PRIMARY TEETH TRAUMA

PRIMARY TEETH TRAUMA
1. CONCUSSION - DIAGNOSTIC SIGNS

DESCRIPTION

AN INJURY TO THE TOOTH-SUPPORTING STRUCTURES WITHOUT
INCREASED MOBILITY OR DISPLACEMENT OF THE TOOTH, BUT
WITH PAIN TO PERCUSSION AND WITHOUT GINGIVAL BLEEDING.
THE DIAGNOSTIC SIGNS OF CONCUSSION ARE TRANSIENT. IT IS
THEREFORE NOT POSSIBLE TO DIAGNOSE CONCUSSION IF THE
EXAMINATION IS DONE SEVERAL DAYS AFTER INJURY.

VISUAL SIGNS

NOT DISPLACED.

PERCUSSION TEST

TENDER TO TOUCH OR TAPPING.

MOBILITY TEST

NO INCREASED MOBILITY.

PULP SENSIBILITY

NOT RELIABLE IN PRIMARY TEETH. INCONSISTENT RESULTS.

TEST

RADIOGRAPHIC

FINDINGS

NO RADIOGRAPHIC ABNORMALITIES. NORMAL PERIODONTAL
SPACE.

RADIOGRAPHS

AN OCCLUSAL EXPOSURE IS RECOMMENDED IN ORDER TO SCREEN

RECOMMENDED

FOR POSSIBLE SIGNS OF DISPLACEMENT OR THE PRESENCE OF A
ROOT FRACTURE. THE RADIOGRAPH CAN FURTHERMORE BE USED
AS A REFERENCE POINT IN CASE OF FUTURE COMPLICATIONS.

TREATMENT


NO TREATMENT IS NEEDED ONLY OBSERVATION.

PATIENT INSTRUCTIONS



SOFT FOOD FOR 1 WEEK.
GOOD HEALING FOLLOWING AN INJURY TO THE TEETH AND ORAL TISSUES
DEPENDS, IN PART, ON GOOD ORAL HYGIENE. BRUSH WITH A SOFT BRUSH AFTER


EVERY MEAL AND APPLY CHLORHEXIDINE 0.1 % TOPICALLY TO THE AFFECTED

AREA WITH COTTON SWABS TWICE A DAY FOR ONE WEEK. THIS IS BENEFICIAL TO
PREVENT ACCUMULATION OF PLAQUE AND DEBRIS ALONG WITH RECOMMENDING A
SOFT DIET.



PARENTS SHOULD BE FURTHER ADVISED ABOUT POSSIBLE COMPLICATIONS THAT
MAY OCCUR, LIKE SWELLING, DARK DISCOLORATION OF THE CROWN, INCREASED
MOBILITY OR FISTULA. CHILDREN MAY NOT COMPLAIN ABOUT PAIN; HOWEVER,
INFECTION MAY BE PRESENT AND PARENTS SHOULD WATCH FOR SIGNS OF
SWELLING OF THE GUMS AND BRING THE CHILD IN FOR TREATMENT.

FOLLOW-UP


CLINICAL CONTROL AT 1 WEEK, 6-8 WEEKS.

2. EXTRUSION
Partial displacement of the tooth out of its socket
An injury to the tooth characterized by partial or total separation of the periodontal
ligament resulting in loosening and displacement of the tooth. The alveolar socket bone
remains intact. In addition to axial displacement, the tooth usually will have some
protrusive or retrusive orientation.

Definition

Partial displacement of the tooth out of its socket
An injury to the tooth characterized by partial or total separation of
the periodontal ligament resulting in loosening and displacement of
the tooth. The alveolar socket bone remains intact in an extrusion

injury as opposed to a lateral luxation injury. In addition to axial
displacement, the tooth will usually have an element of protrusion
or retrusion. In severe extrusion injuries the retrusion/protrusion
element can be very pronounced. In some cases it can be more
pronounced than the extrusive element.

Visual signs

Appears elongated.

Percussion test

Tenderness to percussion.

Mobility test

Excessively mobile.


Sensibility test

Not reliable in primary teeth. Inconsistent results.

Radiographic
findings

Increased periodontal ligament space apically.

Radiographs
recommended

An occlusal exposure is recommended in order to evaluate the size
of the displacement and rule out the presence of a root fracture. The
radiograph can furthermore be used as a reference point in case of
late complications.

TREATMENT
The treatment choice should be based on the degree of displacement, mobility, root
formation and the ability of the child to cope with the emergency situation.
For minor extrusion (< 3mm) in an immature developing tooth, either careful reposition
the tooth or leave the tooth for spontaneous alignment.
Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth.
PATIENT INSTRUCTIONS






Soft food for 1 week.
Good healing following an injury to the teeth and oral tissues depends, in part, on
good oral hygiene. Brush with a soft brush after every meal and apply
chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day
for one week. This is beneficial to prevent accumulation of plaque and debris
along with recommending a soft diet.
Parents should be further advised about possible complications that may occur,
like swelling, dark discoloration of the crown, increased mobility or fistula.
Children may not complain about pain; however, infection may be present and
parents should watch for signs of swelling of the gums and bring the child in for
treatment.

FOLLOW-UP


Clinical control after 1 weeks. Clinical and radiographic control at 6-8 weeks, 6
months, and 1 year.

3. SUBLUXATION - DIAGNOSTIC SIGNS


Description

An injury to the tooth supporting structures resulting in increased
mobility and pain to percussion but without displacement of the
tooth. Bleeding from the gingival sulcus is evident if the child is
seen shortly after the accident.
The diagnostic signs of subluxation are transient. It is therefore not
possible to diagnose subluxation if the examination is done several
days after injury.

Visual signs

Not displaced.

Percussion test

Tender to touch or tapping.

Mobility test

Increased mobility.

Pulp sensibility
test

Not reliable in primary teeth. Inconsistent results.

Radiographic
findings

Normal periodontal space

Radiographs
recommended

An occlusal exposure is recommended in order to screen for
possible signs of displacement or the presence of a root fracture.
The radiograph can furthermore be used as a reference point in
case of future complications.

TREATMENT OBJECTIVE


No treatment is needed.

TREATMENT


No treatment is needed. Observation.

PATIENT INSTRUCTIONS



Soft food for 1 week.
Good healing following an injury to the teeth and oral tissues depends, in part, on
good oral hygiene. Brush with a soft brush after every meal and apply
chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day


for one week. This is beneficial to prevent accumulation of plaque and debris
along with recommending a soft diet.



Parents should be further advised about possible complications that may occur,
like swelling, dark discoloration of the crown, increased mobility or fistula.
Children may not complain about pain; however, infection may be present and
parents should watch for signs of swelling of the gums and bring the child in for
treatment.

FOLLOW-UP


Clinical control at 1 week, 6-8 weeks

4.LATERAL LUXATION - DIAGNOSTIC SIGNS
Description

Displacement of the tooth other than axially.

Displacement is accompanied by comminution or
fracture of either the labial or the palatal/lingual
alveolar bone.
Palatal/lingual luxation of the maxillary incisors may
result in occlusal interference expressed by premature
contact with the opponent teeth.
Lateral luxation injuries, similar to extrusion injuries,
are characterized by partial or total separation of the
periodontal ligament. However, lateral luxations are
complicated by fracture of either the labial or the
palatal/lingual alveolar bone and a compression zone
in the cervical and sometimes the apical area. If both
sides of the alveolar socket have been fractured, the
injury should be classified as an alveolar fracture
(alveolar fractures rarely affect only a single tooth). In
most cases of lateral luxation the apex of the tooth has
been forced into the bone by the displacement, and the
tooth is frequently non-mobile.

Visual signs

Displaced, usually in a palatal/lingual or labial


direction.
Percussion test

Usually gives a high metallic (ankylotic) sound.

Mobility test

Usually non-mobile.

Sensibility test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

Increased periodontal ligament space apically is best
seen on the occlusal exposure.

Radiographs recommended

An occlusal exposure can sometimes show the position
of the displaced tooth and its relation to the permanent
successor.

TREATMENT
Spontaneous repositioning
If there is no occlusal interference, as is often the case in anterior open bites, the tooth
should be allowed to reposition spontaneously.
Repositioning
When there is occlusal interference local anesthesia should be applied where after the
tooth should be repositioned by gentle combined labial and palatal pressure.
Extraction
For teeth with severe displacement in a labial direction, extraction is the treatment of
choice. Extraction is indicated in these cases because of the collision between the primary
tooth and the permanent tooth germ.
Slight grinding

In cases with minor occlusal interference, slight grinding is indicated.
PATIENT INSTRUCTIONS
Soft food for 10-14 days.
Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 %
topically to the affected area with cotton swabs twice a day for one week. This is
beneficial to prevent accumulation of plaque and debris along with recommending a soft


diet.
Parents should be further advised about possible complications that may occur, like
swelling, dark discoloration of the crown, increased mobility or fistula. Children may not
complain about pain; however, infection may be present and parents should watch for
signs of swelling of the gums and bring the child in for treatment.
FOLLOW-UP
Clinical control after 1 and 2-3 weeks. Clinical and radiographic control at 6-8 weeks and
1 year.

5.INTRUSION - DIAGNOSTIC SIGNS
Description

Displacement of the tooth into the alveolar bone. This
injury is accompanied by comminution or fracture of the
alveolar socket.
The tooth can be impinging upon the permanent tooth
germ.

Visual signs

The tooth is displaced axially into the alveolar bone and

frequently penetrating the labial bone plate where it can
be palpated. The tooth may disappear completely in the
tissues resembling avulsion and root fracture with
complete extrusion of the coronal fragment. In this case
diagnosis is based on an occlusal radiograph.
Penetration of the tooth into the nasal cavity can be
diagnosed by bleeding from the nose or simple
observation of the nostril.

Percussion test

The test will usually give a high metallic (ankylotic)
sound. However in severe intrusion cases the test will not
always be possible to perform.

Mobility test

The tooth is non-mobile.


Sensibility test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

When the apex is displaced toward or through the labial
bone plate the apical tip can be visualized and appears
shorter than the unaffected contralateral tooth.
When the apex is displaced toward the permanent tooth

germ, the apical tip cannot be visualized and the tooth
appears elongated.

Radiographs recommended

An occlusal or periapical exposure will normally show
the position of the displaced tooth and its relation to the
permanent successor. If the tooth is totally intruded an
extra-oral lateral exposure may be indicated to make sure
that the tooth has not penetrated the nasal cavity.

TREATMENT
Tooth intrusion is associated with a potential risk of damage to the permanent tooth bud.
Spontaneous eruption
If the apex is displaced toward or through the labial bone plate, the tooth should be left
for spontaneous repositioning. In order to evaluate re-eruption, the degree of intrusion
should be assessed by measuring the distance between the incisal edge of the intruded
tooth and that of adjacent unaffected teeth.
Extraction
If the apex is displaced into the developing tooth germ the tooth should be extracted to
minimize the damage done to the permanent successor.
PATIENT INSTRUCTIONS
Soft food for 10-14 days.
Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 %
topically to the affected area with cotton swabs twice a day for one week. This is
beneficial to prevent accumulation of plaque and debris along with recommending a soft
diet , restrict the use of a pacifier.

Parents should be further advised about possible complications that may occur, like
swelling, dark discoloration of the crown, increased mobility or fistula. Children may not
complain about pain; however, infection may be present and parents should watch for
signs of swelling of the gums and bring the child in for treatment.
Inform the parent about possible complications in the development of the permanent
successor, especially following intrusion injuries sustained in children under 3 years of
age.
FOLLOW-UP
Clinical control after 1 week. Clinical and radiographic control at 3-4 weeks, 6-8 weeks,
6 month, 1 year and yearly clinical and radiographic control until eruption of the
permanent successor.
6.AVULSION - DIAGNOSTIC SIGNS

Description

The tooth is completely displaced out of its socket.
Clinically the socket is found empty or filled with a
coagulum.

Visual signs

The tooth is removed from its socket.

Percussion test

Not relevant.

Mobility test

Not relevant.

Sensibility test

Not relevant.

Radiographic findings

The alveolar socket will be empty. If the avulsed tooth is
not present a radiographic examination is essential to
ensure that the missing tooth is not intruded.

Radiographs recommended

An occlusal exposure is recommended in order to screen
for the presence of root fragments and to make sure that
the missing tooth is not intruded.

TREATMENT


It's not recommended to replant avulsed primary teeth.
A the initial examination make sure that all avulsed teeth are accounted for. If not it is
highly recommended to make a radiographic examination in order to ensure that the
missing tooth is not a case of complete intrusion or root fracture with loss of the coronal
fragment. If the avulsed tooth has not been found refer the child to the paediatrician to
exclude aspiration.
Patient instructions
Soft food for 1 week.
Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene.

Inform the parent about possible complications in the development of the permanent
successor, especially following avulsion injuries sustained in children under 3 years of
age.
FOLLOW-UP
Clinical control after 1 week and clinical and radiographic control after 6 months and 1
year. Yearly clinical and radiographic controls until eruption of the permanent successor.
7.INFRACTION - DIAGNOSTIC SIGNS

Description

An incomplete fracture (crack) of the enamel without
loss of tooth structure.

Visual signs

A visible fracture line on the surface of the tooth.

Percussion test

Not tender. If tenderness is observed evaluate the tooth
for a possible luxation injury or a root fracture.

Mobility test

Normal mobility.

Sensibility pulp test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

No radiographic abnormalities.


Radiographs recommended

None.

TREATMENT
No treatment necessary
FOLLOW-UP
No follow-up is needed for infraction injuries unless they are associated with a luxation
injury or other fracture types involving the same tooth.
8.ENAMEL FRACTURE - DIAGNOSTIC SIGNS

Description

A fracture confined to the enamel with loss of tooth
structure.

Visual signs

Visible loss of enamel. No visible sign of exposed
dentin.

Percussion test

Not tender. If tenderness is observed evaluate the tooth
for a possible luxation or root fracture injury.

Mobility test

Normal mobility.

Sensibility pulp test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

The enamel loss is visible.

Radiographs recommended

None.

TREATMENT
Smooth sharp edges. In patients with lip or cheek lesions it is advisable to search for
tooth fragments or foreign material.
FOLLOW-UP
No followup required.


9.ENAMEL-DENTIN FRACTURE - DIAGNOSTIC SIGNS

Description

A fracture confined to enamel and dentin with loss of
tooth structure, but not involving the pulp.

Visual signs

Visible loss of enamel and dentin. No visible sign of
exposed pulp tissue.

Percussion test

Not tender. If tenderness is observed evaluate the tooth
for possible luxation or root fracture injury.

Mobility test

Normal mobility.

Sensibility pulp test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

The enamel-dentin loss is visible. The distance between
the fracture and the pulp chamber can be evaluated.

Radiographs recommended

None.

TREATMENT
If possible, seal completly the involved dentin with glass ionomer to prevent

microleakage. In case of large lost tooth structure, the tooth can be restored with
composite.
FOLLOW-UP
Clinical control at 3-4 weeks.
10.ENAMEL-DENTIN-PULP FRACTURE - DIAGNOSTIC SIGNS

Description

A fracture involving enamel and dentin with loss of tooth
structure and exposure of the pulp.

Visual signs

Visible loss of enamel and dentin and exposed pulp


tissue.
Percussion test

Not tender. If tenderness is observed evaluate the tooth
for luxation or root fracture injury.

Mobility test

Normal mobility.

Sensibility test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

The loss of tooth substance is visible.

Radiographs recommended

An occlusal exposure is recommended in order to screen
for possible signs of displacement or the presence of a
root fracture.
The radiograph can furthermore be used as a reference
point in case of future complications.

TREATMENT
If possible, preserve pulp vitality by partial pulpotomy. Calcium hydroxide is a suitable
material for such procedures. A well-condensed layer of pure calcium hydroxide paste
can be applied over the pulp, covered with a lining such as reinforced glass ionomer.
Restore the tooth with composite.
The treatment is depending on the child's maturity and ability to cope. Extraction is
usually the alternative option.
FOLLOW-UP
Clinical after 1 week. Clinical and radiographic control after 6-8 weeks and 1 year.
11.CROWN-ROOT FRACTURE WITHOUT PULP INVOLVEMENT - DIAGNOSTIC SIGNS

Description

A fracture involving enamel, dentin and cementum with
loss of tooth structure, but not involving the pulp.


Visual signs

Crown fracture extending below gingival margin. The
crown is split into two or more fragments, one of which
is mobile.

Percussion test

Tenderness to percussion.

Mobility test

At least one coronal fragment is mobile. Because of
mobility during mastication there might be transitory
pain.

Sensibility pulp test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

Apical extension of fracture usually not visible. In
laterally positioned fractures, the extent in relation to the
gingival margin can be seen.

Radiographs recommended

An occlusal exposure.

LOCALIZATION OF FRACTURE LINE



The fracture involves the crown and root of the tooth and is in a horizontal or
diagonal plane. A radiographic examination usually only reveals the coronal part
of the fracture and not the apical portion

TREATMENT

Depending on the clinical findings, two treatment scenarios may be considered. Most of
these may be deferred to later treatment.




Fragment removal only
If the fracture involves only a small part of the root and the stable fragment is
large enough to allow coronal restoration, remove the mobile fragment.
Extraction
Extraction in all other instances.

PATIENT INSTRUCTIONS
Soft food for 10-14 days.


Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 %
topically to the affected area with cotton swabs twice a day for one week. This is
beneficial to prevent accumulation of plaque and debris along with recommending a soft
diet.
Parents should be further advised about possible complications that may occur, like

swelling, increased mobility or fistula. Children may not complain about pain; however,
infection may be present and parents should watch for signs of swelling of the gums and
bring the child in for treatment.
FOLLOW-UP
In case of fragment removal only: Clinical control after 1 week. Clinical and radiographic
control after 3-4 weeks. Clinical control after 1 year.
In case of tooth extration: Clinical and radiographic control at 1 year and every year until
eruption of the permanent successor.
12.CROWN-ROOT FRACTURE WITH PULP INVOLVEMENT - DIAGNOSTIC SIGNS

Definition

A fracture involving enamel, dentin, cementum and the
pulp.

Visual signs

Crown fracture extending below gingival margin. The
crown is split into two or more fragments, one of which
is mobile.

Percussion test

Tenderness to percussion.

Mobility test

At least one coronal fragment is mobile. Beause of
mobility during mastication there might be transitory
pain.

Sensibility test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

Apical extension of fracture usually not visible. In
laterally positioned fractures, the extent in relation to the


gingival margin can be seen.
Radiographs recommended

An occlusal exposure.

LOCALIZATION OF FRACTURE LINE
The fracture involves the crown and root of the tooth and is in a horizontal or diagonal
plane. A radiographic examination usually only reveals the coronal part of the fracture
and not the apical portion.
TREATMENT
Depending on the clinical findings, two treatment scenarios may be considered.



Fragment removal only if the fracture involves only a small part of the root and
the stable fragment is large enough to allow coronal restoration.
Extration in all other instances.

PATIENT INSTRUCTIONS

Soft food for 10-14 days.
Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene. Brush with a soft brush after every meal. This is beneficial to prevent
accumulation of plaque and debris along with recommending a soft diet.
Parents should be further advised about possible complications that may occur, like
swelling or fistula. Children may not complain about pain; however, infection may be
present and parents should watch for signs of swelling of the gums and bring the child in
for treatment.
FOLLOW-UP
In case of fragment removal only: Clinical and radiographic control at 1 year and every
year until eruption of the permanent successor.
In case of tooth extration: Clinical and radiographic control at 1 year and every year until
eruption of the permanent successor.
13.ROOT FRACTURE - DIAGNOSTIC SIGNS


Description

A fracture confined to the root of the tooth involving
cementum, dentin, and the pulp.

Visual signs

The coronal segment is usually mobile and may be
displaced. Transient crown discoloration (red or grey)
may occur.

Percussion test

The tooth may be tender.

Mobility test

The coronal segment is usually mobile.

Sensibility pulp test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

The fracture is usually located mid-root or in the apical
third.

Radiographs recommended

An occlusal or periapical exposure.

TREATMENT
No treatment
If the coronal fragment is not displaced no treatment is required.
Extraction
If the coronal fragment is displaced, repositioning and splinting might be considered.
Otherwise extract only that fragment. The apical fragment should be left to be resorbed.
PATIENT INSTRUCTIONS
Soft food for 10-14 days.
Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 %
topically to the affected area with cotton swabs twice a day for one week. This is
beneficial to prevent accumulation of plaque and debris along with recommending a soft

diet, restrict the use of a pacifier.
Parents should be further advised about possible complications that may occur, like
swelling, increased mobility or fistula. Children may not complain about pain; however,


infection may be present and parents should watch for signs of swelling of the gums and
bring the child in for treatment.
FOLLOW-UP
Clinical control after 1 week. Clinical and radiographic control after 6-8 weeks and 1
year.
In case of tooth extration: Clinical and radiographic control at 1 year and every year until
eruption of the permanent successor.
14.ALVEOLAR FRACTURE - DIAGNOSTIC SIGNS

Description

A fracture of the alveolar process which may or may not
involve the alveolar bone socket.
Teeth associated with alveolar fractures are characterized
by mobility of the alveolar process; several teeth
typically will move as a unit when mobility is checked.
Occlusal interference is often present

Visual signs

Displacement of an alveolar segment. An occlusal
change due to misalignment of the fractured alveolar
segment is often noted. This may cause occlusal
interference.

Percussion test

Tenderness to percussion.

Mobility test

Entire segment mobile and moves as a unit.

Sensibility pulp test

Not reliable in primary teeth. Inconsistent results.

Radiographic findings

The vertical line of the fracture may run along the PDL
or in the septum. Thehorizontal line may be located
apical at the apex or coronal to the apex. An associated
root fracture may be present. The horizontal fracture line
may run at any level in regard to the permanent tooth
germs. The radiograph will give valuable information in


the assessment of the risk for damage to the permanent
teeth.
A lateral radiograph may give further information about
the spatial relation between the two dentitions.
Radiographs recommended

An occlusal exposure.

TREATMENT
Manual repositioning or repositioning using forceps of the displaced segment. General
anesthesia is often indicated.Stabilize the segment with flexible splinting for 4 weeks.
Monitor teeth in the fracture line.
PATIENT INSTRUCTIONS
Soft food for 10-14 days.
Good healing following an injury to the teeth and oral tissues depends, in part, on good
oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 %
topically to the affected area with cotton swabs twice a day for one week. This is
beneficial to prevent accumulation of plaque and debris. Along with recommending a soft
diet, restrict the use of a pacifier.
Parents should be further advised about possible complications that may occur, like
swelling, increased mobility or fistula. Children may not complain about pain; however,
infection may be present and parents should watch for signs of swelling of the gums and
bring the child in for treatment.
Inform the parents about possible complications in the development of the permanent
teeth.
FOLLOW-UP
Splint removal and clinical and radiographic control after 4 weeks.
Clinical control after 1 week. Clinical and radiographic control and splint removal after
3-4 weeks. Clinical and radiographic control after 6-8 weeks and 1 year then yearly untill
exfoliationh.