1. History  1. Patient name, age etc  2. When did the occur?  3. Where did injury occur?

2. 4. How did injury occur?

3. 5. Previous treatment

4. History  6. Medical history  7. Subjective complaints:  a. Did trauma causes amnesia, un-con. vomiting or headache.  b. Is there any disturbance in bite which imply: tooth luxation,  alveolar fracture, jaw fracture, or fracture of the TMJ.  c. Reaction to thermal or other stimuli.

5. Clinical examination : P rovides all information necessary to make correct diagnosis and design an appropriate treatment plan  Before initiating the C.E. the areas should be cleaned of all debris and blood.

6. Clinical Examination should include:  1: Injury to the soft tissues. (Intra & Extra )  2: Presence of foreign material or tooth structure.

7. 2: Presence of foreign material or tooth structure

8. Clinical Examination should include  3: Bony fracture  4: Hemorrhage into floor of the mouth J Fra.  5: Cracks and Craze lines, fracture, pulp exposure  6: Displacement of the tooth in any direction

9. Clinical Examination should include:  7: Abnormal, horizontal and vertical mobility.  8: Injury to PDL.  9: Abnormalities in the occlusion.  10: Percussion test  11: Reaction of teeth to sensibility testing:

10. 11: Reaction of teeth to sensibility testing:  1. Heat  2. Cold, ethyl chloride, carbon dioxide snow -78, dichlorodifluoromethane -28.  3. Electric pulp tests:  Before initiating vitality testing, the following factors should be considered:  A. erupting non-injured teeth  B. testing should be conducted away from the gingival area  C. splinted and crowned teeth.  D. since pt. adapt sustained E C, pain threshold should be determined by rapid, steady increase in current rather than slow, gradual increase.

11. Radiographic Examination

12. 1. Four films

13. Some points to be considered  1. Four films  2. Fracture Line are usually obliquely positioned. 10-15 apical or coronal.  3. A bend in a film Tracing P ligament around the root.  4. After six week another x-ray.

14. Root Fracture  Complex healing pattern, E,D,P,C,PDL  After age of 10 years ( incomplete root, resilient supportive structure )  Types of fracture  Healing events depends on :pulp cut off, bacteria invasion  Types of healing events  Treatment include repositioning and splinting  Prognosis depends on degree of displacement of the coronal fragment and the stage of root development

15. Concussion and Subluxation  Concussed Tooth is tender to percussion due to edema and Hemorrhage in PDL  Subluxated Tooth is tender to percussion and abnormally loose due to rupture of PDL, gingival hemorrhage around the gingival margin  Treatment:  adjustment of occlusion  soft diet  splinting for the comfort of the pat. Does not prompt healing  repeated sensibility testing

16. Extrusive luxation  E xtrusive Luxation :Partial displacement of the tooth out of its socket  X-ray: revealed increased P L space at peri-apical region  Clinical findings:  extrusive tooth appear elongate  bleeding from PL  percussion is dull  increase mobility  tenderness to percussion  sensibility test is -ve  pulp necrosis 15%-59%

17. Lateral Luxation  Lateral lux: eccentric displacement of the tooth accompanied with comminuted fracture or fracture of the alveolar socket  X-ray findings: reveals P space apically only by occlusal view  Clinical findings:  crown displaced palataly  usually of socket wall and root apex locked  percussion test metallic sound  little mobility  pulp necrosis 58%  temporary breakdown of the marginal bone within 2-4 weeks, extend  splinting 2 months

18. Intrusion Luxation  Displacement of the tooth deeper into the alveolar bone with comminuting or fracture of the alveolar bone.  Clinical findings:  the affected tooth appears shorter than the contra lateral tooth  high metallic sound in percussion  no mobility  x-ray: PL space partially or totally disappears  pulp necrosis 63% in immature teeth and 100% in mature ones.

19. DiagnosisTreatment Concussion −Tooth is tender to percussion(TTP) but is not displaced or mobile; no radiographic abnormalities. Monitor pulpal status for 1 year. Subluxation −Tooth is TTP and has increased mobility but is un-displaced. Radiographic abnormalities not normally found. Flexible splint for up to 2 weeks. Extrusive Luxation –Tooth displaced axially out of alveolar bone with mobility monitor pulpal status. but still retained within socket. Radio-graphically tooth appears elongated with increased apical PDL space. Reposition, flexible splint for 2 weeks, Lateral Luxation –Tooth is horizontally displaced, usually in palatal/lingual direction. Immobile, and usually gives high, metallic note on percussion. Reposition with finger pressure, disengaging from bony lock with forceps applied to the crown if required, flexible splint for 4 weeks, monitor pulpal status. Intrusive Luxation –Tooth displaced axially into alveolar bone. Tooth is immobile and may give high, metallic sound on percussion. PDL space may be absent from all or part of the root on radiographs. Can be subdivided into mild, moderate and severe intrusion Incomplete root formation − Allow spontaneous re- eruption; if no movement in 3 weeks, rapid orthodontic repositioning. Complete root formation − Reposition orthodontically or surgically as soon as possible. Extirpate and dress with non-setting calcium hydroxide paste.

20. avulsion  Maxillary incisors (prominent)  Children 7-10 years old  Success rate 4-50%  Two important aspects in the successful treatment:  A. the condition under which the tooth has been preserved. B the time interval between the injury and the treatment  The following condition to be considered before R.A.T:  A. The avulsed tooth should be without advanced P.diseas  B. The alveolar process should be intact to provide a seat  C. Their should be no orthodontic contraindication  D. The stage of root development should be evaluated

21.  To provide the best chance of success, the PL cells should be kept in the most physiologically healthy status as possible.  If the avulsed tooth does not replanted within 60-120 min., the PL cells undergo necrosis then root resorption begins and leads to the loss of pre-cementum layer. Because PL cells deprived from its blood supply and depletion of the stored cell metabolites.

22. Storage media  Water and saline are damaging to PL cells (one hour)  Milk (low fat) limited in benefit (two hours)  Hank’s Balance Saline Solution (HBSS) (Save-A-tooth sys)  Gingival fluid storage media not available commercially  Emdagon is an enamel matrix derivative gel Promote regeneration of periodontal ligament cells (60 minutes).

23. TimeMature rootImmature root >15 mClean with HBSS5% doxycycline 5 minutes 15 m-24H(G.M) Implant immediately5% Doxy. 5 minutes 15 m-24 H <24 H (B.M) HBSS 30 minutes Dry media Shaving PL 30 m Sod.Hyp Endo. Treat Citric acid 3 m 5% Doxy 5m Canal dried then Ca(OH)2 Replanted Gatta P. months filling HBSS 30 m then 5% Doxy 5 m The same as mature root

24. Complication of primary teeth injuries on developing permanent teeth  white or brown discoloration of the permanent tooth with or without hypoplastic defects;  dilaceration of the crown of the tooth causing eruption disturbance or failure.  dilaceration of the root of the tooth causing eruption disturbance or failure; odontome-like formation.  partial or total failure of root development;  total failure of tooth development.