College of Dentistry

Pedodontic II
Management of Traumatic Injuries in Children
-4Dr. Hazem El Ajrami
Master Degree in Orthodontic & Pedodontic

Class III:
The treatment depends on many factors such
as:
1. Vitality of the exposed pulp (Vital or Non
vital). Size of the exposure (Small or Large).
2. Time elapsed since the exposure (Early, within
6 hours or Late).

3. Degree of root maturation (Open apex or close

apex).
4. Restorability of the fractured crown (Restorable
or not).
5. Physical condition of the patient (Medically
compromised or not).

 The main objective of treatment in managing

these injuries is to retain the tooth and
maintain its vitality. This allow for physiologic
closure of the root apex in immature teeth.
The following procedures may be adopted to
accomplish the preceding objective:
Direct pulp capping.
Calcium hydroxide pulpotomy.
Apexification.
Pulpectomy.

Management of Class III

Small exposure
Early
Open
Closed
Direct pulp capping

Late
Open

Closed

Pulpotomy
(transient
procedure)
Pulpectomy

Pulpectomy

Management of Class III

Large exposure
Early
Open

Late
Closed

Open

Closed

Pulpotomy Pulpectomy Apexificatio Pulpectomy

(transient
n
procedure)
Pulpectomy
Pulpecto
my

Class IV:
Crown fracture where the fracture line
passes beneath the gingival margin. This may be
a vertical or oblique fracture. Treatment will
usually involve removing the loose fragment
which is often held in a close position to the rest
of the tooth by the periodontal ligament fibers.
Then it can be decided if the remaining part of
the tooth can be extruded orthodontically or
whether a surgical approach will be required to
gain access to the apical part of the fracture line
prior pulp therapy and placement of a
restoration.

Class V:
In the permanent dentition root fractures
mainly affect the maxillary central incisors and
are most common at 11 to 20 years of age.
Below 11 years of age, the root is in its
formative stage and more resilient to the
effects of trauma. Fracture may occur in the
cervical third, middle third or apical third of
root.

A. Apical third root fracture:

No treatment is needed follow up with xray should be continued up to six weeks.
B. Middle third root fracture:
With this type of fracture there will be
displacement of the fractured crown-root
segment, usually palataly or lingualy.
Under local anesthesia, achieve reduction
into position by digital pressure, and stabilize
the tooth or teeth in this position by splinting
(4-6 weeks). After reduction check the
position radiographically.

 Splinting:
The purpose of splinting is to stabilize the
tooth in the arch in order to prevent further
damage to the pulpal and periodontal tissues.
Splints can be fixed or removable.

Types of fixed splints:

1. Acid-etched resin composite splint.
2. Orthodontic brackets and wire splint.
3. Interdental wiring.
4. Arch wire and resin splint.
5. Full arch, vacuum molded acrylic splint.

C. Coronal (Cervical) third root fracture:

Remove the coronal segment. If the fracture
is 1-2 mm. infra-bony a possible osteoplasty
to expose the root or orthodontic root
extrusion may be required.
Root canal treatment with post and crown
restoration can be accomplished. Otherwise
extraction is the treatment of choice.

Treatment of Traumatic Dental Injuries

(Permanent Dentition)
I.

Soft tissue injuries.

II.

Concussion.

III. Subluxation.
IV. Tooth Fracture.
V.

Displacement of permanent anterior teeth.

V.

Displacement of permanent anterior teeth:

Intrusion:
An intruded permanent tooth can be
treated in one of three ways:
1) In case of intruded tooth with incomplete
root formation, the tooth will erupt
spontaneously.
2) Immediate
surgical
repositioning,
splinting, and endodontic therapy.

3) Orthodontic extrusion and repositioning.

Complications such as external root
resorption and loss of marginal bony support
do occur in surgically repositioned teeth. A
far better success rate has been achieved with
orthodontic repositioning which occurs
slowly over 3 to 4 weeks. Endodontic
therapy can be performed when there is
adequate crown available.

 Extrusion:
Reposition an extruded tooth by digital
pressure on the incisal edge, returning the
tooth to its original position. Delay in treating
the tooth may result in its being fixed in its
extruded position. After repositioning,
maintenance of position is by splinting. If
vitality of the tooth is lost, begin root
treatment immediately, placing calcium
hydroxide in the canal for 6 months to 1 year
followed by a more permanent filling.

 Avulsion:
In the permanent dentition avulsion of the
maxillary central incisors is most common in
the age of 7 to 10 years.
There are two important factors to be
considered in cases of avulsion:
Time, interval between injury and treatment.
Conditions under which the tooth or teeth have
been stored.
The treatment of choice, for permanent teeth,
is immediate re-plantation within 30-60
minutes of injury.

 The tooth must be kept moist to prevent

irreversible

damage

to

the

periodontal

membrane.
Storage media may be: Saliva, Saline, Milk.

 In many cases the initial patient/dentist

contact is by phone. It is essential to advise
the parent to follow these procedures:
1) The tooth should be handled by the crown
only.
2) The tooth should be rinsed under running
tap water (soap and alcohol as cleaning
agents are contraindicated).
3) Insert the tooth back into its socket if
possible.

4) Let the child gently occlude on a gauze or

handkerchief for stability and present to the
dental office as soon as possible.
5) If re-plantation is not possible, the tooth
should be placed in a suitable storage
medium as milk, saliva, contact lenses
solution or unsalted water.
6) If no storage medium is available, the tooth
should be placed in the mouth between cheek
and gum or under the tongue.

 At the dental office

A. Information

on

current

tetanus

immunization should be obtained.

B. Stabilization of the tooth in the socket is
obtained by acid etch composite resin
splint (one week is sufficient to obtain
adequate periodontal support).

C. Calcium hydroxide should be placed in the

tooth after 1 week. This will prevent the
initiation of inflammatory root resorption.
D. Root canal therapy.
E. In immature teeth with open apices, the tooth
should be splinted for approximately 2
weeks. This will give the neurovascular
tissues an opportunity to re-anastomose.

Thank You