management of traumatic injury

lecture given 6/12/2026

dental trauma

an acute transmission of energy to the tooth and supporting tissues through a shock resulting in fracture and/or displacement of the tooth and/or separation or crushing of the supporting tissues (gingiva, PDL, bone)

what is the epidemiology of dental trauma?

peak ages 2-3 yr, 9-10 yr

incisors most affected

boys > girls

50% of children <15 yr, 60% deciduous teeth, 40% permanent

what is the etiology of dental trauma?

falls

traffic injuries

acts of violence

sports accidents

how should you begin an examination and diagnostic testing after trauma?

clean pts face and disinfect injured tissues

detailed history of the trauma

physical exam

radiographic exam

photographic registration

what questions should be asked after dental trauma?

when, where, how?

was there a loss of consciousness?

is there a change in occlusion?

is there an increased reaction to heat/cold?

medical history

what should be done during the physical exam after trauma?

pupillary reflex, blood pressure, pulse, bleeding (ear, nose)

head and neck hematomas, existence of an injury that would require the intervention of stitches

oral opening: amplitude, opening path, pain

soft tissue (throat, lips, cheeks, gums), in case of bleeding make a hemostasis with a sterilized gauze

in case of tooth loss look for foreign bodies, palpate all injuries and perform x rays

what should be done during the dental portion of a physical exam after trauma?

dental age of the child, search for the fractured/displaced tooth and classify the trauma

mobility, percussion, sensibility test

mobility test

to determie the extent of loosening of individual teeth and mobility of a group of teeth

0- no loosening

1- horizontal loosening <1mm

2- horizontal loosening >1mm

3- axial loosening

why is mobility testing important

distinguish between no mobility (normal physiologic) and no mobility (injured blocked tooth) after intrustion, lateral luxation, or ankylosis at the follow up visit

percussion test

to determine the health of the tooth and surrounding structures

if tenderness to percussion there is damage to PDL

if percussion not easily felt through the tooth and sounds like high metalic tone the tooth is blocked in the bone - lateral luxation/intrusion or ankylosis

pulpal sensibility test

to determine the nerve function and NOT to indicate the presence or absence of blood circulation within the pulpal space

cold test AND EPT

important for future comparison testing and follow up

t/f with pulp sensibility tests, there is a possibility of false negative readings

true- if the condution capability of the nerve endings is altered

this is NOT a sign of pulp necrosis but a sign of pulpal damange- many pulps will recover but it may take several months

why is radiographic examination done after trauma?

diagnosis, initial medical file, insurance

what are the 4 radiographs that should be taken after injury?

a direct 90 degree on the axis of the tooth

2 with different vertical/horizontal angulations

one occlusal film

what is the benefit of CBCT in dental trauma?

to determine the exact location, extent, and direction of fracture

should you take a CBCT after trauma just because?

no- there is a risk of hematological malignancies so use ALARA

x rays of soft tissue

check the presence of foreign substances or tooth fragments

reduce the intensity

when should the suturing of lip lesions be performed?

after the intra oral treatment has been completed

why is photographic registration important?

follow up examination

monitoring soft tissue healing

assessment of tooth discoloration

re-reuption of an intruded tooth

medico-legal documentation used in litigation cases

t/f no single element of the diagnostic process should be relied on to make even waht appears to be an uncomplicated diagnosis- before any treatment there should be at least 2 independent diagnostic test results

true

uncomplicated crown fractures

enamel infraction, enamel fracture, enamel-dentin fracture

complicated crown fractures

enamel-dentin-pulp fracture

enamel infraction

an incomplete fracture or crack of the enamel without loss of tooth structure

cracks visible by indirect illumination, + vitality test, normal mobility, - percission

x rays: 1 occlusal, 3 PA: straight on, mesial, distal, soft tissues in case of laceration

what is the treatment for enamal infraction?

abstention or polishing

no follow up is generally needed

6-8 weeks and 1 year recommended but not required

enamel fracture

a fracture confined to the enamel with loss of tooth fracture

+vitality test, normal mobility, - percussion

x rays: 1 occlusal, 3 PA: straight on, mesial, distal, soft tissues in case of laceration

what is the treatment for enamel fracture?

polishing, reconstruction

recall: 4 weeks, 6-8 weeks, 1 year (monitor vitality)

enamel- dentin fracture

a fracture confied to enamel and dentin without pulp exposure

+vitality test, normal mobility, - percussion

x rays: 1 occlusal, 3 PA: straight on, mesial, distal, soft tissues in case of laceration

what is the treatment for enamel-dentin fracture?

seal exposed dentin ASAP- minimize bacterial ingress, reduce patient discomfort

if remaining dentin thickness is <0.5mm (dentin is pink)- pulp capping

if remaining dentin thickness is >0.5mm- direct restorative treatment, possible to glue the fractured fragment if available

recall: 4 weeks, 6-8 weeks, 1 year (monitor vitality)

enamel-dentin-pulp fracture

a fracture confined to enamel and dentin, with pulp exposure

+vitality, normal mobility, - percussion

x rays: 1 occlusal, 3 PA: straight on, mesial, distal, soft tissues in case of laceration

recall: 4 weeks, 6-8 weeks, 6 months, yearly for at least 5 years

what is the treatment for enamel-dentin-pulp fracture?

depends on the stage of development of the tooth

immature- apexogenesis, apexification, regeneration

mature- non-surgical root canal treatment, vital pulp therapy (pulp capping/pulpotomy)

treatment also depends on the time between trauma and treatment, the concomitant periodontal injury, and the restorative treatment plan

immature teeth

immature permanent tooth has considerable capacity for healing after traumatic pulp exposure

every effort should be made to preserve the pulp to ensure continued root development

crown root fractures

the fracture includes enamel, dentin, and cementum with (complicated) or without pulp exposure (uncomplicated)

+vitality test, + mobility on the coronal fragment, +percussion

x rays: 1 occlusal, 3 PA: straight on, mesial, distal, soft tissues in case of laceration

CBCT: consider if needed to reveal the extension and direction of the fracture

what is the treatment for crown root fractures?

ensure restorability- periodontal challenge rather than an endodontic one

with or without gingivectomy or crown lengthening, orthodontic extrusion, surgical extrusion

without pulp exposure- cover the exposed dentin

with pulp exposure- immature tooth→vital pulp therapy, mature tooth→non surgical root canal treatment

recall: 1 week, 4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, yearly for at least 5 years

root fractures

include cementum, dentin, and pulp

can be localized at the apical, middle, or cervical 1/3

unusual with permanent incisors with incomplete root develpment (more prone to avulsion)

tooth can appear elongated

coronal fragment may be mobile and is displaced sometimes

apical fragment is usually not displaced → apical blood circulation is not disrupted (apical necrosis is rare)

vitality may be initially - indicating transient pulpal damage, + percussion

x rays: 1 occlusal, 3 PA with different vertical/horizontal angulation (located fracture in the cervical 1/3), soft tissues in case of laceration

CBCT: if needed, location, extent, and direction of the fracture

why is it important to take different angulations of a root fracture?

the fracture can appear different on radiographs, need multiple angles to confirm number of fractures

what is the treatment for root fracture

determine location of fracture

reposition coronal fragment ASAP, check with an x ray

stabilize the tooth with a flexible splint for 4 weeks (if the root fracture is near the cervical area, up to 4 months)

recall: 4 weeks, 6-8 weeks, 4 months, 6 months, 1 yr, yearly for at least 5 yrs

when indicated- NSRCT only to the coronal fragment, or surgical removal of the apical fragment

what are the responses to root fractures?

healing with calcified tissues

healing with interproximal connective tissue

healing with interproximal bone and connective tissue

no healing- interposition of granulated tissues

healing with calcified tissues

occurs after minimal or no displacement of the coronal fragment, most often in teeth with immature root formation

dentin (odontoblasts) + cementum (periodontium)

normal sensibility

normal mobility

fracture line discernible but fragments in close contact

pulp tissue of the coronal fragment: intact

successful healing!

healing with interproximal connective tissues

occurs after displacement of the coronal fragment

PDL cells

normal sensibility

increased mobility

fracture lines visible, fragments separated by a narrow radiolucent line

pulp space obliteration of coronal fragment is possible

successful healing!

healing with interproximal bone and connective tissue

occurs after root fracture prior to completed growth of the alveolar bone (young pts)

fragments separated by a distinct bony bridge

total pulp canal obliteration in both fragments is common

successful healing!

interposition of granulated tissues

occurs when bacteria gain access

granulation tissue is formed

negative sensibility

excessive mobility

a wide fracture line with a radiolucency (bone resorption)

necrosis of the coronal fragment

no healing!

supra-crestal root fracture in the coronal third

no PDL attachment to bone

pulp of both fragments will be susceptible to bacterial infection through the fracture line

healing is unlikely to occur

what should you do if your pt has a supra-crestal root fracture in the coronal third?

removal of the coronal fragment

if apical fragment restorable (gingivectomy, crown lengthening, orthodontic, or surgical extrusion) → RCT

if apical fragment not restorable → extraction

concussion

injury to the tooth supporting structures without mobility or tooth movement

+vitality, - mobility, + percussion

x ray: 3 PA different angulations to show normal tooth position in the socket

no treatment, release the traumatic occlusion

recall: 2 weeks, 4 weeks, 6-8 weeks, 3 mo, 6 mo, 1 yr, yearly for at least 5 yr

rare necrosis and root resorption

subluxation

injury to the tooth-supporting structures with mobility but without displacement of the tooth

+vitality, slightly + mobility, + percussion, bleeding from gingival suclus

x ray: 3 PA different angulations to show normal tooth position in the socket

no treatment (flexible splint if needed for 2wk), release from traumatic occlusion, pt under soft diet

recall: 2 wks, 4 wks, 6-8 wks, 3 mo, 6 mo, 1 yr, yearly for at least 5 yr

rare necrosis and root resorption

extrusive luxation

partial displacement of the tooth following the axis out of its socket but without leaving the socket

-vitality, ++ mobility, + percussion, tooth appears elongated

x ray: 1 occlusal and 3 PA different angulations- tooth appears dislocated with the apical part of the socket empty

what is the treatment for extrusive luxation?

repositioning and x ray, non rigid splint for 2 wks, release the traumatic occlusion, pt under soft diet

recall: 2 wks, 4 wks, 6-8 wks, 3 mo, 6 mo, 1 yr, yearly for at least 5 yr

if necrosis- immature teeth regeneration or apexification, mature teeth RCT

lateral luxation

lateral eccentric displacement of the tooth, usually associated with a fracture of the alveolar bone plate

-vitality, tooth in the bone immobile, + percussion with metallic sound, fracture of the alveolar bone may be palpable

x ray: 1 occlusal and 3 PA different angulations- tooth appears dislocated with the apical part of the socket empty

what is the treatment of lateral luxation?

tooth slightly pulled down to disengage the apex from the bone then repositioned (with anesthesia) and x ray

non rigid splint for 4 wks, release traumatic occlusion, pt under soft diet

recall: 2 wks, 4 wks, 6-8 wks, 3 mo, 6 mo, 1 yr, yearly for at least 5 yrs

if necrosis immature tooth regeneration or apexification, mature tooth RCT

intrusive luxation

displacement of the tooth deeper into the alveolar bone

it is a complex injury- compression and rupture of the PDL, the bone, and the neurovascular supply of the tooth

-vitality, locked tooth immoble, + percussion with metallic sound, infra occluded tooth, fracture of the alveolar bone may be palpable

x ray: 1 occlusal and 3 PA different angulation, tooth appears dislocated in an apical direction with partial or complete disapperance of PDL space

what is the treatment for intrusive luxation of an immature tooth?

if intrusion is <7mm- wait for re-eruption without intervention, if no movement initiate orthodontic repositioning within 4 wks

if intrusion is > 7mm- reposition orthodontically or surgically within 4 weeks

recall: 2 wks, 4 wks, 6-8 wks, 3 mo, 6 mo, 1 yr, yearly for at least 5 yrs

if necrosis- regeneration or apexification

what is the treatment for intrusive luxation of a mature tooth?

if intrusion <3mm, wait for re-eruption without intervention, if no movement position orthodontically or orthodontically after 8 wks

if intrusion >3mm but <7mm, reposition orthodontically or surgically within 3 wks

if intrusion >7mm, reposition surgically, flexible splint for 2 wks (4 wks if extensive), RCT (the pulp will likely become necrotic) → Ca(OH)2 recommended for 4 wks

recall: 2 wks, 4 wks, 6-8 wks, 3 mo, 6 mo, 1 yr, yearly for at least 5 yr (complications can occur due to the extensive PDL and pulpal injuries)

avulsion

the tooth is displaced completely out of its socket

young ages (7-9yr) most affected because there is no resistance due to the loosely structured PDL and low mineralized bone

no tooth!

x ray: to rule out intrusion or root fracture if the tooth is not found, to rule out root fracture of adjacent teeth

CBCT: if needed to rule out bone fracture

what is the first aid for avulsed teeth?

keep the pt calm, find the tooth and hold it by the crown (avoid touching the root)

if the tooth is dirty rinse it gently in milk, saline, or in the pts saliva → reposition within 15-20 min

if not possible to reposition → storage in a suitable storage medium

what are the suitable storage mediums for an avulsed tooth?

hanks balanced saline solution (HBSS)

milk

saliva

physiologic saline

water (rapid cell lysis and increased inflammation on replantation)

what conditions do you need to consider before replanting a permanent tooth?

no advanced periodontal disease

alveolar socket is reasonably intact to provide a seat for the avulsed tooth

the extra alveolar period (which affects the condition of the PDL cells)

should a deciduous tooth be replanted?

no! risk of damaging the permanent tooth germ

what is the goal of treatment of avulsion, and what does the prognosis depend on?

promote the survival of PDL, to minimize attachment damage and infection

the stage of development of the tooth, the extra-alveolar period and storage

how should you treat an avulsed mature tooth if it has already been replanted?

chlorhexidine/saline rinse

verify correct tooth position (clinically and w xray)

leave tooth in place (unless malposition)

flexible splint for 2 wks + suture lacerations if present

systemic antibiotics (based on pt risk factors) + tetanus shot

non surgical RCT 7-10 days

favorable prognosis

how should you treat an avulsed mature tooth if it been in a storage medium for < 60min?

rinse tooth with saline

local anesthesia (perferable without vasoconstrictor)

irrigate socket with saline

check the alveolar socket (reposition if fractured)

replant the tooth (do not use force) + xray

flexible splint for 2 wks + suture lacerations if present

systemic antibiotics (based on pt risk factors) + tetanus shot

non surgical RCT 7-10 days

favorable to guarded prognosis

how should you treat an avulsed mature tooth if it been in dry for > 60 min or long storage in non-physiologic media?

rinse tooth with saline

immerse the tooth in 2% sodium fluoride solution for 20 min → slow down osseous replacement (not an absolute recommendation)

local anesthesia (perferable without vasoconstrictor)

irrigate socket with saline

check the alveolar socket (reposition if fractured)

replant the tooth (do not use force) + xray

flexible splint for 2 wks + suture lacerations if present

systemic antibiotics (based on pt risk factors) + tetanus shot

non surgical RCT 7-10 days (Ca(OH)2 recomended 2-4 wks)

poor long term prognosis → high chance of ankylosis

decoronation in future to preserve the contour of the alveolar ridge

how should you treat an avulsed immature tooth if it has already been replanted?

chlorhexidine/saline rinse

verify position (clinically and w xray)

leave tooth in place (unless malposition)

flexible splint for 2 wks + suture lacerations if present

systemic antibiotics (based on pt risk factors) + tetanus shot

monitor for root formation- regeneration if tooth gets necrotic, apexification if regeneration fails

favorable prognosis

how should you treat an avulsed immature tooth if it been in a storage medium for < 60min?

rinse tooth with saline

local anesthesia

irrigate socket with saline

check the alveolar socket

replant the tooth (do not use force) + xray

flexible splint for 2 wks + suture lacerations if present

systemic antibiotics (based on pt risk factors) + tetanus shot

monitor for root formation- regeneration if tooth gets necrotic, apexification if regeneration fails

favorable to guarded prognosis

how should you treat an avulsed immature tooth if it been in dry for > 60 min or long storage in non-physiologic media?

rinse tooth with saline

immerse the tooth in 2% sodium fluoride solution for 20 min → slow down osseous replacement (not an absolute recommendation)

local anesthesia

irrigate socket with saline

check the alveolar socket

replant the tooth (do not use force) + xray

flexible splint for 2 wks + suture lacerations if present

systemic antibiotics (based on pt risk factors) + tetanus shot

monitor for root formation- regeneration if tooth gets necrotic, apexification if regeneration fails

poor long term prognosis → high chance of ankylosis

decoronation in future to preserve the contour of the alveolar ridge

what are patient instructions for an avulsed tooth?

systemic antibiotics- pencillin class for 7 days, azithromycin if allergy to penicillin (IF NEEDED, use AAE guidlines for pt immune status, level of contamination, presence of severe gingival injuries)

avoid sports

soft diet for 2 wks

0.12% CHX mouth rinse for 2 wks (to reduce bacterial load)

recall: 2 wks, 4 wks, 3 mo, 6 mo, 1 yr, yearly for 5 yr

alveolar fracture

the bone segment containing the involved teeth is fractured and mobile, it usually involves more than 2 teeth

complex injury- damage to supporting bone, pulp, PDL, and gingiva

mobility may be segmental (more than 1 tooth involved)

percussion dull sound

occlusal interference

displacement of an alveolar segment

vitality of involved teeth may be initially -

x ray: 1 occlusal + 3PA different angulations- fracture line move up or down along the root surface according to the xray beam angulation

with root fracture- fracture position on the root surface is not altered with the x ray beam angulation

pano- for extension and direction of fracture

CBCT- full set of labio-lingual information about the fracture

what is the treatment for alveolar fracture?

reposition the fragment ASAP

stabilize it with a flexible splint for 4 wks

suture gingival and soft tissue lacerations if present

recall: 4 wks, 6-8 wks, 4 mo, 6 mo, 1 yr, yearly for at least 5 yr

necrosis frequent, root resorption rare

for an alveolar fracture, if the fracture line does not involve root apices…

less chance of necrosis

for an alveolar fracture, if the fracture line does involve root apices…

higher chance of necrosis

when can you get ortho after dental trauma?

suggestion of waiting 3 mo after minor injuries, 6-12 mo for more severe injuries

what are the types of pulpal responses?

pulp healing, pulp necrosis, pulp canal obliteration, internal root resorption

what are the types of periodontal response: external root resorption?

repair-related resorption (surface resorption), infection related resorption, replacement resorption/ankylosis

what does the pulp response depend on?

the type and degree of displacement, the time until repositioning of the tooth, the stage of root development, the bacterial contamination of the affected tissues

what is the prognosis for concussion and subluxation injuries?

best prognosis

what is the prognosis for extrusion, lateral luxation, intrusion, and avulsion?

increasingly greater risk of pulp necrosis and infection

pulp healing

revascularization starts to occur in an apico-coronal direction at 4 days after injury at a growth rate of 0.5mm/day

vitality + (after 2-3 mo)

narrowing of the pulp canal

root maturation

pulp necrosis

discoloration of the crown

-vitality

persistent tenderness to percussion

periapical radiolucency on x ray

if 2 or more signs → RCT

pulp canal obliteration

when revascularization and re-innervation of the ischemic pulp succeed → hard tissue deposition along the pulp canal walls

the exact mechanism is unknown, usually occurs within 1 yr after trauma, more common in open apices (>0.7mm)

frequent after extrusive or lateral luxation injuries and rigidly splinted teeth

presents challenge to NSRCT

internal root resorption

the inflammed pulp is the tissue involved in resorbing the root structure

on x ray- a fairly uniform radiolucent enlargement of the pulp canal

RCT with Ca(OH)2

external root resorption

most commonly seen after intrusive luxation

severe lateral luxation

subluxation, concussion (rare cases)

repair related resorption (surface resorption)

response to mild injury to PDL or cementum- concusssion to subluxation

limited, localized PDL and cementoblast damage

no pulp necrosis/infection involved

odontoclast activity

cementoblast spontaneous repair (new cementum and PDL)

on x ray- not usually seen due to their small size

self limiting and reversible (healing response)

infection related resorption (inflammatory response)

response to moderate injury to the PDL and cementum

damage to PDL and cementum and apical neurovascular

pulp necrosis and infection through dentinal tubules to root surface

granulation tissues adjacent to exposed root surface

odontoclastic activity stimulation

continuous loss of cementum and dentin

on x ray: root resorption and radiolucency

once infection is removed → new repair cementum and PDL expected

ankylosis related resorption (replacement resorption)

response to intensive injury to PDL and cementum (intrusive luxation or extended avulsion)

extensive damage: PDL to cementum (failure of regeneration)

ankylosis- direct bone to root contact

bone remodeling- osteoclast (resorb)/odontoblast (replace)

progressive bone replacement of the resorbed root surface

irreversible and not affected by RCT

splinting

indicated in all cases after repositioning (luxation, avulsion, root or alveolar bone fracture)

a flexible splint may optimize pulp and PDL healing

orthodontic and composite wire- the most used (buccal side, away from marginal gingiva)

wire composite splints- 0.4mm (physiologic stabilization)

avoid rigid and extended duration splint (can lead to ankylosis)

which injuries should be splinted for 2 wks?

subluxation, extrusive luxation, avulsion

which injury should be splinted for 2-4 wks?

intrusive luxation

which injuries should be splinted for 4 wks?

lateral luxation, root fracture (apical and middle third), alveolar bone fracture

which injury should be splinted for 4 mo?

root fracture (cervical third)

why is radiographic examination important for primary dentition injuries?

to see the degree of development of the primary tooth and its permanent successor

to determine if the primary tooth has invaded the follicle of the developing permanent tooth

when the primary root apex is away from the follicle…

forshortened image

developing teeth symmetric

when the primary root apex is forced into the follicle…

elongated image

developing teeth asymmetric

what is the treatment for primary dentition injuries?

whatever the type of injury is, the main goal is to optimize periodontal and pulpal healing in the primary dentition to minimize the disturbance to the developing permanent tooth germ, that can affect both mineralization and malformation

depends on: the relatively short period primary teeth are in function in the child’s mouth, the close proximity of the root of the primary tooth to its developing permanent successor, the difficulty of gaining the child’s compliance

what is the treatment for a crown fracture in primary dentition?

restorative and pulpotomy if needed and if possible

what is the treatment for a crown-root fracture in primary dentition?

extraction

what is the treatment for a root fracture in primary dentition?

if minimal displacement of the coronal fragment→ no treatment

if coronal fragment displaced → extract it, keep apical fragment (physiological resorption)

what is the treatment for concussion and subluxation in primary dentition?

observation, pulp healing is frequent

permanent tooth: rare complications

what is the treatment for extrusive luxation in primary dentition?

reposition or extraction, pulp healing depends on the stage of root development

permanent tooth: moderate complications

what is the treatment for lateral luxation in primary dentition?

if minimal displacement → no treatment, occlusion check

if severe displacement → extraction

pulp healing depends on the stage of root development

permanent tooth: moderate complications

what is the treatment for intrusion in primary dentition?

if intrusion to labial bone plate → no treatment

if intrusion into the developing germ (rare cases) → extraction

pulp necrosis

permanent tooth: frequent complications

what is the treatment for avulsion in primary dentition?

x ray to ensure that the missing tooth is not intruded

permanent tooth: frequent complications