11

Rami Mohammad

Ahmad Ja'fari

Rahaf AL-Najdawi
This sheet is correction from 2013 sheet , All slides are included
Management of injuries to dental tissues and pulp
General aims and principles of trauma management:
1- emergency (1st stage):
• retain vitality of tooth (by treating exposed dentine and pulp).
• reduce and immobilize displaced teeth.
• antiseptic mouthwash/ antibiotic/ tetanus prophylaxis. (if needed).
*not every trauma will need the above three aims ; like displacement or luxation injury my concern is to
retain the tooth in its place and splint it then give him antibiotic or antiseptic mouthwash if needed.

2- intermediate treatment. (e.g after one or two week of trauma) when things have been stabilized
• pulp therapy if needed.
• minimally invasive crown restoration.
• permanent/long term stage.
• apexogenesis/ apexification.
• RCT/ root extrusion (in the case of intrusion).
• gingival and alveolar modification.
• permanent coronal restoration. (sometimes we put a large composite restoration and the patient
is indicated for the crown but because of his age we postpone the crown).

3- maintenance/ follow up stage.

Enamel infraction
Is a crack within the enamel without loss of tooth structure.
Treatment: most of the time, no need to do anything, just give
the patient an advice how to prevent trauma in the future,
Check if he needs a mouth guard or any other devices and
then dismiss the patient.
In cases of marked infractions, itching and sealing with resin
(e.g flowable composite) to prevent discoloration of the
infraction lines.
The follow up is not needed usually unless associated with
other injury
Prognosis: very good.
Enamel fracture
Treatment: depends on extent(severity) and location of fracture and the presence of fractured fragment.

• smothen sharp enamel edges (you have to decide if this will be esthetically pleasing or not).
• restore with composite resin.
• If fragment is available, it can be bonded to the tooth.

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Follow up: clinical and radiographic examination
after 6-8 weeks and after 1 year. (we check If there
was pulpal necrosis).
Prognosis: generally very good.
Prognosis means the pulp status well remain vital or not
Clinical signs of necrosis
-discoloration.
–abscess with sinus tract.
– increased mobility of the tooth.
- tenderness to percussion.

Radiographic signs of necrosis

-radiolucency.
–open apex (arrested development) normally the root closure takes 3-5 years after eruption to be
completed.

Uncomplicated Enamel Dentine fracture

Emergency treatment: my primary goal is maintain vital pulp
• clean the injury area with water, saline or
chlorhexidine.
• disinfect fracture with NAOCL or chlorhexidine.
• provide emergency GI or resin bandage on
fracture area to protect exposed dentine.
• If the fracture is too large, consider using an
ortho- band to hold GI bandage.
Definitive treatment:
Composite restoration or fragment reattachment.
How to reattach a tooth fragment?
Never let the fragment dry cuz it will loss its
1. Confirm pulp vitality. esthetic property and become brittle always
2. Check fragment fit. instruct the parent to put it in saline.
3. Clean fragment with pumice and water.
4. Isolate tooth with rubber dam
5. Attach fragment to a piece of sticky wax to ease
handling
6. Etch enamel for 30 seconds on both fracture surface. Wash and dry
7. Apply bonding agent + primer to both surfaces and light cure.
8. Place appropriate composite shade to both surfaces and position fragment
9. Remove excess, light cure, and finiPshaagned 2po|li6sh restoration
 10. Remove a 1mm gutter of enamel on the fracture line palatally and labially
to a depth of 0.5 mm using a small round bur(creating a ditch). The finish line
should be irregular (ZigZag)to increase retention.
11. Etch, wash, dry, apply composite, cure and finish.

When you put the fragment and push it

against the tooth the excess composite
will go out and remaining composite
that connect the fragment to the tooth is
too thin so we do step No.(10+11) to
increase the retention .

Follow up (regardless If we did composite restoration or reattachment): clinical and radiographic after 6-8 weeks and
1 year.
Prognosis: generally, very good. A few teeth (less than 5%) can lose vitality.
Complicated enamel dentine fracture
*In this case I have exposed pulp so I need to manage the pulp + restoration
*The treatment will depend on the maturity of the tooth (open / close apex) , when the root formation
completed for incisor ? after 3 years of eruption central on 10 and lateral on 11 this is a ruff estimate
always depend on x ray.
The major aim of treatment in immature teeth is to preserve pulp vitality and allow continued root
growth.
Treatment: open apex? Things that allow apexogenesis
we have 2 options and our decision depends on the size
of exposure and how long the pulp has been exposed:
• direct pulp capping with ca(OH)2 or
MTA.(only if injury is fresh happened less
than 24 hrs ago).
• Partial puplotomy . More than a day
If the apex is closed and the injury is associated with
luxation and displacement, root canal treatment is usually
the treatment of choice. When apex is close is more
flexible cuz I can do endo
Follow up: clinical and radiographic control at 6-8 weeks and 1 year.

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 →In open apex teeth, monitor:
• root growth in length.
• narrowing of root canal.
Prognosis: generally good, especially when apex is open because there will be good blood supply.

Uncomplicated crown-root fracture

Emergency treatment:
• temporary stabilization of a loose segment to adjacent teeth
can performed until a definitive treatment plan is made.
• soft food for 1 week.
• brushing with a soft brush and rinsing with chlorhexidine
0.1% is beneficial to prevent accumulation of plaque and
debris.

Definitive treatment: we have a variety of options depends

on the severity and location of injury :
1-Removal of a superficial coronal crown- root fragment and
subsequent restoration of exposed dentin above the gingival
level.(for superficial fracture if it barely exceeds the gingival
level, easiest to perform).
Definitive treatment will depend on the
fracture line location:
*Superficial > remove the fragment and
restore to he gingival level.
*Deeper (beyond the gingiva) > RCT
then gingivectomy or otectomy or ortho

2-Removal of coronal fragment with subsequent endodontic

treatment and gingivectomy (sometimes ostectomy).
(indicated in crown-root fractures with palatal subgingival extension where esthetics won't be
impaired).
3- Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of
the remaining root. (there needs to be sufficient length after extrusion to support a post retained
crown(crown root ratio is good). Time consuming)indicated for esthetic purposes or fracture line is
too deep
More esthetic why ?? cuz the location of the gingival margin didn’t change

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4-Removal of the mobile fractured fragment with subsequent surgical repositioning of the root in
a more coronal position.

• a rotation of the root (90 or 180) may offer a better position for periodontal healing because the
fracture site becomes exposed labially and thereby more periodontal ligament can be saved
(because it will be easy to maintain a good oral hygiene).
• Some risk of root repositions and marginal breakdown of periodontium.
Change the fracture line position from palatal position to more labial position in order easy maintains a
good oral hygiene and prevents infection.

5-Decoronation (root submergence).

• Implant solution is planned; the root fragment may be left in situ after in order to avoid
alveolar bone resorption and thereby maintaining the volume of the alveolar process for late
optimal implant installation. No need for RCT unless the tooth have symptoms of irreversible
pulpitis you have to do RCT
6- Extraction with immediate or delayed implant-retained crown restoration or a conventional
bridge. ( Depending on the age of the patient).
• extraction is inevitable crown-root fractures with a severe apical extension, the extreme being a
vertical fracture.

Follow up: clinical and radiographic after 6-8 weeks and 1 year.
Prognosis: depends on root development, injury severity and treatment modality (the less invasive the
treatment, the better the prognosis we will be)

Complicated crown root fracture:

Is the same of the uncomplicated crown root fracture
Emergency Treatment:
• temporary stabilization of a loose segments to
adjacent teeth.

• in patients with open apices, it is advantageous to

preserve pulp vitality by a partial puplotomy. This
treatment is also the choice in young patients with
completely formed teeth.
Definitive treatment:
• similar to options available in uncomplicated
crown-root facture.

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Root fracture
It can be cervical or middle third or apical third fracture and maybe with displacement or without
displacement for the coronal part.
Treatment
• rinse exposed root surface with saline or chlorohexidine before repositioning.
• If displaced, reposition the coronal segment of the teeth as soon as
possible.
• Check that correct position has been reached radiographically and clinically.
• stabilize the tooth with a flexible splint for 4 weeks in apical third
and mid-root fractures. If the root fracture is near the cervical area
of the tooth stabilization is beneficial for a longer period of time
(up to 4 months).

Type of splint to use is out of doubt the

guideline says it should be flexible but other
people says it should be semi rigid cuz the
type of healing is diff from pdl healing instead
I am trying to form hard tissue(bone) to
stabilize the root

• Advice soft diet for 1 week. always advise it with splint

• Advice brushing with a soft brush and rinsing with chlorhexidine 0.1% for 1 week.
follow up: clinical and radiographic control after 6-8 weeks, 4 months, 6 months, 1 year, and
yearly for 5 years. Exam Q
Follow up may include endodontic treatment of the coronal fragment if pulp necrosis develops.
(mostly we will see the radiolucency at the end of the coronal part not at the periapical area because
the radicular pulp is not contaminated as the coronal pulp).
General rule: The decision for endodontic treatment may be taken after 3 months of follow up if the
tooth still does not respond to electrometric or thermal pulp testing and if radiographs show
radiolucency next to the fracture line.
When you don’t wait 3month for RCT?? X ray shows external resorption or abscess or increase
mobility otherwise wait 3month
Prognosis: generally moderate. Depends on root development and injury location and severity

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