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Trauma to the teeth
and the supporting
tissue
BY : DR. HAMSA THABIT
MSC IN PEDIATRIC DENTISTRY
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Classification of traumatized teeth
Ellis and Davey classification of crown fracture is useful in recording extent of
damage to crown
✓Class I - simple fracture of crown involving little or no dentin
✓ClassII - extensive fracture of crown involving considerable dentin but
not dental pulp
✓Class III - extensive fracture of crown with an exposure of dental pulp
✓Class IV - loss of entire crown
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Enamel Fracture Class I :
Visual sign:
• visible loss of enamel
no visible sign of exposed
dentin
Percussion test:
not tender
Mobility test:
• normal mobility
Sensibility test:
usually positive
fracture confined to the enamel with loss of tooth structure
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Radiographic findings :
• enamel lost is visible
Radiographs :
• occlusal
• periapical
recommended to rule out
possible presence of root
fracture or as a record for
future visits
( follow up).
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Treatment
Class I
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Enamel-Dentin Fracture ClassII
Visual sign:
• visible loss of enamel + dentin
• no visible sign of exposed pulp tissue
Percussion test:
• not tender
• if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Mobility test:
normal mobility
Sensibility test:
usually positive
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Radiographic findings:
• enamel-dentin lost is visible
Radiographs:
• occlusal
• periapical
• recommended to rule out displacement or
possible presence of root fracture
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Treatment of Enamel-Dentin Fracture
ClassII :
 If tooth fragment is available, it can be bonded to the tooth.
I. Covering the dentin with liner .
II. Removing the dentin layer from the fragment.
III. Itching and bonding for both.
IV. Flowable composit placement and repositioning the fragment and curing.
 • Otherwise perform provisional treatment by covering exposed
dentin with glass ionomer or a permanent restoration using a
bonding agent.
The patient should be reexamined at 2 weeks and again at 1
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Enamel-Dentin-Pulp Fracture
Visual sign:
• visible loss of enamel + dentin + exposed pulp tissue
Percussion test:
Examining the tooth if
• not tender
• if tenderness is observed
evaluate tooth for a possible
luxation or root fracture injury
Mobility test:
• normal mobility
Sensibility test:
Usually positive
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Radiographic findings:
lost of tooth substance is visible
More than 1 month expecting
radiolucency.
Radiographs:
• occlusal
•periapical recommended
to rule out displacement,
possible presence of luxation, root
fracture or pathologic change.
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Teeth
primary
Permenant
Non-vital vital
Vital
Non-vital
Open
apex
Open
apex
Open
apex
Closed
apex
Closed
apex
apexification
Apexogenesis pulpectomy pulpotomy
RCT
Direct
Pulp
capping
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Open
apex
Closed
apex
Closed
apex

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Pulptomy
If the tooth tender to percussion
The coronal portion of the pulp should be amputated
debris should be removed from the chamber
hemorrhage should be controlled If there is evidence of hyperemia
Although the formocresol pulpotomy technique has been recommended for many years as the
principal method for treating primary teeth with carious exposures
Substantial shift because of concerns about its toxic effects
Many alternatives, including MTA, sodium hypochlorite, ferric sulfate, electrosurgery, and lasers.
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The pulp chamber is dried with sterile cotton pellets.
Next, a pellet of cotton moistened with a 1:5 concentration of Buckley’s formocresol and blotted on
sterile gauze to remove the excess is placed in contact with the pulp stumps and allowed to remain for
5 minutes.
Because formocresol is caustic, care must be taken to avoid contact with the gingival tissues.
The pellets are then removed, and the pulp chamber is dried with new pellets. A thick paste of hard-
setting zinc oxide–eugenol is prepared and placed over the pulp stumps. The tooth is then restored
with a stainless-steel crown.
Buckley’s original formula for formocresol calls for equal parts of (formaldehyde and cresol).
The 1:5 concentration of this formula is prepared by first thoroughly mixing three parts of glycerin with
one part of distilled water, and then adding four parts of this diluent to one part of Buckley’s
formocresol,
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Pulpectomy
clinical evidence of
hyperemia
the root canals show
evidence of necrosis
no blood in the pulp
chamber
If there is a fistula
They may be opened
for drainage and
often remain
asymptomatic for an
indefinite period
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Giving Anesthesia to the
patient
Cleaning the cavity walls reaching to the floors then removing the pulp
chamber roof
examining the pulp
chamber
Many dentists prefer to use root canal instruments with a special rotary handpiece and nickel
titanium files for root canal debridement.
a syringe is used to irrigate them with sodium hypochlorite or
chlorhexidine .
The canals should then be dried with sterile paperpoints
tricresole and TF.
2nd visit if no signs of pus then obturation with thin mix of filling paste may be prepared then
thick mix of the material in canals.
Small Kerr files may be used to apply the paste to the walls. thin paste first then thick mix of
the treatment paste carried into the canal.
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Materials for obturation
Although zinc oxide–eugenol paste has been viewed as
the traditional root canal filling material for primary teeth
The primary components of KRI paste are zinc oxide and
iodoform.
Vitapex are calcium hydroxide and iodoform.
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Treatment of
permanent teeth
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Calcium hydroxide
(dycal) or MTA
For further root
development
apexogensis
Do extirpation to the
pulp apexification
Mta
Or
Calcium hydroxide
with iodoform
Treatment of Enamel-Dentin-Pulp Fracture
Class III :
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less than one
hour
open
apex
open
apex
Might be an
invasion of
bacteria to
the canals
Non vital
pulp capping
or partial
pulpotomy

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Calcium
hydroxide (dycal )
or MTA
To preserve the
vitality
Do extirpation to the
pulp endodontic
treatment
Calcium hydroxide
with iodoform
As intra canal
medication
Treatment of Enamel-Dentin-Pulp Fracture
Class III :
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less than one
hour
closed
apex
closed
apex
Might be an
invasion of
bacteria to
the canals
Direct pulp
capping or
partial
pulpotomy

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Most challenging endodontic procedures is the
treatment and subsequent filling of the root
canal of a tooth with an open apex.
The surgical procedure is traumatic for the young
child and should be avoided if possible.
young permanent teeth with incomplete root growth
and a vital pulp, Apexogenesis technique is the
procedure of choice.
IF the eventual restoration may require a post in the root canal.
the dentinal bridge that has formed after the Apexogenesis can be
perforated and routine endodontic procedures can be undertaken in a
now completely developed root canal.
If an abscess is present, it must be treated first,
drainage through the pulp canal will give the child
almost immediate relief
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The lumen of the root canal of such an immature tooth is largest at the
apex and smallest in the cervical area and is often referred to as a
blunderbuss canal.
The term "blunderbuss" is of Dutch origin, from the Dutch word
donderbuis, which is a combination of donder, meaning "thunder", and
buis, meaning "pipe"

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DIRECT PULP CAP
If the patient is seen within an hour or two after the
vital exposure is small
If the final restoration of the tooth will require the use
the pulp chamber or pulp canal for retention, a
or a pulpectomy is the treatment of choice.
The healthy pulp may survive and repair small injuries
in the presence of a few bacteria
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DIRECT PULP CAP
If pain persist then endodontic tratment
If no signs and symptoms then final restoration
6-8 weeks appointment
Zinc oxide powder + euoginol liquid as a T.F
Application of the calcium hydroxide (dycal) or MTA (passively)
Drying the cavity with cotton
Rubber dam
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APEXOGENESIS
Is the preservation of vital pulp tissue so that continued root
with apical closure may occur.
Pulp exposure in a traumatized, immature permanent (open apex)
large, if even a small pulp exposure exists and the patient did not
treatment until 48 hours after the injury.
If there is insufficient crown remaining to hold a temporary
Apexogenesis is also indicated for immature permanent teeth if
pulp tissue is evident at the exposure site with inflammation of the
underlying coronal tissue.
trauma to a more mature permanent (closed apex) tooth that has
both a pulp exposure and a root fracture.
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APEXOGENESIS
Follow up and x-ray
Glass ionomer filling material ?(good seal)
Application of MTA or dycal or morphogenic protein
Dryness with cotton
Washing the pulp chamber with normal saline
Removing the pulp tissue in pulp chamber
If open apex , vital , permanent teeth
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