Lec.

11
Management of
Trauma to the Teeth
and Supporting
Tissues
Assistant Professor
Aseel Haidar
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Assist. Prof. Dr. Aseel Haidar

Methods of Clinical Examination

1. Visual Examination:
a. Any leakage of straw colored fluid from the nose, bruising, hemorrhage or
laceration of the soft tissues or swelling.
b. Type of fracture.
c. Discoloration of the tooth.
d. Oral hygiene.
e. Occlusion.
f. Deviation in the path of mandible during mouth opening.

The clinical examination should be conducted after the teeth in the area of injury
have been carefully cleaned of debris. A piece of cotton moistened with saline or hydrogen
peroxide can be used to clean the teeth and surrounded area .When the injury has resulted
in a fracture of the crown, the dentist should observe the amount of tooth structure that has
been lost and should look for evidence of pulp exposure. With the aid of a good light, the
dentist should carefully examine the clinical crown for cracks and craze lines, the presence
of which could influence the type of permanent restoration used for the tooth. With light
transmitted through the teeth in the area, the color of the injured tooth should be carefully
compared with that of adjacent uninjured teeth.

2. Digital examination:
a. Tenderness of the tooth to gentile percussion.
b. Mobility of the tooth.
c. Vitality test of the injured tooth by thermal or electrical pulp tester.
Immediately after trauma, it does not give response to vitality test (why?)
reexamine the tooth after 6 weeks and if the child does not give response, this is an indicator
that the tooth is non vital. The injured tooth should be performed, and the teeth in the
immediate area, as well as those in the opposing arch, should be tested. When the electric
pulp tester is used, the dentist should first determine the normal reading by testing an
uninjured tooth on the opposite side of the mouth and recording the lowest number at which
the tooth responds. If the injured tooth requires more current than does a normal tooth, the
pulp may be undergoing degenerative change, whereas if it required less current, pulpal
inflammation is usually indicated. Pulp testing following traumatic injuries is a
controversial issue. These procedures require cooperation and a relaxed patient, in order to
avoid false reaction. However, this is often not possible during initial treatment of injured

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patients, especially children. Furthermore, the electric pulp test is frequently unreliable,
even on normal teeth when apices are incompletely formed.
The thermal test is also somewhat helpful in determining the degree of pulpal
damage after trauma. Although there are difficulties with the thermal test, it is probably
more reliable than the electric pulp test in testing primary incisors in young children.
Failure of a tooth to respond to heat indicates pulpal necrosis. The response of a tooth to a
lower degree of heat than is necessary to elicit a response in adjacent teeth is an indication
of inflammation. Pain occurring when ice is applied to a normal tooth will subside when
the ice is removed. A more painful and often lingering reaction to cold indicates a
pathologic change within the pulp, the nature of which can be determined when the reaction
is correlated with other clinical observations.
Failure of a recently traumatized tooth to respond to the pulp test is not uncommon and
may indicate a previous injury with a resulting necrotic pulp. However, the traumatized
tooth may be in a state of shock and as a result may fail to respond to the accepted methods
of determining pulp vitality. The failure of a pulp to respond immediately after an accident
is not an indication for endodontic therapy. Instead, emergency treatment should be
completed, and the tooth should be retested at the next follow-up visit.

Note: In children the electric pulp tester is controversy because it needs cooperation
and a relaxed child. When the child come from the 1st time because of anxiety the child
will give false response.

3. Radiographical Examination:
The examination of traumatized teeth cannot be considered complete without a
radiograph of the injured tooth, the adjacent teeth, and sometimes the teeth in the opposing
arch. In search of a fractured tooth fragment, it may be necessary to obtain a radiograph of
the soft tissue surrounding the injury site.
Radiographs are taken for:
1) Baseline evaluation.
2) Medicolegal records.
3) Follow up evaluation (comparison with the records in future). Frequent, periodic
radiographs reveal evidence of continued pulp vitality or adverse changes that take
place within the pulp or the supporting tissues. In young teeth in which the pulp
recovers from the initial trauma, the pulp chamber and canal decrease in size
coincident with the normal formation of secondary dentin. After a period of time an
inconsistency in the true size or contour of the pulp chamber or canal compared with
that of adjacent teeth may indicate a developing pathologic condition.
4) To assess the size of pulp chamber and proximity to the fracture line. The relative
sizes of the pulp chamber and canal should be carefully examined. Irregularities or

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an inconsistency in the size of the chamber or canal compared with that of adjacent
teeth may be evidence of a previous injury. This observation is important in
determining the immediate course of treatment.
5) Determine the stage of root development (the stage of apical development often
indicates the type of treatment).
6) Presence of root fracture or alveolar bone fracture. A root fracture as a result of the
injury or one previously sustained can be detected by a careful examination of the
radiograph. However, the presence of a root fracture may not influence the course
of treatment, particularly if the fracture line is in the region of the apical third. Teeth
with root fractures in this area rarely need stabilization, and a fibrous or calcified
union usually results.
7) To ascertain the position of traumatized tooth and its relationship to the unerupted
teeth in the area (dislocation of the tooth). If teeth have been discernibly dislocated,
with or without root fracture, two or three radiographs of the area at different angles
may be needed to clearly define the defect and aid the dentist in deciding on a course
of treatment.
8) Periodontal ligament condition.
9) Pre-existing pathological condition.
10) Extraoral radiographs help in diagnosis of jaw fractures, complex injuries (to
identify the extent and location of all injuries e.g. panoramic, oblique lateral
jaw radiograph are useful in addition to the diagnostic process.
11) Soft tissue radiographs are helpful in determining displacement of tooth/teeth
fragments into adjacent soft tissue.

Emergency Treatment of Soft Tissue Injury

Injury to the teeth of children is often accompanied by:
1) Open wounds of the oral tissues,
2) Abrasion of the facial tissues,
3) Puncture wounds.
The dentist must recognize the possibility of the development of tetanus
after the injury and must carry out adequate first-aid measures. Primary immunization
is usually a part of medical care during the first 2 years of life. However, primary
immunization cannot be assumed—it must be confirmed by examination of the child’s
medical record. When the child who has had primary immunization receives an injury
from an object that is likely to have been contaminated, the antibody-forming
mechanism may be activated with a booster injection of toxoid. An unimmunized child
can be protected through passive immunization or serotherapy with tetanus antitoxin
(tetanus immune globulin, or TIG).

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The dentist examining the child after an injury should determine the child’s
immunization status, carry out adequate debridement of the wound, and, when
indicated, refer the child to the family physician. Tetanus is often fatal, and preventive
measures must be taken if there is a possibility that an injured child is not adequately
immunized.
Debridement, suturing, and/or hemorrhage control of open soft-tissue
wounds should be carried out as indicated.
Working with an oral and maxillofacial surgeon or a plastic surgeon may also be
indicated. In extensive injury the child should be hospitalized.

Note: The aim of treatment of any injured tooth is to:

1) Maintain vitality
2) Allow normal development and growth of the jaws and alveolar bone

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