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Self‐Study Questions
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OrOfacial Trauma
1. Can one wait and watch an extruded permanent
incisor for signs of pulpal necrosis?
2. How is pulpal necrosis managed in a root‐fractured
tooth?
3. What are important principles regarding splinting
root‐fractured teeth?
4. Will extruded teeth have normal mobility when
the splint is removed?
5. What clinical and radiographic signs indicate
successful healing of root‐fractured teeth?
Answers are located at the end of the case
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Self‐Study Answers
1. The neurovascular pulpal tissue is surely
severed at the apex when a tooth is extruded.
Immature teeth with open apices have the potential
to revascularize, so monitoring them for several
weeks is appropriate prior to beginning root canal
treatment. On the other hand, mature teeth with
closed apices are very unlikely to revascularize and
their pulps should be extirpated within three weeks
to prevent inflammatory resorption
2. The pulps of approximately three‐quarters of
root‐fractured teeth survive, but when they fail, it is
almost always in the coronal fragment. Treatment
is to complete root canal therapy on the coronal
fragment only
3.
Recent evidence indicates that flexible splints
applied for shorter periods of time than previously
Bibliography
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12.
Andreasen JO, Andreasen FM, Bakland LK, Flores MT. 1999.
Traumatic Dental Injuries – A Manual. Copenhagen:
Munksgaard. pp. 26–7.
Andreasen JO, Andreasen FM, Mejare I, Cvek M. 2004a.
Healing of 40 intra‐alveolar root fractures. 1. Effect of pre‐
injury and injury factors such as sex, age, stage of root
development, fracture type, location of fracture and severity
of dislocation. Dent Traumatol 20:192–202.
thought favor healing. Four weeks is recommended
for fractures in the middle and apical thirds. Two
to three months of splinting time is indicated for
fractures in the coronal third
Extruded teeth are splinted for two weeks. The
4.
PDL reattachment process is not complete at that
time, so normal mobility may not yet be reached.
Evidence indicates that healing is improved under
these conditions and the patient is instructed
to avoid biting on the injured teeth until normal
mobility has returned
5.
Root‐fractured teeth may heal with a hard tissue
union, with interposition of connective tissues or
with interposition of bone and connective tissues.
Radiographic signs of success indicate presence of
lamina dura and no signs of bone or root resorption
Andreasen JO, Andreasen FM, Mejare I, Cvek M. 2004b. Healing
of 40 intra‐alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type
and period and antibiotics. Dent Traumatol 20:203–211.
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
Cvek M, Andreasen JO, Borum MK. 2001. Healing of 208 intra‐
alveolar root fractures in patients aged 7–17 years. Dental
Traumatol 17:52–62.
Flores MT, Andersson L, Andreasen JO etal. 2007. Guidelines
for the management of traumatic dental injuries. I. Fractures
and luxations of permanent teeth. Dent Traumatol 23:66–71.
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Case 6
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Permanent Incisor Intrusion
OrOfacial Trauma
C.
Social History
• Patient is in seventh grade
• Child is currently in foster care due to history of
physical abuse at home
Upper‐middle class foster family
•
D. Medical History
• No significant findings, no known drug or food
allergies, no medications, vaccinations are up to date
Figure 4.6.1 Facial photograph.
A. Presenting Patient
• Twelve‐year‐, seven‐month‐old male (Figure4.6.1)
• New patient presenting for an emergency
B. Chief Complaint andHistory of
PresentInjury
•
Foster father reports, “He fell while running and
pushed his tooth up”
• Patient fell while playing dodge‐ball at home
approximately 45 minutes ago. Foster father
brought him immediately to the hospital dental
clinic. There was no loss of consciousness but
patient could not remember anything about the
injury, which was witnessed by two friends. He
said his head hurt and that he felt sick to his stomach. The dentist sent him to the emergency department (ED) immediately to be examined for closed
head injury. He returned to the dental clinic 90
minutes later with no additional medical findings or
recommendations from the ED
E. Medical Consult
• Completed in the ED
F. Dental History
• Child is patient of a local dentist who was not available to provide care
• Has received limited orthodontic treatment; has
retention wire on lingual surfaces of maxillary incisors
• Foster father reports that patient eats “everything put
in front of him.” He particularly likes chips, soda, and
fried foods
• Oral hygiene is good
• Brushes with fluoridated toothpaste
• Lives in an optimally fluoridated community and rarely
drinks bottled water
• No history of previous dental injury
G. Extraoral Exam
• No significant findings
H. Intraoral Exam
Soft Tissues
• Attached gingiva lacerated adjacent to intruded
maxillary right permanent central incisor (Figure4.6.2)
Hard Tissues
• No bone fractures
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Dental Exam Findings (Figure4.6.2)
• Maxillary right permanent lateral incisor: class I mobility
• Maxillary right permanent central incisor: intruded
approximately 10 mm, no mobility, uncomplicated
mesio-incisal crown fracture (enamel and dentin)
• Maxillary left permanent central incisor: class I
mobility, uncomplicated mesio-incisal crown fracture
(enamel and dentin)
Figure 4.6.2 Intraoral photograph showing soft tissue and
dental trauma.
FUNDAMENTAL POINT 1
Trauma History
• Rule out closed head injury and refer for medical
consult if the patient is positive for any of the
following (Centers for Disease Control and
Prevention 2017):
Amnesia
Nausea/vomiting
Headache
Lethargy/irritability/confusion
Loss of consciousness
• Conrm that tetanus immunizations are up to
date. If last tetanus booster was ve or more
years prior and wound is contaminated with soil/
debris, another tetanus toxoid booster is indicated (American Academy of Pediatrics 2011)
• Secure informed consent for treatment from a
person authorized by the court to make decisions about children in foster care. That may not
be the foster parent, so the agency should be
contacted to verify consent procedures. Specic
rules vary among states
Occlusal Evaluation ofPermanent Dentition
• Class I canines, class I molars: 4 mm overjet, 20%
overbite
Other
• Moderate plaque
• Dentition is caries‐free
I. Diagnostic Tools
• Radiographs of maxillary anterior area (Figure4.6.3):
Demonstrate mature root formation of anterior
teeth and closed apices
The maxillary right permanent central incisor is
intruded approximately 10 mm and labially luxated
with concomitant fracture of alveolar plate
The periodontal ligament (PDL) space is obliterated
on the occlusal radiographic image
• Panoramic radiograph:
Normal development
No fractures or displacements of skeletal tissues
• Percussion tests
Maxillary right permanent lateral incisor: positive
Maxillary right permanent central incisor: negative,
high metallic sound
Maxillary left permanent central incisor: positive
Maxillary left permanent lateral incisor: negative
• Vitality tests:
Deferred because results are not reliable at the time
of injury
A
Figure 4.6.3 (A, B) Radiographs showing dental trauma.
B
J. Diagnosis
• Maxillary right permanent central incisor: intrusion/
lateral luxation and uncomplicated mesio-incisal
crown fracture
• Maxillary left permanent central incisor: uncomplicated mesio-incisal crown fracture
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FUNDAMENTAL POINT 2
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Complications withIntrusion Injuries
• False‐negative response to vitality tests possible
for up to three months
• Intruded teeth yield a high‐pitched, metallic
sound upon percussion and demonstrate loss of
PDL space, radiographically
• Healing complications (pulp necrosis, root
resorption, and marginal bone loss) occur more
frequently in teeth with completed root development than in immature teeth
• Associated crown fractures with exposed dentin
increase the risk for pulp necrosis in intruded
teeth (Andreasen etal. 2006)
K. Treatment
• See Flowchart A: Intrusion Injuries at the end of this
chapter
• Maxillary right permanent central incisor: surgically
reposition as soon as possible and splint with 40 lb
monofilament fishing line or light orthodontic wire for
three to four weeks
• Maxillary left permanent central incisor: apply glass
ionomer or composite resin temporary restoration on
fracture to cover exposed dentin (Figure4.6.4)
A
OrOfacial Trauma
Discharge Instructions
• Advise acetaminophen or ibuprofen for pain as
needed
• Chlorhexidine mouth rinse for duration of splint
• Soft diet and avoid incising on injured tooth until
tenderness resolves
• Maintain good oral hygiene by gentle toothbrushing
after meals
Follow‐Up Treatment
• Maxillary right permanent central incisor: complete
pulpectomy within three weeks of injury. Fill canal
with Ca(OH)
for two to four weeks. Because this
2
tooth is likely to ankylose and undergo replacement
resorption, do not place gutta‐percha unless healing is
indicated by presence of lamina dura and no signs of
resorption. Remove splint after four weeks and
complete final composite restoration
• Maxillary left permanent central incisor: complete
final composite restoration after splint is removed
FUNDAMENTAL POINT 3
Intrusion Injuries
• Teeth intruded 6 mm or less can be repositioned
with light orthodontic forces. This may improve
the chance of optimal healing
• Immature teeth with open apices and intruded
6 mm or less can be allowed to reposition
spontaneously. Rapidly reposition orthodontically
if no movement is noted within three weeks
• Systemic antibiotic administration does not
improve healing in intrusion injuries
(Andreasen etal. 2006)
B
Figure 4.6.4 (A, B) Intraoral photographs showing repositioning
of intrusion and splint.
L. Prognosis andDiscussion
• Maxillary right permanent central incisor: the short‐
term prognosis for this tooth is favorable because the
tooth was repositioned quickly and the pulp was
extirpated before it could become necrotic and
initiate inflammatory resorption. The root is also
mature, having achieved complete root length and
substantial root wall thickening. The long‐term
prognosis for tooth retention is guarded due to the
severity of the intrusion injury which surely caused
severe damage to the PDL. Intruded permanent
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teeth are at high risk for pulp necrosis, marginal bone
loss, and inflammatory and replacement root resorption, particularly when intruded greater than 7 mm.
This tooth is at great risk for ankylosis and replacement resorption, which would become clinically and
radiographically apparent within two to three months.
Clinical signs included loss of physiologic mobility,
high‐pitched, metallic sound on percussion, and
relative infraocclusion as the child’s maxilla grows.
Radiographic signs include loss of PDL space and
bony infringement
• Maxillary left permanent central incisor: the long‐term
prognosis appears good because the tooth did not
appear to be luxated but it should be closely monitored clinically and radiographically for at least one
year and perhaps longer due to the injury of the right
central incisor
M. Complications andAlternative
TreatmentPlans
• The most damaging complication would be ankylosis
and replacement resorption of the intruded right
central incisor. Because the patient is only 12 years
old, significant future maxillary growth is anticipated.
This tooth will then begin to infraocclude, causing
periodontal defects and an esthetic dilemma.
Extracting the tooth at this age would result in
substantial loss of alveolar bone support in that area,
necessitating bone grafting prior to implant placement
or restoration with a fixed prosthesis. A better alternative would be to surgically remove the crown below
the level of the alveolar bone (decoronation) to
maintain alveolar bone height and breadth in advance
of the final restoration after maxillary growth is
completed
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Self‐Study Questions
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OrOfacial Trauma
1. What are the most common complications of an
intrusion injury?
2. How do you assess the neurologic status of an
injured patient?
3. How does the management of an intruded immature (open apex) permanent tooth differ from that of
a mature tooth?
4. In children in the early stages of the mixed denti-
tion, it is sometimes hard to know if an incisor was
intruded or if it had just not erupted completely.
What clinical tests improve the diagnosis of an
intrusion injury?
5. What clinical and radiographic signs indicate suc-
cessful treatment of intrusion injuries?
Answers are located at the end of the case
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Self‐Study Answers
1. Intrusions are serious injuries with a relatively
poor prognosis because of the crushing of the PDL
fibers, pulp tissue, and supporting bone. Ankylosis with resulting replacement root resorption is
common, as is pulp necrosis and inflammatory root
resorption
2. Serious closed head injury may accompany
significant dental injuries in children. Symptoms
of concussion include confusion, disorientation,
memory loss, headache, nausea, and emotional
liability. Medical consultation to rule out serious
head injury is indicated immediately if the child is
positive for any of these findings
3. Recent evidence indicates that immature teeth
may reposition themselves spontaneously so
Bibliography and Additional Reading
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12.
Andreasen J, Bakland LK, Andreasen FM. 2006. Traumatic intru-
sion of permanent teeth. Part 2. A clinical study of the effect
of preinjury and injury factors, such as sex, age, stage of root
development, tooth location, and extent of injury including
number of intruded teeth on 140 intruded permanent teeth.
Dent Traumatol 22:90–8.
they can be monitored for several weeks. If no
movement occurs, repositioning with orthodontic
forces should be initiated. Some clinicians recommend mildly luxating the tooth prior to applying the
orthodontic force
4. Intruded teeth are displaced forcefully into the
alveolar bone and will be completely immobile. A
percussion test will yield a high‐pitched hollow or
metallic sound. The PDL space will not be visible on
radiographic exam
5. The tooth is in normal position and responds nor-
mally to mobility and percussion tests. Radiographically, no replacement or inflammatory root resorption is occurring and intact lamina dura is evidenced
around the root
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
McTigue D, Thikkurissy S. 2018. Trauma. In: The Handbook of
Pediatric Dentistry, 5th edition. Nowak AJ, Casamassimo
PS (eds). Chicago: American Academy of Pediatric Dentistry.
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Case 7
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Permanent Tooth Avulsion
OrOfacial Trauma
C. Social History
• Patient is in sixth grade
• Lives at home with parents and younger sister
• Middle class family
D. Medical History
• Review of medical history reveals no significant
findings, no known drug or food allergies, no medications, vaccinations are up to date
Figure 4.7.1 Facial photograph.
A. Presenting Patient
• Eleven‐year‐, five‐month‐old Hispanic male
(Figure4.7.1)
• Presenting as an emergency
B. Chief Complaint andHistory ofPresent Injury
• Father reports, “My son took an elbow playing
basketball and knocked out a tooth”
• Injury occurred at school approximately 60 minutes
ago and was witnessed by coach and teammates.
There was no loss of consciousness or other injuries.
The maxillary right permanent central incisor fell on
the basketball court floor. The tooth was placed first in
a cup with the patient’s saliva and was transferred to
a carton of milk within 10 minutes. The coach called
the father at work, who then transported the patient
to his dentist’s office. Bleeding from the socket and
lips was easily controlled with gauze pressure
E. Medical Consult
• Not applicable
F. Dental History
• Routine recall exams every six months since age 4
inthe same dental office
• Good oral hygiene and dietary habits
• Uses toothpaste containing fluoride
• Optimal water fluoridation
• No history of trauma before today
G. Extraoral Exam
• No bony fractures
• Upper and lower lip lacerations and contusions
• Competent lips
H. Intraoral Exam
Soft Tissues
• Minor lacerations of the upper lip
Hard Tissues
• Caries‐free dentition
• Traumatized teeth (Figure4.7.2)
Maxillary right permanent central incisor: avulsed,
mesioangular fracture of enamel and dentin
• Maxillary left permanent central incisor: mesioangular
fracture of enamel and dentin
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A
B
Figure 4.7.2 (A, B) Intraoral photographs showing avulsion and
dental fracture.
Occlusal Evaluation ofEarly Permanent
Dentition
• Canines and molars in class II, lower anterior crowd-
ing: overjet, 3 mm; overbite, 95%
I. Diagnostic Tools
• Radiograph deferred until tooth replanted to minimize
extraoral time
• Percussion tests
Maxillary right permanent lateral incisor:
negative
Maxillary left permanent lateral incisor: negative
• Vitality tests
Deferred
J. Diagnosis
Maxillary right permanent central incisor: avulsion and
mesioangular fracture of enamel and dentin
Maxillary left permanent central incisor:
•
subluxationand mesioangular fracture of enamel
anddentin
• Lip lacerations
• Malocclusion
FUNDAMENTAL POINT 1
Replantation andHistory ofDental
Avulsion
• Immediate replantation is the best treatment for
an avulsed tooth
The person answering the phone at the doctor’s
office should advise responsible person with the
injured child to replant the tooth immediately if
appropriate
• Management of avulsed permanent teeth at
injurysite:
Hold tooth by the crown, rinse gently for no
more than 10 seconds under cold, running
water, do not scrub root surface
Immediately replant tooth at site of injury, if
possible. After replantation, bite on gauze or a
clean towel to avoid tooth aspiration. If
replantation is not possible, place tooth in
Hank’s Balanced Salt Solution (HBSS),
coldmilk, saline, or saliva–in that order of
preference–to maximize vitality of the root
surfacecells
• When patient with avulsed tooth arrives, ask parents:
1. How did the accident occur? Rule out closed head
injury and refer for medical consult if the patient is
positive for any of the following (Centers for Disease
Control and Prevention 2017):
Amnesia
Nausea/vomiting
Headache
Lethargy/irritability/confusion
Loss of consciousness
2. Where did the accident occur? Confirm that
tetanus immunizations are up to date. If last
tetanus booster was five or more years prior
and wound is contaminated with soil/debris,
another tetanus toxoid booster is indicated
(American Academy of Pediatrics 2011)
3. When did the accident occur?
Extraoral dry time determines prognosis of
replanted tooth
Dry time greater than 60 minutes increases
risk of ankylosis and replacement resorption
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