Dental Trauma in Children. Injury Of Periodontal Tissues. Diagnosis, Treatment, Prognosis

The International Classification of Diseases (ICD) categorizes injuries of the periodontal tissues under traumatic dental injuries. According to the ICD-10 and ICD-11 classifications, injuries to the periodontal tissues typically include:

ICD-10

• S03.2 – Dislocation of tooth (includes various luxation injuries such as extrusive, lateral, and intrusive luxations).

ICD-11

The ICD-11 provides more detailed descriptions of dental injuries:

• NA0D.1 Injury of periodontal tissues
  •  NA0D.10 Concussion of periodontal tissue
  •  NA0D.11 Subluxation of tooth
  •  NA0D.12 Extrusive luxation of tooth
  •  NA0D.13 Lateral luxation of tooth
  •  NA0D.14 Intrusive luxation of tooth
  •  NA0D.15 Avulsion of tooth
  •  NA0D.1Y Other specified injury of periodontal tissues
  •  NA0D.1Z Injury of periodontal tissues, unspecified
•  NA0D.Y Other specified injury of teeth or supporting structures
•  NA0D.Z Injury of teeth or supporting structures, unspecified

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Concussion of tooth

A concussion occurs when a mechanical force impacts a tooth without causing visible structural damage. As a result, the crown of the tooth often appears intact upon visual inspection. However, due to the absence of external signs and the tendency of children to conceal such injuries from their parents, isolated tooth concussions frequently go unnoticed and are statistically underreported. This diagnosis is more commonly identified as part of combined injuries (e.g., crown fractures) or when complications arise later, such as discoloration or fistula formation.

Impact on the Pulp
The condition of the pulp in an injured tooth depends on the changes occurring within it. Disruption of blood supply and nerve innervation to the neurovascular bundle, caused by compression from a hematoma or exudate near the apical foramen, can result in prolonged ischemia, potentially leading to pulp necrosis. In some cases of pulp concussion blood leakage forms a hematoma. This can cause dentin to absorb blood cells, giving the tooth’s crown a bluish-red tint.

Clinical Presentation

The tooth is not displaced and does not have increased mobility. In the days following the injury, children may complain of discomfort when biting or applying pressure to the tooth due to periodontal tissue damage. Discoloration of the tooth is another possible symptom.

Compression or partial tearing at the apical foramen may also impair the blood supply to the neurovascular bundle. While this condition is reversible, prolonged ischemia may lead to pulp necrosis. As these internal processes often remain asymptomatic, patients typically seek dental care only when the crown color changes. A gray hue may indicate pulp death, while a yellow tint suggests secondary dentin deposition within the tooth. The tooth might be tender to touch or tapping. Chronic periodontitis symptoms or the discovery of a fistula on the mucosa near the root apex are other reasons for delayed consultations.

Observations upon Examination:

• The tooth crown often appears unchanged externally.
• Percussion sensitivity is common in the early days following trauma.
• Tooth mobility is either absent or minimal.
• Discoloration of the tooth (ranging from pink to darker shades) may result from internal bleeding.
• Radiographic imaging typically shows no pathological changes, although pulp’s electrical excitability may decrease shortly after trauma.

Treatment

Treatment for both primary and permanent teeth focuses on creating a rest period of 3–4 weeks. This involves reducing occlusal load by adjusting the bite through selective preparation or temporarily opening the bite with orthodontic appliances. Patients should avoid biting and consuming hard foods.

For all acute dental injuries, including tooth concussions, physical therapy methods are recommended to enhance treatment outcomes and minimize complications. Low-intensity laser radiation combined with a constant magnetic field is particularly effective in reducing inflammation, swelling, and pain, while improving microcirculation and promoting tissue repair in the injured area.

A follow-up examination is essential in 3–4 weeks, then 6-8 weeks and 1 year post-trauma to assess the tooth’s condition. If aseptic pulp necrosis develops, indicated by a grayish tooth crown and enamel losing its sheen, the tooth requires trepanation, removal of necrotic pulp, thorough cleaning, and root canal filling. Pulp status in permanent teeth is monitored using electrical pulp testing (EPT).

Tooth Luxation

Tooth luxation involves significant damage to the tooth’s supporting structures, leading to its displacement in the direction of the applied force. While more common in primary teeth, permanent teeth can also be affected. Typically, the periodontal tissues suffer alongside the neurovascular bundle, which may experience stretching, compression, partial tears, or complete rupture.

Subluxation of tooth

This is the most frequent type of dislocation, characterized by partial damage to the periodontal ligament. The degree and direction of tooth displacement depend on the nature of the force involved.

Clinical Presentation
Patients with tooth subluxation often report:

• Tooth increased mobility
• Pain when biting or chewing
• Bleeding from gingival crevice due to periodontal tissue damage may be noted

In severe cases, occlusal contacts may be disrupted, making it difficult or even impossible to close the mouth properly.

Upon examination, soft tissue injuries in the maxillofacial region are often evident. The gums may appear bruised or swollen. Mobility is typically more pronounced in the first few days after the trauma. Percussion tests of the affected tooth usually elicit pain.

Diagnosis

Electrodiagnostic testing (EPT) of the pulp often reveals reduced excitability due to damage to the neurovascular bundle. This impairment is usually temporary, caused by tissue compression from hematomas or exudates. However, persistent reductions in excitability exceeding 100 microamps may indicate pulp necrosis.

Radiographic abnormalities are usually not found.

Treatment

Primary Teeth:

• Mild Mobility: Reduction of occlusal load by selective preparation of antagonists are performed, along with a soft diet. Splinting is usually unnecessary.
• Significant Mobility: a flexible splint to stabilize the tooth can be used for up to 2 weeks.

Monitoring: If there are no complaints, discoloration, mobility, or radiographic signs of pathology, the tooth may be considered healthy. However, a gray hue, increased mobility, or radiographic signs of root or bone resorption indicate chronic periodontitis, requiring tooth extraction. Orthodontic appliances may then be used to maintain proper spacing and prevent dental arch anomalies.

Permanent Teeth:
Treatment begins with splinting for 3–4 weeks. This method ensures both stability and physiological mobility, reducing the risk of ankylosis. Throughout treatment, dynamic monitoring of pulp excitability is critical. If necrosis occurs, endodontic intervention is required.

Prognosis

The outcome of incomplete dislocation treatment depends on several factors:

• Severity of injury
• Degree of tooth mobility
• Time elapsed before treatment

A follow-up examination should be done in 2 weeks (for splint removal, clinical and radiographic examination), 4 weeks, then 6-8 weeks, 6 months and 1 year post-trauma.

Teeth with immature roots have a higher chance of preserving the neurovascular bundle due to their anatomical and physiological characteristics. However, if pulp necrosis develops, endodontic treatment becomes necessary, which poses additional challenges for teeth with incomplete root formation.

Extrusion of tooth

Clinical Presentation

Patients commonly complain of:

• Pain when biting, chewing, or consuming food
• Mobility and displacement of the tooth
• Bleeding from the gums
• The tooth seems elongated

Clinically, a shift in the position of the tooth is observed, often displacing it in an oral or vestibular direction or extruding it from its socket. In cases of primary teeth, determining the angle of displacement is crucial, as the roots of primary teeth are closely located near the buds of permanent teeth. A crown displacement toward the lingual side may lead to a vestibular shift in the root, reducing the risk of damage to the permanent tooth beneath. However, when the root is displaced lingually or intruded, the likelihood of damage to the permanent tooth significantly increases. The tooth may be mobile and sensitive upon percussion, with symptoms varying depending on the degree of displacement. Minor bleeding may occur from the gingival sulcus due to injury to the periodontal ligament. Radiographically, the widening of the periodontal space may be evident.

Treatment
For extrusive luxation of permanent teeth, the primary treatment involves repositioning the damaged tooth and stabilizing it with splinting. The time elapsed before repositioning is critical, as delayed repositioning increases the risk of root resorption. Ideally, repositioning should occur within 1–2 hours after the trauma. If repositioning is delayed, not only does the risk of root resorption increase, but there is also a greater chance of periodontal ligament necrosis. In cases of mild displacement, endodontic treatment is typically not performed. However, in approximately half of these cases, pulp necrosis eventually occurs, requiring endodontic intervention. Therefore, clinical monitoring of the pulp's condition is essential.

For permanent teeth with fully formed roots, significant lateral or extrusive displacements require repositioning and splinting for 2–4 weeks. Generally, follow-up check-ups are recommended in 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1 year and early for 5 years post-trauma. In the first two weeks, pulp extirpation is performed, followed by temporary root canal filling with calcium hydroxide, which is replaced every 3 months for at least a year. If no root resorption is detected, the root canal is filled with gutta-percha.

Splinting after repositioning is performed using a flexible splint. A follow-up radiograph is taken to monitor the healing process. Patients are instructed on proper oral hygiene (ensuring the splint remains clean) and dietary guidelines (avoiding hard foods and cutting food into small pieces).

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Permanent Teeth with an Open Apex:
For permanent teeth with developing roots, the prognosis for pulp survival is generally favorable. However, inflammatory root resorption progresses more rapidly in teeth with developing roots due to their thinner walls. Consequently, these teeth require careful monitoring. Pulp vitality is tested 2–3 days after repositioning and splinting, and then weekly for the next 3–4 weeks. If necessary, testing can continue for several months. If pulp necrosis is detected on subsequent visits or if radiographic evidence shows periapical radiolucency or root resorption, endodontic treatment is necessary. Until the root apex closes and root resorption ceases, the canal is filled with calcium hydroxide, followed by permanent filling with gutta-percha once healing is complete.

Primary Teeth:
In primary teeth with minor displacement, treatment typically involves clinical observation and radiographic monitoring.
For luxation of intact primary teeth with fully formed roots, treatment follows the same principles as for permanent teeth. When splinting primary teeth, it is essential to roughen the vestibular surface of the tooth with a diamond bur to enhance the composite's adhesion. After the splint is removed, this roughened surface is polished. The primary factor in determining the success of repositioning and splinting a primary tooth is the child’s behavior.

If there is significant displacement or severe mobility, primary teeth should be extracted. Extracting is also recommended for displaced primary teeth with resorbing roots or complications from caries. Due to the difficulty in repositioning and stabilizing primary teeth with unformed roots (especially in children under 2.5 years old), they are often extracted as well.

Intrusion of Tooth

Intrusion, or intrusive luxation, is a severe traumatic injury in which the tooth is forced deeper into its socket, embedding its root into the surrounding bone. This type of dislocation often results in a fracture of the alveolar process of the jawbone.

Clinical Presentation

Patients typically report:

• Shortening of the visible crown or its complete disappearance
• Pain and bleeding from the gums

Upon examination, the affected area often shows:

• Swelling and redness of the mucosa
• Hematoma formation under the mucosa of the alveolar ridge
• Bleeding from the gingival crevice
• Percussion gives a high, metallic sound

The crown may appear shortened or entirely absent, the tooth is immobile. While percussion is usually painless or mildly painful, the tooth is often displaced vestibularly or orally. In some cases, the tooth may also rotate around its axis.

Diagnosis

Radiographic imaging reveals the tooth displaced deeper into the socket. The periodontal ligament space is typically absent from all or part of the root, and the enamel-dentin junction appears higher than adjacent teeth, making the root appear elongated.

In cases of deep intrusion, the tooth may extend into the jawbone, maxillary sinus, nasal cavity, or other regions. When the tooth is not visible in its expected location, thorough radiographic studies in 2–3 projections are essential.

Dental computed tomography (CBCT) provides more precise information about the tooth’s position, fractures of the alveolar ridge or maxillary sinus wall, root alignment, and other pathological changes. Electrodiagnostic testing (EPT) is generally not performed for primary teeth with intrusion, as pulp sensitivity is often significantly reduced or absent due to irreversible damage.

Treatment

Primary Teeth
Treatment for intruded primary teeth often involves extraction, particularly when the root is displaced palatally, as this poses a risk of damaging the permanent tooth germ and causing enamel hypoplasia in the developing tooth.

In cases where the roots of primary teeth are not fully formed, and displacement is minimal and favorably directed, observation may be considered. Over time, the injured tooth may re-erupt naturally toward the occlusal plane.

Extraction is mandatory if the intruded tooth is found in abnormal locations (e.g., deep in the jawbone, soft tissues, or maxillary sinus). Parents should always be informed about the potential for damage or loss of the corresponding permanent tooth.

Permanent Teeth
Treatment depends on the degree of root development and the time elapsed since the injury:

• Immature roots (incomplete apex formation): A wait-and-see approach is recommended, as spontaneous re-eruption is highly likely. This process can take up to 9–12 months. If the tooth is intruded more than 7 mm or no movement within a few weeks, reposition surgically or orthodontically.
• Mature roots (complete apex formation): Spontaneous re-eruption is less likely (allow eruption without intervention only if tooth is intruded less than 3 mm), if no movement within 2-4 weeks orthodontic repositioning using fixed appliances is required. If the tooth is intruded beyond 7 mm, reposition surgically. Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with a flexible splint for 4–8 weeks

For teeth deeply embedded in the socket, surgical exposure of the crown may precede orthodontic treatment. If the tooth is severely misaligned and orthodontic correction is not feasible, surgical repositioning followed by splinting is performed.

Since pulp vitality is often lost in cases of intrusion, endodontic treatment is typically required. Root canals are filled using calcium hydroxide-based pastes, which are replaced every 3–6 months. Parents and patients should be cautioned about potential complications, including root resorption. This process may occur days, months, or even years after the trauma and often leads to tooth loss.

Prognosis

Recovery is possible if the affected tooth – whether primary or permanent – retains its natural color, maintains proper alignment, shows no pathological mobility, and displays no signs of root or bone resorption on radiographs.

However, changes in crown color, radiographic evidence of bone or root destruction, or pathological mobility indicate the need for endodontic treatment. For primary teeth, clinical and radiographic evidence of pathology often necessitates extraction to protect the developing permanent teeth.

With timely intervention and vigilant follow-ups in 2 weeks (for splint removal, clinical and radiographic examination), 4 weeks, 6-8 weeks, 6 months, 1 year and then yearly for 5 years, the prognosis for intrusive dislocations can be significantly improved, particularly in cases involving permanent teeth.

Avulsion of tooth

Avulsion is a severe traumatic injury characterized by the total rupture of the periodontal and circular ligaments, resulting in the tooth being ejected from its socket due to a significant force directed toward the occlusal plane. Most commonly, such trauma affects children during the early mixed dentition phase when the ligamentous apparatus of the tooth is still underdeveloped.

Clinical Presentation

Patients typically report:

• The sudden absence or loss of a tooth
• Pain and bleeding from the socket
• Aesthetic concerns
• Discomfort during eating
• Speech defects

Complete dislocation often involves tearing of the surrounding soft tissues, fractures of the alveolar socket wall, and, in some cases, fractures of the alveolar process of the jaw. Upper incisors are most frequently affected.

Diagnosis

On examination:

• The tooth crown is absent, and the socket is filled with a blood clot.
• Swelling, redness, and possible mucosal tears around the missing tooth are evident.

Radiographs may reveal damage to the compact and spongy bone, indicating the direction of the traumatic force. Electrodiagnostic testing (EPT) is performed on adjacent and opposing teeth since trauma of this severity rarely affects only one tooth.

In many cases, the avulsed tooth is brought in by the patient or their parents. However, there is also the risk of aspiration or swallowing of the tooth, which must be ruled out.

Treatment

For Primary Teeth
Replantation of primary teeth is generally ineffective and not recommended. After the socket heals, the resulting gap is addressed with removable prosthetics to restore function and aesthetics.

For Permanent Teeth
The success of treatment for permanent teeth depends on:

• The time elapsed between the injury and medical intervention
• The stage of root development
• The condition of the root and socket
• How the tooth was preserved and transported

The best prognosis is achieved if replantation is performed within 30-60 minutes of the injury. The tooth should be held by the crown, to avoid touching the root, if it is dirty, it can be washed for a maximum of 10 seconds under cold running water. The ideal transport medium keeps the root surface moist, such as the patient’s saliva, pasteurized milk, or isotonic saline.

Immediate Replantation

• If the tooth is not contaminated, parents can be instructed over the phone to reinsert the tooth within the first 30 minutes.
• Otherwise, the tooth should be transported in a moist medium for professional replantation.

Replantation Process

• The root is assessed for damage, and visible debris is gently cleaned using saline.
• The root may be soaked in an antibiotic solution before replantation to reduce the risk of infection.
• Prior to replantation, foreign bodies are removed from the socket, and the alveolar ridge is examined for fractures.
• Handling of the root should be minimal to preserve any remaining periodontal tissue.
• After verifying the normal position of the tooth clinically and radiographically, a flexible splint should be applied for up to 2 weeks.
• Extraction of the pulp is rarely necessary during initial treatment, especially in immature teeth with open apices, as revascularization is still possible.

If endodontic treatment is required, it is typically performed 7-10 days after the injury before splint removal, using calcium hydroxide-based materials for root canal filling. Systemic antibiotics are supposed to be administered.

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Types of Healing

Three types of healing can occur between the alveolar walls and the tooth root:

1. Periodontal Healing
   • Occurs when periodontal fibers are preserved on the root and socket walls.
   • Radiographs show a uniform periodontal ligament space, indicating a favorable outcome.
2. Periodontal-Fibrous Healing
   • Results from insufficient connective tissue.
   • Radiographs reveal an irregular periodontal ligament space, with areas of narrowing and loss.
3. Osteoid Healing
   • Occurs when periodontal tissue is entirely lost from the root and socket walls.
   • Radiographs show no identifiable ligament space. This type is the least favorable and often leads to root resorption at varying rates.

Prognosis

The prognosis for an avulsed tooth depends on numerous factors, including:

• The time elapsed between the injury and replantation
• The transport conditions of the tooth
• The amount of preserved periodontal tissue
• The presence of infection in the socket
• Local and systemic immune factors

Parents and patients should be informed of potential complications, including inflammation and root resorption, which can occur months or even years after the injury. Despite this, retaining the tooth for as long as possible is essential to prevent dental arch anomalies and maintain proper occlusion until more permanent solutions can be implemented.