Perspective Chapter: Update and Making-Decisions in Dental Traumatology

Abstract

Dental traumatology is highlighted as an unexpected emergency event which can occur at any moment, age, sex, and gender. Crown fractures account for most traumatic injuries occurring in the permanent dentition. A complete radiographic examination is considered essential in order to assess the state of the pulp, the degree of root development, and the existence of any pathologies affecting the supporting tissues. These examinations also provide a useful tool for subsequent comparisons with those conducted after treatment, ensuring adequate clinical follow-up. Additionally, avulsion of permanent teeth has been highlighted as one of the most relevant dental injuries; therefore, the prognosis of this traumatic event has been directly related to the treatment decision-making process and the time passed since the accident. In addition, dental trauma is also one of the most frequent emergency situations seen in Pediatric Dentistry; moreover, the dental injury of the temporary teeth could also affect to the permanent teeth; hence, it is necessary to perform an exhaustive clinical and radio diagnostic exam to allow a correct diagnosis and a predictable treatment plan. Therefore, the creation of action protocols makes it possible to simplify and facilitate decision-making under stressful situations for patients and clinicians.

1. Introduction

Avulsion of permanent teeth has been highlighted as one of the most relevant dental injuries; it has been reported to make up between 0.5 and 16% of all dental injuries [1, 2]. Additionally, the prognosis of this dental injury is directly related to the treatment decision-making process and the time passed since the accident [3, 4, 5, 6]; it is therefore essential to inform society and keep professionals updated so that the decision-making chain is as optimal as possible and leads to a predictable prognosis [7, 8]. Currently, dental replantation is the treatment of choice; however, certain scenarios prevent it from being carried out immediately, including extensive caries, periodontal disease, uncooperative patients, immunosuppression, or heart disease, which require individualized treatment procedure. Additionally, the final decision must be made with the consent of the parents. Therefore, the creation of action protocols makes it possible to simplify and facilitate decision-making under stressful situations for patients and clinicians. For this reason, guides developed by scientific societies are published in the most popular media, so that they might reach the majority of society and clinicians. 2. Treatment guidelines and decision-making for dental fractures.

1.1 Crown fractures

Crown fractures account for most traumatic injuries occurring in the permanent dentition. The most common etiology of this type of injury is accidental falls, contact sports, traffic accidents, or accidents at work.

A complete radiographic examination is considered essential in order to assess the state of the pulp, the degree of root development and the existence of any pathologies affecting the supporting tissues. These examinations also provide a useful tool for subsequent comparisons with those conducted after treatment, ensuring adequate clinical follow-up [9].

1.1.1 Enamel fissures (enamel infraction)

These types of fractures are located on the vestibular surface of the anterior teeth and may go unnoticed because there is no loss of tooth structure. Clinically, they appear as fissures that do not cross the amelo-dentinal junction [10, 11], and they are usually revealed when light is targeted perpendicular to the major axis of the tooth (transillumination).

Vitality tests are usually positive3, although they may be temporarily negative after any impact [9].

The presence of crack lines in the enamel should alert the clinician to the possibility of injury to the surrounding supporting structures (e.g. luxation). In such cases, there may visible changes in dental color.

Fissures limited to enamel generally do not require treatment. In selected cases, to avoid potential staining by external agents, the enamel surface can be sealed [9, 11].

The long-term prognosis of this type of lesion is very good, with tooth survival approaching rates of 100%.

1.1.2 Fracture without pulp exposure (uncomplicated crown fracture)

Fortunately, this type of fracture occurs more frequently than those with pulp involvement.

On initial examination, thermal tests may be negative for a certain period of time (primarily if the lesion coexists with a luxation), but with this type of fracture there is usually sensitivity to thermal changes due to dentine exposure (more prevalent in younger teeth due to the larger diameter of the dentin tubules and the proximity of the fracture to the pulp), pressure changes, and dehydration [9, 11].

Just like with enamel fissures, the surrounding tissues should be routinely examined to exclude other pathologies that might affect the supporting tissues.

The primary goal of treatment is to achieve adequate esthetics and function. Nowadays, with composite resins [12] and the use of adequate bezels to mask the fracture line, it is possible to attain very satisfactory results [13].

Another therapeutic option involves the fixation of the detached crown segment with a total acid etching technique and the application of composite resins at the fracture line. This type of fixation is more predictable the larger the fragment is, and if it is a single fragment (smaller and multiple fragments have a worse prognosis) [9]. Before being bonded to the remaining tooth structure, the fragment must be rehydrated [11].

According to different authors, failures in this type of restorations can be attributed to:

1. Failure of the bonding system.

2. Cohesive fractures of the composite resin.

3. Color instability.

4. Recurrent caries.

5. Horizontal tensile forces exerted either on the restoration or on the bonded fragment [9].

1.1.3 Crown fracture with pulp exposure (complicated crown fracture)

In this case, visible loss of tooth structure is evident, and a slight hemorrhage can be observed at the site of pulp exposure. In cases in which there is a delay in treatment, and particularly in young teeth, a pulp polyp may be observed.

Due to this pulp exposure, the teeth are often sensitive to thermal and pressure changes.

Radiographs are very useful for diagnosis, mainly to assess the extent of the lesion and to determine the degree of root development, in order to choose the most appropriate treatment option for each individual case.

The primary objective of treatment is the preservation of pulp vitality without inflammation, to achieve the formation of a hard tissue barrier [9, 13].

The prognosis of treatment will depend on:

1. State (maturity or immaturity) of the apex: This is perhaps the most important factor. Pulp conservation is desirable in teeth with immature apexes, whereas in teeth with closed apexes, pulp tissue can be removed.

2. Time elapsed between the lesion and treatment.

3. Extent of pulp exposure: The smaller the size of the exposure, the greater the likelihood of dentin bridging.

4. Existence of other surrounding hard tissue injuries, e.g. luxation, as it compromises the neurovascular supply to the pulp, compromising pulp vitality.

5. Existence of prior trauma: Healing capacity is considerably decreased in teeth that have already suffered a previous trauma [9].

Treatment of teeth with an open/immature apex should be as conservative as possible, trying to maintain pulp vitality. The therapeutic options that can be considered are as follows:

• Direct pulp capping: This is used in small pulp exposures in which treatment can be carried out in less than 24 h and the bleeding stops when pressure is applied with cotton wool.

  Pulp capping, which may consist of applying glass ionomer cement (GIC) or mineral trioxide aggregate (MTA) before placing the restoration to prevent bacterial invasion [14].

• Partial pulpotomy (Cvek pulpotomy): The treatment of choice if the trauma occurred more than 24 h before. It consists of removal of the damaged tissue until clinically healthy pulp is available [15].

  Depending on the size of the pulp exposure, it may be performed partially or coronally. This treatment be used in both mature and immature teeth.

  After removal of the affected pulp and controlling the bleeding, Calcium Hydroxide (CaH) or MTA is placed. Zinc oxide eugenol or another cement can be placed on top. After 3 months, if appropriate sensitivity has been preserved and a dentin barrier can be observed via radiographic examination, definitive reconstruction can be carried out.

• Coronal pulpotomy: Consists of removing the entire coronal pulp while keeping the root pulp intact. For this procedure, the root pulp must be healthy [16]. It is performed in immature permanent teeth if the inflammation is larger than 2 mm in order to achieve complete root development1, or currently even on teeth with a closed apex. An optimal treatment result would include the formation of a dentine bridge under the CaH or MTA veneer used [17].

• Deep pulpotomy: In this case, coronal pulp and the coronal third of the root portion are removed.

  As in the previous cases, bleeding must be controllable (hemostatic agents can be used). The material of choice is CaH [9], although calcium silicate–based cement is also used [18].

  Despite advances in both technique and materials used, it is particularly difficult to assess the state of the pulp in root canals, so the prognosis of this therapeutic option remains controversial.

• Non-vital teeth: Teeth with complete root formation can be treated with standard endodontic procedures, producing a predictable outcome.

  Teeth without complete root formation have a poorer prognosis, as cessation of the neurovascular supply leads to incomplete apex closure, thinner root walls, and, in some cases, even an unfavorable crown-root ratio [19].

  The apexification procedure allows for complete root development by forming an apical hard tissue barrier [20].

  This was traditionally carried out using CaH, which induced apex closure until complete apical closure was achieved, enabling conventional endodontic treatment. Nowadays, MTA is used to achieve apical closure in a single step [19], and even platelet-rich plasma is used in combination with MTA [21].

  If CaH is used, endodontic reopening of the tooth is performed when the clinician observes the desired apical closure radiographically, and the existence of the apical barrier is checked with a file.

  If MTA is used, after proper opening and cleaning of the canal, the MTA is loaded into a dental plate holder and placed at the apex with the aid of a thick paper tip 1–2 mm shorter than the estimated working length and a thick stripper until a 4–5 mm thick plug is formed. When the plug is deemed to be adequate, a radiographic check of the plug is necessary, and once the MTA has set, the root canal can be filled [9].

1.2 Intra-alveolar root fractures

These represent a much lower percentage than coronal fractures. Furthermore, they are much less common in the primary dentition and in teeth with immature apexes (these tend to dislocate rather than fracture). These types of fractures can be located horizontally or vertically with respect to the major axis of the tooth and involve enamel, dentine, and cementum [9, 13]. Vertical fractures usually have a worse prognosis, the tooth is not usually restorable, and often the only option is to extract the tooth.

Horizontal fractures, depending on their location, can affect the coronal, middle, or apical third.

Clinically, the affected teeth will appear as if they were extruded. As the trauma usually comes from the vestibular side, we will often also find the tooth is slightly lingually inclined, in addition to exhibiting mobility, bleeding from the gingival sulcus, and positive percussion. In terms of vitality, both fragments may be necrotic, or the coronal fragment may be endodontically treated and the apical fragment may still be vital.

The diagnosis of an intra-alveolar fracture is sometimes complicated by the small separation of fragments at the time of impact. This separation usually increases over the following days, which often makes diagnosis easier as the fracture line can be seen on the radiographic scan if the beam is directed at approximately the same angle as the fracture line. This is usually easier when the fracture is more horizontal rather than oblique. Therefore, in a patient with a possible intra-alveolar fracture, several radiographs should be taken, changing the degree of angulation [9]. If the radiographic projections do not give us the information we need, it is advisable to perform a CBCT (Cone Beam Computed Tomography) to determine the location, extension, and trajectory of the fracture [12].

The different types of scarring between fragments were first classified by Andreasen and Hjorting-Hansen [22] into four different categories (Table 1).

Calcifying fusion of fragments	There is radiographic evidence of fracture but no radiolucent lesion between the two fragments
Band of connective tissue between fragments	There is a narrow radiolucent image between the fragments
Bone formation between fragments	Bone deposition can be observed in the diastasis area
Granulation tissue between fragments	The space between the two fragments is wider and radiolucent

Table 1.

Types of scarring observed in fragments [22].

In addition, intra-alveolar fractures present four types of sequelae, which are summarized in Table 2.

Internal resorption	This is not a frequent finding in intra-alveolar fractures. It is a pulp reaction to a chronic inflammatory process in the form of lacunae or spaces that appear within the root canal 14
External resorption	Occurs in the form of resorption in those areas close to the fracture, beginning on the external or lateral surface of the tooth root 15
Pulp survival with canal obliteration	Calcification of the canal lumen, although the vitality of the tooth is sometimes preserved
Loss of the osseous crest	More frequent when the fracture affects the coronal third and extends into the gingival sulcus. Very poor prognosis

Table 2.

Sequelae of intra-alveolar fractures [9].

The treatment and prognosis of the tooth will depend largely on the location of the root fracture: whenever possible, it is advisable to reduce the fracture by repositioning the coronal fragment in an appropriate position. If it is very mobile, it should be splinted passively and flexibly (semi-rigid) [23].

If the fracture affects both the crown and the root but there is no pulp exposure, the fractured fragment should be reconstructed [12].

In the case of an intra-alveolar fracture, it should be noted that vitality tests may initially be negative. If the diagnosis of loss of vitality is confirmed, or if it is confirmed that the root of an immature tooth is not continuing to develop, endodontic treatment should be carried out. Depending on the case, treatment of both fragments can be carried out in several ways:

• Endodontic treatment of the coronal fragment.

• Endodontic treatment of the coronal fragment and extraction of the apical fragment.

• Treatment of both fragments (coronal and apical).

• Treatment of the apical fragment and extraction of the coronal fragment [9].

2. Introduction of the treatment guidelines and decision-making for avulsed permanent teeth

2.1 Patient recommendations

Traumatic events occur suddenly and unexpectedly, and first aid responses for an avulsed permanent tooth is usually performed by a guardian, teacher, or parents, who call the dental clinic asking for instructions on how to respond to the traumatic event. Afterwards, it is necessary to confirm that it is a permanent tooth that has been avulsed, as a primary tooth should not be replanted. Subsequently, clinicians should provide the following recommendations [24]:

1. Keep the patient and the guardian, teacher, and/or parents calm.

2. Encourage them to find the avulsed permanent tooth and pick it up by the crown, trying to avoid damaging the root and therefore the periodontal ligament cells.

3. Rinse the avulsed permanent tooth gently with a saline solution or milk to remove dirt, taking care not to apply heavy pressure to avoid damaging the periodontal ligament [25].

4. Encourage the guardian, teacher, and/or parents to immediately replant the avulsed permanent tooth on the alveolus, preferably before blood clot formation, which could complicate replantation of the avulsed permanent tooth. It must be taken into consideration that the guardian, teacher, and/or parents are not specialists and that bleeding and stress can make replantation difficult.

5. Some situations preclude immediate replantation of avulsed permanent teeth, for example if the patient is uncontrolled or non-cooperative, unconscious, or presenting with vital injuries requiring urgent attention. In such cases, it is recommended to store and transport the avulsed permanent tooth in a wet medium such as milk, Hank’s Balanced Salt solution (HBSS), saliva, or saline solution to avoid dehydration of the periodontal ligament tissue which is responsible for the fixation of the root to the alveolus [24, 25]. Finally, it is recommended to emphasize that time may affect the prognosis of the avulsed permanent teeth, since most of the periodontal ligament cells do not survive after 30 minutes of extra-alveolar dry time [26, 27].

6. Go immediately to a dental clinic to be attended by a clinician, both to follow the preceding guidelines/treatments and to perform the autotransplantation of the permanent tooth.

In addition, the International Association of Dental Traumatology (IADT) has developed the free app “ToothSOS”, which provides useful information for patients affected by dental injury.

2.2 Management and decision-making for avulsed permanent teeth

Once the patient arrives to the dental clinic, the clinician should ask whether or not it was possible to replant the avulsed permanent tooth. If the tooth was replanted on the alveolus, the clinician should verify that the tooth has been replanted correctly by comparing the angulation and incisal border with respect to the adjacent teeth, as well as by using a periapical radiograph. However, if the tooth could not be successfully replanted on the alveolus, the clinician should first analyze the condition of the periodontal ligament fibers according to the classification of the IADT in order to obtain useful information regarding the prognosis of the avulsed permanent tooth [28]:

Most of the periodontal ligament fibers are viable, since the tooth was replanted immediately or within the first 15 min after the accident.

The periodontal ligament fibers are damaged, as the extra-oral dry time did not exceed 60 min, despite being stored in a wet medium.

Most of the periodontal ligament fibers are non-viable, as the extra-oral dry time exceeded 60 min.

Regardless of treatment prognosis, replantation should be the treatment of choice; that being said, the stage of development of the avulsed permanent tooth is an important factor.

2.2.1 Management of avulsed permanent teeth with closed apex

Three different scenarios can occur, depending on the replantation site and length of extra-oral dry time:

2.2.1.1 Mature permanent tooth replanted immediately at the accident site

If the avulsed permanent tooth with closed apex has been replanted at the injury site, the clinician should follow the following recommendations:

1. Administer local anesthesia, preferably without a vasoconstrictor.

2. Clean the damaged area, removing any traces of dirt and blood with a saline serum or chlorhexidine.

3. Verify that the tooth has been replanted correctly by comparing the angulation and incisal border position with respect to the adjacent teeth, in addition to with a periapical radiograph. If the tooth was not correctly replanted, try to gently reposition it.

4. Splint the avulsed tooth using a 0.016″/0.4-mm diameter wire attached to the tooth and adjacent teeth for 2 weeks, avoiding invading the gingival margin [29]. However, the splint should be more rigid and left for 4 weeks if there is an associated alveolar or jawbone fracture.

5. Perform the root canal treatment after 15 days.

6. Prescribe systemic antibiotics.

7. Check tetanus vaccine status.

8. Monitor outcome with a follow-up appointment.

2.2.1.2 Avulsed permanent tooth stored in wet medium for less than 60 min

The medium used to store depends on the accident location; however, tissue culture media such as milk or HBSS are recommended to preserve the viability of periodontal ligament cells.

1. Gently rinse the avulsed permanent tooth with saline solution or milk to remove any dirt, taking care not to apply heavy pressure to avoid damaging the periodontal ligament.

2. Leave the tooth hydrated in a moist environment while you examine the patient and take their medical history.

3. Administer local anesthesia, preferably without a vasoconstrictor.

4. Gently irrigate the socket with saline, removing the coagulum for easier replantation of the avulsed tooth.

5. Examine the alveolus to rule out any fractures in the alveolar walls. If there is a fracture of the alveolar walls, replace the fragment.

6. Gently replant the avulsed tooth, picking it up by the dental crown (Figure 1).

7. Verify that the tooth has been replanted correctly by comparing the angulation and incisal border position with regard to the adjacent teeth, as well as with a periapical radiograph. If the tooth was not correctly replanted, try to gently reposition it.

8. Splint the avulsed tooth using a 0.016″/0.4-mm diameter wire attached to the tooth and adjacent teeth for 2 weeks.

9. Suture any cuts or lacerations.

10. Perform the root canal treatment after 15 days.

11. Prescribe systemic antibiotics.

12. Check tetanus vaccine status.

13. Monitor outcome with a follow-up appointment.

Figure 1.

(A) Avulsed permanent tooth held by the dental crown, (B) replantation procedure, (C) root canal treatment after 15 days, and (D) 6 months follow-up after replantation.

2.2.1.3 Extra-oral dry time longer than 60 min

1. Gently rinse the avulsed permanent tooth with a saline solution or milk to remove any dirt, taking care not to apply heavy pressure to avoid damaging the periodontal ligament.

2. Leave the tooth hydrated in a moist environment while you examine the patient and take their medical history.

3. Administer local anesthesia, preferably without a vasoconstrictor.

4. Gently irrigate the socket with saline, removing the coagulum for easier replantation of the avulsed tooth.

5. Examine the alveolus to rule out any fractures in the alveolar walls. If there is a fracture of the alveolar walls, replace the fragment.

6. Gently replant the avulsed tooth, picking it up by the dental crown (Figure 1).

7. Verify that the tooth has been replanted correctly by comparing the angulation and incisal border position with regard to the adjacent teeth, as well as with a periapical radiograph. If the tooth was not correctly replanted, try to gently reposition it.

8. Splint the avulsed tooth using a 0.016″/0.4-mm diameter wire attached to the tooth and adjacent teeth for 2 weeks.

9. Suture any cuts or lacerations.

10. Perform the root canal treatment after 15 days.

11. Prescribe systemic antibiotics.

12. Check tetanus vaccine status.

13. Monitor outcome with a follow-up appointment.

2.2.2 Management of avulsed permanent teeth with open apex

Three different scenarios can also occur here, depending on the replantation site and length of extra-oral dry time:

2.2.2.1 Immature permanent tooth replanted immediately at the accident site

If the avulsed permanent tooth with closed apex has been replanted at the injury site, the clinician should follow the following recommendations:

1. Administer local anesthesia, preferably without a vasoconstrictor.

2. Clean the damaged area with a saline solution or chlorhexidine, removing any traces of dirt or blood.

3. Verify that the tooth has been replanted correctly by comparing the angulation and incisal border position with regard to the adjacent teeth, as well as with a periapical radiograph. If the tooth was not correctly replanted, try to gently reposition it.

4. Splint the avulsed tooth using a 0.016″/0.4-mm diameter wire attached to the tooth and adjacent teeth for 2 weeks, avoiding invading the gingival margin [29]. However, the splint should be more rigid and left for 4 weeks if there is an associated alveolar or jawbone fracture.

5. Pulp revascularization must be the first treatment choice, as it enables the development of the root process; however, clinicians should be aware of inflammatory root resorption. Should pulp revascularization fail, apexogenesis or apexification procedures must be initiated.

6. Prescribe systemic antibiotics.

7. Check tetanus vaccine status.

8. Monitor outcome with a follow-up appointment.

2.2.2.2 Avulsed immature permanent tooth stored in wet medium for under 60 min

The medium used to store depends on the accident location; however, tissue culture media such as milk or HBSS are recommended to preserve the viability of periodontal ligament cells.

1. Gently rinse the avulsed permanent tooth with a saline solution or milk to remove any dirt, taking care not to apply heavy pressure to avoid damaging periodontal ligament [30, 31].

2. Leave the tooth hydrated in a moist environment while you examine the patient and take their medical history.

3. Administer local anesthesia, preferably without a vasoconstrictor.

4. Gently irrigate the socket with saline, removing the coagulum for easier replantation of the avulsed tooth.

5. Examine the alveolus, ruling out any fractures in the alveolar walls. If there is a fracture of the alveolar walls, replace the fragment.

6. Gently replant the avulsed tooth, picking it up by the dental crown (Figure 1).

7. Verify that the tooth has been replanted correctly by comparing the angulation and incisal border position with regard to the adjacent teeth, as well as with a periapical radiograph. If the tooth was not correctly replanted, try to gently reposition it.

8. Splint the avulsed tooth using a 0.016″/0.4-mm diameter wire attached to the tooth and adjacent teeth for 2 weeks.

9. Suture any cuts or lacerations.

10. Pulp revascularization must be the first treatment choice, as it enables the development of the root process; however, clinicians should be aware of inflammatory root resorption. Should pulp revascularization fail, apexogenesis or apexification procedures must be initiated.

11. Prescribe systemic antibiotics.

12. Check tetanus vaccine status.

13. Monitor outcome with a follow-up appointment.

2.2.2.3 Extra-oral dry time longer than 60 min

1. Gently rinse the avulsed permanent tooth with a saline solution or milk to remove any dirt, taking care not to apply heavy pressure to avoid damaging periodontal ligament.

2. Leave the tooth hydrated in a moist environment while you examine the patient and take their medical history.

3. Administer local anesthesia, preferably without a vasoconstrictor.

4. Gently irrigate the socket with saline, removing the coagulum for easier replantation of the avulsed tooth.

5. Examine the alveolus, ruling out any fractures in the alveolar walls. If there is a fracture of the alveolar walls, replace the fragment.

6. Gently replant the avulsed tooth, picking it up by the dental crown (Figure 1).

7. Verify that the tooth has been replanted correctly by comparing the angulation and incisal border position with regard to the adjacent teeth, as well as with a periapical radiograph. If the tooth was not correctly replanted, try to gently reposition it.

8. Splint the avulsed tooth using a 0.016″/0.4-mm diameter wire attached to the tooth and adjacent teeth for 2 weeks.

9. Suture any cuts or lacerations.

10. Pulp revascularization must be the first treatment choice, as it enables the development of the root process; however, clinicians should be aware of inflammatory root resorption. Should pulp revascularization fail, apexogenesis or apexification procedures must be initiated.

11. Prescribe systemic antibiotics.

12. Check tetanus vaccine status.

13. Monitor outcome with a follow-up appointment [28].

3. Introduction of the treatment guidelines and decision-making for traumatic dental injuries (TDI) in temporary teeth

Dental trauma is one of the most frequent emergency situations seen in Pediatric Dentistry, especially in notable hospitals or dental clinics, or those linked to schools or sports centers. Dental trauma often happens in the schoolyard or in sports facilities where children practice some sport without the presence of the parents, who are notified by the institution, go to pick up their child, and come to us bewildered, nervous, and scared regardless of the severity of the blow.

The situation is one of tension, anguish, and chaos, further exacerbated by the presence of blood, crying, having to dental fragments or missing teeth... Therefore, when these situations reach us, we must prioritize their attention and transmit our sense of calm to the patient and their family members. In addition, in cases of multiple traumas, time is essential for the best possible prognosis and evolution of the case.

Once the anamnesis and medical history have been taken, we collect data on the accident, how it happened, where, how long ago, whether it is the first time the area has been hit, whether there is pain, bleeding, dental dyschromia, changes in bite, or if you have had any neurological symptoms that force us to prioritize another type of medical assessment by professionals from another specialty.

Then, once in the clinical area, we must wash the patient’s face and thoroughly clean the injured areas with saline solution and gauze pads, using 5-ml syringes for areas that are difficult to access, such as the back of the vestibule. Often once this cleaning has been carried out, the diagnosis is nothing more than the most banal of injuries, despite the initial appearance of the blow (Figure 2) [32, 33, 34, 35, 36, 37, 38, 39, 40].

Figure 2.

Trauma in temporary teeth prior to thorough cleaning of the area.

It is important to highlight that when a tooth suffers a trauma, no matter how slight, the neurovascular bundle that innervates it and supplies it with nutrients through the apical foramen is always involved. This can undergo compression or stretching that may well evolve without any complications, or it may evolve to necrosis that requires treatment. For this reason, it is essential that we monitor the evolution of the pulp over time and that we follow up on the signs and symptoms that may appear, sometimes several months after the trauma [41].

With regard to this evolution of the pulpal state of a tooth that has suffered a trauma, any change in color or darkening of the tooth become especially important. Many traumas give rise to a more or less immediate darkening of the color of the tooth due to internal bleeding that enters through the dentinal tubules, resulting in dyschromia. This tone lightens in the days after the trauma, although it does not usually disappear completely, but it does not indicate any pulpal degenerative processes at all. It is important that we note the color of the tooth during the initial exploration of the trauma, assessing whether there has been a change in shade or not; if the darkening of the tooth occurs gradually, becoming increasingly darker over time, this would be a sign of pulpal degeneration and necrosis (Figure 3) [42, 43, 44, 45].

Figure 3.

(A) Dyschromia of 61 caused by internal bleeding at the time of injury and (B) dyschromia of 51 and 61 caused by pulp necrosis.

Essentially, when assessing our case, we must classify injuries according to the tissues affected: soft tissues, periodontal ligament, dentin-pulp complex, and bone tissue, doing our best to explain to the parents that each tissue has a unique healing capacity and rhythm requiring different types of care and/or treatment. As a general rule, soft tissues heal in 3–4 days when following the specific guidelines for their care, the periodontal ligament in 7–10 days, depending on the degree of severity, and the pulp can suffer direct effects that require immediate treatment to avoid potential long-term complications, a condition that we will diagnose later if observed during the follow-up appointments that we schedule after the trauma.

Dental trauma can affect both primary and permanent dentition, and many times traumas that occur in temporary dentition can even affect permanent dentition regardless of the age at which they occur, given the intimate contact between the roots of temporary incisors and the germs of permanent incisors. In fact, the younger the patient is when a primary tooth suffers trauma, the more severe the consequences may be for the future permanent tooth, given the immaturity of its formation at the time of the trauma. These possible consequences of injuries must be kept in mind when writing the accident damage report, as it is often the insurance companies that bear the cost of immediate treatment, follow-up appointments to assess their evolution, and treatment of any complications or sequelae should they occur [46, 47, 48, 49].

3.1 Dental tissue injuries involving pulp

3.1.1 Crown infraction

This is an incomplete fracture of the enamel without any loss of dental substance. They are small fissures that can be vertical, horizontal, or diagonal, generally diagnosed because the hemorrhage itself deriving from the soft tissues stains the surface of the dental crown, making crown infractions evident. It can also be diagnosed using transillumination, aiming the light beam from the palatal position to be able to visualize the fracture lines on the buccal surface of the crown. Treatment for this type of injury depends on the case, ranging from a simple supply of fluoride to remineralize the area to polishing of the fissure and application of fluoride, or even sealing of the fissure if so required.

However, the most important thing that we must not overlook is that at the moment of the blow, the neurovascular bundle suffers, and the evolution of the pulp must be monitored after 1, 3, and 6 months to monitor the evolution of the pulp. Given that vitality tests in children are uncertain, we will base our pulp monitoring on assessing the absence of clinical signs over time, such as darkening of tooth color, appearance of fistulae or swelling of the attached gingiva at the level of the dental apex, and/or mobility. Radiographically, we must also ensure that the root development of the tooth continues to advance over time, narrowing the lumen of the canal and thickening the dentin of its walls, as well as ensuring the absence of atypical root resorption or apical focus.

3.1.2 Uncomplicated fracture of the crown

This is a fracture limited to enamel or enamel and dentin in which there is already loss of substance. Treatment depends on the affected tissues and can range from application of fluoride, if it is only a small loss of enamel, to rounding and polishing of sharp edges and application of fluoride if the loss of enamel is greater or damages the tongue or lip of the patient. If there is exposed dentin, it is always necessary to reconstruct, either with composite materials or by replacing the fragment, although in temporary dentition this latter option is not very frequent (Figure 4).

Figure 4.

Enamel and dentin fracture of a 51 without pulp exposure.

Again, the most important thing that we must not forget is the neurovascular bundle. It is necessary to monitor evolution at 1, 3, and 6 months to monitor the evolution of the pulp. Assess pulp vitality at these appointments, controlling for the absence of clinical signs over time, such as darkening of tooth color, appearance of fistulae or swelling of the attached gingiva at the level of the dental apex, and/or mobility. Radiographically, we must also ensure that the root development of the tooth continues to advance over time, narrowing the lumen of the canal and thickening the dentin of its walls, as well as ensuring the absence of atypical root resorption or apical focus. It is not uncommon for these injuries to lead to pulpal necrosis in the long term, requiring a pulpectomy of the tooth to be carried out later (Figure 5).

Figure 5.

Uncomplicated fracture of tooth 61 in a 3-year-old patient. Reconstruction with preformed crown and composite resin.

3.1.3 Complicated crown fracture

This is a fracture of enamel and dentin with pulp exposure. In these cases, if the tooth is restorable and the physiological resorption is still slight, pulp treatment can be carried out, generally a pulpectomy and restoration with composite materials. If pulp exposure was minimal (<1 mm) and recent (<1 h), direct pulp capping (DPR) could be carried out with bioactive materials such as MTA or Biodentine™ before restoration with composite materials. If the tooth is not restorable or the physiological resorption is already very advanced, extraction would be the treatment of choice (Figures 6 and 7).

Figure 6.

Complicated crown fracture of tooth 52. Pulpectomy with iodoform paste and reconstruction with composite resin in tooth 52.

Figure 7.

Complicated fracture of tooth 61 with presence of pulp polyp in a 2-year-old patient. X-ray of teeth 51–61. Tooth extraction of tooth 61.

3.1.4 Uncomplicated crown and root fracture

This is a fracture of enamel, dentin, and cement without pulp exposure. These fractures are difficult to diagnose; pain may appear when chewing. To tailor the treatment, it will be necessary to remove the coronal fragment under local anesthesia and assess whether it is possible to restore it or not. If restoration is not possible, extraction will have to be carried out.

3.1.5 Complicated crown-root fracture

This is a fracture of enamel, dentin, and cementum with pulp exposure. In primary dentition, they often follow the longitudinal axis of the tooth. In this case, and when the fracture covers more than a third of the clinical root, the treatment of choice is extraction. When the fracture covers less than a third of the clinical crown, after extracting the coronal fragment under local anesthesia, the possibility of restoration is assessed. If it is restorable, a pulpectomy and reconstruction with composite materials is carried out (Figure 8).

Figure 8.

Complicated crown-root fracture and extraction of tooth 61.

It is very common to find this type of fracture in maxillary primary first molars as a result of the violent closure of the mandible against the maxilla after a contraction injury caused by trauma to the chin. For this reason, with this type of trauma it is very important to examine the crowns of the upper molars, always trying to separate their cusps with the probe in order to diagnose them. If we do not take this precaution, the most common outcome is that the fracture goes unnoticed and the patient arrives at the consultation weeks after the trauma presenting with pain and inflammation in one side of the face and an almost healed lesion on the chin. By exploring the upper molars, we can identify the fracture (Figure 9).

Figure 9.

Complicated crown-root fracture of tooth 64. Using the probe to separate the cusps. Extraction of tooth 64. Healed injury on the chin.

3.1.6 Root fracture

This is a dentin and cement fracture with pulp involvement that can affect the apical third, middle third, or coronal third. Clinical experience tells us that most root fractures are diagnosed as incidental findings over time; this is because only 20–44% of root fractures result in pulpal necrosis. For this reason, we must take a preventative approach, monitoring the evolution of the case with a follow-up appointment at 1, 3, and every 6 months to assess the pulpal response. In most cases, obliteration of the duct occurs as a reparative response, without any associated clinical symptoms. If necrosis occurs, the treatment would involve the extraction of the coronal fragment; the apical fragment must be left so as not to damage the germ of the permanent tooth. A vital apical fragment is usually resorbed without problem. There are times when the root fracture is very apical and we can perform a pulpectomy up to the fracture line and restore with composite materials, subsequently monitoring the evolution of the case (Figure 10) [50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66].

Figure 10.

Root fracture of 51. Clinical appearance. Root fracture of tooth 51. X-ray. 1-year follow-up.

3.2 Periodontal tissue injuries

3.2.1 Concussion

This is an incomplete rupture of the periodontal fibers, with hemorrhage and edema of the same but without mobility or displacement of the tooth. There may be percussion tenderness but no radiological signs.

3.2.2 Subluxation

This is damage to the supporting tissue, which results in mobility but not displacement of the tooth. Sensitivity to percussion and occlusal forces is increased, and upon radiographic examination, an increase in the space of the periodontal ligament can be seen.

The treatment for both concussion and subluxation is to recommend resting the area to allow the damaged periodontal fibers to heal. Depending on the child’s age, emphasis must be placed on reducing the use of bottles and pacifiers, limiting the use of teethers, following a bland diet, following extreme hygiene measures, and once again, scheduling a follow-up appointment at 1, 3, and 6 months to monitor pulpal evolution as any trauma, no matter how slight, can damage the neurovascular bundle and lead to long-term pulpal complications. During these follow-up appointments, the color of the tooth becomes important, because while darkening of the clinical crown is a very noticeable sign for parents and can alert us to pulpal necrosis, it is common in this type of trauma; at the time of the blow, a small internal hemorrhage occurs, resulting in immediate dental darkening. It is important not to confuse this dyschromia with that caused by pulpal necrosis, and for this reason, care must be taken to note the color of the tooth in the first assessment or to ask the parents about the color change. When it comes to staining due to hemorrhage immediately after trauma, the color tends to lighten over time, unlike in cases of necrosis, in which the color darkens over time (Figure 11) [41].

Figure 11.

Injuries 2 years ago to teeth 51–61 in a 4-year-old patient with no prior dental assistance. X-ray of teeth 51–61, apical focus with pulp necrosis. Pulpectomy of teeth 51–61 at a very early stage of root development. Evolution 1 year after treatment.

3.2.3 Intrusive luxation

This is the movement of the tooth into the socket. It is associated with a comminuted fracture of the alveolar bone. Sometimes we see part of the tooth in the intraoral examination and it is easy to diagnose, and other times the tooth completely disappears inside the socket and an X-ray is needed to diagnose it because the parents believe that it has been lost and they simply have not found it at the site of trauma. In temporary dentition, the treatment will be to monitor the evolution over time, as it is common for the tooth to re-erupt to its position in the arch. Clinical and radiographic controls must be performed at 1, 3, and 6 months. During these follow-up evaluations, it is most common to see that the tooth is advancing on the path towards re-eruption, being closer to the occlusal plane, and it is usually almost complete at 6 months. In addition to monitoring the eruption, as in the previous cases, pulp vitality must also be monitored. If after 6 months of follow-up, the tooth has not undergone any progress or has been the origin of an infectious process while still in the place of inclusion, we must schedule the extraction of the piece (Figures 12–14) [50, 67].

Figure 12.

X-ray. Intrusion of tooth 61.

Figure 13.

Intrusion of teeth 52–51–61–62. Clinical photos and radiography.

Figure 14.

Intrusion of 51–61. 1-, 3-, and 6-month follow-up.

3.2.4 Extrusive luxation

Movement of the tooth out of the alveolus as a result of a sharp blow. Radiographic examination always shows the increase in the periodontal space. The neurovascular bundle may be completely ruptured. In temporary dentition, we should not reposition the tooth in the alveolus due to the risk of damaging the germ of the permanent tooth in formation, so the treatment of choice is extraction (Figure 15).

Figure 15.

Extrusive luxation of tooth 51–61. Tooth extraction.

3.2.5 Lateral luxation

This is a lesion to the supporting tissue of the tooth with its deviation in an axial direction. The most frequent cause is a horizontal impact that forces the crown towards the palatal wall and the apex towards the vestibular wall, resulting in occlusal interference and bleeding through the groove. It is always accompanied by a fracture of the alveolar process, so there is no mobility since the tooth is impacted on the cortical bone. Upon radiographic examination, the widening of the periodontal space is visible. In temporary dentition, we should never reposition the tooth in its original position due to the danger of damaging the germ of the permanent tooth in formation, but if the displacement is small, we can keep the tooth in the mouth and relieve the occlusion by placing bite lifts to gently reposition it spontaneously with the help of the tongue. If the displacement of the tooth is larger, tooth extraction is recommended (Figures 16 and 17) [50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66].

Figure 16.

Intrusion of tooth 51–61 and palatine luxation of tooth 62 with occlusal interference. Bite lifts on tooth 74–84 to physiologically correct the luxation of tooth 62. Follow-up at 1 week.

Figure 17.

Palatine luxation of tooth 61 in an 18-month-old baby.

3.2.6 Avulsion

This is the complete expulsion of the tooth from the alveolus. In temporary dentition, we should never replant an avulsed tooth due to the danger of damaging the permanent tooth in formation. There are different fixed or removable therapeutic procedures to replace lost pieces early in the deciduous dentition (Figure 18) [49].

Figure 18.

Avulsion of teeth 51–61 in a 4-year-old patient. Replacement with removable acrylic plate.

4. Bone tissue injuries

4.1 Comminuted fracture of alveolar bone

Internal breakage of the alveolar bone that usually occurs as a result of an intrusion or lateral dislocation.

4.2 Fracture of the alveolar wall

This can be a fracture of the facial or lingual wall (Figure 19).

Figure 19.

Superior maxillary vestibular alveolar wall fracture between tooth 61 and 62 and palatine luxation of 52. 1-day follow-up.

4.3 Alveolar process fracture

A fracture of the alveolar process may also include the alveolus.

In this type of bone fractures, we need to splint for consolidation, often with 0.12–0.14 braided wire anchored to the teeth with composite. On many occasions, the teeth that we use to anchor the splint have to be extracted, but first we use them as anchors. We let them consolidate and heal the bone fracture, and after that is when we plan the corresponding dental extractions. In conclusion, we must prioritize bone healing and never extract a tooth when there is a fracture of the wall or alveolar process until it has consolidated (Figures 20–22).

Figure 20.

Fracture of the superior alveolar process in an 18-month-old patient.

Figure 21.

Alveolar process fracture in a 5-year-old patient. Splinting and suture. 1-month follow-up.

Figure 22.

Avulsion of tooth 61, luxation of tooth 51, superior alveolar process fracture with occlusal interference and foreign body in upper lip of a 5-year-old patient. Radiographic control. Soft tissue and periapical radiography. Splinting and bite lifts on teeth 74–84.

5. Gum or oral mucosa injuries

5.1 Laceration of gum or oral mucosa

Superficial or deep injury to the epithelium that is usually produced by a sharp instrument. For treatment, the wound must be irrigated with saline. If the edges can be approximated, we suture and close by first intention; if they cannot be approximated, we will control the bleeding with compression and close by second intention. We must always give recommendations to the patient and their parents for exhaustive cleaning of the area, application of chlorhexidine gel, analgesic and anti-inflammatory treatment, and antibiotic therapy if necessary, depending on whether the injury occurred in a dirty environment or depending on the condition of the instrument that caused the injury (Figure 23).

Figure 23.

Laceration on the internal side of the lip in a 5-year-old patient. 10-day follow-up.

If we suture the inner area of the lips, we must remember that they should not be revealed to visualize the wound because it is very likely that the margins of the injury will tear again and end up healing by secondary intention (Figures 24–27).

Figure 24.

Four days post-injury with fibrin at the edge of the lesion as a result of lip traction and new tearing.

Figure 25.

Upper lip laceration in a 4-year-old patient. Suture.

Figure 26.

Tongue laceration in a 4-year-old patient. Suture.

Figure 27.

Laceration of upper lip brace in a 4-year-old patient.

5.2 Contusion of gum or oral mucosa

This is an injury caused by blunt force trauma with blunt surfaces. It causes edema and hematoma of the subcutaneous tissue, while the skin and mucosa remain intact. Generally, this type of injury only requires analgesic anti-inflammatory treatment, and we recommend the application of a cold compress. We must remember that it is important that when we see an injury of this type on the chin, the crowns of the upper molars must be examined very thoroughly, as it is very common for fractures to occur due to the counterblow, and we do not inspect carefully, we will not be able to diagnose these until the appearance of later complications (Figure 28).

Figure 28.

Contusions on the skin and mucosa of the lip and chin.

5.3 Abrasion of the gum and oral mucosa

This occurs due to friction trauma. It removes the reticular and papillary layer of the epidermis, exposing the bleeding reticular layer of the dermis. There is continuity of the tissue and it is painful given the nerve endings of the dermis. A thorough cleaning of the area must be carried out to avoid the retention of dirty particles that can lead to infections or permanent discoloration. It scars by secondary intention, and as treatment recommendations we must insist on cleaning the area, application of chlorhexidine gel, analgesic anti-inflammatory treatment, and antibiotic and anti-tetanus prophylaxis (Figures 29–31) [50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66].

Figure 29.

Gum abrasion on teeth 51–52 in a 4-year-old patient.

Figure 30.

Upper lip abrasion in a 7-year-old patient.

Figure 31.

Extraction of teeth 51 and 61 involved in a trauma with abrasion of the gum. Periapical radiography.

6. Affectation of the permanent teeth as a consequence of injuries to the temporary dentition

As we discussed previously, trauma to the primary dentition may have consequences for the permanent dentition. These consequences may be due to:

• Direct impact of the root of the temporary tooth on the germ of the permanent tooth. This can result in:

  1. Displacement of the tooth inside the bone, altering its eruption trajectory in the future. The permanent tooth may erupt out of place, have delayed eruption, or even fail to erupt.

  2. If there is an impaction of the apex of the temporary tooth in the structures in formation of the permanent tooth, after eruption we may observe areas of hypoplasia, hypomineralization, dilacerations, or other alterations in the structure or tooth shape.

• Injuries resulting from an infection present over a period of time. Silent, long-term necrosis of the neurovascular bundle of the primary tooth may:

  1. Accelerate resorption of the primary tooth root and alter the timing of tooth replacement.

  2. Alter the odontogenesis of the permanent tooth, producing circumscribed chromatic lesions or structural alterations on the buccal surface of the crown of the permanent incisors (Figure 32) [35, 46, 47, 48, 49].

Figure 32.

Ulectomy. Eruptive delay of 11 by intrusion of 51 after 2 years. 48-hour and 7-day follow-up. Alteration in the structure and dyschromia due to impaction of the apex of tooth 51. Esthetic restoration of tooth 11, 6 years after the causing trauma.

7. Discussion

Crown fractures, regardless of the degree of involvement of the tooth, are the most common fractures in the permanent dentition. They are usually caused by contact sports or accidental falls.

In all cases, a radiographic examination should be carried out to provide an idea of the best therapeutic option in each case and to evaluate the surrounding tissues for any associated soft tissue lesions [9].

Treatment in cases of fissures limited to enamel usually consists of simply observing and monitoring the tooth or some authors even suggest sealing the enamel surface [9].

If the lesion affects enamel and dentine but there is no pulp involvement, there are several therapeutic options: if the fragment is available, it can be bonded to the tooth surface with the help of composite resins [9, 12] or the fractured segment can be directly restored with reconstructions made of composite resins [13, 14].

Finally, in the most complicated cases in which pulp tissue exposure occurs, it is necessary to evaluate whether the camera pulp or healthy root pulp can be maintained in those cases in which complete root development has not finalized [9, 14]. For this purpose, there are available different therapeutic options, depending on the pulp involvement, which are as follows:

• Direct pulp capping [15].

• Partial pulpotomy (Cvek pulpotomy) [16].

• Coronal pulpotomy [17].

• Deep pulpotomy [9, 18].

In those clinical situations in which the pulp is necrotic, the degree of root development will also be assessed, so that in teeth with an open apex, apexification with CaH or MTA [18, 19, 20] will be chosen, and in teeth with a closed apex, the relevant endodontic treatment will be carried out.

Intra-alveolar root fractures occur much less frequently than coronary fractures and even less frequently in the primary dentition or teeth with immature apex. They can be horizontal (better prognosis) or vertical (worse prognosis).

As with coronal fractures, it is essential to carry out a correct radiographic examination, modifying the degree of angulation of the fracture in multiple shots [9, 13]. Currently, CBCT (Cone Beam Computed Tomography) is also used for a correct diagnosis by image, which helps us to locate the fracture and even the direction and extent [12].

The treatment of intra-alveolar fractures depends mostly on the location of the fracture, but in any case, when possible, semi-rigid splinting of the fragments should be attempted [23]. Since vitality tests can be confusing at first, the treatment options available for intra-alveolar fractures are as follows:

• Endodontic treatment of the coronal fragment.

• Endodontic treatment of the coronal fragment and extraction of the apical fragment.

• Treatment of both fragments (coronal and apical).

• Treatment of the apical fragment and extraction of the coronal fragment [9].

The most relevant factors related to the prognosis of the avulsed teeth are the storage medium and the extra-oral dry time; therefore, previous studies have been conducted in order to assess the management procedures and behavior that are most recommendable in this scenario [63]. Zeissler-Lajtman et al. reported that cling film possibly could be used as an alternative transport medium for a storage period of up to 6 h [64]. However, De Brier et al. reported that although milk was shown to extend the periodontal ligament cell viability before replantation compared with saline or tap water, Hank’s balanced salt solution, propolis, oral rehydration salts, rice water, and cling film media have also demonstrated efficacy at preserving the cell viability [65]. Additionally, Adnan et al. concluded that milk is the most recommended storage medium individually, based not only on PDL cell viability, but also practical considerations [66].

Moreover, the management procedures and making decisions after the accident comprising dental avulsion are also relevant for the long-term prognosis of these teeth. Therefore, some approaches have been performed in order to improve the attachment of the periodontal cells. Parthasarathy et al. performed an interdisciplinary approach to regenerate the osseous defect including the placement of PRF membrane around the root surface [68]. However, Schjøtt et al. analyzed the efficacy of Emdogain to promote regeneration of the periodontal tissues of avulsed teeth and reported that the teeth were all extracted, the ankylosis sites removed and the root and socket treated with Emdogain. After 6 months all teeth showed recurrence of ankylosis and concluded that Emdogain was not able to prevent or cure ankylosis [69]. Recently, Aksel et al. analyzed cell- or stem cell-based regenerative medicine and concluded that this approach has a promising future for the regeneration of periodontal regeneration of avulsed teeth [67].

Currently, studies agree that the highest prevalence of trauma in primary dentition is subluxation, followed by lateral dislocation and avulsion. This is due to the fact that, in children, the resistance capacity of the bone and the periodontal ligament is high given their elasticity and absorbs most of the energy of the impact, in addition, anatomically, the primary teeth have small crowns and short roots, trait that may favor dislocations over fractures.

It is important to know and establish an appropriate follow-up and/or treatment guideline in each case according to the complexity of the trauma. In fact, most of the sequelae derived from trauma are the consequence of inadequate treatment, lack of follow-up or not having acted within the necessary period of time.

Many times, this delay in the time of action is a consequence of the patient not coming to our consultations until a few weeks after the trauma. We must make parents and caregivers aware that in the event of any dental trauma, professional attention should be sought, since early diagnosis and treatment is essential, as well as monitoring the evolution of the case over time, to avoid unfavorable prognoses.

The international guidelines for dental traumatology agree that the early diagnosis and treatment of traumatisms will frequently determine the medium and long-term prognosis of the teeth involved in the trauma. For this reason, it is essential to have a clear action protocol that facilitates the dentist’s decision-making to achieve an adequate immediate or deferred treatment based on the evidence, as well as a follow-up that allows early detection of an unfavorable evolution of the case, establishing a change in the mode of action. This will be the basis for the success of the treatment.

It should not be forgotten that even the slightest trauma to the primary dentition can have direct or indirect consequences on the permanent dentition given the close relationship between the apex of the root of the primary teeth and the permanent tooth in formation, and that these consequences they will be even more severe the younger the patient is at the time of impact due to the degree of immaturity in the formation of the permanent tooth germ. It is another of the key points that parents, caregivers and other health professionals must be made aware of so as not to downplay dental trauma in young patients [70].

8. Conclusions

In both types of fractures, a complete radiographic examination is essential for a proper diagnosis and treatment of the lesion. The surrounding tissues should always be evaluated regardless of the type of injury. In addition, one of the most decisive characteristics in terms of treatment is the degree of root development of the tooth and whether or not there is pulp exposure, characteristics which in most cases are what will indicate which treatment option will be more accurate.

It is recommended to maintain the avulsed teeth in a wet storage medium; preferably milk, Hank’s Balanced Salt solution (HBSS), saliva, or saline solution and visit a dentist under 60 min after injury.

Dental trauma is the result of the interaction of many factors, so the success of treatment is unpredictable. Most professionals follow the general guidelines of the IADT to perform treatments on traumatized teeth, although clinical experience, good behavior management and continuous updating on the knowledge of trauma are essential for the dentist when it comes to treat and monitor these injuries.

Prevention and information on how to act at the scene of the accident by people close to the child is essential to carry out a favorable treatment, as well as instilling in the population the importance of going to a qualified professional whenever a fall or a blow is involved the oral cavity.

In this chapter we have tried to capture in a simple way the recommendations, most frequent situations and the most effective way of proceeding when dealing with trauma in primary dentition, as a result of the clinical experience of professionals in a reference center for diagnosis and treatment. of dental trauma emergencies and supported by the most current bibliography.

Conflict of interest

The authors declare no conflict of interest.