International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 3. Injuries in the Primary Dentition

Board takeaway

Protect the child and developing permanent tooth, relieve pain, and avoid unnecessary invasive treatment.

• Avulsed primary tooth: do not replant.
• Intruded primary tooth: allow spontaneous repositioning regardless of the root's direction, with prompt referral and scheduled review.
• Other displacement: decide whether observation is acceptable from aspiration/ingestion risk, occlusal interference, mobility, injury severity, and cooperation.
• Observation includes care: home care and follow-up; it is not dismissal.

The IADT tables primarily address medically healthy children with sound primary teeth, and many recommendations rely on consensus.

First visit: triage and documentation

• Reduce parent/child anxiety; a knee-to-knee examination may help. Use a team experienced in young children, with access to pain management, sedation, and general anesthesia when needed.
• Record medical, social, dental, and accident histories, including accompanying adults. Examine head/neck, bone, occlusion, lips, mucosa, gingiva, and frenula. Seek medical assessment for associated head injury, facial fracture, or other concerning findings.
• Account for every missing tooth/fragment: soft-tissue embedding, ingestion, aspiration, or displacement into the nose are possible. Image soft tissues if an embedded fragment is suspected.
• Compare the mechanism with the injuries. Suspected non-accidental injury requires prompt referral for physical examination/investigation under local protocols.
• Photograph extraoral/intraoral findings. Record each tooth's mobility, tenderness, displacement, and color at presentation and follow-up; diagnose concurrent fracture and luxation injuries.
• Pulp sensibility testing is unreliable in primary teeth and is not recommended. Concurrent injuries can worsen pulp survival after extrusion/lateral luxation.

Imaging and successor counseling

• Justify each exposure by whether it can change diagnosis/treatment; use ALARA. CBCT is rarely indicated in young children after trauma.
• Baseline periapical or occlusal imaging is recommended for pulp-exposing crown fractures, crown-root/root/alveolar fractures, subluxation, extrusion, lateral luxation, and intrusion. Enamel fracture: none; enamel-dentin fracture: optional; concussion: none.
• For suspected avulsion when the tooth is not brought in, dental imaging is essential to exclude complete intrusion and assess the successor.
• Intrusion imaging: a visible apex with a shortened tooth image suggests labial displacement; an unvisualized apex with an elongated image suggests displacement toward the permanent germ. This distinction does not mandate extraction.
• Explain and document possible successor malformation, impaction, and eruption disturbance, especially after intrusion, avulsion, and alveolar fracture. Extraction itself can injure the germ; evidence does not show that immediate extraction toward the germ prevents damage.

Crown and crown-root fractures

• Enamel only: smooth sharp edges; no routine clinical/radiographic follow-up.
• Enamel-dentin, no pulp exposure: seal all exposed dentin with glass ionomer or composite; restore lost structure with composite immediately or later.

Pulp exposure

• Aim to preserve pulp with partial pulpotomy under local anesthesia; large exposures may need cervical pulpotomy.
• The 2020 table describes non-setting calcium hydroxide, glass ionomer, then composite; evidence for non-staining calcium silicate materials was emerging.
• Assess pulp condition, restorability, cooperation, and the time to exfoliation.
• The 2024 primary-caries VPT guideline found no suitable trauma studies, so its graded material comparisons should not be transferred to this injury as though they were trauma evidence.

Crown-root fracture

• Remove the loose fragment and assess restorability.
• Restorable without exposure: cover dentin.
• Restorable with exposure: pulpotomy or root canal treatment according to root development and fracture level.
• Unrestorable: remove loose fragments while protecting the successor and leave a firm root fragment, or extract the whole tooth.

Before invasive fracture care

• For invasive care, discuss options and cooperation with parents.
• Deferring emergency treatment is conditional on rapid referral within several days to an experienced child-oriented team; it is not permission for indefinite observation.

Root and alveolar fractures

Root fracture

• Coronal fragment may be displaced/mobile; fractures commonly lie in the middle/apical third.
• Obtain baseline imaging.
• Undisplaced coronal fragment: no treatment.
• Displaced but not excessively mobile: allow spontaneous repositioning, even with some occlusal interference.
• Displaced, excessively mobile, and interfering with occlusion: under local anesthesia, either remove only the loose coronal fragment and leave the apical fragment to resorb, or gently reposition.
• If unstable, use a flexible splint to adjacent uninjured teeth for 4 weeks.

Alveolar fracture

• Several teeth moving together suggests segment injury; occlusal interference is common.
• Reposition a displaced segment that is mobile and/or interferes with occlusion under local anesthesia; flexible splint for 4 weeks.
• Alveolar imaging may need a lateral view or additional views to define extent, only when treatment could change.
• Fractures can involve successors; an apical-level fracture can later produce an abscess/periapical radiolucency.

Concussion, subluxation, and displacement

• Concussion: tender, normal mobility, no displacement or sulcular bleeding. Observe; no active treatment.
• Subluxation: increased mobility without displacement, sometimes sulcular bleeding. Observe; no active treatment.

Extrusion

• Elongated, partly out of socket, often mobile.
• If no occlusal interference, allow spontaneous repositioning.
• Excessive mobility or extrusion >3 mm: extract under local anesthesia. Assess displacement, occlusion, root formation, and cooperation together.

Lateral luxation

• Displaced palatally/lingually or labially and typically immobile.
• Minimal/no occlusal interference: allow spontaneous repositioning, usually within 6 months.
• Severe displacement: extract if ingestion/aspiration risk, or gently reposition under local anesthesia; splint for 4 weeks if unstable.

Intrusion

• Partly/completely disappeared into socket, often palpable labially.
• Allow spontaneous repositioning regardless of direction; improvement usually occurs within 6 months, occasionally up to 1 year.
• Refer to an experienced team within a couple of days.

Avulsion

• Do not replant; treatment burden, successor injury, and particularly aspiration risk drive this rule.
• If the missing tooth is not found, refer for emergency medical evaluation, especially with respiratory symptoms.

Decision map: displaced primary incisor

Loading diagram…

• Triage associated injury and respiratory symptoms before dental management; an unlocated tooth requires medical assessment, particularly with respiratory symptoms.
• Primary avulsion is never replanted. Intrusion is observed irrespective of root direction, with rapid child-oriented dental referral.
• Extrusion greater than 3 mm or excessive mobility supports extraction; without occlusal interference, allow repositioning.
• Severe lateral displacement may require extraction when aspiration/ingestion is a risk, or gentle repositioning with a four-week flexible splint if unstable. The complete injury-specific reviews and imaging indications remain below.

Follow-up checkpoints

Intervals below are clinical reviews after injury; splinted schedules include removal. Return sooner for complications.

• Continue annual clinical review until permanent eruption when unfavorable outcomes are a concern after root fracture, subluxation, extrusion, or lateral luxation.
• Follow-up radiographs generally depend on clinical evidence of pathology. Exceptions: 1 year after pulpotomy/root canal treatment for crown/crown-root fractures; 4 weeks and 1 year after alveolar fracture, with frequency adjusted to findings.
• Favorable healing: symptom resolution, no infection, continued immature-root development, periodontal healing/realignment where applicable, and unaffected successor development/eruption. Transient discoloration or pulp canal obliteration may accompany healing.
• Unfavorable findings: sinus tract, swelling/abscess, increasing mobility, radiographic necrosis/infection or inflammatory resorption, arrested root development, failed realignment, ankylosis after lateral luxation/intrusion, or successor disturbance.
• Dark discoloration alone does not justify root canal treatment. Look for accompanying clinical/radiographic infection. Children may have infection without reporting pain.
• Record prognostic factors at initial and subsequent visits; use structured records and the IADT generic/injury-specific core outcome framework. The detailed core outcome set is in the companion General Introduction.

Pain, infection prevention, and homecare

• Anticipate pain after intrusion, lateral luxation, and root fracture; the source recommends ibuprofen and/or acetaminophen when pain is expected, without a dosing regimen here.
• No evidence supports routine systemic antibiotics for primary-tooth luxation. Consider associated soft-tissue injuries, significant surgery, or medical indications individually; consult the pediatrician when uncertain.
• Contaminated wounds may require tetanus assessment/booster; uncertain status warrants medical referral within 48 hours.
• Parents clean gently with a soft brush/cotton swab. The narrative specifies alcohol-free 0.12% chlorhexidine, applied topically twice daily for 1 week; injury tables give 0.1%–0.2%.
• Avoid additional trauma while eating; resume normal function as soon as feasible. Supervise hazardous activities. Seek prompt dental review for swelling, sinus tract, increased mobility, or other unfavorable changes.
• Explain possible further visits and treatment. Complex follow-up needs pediatric expertise and access to behavioral support, sedation/anesthesia, and pain management.

Common board traps

Answer aloud

A primary incisor has disappeared after a fall. What must you distinguish?

Distinguish intrusion from avulsion, and account for the tooth before deciding treatment.

• Examine the socket and soft tissues; obtain dental imaging if the tooth was not brought in to exclude complete intrusion.
• If the tooth remains missing, arrange emergency medical evaluation, especially with respiratory symptoms or concern for aspiration.
• Do not replant an avulsed primary tooth. Review at 6–8 weeks and around age 6 for successor eruption.

An intruded primary incisor's apex points toward the permanent germ. What is the plan?

Allow spontaneous repositioning regardless of root direction; arrange an experienced child-oriented team within a couple of days.

• Improvement usually occurs within 6 months, occasionally up to 1 year.
• Explain and document successor risks; give home care and complication instructions.
• Clinical reviews: 1 week, 6–8 weeks, 6 months, and 1 year; severe intrusion also warrants review around age 6.
• Follow-up radiographs depend on clinical evidence of pathology.

When should an extruded primary incisor be extracted?

Extract under local anesthesia if it is excessively mobile or extruded >3 mm.

• If there is no occlusal interference, spontaneous repositioning is an option.
• Assess displacement, occlusion, root formation, and cooperation together.
• Clinical reviews after extrusion: 1 week, 6–8 weeks, and 1 year; continue annually when an unfavorable outcome is a concern.

How do you manage lateral luxation of a primary incisor?

Observe minimal displacement without significant occlusal interference; severe displacement requires an aspiration-risk and repositioning decision.

• Observation: spontaneous repositioning usually occurs within 6 months.
• Severe displacement: extract if ingestion/aspiration risk, or gently reposition under local anesthesia.
• If repositioned and unstable, use a flexible splint for 4 weeks.
• Observed tooth: 1 week, 6–8 weeks, 6 months, and 1 year.
• Repositioned/splinted tooth: 1 week, 4 weeks (remove splint), 8 weeks, 6 months, and 1 year.

A root-fractured primary incisor has a very mobile displaced coronal fragment blocking occlusion. What are the options?

Remove only the loose coronal fragment, leaving the apical fragment, or gently reposition under local anesthesia.

• If repositioned and unstable, flexibly splint to adjacent uninjured teeth for 4 weeks.
• Select according to cooperation and informed parental preferences; protect the successor.
• An undisplaced fragment needs no treatment; a displaced but not excessively mobile fragment may reposition spontaneously, even with some interference.

Several injured primary teeth move together. What changes your management?

Suspect an alveolar fracture, assess the segment, and reposition a displaced mobile and/or occlusally interfering segment under local anesthesia.

• Flexible splint: 4 weeks.
• Clinical reviews: 1 week, 4 weeks for removal, 8 weeks, 1 year, and age 6 for successor eruption.
• Radiographs at 4 weeks and 1 year, adjusted to findings; assess possible successor involvement.

How do you manage a traumatic pulp exposure in a restorable primary incisor?

Aim to preserve the pulp with partial pulpotomy; a large exposure may require cervical pulpotomy.

• Assess pulp condition, restorability, cooperation, and time to exfoliation.
• The 2020 trauma table describes non-setting calcium hydroxide, glass ionomer, then composite; evidence for non-staining calcium silicates was emerging.
• The 2024 primary-caries vital pulp guideline found no suitable trauma studies; do not transfer its graded material comparisons to trauma.
• Clinical review: 1 week, 6–8 weeks, 1 year; obtain the scheduled 1-year radiograph after pulpotomy.

Does dark discoloration alone justify pulp treatment after primary-incisor trauma?

No. Assess accompanying clinical and radiographic evidence of infection.

• Record color over time; an asymptomatic tooth may remain radiographically normal despite discoloration.
• Swelling, sinus tract, increasing mobility, or radiographic infection changes the decision.
• Primary-tooth sensibility testing is unreliable and is not recommended.

What home care and infection prevention follow primary-tooth luxation?

Pain relief, gentle cleaning, and scheduled follow-up; routine systemic antibiotics are unsupported.

• Consider antibiotics individually for soft-tissue injury, significant surgery, or medical indications.
• Parent applies alcohol-free chlorhexidine topically twice daily for 1 week: narrative 0.12%, tables 0.1%–0.2%; use a soft brush/cotton swab.
• Avoid further trauma while eating and resume normal function as feasible; return promptly for unfavorable changes.
• Contaminated wounds need tetanus assessment; uncertain status warrants medical referral within 48 hours.