management of traumatic injuries to primary young permanent teeth pedo

• Examination and diagnosisExamination and diagnosis

Consider traumatic injuries as emergency,Consider traumatic injuries as emergency,

• To relieve pain. To relieve pain.

• Reduce psychological stress.Reduce psychological stress.

• Facilitate reduction of # or avulsion.Facilitate reduction of # or avulsion.

• For good prognosis.For good prognosis.

When did injury occurred ?When did injury occurred ?

• Time interval between injury and treatment started.Time interval between injury and treatment started.

• Alter possible prognosis and line of treatment specially in Alter possible prognosis and line of treatment specially in

cases of re-implantation, pulp exposure, bone# and severe cases of re-implantation, pulp exposure, bone# and severe

soft tissue injuries.soft tissue injuries.

Where did injury occurred ?Where did injury occurred ?

• For tetanus prophylaxis.For tetanus prophylaxis.

• How did injury occurred ?

• Direction of blow which tells possible structure affected.

• Object in mouth like pacifier labial displacement of teeth.

• Young child and women with multiple soft tissue injury at deferent stage of healing improper history child abuse.

Treatment else where ?Treatment else where ?

• Storage of avulsed teeth.Storage of avulsed teeth.

• Medication taken.Medication taken.

• Re-implantation and immobilization considered.Re-implantation and immobilization considered.

History of previous injury ?History of previous injury ?

• Sustained repeated injury influence pulp vitality test.Sustained repeated injury influence pulp vitality test.

• Affects healing capacity of pulp and PDL. Affects healing capacity of pulp and PDL.

General health and medical history ?General health and medical history ?

• Allergic reactionAllergic reaction

• EpilepsyEpilepsy

• Bleeding disorderBleeding disorder

• Differs emergency and later treatmentDiffers emergency and later treatment

ExaminationExamination

• Color changeColor change of traumatized tooth noted occurs in post injury period. of traumatized tooth noted occurs in post injury period.

• Deranged Deranged occlusionocclusion

• Abnormal Abnormal mobilitymobility

• PalpationPalpation of alveolar process of alveolar process

• PercussionPercussion

• Vitality testVitality test

• Radiographic examinationRadiographic examination

Management of patientManagement of patient

• Emergency managementEmergency management

A- Airway with cervical spine controlA- Airway with cervical spine control

B- Breathing and ventilationB- Breathing and ventilation

C- Circulation and hemorrhage controlC- Circulation and hemorrhage control

D- Disability neurological states D- Disability neurological states

• Central nervous system injuryCentral nervous system injury

Classification based on tissue and siteClassification based on tissue and site

All injuries to the face may be divided into two basic All injuries to the face may be divided into two basic

groups,groups,

• Injuries to soft tissuesInjuries to soft tissues

• Injuries to bone Injuries to bone

• Rabinowitch Classification (1956)

• Fractures of the enamel

• Fractures into the dentin

• Fractures into the pulp

• Fractures of the root

• Comminuted fractures

• Displaced teeth

Ellis and Davey Classification (1960)Ellis and Davey Classification (1960)

• Class 1Class 1 - Simple fracture of the crown involving little or no - Simple fracture of the crown involving little or no

dentin.dentin.

• Class 2 Class 2 - Extensive fracture of the crown involving - Extensive fracture of the crown involving

considerable dentin, but not the dental pulp.considerable dentin, but not the dental pulp.

• Class 3Class 3 - Extensive fracture of the crown involving - Extensive fracture of the crown involving

considerable dentin and exposing the dental pulp. considerable dentin and exposing the dental pulp.

• Class 4Class 4 - The traumatized teeth that become non-vital with - The traumatized teeth that become non-vital with

or without a loss of crown structure.or without a loss of crown structure.

• Class 5Class 5 - Teeth lost as a result of trauma - Teeth lost as a result of trauma

• Class 6Class 6 - Fracture of the root with or without a loss of the - Fracture of the root with or without a loss of the

crown structure.crown structure.

• Class 7Class 7 - Displacement of a tooth without fracture of the - Displacement of a tooth without fracture of the

crown or root.crown or root.

• Class 8Class 8 - Fracture of crown en masse and its replacement. - Fracture of crown en masse and its replacement.

• Class 9Class 9 - Traumatic injuries to primary teeth. - Traumatic injuries to primary teeth.

Modification of Ellis classification by McDonald, Avery Modification of Ellis classification by McDonald, Avery

and Lynch (1983)and Lynch (1983)

• Class 1Class 1 - Simple fracture of the crown involving little or no - Simple fracture of the crown involving little or no

dentin.dentin.

• Class 2Class 2 - Extensive fracture of the crown involving - Extensive fracture of the crown involving

considerable dentin, but not the dental pulp.considerable dentin, but not the dental pulp.

• Class 3Class 3 - Extensive fracture of the - Extensive fracture of the

crown with an exposure of the dental crown with an exposure of the dental

pulp.pulp.

• Class 4Class 4 - Loss of the entire crown. - Loss of the entire crown.

WHO Classification (1992)WHO Classification (1992)

• Adapted from Adapted from WHO Geneva 1992.WHO Geneva 1992.

• Based on anatomy, therapeutic and prognostic Based on anatomy, therapeutic and prognostic

consideration.consideration.

• It is applied to both primary and permanent teeth.It is applied to both primary and permanent teeth.

• Code numbers used according to the Code numbers used according to the International International

classification of diseases 1992classification of diseases 1992

Injuries to the hard dental Injuries to the hard dental

tissues and pulptissues and pulp

Enamel infraction N Enamel infraction N

502.50:502.50: An incomplete An incomplete

fracture (crack) of the fracture (crack) of the

enamel without loss of enamel without loss of

tooth substance.tooth substance.

Injuries to the hard dental Injuries to the hard dental

tissues and pulptissues and pulp

Enamel infraction N Enamel infraction N

502.50:502.50: An incomplete An incomplete

fracture (crack) of the fracture (crack) of the

enamel without loss of enamel without loss of

tooth substance.tooth substance.

Enamel fracture Enamel fracture

(Uncomplicated (Uncomplicated

crown fracture) N crown fracture) N

502.50:502.50: A fracture A fracture

with loss of tooth with loss of tooth

substance confined to substance confined to

enamel.enamel.

Enamel - dentin fracture Enamel - dentin fracture

(Uncomplicated crown (Uncomplicated crown

fracture) N 502.51: fracture) N 502.51: A A

fracture with loss of tooth fracture with loss of tooth

substance confined to substance confined to

enamel and dentin but not enamel and dentin but not

involving pulp.involving pulp.

Complicated crown Complicated crown

fracture N 502.52fracture N 502.52

A fracture involving A fracture involving

enamel and dentin enamel and dentin

and exposing the and exposing the

pulp.pulp.

Uncomplicated crown Uncomplicated crown

root fracture N root fracture N

502.54502.54

A fracture involving A fracture involving

enamel, dentin and enamel, dentin and

cementum but not cementum but not

involving the pulp.involving the pulp.

Complicated crown Complicated crown

root fracture N root fracture N

502.54502.54

A fracture involving A fracture involving

enamel, dentin and enamel, dentin and

cementum and cementum and

exposing pulp. exposing pulp.

Root fracture N Root fracture N

502.53:502.53: A A

fracture involving fracture involving

dentin, cementum dentin, cementum

and the pulp.and the pulp.

Injuries to the periodontal Injuries to the periodontal

tissuestissues

Concussion N 503.20: Concussion N 503.20:

An injury to the tooth An injury to the tooth

supporting structures supporting structures

without abnormal without abnormal

loosening or displacement loosening or displacement

of the tooth.of the tooth.

Subluxation N 503.20Subluxation N 503.20

An injury to the tooth An injury to the tooth

supporting structures supporting structures

with abnormal with abnormal

loosening but without loosening but without

displacement of the displacement of the

tooth. tooth.

Subluxation N 503.20Subluxation N 503.20

An injury to the tooth An injury to the tooth

supporting structures supporting structures

with abnormal with abnormal

loosening but without loosening but without

displacement of the displacement of the

tooth. tooth.

Extrusive luxation Extrusive luxation

(peripheral (peripheral

dislocation, partial dislocation, partial

avulsion) N 503.20avulsion) N 503.20

Partial displacement Partial displacement

of the tooth out of its of the tooth out of its

socket. socket.

Lateral luxation N Lateral luxation N

503.20503.20

Displacement of the Displacement of the

tooth in a direction tooth in a direction

other than axially. This other than axially. This

is accompanied by is accompanied by

fracture of the alveolar fracture of the alveolar

socket.socket.

Intrusive luxation (central Intrusive luxation (central

dislocation) N 503.21:dislocation) N 503.21:

Displacement of the Displacement of the

tooth into the alveolar tooth into the alveolar

bone. This injury is bone. This injury is

accompanied by fracture accompanied by fracture

of the alveolar socket. of the alveolar socket.

Exarticulation Exarticulation

(complete avulsion) (complete avulsion)

N 503.22N 503.22

Complete Complete

displacement of the displacement of the

tooth out of its socket. tooth out of its socket.

Injuries of the supporting Injuries of the supporting

bonebone

Comminution of alveolar Comminution of alveolar

socket (mandible N socket (mandible N

502.60, maxilla N 502.60, maxilla N

502.40): 502.40): Crushing and Crushing and

compression of the alveolar compression of the alveolar

socket. intrusion and lateral socket. intrusion and lateral

luxation.luxation.

Fracture of the Fracture of the

alveolar socket wall alveolar socket wall

(mandible N 502.60, (mandible N 502.60,

Maxilla N 502.40)Maxilla N 502.40)

A fracture contained A fracture contained

to the facial or lingual to the facial or lingual

socket wall.socket wall.

Fracture of the alveolar Fracture of the alveolar

process process

(Mandible N 502.60, (Mandible N 502.60,

Maxilla N 502.40)Maxilla N 502.40)

A fracture of the alveolar A fracture of the alveolar

process which may or may process which may or may

not involve the alveolar not involve the alveolar

socket.socket.

Fracture of mandible and maxilla Fracture of mandible and maxilla

(Mandible N 502.61, Maxilla N 502.42)(Mandible N 502.61, Maxilla N 502.42)

A fracture involving the base of the A fracture involving the base of the

mandible or maxilla and often the alveolar mandible or maxilla and often the alveolar

process (jaw fracture). The fracture may or process (jaw fracture). The fracture may or

may not involve the alveolar socket. may not involve the alveolar socket.

Injuries to gingival or oral Injuries to gingival or oral

mucosamucosa

Laceration of gingival Laceration of gingival

or oral mucosa N or oral mucosa N

S01.50:S01.50: A shallow or A shallow or

deep wound in the mucosa deep wound in the mucosa

resulting from a tear and resulting from a tear and

usually produced by a usually produced by a

sharp object.sharp object.

Contusion of gingival or Contusion of gingival or

oral mucosa N S00.50oral mucosa N S00.50

A bruise usually produced A bruise usually produced

by an impact from a blunt by an impact from a blunt

object and not object and not

accompanied by a break of accompanied by a break of

the continuity in the the continuity in the

mucosa, causing sub-mucosa, causing sub-

mucosal hemorrhage.mucosal hemorrhage.

Abrasion of gingiva or Abrasion of gingiva or

oral mucosa N S00.50oral mucosa N S00.50

A superficial wound A superficial wound

produced by rubbing or produced by rubbing or

scraping of the mucosa scraping of the mucosa

leaving a raw bleeding leaving a raw bleeding

surface. surface.

BY ANDREASENBY ANDREASEN

Classification of trauma in injury of hard Classification of trauma in injury of hard tissues and pulp.tissues and pulp.

• This is based on W.H.O. classification.This is based on W.H.O. classification.

• 873.60 873.60 Incomplete fracture. Incomplete fracture.

• 873.61 873.61 Uncomplicated crown fracture. Uncomplicated crown fracture.

• 873.62 873.62 Complicated crown fracture. Complicated crown fracture.

• 873.64 873.64 Uncomplicated crown and Uncomplicated crown and root fracture.root fracture.

• 873.64 873.64 Complicated crown and Complicated crown and root fracture.root fracture.

• 873.63 873.63 Root fracture. Root fracture.Injuries to the periodontal tissues:Injuries to the periodontal tissues:• 873.66 873.66 Concussion. Concussion.• 873.66 873.66 Subluxation (loosening). Subluxation (loosening).

• 873.67 873.67 Intrusive luxation (central Intrusive luxation (central dislocation).dislocation).

• 873.67 873.67 Extrusive luxation (peripheral Extrusive luxation (peripheral dislocation, partial avulsion).dislocation, partial avulsion).

• 873.66 873.66 Lateral luxation. Lateral luxation.• 873.68 873.68 Exarticulation (Avulsed tooth). Exarticulation (Avulsed tooth).

Injuries to the supporting bone:Injuries to the supporting bone:• Mandible No. 802.20, maxilla No. Mandible No. 802.20, maxilla No.

8.2.40 – comminution of alveolar socket.8.2.40 – comminution of alveolar socket.

• Mandible No. 802.20, Maxilla No. Mandible No. 802.20, Maxilla No. 802.40 – Failure of alveolar socket wall.802.40 – Failure of alveolar socket wall.

• Mandible No. 802.20, Maxilla No. Mandible No. 802.20, Maxilla No. 802.40 – Fracture of alveolar process.802.40 – Fracture of alveolar process.

• Mandible No. 802.21, Maxilla No. Mandible No. 802.21, Maxilla No. 802.42 – Fracture of mandible / maxilla.802.42 – Fracture of mandible / maxilla.

Injuries to Gingiva/ Oral mucosa:Injuries to Gingiva/ Oral mucosa:

• 873.69 873.69 Laceration of gingiva/oral Laceration of gingiva/oral mucosa.mucosa.

• 920.X0 920.X0 Contusion of gingiva/oral Contusion of gingiva/oral mucosa.mucosa.

• 910.00 910.00 Abrasion of gingiva or oral Abrasion of gingiva or oral mucosa.mucosa.

• BASRANI CLASSIFICATIONBASRANI CLASSIFICATION• Crown fractures.Crown fractures.

– Fracture of enamel.Fracture of enamel.– Fracture of enamel and dentin.Fracture of enamel and dentin.

•Without pulp exposure.Without pulp exposure.•With pulp exposure.With pulp exposure.

• Root fractures.Root fractures.• Crown root fractures. Crown root fractures.

BY ULFOHNBY ULFOHN

• His classification is based on clinical endodontics His classification is based on clinical endodontics and does not reveal the extent of fracture or and does not reveal the extent of fracture or amount of dentin exposed.amount of dentin exposed.

• He based his classification on 3 aspects:He based his classification on 3 aspects:• Clinical state of the pulp.Clinical state of the pulp.• Pulp and dentin as one organ.Pulp and dentin as one organ.• Determination of treatment.Determination of treatment.• Crown fractures:Crown fractures:

– Of enamel.Of enamel.– With indirect pulp exposure through dentine.With indirect pulp exposure through dentine.– With direct pulp exposure.With direct pulp exposure.

ETIOLOGYETIOLOGY

• Iatrogenic injuries in new Iatrogenic injuries in new

bornborn

• Fall in infancy Fall in infancy

• Child physical abuseChild physical abuse

• Automobile / bicycle AccidentAutomobile / bicycle Accident

• Drug related /Mental Drug related /Mental

retardationretardation

• Dentinogenesis imperfectaDentinogenesis imperfecta

• Contact sportsContact sports

Management of infraction and Management of infraction and fracture of enamelfracture of enamel

• Smoothening of rough edges.Smoothening of rough edges.

• Composite resin using acid-etch Composite resin using acid-etch technique technique

Treatment of enamel and Treatment of enamel and dentine Fracturedentine Fracture• Most effective method is placement of a Most effective method is placement of a

protective material over exposed dentin to protective material over exposed dentin to allow the pulp to form a protective barrier allow the pulp to form a protective barrier e.g. Ca(OH)2 placement (Dycal).e.g. Ca(OH)2 placement (Dycal).

• The fracture site must be covered with a The fracture site must be covered with a restoration material such as acid-etch restoration material such as acid-etch composite restoration.composite restoration.

• Because of the extent of fracture and Because of the extent of fracture and because of esthetics reason – crown may be because of esthetics reason – crown may be required.required.

• Re-attachment of fractured fragments can Re-attachment of fractured fragments can also be done also be done

Treatment of fracture with Treatment of fracture with pulpal involvementpulpal involvement

• Depends on maturity of the tooth.Depends on maturity of the tooth.

Incomplete Root Formation

PULP CAPPING

PULPOTOMY

APEXIFICATION

APEXOGENESIS

Complete root formation

PULPECTOMY

ENDODONTIC TREATMENT

Treatment guideline for avulsed tooth with open apex • Avulsed Tooth Immature Pulp

• Open apex – 2 mm

No Dry Storage Time Dry Storage Time

Repositioning of avulsed tooth with complete root formation

Tooth and socket are cleaned with saline

Prepare socketReposition tooth

Splinting is done