1. Luxation Injuries World Health Organization Classification

2. Great Threat to Pulp Vitality (Luxations) Traumatizes supporting structures of the periodontium Traumatizes supporting structures of the periodontium Potentially severs pulpal blood supply entering the apical foramen Potentially severs pulpal blood supply entering the apical foramen WHO recognizes five main types of luxation injuries WHO recognizes five main types of luxation injuries

3. Luxation Injuries Concussion Concussion Subluxation Subluxation Extrusive luxation Extrusive luxation Lateral luxation Lateral luxation Intrusive luxation Intrusive luxation

4. Concussion Clinical findings: tender to touch, not displaced no increased mobility. Sensitivity test are most likely positive Clinical findings: tender to touch, not displaced no increased mobility. Sensitivity test are most likely positive Radiographic findings: No abnormalities Radiographic findings: No abnormalities Treatment: No treatment is need but it is essential to monitor pulpal condition for one year Treatment: No treatment is need but it is essential to monitor pulpal condition for one year

5. Concussion: follow up Follow up: clinical and radiographic examination at, 4 weeks, 8 weeks, 1 year with clinical and radiographic examination Follow up: clinical and radiographic examination at, 4 weeks, 8 weeks, 1 year with clinical and radiographic examination Favorable outcome: Asymptomatic, positive pulp tests, can have false negative up to 3 months, continued root development, intact lamina dura Favorable outcome: Asymptomatic, positive pulp tests, can have false negative up to 3 months, continued root development, intact lamina dura Unfavorable outcome: Symptomatic, negative pulp test, can have false neg for 3 months no continuing root development, signs of PAP, endo tx appropriate for stage of root development Unfavorable outcome: Symptomatic, negative pulp test, can have false neg for 3 months no continuing root development, signs of PAP, endo tx appropriate for stage of root development

6. Subluxation Clinical findings: tender to touch or tap, increased mobility, not displaced. Bleeding from the gingival crevice. May have negative pulp test initially indicating transient pulpal damage. Clinical findings: tender to touch or tap, increased mobility, not displaced. Bleeding from the gingival crevice. May have negative pulp test initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made Monitor pulpal response until a definitive pulpal diagnosis can be made Radiographic findings: Abnormalities are usually not found Radiographic findings: Abnormalities are usually not found Treatment: no treatment is needed. Monitor pulpal status for one year Treatment: no treatment is needed. Monitor pulpal status for one year

7. Subluxation: follow up Follow up at 2 weeks, 4 weeks, 8 weeks 6 months and one year with clinical and radiographic examination Follow up at 2 weeks, 4 weeks, 8 weeks 6 months and one year with clinical and radiographic examination Favorable outcome: asymptomatic, positive pulp test. Can have false negative up to 3 months. Continued root development of immature teeth. Intact lamina dura. Favorable outcome: asymptomatic, positive pulp test. Can have false negative up to 3 months. Continued root development of immature teeth. Intact lamina dura. Unfavorable outcome: Symptomatic, negative pulp tests, external inflammatory resorption, arrested root development, PAP, endo tx appropriate for stage of root development. Unfavorable outcome: Symptomatic, negative pulp tests, external inflammatory resorption, arrested root development, PAP, endo tx appropriate for stage of root development.

8. Extrusive Luxations

9. Extrusive Luxation Clinical Findings: Tooth appears elongated and is excessively mobile. Sensitivity test give negative results Clinical Findings: Tooth appears elongated and is excessively mobile. Sensitivity test give negative results Radiographic findings: Increased periodontal ligament space apically Radiographic findings: Increased periodontal ligament space apically Treatment: Reposition tooth by gently re- inserting it into the socket. Stabilize for 2 weeks with a flexible splint. In mature tooth pulp necrosis is expected. With immature teeth watch for signs and symptoms of pulpal necrosis. Endodontic therapy indicated. Treatment: Reposition tooth by gently re- inserting it into the socket. Stabilize for 2 weeks with a flexible splint. In mature tooth pulp necrosis is expected. With immature teeth watch for signs and symptoms of pulpal necrosis. Endodontic therapy indicated.

10. Extrusive Luxation: follow up Remove splint in 2 weeks. Perform clinical and radiographic exam at 2 weeks, 4 weeks, 8 weeks, 6 months, then yearly Remove splint in 2 weeks. Perform clinical and radiographic exam at 2 weeks, 4 weeks, 8 weeks, 6 months, then yearly Favorable outcome: Asymptomatic, clinical and radiographic signs of healed periodontium, positive pulp tests (false neg up to 3 mos), marginal bone height maintained, continued root development Favorable outcome: Asymptomatic, clinical and radiographic signs of healed periodontium, positive pulp tests (false neg up to 3 mos), marginal bone height maintained, continued root development Unfavorable outcome: Symptoms and radiographic signs of apical periodontitis, negative response to pulp tests, if breakdown of marginal bone is noted splint for an additional 4 weeks, signs of external inflammatory root resorption, endodontic therapy appropriate for root development. Unfavorable outcome: Symptoms and radiographic signs of apical periodontitis, negative response to pulp tests, if breakdown of marginal bone is noted splint for an additional 4 weeks, signs of external inflammatory root resorption, endodontic therapy appropriate for root development.

11. Inflammatory Root Resorption

12. Lateral Luxations Clinical findings: displacement usually palatal/lingual direction. Often immobile and percussion gives metallic sound. Fracture of alveolar process is present. Negative pulp tests. Clinical findings: displacement usually palatal/lingual direction. Often immobile and percussion gives metallic sound. Fracture of alveolar process is present. Negative pulp tests. Radiographic findings: widen PDL, best seen on occlusal exposure Radiographic findings: widen PDL, best seen on occlusal exposure Treatment: Reposition digitally to disengage from its boney lock and gently reposition to original location. Stabilize 4 weeks with flexible splint. Monitor vitality. If necrotic endodontic therapy is indicated to prevent root resorption Treatment: Reposition digitally to disengage from its boney lock and gently reposition to original location. Stabilize 4 weeks with flexible splint. Monitor vitality. If necrotic endodontic therapy is indicated to prevent root resorption

13. Lateral Luxations Lateral Luxations

18. Lateral Luxation: follow up Follow up: 2 weeks splint removal, 2-4-6weeks, 6-12 months and yearly for 5 years clinical and radiographic exam. Follow up: 2 weeks splint removal, 2-4-6weeks, 6-12 months and yearly for 5 years clinical and radiographic exam. Favorable outcome: asymptomatic, clinical and radiographic signs of normal periodontium. Positive pulp tests. Potential false neg. for 3 months. No loss of marginal bone height. Continued root development in immature teeth. Favorable outcome: asymptomatic, clinical and radiographic signs of normal periodontium. Positive pulp tests. Potential false neg. for 3 months. No loss of marginal bone height. Continued root development in immature teeth. Unfavorable outcome: Symptomatic with radiographic PAP. Negative vitality. (False negative up to 3 months) If marginal bone is breaking down splint for additional 4 weeks. External inflammatory root resorption or replacement resorption. Endodontic therapy appropriate for root development stage. Unfavorable outcome: Symptomatic with radiographic PAP. Negative vitality. (False negative up to 3 months) If marginal bone is breaking down splint for additional 4 weeks. External inflammatory root resorption or replacement resorption. Endodontic therapy appropriate for root development stage.

19. Intrusive Luxation Clinical findings: tooth displaced axially into the alveolar bone. Immobile with metallic sound to percussion (ankylotic). Negative to vitality tests. Clinical findings: tooth displaced axially into the alveolar bone. Immobile with metallic sound to percussion (ankylotic). Negative to vitality tests. Radiographic findings: PDL absent. CEJ more apical then adjacent non-injured teeth. Radiographic findings: PDL absent. CEJ more apical then adjacent non-injured teeth. Treatment: contingent on root development. Teeth with incomplete root development vs teeth with complete root formation Treatment: contingent on root development. Teeth with incomplete root development vs teeth with complete root formation

20. Intrusive Luxations

21. Intrusive Luxation: treatment Incomplete root formation: Allow eruption with no intervention. If no movement within three weeks initiate orthodontic repositioning. If tooth was intruded more than 7 mm immediately reposition surgically or orthodontically. Incomplete root formation: Allow eruption with no intervention. If no movement within three weeks initiate orthodontic repositioning. If tooth was intruded more than 7 mm immediately reposition surgically or orthodontically. Complete root formation: allow eruption if intruded less than 3 mm. If no movement in 3 weeks reposition surgically or orthodontically before ankylosis sets in. More extensive intrusions promptly reposition surgically. Complete root formation: allow eruption if intruded less than 3 mm. If no movement in 3 weeks reposition surgically or orthodontically before ankylosis sets in. More extensive intrusions promptly reposition surgically. Pulpal necrosis likely initiate endodontic therapy with CAOH 2 weeks after surgery. Pulpal necrosis likely initiate endodontic therapy with CAOH 2 weeks after surgery. Once repositioned surgically or orthodontically stabilize with flexible splint for 4-8 weeks Once repositioned surgically or orthodontically stabilize with flexible splint for 4-8 weeks

22. Intrusive Luxation: Follow up 2 weeks splint removal. Clinical and radiographic exam. Then continue checking at 4 weeks 8 weeks 6 months and yearly for 5 years. 2 weeks splint removal. Clinical and radiographic exam. Then continue checking at 4 weeks 8 weeks 6 months and yearly for 5 years. Favorable outcome: tooth erupting or in place. Intact lamina dura. No sign of resorption. Continued root development. Favorable outcome: tooth erupting or in place. Intact lamina dura. No sign of resorption. Continued root development. Unfavorable outcome: Tooth locked in place (ankylotic) Apical periodontitis. External inflammatory root resorption or replacement resorption. Endodontic therapy appropriate for stage of root development. Unfavorable outcome: Tooth locked in place (ankylotic) Apical periodontitis. External inflammatory root resorption or replacement resorption. Endodontic therapy appropriate for stage of root development.

23. Intrusive Luxation Immature

24. Re-erupting

25. Replacement Resorption (Ankylosis)