Soft Tissues & Dentoalveolar Injuries (Oral & Maxillofacial Trauma)

OMFS Final Year Roll # 21
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ORAL AND MAXILLOFACIAL TRAUMA
DIAGNOSIS AND MANAGEMENT OF INJURIES TO THE MAXILLOFACIAL REGION.
SOFT TISSUE INJURIES
ETIOLOGY;
1) Dento alveolar trauma
a. It is injury which is limited to teeth and supporting structures of alveolus and soft tissues.
2) Iatrogenic
a. Trauma from rotating bur or forceful removal of gauze pack.
TYPES OF SOFT TISSUE INJURIES
 Abrasion
 Contusion
 Laceration
ABRASION
 It is caused by friction between an object and surface of soft tissues.
o Examples; Scrapes from rough play in kids.
 Frequently superficial and rarely involves deep layers.
 Painful due to damage to terminal branches of nerve fibers
 Minor bleeding from superficial capillaries.
o Respond well to gentle pressure.
 Heal by re-epithelization under eschar without scarring within 7 – 10 days.
o Eschar; crust of dried blood and serum develops after injury to soft tissue. (shodo in
sindhi)
 Sites which dentists usually face in clinics in a patient of dento alveolar trauma;
o Nose, lips, cheeks & chin.
 Management
o Cleaning and removal of foreign material to prevent formation of tattoo (wound
pigmentation)
 By surgical hand soap or normal saline irrigation
 By surgical scrub brush or tooth brush under local anesthesia in case of deep
abrasion.
o Topical antibiotics
 Systemic antibiotics are not usually indicated.
o Loose bandage in case of deep abrasion.
CONTUSION
 Aka BRUISE
 Caused by;
o Frequently Blunt Trauma
o Dento alveolar injury
o Facial bone fractures
 It is Subcutaneous or Submucosal Hemorrhage without Break in Soft Tissue Surface.
 When contusion is present on should always search for osseous fractures. (important from
diagnostic point of view)
 Management of Contusion
o Generally body resorbs the hemorrhage formed within contusion and require no surgical
treatment.
o If small and is seen early application of ice or pressure dressing may decrease the amount
of hematoma.
o Surgical exploration and ligation of hemorrhaging vessel in rapidly expanding contusion.
o Ecchymosis may develop and turns a variety of colors before fading
 An ecchymosis is a subcutaneous spot of bleeding (from extravasation of blood)
with diameter larger than 1 centimeter.

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 You will see black and blue marks in patient
 Ecchymosis are HARMLESS
o Systemic antibiotics
 Coagulated blood is ideal cultural media for microorganisms.
LACERATION
 It is Tear in the epithelial and sub epithelial tissues.
 Most frequent type of soft tissue injury
 Usually caused by sharp objects like knife or glass etc.
o Clean margins in case of very sharp object
o Jagged or rough margins in case of dull objects.
 May extend deep into tissue and disrupt nerves, vessels, muscles and other vital structures.
 Frequent sites of laceration seen in dentistry;
o Lips
o Floor of mouth
o Tongue
o Labial mucosa
o Bucco-labial vestibule
o Gingiva
Soft tissue wounds associated with dento-alveolar trauma are always treated after management of hard
tissue injury.
MANAGEMENT OF LACERATIONS
 Anesthesia
 Cleansing
1. Surgical soap
2. Pulsed saline irrigation (pulsed means pressurized delivery of saline)
 Debridement
1. It refers to removal of devitalized tissue from wound and removal of jagged pieces of surfaces
to enable linear closure
2. Amount of debridement should be kept minimum in case of maxillofacial region because of
rich blood supply.
 Hemostasis
1. Bleeding should be stopped to prevent hematoma formation in wound which prevent the
repair of wound by opening the laceration after sutures.
2. Occurs by Clamping and tied with ligature of artery or cauterization of artery.
3. Labial artery runs horizontally across the lip and is approx. 1 mm in diameter.
 Closure
1. Small laceration does not need sutures for their closure, these wound can heal well be
secondary intention.
2. If closure is going to be by sutures, then the goal during closure is proper position of all tissue
layers.
 Manner of closure of laceration depends upon its location and depth.
3. Laceration of gingiva, alveolar mucosa or floor mouth are closed in one layer.
4. While, laceration of tongue or lips, resorb-able suture should be placed to close different
layers
5. Laceration of Lip involving entire thickness
 Triple layered closure is necessary
 Initially a suture is placed at mucocutaneous junction for its realignment and then;
 1st oral mucosa
 With silk (natural suture) or resorb able suture
 2nd muscles (orbicularis oris)
 Sutured with interrupted resorb able sutures
 3rd dermal surface
 Closed with 5-0 or 6-0 nylon sutures
 And then covering with topical antibiotic
 Systemic antibiotics in case of full thickness laceration to help in healing

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 Facial skin sutures should be removed after 4 to 6 days.
DENTOALVEOLAR INJURIES
HISTORY
 Dent alveolar trauma has existed since humans began to walk the earth.
 Hippocrates of Cos, who lived during the Greco-Roman period was the first to document treatment
regimens for dent alveolar trauma in his writings
o He discussed binding teeth together in mandible fractures. Gold wire or linen thread was used
as “bridle wire.”
o He introduced to various splinting techniques that involved teeth that were distant to the
fractured or subluxed area
o To accelerate the healing process, he stressed recapturing proper occlusion, a concept that is
still practiced today.
ETIOLOGY AND ICIDENCE
 Falls
o Peak incidence of DAT in children is in 2 to 4 year age and 8 to 10 years are or before school.
o Mostly in pediatric group
 Contact sports or playground activities/ accidents.
 Child abuse
 Motor vehicle accidents
 Contact sports
 Altercations (intentional quarrels; jehro) or assaults
 Industrial accidents
 Medical or dental misadventures
 Patients with seizure and mental disorders and congenital maxillofacial abnormalities.
 Direct Trauma to face; mostly maxillary incisors are injured
 Trauma to primary dentition usually cause subluxation while to permanent it causes crown to
root fracture.
 Indirect trauma to face often by blow to chin result in damage of posterior teeth.
MANAGEMENT OF DENTOALVEOLAR INJURIES
HISTORY
 Demographic data
 Time of injury
o Sooner the treatment better the prognosis
 Location of trauma
o To exclude bacterial or chemical contamination
 Mechanism or manner of injury
o Provide help to what the resultant tissue injury is likely to be.
 Treatment provided since the injury
 Find the missing teeth
 Medical history
 Rule out intracranial injury by asking following things;
o Nausea
o Vomiting
o Unconsciousness
o Amnesia
o Headache
o Visual disturbance
o Confusion
If any of the above were present after injury then intracranial injury is present, refer the patient to neuro
surgery department.

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 Ask disturbance in the bite.
CLINICAL EXAMINATION OR MAXILLOFACIAL EXAMINATION
MEAUSRE VITAL SIGNS ASAP
Following things will be examined in a patient of DAT
1. Extra oral soft tissue wounds
2. Intra oral soft tissue wounds
3. Jaws and alveolar process
4. Teeth
a. Examination of fracture of crow
or roots
b. Displacement of teeth
c. Mobility of teeth
d. Percussion of teeth
e. Vitality of teeth
1. EXTRA ORAL SOFT TISSUE WOUNDS
 Evaluate the soft tissue injuries after cleaning extra oral region with mild antiseptic soap
cautiously.
 Find the underlying damage from the mechanism of trauma elicited in the history
o If mechanism of injury stated in history is not co relating with the injuries examined
clinically, suspect and rule out abuse.
2. INTRA ORAL SOFT TISSUE WOUNDS
 Before examination cleanse oral cavity by irrigation of normal saline
 Find if fragments of bone or tooth has penetrated the intra oral soft tissues.
 Buccal mucosal laceration if present, rule out damage to Stenson’s duct
 Find all missing or fractured tooth or restorations, if not found assume they may be aspirated go
for CXR and abdomen radiograph or maxillary sinus radiographs.
3. JAWS AND ALVEOLAR PROCESS
 Sublingual ecchymosis at the floor of mouth or bleeding into lower labial vestibule is
pathognomonic for underlying mandible fracture.
 Fractures are more quickly found by palpation.
TEETH
CROWN AND ROOTH FRACTURE EXAMINATION
 Complete mobility of crown may suggest crown-root fracture.
 Cracks or incomplete fractures of crown of tooth can be identified by direct light source given
perpendicular to long axis of tooth at incisal edge.
DISPLACEMENT OF TEETH
 Mostly teeth are displaced in Bucco lingual direction
 Check occlusion to asses displacement
 Teeth may sometimes be extruded or intruded or avulsed (defined later)
MOBILITY OF TEETH
 A tooth that does not appear to be displaced by exhibit mobility may have root fracture.
 If adjacent teeth move with the tooth being examined then a dento alveolar fracture may be
present in this alveolar bone with teeth is separated from jaw.

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PERCUSSION OF TEETH
 Determines whether the tooth has undergone some injury
to PDL or fractured
 Dullness may suggest possibility of luxation injury or
alveolar fracture.
 Fractured enamel will produce the sound of “cracked tea
cup”
 The sound of healthy and uninjured tooth is SOLID
METALLIC RESONANCE
VITALITY OF TEETH
 Non myelinated nerve fibers regulate vascular changes in
pulp
 Myelinated nerve fibers respond to pain stimuli.
RADIOGRAPHIC EXAMINATION
 For a radiograph to show fractured root, central beam of x ray should be parallel to line of
fracture.
 Displaced teeth shows widening of PDL space or lamina dura
o Extruded teeth may show conical periapical radiolucency
o Intruded teeth may show absence of PDL space
 Reduced radiographic exposure time (1/3 to normal) is used for evaluation of foreign bodies in
soft tissues.
CLASSIFICATION DENTOALVEOLAR INJURIES.
3 Classification as under;
1) Ellis and Davey
2) Andreasen or WHO
3) Sanders et al.
1. ELLIS & DAVEY CLASSIFICATION OF DAI
 Class I; fracture within enamel;
 Class II; fracture of enamel-dentin;
 Class III; fracture involving pulp;
 Class IV; fractures involving the roots.
2. ANDREASEN OR WHO CLASSIFICATION
BASED ON DESCRIPTION OF INJURIES TO TEETH, SUPPORTING STRUCTURES AND GINGIVAL AND ORAL
MUCOSA
 Injuries to dental tissues and pulp
 Injuries to periodontal tissues
 Injuries to supporting tissues(bone)
 Injuries to gingival and oral mucosa
INJURIES TO DENTAL TISSUES AND PULP
 Crown infraction (fig 24-9)
o It is crack or incomplete fracture of tooth with loss of tooth structure/ substance.
 Uncomplicated crown fracture
o Crown fracture confined to enamel or dentine or both without pulp exposure
 Complicated crown fracture
o Crown fracture confined to enamel or dentine or both with pulp exposure
 Uncomplicated crown root fracture
o Crown fracture confined to enamel or dentine and cementum without pulp exposure.

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 Complicated crown root fracture
o Crown fracture confined to enamel or dentine and cementum without pulp exposure.
 Root fracture
o Fracture involving dentine and cementum with pulp exposure.
INJURIES TO PERIODONTAL TISSUES
 Concussion
o Pain to percussion without loosening or displacement of teeth.
 Subluxation
o Tooth mobility or looseness without displacement of teeth
 Luxation
o Dislocation or partial avulsion of tooth.
o In this tooth is displaced without fracture of alveolar process
 Intrusion
o Displacement of tooth into its socket, associated with compression fracture of socket.
 Extrusion
o Partial displacement of tooth out of its socket without fracture of socket
INJURIES TO SUPPORTING TISSUE (BONE)
1. Fracture of alveolar socket
2. Fracture of alveolar process
3. Fracture of maxilla & mandible
INJURIES TO INTRA ORAL SOFT TISSUES
 Abrasion
 Contusion
 Laceration
3. SANDERS ET AL. CLASSIFICATION OF DAI
 Crown craze of crack (i.e., infraction)
 Horizontal or vertical crown fracture
o Enamel only
o Enamel and dentine
o Enamel, dentine and exposed pulp
o Horizontal or vertical
o Oblique (mesio-incisal or disto-incisal line angle)
 Crown-root fracture
o Without pulp involvement
 Horizontal root fracture
o Apical 3rd
o Middle 3rd
o Cervical 3rd
o Horizontal or vertical
 Concussion
 Subluxation
 Tooth displacement
o Intrusion
o Extrusion
o Labial displacement
o Lingual displacement
o Lateral displacement (into mesial or distal direction, mostly moves to missing tooth space)
 Avulsion
o Complete displacement of tooth from its socket may or may not be associated with
alveolar wall fractures.
 Alveolar process fracture.
MANAGEMENT OF DENTOALVEOLAR INJURIES

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CROWN CRAZE/ CRACK/ ENAMEL FRACTURE/ CROWN INFRACTION
 They are present in enamel only and does not extend to ADJ
 Can be seen by indirect light or trans-illumination.
 Usually no treatment needed or smoothening of rough edges or sealing of cracks with composite.
 Periodic follow-up examination to monitor pulp and periodontal health.
CROWN FRACTURE (WITH OR WITHOUT PULP INVOLVEMENT)
CROWN FRACTURES WITHOUT PULP EXPOSURE
 If minimal amount of dentine is involved then simply smooth the sharp edges and restore with
composite.
 If large amount of dentine is exposed then we have to protect pulp by sealing dentinal tubules
with following actions.
o ZOE
 It is best antibacterial seal to prevent transport of bacteria into pulp but is not
used where composite restoration is going to be placed because it interfere with
polymerization of composite.
o Calcium hydro oxide
 Traditionally applied to exposed dentine and also can be used in OPD but in long
term it also interferes with strength of composite restorations.
o Dentine bonding agents or Glass ionomer cement
 Currently these both materials are recommended to be used in exposed dentin
followed by restoration by composite.
 Periodic follow-up examination to monitor pulp and periodontal health.
CROWN FRACTURES WITH EXPOSED PULP
 Prognosis of this type of fracture depends upon following factors;
o Length of time between injury and start of treatment
 Smaller the time better the prognosis
 Best prognosis if treated with 24 hours.
o Size of pulp exposure.
 Make every effort to preserve the pulp in immature tooth. The more the apex is
immature the best is prognosis
o Condition of pulp
 Vital or non-vital
o Stage of root development
 The more the apex is immature the best is the prognosis.
 Following treatment will be given in this conditions, we will described them in detail.
o Direct pulp capping
o Root canal therapy
 Treatment
o If the pulp exposure is very small pinpoint or large and has open apex and is treated within
24 hours then;
 Direct pulp capping with calcium hydroxide after Pulpotomy
 Pulpotomy is aseptic removal of damaged and inflamed pulp tissue to the
level of clinically healthy pulp.
 RCT should not be started after pulp capping but should be started after
the apex is closed
 After pulp capping by CaOH, GIC or dentine bonding agent is placed over exposed
dentine followed by composite restoration.
 Indications of Pulp Capping
 Exposure of pulp is small
 Patient is seen soon after injury
 Absence of root fracture
 No displacement injury to tooth
 No large or deep filling already present
o If the pulp exposure is smaller and apex is closed, perform direct pulp capping
o If the pulp exposure is larger and apex is closed perform RCT.

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o Periodic follow-up examination.
PULPOTOMY TECHNIQUE FIG. 24-11
1) Removal of coronal pulp aseptically
2) Calcium hydro oxide is applied over exposed pulp for pulp capping
3) GIC is then used to fill the remaining coronal pulp chamber
4) Temporary or permanent filling is placed
CROWN – ROOT FRACTURE
 If the fracture is longitudinal or it involves so much deep that coronal portion is about 1/3 of total
tooth length then perform extraction.
 If fracture is not gone in depth perform the procedure as described above in crown fracture.
 If concomitant alveolar fracture is formed delay the extraction for several weeks to permit the
fracture to heal and to prevent loss of alveolar bone.
ROOT FRACTURE
 Prognosis and treatment in root fracture cases depends on;
o Location of fracture
 They may be horizontal, oblique etc.
 Radiograph may show fractures after 1 or 2 weeks after inflammation or hemorrhage and not
immediately after fractures.
 If fractures is in cervical 1/3rd of root
o Extraction of whole tooth
o Extraction of coronal portion and RCT on remaining root followed by post and core.
 If fracture is in middle or apical 1/3rd (good prognosis)
o Apposition of both fractured parts for about 12 weeks or 2-3 months (splinting if teeth
are mobile)
SENSITIVITY (CONCUSSION)
 Following things are absent in concuss tooth
o Clinical or radiological features of trauma
o Mobility
o Displacement
o Bleeding
 Sever sensitivity to percussion in vertical and horizontal direction
 Treatment is relief from occlusal contact by grinding the occlusal contacts of opposing tooth.
 Follow-up.
MOBILITY
 Mild mobility = remove the occlusal contact
 Sever mobility = splinting for 7-10 days
DISPLACEMENT INJURIES OR LUXATION INJURIES
 Mostly involves, Permanent & Primary Maxillary incisors.
o Mandibular rarely or in Class 3 malocclusion.
 Prevalent in Primary teeth 62% - 73%
o Permanent 15% - 61%

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INTRUSION / INTRUSIVE LUXATION
 Compression fracture to alveolar socket
 Metallic sound on percussion similar to ankylosed tooth.
 Mostly involve maxillary teeth, because;
o Less dense bone
o Irregular pre-maxillary configuration
o Hollow cavities at apex of maxillary anterior
o Thin floors of maxillary and nasal sinus.
 Have worst prognosis
 Absence of PDL space along apex in radiographs
 Complications of intrusion
o Damage to permanent tooth bud in case intrusion to primary teeth
o Pulp necrosis; 96%
o Resorption of tooth; 52%
TREATMENT
1) Surgically repositioning and splinting of these teeth
a. Result in complications
2) Left these teeth alone to allow them to re-erupt
a. In case of incomplete root development is present this method is recommended.
i. If not erupting use orthodontic re-eruption
3) Orthodontic re-eruption (described below)
a. In case of complete root development with closed apices.
 If intruded primary tooth is touching follicle of permanent tooth bud remove the tooth as
atraumatically as possible
o If it is not touching the follicle, leave that tooth there it will re erupt.
o If dentist is not sure about position, extract that tooth for prophylaxis.
 Endodontic therapy in 10 – 14 days after injury
o Use CaOH as canal filler to inhibit inflammation and resorption
ORTHODONTIC RE-ERUPTION (FIGURE 24-15 IN COTEMPORARY OMFS & FIGURE 21-12 IN PETERSON)
A. Orthodontic traction slowly over 3 to 4 weeks
B. Splinting of extruded teeth with this therapy for about 2 to 3 months
EXTRUSION/ EXTRUSIVE SUBLUXATION
 Rupture and severance of neurovascular bundle & PDL, respectively.
 Gross mobility and bleeding at gingival margin
 Wide PDL space on radiographs
 Dull sound on percussion
 Complications
o Pulp necrosis 64%
o Resorption 7%
 Treated by;
o Placing the extruded tooth properly back to its socket and splinted for 2 to 3 weeks.
o Endodontic therapy in case of pulp damage.
 Follow up.
LATERAL DISPLACEMENT OR LATERAL LUXATION
 Mostly in lingual direction
 May or may not involve fracture of bony socket
 Radiologically similar to extruded tooth
 Tooth mobility present
 Soft tissue damage is present
 Percussion and mobility similar to intruded tooth

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 Treatment
o Manually repositioned the laterally luxate tooth and bone fragments in cases when
patient arrives within 48 hours. If after 48 hours he / she arrives and repositioning is not
happening manually then use orthodontic procedure.
 Avoid use of forceps or surgical instruments when repositioning
o Apply non rigid splint for at least 2 to 8 weeks
o Endodontic therapy
o Frequent follow up
SUBLUXATION
Treatment is similar to concussion
AVULSION (EXARTICULATION)
 Mostly in permanent dentition.
o Mostly in Maxillary Central Incisor
 Prognosis of Avulsed tooth depends on;
o State of Tooth
o Length of time the tooth has been out of socket
 Less than 2 hours results in good prognosis and poor in more than 2 hours.
o Periodontal tissues viability
o The manner in which the tooth was preserved
HOW TO PRESERVE THE AVULSED TOOTH
If you receive a call from someone regarding avulsed tooth, dentist should say following things;
1) Rinse the tooth immediately with patient’s saliva/ tap water/ saline solution
2) After rinsing replant the tooth and patient have to hold the tooth from crown and not touch the
root.
3) Go to dentist.
If unable to perform this then place the avulsed tooth in one of appropriate storage medium till you
reach to dentist.
PRESERVING SOLUTION OR STORAGE MEDIUM FOR TOOTH
 Water (avoid)
o Hypotonic and cause cell lysis
 Vestibule of mouth (saliva)
o Keep tooth moist
o Incompatible osmolality & pH
o Contain bacteria
 Normal saline
 Milk
o Medium of choice in absence of Hanks balanced salt solution
o Readily available
o pH; 6.5-6.7 & osmolality compatible with cells & free of bacteria
o Will be effective when tooth is present outside the socket for less than 20 minutes.
 After more than 15 minutes cells start to die
 Cell culture media
 Hanks balanced salt solution (ideal) (Save-A-Tooth)
o Storage medium of choice
o can store tooth for about 24 hours
o pH; 7.2
 Viaspan
o pH; 7.4
o solution of choice for organ storage for transport
o costly
o can store tooth in good condition for about 1 week

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FACTORS TO BE CONSIDERED BEFORE REPLANTING AVULSED TEETH
 Does not have advanced periodontal disease.
 Alveolar socket should be intact
 Apical abscess in socket, do not replant
 No orthodontic contraindication like crowding should be present
 Extra alveolar period
o Within 30 minutes; excellent prognosis
o > 2 hours; poor prognosis
o < 2 hours; good prognosis
 Stage of root development
o Open apices; good prognosis
o Closed apices; less prognosis
TREATMENT OF AVULSION
 If the tooth is replanted by patient and is in good position
o Take radiograph and splint for 7 to 10 days
 if the tooth is placed out of socket for less than 20 minutes out of the mouth
o Rinse the tooth and socket in saline and immediately replant and splint.
 If the tooth is placed out of socket for more than 20 minutes and less than 2 hours;
o Place the tooth in hanks balanced salt solution for 30 minutes & then,
 reduce post-operative ankyloses of tooth, cleanse the root and dilutes bacteria
o In doxycycline solution (1mg/20 mL saline) for 5 minutes.
 Inhibit bacteria in pulp lumen.
o Followed by immediate replantation and splinting for 7 to 10 days
o Perform apexification followed by RCT with CaOH or MTA if pulp is damaged
 If the tooth is placed out of socket for more than 2 hours;
o Eliminate necrotic PDL strands manually or chemically with sodium hypochlorite wash for
3 minutes.
o Then perform RCT extra orally.
o Withhold final obturation till following process has not been performed
 Citric acid bath for 3 minutes followed by;
 Rinsing with 0.9% NaCl
 Open and debride dentinal tubules to increase the unimpeded growth of
connective tissue to root surface.
 Then move the tooth to 1% stannous fluoride solution for 5 minutes
 Decrease the risk of resorption
 Finally set up a 5 minute bath of 1mg/ 20 mL doxycycline solution
o Now obturate root canal with Gutta Percha
o Now replant and splint for 7 to 10 days
 Give antibiotic Penicillin for 7 to 10 days.
Treatment summary for avulsed teeth table 21-3 in Peterson OMFS
SPLINTING
Why we splint teeth?
 Immobilize the tooth to pre injury alignment
 Allows pulpal revascularization & PDL healing process.
There are various methods of splinting but most commonly and method of choice now a days is acid-
etch resin splint technique.
REQUIRMENTS OF SPLINTS
The splint should
 be able to be applied directly in the mouth without delay owing to laboratory procedures
 Stabilize the injured tooth in a normal position
 Provide adequate fixation throughout the entire period of immobilization
 Neither damage the gingiva nor predispose to caries and should allow for a basic oral hygiene
regimen
 Not interfere with occlusion or articulation

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 Not interfere with any required endodontic therapy 7. Preferably fulfill esthetic demands
 Allow a certain mobility (no rigid) to aid periodontal ligament healing in cases of fixation after
luxation injuries and replacement of avulsed teeth; however, after root fracture, the splint should
be rigid to permit optimal formation of a dentine callus to unite the root fragments
 Be easily removed without re-injury to tooth
SEQUENCE OF ACID ETCH SPLINT TECHNIQUE
1) Perform alveolar bony reduction and/or replantation.
2) Perform localized cleansing and debridement.
3) Isolate and dry area.
4) Custom fabricate wire (~26 Ga),double-stranded monofilament nylon line, or paper clip Extend
wire to at least 1 or 2 teeth on either side of the involved tooth or teeth.
5) Etch the incisal half of the labial surface of the involved and adjacent teeth with gelled phosphoric
acid for 30–60 s.
6) Remove etchant with water stream for ~20 s.
7) Air dry etched surface; surface should appear chalky white.
8) Passively place prefabricated wire to involved teeth.
9) Stabilize splint with fast-setting auto cure or light-cure composite resin.
10) After resin is set, smooth rough edges with a fine acrylic or diamond finishing bur (Check
occlusion).
11) Perform soft tissue and gingival repair as needed 12. Remove splint in 7–10 d.
ROOT RESORPTION
1) External resorption/ root surface resorption
a. Surface resorption
b. Replacement resorption
c. Inflammatory resorption
2) Internal resorption/ root canal resorption
a. Internal replacement resorption
b. Internal inflammatory resorption
EXTERNAL RESORPTION (SURFACE RESORPTION)
 Mostly seen in intrusive injuries.
 Tooth root displays resorption lacunae, repaired with newly formed cementum.
 Result from localized response of PDL and cementum to injury
 Less aggressive and self-limiting.
 Replacement resorption
o Aka ankyloses
 Inflammatory resorption
o Appear as well circumscribed area of cementum and dentine resorption
o Adjacent periodontal tissue are inflamed.
ROOT CANAL RESORPTION
 Aka internal root resorption
 Less often than external resorption
 Internal replacement resorption
o Shows metaplastic replacement of normal pulp tissue into cancellous bone, resulting in
widening of pulp chamber
 Internal inflammatory resorption
o Usually at cervical region of pulp
o Radiographically oval shaped radiolucency within pulp chamber.
o Require RCT.
FRACTURES OF ALVEOLAR PROCESS/ ALVEOLAR FRACTURES
 These fracture may be alone or accompany with injuries to tooth.
 Usually occur at incisor and premolar regions.
 Treatment involves;

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o Proper positioning of broken segments with closed (manually) or open surgery
(reduction)
o Followed by stabilization until osseous healing occur at approximately 4 weeks.
o Endodontic treatment within 1 to 2 weeks of injury if apex is mature and closed.
 Stabilization occur by;
o Rigid arch bar (closed or open surgery)
o Trans-osseous wire (open surgery)
o Monofilament cortical plate (2.0 mm)
 Steps of stabilizing of fractured part.
o 1st maxillary or mandible fracture
o 2nd alveolar fractures
o 3rd injuries to teeth
o 4th soft tissue injuries
 Do not wire that tooth with arch bar which is adjacent to fracture line to prevent their loosening
from wire forces.
TREATMENT OF PULP
HOW PULP IS DAMAGED DURING TOOTH INJURIES
 Direct exposure
 Inflammation
 Disruption of nutrient artery of pulp
WHAT HAPPEN IF WE TREAT TOOTH INJURIES WITHOUT TREATING PULP
 Ankyloses
 Resorption
 RCT should not be performed at the time of tooth repositioning.
o Should be started after approx. 2 weeks of injury
 In this root canal is filled with 1:1 mixture of calcium hydroxide and barium sulfate for 6 to 12
months instead of Gutta-Percha
o CaOH dissipates slowly within root canal system after placement and that’s why barium
sulfate is added to allow radiographic evaluation of amount of CaOH.
o That’s why we have to replace this CaOH every 3 months.
 In teeth with open apex, delay endodontic treatment with follow up examination of pulp.
o If RCT is need, perform apexification with CaOH before filling Root canal with permanent
filling.
APEXIFICATION (FIGURE 21-21 IN CONTEMPORARY OMFS)
 The process of inducing the development of the root and apical closure in an immature pulpless
tooth with an open apex.
 Steps
o Removal of entire pulp and filling with CaOH solution with injection.
 Replace CaOH every 3 months.
o Cotton with or without formocresol is then placed.
 Formocresol is solution of cresol, formaldehyde & glycerin, used in Pulpotomy.
o Followed by GIC filling and then
o Temporary or permanent composite filling

Page | 14
PEDIATRIC DENTO ALVEOLAR TRAUMA TREATMENT (FIG 21-20 IN PETERSON)
 In them Displacement injuries are more common than tooth fractures because of resilient
surrounding bone.
 Trauma to primary dentition may compromise the tooth bud present in Bucco-occlusal position.
o Bucco occlusal means root of primary tooth on buccal surface of permanent bud.
o These displacement injuries to primary teeth may cause defect in odontogenesis of
permanent tooth.
THE END
Written By:
Dr. SARANG SURESH HOTCHANDANI (BDS)
Bibi Aseefa Dental College, SMBBMU
Larkana, Sindh, PAKISTAN
Email: hotchandaniss@hotmail.com
Twitter: www.twitter.com/fetusdentista

Soft Tissues & Dentoalveolar Injuries (Oral & Maxillofacial Trauma)

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