Intrusion

Clinical Findings:

This injury is an injury to a tooth

that displaces the tooth into the
alveolar bone.
When conducting a percussion
test, the tooth will yield a high
metallic (ankylosed) sound. The
tooth will not have any mobility.
Pulp sensibility testing will most
likely be negative.
Radiographic Findings:
Periodontal ligament space will be absent, and the tooth will be sitting apical to the
adjacent teeth. One occlusal and two periapical radiographs from mesial and distal. It is
also helpful to take a lateral view from the mesial or distal aspect of the tooth in question
to rule out the displacement of the tooth into the nasal cavity.
Treatment:
Treatment options include:
1. Spontaneous eruption. Spontaneous eruption is best for permanent teeth that have
incomplete root formation with a minor or moderate intrusion. In teeth with mature
root development, it is only recommended for teeth with a minor intrusion. This option
will have fewer healing complications compared to other treatment options. If no
movement within 2-3 weeks, one of the other treatment options should be considered.
Patients <17 years old.
2. Orthodontic repositioning. This treatment is a good choice for patients who are
receiving delayed treatment. It does help to repair marginal bone with slow repositioning of the tooth.
This procedure should be initiated within the first three
weeks.
3. Surgical repositioning. This option is best for the acute phase of treatment. If the
intrusion resulted in the major dislocation of the tooth (more than 7 mm), this is a good
option. This treatment should be initiated within the first three weeks. A Flexible splint
should be applied for four weeks (up to 0.016” or 0.4mm).
This type of injury has a high risk of future tooth loss due to root resorption (ankylosis or
inflammatory resorption).
Root canal therapy for the above three options can prevent inflammatory root resorption.
Root canal therapy should be considered for all cases with completed root
formation. Root canal therapy should be initiated within two weeks post-injury. After
cleaning and disinfection, a temporary dressing with calcium hydroxide is recommended
for four weeks.
Teeth with an open apex should be monitored for pulp vitality. If the pulp becomes
necrotic, revascularization or apexification should be considered.
Patient Instructions:
1. Soft diet for one week.
2. Have good oral hygiene, brush 2 x/day.
3. Rinse with chlorhexidine 0.1% mouthwash 2x/day for one week.
4. Come to follow up appointments to remove the splint and check healing progress.

Follow up:
1. Follow up after two weeks.
2. Remove splint at four weeks (if indicated).
3. Follow up clinical and radiographic examinations at four weeks, 6-8 weeks, six months,
one year, and yearly for five years.

Extrusion
Clinical Findings:
This injury is when the tooth is partially displaced out of the socket. This injury is also
characterized by partial or total separation of the periodontal ligament. The alveolar
socket bone should be intact, unlike seen with a luxation injury. The tooth itself will most
likely have a slightly protruded or retruded position.
Pulp sensibility testing will most likely be negative, except for minor displacements. A
lack of response indicates a higher risk of later pulpal necrosis. In immature teeth, pulpal
revascularization usually occurs. Revascularization is not as common with fully formed
teeth.
Radiographic Findings:
Periodontal ligament space will appear widened. An occlusal and two periapical
exposures from the mesial and distal are indicated. It is also helpful to take a lateral view
from the mesial or distal aspect of the tooth in question.
Treatment:
1. Clean the area with water, saline, or chlorhexidine.
2. Apply local anesthesia if necessary.
3. Reposition tooth by gently re-inserting it into the socket with axial digital pressure.
4. Verify the correct positioning with a radiograph.
5. Apply flexible splint for two weeks (up to 0.016” or 0.4mm).
Monitor the pulpal condition to prevent future complications such as inflammatory root
resorption. If the tooth is immature, revascularization can be confirmed radiographically.
To confirm revascularization, look for continued root formation, initiation of pulp canal
obliteration and possibly a return of positive response to sensibility tests. If tooth is fully
formed, a continued lack of response to testing for up to 3 months should be taken as
evidence of pulpal necrosis and warrant root canal therapy. A color change of the crown
could also signify pulpal necrosis. Pulp necrosis is common.

Patient Instructions:
1. Soft diet for one week.
2. Have good oral hygiene, brush 2 x/day.
3. Rinse with chlorhexidine 0.1% mouthwash 2x/day for one week.
4. Come to follow up appointments to remove the splint and check healing progress.
Follow up:
1. Follow up clinical and radiographic examinations and splint removal after two weeks.
2. Follow up clinical and radiographic examinations at four weeks, 6-8 weeks, six months,
one year and yearly for five years. For normal pulp responses, no further treatment
indicated.

Avulsion
Clinical Findings:
This injury is an injury where the tooth is completely displaced out of its socket.
Pulp sensibility testing is not indicated for this injury.

Radiographic Findings:
A radiograph is taken to
rule out possible intrusive
injury or root fracture. A
radiograph is more
important when the
avulsed tooth cannot be
found or the patient is
unsure of what happened.
An occlusal or periapical
radiograph can be helpful
to confirm the diagnosis.
Obtain two periapical
radiographs from mesial
and distal.
Treatment:
An avulsed tooth is one of the few real emergencies in dentistry. It is not only important
that the dentist understands how to treat this injury but it also important that other
healthcare providers, parents, and teachers also know how to deal with these types of
injuries to help have the best possible outcome and prognosis.
Immediately after the injury has occurred:
1. If a tooth is avulsed, FIRST, make sure the tooth is permanent! Primary teeth should not
be re-implanted!
2. Find the tooth and pick it up by the crown (the white part). Try not to touch the root.
3. If the tooth is dirty, wash it briefly (10 seconds) under cold running water and
reposition it back into the socket. It is always better if the patient or a parent can reimplant the tooth if
possible.
4. If reimplantation is not possible, place the tooth in a storage medium, a glass of milk or
a special storage media such as Hank’s balanced storage solution or saline. The tooth
may also be transported in the mouth. With this option, the tooth is placed between
the molars and the inside of the cheek. Transporting in the mouth should only be done
by more mature patients to avoid swallowing the tooth. If the patient is very young, the
patient could spit into a container and place the tooth into it. DO NOT store in water.
5. Seek emergency dental care immediately or within 2 hours.