then every
3 months
2. Clinical Examination
 Calcific metamorphosis may develop
a. Extraoral Examination
 One of the most dangerous injury to the developing tooth bud
1) Wounds or bruises
 Extract if the underlying permanent tooth bud is endangered
2) Discuntinuity of facial bone
e. Extrusion Injuries
3) evaluate: TMJ
 Minor cases: splinting until PDL reattach ( 2 weeks)
4) Mandibular function
 Extraction, if there is danger of repositioning
f. Avulsion Injuries
b. Intraoral Examination
 Tooth should not be re-implanted
1) Examine soft tissues
 Fixed or removable appliance can be fabricated
2) Presence of foreign matter
3) Check all teeth for fracture, pulp exposure and discoloration
Treatment of Traumatic Injuries to the Permanent Dentition
4) Note any displacement of teeth
1. Enamel Fractures
5) Reaction to palpation and percussion
 Selective grinding or composite restoration
2. Enamel & Dentin Fractures
3. Radiographic Examination
 CaOH/GI + composite resin
1) Root fractures
3. Fractures Involving the Pulp – the following should be noted:
2) Pulp chamber size
3) resorption  vitality of the pulp
4) Jaw fractures  size of the exposure
5) Extent of root development  Time elapsed since the exposure
6) Periapical radioluscency  Restorability of the fractured crown
7) Degree of tooth displacement  Degree of root maturation of the fractured crown
8) Unerupted tooth position
9) Tooth fragments & other foreign bodies in soft tissue 4. Fractures Involving the Pulp
4. Pathologic Sequelae of Traumatized Teeth Treatment alternatives:
1. Pulpal hyperemia a. Small exposure > 24 hrs since accident, do CaOH pulp capping,
restore w/ composite resin
 b. Large exposure > with questionnable vitality - If the tooth is out of the mouth for more than 2 hours, soak in topical
 CaOH pulpotomy fluoride for 5 – 20 minutes, rinse & replant
 apexification/pulpectomy - Open apex: splint for 2 weeks; prognosis is good; RCT if there are
5. Root Fractures signs of necrosis
 Prognosis is good if it’s on the apical third & worsens when it - Closed apex: splint for 7 – 10 days; for bone fractures, 2 – 8 weeks
occurs more cervically - Medicate canal with CaOH then replaced by gutta percha
 Treatment:
a. Apposition of the fractured parts > Management of root surface:
b. Immobilization  Keep the tooth moist
 Antibiotic for the 1st week of treatment  Do not touch root surface
c. Close observation for pathologic cahnges  Do not scrape/brush periodontal ligament
 RCT should be done only if there is clinical & radiographic > Transport medium that can be used
signs of necrosis & resorption  milk
 normal saline solution
Characteristics of Splint  Saliva (buccal vestibule)
1. passive & atraumatic
 “Save a Tooth” medium
2. easy to apply & remove
 water
3. allow vitality testing & endodontic access
> Medication:
4. flexible
 antibiotics
Treating Luxation Injuries in the Permanent Dentition  analgesics
Concussion  chlorhexidine
- Tender to percussion due to edema in the apical area  Tetanus consultation within 48 hours
- To treat: take the tooth out of occlusion
- Usually no root resorption or pulpal necrosis Managing Sequelae to Dental Trauma
Calcific Metamorphosis
- Prognosis is usually good
 Monitor the tooth and initiate RCT only when periapical changes occur
Inflammatory Resorption
Intrusion
 RCT
- minor: allow the tooth to re-erupt
 CaOH for 6 – 24 months, then replaced by gutta percha as final filling
- major: at the time of injury, reposition by hand then splint; if the tooth
material
has healed into place, reerupt it orthodontically. Replacement Resorption
o RCT should be done within the 1st 7 – 14 days  Periodontal ligament cells are destroyed, making alveolar bone &
- Open apex: may ankylose or have a malformed root; Tx: Ca(OH)2 cementum directly incontact
apexification  Cosmetic problem can be corrected with a jacket crown
- Closed apex: fill the canal with Ca(OH)2 to prevent root resorption,
then fill with gutta percha

Extrusion
- reposition & splint ( 2 – 3 weeks)
- Open apex:
o 50% pulpal survival rate
o Monitor for any sign of necrosis
- Closed apex:
o *More than 5 mm will undergo degeneration
o fill canals with CaOH then gutta percha
o *RCT within 2 weeks

Lateral Luxation
- Often associated with alveolar bone fracture
- Tx: reposition the tooth & alveolar fragments then splint for 3 – 8
weeks
o Open apex: about 60% pulpal survival rate
o Closed apex: RCT, fill canals w/ CaOH

Avulsion
- The longer the tooth is out of the socket, the lesser the chance of
saving the tooth
- Vitality of the periodontal ligament should be maintained
- Procedure:
o Tooth should be held by the crown
o Rinse with tap water
o replant
o splint