Traumatic Injuries

to the Anterior Teeth

Presented by:
Dr. Navroop Kaur
MDS (Pedodontics)

Introduction

Traumatic episodes, depending on the energy of the impact,

can result in injuries which may range in severity from
enamel fractures to complex dental injuries involving the
pulp and the periodontium. The extent of injury is influenced
by the severity of the traumatic event, direction of force
against the teeth and supporting structures and the type of
impactblunt or sharp. The injury may remain limited to the
dental tissues or may involve the supporting structures
including the periodontal ligament and the alveolar bone.
Majority of dental injuries occur unexpectedly during daily life
activities and mostly involve the anterior teeth, thus affecting
their function.

Incidence- In the deciduous dentition, there

are 5% new cases of dental trauma every year.
There is an increase in incidence of traumatic
injuries from 1 year of age with a peak of 10%
at 3 years of age because by 1 year of age
most of the children learn to walk and by the
age of three they can indulge in riding a bicycle/
tricycle making them prone to falls and injuries.

Etiology- Traumatic injuries

Motor incontrol- especially at 2-3 years of age leads to

falls and collisions and hence increased incidence of
dental trauma.

Medical ailments- like isolated convulsions and

epilepsy also predispose a child to traumatic injuries
especially complicated crown fractures.

Contact sports- injuries due to contact sports are

generally seen in older age group when children start
to indulge in outdoor sports activities.

 Automobile accidents- injuries due to road

side accidents may be seen in children of
any age group but most common in teenage
children and especially in boys.
Fights- commonly leads to complex oromaxillofacial injuries along with associated
dental trauma which may be luxation injuries
or crown fractures.

Risk factors- 1. Anteroposterior molar relation- Studies

have reported that increased prevalence of dental trauma
is seen in children with Angles Class II div I malocclusion
and also in children with an Angles Class I molar relation.
2. Lip incompetency- Lips form a natural barrier against
trauma to the teeth. Reduction of cushioning effect in the
presence of incompetent lips predisposes to dental
trauma.
3. Incisal overjet- Children with greater than 5 mm overjet
are considered to be 1.5 times more susceptible than
children with an overjet of less than 5 mm. The incidence
increases to twofold when the overjet is greater than 9
mm.

Traumatic Injuries to the Teeth

Classification of traumatic injuries to anterior teeth- Ellis and Davey (1970)

Cl-1- Simple fracture of crown involving only enamel with little or no dentin.
Cl-2- Extensive fracture of crown involving considerable dentin but not exposing
dental pulp.
Cl-3- Extensive fracture of crown involving considerable dentin and exposing
pulp.
Cl-4- Traumatized tooth which becomes non- vital with/ without loss of crown
structure.
Cl-5- Tooth loss- avulsion.
Cl-6- Root fracture with/ without loss of crown structure.
Cl-7- Displacement of tooth without fracture of crown or root.
Cl-8- Fracture of crown en masse and its displacement.
Cl-9- Traumatic injuries of primary teeth

Traumatic Injuries to the Teeth

Clinical examination Medical history- Assess the need for SBE
prophylaxis. Determine if the child has a
bleeding disorder, or is immune compromised.
Record any current medications. Question the
parent about allergies to medications.
Determine if the childs tetanus immunization
is up-to-date. Determine if the child lost
consciousness due to the injury.

Dental and trauma history- The clinician should determine how,

when and where the injury occurred.
How is important because it provides information on the
severity of the injury. When is important, because the
prognosis for the injured tooth worsens with every minute of
delay in treatment. Where is important, because it may

Intra oral examination- Each tooth should be

examined for damage or mobility.
The labial mucosa, maxillary frenum, gingival
tissues, and tongue should be examined for
bruising or lacerations.
Radiographic examination
Photographic documentation
Vitality testing- Recently traumatized teeth fail to

Ellis class 1 fracture

Ellis class 1 fractures can be of two types1. Crown infractions- Infraction lines are
visualized easily with trans- illumination and
their presence indicates a significant force,
hence the status of the pulpal and supporting
periodontal structures should be evaluated.
Treatment- Sealing the infraction line with an
unfilled resin following an acid etch technique
may prevent stains from becoming an esthetic
problem.

RECONTOURING FOR ELLIS CLASS I FRACTUR

2. Enamel fractures- Managementa. Recontouring- Recontouring of the

injured or adjacent opposing tooth may
be done. Recontouring eliminates the
sharp enamel edges associated with
minor injuries and prevents laceration of

Ellis class 2 fractures

The tooth should be examined for minor pulp

exposures. Vitality testing should be done immediately
and regularly at periodic recall visits for a minimum
time period of six months and symptoms like thermal
sensitivity and pain on mastication should be noted.

Intra oral peri apical radiograph of the tooth should

reveal an intact periodontal ligament space and solid
cortical bone associated with the tooth.

Clinical management

1. Indirect pulp capping and composite

resin build up- If the thickness of remaining
dentin is within 0.5 mm of the dental pulp,
application of hard setting calcium hydroxide
cement as a liner over the exposed dentinal
tubules and restoration with a composite
resin is done.
2. Reattachment of the fractured segment

ELLIS CLASS II FRACTURE

BEVEL MARGIN
BEFORE
COMPOSITE
RESTORATION

APPLICATION OF CALCIUM HYDROXIDE

FOLLOWED BY ACID ETCHING AND
COMPOSITE RESTORATION

Reattachment procedure

ELLIS CLASS 3 FRACTURES

Ellis class 3 fractures are defined as crown fractures

involving enamel, dentin and pulp.
Radiographic evaluation and sensitivity testing is mandatory
Sensitivity testing is usually not indicated initially since
vitality of the pulp can be visualized clinically.
Clinical managementA. Teeth with immature root apices and vital pulpal
exposures require:
1. Pulp capping- Capping of the pulp is to be done only for
small exposures that can be treated immediately after the
injury.

2. Partial pulpotomy or
3. Pulpotomy depending on the individual caseStudies indicate that it may be safe to proceed with
shallow pulpotomies up to 1 week post fracture.
After that, it is questionable in mature, fully formed
teeth. Although in young, developing teeth with
wide-open apices, pulpotomy can be tried even
when the tooth has been exposed for more than a
week.

TREATMENT PLAN FOR ELLIS CLASS3 FRACTURES

B. Fractured crown with mature apex- In

case of teeth with closed apex, vital pulp
procedures are performed according to
individual case. If on follow up, signs of failure
of therapy are seen, for instance, periapical
radiolucency, pain or tenderness on percussion
is seen, extirpation of pulp and conventional
endodontic treatment are carried out.

ELLIS CLASS 3 FRACTURE MANAGEMENT

REMOVAL OF CORONAL PULP

APPLICATION OF
CALCUM
HYDROXIDE
PULPOTOMY
PROCEDURE

ELLIS CLASS 4 FRACTURES

In Ellis class 4 fracture, the tooth becomes non vital

with/ without loss of tooth structure.
Management of Ellis class 4 fracture- depends on
the status of root completion of the tooth.
In case of a tooth with an incomplete/ open apex
and a non vital pulp, the process of apexification is
used to induce the completion of the root apex.
In case of a tooth with mature apex and a necrotic
pulp the line of treatment is pulpectomy and
obturation of the canal.

TREAMENT PLAN FOR ELLIS CLASS 4 FRACTURES

A. In case of a tooth with an incomplete/ open

apex and a non vital pulp: Two treatment options
can be considered in such cases.
1. Apexification procedure is used to induce apex
completion- can be done in one ormultiple visits
depending on the material used.
Materials for apexification1. calcium hydroxide
2. MTA

Discolored non vital tooth- access opening, working

length measurement and CA(OH)2 placement
APEXIFICATION PROCEDURE

2. Revascularization of the pulp- IndicationsPulp revascularization is indicated as a

procedure in cases with immature permanent
teeth where disinfection of the canal can be
achieved.
The necrotic infected pulp may act as a scaffold
for the in growth of new tissue from the
periapical area. This process is called pulp

B. In case of a tooth with mature apex and a

necrotic pulp: pulpectomy followed by
obturation of the root canal is the recommended
treatment.
Reattachment of the fragment- Reattachment
of the fragment is carried out in a similar way as
for an uncomplicated fracture except that an
internal groove is made in the dentin of the
fractured fragment for the coronal part of the

Management of crown discoloration- In cases

where crown discoloration occurs due to seepage
of necrotic pulp remnants into the dentinal
tubules1. Non vital bleaching- thermocatalytic technique
light bleach
walking bleach.
2. Veneers
3. Acrylic crowns

ELLIS CLASS 5 FRACTURES

Dental avulsion occurs when a tooth is
completely displaced or knocked out of the

Incidence
dental
socket.
0.5% to 16% of
traumatic injuries

Main etiologic
factors

Fights
Sports injuries
Automobile
accidents

Avulsed Permanent Teeth

Maxillary central incisor

Most commonly avulsed tooth

Mandibular teeth
Seldom affected

Most frequently involves a

single tooth
Most common age - 7 to 11
Permanent incisors erupting
Loosely structured PDL

Avulsed Permanent Teeth

Associated injuries
Fracture of alveolar
socket wall
Injuries to the lips
and gingiva

Periodontal Ligament
Responses

Surface Resorption
Replacement Resorption (Ankylosis)
Inflammatory Resorption

Periodontal Ligament
Responses

Surface resorption
Superficial resorption
cavities
Mainly in cementum
Complete repair of
PDL

Periodontal Ligament
Responses

Replacement
resorption
(Ankylosis)
Direct union of bone
and root
Resorption of root Replacement with
bone
Direct result of loss of
vital PDL

Periodontal Ligament
Responses

Inflammatory resorption
Resorption of cementum
and dentin
Inflammatory reaction in the
periodontal ligament

TYPES OF HARD TISSUE BARRIERS FORMED

The hard tissue barrier has been described by Ghose
et al as
1) A cap,
2) Bridge or
3) Ingrown wedge
AND MAY BE COMPOSED OF
Cementum,
Dentin,
Bone
or
Osteodentin.

Treatment Considerations

Extraoral time- Shorter time = Better

prognosis*
< 30 min 10% resorption
> 90 min 90% resorption

Extra oral environment

Root surface manipulation
Management of the socket
Stabilization

Recommended Storage Media- physiological

storage media are recommended which
maintain the environment conducive to vitality
of PDL cells
1. Socket (immediate
replantation)
2. Cell culture
medium
3. Milk
4. Physiologic saline
5. Saliva
6. Tap water

Milk As A Storage Medium

Physiologic osmolality
Markedly fewer bacteria than saliva
Readily available
Storage for 2 hrs
Periodontal healing almost as good as
immediate replantation

Storage for 6 hrs

Saliva extensive replacement resorption
Milk healing almost as good as immediate
replant

Hanks Balanced Salt Solutionideal storage medium

Proper pH and osmolality

Reconstitutes depleted cellular metabolites
Washes toxic breakdown products from the
root surface

EMERGENCY TREATMENT AT THE TIME

AND SITE OF INJURY
1. Replant the tooth as soon as possible after
the avulsion.
2. If it is not possible to reinsert the tooth, place
it in a suitable transport medium.

EMERGENCY TREATMENT AT THE DENTAL

OFFICE
1. Place the tooth in normal saline. Take
relevant history, examine the area and
take radiographs as thoroughly and as quickly
as possible.
2. Any gross debris should be wiped away
gently from the root surface with a wet sponge.

Replantation guidelines

For a mature tooth with a closed apex:

1. If the tooth has already been replanted - Clean
affected area with water spray, saline or chlorhexidine.
2. If the extraoral dry time is <60 minutes and the
tooth has been kept in suitable transport medium Clean the contaminated root surface and apical foramen
with a stream of saline. Remove the coagulum from the
socket with a stream of saline. Examine the alveolar
socket. If there is a fracture in the socket wall, reposition
it. Replant the tooth slowly with slight digital pressure.

Root Surface Manipulation

Extraoral dry time > 1 hr

Loss of PDL cell viability inevitable
Treatment recommendations
Remove tissue tags
Soak in accepted dental
fluoride solution for 20 min

1.0-2.4% topical fluoride

solution
Sodium fluoride

(Andreasen)

Stannous fluoride (Krasner)- Fluoride is used because fluoroapatite

formed is more resistant to resorption.

MANAGEMENT OF A TOOTH WITH A NON VITAL PERIODONTAL LIGAMENT

curettage of
PDLremnants
followed by
extraoral root ca
treatment,
replantation and
splinting

MATERIALS USED TO PREVENT FAILURE

OF REIMPLANTED TOOTH1. Emdogain- Emdogain consists of
hydrophobic enamel matrix proteins extracted
from porcine developing embryonic enamel. It
can be used for treating avulsed teeth prior to
replantation to prevent or delay replacement
root resorption by regenerating a healthy
periodontium because of its ability to produce

For an immature tooth with an open apex:

A. If the tooth has already been replantedClean affected area with water spray, saline or
chlorhexidine rinse.
B. The tooth has been kept in special
storage media, milk, saline or saliva. The
extra-oral dry time is <60 minutesIf contaminated, the root surface and apical

MANAGEMENT OF A TOOTH WITH INCOMPLETE APEX FORMAT

INTRA CANAL CALCIUM HYDROXIDE DRESSING- APEXIFICAT

For cases with extra oral time of 20 to 60

minutesIntracanal placement of Ledermix paste has
been shown to produce promising results in
such cases. Ledermix paste consists of
triamcinolone (steroid) and demeclocycline
(tetracycline).

Management of the Socket

Remove contaminated coagulum in

socket
Irrigate with sterile saline

Management of the Socket

Examine socket If fracture is evident

Reposition fractured bone with a blunt
instrument

Management of the Socket

Replant using light digital pressure

Stabilization

Splint
Definition a rigid or flexible device used to
support, protect, or immobilize teeth, preventing
further injury for 7 to 10 days.
Types
Acid etch composite
Cross-suture
Titanium trauma splint
Acid etch wire composite splint
Ribbond

Acid Etch Composite Splints

Interproximal composite

Acid Etch Composite Splints

Composite with arch wire

Acid Etch Composite Splints

Composite with monofilament nylon

Cross-Suture Splint
Indications
No adjacent teeth to splint to
Unmanageable traumatized children

Titanium trauma
splint

Splinting with
Ribbond

Pulpal Prognosis

Stage of root development- as the maturity

increases, the chances of revascularization
decreases.
Dry storage time- if more, decreases chances
of pulp survival
Storage media- physiological media favor
pulp survival
Antibiotics-topical antibiotics have a beneficial
effect

Endodontic Rationale Mature

Root

Pulpectomy 7-14 days

Endodontic Rationale Mature

Root

Calcium hydroxide
placement
Antibacterial
Increases pH in dentin
Favors mineralization over resorption
Ca(OH)2 therapy for as long as practical,
usually 6-12 months to stop external
resorption.

Treatment Flowchart
Extraoral Dry Time
< 1 hr

Closed
Pulpecto
my7-14
days

> 1 hr

Apex Maturity

Open
Observ
e

Open or Closed
Pulpecto
my 7-14
days
Option:
Extraoral
RCT

Additional Considerations
Analgesics- Paracetamol or NSAID based
analgesics are generally prescribed like
paracetamol and codeine combination or
ibuprofen.
Chlorhexidine mouthwash (0.12%) to
maintain oral hygiene
Tetanus- History of prophylaxis should be
taken and toxoid injection advised if
required.
Antibiotics- Penicillin
500 mg qid for 4-7 days

In case the avulsed tooth cannot be locatedThere are two treatment options:
1. A provisional removable partial denture.
2. AutotransplantationAutotransplantation is defined as the extraction
of a tooth from one location and its replantation
in a different location in the same individual.

AUTOTRANSPLANTATION
OF SECOND
PREMOLAR IN PLACE
OF MAXILAARY
CENTRAL INCISOR
FOLLOWED BY
CONTOURING AND
FULL COVERAGE
ALL CERAMIC
CROWN PLACEMENT

ELLIS CLASS 6 FRACTURES

Root fractures can be in two planes1. Horizontal plane.
2. Vertical plane.
Horizontal fractures are further classified
depending on the level of fracture
Apical 1/3rd fracture: zone I
Middle 1/3rd fracture: zone II
Cervical 1/3rd fracture: zone III

1. Root fractures are often not apparent during

a clinical examination and can usually be
diagnosed using appropriate radiographs.
2. Clinical features when present are mobility of
the coronal fragment. The level of fracture can
be discerned by arc of mobility of the mobile
fragment. The greater the arc, the coronal is the
level of fracture.

Treatment of horizontal fracturesThe definitive treatment of a horizontal root

fracture is the immediate reduction of the
fractured segments and complete immobilization
of the coronal segment. If more than 24-72 hours
have elapsed, close apposition of the segments is
generally impossible.

MANAGEMENT OF ELLIS CLASS 6 FRACTURE BY SP

3. Endodontic treatment- Healing is monitored

for at least 1 year to determine pulpal status. If
pulp necrosis develops, root canal treatment of
the coronal tooth segment to the fracture line is
indicated to preserve the tooth. Endodontic
treatment of both or the coronal fragment may
be carried out.
In case of coronal third fractures where the

ACCESS OPENING FOLLOWED BY INTRA CANAL

CALCIUM HYDROXIDE DRESSING TILL THE
FRACTURE LINE AND THEN FINALLY OBTURATION
WITH GUTTA PERCHA

Vertical fractures- The fracture runs lengthwise

from the crown towards the apex.
Clinical recognition- 1. Persistent dull pain of long
standing origin.
2. Pain is elicited by applying pressure.
3. A chronically non healing pocket that is not

Treatment- In general, prognosis for single

rooted teeth is poor and extraction is generally
the suggested treatment. However innovative
methods like bonding the fragments using a
biocompatible material have also been
reported.

ELLIS CLASS 7 FRACTURES

This class of fractures includes:
1. Concussion- Injury to tooth supporting structures
without abnormal loosening or displacement of tooth.
2. Subluxation- Injury to tooth supporting structures
with abnormal loosening but without displacement of
tooth.

SUBLUXATION AND DENTAL CONCUSSION

These injuries represent minor injuries to the
periodontal ligament and pulp caused by an
acute impact.
Radiographically, there are no pathological
changes in the supporting tissues.
Treatment consists of:
- Occlusal relief (e.g. by selective grinding of

CONCUSSION AND SUBLUXATION

CLINICAL AND RADIOGRAPHIC PICTURE

MANAGEMENT- REMOVAL OF OCCLUSAL INTERFERENCE

FOR CONCUSSION AND SPLINTING FOR SUBLUXATION

EXTRUSIVE LUXATION
An extrusion occurs when a tooth is only
partially removed from the socket.
Clinical recognition- 1. The tooth appears
elongated and is excessively mobile.
2. Sensitivity tests will likely give negative
results.

3. Orthodontic intrusion may also be carried out by

fixed appliance therapy.
4. Endodontic treatment is certain in cases of
significant extrusion (more than 2 mm) of mature
teeth. In such cases, pulpectomy should be
performed and root canal space obturated with gutta
percha.
5. Crown discoloration in such cases may be treated
with non vital bleaching methods, veneers or full

MANAGEMENT OF EXTRUSION BY MANUAL REPOSITIONING

AND SUTURING TO SECURE THE TOOTH

INTRUSION
An intrusion injury is the most severe type of
luxation injury. The intruded tooth is impacted
into the alveolar bone, and the alveolar socket
is fractured.
Clinical recognition1. In many cases, the tooth may not be visible.
2. The tooth is displaced axially into the alveolar

Clinical management- Management strategies:

1. surgical reduction (immediate repositioning),
2. repositioning with traction (active repositioning),
3.Incisors
waiting
for theless
tooth
return
pre-injury
intruded
thanto
3mm
may to
be its
allowed
to reposition
themselves.
position
(passive repositioning).

Prognosis of incisors intruded between 3 6 mm is unpredictable,

but they may be orthodontically extruded within 3-6 weeks.
Incisors that have been intruded beyond 6 mm should be
immediately repositioned (surgically) to their normal
followed by root canal treatment.

MANAGEMENT OF
INTRUSION

SPONTANEOUS ERUPTION

ORTHODONTIC
EXTRUSION

LATERAL LUXATION
In lateral luaxation, a horizontal impact forces
the crown palatally and the apex labially.
Clinical recognition- 1. The tooth is displaced,
usually in a palatal/lingual or labial direction.
2. It will be immobile and percussion usually
gives a high, metallic (ankylotic) sound.

Clinical management1. An anti-inflammatory agent, an analgesic and an

antibiotic are prescribed.
2. Repositioning after local anesthesia, and applying a
semi-rigid splint for 4 weeks. A post-treatment
radiograph should be performed to assure proper
position of the tooth in the socket.

ELLIS CLASS 8 FRACTURES

It is the fracture of the crown enmasse and its
displacement.
Clinical examination- 1. Hemorrhage or
swelling are seen in the related area.
2. Pulpal exposure will be observed in the
affected tooth.
3. Vitality of the tooth should be checked by an
electrical pulp tester.

Clinical management1. ReattachmentFractured fragment is removed and kept in

saline.
Obturation of the canal carried out followed by
post space preparation.
Fiber reinforced post is cemented into the
canal.
The fractured fragment is cemented to the

MANAGEMENT OF ELLIS CLASS 8 FRACTURE BY SUR

EXTRUSION AND POST AND CORE BUILD UP FOLLOW
FULL COVERAGE CROWN

MANAGEMENT BY ORTHODONTIC
EXTRUSION

ELLIS CLASS 9 FRACTURES

Ellis class 9 fractures include all the injuries to
the primary teeth and the supporting tissues.
Trauma to the primary dentition presents
special problems and the management is often
difficult and different as compared to the
permanent dentition. As much as 18% of all the
injuries are seen in the oral region in children,

In the primary dentition, small coronal

fractures may be observed in primary teeth
but luxations are more common. This is
because of the pliability of the facial skeleton
and of the periodontal ligament, the large
volume of teeth in relation to the bone in
primary and mixed dentition period and
finally, the shorter roots of primary teeth.

Sequelae for permanent dentition after traumatic

injuries to primary dentition1. Hypoplastic defects- may range from white opacities to brown
spots or pits on the labial surface.
2. Turners hypoplaisa is another example marked by discoloration of
teeth or structural alteration in the crown.
3. Structural alterations associated with enamel hypoplasia, crown
dilaceration and white, yellow or brown discoloration.
4. Root duplication, root dilaceration and partial or complete arrest of
root formation.
5. Alterations to the process of eruption of the permanent tooth, or
malformation of the permanent tooth germ.

Sequelae to injury to permanent teeth due to trauma to primary teeth

Clinical examination- A detailed history about

the accident causing the trauma and the time
elapsed since the accident are important
components to be evaluated. Thorough extra
oral and intra oral examination must be carried
out to discern any associated injuries.

1. Uncomplicated crown fracture- Fracture

involves enamel or dentin and
enamel; the pulp is not exposed.
Radiographic findings- An intra oral periapical
view will show the relation between the fracture line
and the pulp chamber.
Treatment -1. Smoothen sharp edges if possible the
tooth can be restored with glass ionomer cement or
resin composite.

2. Complicated crown fracture- Fracture involves enamel

and dentin and the pulp is exposed.
Radiographic examination- A periapical view is used to
discern the extent of fracture and the stage of root
development.
Treatment- In very young children with immature, still
developing roots, it is advantageous to preserve pulp vitality
by pulp capping or partial pulpotomy. Calcium hydroxide is

MANAGEMENT OF A CROWN ROOT FRACTURE BY

EITHER EXTRACTION OR
ROOT CANAL TREATMENT IF THE PROGNOSIS IS
FAVORABLE

3. Crown root fracture- Fracture involves enamel, dentin and

root structure; the pulp may or may not be exposed. Additional
findings may be loose but still attached fragments of the tooth.
There is minimal to moderate tooth displacement.
Radiographic examination- In laterally positioned i.e. oblique
fractures, the extent of the fracture line in relation to the
gingival margins can be seen.
Treatment- Extraction is the only recommended treatment

4. Root fracture- The coronal fragment is generally

mobile and may be displaced.
Radiographic examination- Generally, the fracture is
located in the middle or the apical third.
Treatment- Root fractures in primary teeth,
particularly those occurring in the apical third of the

4. Alveolar fracture- The fracture involves the alveolar

bone supporting the primary teeth and permanent tooth
germs.
The tooth containing segment is mobile and usually
displaced.
Occlusal interference is usually noted.
Radiographic examination- The fracture line close to
the apices of the primary teeth and their permanent
successors will be disclosed. A lateral radiograph may

LUXATION INJURIES IN THE PRIMARY

DENTITION
1. Concussion- The tooth is tender to touch; it
has no increased mobility or sulcular bleeding.
Radiographic examination- No radiographic
abnormalities are visible. The periodontal space
is normal in width.
Treatment- No treatment is needed except

2. Subluxation- The tooth has increased mobility but

has not been displaced.
Radiographic examination- No radiographic
abnormalities are visible. The periodontal space is
normal in width.
Treatment- Monitoring of afflicted teeth should be

Extrusive Luxation- The tooth appears elongated

and is excessively mobile.
Radiographic examination- Increased periodontal
ligament space apically.
Treatment- Treatment depends upon the degree of

Lateral luxation- The tooth is displaced usually in a

palatal/ lingual direction. It will often be immobile .
Radiographic examination- Increased periodontal
ligament space apically is best seen on an occlusal
view.
Treatment- If there is no occlusal interference as is

Intrusive luxation- The tooth is usually

displaced through the labial bone plate or can
impinge upon the succedaneous tooth bud.
Clinical examination- Clinically, the tooth may
disappear completely into the surrounding

It is extremely important to determine after the injury whether

the primary tooth is in contact with the permanent tooth germ
or has been pushed away in the labial direction.
Several clinical and radiographic signs support the diagnosis
of labial alignment of the root:
1. Palatal inclination of the crown.
2. Hemorrhage and hard swelling palpated in the vestibule
due to fracture of the labial cortical plate by the root of the
primary incisor.
3. A shortened and more opaque image of the primary incisor
as compared to an adjacent non intruded tooth.
4. Proper alignment of the permanent successor as seen on a
periapical radiograph.

Radiographic examination- When the apex is

displaced toward or through the labial bone plate,
the apex can be visualized and appears shorter
than the contra lateral tooth.
When the apex is displaced towards the permanent
tooth germ, the apex cannot be visualized and the
root appears elongated.
Treatment- If the apex is displaced toward or
through the labial bone plate, the tooth is left for
spontaneous repositioning. If the apex is displaced
into the developing tooth germ, extraction of the
tooth is indicated.

INTRUSION FOLLOWED BY SPONTANEOUS

ERUPTION

INTRUSION- PRIMARY TOOTH INTRUDING INTO

THE PERMANENT TOOTH FOLLICLE
SHOULD BE TREATED BY EXTRACTION OF THE
PRIMARY TOOTH

Avulsion- The tooth is displaced completely out of the socket.

Radiographic examination- A radiographic examination is
essential to ensure that the missing tooth is not intruded.
Treatment- It is generally not recommended to replant an
avulsed primary tooth because of the elevated potential for
chronic infection and subsequent dystrophic changes that could
occur within the developing teeth.
Reimplantation of avulsed primary teeth - Case selection
criteria include teeth with an extraoral dry time of less than 30
minutes and periodontal ligament cell maintenance through an
appropriate tooth storage medium.
Functional space maintainers after exarticulation of
primary teeth- In case the primary tooth/ teeth are extracted, a
removable or a fixed functional space maintainer should be
given to the patient till the time the permanent teeth erupt.

To conclude- The majority of dental and oral

injuries are unexpected which makes their
prevention difficult. Hence, education is the best
method of prevention of such injuries.
Altogether, 7- 25% of dental injuries appear to
be preventable by means of preventive devices
like helmets, mouth guards and face guards
etc.

Thank you