Traumatic injuries in pediatric dentistry

TRAUMATIC INJURIES IN PEDIATRIC
DENTISTRY
INJURIES TO PERIODONTAL
TISSUES, BONE AND SOFT
TISSUES
PRESENTED TO AND GUIDED BY :
DR(MRS.) NIRAPJEET KAUR
PRESENTED BY : SHILPA (MDS 2ND YEAR)

INJURIES TO THE HARD DENTAL TISSUES AND PULP :
1. Crown infarction : An incomplete fracture (crack) of the enamel
without loss of the tooth substance.
2. Uncomplicated crown fracture: A fracture contained to the enamel or
involving enamel and dentin, but not exposing the pulp
3. Complicated crown fracture :A fracture involving enamel and dentin and
exposing the pulp.
4. Uncomplicated crown root fracture: A fracture involving enamel, dentin
and cementum but not involving the pulp.
5. Complicated crown root fracture: A fracture involving enamel, dentin
and cementum and exposing pulp.
6. Root fracture : A fracture involving dentin, cementum and the pulp
According to ANDREASEN classification(1981)

INJURIES TO THE PERIODONTAL TISSUES :
1. Concussion: An injury to the tooth supporting structures without
abnormal loosening or displacement of the tooth, but with marked
reaction to percussion.
2. Subluxation: An injury to the tooth supporting structures with
abnormal loosening but without displacement of the teeth.
3. Intrusive Luxation (central dislocation) : Displacement of the tooth
into the alveolar bone. This injury is accompanied by comminution or
fracture of the alveolar socket.
4. Extrusive luxation (peripheral dislocation partial avulsion) : Partial
displacement of the tooth out of its socket.
5. Lateral Luxation : Displacement of the tooth in a direction other than
axially. This is accompanied by comminution or fracture of the alveolar
socket.
6. Exarticulation (complete avulsion): Complete displacement of the tooth
out of its socket.

INJURIES OF THE SUPPORTING BONE
1. Comminution of alveolar socket: Crushing and compression
of the alveolar socket. This condition is found together with
intrusive and lateral luxation.
2. Fracture of the alveolar socket wall (Mandible, Maxilla ): A
fracture contained to the facial or lingual socket wall.
3. Fracture of the alveolar process: A fracture of the alveolar
process, which may or may not involve the alveolar socket.
4. Fracture of the Mandible and Maxilla: A fracture involving
the base of the mandible or maxilla and often the alveolar
process (jaw fracture). The fracture may or may not involve
the alveolar socket.

Injuries to gingiva or oral mucosa.
1. Laceration of gingiva or oral mucosa: A shallow or deep
wound in the mucosa resulting from a tear and usually
produced by a sharp object.
2. Contusion of gingiva or oral mucosa: A bruise usually
produced by an impact from a blunt object and not
accompanied by a break of the continuity in the mucosa,
causing submucosal hemorrhage.
3. Abrasion of gingiva or oral mucosa: A superficial wound
produced by rubbing or scrapping of the mucosa leaving raw
bleeding surface.

INJURIES TO THE PERIODONTAL TISSUES
 CONCUSSION
 SUBLUXATION
 INTRUSIVE LUXATION
 EXTRUSIVE LUXATION
 LATERAL LUXATION
 EXARTICULATION/AVULSION

 EPIDEMIOLOGY OF DENTAL TRAUMATIC INJURIES

Bastone et al, 2000, ‘Epidemiology of dental trauma: A review of the
Literature’ , Australian dental journal, 45:(1):2-9

 Reported studies demonstrate that the most frequent type of
injury was a simple crown fracture of the maxillary central
incisors in the permanent dentition while injuries to the
periodontal tissues were more common in the primary
dentition.
 Accidents within and around the home were the major
sources of injury to the primary dentition, while accidents at
home and school accounted for most of the injuries to the
permanent dentition.
 Males tend to experience more dental trauma in the
permanent dentition than females, however, there does not
appear to be a difference between the sexes in the primary
dentition.

Prevalence of traumatic dental injuries (TDIs) to permanent teeth in population-based
surveys in different regions of the world

Ulf Glendor, 2008, ‘Epidemiology of traumatic dental injuries –
a 12 year review of the literature’ Dental Traumatology 2008; 24: 603–611;
doi: 10.1111/j.1600-9657.2008.00696.x

 Result:
The results indicate a high prevalence of TDIs in primary
and permanent teeth and that TDIs exists throughout the
world.
The prevalence shows that one third of all preschool
children have suffered a TDI involving the primary dentition,
one fourth of all school children and almost one third of adults
have suffered a trauma to the permanent dentition, but
variations exist both between and within countries.
Activities of a person and the environment are probably
more determining factors of TDIs than gender and age.

R Lam, 2016, ‘Epidemiology and outcomes of traumatic dental injuries:
a review of the literature’ Australian dental journal, 61:(1 Suppl): 4–20
doi: 10.1111/adj.12395

 Epidemiological studies indicate the annual
incidence of dental trauma globally is at about
4.5%. Approximately one-third of children and
toddlers (primary teeth) and one-fifth of adolescents
and adults (permanent teeth) sustained a traumatic
dental injury. The majority involved the maxillary
central incisors, mainly from falls in toddlers at
home and contact sport in adolescents.

 Total subjects examined were 963
 Involvement percentage was found to be: Males 16.2%
and Females 12.7%.
 Permanent maxillary central incisors most commonly
involved
 Enamel fracture – incidence of 80% was seen.
 A large number of children with incisal overjet greater
than 3 mm had TDI than those with less than 3 mm,
although this difference was not statistically significant.
 Class III (16.2%) and Class II Div II (17.7%)
malocclusion.
Kumar A, Bansal V, Veeresha KL, Sogi GM. Prevalence of traumatic dental injuries
among 12- to 15-year-old schoolchildren in Ambala district, Haryana, India. Oral
Health Prev Dent. 2011;9(3):301-5.

 63.2% males and 36.4% females were found to be
affected.
 The maxillary central incisor (most commonly
involved) - 43.8%.
 Most common etiology was fall during playing -
37.5%.
 Enamel fracture was most prevalent - 50%.
 Children with Angle's class II div 1 malocclusion
exhibited greater risk factor for traumatic injuries.
Dua R,Sharma S. Prevalence, causes, and correlates of traumatic
dental injuries among seven-to-twelve-year-old school children in Dera
Bassi. Contemp Clin Dent. 2012 Jan-Mar; 3(1): 38–41.

 TDI - Ratio of boys were more as compared to girls.
 Angle Class II Div 1 molar relationship and/or
overjet greater than 5.5 mm.
 The most predominant injuries were enamel
fractures.
 The most common place for occurrence was home
and fall against object
Patel MC, Sujan SG. The prevalence of traumatic dental injuries to
permanent anterior teeth and its relation with predisposing risk factors
among 8-13 years school children of Vadodara city: an epidemiological
study. J Indian Soc Pedod Prev Dent. 2012 Apr-Jun;30(2):151-7.

 Subjects examined: 800
 An overall prevalence of 10.2% was found
 Involvement of male children- 11.87%
 Female children- 8.14%
 Enamel fracture (69%) found to be the most
prevalent type of dental traumatic injury
Anil S, Chalissery VP, Marwah N, Jafer M, Chalisserry EP, Bhatt T. Prevalence of
anterior dental trauma and its associated factors among children aged 3-5 years
in Jaipur City, India - A cross sectional study. Journal of International Society of
Preventive and Community Dentistry.
2016 April;6:35-40.

CONCUSSION
Description
Visual Signs
Percussion
Test
Mobility Test
Pulp Sensibility
Test
An injury to the tooth-supporting structures
without increased mobility or displacement of
the tooth, but with pain to percussion.
Not displaced.
Tender to touch or tapping.
No increased mobility.
Usually a positive result.The test is important in
assessing future riskof healingcomplications.
A lack of response to the test indicates an
increased risk of later pulp necrosis.

 Radiographic findings
 Radiographs
recommended
No radiographic abnormalities,
the tooth is in - situ in itssocket.
As a routine: Occlusal, periapical
exposure and lateral view from
mesial or distal aspect of the tooth
in question. This should be done in
order to excludedisplacement.
Diangelis AJ et al. International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent
Traumatol. 2012 Feb;28(1):2-12.

 CLINICAL AND RADIOGRAHIC PRESENTATION:

TREATMENT GUIDELINES FOR CONCUSSION
Treatment objectives
• To optimize healing of the periodontal ligament and maintain pulp vitality
Treatment
Usually there is no need for treatment.
Monitor pulpal condition for at least 1 year.
General prognosis
For primary teeth, unless associated infection exists, no pulpal therapy is indicated.
Although there is a minimal risk for pulp necrosis, mature permanent teeth with closed
apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the
apex and, therefore, must be followed carefully.
Patient instructions
•Soft food for 1 week.
Good healing following an injury to the teeth and oral tissues depends, in part,
on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine
0.1 % is beneficial to prevent accumulation of plaque and debris.
Follow-up
•Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year.

SUBLUXATION
Description An injury to the tooth supporting structures resulting in
increased mobility, but without displacement of the
tooth. Bleeding from the gingival sulcus confirms the
diagnosis
Visual signs
Percussion
test
Mobility test
Pulp sensibility
test
Not displaced.
Tender to touch or
tapping
Increased mobility.
Sensibility testing may be negative initially indicating
transient pulpal damage. Pulpal response is monitored until
a definitive pulpal diagnosis can be made.
There is a positive sensibility test result in about half the
cases. The test is important in assessing future risk of healing
complications. A lack of response at the initial test indicates
an increased risk of later pulp necrosis.

Radiographic findings Usually no radiographic abnormalities.
Radiographs
recommended
As a routine: Occlusal, periapical exposure
and lateral view from the mesial or
distal aspect of the tooth.
Traumatol. 2012 Feb;28(1):2-12.

 PATHOPHYSIOLOGY:
LOOSENING
OF
TOOTH

 TREATMENT GUIDELINES FOR SUBLUXATION:
TREATMENT OBJECTIVES
To optimize healing of the periodontal ligament and neurovascular
supply.
TREATMENT:
• Primary teeth: The tooth should be followed for pathology.
• Permanent teeth: Stabilize the tooth and relieve any occlusal
interferences. For comfort, a flexible splint can be used. Splint for no
more than 2 weeks.
GENERAL PROGNOSIS:
Prognosis is usually favorable.The primary tooth should return to
normal within 2 weeks. Mature permanent teeth with closed apices
may undergo pulpal necrosis due to associated injuries to the blood
vessels at the apex and, therefore, must be followed carefully.

 PATIENT INSTRUCTIONS
Soft food for 1week.
Good healing following an injury to the teeth and oral tissues
depends, in part, on good oral hygiene. Brushing with a soft
brush and rinsing with chlorhexidine 0.1% isbeneficial to prevent
accumulation of plaque and debris.
 FOLLOW-UP
Clinical and radiographic control at 4 weeks, 6-8 weeks and 1
year.

EXTRUSION
 Description Partial displacement of the tooth out of its alveolar socket.
An injury to the tooth characterized by partial or total
separation of the periodontal ligament resulting in
loosening and displacement of the tooth. The alveolar
socket bone isintact in an extrusion injury as opposed to a
lateral luxation injury. Apart from axial displacement,
the tooth will usually have an element of protusion or
retrusion. Insevere extrusion injuries the retrusion/protrusion
element can be very pronounced. Insome cases it can
be more pronounced than the extrusive element.
Visual signs
Percussion test
Mobility test
Appears elongated.
Tender.
Excessively mobile.

Sensibility test Usually lack of response except for teeth with
minor displacements.
The test is important in assessing risk of
healing complications.
A positive result to the initial test indicates a
reduced risk of later pulp necrosis.
Radiographic
findings
In immature, not fully developed teeth, pulpal
revascularization usually occurs. In mature teeth pulp
revascularization sometimes occurs.
Increased periapical ligament space.
Radiographs
recommended
As a routine: Occlusal, periapical exposure and view
from the mesial or distal aspect ofthe tooth.
Traumatol. 2012 Feb;28(1):2-12.

 TREATMENT GUIDELINES FOR EXTRUSION:
Treatment objectives:
• Primary teeth: to allow tooth to reposition spontaneously or reposition
and allow for healing for minor extrusion (<3 mm) in an immature
developing tooth. Indications for an extraction include severe extrusion or
mobility, the tooth is nearing exfoliation, the child’s inability to cope with the
emergency situation, or the tooth is fully formed.
• Permanent teeth: to reposition as soon as possible and then to stabilize
the tooth in its anatomically correct position to optimize healing of the
periodontal ligament and neurovascular supply while maintaining esthetic
and functional integrity. Repositioning may be accomplished with slow and
steady apical pressure to gradually displace coagulum formed between root
apex and floor of the socket. Splint for up to 2 weeks. There is considerable
risk for pulp necrosis and pulp canal obliteration.

 PATIENT INSTRUCTIONS:
Good healing following an injury to the teeth and oral tissues depends, in part,
on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine
0.1% is beneficial to prevent accumulation of plaque and debris
FOLLOW-UP
Clinical and radiographic control and splint removal after 2 weeks. Clinical and
radiographic control at 4 weeks, 6-8 weeks, 6 months and 1 year.

LATERAL LUXATION
 Description Displacement of the tooth other than axially.
Displacement is accompanied by comminution or fracture
of either the labial or the palatal/lingual alveolar bone.
Lateral luxation injuries, similar to extrusion injuries, are
characterized by partial or total separation of the periodontal
ligament. However, lateral luxations are complicated by
fracture of either the labial or the palatal/lingual alveolar bone
and a compression zone in the cervical and sometimes the
apical area. If both sides of the alveolar socket have been
fractured, the injury should be classified as an alveolar fracture
(alveolar fractures rarely affect only a single tooth). In most
cases of lateral luxation the apex of the tooth has been forced
into the bone by the displacement, and the tooth is frequently
non-mobile.
Visual signs
Percussion test
Mobility test
Displaced, usually in a palatal/lingual or labial direction.
Usually gives a high metallic (ankylotic) sound.
Usually immobile.

Sensibility tests Sensibility tests will likely give a lack of response
except for teeth with minordisplacements.
The test is important in assessing risk of healing
complications. A positive result at the initial
examination indicates a reduced risk of future pulp
necrosis.
Traumatol. 2012 Feb;28(1):2-12.

 TREATMENT GUIDELINES FOR LATERAL LUXATION:
TREATMENT OBJECTIVES-
 Primary teeth: to allow passive or spontaneous repositiong if there is
no occlusal interference. When there is occlusal interference, the tooth
can be gently repositioned or slightly reduced if the interference is minor.
When the injury is severe or the tooth is nearing exfoliation, extraction is
the treatment of choice.
 Permanent teeth: to reposition as soon as possible and then to stabilize
the tooth in its anatomically correct position to optimize healing of the
periodontal ligament and neurovascular supply while maintaining esthetic
and functional integrity. Repositioning of the tooth is done with digital
pressure and little force. A displaced tooth may need to be extruded to
free itself from the apical lock in the cortical bone plate. Splinting an
additional 2 to 4 weeks may be needed with breakdown of marginal
bone.

 GENERAL PROGNOSIS:
Primary teeth requiring repositioning have an increased risk of developing
pulp necrosis compared to teeth that are left to spontaneously reposition. In
mature permanent teeth with closed apices, pulp necrosis and pulp canal
obliteration are common healing complications while progressive root
resorption is less likely to occur.
PATIENT INSTRUCTIONS
Good healing following an injury to the teeth and oral tissues depends,
in part, on good oral hygiene. Brushing with a soft brush and rinsing
with chlorhexidine 0.1 %isbeneficial to prevent accumulation of plaque
and debris.
FOLLOW-UP
 Clinical and radiographic control after 2 weeks. Clinical and
radiographic control and splintremoval after 4weeks.
 Clinical and radiographic control at 6-8weeks, 6 months, 1 year
and yearly for 5years.

INTRUSION – INTRUSIVE LUXATION
 Description Displacement of the tooth intothe alveolar bone. This injury
is accompanied by comminution or fracture of the
alveolarsocket.
Visual signs The tooth is displaced axially intothe alveolar bone.
Usually gives a high metallic (ankylotic) sound.
The tooth is immobile.
Sensibility test will likely give negative response.
Mobility test
Percussion test
Sensibility test
In immature, not fully developed teeth, pulpal
revascularization may occur.
The periodontal ligament space may be absent from all or
part of the root. The cemento-enamel junction is located
more apically in the intruded tooth than in adjacent non-
injured teeth, at times even apical to the marginal bone
level.
As a routine: Occlusal, periapical exposure and lateral view
from the mesial or distal aspect of the tooth in
Radiographic
findings
Radiographs
recommended

 TREATMENT GUIDELINES FOR INTRUSION:
Tooth intrusion is associated with a potential risk of tooth loss
due to progressive root resorption (ankylosis or infection
related resorption). The following three methods are only
partly evidence based.
Spontaneous eruption
This is the treatment of choice for permanent teeth with
incomplete root formation with minor or moderate intrusion. In
teeth with mature root development it is only recommended for
teeth with minor intrusion.This treatment seems to lead to fewer
healing complications than orthodontic and surgical
repositioning. If no movement within a few weeks, initiate
orthodontic or surgical repositioning before ankylosis can
develop.
Orthodontic repositioning
This treatment may be preferred for patients coming in for
delayed treatment. This treatment method enables repair of
marginal bone in the socket along with the slow repositioning of
the tooth.

 Surgical repositioning
This treatment technique is preferable in the acute phase.
Intrusion with major dislocation of the tooth (more than 7
mm) may be an indication for surgical repositioning.
 Common foralltreatments
Endodontic treatment can prevent the necrotic pulp from
initiating infection-related root resorption. This treatment
should be considered in all cases with completed root
formation where the chance of pulp revascularization is
unlikely.
Endodontic therapy should preferably be initiated within 3-
4 weeks post-trauma.

 For PRIMARY TEETH:
Allow spontaneous reeruption except when displaced into the
developing successor. Extraction is indicated when the apex is
displaced toward the permanent tooth germ
 GENERAL PROGNOSIS:
In primary teeth, 90% of intruded teeth reerupt spontaneously
(either partially or completely) in 2 to 6 months. Even in cases of
complete intrusion and displacement of primary teeth through the
labial bone plate. Ankylosis may occur, if the periodontal ligament
of the affected tooth was severely damaged, thereby delaying or
altering the eruption of the permanent successor.

In mature permanent teeth with closed apices, there is considerable risk
for pulp necrosis, pulp canal obliteration, and progressive root resorption.
Immature permanent teeth that are allowed to reposition spontaneously
demonstrate the lowest risk for healing complications. Extent of intrusion (7
mm or greater) and adjacent intruded teeth have a negative influence on
healing

 PATIENT INSTRUCTIONS
Good healing following an injury to the teeth and
oral tissues depends, in part, on good oral hygiene.
Brushing with a soft brush and rinsing with
chlorhexidine 0.1 % is beneficial to prevent
accumulation of plaque and debris.
 FOLLOW UP
Clinical and radiographic ontrol after 2 weeks.
Splint removal and control after 4 weeks, 6-8 weeks, 6
months, 1 year and yearly for 5years

 Selection criteria:
 (1) Population: only studies on humans with one or more
traumatically intruded permanent teeth were included.
 (2)Intervention: spontaneous re-eruption, orthodontic
repositioning, or surgical repositioning of the intruded
tooth/teeth were evaluated.
 (3)Comparison: comparisons between orthodontic and
surgical repositioning, between one of the two types of
repositioning and no repositioning, and between the two types
of repositioning and no repositioning were evaluated
 (4)Outcome: root resorption was the primary outcome
evaluated, and marginal bone defects and pulpal changes
were the secondary outcomes. All studies that evaluated at
least one type of periodontal parameter were included.
Costa LA, et al. Treatments for intrusive luxation in permanent teeth: a
systematic review and meta-analysis, Int J Oral Maxillofac Surg (2016),
http://dx.doi.org/10.1016/j.ijom.2016.08.021

 Reported outcomes:
All of the articles reported the primary outcome
(inflammatory or replacement root resorption). Two
studies did not report on the secondary outcome of
marginal bone defects. Seven studies reported on the
secondary outcome of pulpal changes .
 Results :
Whenever possible, spontaneous re-eruption should be
the treatment of choice. When spontaneous re-eruption
is not indicated, there is no difference between
orthodontic and surgical repositioning in terms of the
positive outcome rates. The degree of root formation is
important to the prognosis of the teeth, where teeth with
incomplete root formation display a better prognosis.

 A 4-year-old girl presented with the chief complaint of a
broken left upper front tooth after a fall while playing.
 The intraoral clinical examination showed laceration of the
lower lip, intrusion of the maxillary left central incisor (61) and
subluxation of the left lateral incisor (62) . The tooth apex was
displaced labially and the crown lingually in 61
HV Shanmugam et al, 2011,’Management of intrusive luxation in the primary
dentition by surgical repositioning: an alternative approach, Australian Dental
Journal 2011; 56: 207–211 doi: 10.1111/j.1834-7819.2011.01325.x

 Radiographic findings confirmed the same and the
obliteration of periodontal ligament space was seen in
61. A mesiodens was also found between 51 and 61.
The incisor was surgically repositioned with forceps .After surgical
repositioning, the position was confirmed with an intraoral periapical
radiograph (IOPA). The tooth was splinted with rectangular stainless steel
wire and composite. The subluxated 62 was also included in the splint.
Endodontic tehrapy was carried out wrt 61

After splinting
r/g after 20 months
After 20 months

AVULSION
 INTRODUCTION
 It is complete and total displacement of tooth from
its socket.
Incidence:
0.5%to 16%of dental traumatic injuries
Mainetiologic factors
Fights Sportsinjuries Automobile accidents
Maxillary central incisor is the most commonly avulsed tooth
Mandibularteeth are seldom affected
Most frequently avulsion involves a singletooth

 Most common age :-7 -11yearsofagebecause
of :
Permanent incisors erupting
Loosely structuredPDL
Associatedinjurieswithavulsion are:-
Fracture of alveolar socket wall
Injuriesto the lips and gingiva

 MANAGEMENT OF AVULSED TOOTH :
What tissue should be our primary concern?
PULP SOCKET PDL

 Most criticalfactor
Maintaining an intact andviable PDLon the
root surface
 Prognosis depends on
1) Storage media
2) Extra alveolar time
3) Preservation of root structure
 Ultimategoal
PDL healingwithout root resorption

CLINICAL FEATURES
Bleeding socket with missing tooth
RADIOGRAPHIC FEATURES
Empty socket
Associated bone fractures
If the wound is recent then lamina dura is visible
otherwise obliterated

 TRANSPORT AND STORAGE MEDIA FOR
AVULSED TOOTH :
A study to evaluate the level of awareness and knowledge of regarding
tooth avulsion among the primary contact doctors was conducted
J IndianAssoc Pediatr Surg. 2013Apr-Jun; 18(2): 93. doi:
10.4103/0971-9261.109368
PMCID: PMC3687158
Awareness about management of ‘avulsed teeth’among primary contact doctors
Vishal Khandelwal, Anupam Gupta, and SushmaKhandelwal
91 % NO
9% YES
AWARENESS ABOUT TRANSPORT
MEDIA

IDEAL STORAGE MEDIA :
 Antimicrobial properties
 Capable of preserving cellular PDL (viability)
 Promotes mitogenicity
 Non toxic, non reactive with body fluids.
 Preserve functional capabilities
 Osmolality 290-330 mOsm/L * (critical role )
 pH of 6.6 to 7.8.*
 Should reduce the risk of post reimplantation
root resorption or ankylosis.
Storage media for avulsed tooth a review
Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 3,

GOOD
ACCESSIBILTY
POOR
ACCESSIBILITY
Milk
Coconut
water
Egg white
Water
Saliva
GOOD
ACCESSIBILITY
POOR
ACCESSIBILITY
Red mulbery
Propolis
extract
Green tea
extract
Honey milk
Aloevera
pomegranate
juice
Salvia extract
Normal
saline
Gatorade
Contact lens
solution
ORS
Ricetral
Autologous
serum
Probiotics
HBSS
Cryoprotectives
Culture media
Organ storage
fluids
Specialized kits
Additives
Classification of Storage media
Natural Synthetic

BASED ON CELL
VIABILITY
Short term
(2 to 6 hrs )
• Milk
• Propolis
• Green tea
• Coconut water
• Egg white
• ORS
• Red mulbery
Intermediate
(upto 1 hr)
• Saliva
• Normal saline
• Gatorade
• Tap water
Long term
(24 to 48 hrs)
• HBSS
• Viaspan
• Custodiol
• MEM
• Viaspan
• Eurocollins
• Additive supplemented
media

Malhotra N, 2011,’Current developments in interim transport (storage) media in dentistry: an
update’ ,British dental journal, vol 211, no. 1

 Population: Human PDL cells (isolated from avulsed permanent
teeth).
 Intervention: Placement of PDL cells of an adult avulsed tooth in
the storage medium.
 Comparison: Placement in no storage medium, a different
storage medium, or the same storage medium with variability in
composition, concentration or temperature, serving as its own
comparator.
 Outcome: Survival of PDL cells in terms of viability, increase in
numbers, no change in morphology, or any other positive
outcome as determined by the laboratory parameters.
Adnan et al, 2018, Which is the most recommended medium for the
storage and transport of avulsed teeth? A systematic review, Dental
traumatology, 1-12.

 Results:
The initial search yielded 978 articles, but only 67 were selected.
Milk was the most recommended individual medium followed by
Hank’s balanced salt solution.
Among natural products other than milk, propolis and coconut
water were most frequently recommended.
Recommendations were based on maintenance of PDL cell
viability followed by ease of availability, low cost, and long shelf
life.
 Conclusions:
Natural products are more effective in maintaining the PDL cell
viability compared to synthetic products. Some storage media
recommendations were also based upon practical aspects.
Although natural products other than milk have more
recommendations as a group, milk is the most recommended
storage medium individually, based not only on PDL cell viability,
but also practical considerations.

Efficacy Ease of access Storage medium
Excellent ++
Excellent + Milk , coconut water
Excellent - Propolis ,Green tea
Excellent -- Viaspan,HBSS,Euro collins,MEM
Good ++
Good + Egg white , ricetral/ORS
Good - Red mulberry
Good --
Poor ++
Poor + Saline,gatorade,contact lens solution
Poor -
Poor --
Very poor ++ Water , saliva
Very poor +
Very poor -
Very poor --

Efficacy Ease of access Storage medium
Excellent ++
Excellent + Milk , Coconut Water
Excellent - Propolis ,Green tea
Excellent -- Viaspan,HBSS,Euro collins,MEM
Good ++
Good + Egg white , ricetral/ORS
Good - Red mulberry
Good --
Poor ++
Poor + Saline,gatorade,contact lens solution
Poor -
Poor --
Very poor ++ Water , saliva
Very poor +
Very poor -
Very poor --

REPLANTATION
Replantation is the insertion of a tooth in its socket after
its complete avulsion resulting from traumatic injury

MANAGEMENT OF THE SOCKET
 Remove contaminated coagulum insocket
 Irrigate with sterile saline
 E xamine socket whether any fracture is
evident
 Reposition fractured bone with a blunt
instrument
Replant using light digital pressure

AMERICAN ACADEMY OF PEDIATRIC DENTISTRYDECISION TREES FOR MANAGEMENTOFAN AVULSED
PERMANENT TOOTH
*Adapted with permission from: McIntyreJ,LeeJ,TropeM, VannWJ,Permanenttooth replantation following avulsion: Using a
decision tree to achievethe best outcome. Pediatr Dent 2009;31(2):137-44.
Management of anAvulsed
Permanent Incisor with an Open
Apex (Apex≥1 mm)*
Assess medical history and rule out any neurologic and nondental injuries.
Diagnostic tests:
• Rule out alveolar fracture.
• 3 radiographs angulated differently to rule out root fractures.
• Pulp vitality test maxillary and mandibular anteriors.
If tooth was kept
moist (in water, saliva
or other non-
physiologic media)
for 20 to 60 minutes.
• Monitor every 4 weeks + pulp test + radiographs.
• Ideal outcome: revascularization and/or apexogenesis occurs over the next 12 to 18 months.
• Alternative outcomes:
– Initiate apexification with mineral trioxide aggregate (MTA) or calcium hydroxide or root canal therapy if clinical and/or radiographic pathology presents.
– Consider decoronation procedure when clinical infraposition of the tooth appears and/or clinical and radiographic findings of ankylosis manifest.
• Follow-up: 1 week, 1 month, 3 months, 6 months, 12 months, and annually for 5 years.
• Replant and/or reposition.
• Obtain periapical radiographs to verify position.
• Place flexible splint for approximately 2 weeks; 4 weeks for dry time >60 minutes.
• Rx: Antibiotics (eg, doxycyline or penicillin V potassium for non-allergic patients) for 7 days; Chlorhexidine rinse for 1 week.
• Assess tetanus vaccination: if needed, get booster within 48 hours.
• Provide post-operative instructions; inform of prognosis.
• Follow up in 7 to 10 days.
>60 minutes extraoral
dry time/storage.
Debride with soft pumice
prophylaxis, gauze, gentle
scaling/root planing, or 3%
citric acid for 3 minutes, and
rinse well to remove
periodontal ligament.
Soak in doxycycline or ArestinTM
solution for 5 minutes.
Change transport to HBSS. If HBSS
is not available, place in cold milk.
Place in 1.23% sodium fluoride
(eg, acidulated phosphate
fluoride) for 5 to 20 minutes.
Immediately
replanted at
the accident
site.
20 to 60minutes
extraoral dry
time/storage.
Extraoral dry storage
time <20 minutes and
tooth was transported
in Hank’s Balanced
Salt Solution (HBSS)
or milk for 20 minutes
to 6 hours.
 OR: OR:  OR: OR: 

REFERENCE MANUAL V 38 /NO 6 16/17
Assess medical history and rule out any neurologic and nondental
injuries. Diagnostic tests:
• Rule out alveolar fracture.
• 3 radiographs angulated differently to rule out root fractures.
• Pulp vitality test maxillary and mandibular anteriors.
Change transport to HBSS. If HBSS is
not available, place in cold milk.
Place in 1.23% sodium fluoride (eg,
acidulated phosphate fluoride) for 5
to 20 minutes.
Immediately replanted
at the accident site.
Extraoral dry storage
time was <20
minutes and tooth
was transported in
Hank’s Balanced Salt
Solution (HBSS) or
milk for 20 minutes
to 6 hours.
Debride with soft pumice prophylaxis,
gauze, gentle scaling/root planing, or 3%
citric acid for 3 minutes, and rinse well to
remove periodontal ligament.
If root canal therapy was initiated, complete within 1 month.
OR
If patient does not present until >2 weeks after trauma and/or if radiographic resorption is present:
• Pulpectomy/debridement as soon as possible.
• Long-term calcium hydroxide therapy/slurry and change every 3 months.
• Complete root canal therapy when periodontal ligament/lamina dura is observed/healthy.
Follow-up: 1 week, 1 month, 3 months, 6 months, 12 months, and annually for 5 years.
20 to 60 minutes
extraoral dry
time/storage.
If tooth was kept
moist (in water,
saliva or other non-
physiologic media)
for 20 to 60
minutes.
• Replant and/or reposition.
• Obtain periapical radiographs to verify position.
• Place flexible splint for approximately 2 weeks; 4 weeks for dry time >60 minutes.
• Rx: Antibiotics (eg, doxycyline or penicillin V potassium for non-allergic patients) for 7 days; Chlorhexidine rinse for 1 week.
• Assess tetanus vaccination: if needed, get booster within 48 hours.
• Provide post-operative instructions; inform of prognosis.
• Follow up in 7 to 10 days.
• Initiate pulpectomy/debridement on all teeth within 7 to 10 days.
>60 minutes extraoral dry time/storage.
OR: OR:   OR:  OR: 
Management of an Avulsed
Permanent Incisor with an
ClosedApex(Apex<1 mm)*

HEALING AND PATHOLOGY
The pathology of tooth re-implantation can be divided
into:
I. Pupal ractions
II. Periodontal reactions
Both pulp and periodontal ligament suffer extensive
damage during an extra-oral period.

PULPAL REACTIONS
Experiments have shown various distinct pulpo-
dentinal response which can occur after immediate
re-implantation.
1. Regular tubular reparative dentin
2. Irregular reparative dentin
3. Osteodentin (Irregular reparative dentin with
encapsulated bone cells)
4. Irregular immature bone
5. Regular lamellated bone
6. Internal resorption
7. Pulp necrosis

PERIODONTAL REACTIONS
Histologic examination of re-implanted human teeth
has shown four stages of healing:
1. Healing with normal pdl
2. Healing with surfaceresorption
3. Healing with ankylosis (replacement resorption)
4. Healing with inflamatory response (infection
related)
Immediately after re-implantation, a coagulum is
formed between the two parts of severed pdl.
This line of seperation is usually situated in themiddle
of the pdl.

i. HEALING WITH A NORMAL PDL:
Histologically, it is characterised by complete
regeneration of the pdl which usually takes about 4
weeks to complete including the nerve supply.
Radiographically, there is normal pdl space without
signs of root resorption.
Clinically, tooth is in normal position and ellicits a
normal percussion tone.
This type of healing will probably not take place in
clinical conditions as trauma will result in injury to
innermost layer of pdl leading to surface resorption.

Line of seperation
After 3 days
Proliferating
connective tissue
After 2 weeks
new collagenous
Fibres formed
Normal state
Restored(8 mnths)

ii. HEALING WITH SURFACE RESORPTION:
Histologically it is characterised by localised areas on
the root surface which show superficial resorption.
Surface resorption is not progressive and self limiting.
It shows repair with the formation of new cementum.
Radiogrphically they may not be clearly disclosed due
to their small size.
Clinically, tooth is in normal position and
normal percussion toneis ellicited.

iii. HEALING WITH ANKYLOSIS (REPLACEMENT
RESORPTION):
Histologically, ankylosis represents fusion of alveolar
bone and the root surface and can be demonstrated in
2 weeks afterre-implantation.
Etiology may be related to absence of vital pdl cover
over the root.
Depending upon the extent of damage, replacement
resorption can take place in two ways-
i. Progressive (gradually resorbs the entire root; occurs
if entire pdl is removed before re-
implantation/excessive drying)
ii. Transient (once established ankylosis dissappers;
related to minor damage to the root. Ankylosis
formed initially; later replaced by vital pdl)

iii. Healing with ankylosis (replacement resorption):
Histologically, ankylosis represents fusion of alveolar
bone and the root surface and can be demonstrated in
2 weeks afterre-implantation.
Etiology may be related to absence of vital pdl cover
over the root.
Depending upon the extent of damage, replacement
resorption can take place in two ways-
i. Progressive (gradually resorbs the entire root; occurs
if entire pdl is removed before re-
implantation/excessive drying)
ii. Transient (once established ankylosis dissappers;
related to minor damage to the root. Ankylosis
formed initially; later replaced by vital pdl)

 iv. HEALING WITH INFLAMATORYRESPONSE:
Histologically characterised by bowl shaped
resorption cavities in cementum.
Inflamatory reaction consists of granulation
tissue with numerous lymphocytes,plasma
cells,PMNLs.
Adjacent to these areas, root surface undergoes
intense resorption with Howships lacunae nd
osteoclasts.
Radiographically too it is characterised by bowl
shaped radiolucencies along root surface as
early as 2 weeks.
Clinically
I. Tooth is loose and extruded
II. Sensitive to percussion
III. Percussion note isdull.

GRANULATION
TISSUEArea with active
resorption
surface
resorption
repaired with new
cementum
Necrotic pulp
tissue

PROGNOSIS
Tooth survival: 21-89%
Pdl healing: 9-50%
Pulp healing:4-27%
COMPLICATIONS:
If not treated, may lead to migration of adjacent teeth.
Either re-implantation or space maintaince using
orthodontic applianceis indicated.

 REPLANTATION OF PRIMARY TEETH
 Avulsions account for 7–13% of all injuries to the
primary teeth, with the maxillary incisors the most
commonly affected due to their slight vestibular apical
inclination and forces directed towards the palatal
surface.
 A recent guideline for the treatment of traumatic dental
injuries in the primary dentition does not recommend
the replantation of primary teeth; however, paediatric
dentists are often asked to perform this procedure by
parents concerned with the absence of the child’s
primary tooth.
Malmgren B, Andreasen JO, Flores MT et al. International association of dental
traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the
primary dentition. Dent Traumatol 2012; 28: 174–182.

 Number of factors favour replantation, such as the
maintenance of occlusal balance, speech
development, physiological aspects of chewing and
psychological effects on the child.
 But there is little evidence regarding the risks and
benefits of replantation of avulsed primary teeth.

 The aim of this study was to perform a systematic review of
the literature on the replantation of avulsed primary teeth,
analysing the risks and benefits to help guide dentists
regarding the best clinical decision-making in such cases.
Paula Antonio Martins Junior et al , 2014, ‘Replantation of avulsed primary
teeth: a systematic review’ , International Journal of Paediatric Dentistry, vol 24,
77-83.

 There were 41 replanted primary teeth out of which
18 were maxillary central incisors, six maxillary
lateral incisors, nine mandibular central incisors,
four mandibular lateral incisors and four unknown
teeth.
 The time elapsed between avulsion and
replantation ranged from a few minutes to
approximately 4 days. The teeth were splinted in 31
cases and endodontic treatment was performed in
seven cases.

 Result:
All 19 studies were case reports involving a total of
41 replanted primary teeth. No negative
consequences to either the primary tooth or
permanent successor were observed in 15 cases.
Among the other 26 cases, there were negative
consequences to only the replanted primary tooth in
16 cases, only the permanent successor in three
cases and both the replanted primary tooth and
permanent tooth.

 The negative consequences to the replanted primary teeth
were pulp necrosis, fistula, crown discolouration, radicular
cyst development, ankylosis, slight external root resorption,
mobility, and bone resorption.
 In cases of avulsion of primary teeth, permanent teeth may
be affected on different occasions:
(a) at the time of trauma
(b) during the replantation of the avulsed primary tooth
(c) as a result of persistent infection and/or inflammation of
the replanted primary tooth.
 The negative consequences to the permanent successors
were impaction and laceration, tooth extraction, whitish
discolouration and enamel hypoplasia . The follow-up period
ranged from one to 72 months (until the complete eruption of
the permanent successor).

SPLINTING
 A splint has been defined as ‘an apparatus used to
support, protect or immobilize teeth that have been
loosened, replanted, fractured or subjected to
certain endodontic surgical procedures’.
 Splinting has been advocated after repositioning of
a tooth/teeth to stabilize the tooth/teeth and to
optimize healing outcomes for the pulp and/or the
periodontal ligament.

 IDEAL REQUIREMENTS OF A SPLINT:
(1) Allow periodontal ligament reattachment and prevent the risk
of further trauma or swallowing of a loose tooth.
(2) Be easily applied and removed without additional trauma or
damage to the teeth and surrounding soft tissues.
(3) Stabilize the injured tooth/teeth in its correct position and
maintain adequate stabilization throughout the splinting
period.
(4) Allow physiologic tooth mobility to aid in periodontal ligament
healing.
(5) Not irritate soft tissues.
(6) Allow pulp sensibility testing and endodontic access.
(7) Allow adequate oral hygiene.
(8) Not interfere with occlusal movements.
(9) Preferably fulfil aesthetic appearance.
(10) Provide patient comfort.

SPLINT TYPES
 Composite and wire splints: flexible splints when the wire
has a diameter of no greater than 0.3– 0.4 mm.12
 Composite and fishing line splints: An alternative where
fishing line replaces wire and the line is secured with
composite resin.

 Orthodontic wire and bracket splints: involves orthodontic
brackets bonded to the teeth with a resin-based
orthodontic cement and connected with a light 0.014 NiTi
flexible wire.
 Fibre splints: use a polyethylene or Kevlar fibre mesh and
are attached either with an unfilled resin and/or with
composite resin.

 The titanium trauma splint: is a flexible splint made of
titanium, 0.2 mm thick and 2.8 mm wide.
 It can be easily adapted to the contour of the dental
arch. It can be bent with the fingers.
 It is available in two lengths, 52 mm and 100 mm.
 The unique design of the TTS with its rhomboid mesh
structure makes it flexible in all dimensions, thus
allowing physiologic tooth mobility without transfering
orthodontic forces to the splinted teeth.
 The size of the rhomboid openings (1.8 * 2.8 mm)
clearly defines only a small area of bonding, thereby
reducing the amount of composite
to be used.
Thomas von arx et al,2001, ‘Splinting of traumatized teeth
with a new device: TTS (Titanium Trauma Splint)’ ,Dental
Traumatology,17, 180-184

In 26 year old, After repositioning the traumatized maxillary left central incisor, minimal etching gel is
applied according to the small openings of the TTS. B) Using bonding agent and light curing composite
resin, the TTS has been fixed to stabilize the injured tooth. C) At the time of splint removal, the TTS
can just be ‘‘peeled’’ off from the tooth surface. D) Final view after splint removal.

Avulsion of the maxillary left central incisor in a 9-year old boy. B) The radiograph depicts the empty
alveolar socket. C) Following tooth replantation, an extended TTS was placed for stabilization of the
avulsed tooth. D) The radiograph shows the correct replantation of the maxillary left central incisor.

 Arch bar splints: A metal bar is
bent into the shape of the arch and
fixed with ligature wires.
 Wire ligature splints: are sometimes used by oral
surgeons in clinics where dental splinting materials
may not be available.

 Composite splints: resin composite applied to the
surfaces of teeth is a rigid splint and Composite
splints that are bonded interproximally to adjacent
teeth are also reported to be prone to fracture.

 A splint for medical emergency
departments: Stomahesive (ConvaTec Inc.), a skin
barrier adhesive material used for superficial skin
trauma. This material can crudely hold teeth in the
socket and cover coronal fractures to reduce
sensitivity when patients are seen in emergency
medical departments out of hours of routine dental
practice. This approach could require further
repositioning with subsequent splinting in a dental
office.
(a) A Stomahesive splint (b) The Stomahesive splint removed to reveal a crown-root fracture of the maxillary right central incisor
and uncomplicated crown fractures of the left central and lateral incisors.

Type of injury Splinting
time
Splinting type
SUBLUXATION 2 WEEKS FLEXIBLE SPLINT
EXTRUSIVE LUXATION 2 WEEKS FLEXIBLE SPLINT
LATERAL LUXATION 4 WEEKS FLEXIBLE SPLINT
INTRUSIVE LUXATION 4 WEEKS FLEXIBLE SPLINT
ROOT FRACTURE 4 WEEKS FLEXIBLE SPLINT
ROOT FRACTURE
(cervical 1/3)
4 MONTHS FLEXIBLE SPLINT
AVULSION 2 WEEKS FLEXIBLE SPLINT
AVULSION(dry time >
60min)
4 WEEKS FLEXIBLE SPLINT
ALVEOLAR FRACTURE 4 WEEKS FLEXIBLE SPLINT
Current IADT recommendations for splinting time and type for
various types of injuries

 SPLINT REMOVAL
Removal of rigid arch bar splints or interdental wiring is often a
difficult process involving unwiring and cutting of wires close to the
gingival margins with potential damage to soft tissues.
Removing a splint in which composite resin has been used is time
consuming and iatrogenic injury to the enamel is an inevitable
outcome.
Techniques of composite removal involve debonding pliers,
handscalers, ultrasonic scalers, tungsten carbide burs, diamond burs,
Soflex disks , rubber wheels and cups which generate shearing forces
that result in irreversible damage to the enamel. Additionally, the forces
exerted may disturb the periodontal healing of the injured tooth.
Tungsten carbide burs and Soflex discs resulted in the least damage
to the enamel.
B Kahler et al, 2016, ‘Splinting of teeth following trauma: a review and a new
splinting recommendation’ Australian dental journal, 61:(1 Suppl) 59–73
doi: 10.1111/adj.12398

MAXILLOFACIAL TRAUMA IN
CHILDREN

INTRODUCTION:
 Facial injuries in children are much less common
than in adults.
 The principles of treatment of children’s facial
fracture are basically the same as those utilized in
adults.
 However, the techniques used are necessarily
modified by certain anatomical, physiological and
psychological factors.
 Another aspect of facial injuries in children is the
potential for later effects upon facial development.

INCIDENCE:
 Fractures of facial bones are less frequent in
children than in adults.
 Facial fractures are more common in males than
females.
 During the early stage of growth, children live in
more protected environment under close
supervision of parents.
 The resilience of the developing bone and the thick
overlying soft tissue enable the child to withstand
the forces.
 The tooth to bone ratio in the developing mandible
is comparatively high and the bone has a more
elastic resistance.

 SITE AND PATTERN:
 The site and pattern of a fracture depend on the
interrelationship between etiology and force of the
injury and the unique anatomic features of the
child’s stage of development.
 Mandibular fractures are by far the most frequent,
followed by nasal fractures, orbital, frontal and
midfacial fracture. Complex fractures
(nasoorbitoethmoidal) are the least common.

 The condylar region is the most frequently fractured
site in children than in adults because the highly
vascularized pediatric condyle and thin neck are
poorly resistant to impact forces during falls.
 Body fractures of the mandible are less common
than in adults, whereas symphysis and
parasymphysis fractures of the mandible occur
more often.

 This retrospective study included maxillofacial injuries treated in 112
children under 14 years admitted due to maxillofacial injuries during
the period from 2001 to 2011
H. V. Kambalimath et al, 2013 , ‘Maxillofacial Injuries in Children: A 10 year
Retrospective Study, journal of maxillofacial and oral surgery, 12(2):140–144

 RESULTS:
The most common jaw involved in the fracture was
the mandible. Conservative management was done
in 83.04 % of cases and open reduction and
internal fixation was performed in 16.96 % of cases.
Five (4.46 %) cases accounted for post-operative
wound infection.
 CONCLUSION :
Fracture of the mandible is the most common
maxillofacial injury in children, most often caused
by fall from a height.
The osteogenic potential of the mandible in children
leads to conservative management of these
fractures.

 OBJECTIVE: To determine the incidence and pattern of
facial fracture in children of age 0–16 years of age.
 Total 5049 patients were screened and fifty one were
reported to have facial injury.
Ashrafullah, et al., The incidence of facial injuries in children in Indian
population: A retrospective study, J Oral Biol Craniofac Res. (2017),
http://dx.doi.org/10.1016/j.jobcr.2017.09.006

 Child patients were divided into three groups
according to dentition:

Gender wise distribution of patients:

 Results :The age wise distribution of the fracture
amongst groups (I, II and III) were found 17.65%,
54.9% and 27.45% respectively. The sex-wise
distribution of facial fracture was reported twice in
male than females. The mandibular fracture was found
the most common fracture (0.59%) followed by dento
alveolar (0.30%) and midface (0.12%) fractures. Most
of the mandibular fractures were found in the para
symphysis region. Compound fractures seem to be
commonest in the mandible.
 Conclusion: The fall was the predominant cause for
most of the facial fractures in children followed by road
traffic accident. The pattern of facial injury is
influenced by the age and the growth of facial
skeleton.

MANAGEMENT OF MAXILLOFACIAL
TRAUMA
HISTORY
•Indicate the mechanisms and direction
of force of injury.hence provides clues
for any pain, swelling and numbeness in
cranial nerve distribution
•Nasal or oral bleeding ,tooth
displacement, difficulty in eating,
malocclusion, decrease excursion of the
jaw and ecchymosis point to a skeletal
injury
INSPECTION
• CSF leak indicates involvement
of cranial base. And
subcutaneous emphysema is
seen in the periorbital area when
air enters the tissue from
fractures of nose, orbit or
sinuses.
• Orderly inspection of the all the
facial areas is done
PALPATION
• Palpation should be
performed by beginning in
the forehead area to the
orbital rims bilaterally and
nose. and continued over
zygomatic arches, cheeks
and the surface of the
mandible
CLINICAL
EXAMINATION

Severe – score of <9
Moderate – score of 9-12
Mild – score of 13 - 15

ORTHOPANTOGRAPH – choice for
mandibular fractures
POSTERIOANTERIOR – for ramus
angle and body
LATERAL OBLIQUE- view from the
condyle to the mental foramen.
REVERSE TOWNE –medio/lateral
displacement of condylar fractures.
OCCLUSAL VIEWS – used for
evaluationg symphyseal displacement
CT SCANNING – it is especially useful
for temporomandibular joint evaluation
and nasoethmoidal fracture
RADIOGRAPHIC
EXAMINATION

 GENERAL PRINCIPLES OF TREATMENT :
AIRWAY
ASSESSMENT
• Oropharynx
should be cleaned
of blood, food and
the broken teeth.
• Child is ventilated
and intubated.
• Small airway size
in children,
accompanied by
laryngeal odema
and retroposition
of tongue base
may produce
sudden
obstruction
needing an
emergency
tracheostomy .
HAEMORRHAGE
CONTROL
• After airway and
cervical spine
stabilization
bleeding should
be controlled
and venous
access should
be established.
• Bleeding points
should pressure
packed
OBTAIN BASAL
VITAL SIGNS
•If shock is
diagnosed
(haemorrhage,
tachycardia,cool
extremities and
SBP< 70mm of hg),
a fluid bolus of 20
ml/kg of warm
crystalloid should
be given

 SOFT TISSUE INJURIES IN INFANTS AND
CHILDREN:
Maxillofacial soft tissue trauma and
injuries range from contusion and
abrasions to massive avulsive injuries
Tetanus immune globulin should be
administered.
Careful cleaning and irrigation of
wounds is done
If haematoma is present in its
gelatinous phase,it should be incised
and evacuated.
Lacerations of tongue and other facial
areas should be sutured

 SPECIAL CONSIDERATIONS IN PEDIATRIC PATIENT:
 Children have a higher surface-to-body volume ratio,
metabolic rate, oxygen demand and cardiac output than
adults.
 They also have lower total blood and stroke volumes than
adults. Therefore, the risk for hypothermia, hypotension and
hypoxia after blood loss is higher in paediatric patients.
 Even mild airway swelling or mechanical airway obstruction
can quickly compromise the airway. For these reasons,
maintenance of the airway and breathing, control of
hemorrhage and early resuscitation are even more critical
and time dependent in children than in adults

 At birth, the ratio between cranial volume and facial
volume is approximately 8:1. By the completion of
growth, this ratio becomes 2.5:1.
 The retruded position of the face relative to the
‘‘protecting’’ skull is an important reason for the
lower incidence of midface and mandibular
fractures and higher incidence of cranial injuries in
young children (less than 5 years of age).
 With increasing age and facial growth, in a
downward and forward direction, the midface and
mandible become more prominent and the
incidence of facial fractures increases, while cranial
injuries decrease

 Facial fractures in children occur less frequently
than in adults and they are more often minimally
displaced. This is because a thicker layer of
adipose tissue covers the more elastic bones and
the suture lines are flexible.
 In addition, stability is increased by the presence of
tooth buds within the jaws and the lack of sinus
pneumatisation.
 The possibility of adverse post-injury growth
disturbances, particularly after severe nasal septal
and condylar injuries should be considered when
planning treatment.

 Growth potential, on the other hand, may serve to
improve long-term results as with compensatory
condylar growth after condylar fractures.
 Children in the deciduous and mixed dentition stages
demonstrate some capacity for spontaneous occlusal
readjustment by permanent teeth eruption

MANAGEMENT OF FACIAL FRACTURES
IN CHILDREN

DENTOALVEOLAR FRACTURES:
 These are common in children.
 If the fragment is small and mobile and only deciduous
teeth are attached,the fragment is removed.
 If the fragment contains permanent teeth,it should be
repositioned out of occlusion and fixed with a wire and
composite splint.
 Short term (1-2 weeks) maxillomandibular fixation(MMF)
is sometimes necessary to maintain stability of the
fragment.
 Depending on the stage of development,dentoalveolar
injury may lead to a host of dental growth disturbances
ranging from dilaceration to ankylosis with an altered
eruption sequence

FRACTURE OF MANDIBLE
 INFANCY TO 2 YEAR OLD:
 When the fracture is in the tooth bearing part of the
mandible, an acrylic ‘Open cap splint’ is fabricated
and pressed down over the lower teeth and
alveolus following manual disimpaction and
reduction of any displaced fragments.
 The splint is retained in place by two circumferential
wires one on either side of the fracture line.
 2-3 weeks are generally sufficient to ensure reunion

 2-4 YEARS OLD :
 At this stage, if sound sufficient primary teeth are
present, interdental eyelet wiring can be used.
 If there are gaps in the primary dentition, arch bar
may be used.
 If the fracture is within the tooth bearing area of the
mandible, a single one piece lower cap splint is the
best method since immobilization is avoided.

 A case of a 4.5-year-old boy with fractured body of
mandible managed by closed reduction using open
occlusal acrylic splint and circum-mandibular
wiring. Step deformity with tenderness and mobility
was elicited along the lower border of the mandible
on the left side canine region.
Baby john et al, Management of mandibular body fractures in pediatric
patients: A case report with review of literature, Contemp Clin Dent. 2010
Oct-Dec; 1(4): 291–296. doi: 10.4103/0976-237X.76406

 Under sedation, upper and lower arch alginate
impressions were taken and stone casts were
poured. An open occlusal acrylic splint was
fabricated , and under general anesthesia, the
mandibular body fracture was immobilized, fixed
with the acrylic splint which was retained by circum
mandibular wiring

 5-8 YEARS OLD :
 It is the period of exfoliation of deciduous teeth and
eruption of their successors. So there is difficulty
regarding the fixation of the mandible.
 To overcome these shortcomings of this age group, a
partial maxillary and mandibular ‘Gunning type splint’
with occlusal blocker is used.
 This splint is secured by circumferential wires, fixation of
the upper splint to the maxilla is provided by the use of
prenasal wires whereby the splint is suspended by two
wires which rest on the floor of the nose,one on either
side of the septum

Open cap splint Gunning splint

 In children older than 9-12 years, standard
intermaxillary fixation (IMF) with arch bars is
possible because enough permanent dentition has
been established. Cap splints, arch bar elastics,
transosseous wiring and braces may also be used
briefly for fixation.

SYMPHYSEAL AND PARASYMPHYSEAL
FRACTURE
 Bilateral fracture of the anterior mandible is common.
 These fractures are frequently greenstick and require no
active treatment. If mobile they are well managed with
an acrylic splint and circummandibular wires.
 Undisplaced and immobile fractures of the anterior
mandible can be treated with soft diet and careful follow
up
 Displaced anterior fractures may be managed with
closed manipulation and wiring of an acrylic splint or
with open reduction and miniplate and screw fixation
and the splint is placed for 2-3 weeks

ANGLE FRACTURE
 Angle fractures frequently are greenstick fractures
and are managed with soft diet and pain control.
The angle region is not amenable to splints. If the
fracture is nondisplaced or if only minimal-to-
moderate displacement exists, closed reduction
and IMF or IMF with elastics usually suffices. If
open reduction is required, an extraoral approach
may be needed.

CONDYLAR FRACTURE
 Condylar fractures are classified into 3 groups.
 Intracapsular fractures involving the articular
surface and are common in babies and infants.
 High condylar fractures occuring above the
sigmoid notch and usually are medially dislocated
by the force of the impact.
 Low subcondylar fractures which are usually
greenstick fractures in children and are the most
common type of pediatric mandibular fracture
overall.

 In children younger than 5 years, crush injuries to the
articular disk are more common. In the very young
child ( < 3 y), the condylar neck is short and thick, and
the force of trauma generally dissipates on the
articular surface.
 Injuries to the articular surface may cause
hemarthrosis and subsequent bony ankylosis.
 Early range of motion is important in preventing this
complication. Injury to the cartilage also affects the
growth of the mandible.
 In children older than 5 years, neck fractures are
more common and are regarded as relatively self-
correcting.

 Early treatment includes analgesics and a soft diet.
Encourage range of motion exercise once edema
has subsided. Conservatively manage comminuted
fractures of the head and condyle.
 In the edentulous child, no immobilization is
required; in other patients, IMF is placed for 2
weeks. Even if the fracture is displaced it typically
heals well.
 Indications for jaw immobilization are bilateral
fractures with an open bite or severe movement
limitation or deviation. Generally, the period of
immobilization is 2-3 weeks followed by a period of
6-8 weeks of guiding elastics

 Open reduction is indicated in a few situations as
follows:
 (1) dislocation of the mandibular condyle into the
middle cranial fossa,
 (2) condyle prohibiting mandibular movement, and
 (3) bilateral condylar fractures causing reduced
rami height and open bite

Traumatic injuries in pediatric dentistry

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