Pediatric Dentistry 538 WEB Lecture
Dental Trauma and Emergencies
Author -- Dr. Norman Tinanoff
SPECIFIC OBJECTIVES:
The student should know:
1. The essentials of a clinical and radiographic examination for a child
that presents with a traumatic injury.
2. The concepts and treatment of dental traumatic injuries that involve
crown fractures, crown root fractures, root fractures, concussions,
luxations, avulsions, and alveolar fractures.
3. The differences in treatment between similar injuries in primary and
permanent teeth.
4. The clinical signs, diagnosis and treatment of dental emergencies
associated with caries.
METHODOLOGY:
ASSIGNMENT:
WEB lecture
McDonald and Avery, 2000; Chapter 21, pages 485 - 534
Synopsis
History and Examination of a Child with Dental Trauma
Patients that present with dental trauma should have standardized data collected
which included a brief medical history or updated medical history. Minimal medical
history should include: Has the patient ever been hospitalized? Is he/she taking any
medicines? Is the patient being treated by a doctor for any medical problem? Does the
patient have any allergies? Has the patient had any serious illnesses?
A standardized evaluation sheet for an injury can be found on pages 487-488
of McDonald and Avery. At a minimum, the following questions should be recorded to
document the accident: When, where and how did the injury occur? Previous injuries to
the same area? Verbal description of the injuries.
The history of the trauma should also involve neurological questions such as:
Did this injury cause unconsciousness, amnesia, headache, nausea or vomiting?
The clinical examination should be conducted after the teeth and soft tissue
have been cleaned. The examination should be sequential starting with soft tissues, then
teeth should be examined for fractures, and pulp exposures; then teeth examined for
mobility and displacement, then teeth should be examined for tenderness to percussion,
then affected teeth should be radiographed; and finally teeth should be tested for
electrical vitality.
Radiographic examination should involve at least two exposures for affected
teeth to examine for fractured roots. This can be occlusal radiographs, periapical,
bisecting angle exposures and/or parallel technique. The below picture shows how a
single film may be able to diagnose a fracture that is parallel to the beam, but miss other
fractures. Follow up radiograph may need to be taken at 1, 3, 6 and 12 months
depending on the severity of injury.
Vitality test of the injured tooth should be performed and also on the teeth in the
immediate areas as well as those in the opposing arch should be tested. A negative
response, however, is not reliable evidence of pulp death but is an indication of affected
teeth because teeth immediate post injury may respond negatively. Also, teeth with open
apexes will respond negatively
Classification and Treatment of Injuries to Permanent Teeth
Fractures of enamel (Ellis Class I) -- Selective grinding of the incisal
edge and possibly of the adjacent tooth to reestablish symmetry, or acid etch
composite restoration.
Fractures of enamel and dentin (Ellis Class II)-- A bacteria tight
cover of the exposed dentin should be established as soon after injury as
possible. Dentinal coverage can include a calcium hydroxide base followed
by dentin bonded composites and glass ionomer cements or bonding of the
enamel
dentin crown fragment.
Fracture that includes a pulp exposure (Ellis Class III)-- The
exposed pulp can usually be treated successfully (i.e. by the formation of a
calcified bridge).
Three treatment options exist – Direct Pulp Capping for those situations where
the exposure is a pinpoint and less than a couple hours old;
Pulp capping/pulpotomy procedure (Cvek procedure) for those situations
where there is a larger exposure and the time is extended.
CaOH coronal pulpotomy can also be performed where there is an extensive
exposure and significant time that the pulp has been exposed to the oral cavity.
Crown-Root Fractures – three choices depending on where the fracture is:
Removal of the coronal fragment and supragingival restoration (e.g. by
bonding the original crown fragment after removing the subgingival portion, with
composite build up or a crown) in order to permit subgingival healing presumably
with a long junctional epithelium.
Removal of the coronal fragment supplemented by gingivectomy in order
to convert the subgingival fracture surface to supragingival in situations where
esthetics permits; thereafter restoration (e.g. with a post-retained crown).
Removal of the coronal fragment and surgical or orthodontic extrusion of
the root, to move the fracture surface to a more optimal location for final
restoration.
Root Fractures (Ellis Class VI)
Pulp necrosis is infrequent (approximately 25%) and is related to
displacement of the coronal fragment and mature root formation. Progressive
root resorption (i.e. inflammatory resorption ankylosis) is rare.
 Take radiographs with various angulations to diagnose fracture type and
location.
 Reposition the coronal fragment and use firm splinting for 3 months.
 Check for pulpal complications after 1 and 3 months.
 If pulp necrosis occurs as indicated radiographically by resorption of
bone at the level of the fracture, extirpate the pulp to the level of
the fracture and use calcium hydroxide as an interim dressing.
After hard tissue closure of the root canal at the fracture line has
been achieved (usually after 6 months to 1 year), a definitive
root filling with gutta percha is made.
Concussions and Subluxations
A concussed tooth is tender to percussion due to edema and
hemorrhage in the PDL. A subluxated tooth is tender to percussion and also
abnormally loose, due to rupture of PDL fibers. There is only a minimal risk of
pulp necrosis and even less risk of progressive root resorption.
 Occlusal relief (e.g. by selective grinding of opposing teeth) and a soft
diet.
 Immobilization of the injured teeth may be appropriate for patient
comfort. However, splinting does not appear to promote
healing. The fixation period is 2 weeks.
Intrusions
Intrusion is the result of an axial apical impact and results in extensive
damage to the pulp and PDL. There is a high risk of pulp necrosis and
progressive root resorption, especially in teeth with mature root formation.
Immature root formation:

Await spontaneous re-eruption, which usually takes up to 4 months.

Monitor pulpal healing radiographically 1 and 3 months after injury.
Mature root formation:

Await spontaneous re-eruption or extrude orthodontically over a
period of 2-3 weeks.

Extirpate the pulp 2 weeks after injury, using calcium hydroxide
paste as an interim dressing.

Root fill with a permanent gutta percha filling once periodontal
healing has been established radiographically.
Extrusions and Lateral Luxations (Ellis Class VII)
Extrusive luxation represents a rupture of the PDL and the pulp.
Lateral luxation represents a rupture of the PDL and the pulp as well as injury to
the labial and/or palatal alveolar bone plate. In both cases, healing includes both
PDL repair and usually pulpal revascularization. In the case of lateral luxation,
administration of local anesthetic is necessary before repositioning
If the radiographic examination reveals no sign of marginal breakdown,
the splint can be removed. If radiographic examination reveals inflammatory
resorption of the bone and root, immediate Endodontic therapy is required.
There is considerable risk of pulp necrosis in both luxation categories,
especially in teeth with mature root formation. Progressive root resorption is rare
after extrusion, but can occur following lateral luxation
Avulsions (Ellis Class V)
Replantation of avulsed teeth can result in successful healing if there has
been only minimal damage to the pulp and periodontal ligament. The type of
extra alveolar storage and length of storage period have an overwhelming effect
upon healing. Replantation should be attempted only if there is absence of gross
caries and no major loss of periodontal support before injury and physiological
storage of the tooth (in the case of a non-vital PDL, see below).
 Place the avulsed tooth in cold, isotonic solutions.
 Patient and tooth should be immediately transported to the dentist.
 Flush the socket with saline.
 Replant the tooth with gentle finger pressure.
 Splint the tooth for 1 week with a semi-rigid splint
 Antibiotics (e.g. penicillin, 2 million IU immediately thereafter 1
million IU four times daily for 4 days) may do some good but
has not been conclusively proven to prevent abscesses.
 If the patient is not covered for tetanus, tetanus vaccine should be
administered.
In case of an incomplete root formation (i.e. diameter of the apical
foramen exceeding 1 mm), pulpal revascularization is a possibility In the case of
complete root formation, extripate the pulp and place CaOH one week after
injury, just before split removal.
In those cases with a non-vital PDL (e.g. extra alveolar dry period longer
than 1 hour), resorption-preventing treatment is indicated:

Remove the PDL and pulp.

Place the tooth in 2.4% sodium fluoride solution (acidulated to
pH=5.5) for 20 min.

Obturate the root canal with gutta percha and a sealer.

Replant the tooth.

Splint for 6 weeks.
Alveolar Process Fractures
Verify the extent and position of the fracture clinically and radiographically,
using a multiple radiographic exposure technique. The only predictor for pulp
necrosis is late repositioning of the fracture. Root resorption is rare.

Place local anesthetic. Determine whether there is an "apical
lock", implying that the fragment cannot be completely
repositioned. In case of an apical lock, the fragment must first
be slightly extruded to free the apices. It is then possible to
reposition the fragment.

Splint the fragment for 3-4 weeks, according to the age of the
patient.

Monitor pulpal healing of the involved teeth.
Classification and Treatment of Injuries to Primary Teeth (Ellis Class VIII)
Enamel only fractures -- smooth off.
Enamel and dentin fractures -- acid etch composite.
Fractures involving pulp -- extract or root canal therapy.
Traumatized anterior teeth that have become non-vital (darkened)
 Do nothing unless signs of pathology (i.e. pain, abscess, fistula).
 Treatment can be either endodontics with resorbable paste or extraction.
Fractures of root of primary tooth -- extract (do not aggressively try to remove root
tip)
Displaced tooth -- verify contact between a displaced primary tooth and its permanent
successor by lateral extraoral radiograph.
Intrusions -- do nothing and most probably will re-erupt.
Luxations -- do nothing except if excessively mobile and then extract.
Avulsions -- do not reimplant.
Dental Emergencies Associated with Caries
The first thing that needs to be diagnosed is whether the pain is a reversible
pulpitis or irreversible pulpitis. Reversible pulpitis generally presents with intermittent
pain associated with eating, especially sweet foods. Irreversible pulpitis associated
with:
 Spontaneous pain, especially at night.
 A child not being able to localize the pain.
 Fistula.
 History of bad taste in mouth.
 Fever.
 Soft tissue swelling.
 Lymphadenopathy.
Diagnostic tests include:
 Electrical and thermal sensitivity are unreliable in children.
 Teeth often sensitive to percussion.
 Mobility (need to rule out physiologic root resorption).
 Radiographically – Deep caries, periapical, intra-radicular radioluciency.
 Diagnostic caries excavation, which may lead to pulp exposure and
consequently determining vitality.
Emergency treatment for reversible pulpitis may be treated with caries
excavation and temporization or if pulp exposed, vital pulpotomy technique. Irreversible
pulpitis may be treated with pulpectomy or extraction.
It may not be possible to treat the child on day of the emergency visit because
local anesthesia administered in the area of inflammation may not full anesthetize the
tooth. If the tooth cannot be anesthetized (e.g. buccal abscess on a maxillary molar),
postpone treatment for 5-7 days while prescribing penicillin (e.g. Pen V K 25-50 mg / kg /
day in 3-4 divided doses), along with analgesics (e.g., ibuprofen [Motrin] 4-10 mg/kg PO
q6h) to reduce acute inflammation and pain.