Management of Trauma in Children- what you may want to read!

Management of Dental Trauma in Children

1. What are the most common causes of trauma in children?

2. What is the frequency of dental trauma in children?

3. How should a dentist assess a traumatized child?

4. What are the possible consequences of trauma to primary teeth? And how would you manage them?

5. What should you discus with the parents of a child who has been subjected to a traumatic injury of his primary dentition?

6. What are the types of maxillofacial injuries that can occur in children? What are their consequences?

7. How would you manage crown and root fracture of permanent teeth in children?

8. What kinds of luxative injuries might take place in the permanent teeth of young children? And how can you manage them?

9. How can you manage permanent tooth avulsion?

1. According to Hall's study conducted in 1994 in the Royal Children Hospital of Melbourne;
the most common cause of trauma in young children are falls, play accidents and motor vehicle accidents ranging generally between 17% up more than 40% in cases of falls.

Trauma as a result of a fall most commonly occurs in children below the age of 5 years old, especially in toddlers, due to limited abilities of walking properly in this early stage of life and because of the eruption of maxillary incisors earlier than the surrounding teeth which will be more prominent and more liable to receive the force of the fall. Play accidents are more common among 5-10 years old children and so are motor vehicle accidents. Sporting accidents account for about 8% of cases. And dog bites account for about 6% of cases. Sporting events are more common among children 10-15 years old. Dog bites are more common among children aged 5-10 years. This study signified the danger associated with unsupervised communication between young children and home pets.

Child abuse accounts for only 1% of cases of trauma in young children, however what is significant about the role of child abuse as a cause of trauma is that it is more common among very young children less than 5 years old with 80% of cases occurring in preschoolers. 

Child abuse is defined as those actions or omission of care which will prevent the child from achieving his full potential whether physically, emotionally, or socially.
There are 4 main kinds of child abuse recognized:

· Physical abuse

· Emotional abuse

· Sexual abuse

· Neglect

Dental neglect is defined as the knowingly failure of seeking treatment and professional care for an oro-facial condition of the child that might affect his normal growth and development. The first step in prevention of child abuse is to recognize it and report it. Dentist is in a strategic position to recognize cases of child abuse, since he spends lots of times with children and their parents in the dental clinic through many visits extending through different stages of development. In Australia, once a dentist recognizes a case of child abuse, he can report it to child abuse teams in pediatric hospitals or to the department of family and communication services.

Signs of child abuse include:

· Injuries which don't match the given history

· Repeated injuries in different parts of the body through different periods of time

· Soft tissue injuries occurring in areas which don't over lie a bony prominence

· Bite marks are considered to be signs of child abuse until proven otherwise

Back to the etiology of trauma in children, it is important to point out that blunt trauma is associated with soft tissue injuries more commonly, while sharp injuries and high velocity injuries are more commonly associated with dental trauma and hard tissue injuries. One of the most important predisposing factors is the over jet. An over jet between 3-6 mm is associated with double the chance of traumatic injuries of maxillary anterior teeth while an over jet over 6 mm has triple the chance. Class II division I is also among the predisposing factors.

2. 11-30% of children receive trauma to primary teeth, with those kinds of injuries representing 20% of injury cases in children. 22% of children below the age of 14 years old receive trauma to permanent teeth. Traumatic injuries are more common in boys than in girls with the ratio of 2:1. The peak incidence of those traumatic injuries occurs between the age of 2-4 years old and at the age of 8-10 years old. Maxillary anterior teeth are the most commonly involved teeth in those injuries. In most of those injuries a single tooth is involved except in sporting and motor vehicle accidents.

3. A child should be assessed systematically and properly in an ordered logical sequence. Most children with apparently more extensive forms of trauma will be managed in a child causality department, or emergency departments in hospitals, where a thorough medical examination of the entire body is likely to take place. Here, I will focus on those cases of traumatized children which are apparently less extensive and which are brought directly to a general dental practice.

The first step that should be performed by a dentist in such a case is to take a systematic history for the patient.
Questions directed to the child and parents should include:

· Where, when, and how the trauma occurred?

· Is there any other concomitant injury?

· Did similar injuries occur before?

· What are the symptoms that the child complains of in association with the trauma?

· What is the immunization status of the child? If the child is following his normal schedule for immunization, then no special consideration should be made. However, if the injury is contaminated, especially if it occurred in a farm environment, the child should be given a poster tetanus dose of 0.5% tetanus toxoid intramuscularly.

· Does the child have any special medical conditions?

· How the injury was initially managed?

· When did the child last eat or drink something? It is important that a child who is going to be treated under general anesthesia or sedation be fasting. A child under the age of 6 years old shouldn't have had any food whether solid or liquid for 6 years. A child older than 6 years old shouldn't have had any liquid food for 2 hours and solid food for 6 hours.

· Ask questions which might reveal whether or not there is a possibility of child abuse.

The second step in assessing a traumatized child is to perform a full clinical examination of the child in a logical sequence.

It is recommended to photograph the injury. It is very important that the dentist check the child for any other possible injury that might be more significant than the dental trauma which he parents might be mainly concerned with. The most serious injury that a dentist should rule out is closed head injury. Closed head injury is the most common cause of death of children subjected to accidents. 25-50% of children receive injuries in the head region when subjected to an accident.

The clinical signs and symptoms of closed head injuries include the following:

· Altered consciousness or loss of it

· Disorientation

· Prolonged headache

· Amnesia

· Altered vision and dilatation of one pupil

· Nausea and vomiting

· Seizures and convulsions

· Disturbed speech

· Bleeding from the head or ear

In case of a suspected closed head injury, the child should be directed immediately to a child causality department in a hospital or to the emergency department. Level of consciousness can be assessed by Glasgow comma scale. it is also important to exclude possible involvement of cranial nerves.
When there is an evidence of neurological injury, oro-facial trauma occupies second place in importance. Once closed head injury and neurological injuries are excluded,
Clinical examination can be conducted according to the following steps:

· Examine for extra-oral wounds, bruises or swellings

· Palpation of the facial skeleton

· Examination of the oral mucosa and gingiva

· Palpation of alveolar bone

· Examination for displacement of teeth

· Examination of the occlusion

· Examination of the extent of enamel, dentin and pulp involvement in case of dental fractures

· Examination of mobility of the teeth

· Pulp sensibility test, and percussion

The third crucial step in assessment of a traumatized child is   
-   to conduct the essential investigations. 

Those investigations include the following:

· Radiographs: extra-oral exposures such as panoramic radiological examination are highly valuable since they might be the only available option for a child who is so much distressed because of the trauma. However, if periapical radiographs are possible, take many periapical radiographs of the traumatized tooth at different vertical and horizontal angulations to reveal any initially non apparent radicular fractures. It is always advisable to take a second radiographic exposure two weeks following the trauma, since horizontal root fractures tend to be hidden initially and then become apparent radiographicaly with the accumulation of inflammatory exudates that push the fracture segments apart. It is a general requirement to make a radiographic examination of any traumatized tooth as a baseline for the following purposes: to reveal the extent of root development, and to be aware of the condition of the root and periapical supporting structures.

 The recommended radiographs prescribed for various kinds of injuries include the following:

o For dental injuries:   panoramic view, anterior maxillary oclussal and anterior mandibular oclussal, and true lateral maxillary for intruded anterior primary teeth.

o For condylar fractures: panoramic view, CBCT or reverse Town's projection

o For mandibular fractures: panoramic view, anterior mandibular oclussal and true mandibular oclussal, and oblique lateral (even though not commonly used nowadays)

o For maxillary fractures: CBCT or medical CT. views such as reverse Town's and Water's projection (Occipitomental 30 degrees), and lateral oblique views are not commonly used nowadays but they might still be useful in some cases.

· Pulp sensibility test: pulp sensibility test will give negative results in most of the cases of traumatized teeth. However, all traumatized teeth should be examined by pulp sensibility test to record a baseline response against which comparison at review visits can be made. Pulp sensibility test is the name used nowadays to refer to what was previously known as a pulp vitality test. This new nomenclature stresses the distinction between the assessment of neurological component of the pulp and the vascular component. Negative results of pulp sensibility tests reveal neurological damage of the pulp tissue which might take up to one year to be overcome or might never be over come. However, negative responses don't necessarily indicate damage of the vascular component. The integrity of the vascular component is what is of greater significance when it comes to the prognosis of the dental pulp. The clinician should be aware of other clinical signs of pulp infection such as crown discoloration, excessive mobility, gingival swelling, tenderness on percussion, or sinus formation. The clinical must also be aware the positive false results might take place since young children might not be able to differentiate between the tough of the tester and the stimulation itself.

Thermal cold sensibility tests provide the most reliable results. The use of carbon dioxide pencils is the most reliable but expensive option. The use of ethyl chloride spray or ice might also be indicated. One advantage of cold thermal tests is that it can be used when teeth are covered by temporary crowns and splints. Electrical pulp testing might also be used. Their value in young children is equivocal. They allow giving a graded response. However, the rheostat should be increased gradually to avoid unnecessary painful stimulation.

· Percussion is important for two main purposes: to detect the condition of the periapical supporting tissues. However all luxated teeth will tend to be tender to percussion. In addition it provides information through the resultant sound, which is particularly important when it comes to ankylosis.

· Transillumination: particularly important in revealing cracks and fractures and crown discoloration.

· The final point to be put in consideration is that the condition of the child must be discussed with the parents both to reassure them since most of injuries are really less severe than they initially appear and to inform the parents about the sequelae of the trauma as they are so that they would be ready in participating efficiently in management of their child condition.

4. There are two kinds of injuries which might occur in primary teeth:

luxative injuries and dental fractures.

Unlike permanent teeth; primary teeth are more commonly luxated than fractured.
 
Luxation injuries include the following:

· Concussion and subluxation:    concussion injuries are those at which the periodontal ligament has been traumatized, but the teeth themselves are neither mobile nor displaced. Subluxation injuries are those at which the periodontal ligament is mainly injured, the teeth become mobile, but they are not displaced. In both cases there is inflammation and hemorrhage in the periodontal ligament. However, apparent gingival bleeding can only be detected in subluxation injuries. In both cases there is tenderness on percussion. Management of those injuries is very conservative. Take baseline radiographic exposure at different angulations, perform pulp sensibility test as baseline record, advice for soft diet for 1 week, and construct an individualized follow up program.

· Intrusive luxations: this is the most common type of traumatic injury in anterior primary teeth. The tooth is often displaced so that the crown is displaced superiorly and palatally and thus the root is displaced away from the underlying permanent tooth bud. If the intruded tooth is still visible, then it can be left to re-erupt. If the crown of the tooth became totally hidden, then the tooth should be removed.

· Lateral luxation and extrusion: in this type of injury, the tooth is visibly displaced. If the amount of displacement and associated tissue damage is extensive, the tooth should be removed. However, if displacement is limited the tooth can be left as it is.

· Avulsion of primary teeth:    avulsed primary teeth should not be replanted. 
   Replanting an avulsed primary tooth might let the root of the primary tooth encroach upon the underlying permanent tooth bud or might push the blood clot itself damaging the underlying tooth bud. In addition, a young child is not cooperative enough to allow the placement of a splint. In some instances, a parent might have already replanted the tooth before appearing in the dental clinic. The tooth might even become stable and viable. In such cases leave the tooth as it is and follow it up.

In addition to luxation injuries, a primary tooth might be fractured. 

Dental fractures of primary teeth might include the following:

· Uncomplicated crown fractures:    in such fractures, there is no involvement of the dental pulp. In such cases, the fracture might be limited to the enamel. In such cases, all you have to do is to smoothen the enamel margin with an abrasive disk. If the fracture extends into the dentin. Cover the exposed dentin with GIC and restore the tooth with composite resin. Composite strip crowns are highly valuable in such situations. 

· Complicated crown/root fracture:   this is the more common type of fractures occurring in primary teeth. Those fractures involve exposure of the dental pulp and they extend below the gingival margin. Such fractures commonly show various fracture lines in the individual tooth. Such teeth should be removed. A common clinical presentation of those fractures is the child appearing in the dental clinic few days following the trauma with a pulp poly separating the fractures segments apart. This is a protective reaction and pain is commonly absent. In general pain develops associated with movement of the crown fractured segment still attached to the gingiva or to the periodontal ligament. The coronal segment should be removed and the apical portion if small is left where it will undergo resorption with the normal eruption of the underlying permanent successor. If the apical segment is larger it might be removed if convenient. This might require sedation or general anesthesia. Parents should be informed if the apical segment is left.

· Radicular fractures: isolated radicular fractures of primary teeth are uncommon. However, if present, remove the coronal segment and leave the apical segment to undergo resorption with the eruption of the underlying permanent successor.

· Dento-alveolar fractures:   this type of fracture is commonly seen in the lower labial alveolar plate of bone which is fracture and displaced labially with the lower anterior teeth. In such cases, carefully dissect the extensively mobile lower anterior primary teeth without damaging the labial alveolar plate of bone and then reposition the labial alveolar plate of bone together with teeth and suture the labial and lingual alveolar plates of bone together with thick nylon monofilament suture (2-0).

In general antibiotics are not required in those injuries, unless there is extensive contamination of the wounds. In such cases, use prophylactic broad spectrum antibiotics such as amoxicillin. Don't use tetracycline since it might cause staining of permanent teeth. Doses of antibiotics will depend on the child's weight. The use of antibiotics should not replace debridement of the wounds. 

5. The parents must be informed about the sequelae of traumatic injuries to the primary dentition of their child, especially when it comes to the effect it might have on the permanent dentition. 25% of cases of traumatic injuries of primary teeth show some degree of disturbance in the development of permanent dentition.
The extent of this effect will depend upon:

· The direction and force of the trauma

· The degree of alveolar involvement

· The stage of development of the permanent teeth

The sequelae of traumatic injuries to primary teeth include the following:

· Pulp necrosis of the primary tooth together with crown gray discoloration and possibly abscess formation.

· External replacement resorption of anterior teeth. In case of external replacement root resorption, there is ankylosis of the primary tooth together with infra-occlusion. On the other hand, internal resorption might take place as well.

· Enamel hypomineralization or hypoplasia of permanent teeth

· Dilacerations of the crown or root of the permanent tooth

· Resorption of the underlying permanent tooth bud.

However, the parents should be reassured that most of those complications can be managed successfully.
 In case of crown discoloration of an otherwise asymptomatic tooth, a composite resin restoration can be used to provide better esthetics while maintain the tooth.
 In case of abscess formation, pulpectomy or extraction might be needed.
 In case of ankylosis of the primary tooth, commonly the tooth will exfoliate normally. However, in some cases, it might be required to extract the tooth prior to the expected normal time of eruption of the underlying permanent tooth. 
Enamel defects of permanent teeth can be restored with composite. 
Dilacerations might be managed with orthodontic extrusion of the permanent tooth. In sever cases, extraction might be required.

6. Maxillofacial injuries in children rarely occur. They represent only 5% of the total maxillofacial injuries encountered. Their management is complicated with many different factors such as the presence of underlying permanent teeth buds in the jaws that might be involved by the fracture line or might complicate the use of internal fixation with screws and plates. Other complicating factors include stress and anxiety by the child and parents and the possibility of the association of the more serious head injuries. In general those injuries should be managed in children causality departments or emergency departments in hospitals. However, the pediatric dentist should be aware of their signs and symptoms to be able to exclude them.

 The different types of maxillofacial injuries which might be encountered include the following:

· Condylar fractures: they represent tow thirds of mandibular fractures in children. They commonly occur following a fall on the lower border of the chin. They will be associated with pain and swelling. There might be bleeding from the ear due to perforation of the anterior wall of the auditory tube. However, whenever there is bleeding from the ear, the child must be examined with an otolaryngologist. With condylar fractures, the condyle is commonly displaced superiorly and medially by the action of the lateral pterygoid muscle with deviation of the chin toward the site of fracture. The occlusion might be disturbed. The displacement of the condyle into the middle cranial fossa is very rare. In general the treatment of such fractures is conservative with a period of rest followed by early mobilization to avoid ankylosis of the TMJ. In telescopic fractures, the use of functional appliances for 2-3 weeks might help in disimpaction of the fractured segments. In some cases, the displacement of the fractured segments is so severe that an open bite will develop. In such cases the use of internal fixation together with posterior bite blocks can help in correction of this open bite. In more sever cases, the injection of Botox (Botulininum toxins) might relieve the spasm of lateral pterygoid muscle and minimize displacement. In general, the neck of the condyle of a child is thicker than in an adult, with greater portion of cancellous bone. Therefore, intra-capsular fractures are more common in children than in adults. In such case, early active mobilization is necessary to avoid ankylosis of the TMJ. Such fractures should be followed up for one year to detect any early sign of ankylosis to avoid its effect on growth of the jaws of the child.

· Mandibular fractures: those commonly occur as para-symphysial fractures because of the presence of a large permanent canine tooth bud in this region. The signs and symptoms of those fractures include: pain and swelling, labial or infra-lingual echymosis, disturbed occlusion, stepping defect along the lower border of the mandible, deviation of the chin, trismus, and parasethesia along the distribution of mental nerve. Those fractures are commonly managed by reduction and fixation with intermaxillary fixation with elastic or wires with arch bar or silver cap splint fixed with GIC or black copper cement or circummandubular wiring.

· Mid-facial fractures: commonly, mid facial fractures are associated with head injuries in children. When mid-facial fractures occur in children they don't follow the common Lefort lines since the sutures are not fully closed and since there is a greater tendency for green stick fractures to occur. Signs and symptoms of those fractures include: periorbital echymosis, disfigurement of the orbit contours, periorbital surgical emphysema, subconjunctival hemorrhage, diplopia, mobility of mid facial bones, stepping along the zygomatic bone or orbital margin, parasethesia along the distribution of infra-orbital nerve, oclussal disturbances pain and swelling, CSF leak through the nose and epistaxis. Management is commonly done by intermaxillary fixation with elastics or wires with arch bars or cap splints. In more sever cases, extra-oral fixation, intra-osseous, or internal semi-rigid fixation might be required.

The sequelae of maxillofacial injuries of children and alarming and parents should be informed about them.

Those sequelae include:

· Those children are likely to suffer from closed head injuries which occur in 25% of cases of maxillofacial injuries. Such children will be kept in intensive care units for long periods of times which will affect their self esteem and will undergo personality changes. They are likely to suffer of post-traumatic amnesia and neuropathological chewing,

· Loss of permanent teeth which occurs in 10% of cases

· Disturbed growth of the jaws. This occurs due to excessive soft tissue scaring or because of affected growth centers in the jaws. In condylar fractures, ankylosis should be detected early, since it will affect the growth of the manbile with deviation of the chin and antegonial notching. It will secondarily affect the growth of the maxilla. Ankylosis should be managed rapidly with condylectomy and costochondral flap replacement in later childhood.

· Development of defects in permanent teeth which include enamel defects, dilacerations, displacement of the teeth, arrest of normal root development and pulp obliteration

7. Crown and root fracture of permanent teeth can be classified into the following:

· Crown infraction: in which the fracture is limited to the enamel without passing through the amelodentinal junction (cracks). Transillumination or indirect light is essential for their detection. Management includes taking a baseline radiograph at different angulations to exclude other possible fractures, together with pulp sensibility test. Review should be made in the following 3 months and after 12 months. Radiographic examination should be made after 12 months.

· Uncomplicated crown fractures: those fractures might involve the enamel or the dentin without exposure of the dental pulp. In case of fractures involving the enamel only, the fracture line can simply be smoothened with an abrasive disk, or it might be restored with a composite restoration to improve esthetics. In case of crown fractures extending into the dentin, the dentin must be covered with GIC liner and then restored with composite resin. If the dentine is left uncovered, there is a greater chance of pulp involvement especially in case of extensive proximal fractures. The possibility of pulp necrosis with dentine protection is only 8%, without dentine protection it is as high as 54%. Baseline periapical radiographs at different angulations and pulp sensibility test should be performed at the initial visit. Reviews should be made at 6, 8 weeks, 6 months and 12 months. Radiographs and pulp sensibility test should be made at each review. Some parent might keep the fractured segment which can be used to restore the tooth with composite resin. If there is minimal exposure, and the tooth is immature, perform elective Cvek's partial pulpotomy. However, in case of dental fractures, it is unlikely that that root is not fully developed.

· Complicated crown fractures: those are the fractures that involve exposure of the dental pulp. Those fractures extend through the enamel and dentine and extend to involve the dental pulp. They cause laceration of the dental pulp and they cause its exposure to the oral environment. Exposures of the dental pulp won't heal spontaneously. Those exposures must be managed as soon as possible. After several days, micro abscesses will be formed in the dental pulp leading eventually to pulp necrosis. There are two main factors which should be considered in the management of those injuries. First the time lapsed since the occurrence of injury. In general pulp exposures treated within the range of few hours following the injury are likely to be managed properly. The second factor is the stage of root development of the permanent tooth involved. When it comes to immature permanent teeth with open apices and a vital dental pulp are treated to achieve apexogenesis. The aim of management of those cases is to maintain a vital non inflamed dental pulp sealed off the oral environment with a hard tissue barrier to allow the normal continuation of root development to reach its normal length. This is mainly achieved through Cvek's partial pulpotomy and calcium hydroxide treatment. 
The steps of this technique are the following:

o Local anesthesia

o The use of rubber dam is mandatory

o Perform partial pulpotomy with amputation of the superficial layer of pulp tissue in the pulp chamber (generally 1-2 mm below the exposure) with the use of high speed round bur with copious irrigation of saline or water.

o Achieve haemostatsis by irrigation with saline till a blood clot forms

o Then remove the superficial clot with gentle irrigation. It is important that calcium hydroxide is placed over a vital pulp tissue rather than on a blood clot.

o Place a mix of non-setting calcium hydroxide over the vital pulp tissue and then seal this mix by another layer of setting calcium hydroxide.

o Then place GIC and restore the tooth with composite resin

o This technique need not be restricted to coronal pulp only. It can be performed on various level of radicular pulp to allow normal development of the root.

o Review with pulp sensibility test and radiographs at the intervals of 6-8 weeks, 6 months and 12 months. Through radiographs you can check on the formation of dentine bridge and continuation of root development.

o Success rate of this technique is 80-96%

In case of immature permanent teeth with necrotic dental pulp, treatment will be mainly directed toward achieving apexification. By apexification, it is meant to allow the formation of an apical calcific tissue barrier against which a root canal filling can be placed to achieve a successful apical seal of the tooth. Immature permanent teeth have wide open apices which would make it hard to achieve a successful apical seal during Obturation, therefore attempting to achieve apexification is necessary.
 The steps of this technique are the following:

o Placement of rubber dam is mandatory

o Extirpate the dental pulp

o Instrument the canal down to 1mm before the radiographic apex. It is important to instrument the canal effectively to remove necrotic remnants of the dental pulp. However, vigorous instrumentation should be avoided to avoid further thinning of the already thin dentinal walls of the root canals of immature permanent teeth to minimize the chance of their subsequent fracture whether during treatment or later during function. Put in mind that 50% of those teeth show root fracture within 5 years of function.

o Irrigate the root canal with 1% sodium hypochlorite solution to dissolve the necrotic pulp tissue and to disinfect the canals.

o Place ledermix as an initial canal dressing for 1-2 weeks

o Then place a non setting calcium hydroxide mix in the canals with a paste filling instrument.

o Use a wet cotton pellet to condense the calcium hydroxide mix into the canal. It is important to condense calcium hydroxide mix properly to make sure that it is in direct contact with vital apical tissues.

o Fill the pulp chamber with a temporary dressing of GIC, zinc oxide eugenol or IRM.

o Review the child every 3-6 months with radiographic examination. Non setting calcium hydroxide should be replaced with a new mix every 3 months till there is an evidence of the formation of an effective apical barrier, which might not develop except after 18 months. Replacement of calcium hydroxide with a new mix will ensure adequate concentration of calcium hydroxide and will reduce the chance of infection.

o Once there is a radiographic evidence of the formation of an effective apical barrier, remove the non setting calcium hydroxide mix and obdurate the canal with gutta percha. Obturation can be performed with lateral condensation technique or warm vertical condensation technique. Whatever the technique, you are going to use, avoid excessive apical pressure since it might cause fracture of the apical barrier or might cause root splitting. An impression of the apical seal can be made with a softened custom formed gutta percha cone which is then cemented in place with a sealer.

o In general the prognosis of such teeth is poor. They are liable to fracture because of thin cervical dentine and because of thin dentinal walls throughout the root canals. They have a shorter root and are thus liable to fracture.

If the tooth is mature, then treatment will depend upon whether the pulp has been exposed for long or short time. If exposed for short time, then the tooth can be managed with partial Cvek's pulpotomy, unless there is a restorative demand for the placement of a post retained restoration. In such a case root canal treatment is required. If pulp has been exposed for long time, then conventional root canal treatment is carried out.

 · Root fractures might be either vertical or horizontal. They can be revealed by taking several periapical radiographic exposures made at various horizontal and vertical angulations. Root fracture of primary teeth occur in 0.5 -7% of children while fractures of permanent teeth occur in 2-4% of children. Pulp necrosis occurs in 25% of cases it depends on the degree of displacement of the fracture segments. Root resorption whether inflammatory or replacement resorption are rare. Healing of radicular fractures can occur by hard tissue union (osseous-dentine), interposition of bone, interposition of fibrous connective tissue, and interposition of granulation tissue which indicates pulp necrosis. Those fractures are managed by repositioning of the coronal segment. If the coronal segment is extremely mobile, splinting can be performed by a rigid splint with the use of composite resin and wire or by an orthodontic appliance for 4 months. If the fracture is located so far apical, splinting is not required. The tooth should be reviewed with pulp sensibility test and radiographic examination every 1-2 months while the splint is in place. Then after removal of the splint, the tooth should be reviewed 6-8 weeks, 6 months, 12 months and up to 5 years. 

Pulp necrosis of the coronal segment might occur. It is revealed by discoloration of the crown, radiographic evidence of bone loss at the level of fracture, swelling, excessive mobility, or sinus formation. It is uncommon for the radicular segment to undergo necrosis. This complication is managed by endodontic treatment of the coronal segment alone. Instrumentation should be made to 1mm above the level of fracture. You must avoid irritation of the tissues at the level of fracture. Fill the root canal with non setting calcium hydroxide paste to allow the formation of a hard tissue barrier, at the level of the fracture line, against which conventional Obturation can be made. It might take 18 months for the hard tissue barrier to be formed. After its formation obturate with gutta percha.

If necrosis of the radicular segment occurred, you can restore the coronal segment as mentioned above and then perform an apeciectomy to remove the radicular segment. In general the prognosis in such cases is very poor and the tooth should be considered for removal. It has been suggested to perform a root canal treatment together with the use of endodontic implants and intra-radicular splinting. However, clinical evidence shows that those maneuvers have a poor prognosis.

· Crown/Root fractures: in case of uncomplicated crown/root fractures, remove the coronal segment and cover the exposed dentine with GIC and restore the tooth with composite or with crown.

In case of complicated fractures, remove the coronal segment to reveal the extent of fracture properly. Management of those injuries will depend upon whether the fracture extends just below the gingival margin or below the crest of alveolar bone, and upon whether the tooth is mature or not. In general immature teeth with fractures extending below the level of the crest of alveolar bone have a very poor prognosis and should be considered for removal. If the tooth is immature but the fracture doesn't extend so far below the gingival margin, superficial pulpotomy Cvek's pulpotomy and apexogenesis should be considered if the pulp is vital. If the pulp is necrotic, consider apexification. In case of mature teeth with limited fractures, they can still be managed with apexogenesis if pulp is vital or with conventional endodontic treatment if pulp is necrotic. If the fracture extends further apically, consider gingevectomy, crown lengthening if the root length can still support a coronal restoration, or orthodontic extrusion of the tooth. In case of crown lengthening and orthodontic extrusion, gingivoplasty will be required later to allow better adaptation of the gingiva to the coronal restoration. Narrower emergence profile of the root, when compared to the cervical portion of the normal crown, makes esthetics more difficult to be reestablished. Another option is to aim for root burial. In this case, the root is reduced below the level of alveolar bone. A mucoperiosteal flap is raised and sutured over the root to allow bone formation over the root. This technique will maintain normal contours of the ridge which might be beneficial for later orthodontic or prosthodontic treatment options. 

8. Luxation injuries which might occur in permanent dentition include the following:

· Concussion and subluxation: those are managed by advising soft diet for 2 weeks and follow up. The tooth might be relieved of occlusion by slight enamel reduction. The tooth should be followed up at the intervals 1 -3-6 month up to 12 months. Pulp necrosis occurs in 3-6% of those cases and they should be examined after one year to make sure that there are no signs or symptoms of pulp necrosis.

· Lateral and extrusive luxations: those cases are through the following:

o Reposition the crown under local anesthesia. It might be difficult to reposition the crown especially after 24 hours. In such a case a forceps can be used to manipulate the crown. Avoid damaging the root surface. The tooth should be held from the crown.

o Manage any associated soft tissue injury

o Splint the tooth with semi-rigid or rigid splints with composite and wire or orthodontic appliances for 14 days. Rigid fixation for up to 4 weeks in children and 6 weeks in adults, might be required if alveolar bone fracture has occurred which is commonly associated with lateral luxations in particular.

o Mouthwash with 0.2% chlorehexidine gluconate.

o Follow up every two weeks while the splint is in place, then after 1-3-6 months and 12 months up to five years, with pulp sensibility test and radiographs.

o In general prognosis is very good in immature teeth

o Pulp necrosis occurs in 15-85% of cases with greater prevalence in teeth with closed apices.

o Root resorption is rare

o Pulp canal obliteration commonly occurs in teeth with immature apices.

o Transient apical breakdown occur in 2-12% of cases. In which there is radiographic widening of the apical portion of periodontal ligament. This doesn't indicate root canal treatment and the clinician should follow up carefully for signs of infection to decide whether root canal treatment is required or not.

· Intrusion: this is one of the most unfortunate injuries that might occur in permanent teeth. It will be associated with damage to the neurovascular bundle and the periapical supporting tissues. In general, early repositioning of the tooth is required to avoid pressure necrosis of the apical tissues, to avoid ankylosis, and to gain access to the palatal surface of the maxillary incisor to perform an endodontic treatment as early as 10 days following the injury and no later than 21 days. Those injuries are managed like the following:

o If the crown is still visible, and the tooth is immature with a widely open apex, more than 2mm, leave the tooth to re-erupt, but keep monitoring it. Otherwise, reposition the tooth with gentle use of forceps applied to the crown only can be performed or with finger of possible.

o If the tooth is mature, the tooth can be extruded with the use of rapid orthodontic extrusion over the period of 2 weeks. Otherwise it can be repositioned with a finger or forceps applied to crown and avoid rotation of the tooth.

o Endodontic treatment might not be essential for immature teeth which are left to re-erupt. Otherwise, endodontics will be performed. Ledermix is placed for 3 months, followed by calcium hydroxide mix for 3 months. If the root is not full developed replace calcium hydroxide mix every 3 months for apexification.

o Review every 2 weeks while orthodontic appliance is in place, then 6-8 weeks, 6 months, 13 months and up to 5 years.

o 96% of mature teeth will show pulp necrosis. There is high prevalence of root resorption and ankylosis

o 60% of immature teeth will show pulp necrosis and 50% will show ankylosis.

o Progressive inflammatory resorption might take place and immature teeth might be totally lost in a number of weeks following the trauma

o Teeth treated earlier have a better prognosis. 

9. The most crucial aspect of management of avulsion of permanent teeth is to preserve the vitality of the periodontal ligament cells on the root surface of the tooth and to minimize cemental damage in order to allow successful reattachment of the periodontal ligament to the tooth and to minimize the chance of ankylosis. This is achieved through rapid replantation of the tooth as soon as possible. However, even if the rapid replanation is not possible, it might still be advisable to replant the tooth anyway. An ankylosed permanent tooth will preserve the contours and dimensions of the alveolar arch and it will maintain the occlusion which might be of a considerable importance in the mixed dentition period to allow prosthodontic and orthodontic management later. To facilitate early replanation of the avulsed permanent teeth, parents, care givers and school teachers should have quick access to the firs aid advice in those cases. This can be provided through telephone calls, or through instructions provided in schools. First aid advice include the following:

· Calm down the child

· Don't allow the child to eat. If there is extensive trauma, general anesthesia or sedation might be needed and accordingly the child must be fasting.

· Locate the avulsed tooth. Always look for the tooth in the child's clothes if it was thought to be lost.

· Hold the tooth from the crown and not from the root.

· Replant the tooth immediately if it was clean. However if it was contaminated clean it under cold water for 10 seconds only, or by milk if available.

· After replantation of the tooth, let the child bite on a folded handkerchief or clean cloth or on a piece of aluminum foil.

· If it's difficult to replant the tooth, store it in a suitable medium. The best medium available is milk. Milk is readily available, cold and pasteurized containing little amount of bacteria. It preserves the vitality of periodontal ligament cell up to 6 hours. If milk is not available store in the mouth of the child close to the molars. Saliva can maintain the vitality of periodontal ligament cells up to two hours. Otherwise, it can be stored in saline (optic lens solution) or wrapped in plastic cling film; both can preserve the vitality of PDL cells up to 1 hour. Any way, the storage medium must be isotonic. Water is hypotonic. Storage in water will cause lysis of the PDL cells. Don't store the tooth in water.

· Take the child immediately to a dental clinic.

The guidelines of management of avulsed teeth according to Flores et al are the following:

In case of an already replanted the tooth, leave the tooth as it is and follow up regularly.

In case of an avulsed tooth which has been stored in a suitable medium or which has not been avulsed for more than an hour, the tooth should be managed according to the following:

· Irrigate the socket with saline to remove the blood clot. Avoid curetting the bone surface or the PDL.

· Hold the avulsed tooth from the crown with a wet square of gauze, teeth can be slippery.

· Clean the root surface with copious amounts of saline or tissue culture media such as RPMI or Hanks balanced salt solution, or milk if available.

· Reposition the tooth in the dental socket. In most of cases finger pressure is enough and the tooth will click back in position.

In case of teeth which have been stored in unsuitable media or which has been left outside the oral cavity for more than 60 minutes but not yet extensively dry, manage according to the following steps:

· Under local anesthesia, irrigate the socket with saline removing any necrotic tissue but avoid damaging the PDL or the bone surface.

· With a square of gauze remove necrotic periodontal ligament from the root surface.

· Extirpate the dental pulp prior to replanation

· Under local anesthesia replant the tooth gently under finger pressure

· In case of extensively dry teeth soak the root in 2% NaF solution (PH 5.5) for 20 minutes. This will reduce the chance of ankylosis.

Following this initial line of management, avulsed teeth should be splinted and later endodontically treated.

Avulsed teeth should be splinted with a semi-rigid splint with composite and thick nylon fiber (0.6mm) such as fishing line or orthodontic appliances for 14 days. It is better for the splint to be semi rigid to allow some extent of physiologic movement of the tooth to reduce the chance for ankylosis. The use of orthodontic appliances might be preferable since it requires half the time for placement when compared with composite resin and wire. Avulsed teeth with immature apices might require a splinting time of 4 weeks. The tooth should be relieved from occlusion slightly. This can be performed with reduction of enamel, or in more extensive cases, the use of posterior bite blocks or with the placement of composite resin restoration on posterior teeth.

If the avulsed tooth is extremely immature with a widely open apex (wider than 2 mm), and the child is less than 8 years old and the tooth has been outside the oral cavity for a very limited time, endodontic treatment might not be required, however the tooth should be carefully followed up.

In case of immature teeth, enendodontic treatment will be performed not after 10 days. Ledermix will be used as an initial dressing for 3 months, followed by calcium hydroxide non setting mix which will be placed for 3 months and then replaced with a new mix till apexification take place. Then Obturation with gutta percha is done. The survival of avulsed teeth with immature apices is only 30%.

In case of mature teeth, place ledermix temporary dressing for 3 moths followed by calcium hydroxide mix for another 3 months and then conventional gutta percha Obturation. 

Common complication of tooth avulsion include: external inflammatory root resorption and external replacement resorption (ankylosis).

External inflammatory root resorption occur because of necrosis of the dental pulp or the periodontal ligament. It can be minimzed by the use of antibiotics and intitiation of endodontic treatment not later than 10 days. It is also important to avoid initial dressing of calcium hydroxide since it is irritating. It is better to use an initial dressing of ledermix since it doesn't cause inflammation of the dental pulp and has an inhibitory effect on osteoclastic cells. If this type of resorption occurred, it is managed with endodontic treatment and the placement of a temporary dressing of ledermix for 3 months followed by calcium hydroxide for another 3 months.

External replacement resorption occurs mainly because of loss of cementum for a depth greater than 2 mm. there is no treatment for it. To prevent it minimize manipulation of the root and replant immediately. Minimize extra-oral time. The ideal time for replantation is before ten minutes. 50% of cells die after 30 minutes and all of them after 60 minutes.

There are some agents which might have a future in reducing the chance for ankylosis such as emdogain and alendronate.