DEPT.

OF
PEDIATRIC
DENTISTRY

DENT 444
DENTAL TRAUMATOLOGY

Fractures and Luxations of Permanent Teeth

Diagnosis and Contemporary Treatment Approaches

Prof. Dr. Senem SELVİ KUVVETLİ

 Traumatic Injuries
2020 IADT Guidelines for the Evaluation and
Management of Traumatic Dental Injuries
Part I: Fractures and luxations of permanent teeth
 Part II: Avulsion of permanent teeth
Part III: Injuries in the primary dentition

https://onlinelibrary.wiley.com/doi/full/10.1111/edt.12578
Fractures of permanent teeth
etch and seal
 INFRACTION Krack)
>
-

w!th res!n

 ENAMEL FRACTURE

 ENAMEL-DENTIN-PULP FRACTURE

 CROWN-ROOT FRACTURE WITHOUT PULP EXPOSURE

 CROWN-ROOT FRACTURE WITH PULP EXPOSURE

 ROOT FRACTURE

 ALVEOLAR FRACTURE
Infraction
Clinical findings
An incomplete fracture (crack) of the enamel without
loss of tooth structure.
Not tender. If tenderness is observed evaluate the
tooth for a possible luxation injury or a root fracture.
Infraction
Imaging, radiographic assessment, and findings:
No radiographic abnormalities
Recommended radiographs:
One parallel periapical radiograph
Additional radiographs are indicated if signs or
symptoms of other potential injuries are present
Infraction
Treatment

In case of marked infractions, etching and sealing with

resin to prevent discoloration of the infraction lines.

Otherwise, no treatment is necessary.

Infraction
Infraction
Follow-up
No follow up is needed if it is certain that the tooth
-

suffered an infraction injury only

If there is an associated injury such as a luxation
injury, that injury specific follow-up regimen prevails
Infraction
Favorable outcomes
Asymptomatic
Positive response to pulp sensibility testing
Continued root development in immature teeth
Infraction
Unfavorable outcomes
Symptomatic
Pulp necrosis and infection
Apical periodontitis
Lack of further root development in immature teeth
Enamel fracture
Uncomplicated crown fracture
Clinical findings

 A complete fracture of the enamel.

 Loss of enamel. No visible sign of exposed dentin.

 Not tender. If tenderness is observed evaluate the tooth for a

possible luxation or root fracture injury.

 Normal mobility.

 Sensibility pulp test usually positive.

Enamel fracture
Uncomplicated crown fracture
Radiographic findings

 Enamel loss is visible.

Missing fragments should be accounted for:
 If fragment is missing and there are soft tissue injuries,
radiographs of the lip and/or cheek are indicated to search for
tooth fragments and/or foreign materials
Recommended radiographs:
 One parallel periapical radiograph
 Additional radiographs are indicated if signs or symptoms of
other potential injuries are present
Enamel fracture
Uncomplicated crown fracture
Treatment
If the tooth fragment is available, it can be bonded to
the tooth.
Alternatively, depending on the extent and location of
the fracture, the tooth edges can be smoothed, or a
composite resin restoration placed
Enamel fracture
Uncomplicated crown fracture
Follow up
Clinical and radiographic evaluations are necessary:
after 6-8 wk
after 1 y
If there is an associated luxation or root fracture, or the
suspicion of an associated luxation injury, the luxation
follow-up regimen prevails and should be used. Longer
follow ups will be needed
Enamel fracture
Uncomplicated crown fracture
Favorable outcomes
Asymptomatic
Positive response to pulp sensibility testing
Good quality restoration
Continued root development in immature teeth
Enamel fracture
Uncomplicated crown fracture
Unfavorable outcomes
 Symptomatic
 Pulp necrosis and infection
 Apical periodontitis
 Loss of restoration
 Breakdown of the restoration
 Lack of further root development in immature teeth
Enamel fracture
Uncomplicated crown fracture
Enamel Dentin Fracture
Uncomplicated crown fracture

Clinical findings
Normal mobility
Pulp sensibility tests usually positive
No sensitivity to percussion or palpation
Evaluate the tooth for a possible associated luxation
injury or root fracture, especially if tenderness is
present
Enamel Dentin Fracture
Uncomplicated crown fracture
Radiographic findings
 Enamel-dentin loss is visible.
Missing fragments should be accounted for:
 If fragment is missing and there are soft tissue injuries, radiographs of the lip
and/or cheek are indicated to search for tooth fragments and/or foreign
materials
 Radiograph of lip or cheek lacerations to search for tooth fragments or foreign
materials.
Recommended radiographs:
 One parallel periapical radiograph
 Additional radiographs are indicated if signs or symptoms of other potential
injuries are present
Enamel Dentin Fracture
Uncomplicated crown fracture

Treatment
 If the tooth fragment is available and intact, it can be bonded
back on to the tooth. The fragment should be rehydrated by
soaking in water or saline for 20 min before bonding

 Cover the exposed dentin with glass-ionomer or use a bonding

agent and composite resin

 If the exposed dentin is within 0.5 mm of the pulp (pink but no

bleeding), place a calcium hydroxide lining and cover with a
material such as glass-ionomer
Enamel Dentin Fracture
Uncomplicated crown fracture

Follow up
Clinical and radiographic evaluations are necessary:
• after 6-8 wk
• after 1 y
If there is an associated luxation, root fracture or the
suspicion of an associated luxation injury, the luxation
follow-up regimen prevails and should be used. Longer
follow ups will be needed
Enamel Dentin Fracture
Uncomplicated crown fracture
Favorable outcomes
Asymptomatic
Positive response to pulp sensibility testing
Good quality restoration
Continued root development in immature teeth
Enamel Dentin Fracture
Uncomplicated crown fracture
Unfavorable outcomes
 Symptomatic
 Pulp necrosis and infection
 Apical periodontitis.
 Lack of further root development in immature teeth
 Loss of restoration
 Breakdown of the restoration
Enamel Dentin Fractures
Enamel-dentin fracture with pulp exposure
Complicated crown fracture

Clinical findings:

 A fracture involving enamel and dentin with loss of tooth

structure and exposure of the pulp.

 Normal mobility

 No sensitivity to percussion or palpation.

 Evaluate the tooth for a possible associated luxation injury or

root fracture, especially if tenderness is present

 Exposed pulp is sensitive to stimuli (eg,air, cold, sweets)

Enamel-dentin fracture with pulp exposure
Complicated crown fracture
Radiographic findings

 Enamel dentin loss visible.

Missing fragments should be accounted for:

 If fragment is missing and there are soft tissue injuries, radiographs of the lip and/or
cheek are indicated to search for tooth fragments and/or foreign debris

 Radiograph of lip or cheek lacerations to search for tooth fragments or foreign

materials.

Recommended radiographs:

 One parallel periapical radiograph

 Additional radiographs are indicated if signs or symptoms of other potential injuries

are present
Enamel-dentin fracture with pulp exposure
Complicated crown fracture
Treatment

 In patients where teeth have immature roots and open apices,

it is very important to preserve the pulp. Partial pulpotomy or
pulp capping are recommended in order to promote further
root development.

 Conservative pulp treatment (eg, partial pulpotomy) is also the

preferred treatment in teeth with completed root development
Enamel-dentin fracture with pulp exposure
Complicated crown fracture

Treatment

 Non-setting calcium hydroxide or non-staining calcium silicate

cements are suitable materials to be placed on the pulp wound

 If a post is required for crown retention in a mature tooth with

complete root formation, root canal treatment is the preferred
treatment
Enamel-dentin pulp fracture
Complicated crown fracture
Treatment
If the tooth fragment is available, it can be bonded
back on to the tooth after rehydration and the
exposed pulp is treated.
In the absence of an intact crown fragment for
bonding, cover the exposed dentin with glassionomer
or use a bonding agent and composite resin
 ENAMEL-DENTIN
PULP FRACTURE
Pulpectomy
Partial
pulpotomy
(CH/MTA)

&
9 year old girl, fall at school
Enamel-dentin pulp fracture
Complicated crown fracture
Follow-up
Clinical and radiographic evaluations are necessary:
• after 6-8 wk
• after 3 mo
• after 6 mo
• after 1 y
• If there is an associated luxation, root fracture or the
suspicion of an associated luxation injury, the luxation
follow-up regimen prevails and should be used. Longer
follow ups will be needed
Enamel-dentin pulp fracture
Complicated crown fracture
Favorable outcomes
Asymptomatic
Positive response to pulp sensibility testing
Good quality restoration
Continued root development in immature teeth
Enamel-dentin pulp fracture
Complicated crown fracture
Unfavorable outcomes

 Symptomatic

 Discoloration

 Pulp necrosis and infection

 Apical periodontitis

 Lack of further root development in immature teeth

 Loss of restoration

 Breakdown of the restoration

Crown-root fracture
without pulp exposure
Clinical findings
 A fracture involving enamel, dentin and cementum with
loss of tooth structure, but not exposing the pulp.
 Crown fracture extending below gingival margin.
 Percussion test: Tender.
 Coronal fragment mobile.
 Sensibility pulp test usually positive for apical fragment.
Crown-root fracture
without pulp exposure
Radiographic findings

Apical extension of fracture usually not visible.

Radiographs recommended: periapical, occlusal and

eccentric exposures. They are recommended in order
to detect fracture lines in the root.
Crown-root fracture
without pulp exposure
Treatment
 Emergency treatment
As an emergency treatment a temporary
stabilization of the loose segment to adjacent teeth
can be performed until a definitive treatment plan is
made.
 Crown-root fracture
without pulp exposure

Treatment (Non-Emergency Treatment Alternatives)

 Fragment removal only
&
Removal of the coronal crown-root fragment and subsequent
restoration of the apical fragment exposed above the gingival
level.
 Crown-root fracture
without pulp exposure

Treatment (Non-Emergency Treatment Alternatives)

&
 Fragment removal and gingivectomy (sometimes ostectomy)
&

Removal of the coronal crown-root segment with subsequent

endodontic treatment and restoration with a post- retained
crown. This procedure should be preceded by a gingivectomy,
and sometimes ostectomy with osteoplasty.
 Crown-root fracture
without pulp exposure

Treatment (Non-Emergency Treatment Alternatives)

&
 Orthodontic extrusion of apical fragment
Removal of the coronal segment with subsequent endodontic
treatment and orthodontic extrusion of the remaining root
with sufficient length after extrusion to support a post-
retained crown.
 Crown-root fracture
without pulp exposure

Treatment (Non-Emergency Treatment Alternatives)

⑳
 Surgical extrusion
Removal of the mobile fractured fragment with subsequent
surgical repositioning of the root in a more coronal position.

⑨
 Root submergence
Implant solution is planned.
-
 Crown-root fracture
without pulp exposure
Treatment (Non-Emergency Treatment Alternatives)
⑨
 Extraction
Extraction with immediate or delayed implant-retained
crown restoration or a conventional bridge. Extraction is
inevitable in crown-root fractures with a severe apical
extension, the extreme being a vertical fracture.

Follow-up Procedures
6-8 weeks -1 years
Crown-root fracture with pulp exposure
Complicated crown-root fracture
A fracture involving enamel, dentin, and cementum and
exposing the pulp.
Clinical findings
Pulp sensibility tests usually positive
Tender to percussion.
Coronal, or mesial or distal, fragment is usually
present and mobile
The extent of the fracture (sub- or supraalveolar)
should be evaluated
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Imaging, radiographic assessment, and findings
Missing fragments should be accounted for:
- If fragment is missing and there are soft tissue
injuries, radiographs of the lip and/or cheek are
indicated to search for tooth fragments or foreign debris
 Martins et al.
DEPT. OF
Operative Dentistry, PEDIATRIC
2018, 43-3 DENTISTRY

Figure 1. (A) Intraoral view of the Figure 3. Periapical radiograph of the

patient before the treatment. (B) fractured tooth.
Close-up view of the fractured tooth. Figure 4. Clinical aspect of the fragment
Figure 2. Palatine view. still stuck to the gum fibers.
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Imaging, radiographic assessment, and findings
Recommended radiographs:
One parallel periapical radiograph
Two additional radiographs of the tooth taken with
different vertical and/or horizontal angulations
Occlusal radiograph
CBCT can be considered for better visualization of the fracture
path, its extent, and its relationship to the marginal bone; also
useful to evaluate the crown-root ratio and to help determine
treatment options.
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment
Until a treatment plan is finalized, temporary
stabilization of the loose fragment to the adjacent
tooth/teeth or to the non-mobile fragment should be
attempted
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment
In immature teeth with incomplete root formation, it is
advantageous to preserve the pulp by performing a
partial pulpotomy. Rubber dam isolation is challenging
but should be tried.
Non-setting calcium hydroxide or non-staining calcium
silicate cements are suitable materials to be placed on
the pulp wound
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment
In mature teeth with complete root formation, removal
of the pulp is usually indicated
Cover the exposed dentin with glass-ionomer or use a
bonding agent and composite resin
 DEPT. OF
PEDIATRIC
DENTISTRY

Figure 5. Fragment being shifted.

Figure 6. Clinical aspect showing the extension of the
complicated crown-root fracture, invading the biologic width.
Figure 7. Tooth fragment.
Figure 8. Retractor clamp and fragment positioned, certifying
the perfect adaptation to the remaining dental structure.
 DEPT. OF
PEDIATRIC
DENTISTRY

Figure 9. Perfect fragment adaptation to the Figure 11. Diagnostic waxing.

remaining dental structure. Figure 12. Record of occlusal contacts before
Figure 10. Set fragment/remaining dental restoration.
structure light cured for 40 seconds. Figure 13. Fiber post with specified length, from
restoration dimensions previously planned.
 DEPT. OF
PEDIATRIC
DENTISTRY

Figure 14. Restoration completed: incisal view.

Figure 15. Restoration completed: anterior view.
Figure 16. Radiographic view after intra-radicular fiber
post cementation and composite resin reconstruction.

Martins et al.
Operative Dentistry, 2018, 43-3
Crown-root fracture with pulp exposure
Complicated crown-root fracture
The treatment plan is dependent, in part, on the patient's age and
anticipated cooperation. Options include:
 Completion of root canal treatment and restoration

 Orthodontic extrusion of the apical segment (may also need periodontal re-
contouring surgery after extrusion)

 Surgical extrusion

 Root submergence

 Intentional replantation with or without rotation of the root

 Extraction

 Autotransplantation
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment (Non-Emergency Treatment Alternatives)
 Fragment removal and gingivectomy (sometimes ostectomy)
Removal of the coronal fragment with subsequent
endodontic treatment and restoration with a post-retained
crown. This procedure should be preceded by a gingivectomy
and sometimes ostectomy with osteoplasty. This treatment
option is only indicated in crown-root fractures with palatal
subgingival extension.
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment (Non-Emergency Treatment Alternatives)
 Orthodontic extrusion of apical fragment
Removal of the coronal segment with subsequent endodontic
treatment and orthodontic extrusion of the remaining root
with sufficient length after extrusion to support a post-
retained crown.
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment (Non-Emergency Treatment Alternatives)
 Surgical extrusion
Removal of the mobile fractured fragment with subsequent
surgical repositioning of the root in a more coronal position.

 Root submergence
An implant solution is planned, the root fragment may be left
in situ.
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Treatment (Non-Emergency Treatment Alternatives)
 Extraction
Extraction with immediate or delayed implant-retained
crown restoration or a conventional bridge. Extraction is
inevitable in very deep crown-root fractures, the extreme
being a vertical fracture.
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Follow up

Clinical and radiographic evaluations are necessary:

 after 1 wk

 after 6-8 wk

 after 3 mo

 after 6 mo

 after 1 y

 then yearly for at least 5 y

Crown-root fracture with pulp exposure
Complicated crown-root fracture
Favorable outcomes
Asymptomatic
Continued root development in immature teeth
Good quality restoration
Crown-root fracture with pulp exposure
Complicated crown-root fracture
Unfavorable outcomes
 Symptomatic
 Pulp necrosis and infection
 Apical periodontitis
 Lack of further root development in immature teeth
 Loss of restoration
 Breakdown of the restoration
 Marginal bone loss and periodontal inflammation
Root fracture
A fracture of the root involving dentin, pulp and cementum. The
fracture may be horizontal, oblique or a combination of both.

Clinical findings

 The coronal segment may be mobile and may be displaced.

 The tooth may be tender to percussion.

 Bleeding from the gingival sulcus may be noted.

 Pulp sensibility testing may be negative initially, indicating

transient or permanent neural damage
Root fracture
Clinical findings
Sensibility testing may give negative results initially,
indicating transient or permanent neural damage.
Monitoring the status of the pulp is recommended.
Transient crown discoloration (red or grey) may occur.
Root fracture
Imaging, radiographic assessment, and findings
The fracture may be located at any level of the root
Recommended radiographs:
One parallel periapical radiograph
Two additional radiographs of the tooth taken with
different vertical and/or horizontal angulations
Occlusal radiograph
Root fracture
Imaging, radiographic assessment, and findings
Root fractures may be undetected without additional
imaging
In cases where the above radiographs provide
insufficient information for treatment planning, CBCT
can be considered to determine the location, extent
and direction of the fracture
Root fracture
Radiographic findings

If the plane of fracture is more oblique which is

common with apical third fractures, an occlusal view
or radiographs with varying horizontal angles are more
likely to demonstrate the fracture including those
located in the middle third.
Root fracture
Treatment
If displaced, the coronal fragment should be
repositioned as soon as possible.
Check position radiographically.
Stabilize the mobile coronal segment with a passive
and flexible splint for 4 wk. If the fracture is located
cervically, stabilization for a longer period of time (up
to 4 mo) may be needed
Root fracture
Treatment
Cervical fractures have the potential to heal. Thus, the
coronal fragment, especially if not mobile, should not
be removed at the emergency visit
No endodontic treatment should be started at the
emergency visit
It is advisable to monitor healing of the fracture for at
least one year. Pulp status should also be monitored.
Root fracture
Treatment
 Pulp necrosis and infection may develop later.
 It usually occurs in the coronal fragment only. Hence,
endodontic treatment of the coronal segment only will be
indicated.
 As root fracture lines are frequently oblique,
determination of root canal length may be challenging.
 An apexification approach may be needed.
 The apical segment rarely undergoes pathological changes
that require treatment
Root fracture
Treatment
In mature teeth where the cervical fracture line is
located above the alveolar crest and the coronal
fragment is very mobile, removal of the coronal
fragment, followed by root canal treatment and
restoration with a post-retained crown will likely be
required.
Additional procedures such as orthodontic extrusion
of the apical segment, crown lengthening surgery,
surgical extrusion or even extraction may be required
as future treatment options.
Root fracture
Follow-Up
 Clinical and radiographic evaluations are
necessary:
 4 Weeks
 6-8 Weeks
 4 Month
 6 Month
 1 Year
 5 Year
Root fracture

Mobilite ?

Radyografi

11 Palatinale lüksasyon
21 Servikal üçlüde
horizontal kök kırığı,
splintleme süresi 4 aya kadar
Erkek çocuk, 8 yaşında, okulda düşmüş!
Root fracture

Splintleme
kalın retainer teli+kompozit reçine

Canlılık?
Soğuk Testi +
Root fracture

4 ay sonra
Kök kanalında Canlılık?
kasifikasyona bağlı Soğuk Testi +

daralma
Root fracture
Root fracture
Favorable outcomes
 Positive response to pulp sensibility testing; however, a
false negative response is possible for several months.
 Endodontic treatment should not be started solely on the
basis of no response to pulp sensibility testing.
 Signs of repair between the fractured segments
 Normal or slightly more than physiological mobility of the
coronal fragment
 Root fracture
Unfavorable Outcomes
 Symptomatic
Extrusion and/or excessive mobility of he coronal
segment
Radiolucency at the fracture line
Pulp necrosis and infection with inflammation in the
fracture line
Treatment Guidelines
For Luxation Injuries

CONCUSSION
SUBLUXATION
EXTRUSIVE LUXATION
LATERAL LUXATION
INTRUSIVE LUXATION
 CONCUSSION
Clinical findings
Normal mobility
The tooth is tender to percussion and touch
The tooth will likely respond to pulp sensibility testing
 CONCUSSION
Imaging, radiographic assessment, and findings
No radiographic abnormalities
Recommended radiographs:
One parallel periapical radiograph
Additional radiographs are indicated if signs or
symptoms of other potential injuries are present
 CONCUSSION

Treatment
No treatment is needed.

Monitor pulpal condition for at least one year, but

preferably longer
 CONCUSSION
Follow up
Clinical and radiographic evaluations are necessary:
after 4 wk
after 1 y
 CONCUSSION
Favorable Outcome
Asymptomatic
 Positive response to pulp sensibility testing; however, a
false negative response is possible for several months.
Endodontic treatment should not be started solely on the
basis of no response to pulp sensibility testing
Continuing root development in immature teeth
 Intact lamina dura
 CONCUSSION

Unfavorable Outcome
Symptomatic
 Pulp necrosis and infection
Apical periodontitis
No further root development in immature teeth
 SUBLUXATION
Clinical findings
An injury to the tooth supporting structures with
abnormal loosening, but without displacement of the
tooth
The tooth is tender to touch or tapping;
Tooth has increased mobility but is not displaced
Bleeding from the gingival crevice may be present
The tooth may not respond to pulp sensibility testing
initially indicating transient pulp damage
 SUBLUXATION
Imaging, radiographic assessment, and findings
Radiographic appearance is usually normal
Recommended radiographs:
One parallel periapical radiograph
Two additional radiographs of the tooth taken with
different vertical and/or horizontal angulations
Occlusal radiograph
 SUBLUXATION
Treatment
Normally no treatment is needed
A passive and flexible splint to stabilize the tooth for
up to 2 wk may be used but only if there is excessive
mobility or tenderness when biting on the tooth
Monitor the pulp condition for at least one year, but
preferably longer
 SUBLUXATION
Follow up
Clinical and radiographic evaluations are necessary:

 After 2 Weeks
 After 12 Weeks
 After 6 Months
 After 1 Year
 SUBLUXATION

Favorable Outcome
 Asymptomatic
 Positive response to pulp sensibility testing; however, a
false negative response is possible for several months.
Endodontic treatment should not be started solely on the
basis of no response to pulp sensibility testing
 Continuing root development in immature teeth
 Intact lamina dura
 SUBLUXATION
Unfavorable Outcome

 Symptomatic

 Pulp necrosis and infection

 Apical periodontitis

 No further root development in immature teeth

 External inflammatory (infection-related) resorption

if this type of resorption develops, root canal treatment should

be initiated immediately, with the use of calcium hydroxide as an intra-
canal medicament. Alternatively, corticosteroid/antibiotic medicament
can be used initially, which is then followed by calcium hydroxide
 SUBLUXATION

Age 11, girl, autism, fall at school

EXTRUSIVE LUXATION

Displacement of the tooth out of its socket in an incisal/axial

direction
Clinical Findings
 The tooth appears elongated
 The tooth has increased mobility
 The tooth will appear elongated incisally
 Likely to have no response to pulp sensibility tests
EXTRUSIVE LUXATION
Imaging, radiographic assessment, and findings

 Increased periodontal ligament space both apically and laterally

 Tooth will not be seated in its socket and will appear elongated
incisally

Recommended radiographs:

 One parallel periapical radiograph

 Two additional radiographs of the tooth taken with different

vertical and/or horizontal angulations

 Occlusal radiograph
 EXTRUSIVE LUXATION
Treatment

 Reposition the tooth by gently pushing it back into the

tooth socket under local anesthesia
 Stabilize the tooth for 2 wk using a passive and flexible
splint. If breakdown/fracture of the marginal bone, splint
for an additional 4 wk
 Monitor the pulp condition with pulp sensibility tests
 If the pulp becomes necrotic and infected, endodontic
treatment appropriate to the tooth's stage of root
development is indicated
 DEPT. OF
PEDIATRIC
DENTISTRY

Age 7.5, boy, Extrusive luxation in tooth #11

collision accident at school Laceration in the midline frenulum

Repositioning of the tooth Suturing of the mucosa

 DEPT. OF
PEDIATRIC
DENTISTRY

Semi-rigid splinting with orthodontic Intra-oral view after 2 weeks

retainer wire an composite resin

Occlusal view after 2 weeks

Periapical radiography revealing incomplete
root fracture in the middle third
 DEPT. OF
PEDIATRIC
DENTISTRY

6 months

12 months
 DEPT. OF
PEDIATRIC
DENTISTRY

Baseline 6 months 12 months

24 months 36 months
 EXTRUSIVE LUXATION
Follow up
Clinical and radiographic evaluations are necessary:

 after 2 wk

 after 4 wk

 after 8 wk

 after 12 wk

 after 6 mo

 after 1 y

 then yearly for at least 5 y

 EXTRUSIVE LUXATION
Follow up
Patients (and parents, where relevant) should be
informed to watch for any unfavorable outcomes and
the need to return to clinic if they observe any
Where unfavorable outcomes are identified,
treatment is often required.
Referral to a dentist with the relevant expertise,
training and experience is advised.
 EXTRUSIVE LUXATION
Favorable Outcome
 Asymptomatic
 Clinical and radiographic signs of normal or healed
periodontium.
 Positive response to pulp sensibility testing; however, a
false negative response is possible for several months.
Endodontic treatment should not be started solely on the
basis of no response to pulp sensibility testing.
 Marginal bone height corresponds to that seen
radiographically after repositioning.
 Continuing root development in immature teeth.
 EXTRUSIVE LUXATION
Unfavorable Outcome
 Symptomatic
 Pulp necrosis and infection
 Apical periodontitis
 Breakdown of marginal bone
 External inflammatory (infection-related) resorption – if
this type of resorption develops, root canal treatment
should be initiated immediately, with the use of calcium
hydroxide as an intracanal medicament.
 Alternatively, corticosteroid/antibiotic medicament can be
used initially, which is then followed by calcium hydroxide
 LATERAL LUXATION
Clinical findings
Displacement of the tooth in any lateral direction, usually
associated with a fracture or compression of the alveolar socket
wall or facial cortical bone

 The tooth is displaced, usually in a palatal/lingual or labial

direction.

 There is usually an associated fracture of the alveolar bone

 The tooth is frequently immobile as the apex of the root is

“locked” in by the bone fracture

 Percussion will give a high metallic (ankylotic) sound

 Likely to have no response to pulp sensibility tests

 LATERAL LUXATION
Imaging, radiographic assessment, and findings

A widened periodontal ligament space which is best

seen on radiographs taken with horizontal angle shifts or
occlusal exposures.
Recommended radiographs:
- One parallel periapical radiograph
- Two additional radiographs of the tooth taken with
different vertical and/or horizontal angulations
- Occlusal radiograph
 LATERAL LUXATION
Treatment
Reposition the tooth digitally by disengaging it from its
locked position and gently reposition it into its original
location under local anesthesia.

Method: Palpate the gingiva to feel the apex of the

tooth. Use one finger to push downwards over the
apical end of the tooth, then use another finger or
thumb to push the tooth back into its socket
 LATERAL LUXATION
Treatment
 Stabilize the tooth for 4 wk using a passive and flexible
splint. If breakdown/fracture of the marginal bone or
alveolar socket wall, additional splinting may be required

 Monitor the pulp condition with pulp sensibility tests at

the follow-up appointments.

At about 2 wk post-injury, make an endodontic evaluation:

 LATERAL LUXATION
Treatment
Teeth with incomplete root formation:

 Spontaneous revascularization may occur.

 If the pulp becomes necrotic and there are signs of

inflammatory (infection-related) external resorption, root
canal treatment should be started as soon as possible.

 Endodontic procedures suitable for immature teeth should

be used
 LATERAL LUXATION
Treatment
Teeth with complete root formation:

 The pulp will likely become necrotic.

 Root canal treatment should be started, using a

corticosteroid- antibiotic or calcium hydroxide as an intra-
canal medicament to prevent the development of
inflammatory (infection-related) external resorption
 LATERAL LUXATION DEPT. OF
PEDIATRIC
DENTISTRY

Extraoral view showing contusion Panoramic radiograph.

lesion and abrasion on the chin. Normal TMJ structures, without injury.

Honório HM, de Alencar CR, Pereira Júnior ES, de Oliveira DS, de Oliveira GC, Rios D.
Posttraumatic displacement management: lateral luxation and alveolar bone fracture in
young permanent teeth with 5 years of follow-up.
Case Rep Dent. 2015;2015:634237.
 LATERAL LUXATION

Initial intraoral view. Bone fracture reduction by

digital pressure.

Honório HM, de Alencar CR, Pereira Júnior ES, de Oliveira DS, de Oliveira GC, Rios D.
Posttraumatic displacement management: lateral luxation and alveolar bone fracture in
young permanent teeth with 5 years of follow-up.
Case Rep Dent. 2015;2015:634237.
 LATERAL LUXATION

Flexible splint made with resin composite and 0.7mm Radiographic view
orthodontic wire onto the labial surface of the teeth of the injured area.
involved and the immediately adjacent teeth.

Honório HM, de Alencar CR, Pereira Júnior ES, de Oliveira DS, de Oliveira GC, Rios D.
Posttraumatic displacement management: lateral luxation and alveolar bone fracture in
young permanent teeth with 5 years of follow-up.
Case Rep Dent. 2015;2015:634237.
 LATERAL LUXATION

Clinical aspect after removal of the splint Radiographic image without splint
showing the normality of soft tissues. (after 6 weeks of the trauma) indicating
no pulp and periodontal pathologies.

Honório HM, de Alencar CR, Pereira Júnior ES, de Oliveira DS, de Oliveira GC, Rios D.
Posttraumatic displacement management: lateral luxation and alveolar bone fracture in
young permanent teeth with 5 years of follow-up.
Case Rep Dent. 2015;2015:634237.
 LATERAL LUXATION

Five-year clinical follow-up. Radiographic image after 5 years of the trauma.

Full closure of the apexes and marked
obliteration of the root canal lumens.

Honório HM, de Alencar CR, Pereira Júnior ES, de Oliveira DS, de Oliveira GC, Rios D.
Posttraumatic displacement management: lateral luxation and alveolar bone fracture in
young permanent teeth with 5 years of follow-up.
Case Rep Dent. 2015;2015:634237.
 LATERAL LUXATION
Follow up
Clinical and radiographic evaluations are necessary
 after 2 wk
 after 4 wk S+
 after 8 wk
 after 12 wk
 after 6 mo
 after 1 y
 then yearly for at least 5 y
 LATERAL LUXATION
Follow up
Patients (and parents, where relevant) should be
informed to watch for any unfavorable outcomes and
the need to return to clinic if they observe any

 Where unfavorable outcomes are identified,

treatment is often required.

Referral to a dentist with the relevant expertise,

training and experience is advised.
 LATERAL LUXATION
Favorable outcome
 Asymptomatic

 Clinical and radiographic signs of normal or healed

periodontium.

 Positive response to pulp sensibility testing; however, a false

negative response is possible for several months. Endodontic
treatment should not be started solely on the basis of no
response to pulp sensibility testing

 Marginal bone height corresponds to that seen radiographically

after repositioning

 Continued root development in immature teeth

 LATERAL LUXATION
Unfavorable outcome
 Symptomatic
 Breakdown of marginal bone
 Pulp necrosis and infection
 Apical periodontitis
 Ankylosis
 External replacement resorption
 LATERAL LUXATION
Unfavorable outcome
 External inflammatory (infection-related) resorption

 External inflammatory(infection-related) resorption – if

this type of resorption develops, root canal treatment
should be initiated immediately, with the use of calcium
hydroxide as an intracanal medicament.

 Alternatively, corticosteroid/antibiotic medicament can be

used initially, which is then followed by calcium hydroxide.
 INTRUSIVE LUXATION
Clinical findings
Displacement of the tooth in an apical direction into the
alveolar bone.
 The tooth is displaced axially into the alveolar bone
 The tooth is immobile
 Percussion will give a high metallic (ankylotic) sound
 Likely to have no response to pulp sensibility tests
 INTRUSIVE LUXATION
Imaging, radiographic assessment, and findings
 The periodontal ligament space may not be visible for all or
part of the root (especially apically)

 The cementoenamel junction is located more apically in the

intruded tooth than in adjacent noninjured teeth

Recommended radiographs:

 One parallel periapical radiograph

 Two additional radiographs of the tooth taken with different

vertical and/or horizontal angulations

 Occlusal radiograph
 INTRUSIVE LUXATION
Treatment
Teeth with incomplete root formation (immature teeth):
Allow re-eruption without intervention (spontaneous
repositioning) for all intruded teeth independent of
the degree of intrusion
If no re-eruption within 4 wk, initiate orthodontic
repositioning
Monitor the pulp condition
 INTRUSIVE LUXATION
Treatment
Teeth with incomplete root formation (immature teeth):

 In teeth with incomplete root formation spontaneous pulp

revascularization may occur.

 However, if it is noted that the pulp becomes necrotic and

infected or that there are signs of inflammatory (infection-
related) external resorption at follow-up appointments, root
canal treatment is indicated and should be started as soon as
possible when the position of the tooth allows. Endodontic
procedures suitable for immature teeth should be used.

 Parents must be informed about the necessity of follow-up

visits
 INTRUSIVE LUXATION
Treatment
Teeth with complete root formation (mature teeth):
 Allow re-eruption without intervention if the tooth is
intruded less than 3 mm. If no reeruption within 8 wk,
reposition surgically and splint for 4 wk with a passive and
flexible splint. Alternatively, reposition orthodontically
before ankylosis develops
 If the tooth is intruded 3-7 mm, reposition surgically
(preferably) or orthodontically
 If the tooth is intruded beyond 7mm, reposition surgically
 INTRUSIVE LUXATION
Treatment
Teeth with complete root formation (mature teeth):

In teeth with complete root formation, the pulp almost

always becomes necrotic. Root canal treatment should be
started at 2 wk or as soon as the position of the tooth allows,
using a corticosteroid-antibiotic or calcium hydroxide as an
intra-canal medication. The purpose of this treatment is to
prevent the development of inflammatory (infection-related)
external resorption.
 INTRUSIVE LUXATION

9 year old boy.

Traffic accident, a car crashed and fell over the
face.
INTRUSIVE LUXATION

• Surgically exposing of the crowns of

the teeth
• Stainless steel braces and ligature
wires are applied
• Frenectomy for releasing the flap
INTRUSIVE LUXATION

Orthodontic eruption by using

a removable applience
 DEPT. OF
PEDIATRIC
DENTISTRY
INTRUSIVE LUXATION

6 months
Tedaviden 6 ay later
sonra 1 year later
Tedaviden bir yıl sonra
 INTRUSIVE LUXATION
Follow up
Clinical and radiographic evaluations are necessary:
 after 2 wk
 after 4 wk S+
 after 8 wk
 after 12 wk
 after 6 mo
 after 1 y
 then yearly for at least 5 y
 INTRUSIVE LUXATION
Follow up

Patients (and parents, where relevant) should be

informed to watch for any unfavorable outcomes and
the need to return to clinic if they observe any
Where unfavorable outcomes are identified,
treatment is often required. Referral to a dentist with
the relevant expertise, training and experience is
advised
 INTRUSIVE LUXATION
Favorable Outcome
 Asymptomatic

 Tooth in place or is re-erupting

 Intact lamina dura

 Positive response to pulp sensibility testing; however, a false

negative response is possible for several months.

 Endodontic treatment should not be started solely on the basis

of no response to pulp sensibility testing

 No signs of root resorption

 Continued root development in immature teeth

 INTRUSIVE LUXATION
Unfavorable Outcome
Symptomatic
Tooth locked in place/ankylotic tone to percussion
Pulp necrosis and infection
Apical periodontitis
Ankylosis
External replacement resorption
 INTRUSIVE LUXATION
Unfavorable Outcome

External inflammatory (infection-related) resorption –

if this type of resorption develops, root canal
treatment should be initiated immediately, with the
use of calcium hydroxide as an intracanal medicament.
Alternatively, corticosteroid/antibiotic medicament
can be used initially, which is then followed by calcium
hydroxide