Dental Trauma of Primary teeth Flashcards
What is the epidemiology of primary tooth trauma?
- Prevalence is 16-40%
- Male > Female
- Peak incidence 2-4years
What is the aetiology of primary tooth trauma?
- Falls
- Bumping into objects
- Non-accidental
What dental hard tissues and pulp can be injured?
Enamel fracture (uncomplicated crown fracture)
Enamel and dentine fracture (uncomplicated crown fracture)
Enamel, dentine and pulp fracture (complicated crown fracture)
Crown-root fracture
Root fracture
What is a crown root fracture?
- Fracture involves enamel, dentine and root
- Pulp may or may be involved
- Complicated or uncomplicated
What specific types of injury can occur?
- Concussion
- Subluxation
- Lateral luxation
- Intrusion
- Extrusion
- Avulsion
- Alveolar fracture
What is a concussion injury?
- PDL injury
- Tooth tender to touch but not displaced from arch
- Normal mobility and no bleeding into gingival sulcus
What is subluxation injury?
- Tooth tender to touch
- Has increased mobility but not been displaced from line of arch
- Bleeding from gingival crevice can be noted
What is lateral luxation injury?
- Tooth displaced usually in palatal/lingual or labial direction
- Fracture of alveolar socket
What is intrusion injury?
- Type of luxation injury
- Tooth usually displaced through labial bone plate
- It can impinge on permanent tooth bud
What is an extrusion injury?
- Type of luxation injury
- Partial displacement of tooth out its socket
What is an avulsion injury?
- Tooth completely out of the socket
- Location of missing tooth should be determined in history taking
- Risk of being embedded into soft tissues or more seriously inhaled
- If tooth not found send child for medical assessment in emergency department, esp if child has respiratory issues
What is in alveolar fracture injury?
- Fracture involved alveolar bone (labial and palatal/labial)
- May extend to adjacent bone
- Mobility and dislocation of segment with several teeth moving together is common
- Occlusal interference usually present
What is the injury prevalence of different types of injury in primary dentition?
Luxation - 62-69%
Avulsion and ED fracture - 7-13%
Root fracture - 2-4%
Crown root fracture - 2%
What are the steps when managing a patient with trauma?
- Reassurance
- History
- Examination
- Diagnosis
- Emergency treatment
- Important info
- Further treatment and review
suWhat is included in a trauma history?
Injury
- When?
- Where?
- How?
- Any other symptoms or injuries?
- Lost teeth/fragments?
Medical History
- Congenital heart disease
- History of rheumatic fever or immunosuppression
- Bleeding disorders (haematology team contact)
- Allergies (short course of antibiotics may be required)
- Tetanus immunisation status (may need booster - contact health advisor)
- (Liase with GP)
Dental History
- Previous trauma (may raise concerns about physical abuse or neglect)
- Treatment experience
- Legal guardian/child attitude
What is included in the extraoral part of trauma examination?
Extraoral
- Lacerations/ swelling/ bruising (may require suturing or debridement
- Haematoma
- Haemorrhage / CSF
- Subconjunctival haemorrhage
- Bony step deformities
- Mouth opening (may be jaw fracture)
What is included in the intraoral part of trauma examination?
- Soft tissues (penetrating wounds, foreign bodies etc)
- Alveolar bone for any evidence of fracture
- Occlusion (traumatic occlusion demands urgent treatment)
- Teeth (mobility may indicate displacement, root or bone fractures)
- Transillumination may show lines in teeth (crazing), pulpal degeneration, caries
- Tactile test with may help detect horizontal and or vertical fractures, pulpal involvement
- Percussion (duller note indicate fracture)
What special investigations can be used in a trauma examination?
- Radiographs
- May include a trauma stamp of 52,51,61,62
- Mobility - Noted via +/-
- Colour (Normal, Grey, Yellow, Pink)
- TTP (Tender to percussion) - Noted via +/-
- Sinus - noted via +/-
- Percussion note (Normal or Dull)
- Radiograph - Noted via =/-
What radiographs can you request in trauma examination?
- Periapical
- Anterior occlusal
- Lateral pre-maxilla
- Panoramic
- Soft tissue
What are the possible diagnosis’ that can be made for each traumatic tooth?
Fracture
- Enamel (Uncomplicated crown fracture)
- Enamel-Dentine (Uncomplicated crown fracture)
- Enamel-Dentine-Pulp (Complicated crown fracture)
- Crown-Root (Uncomplicated or complicated)
- Root
- Alveolar
Concussion
Subluxation
Luxation
Lateral / Intrusive / Extrusive
Avulsion
What to do during an emergency situation?
- Observation is often most appropriate option in emergency situation
- Unless risk of aspiration, ingestion or occlusal interferences
- Provision of dental treatment depends on child’s maturity and ability to cope - don’t want to make child more anxious
What important info do you need to tell parent/carer ?
- Advise parent/carer regarding care of injured tooth/teeth to optimise healing and prevent further healing
- Analgesia to reduce dental pain like paracetamol
- Soft diet for 10-14days (can be normal diet but cut everything small, chew with molars)
- Brush teeth with soft toothbrush after every meal
- Topical chlorhexidine gluconate 0.12% mouthrinse applied topically twice daily for one week
- Warn about signs of infection
What is an enamel fracture?
- Fracture of tooth involving only enamel
- Uncomplicated injury
- Best to smooth sharp edges using soft flex disc or bond fragment to tooth
- Take 2 periapical radiographs to rule out root fracture or luxation
- Follow up 6-8weeks/6months/1year
Prognosis - 0% risk of pulp necrosis
What is an enamel-dentine fracture?
- Fracture of tooth involving enamel and dentine
- Uncomplicated crown fracture
- Best to cover all exposed dentine with glass ionomer/dentine
- Lost tooth structure can be restored immediately with composite resin or at a later visit
- Clinical exam after 6-8weeks
What is an enamel-dentine-pulp fracture?
- Fracture of tooth exposing pulp
- Complicated crown fracture
Options - Partial pulpotomy
- Extraction
To encourage gingival healing and prevent plaque accumulation parent should clean affected area with cotton swab combined with alcohol free 0.1-0.2% chlorhexidine gluconate mouth rinse twice a day for two weeks
Both options involve LA and depend on child’s ability to manage treatment
- Discuss options with parent/carer
- Can cause dental anxiety
- Clinical exam after 1 week, 6-8weeks then 1year
How to manage a crown-root fracture?
- Remove loose fragment and determine if crown can be restored
If restorable
- No pulp exposed, cover exposed dentine with glass ionomer
- Pulp exposed, pulpotomy or endodontic treatment
If Unrestorable
- Extract loose fragments
- Don’t dig
Where root is retained clinical exam after 1 week, 6-8weeks, 1year
How to manage a root fracture?
- If coronal fragment not displaced then no treatment indicated. Clinical exam 1week/6-8weeks/1year
- If coronal fragment displaced but not excessively mobile - Leave fragment to spontaneously reposition even if some occlusal interference
- If coronal fragment displaced, excessively mobile and interfering with occlusion
Option A - Extract only loose coronal fragment and clinically exam after 1 year
Option B - Reposition loose coronal fragment with flexible splint. Clinical exam 1week/4week splint removal/8week/1year
How to manage a concussion injury?
- Clinical findings - Pain on percussion
- No treatment
- Radiograph
- Review 1 month/1year
How to manage a subluxation injury?
- No treatment
- Splint if excessive mobility or tenderness when biting
- Radiographs
- Review 2-4weeks splint removal/ 3months/ 6months/1year
How to manage lateral luxation injury?
If minimal / no occlusal interference then allow to reposition spontaneously
If severe displacement
- Extraction
- Reposition with flexible splint
How to manage an intrusion injury?
- Allow to spontaneously reposition, irrespective of direction of displacement
Based on radiographs what are the two scenarios of intrusion with respect to direction of displacement?
Scenario 1
- Apical tip of intruded tooth can be seen
- Tooth appears shorter (aka foreshortened) compared to contralateral tooth
- Apex displaced towards/through labial bone plate
- Less likely to impinge on other teeth
Scenario 2
- Apex of intruded tooth can’t be visualised
- Tooth appears elongated compared to contralateral
- Suggest Apex displaced toward permanent tooth germ and increased risk of damage to permanent tooth developing
How to manage extrusion injury?
If not interfering with occlusion
- Spontaneous repositioning
- Gently push back into socket under LA
- Splint
Excessive mobility or extruded >3mm
- Extract
Follow up - 2-4weeks splint removal/ 2months/3months/6months/1year then annually for at least 5years
How to manage avulsion injury?
- Radiograph to confirm avulsion
- In primary dentition a primary tooth should NOT be reimplanted
How to manage an alveolar fracture?
- Reposition segment that is mobile or causing occlusal interference
- Stabilised with flexible splint to adjacent uninjured teeth for 4 weeks
- Teeth may need to be extracted after alveolar stability has been achieved
- Clinical exam after 1week/4week splint removal/8 week/1 year
What are the 3 sequelae of trauma to primary tooth?
- Discolouration
- Discolouration and infection
- Delayed exfoliation
How does discolouration of traumatic primary tooth present?
Asymptomatic but discoloured tooth may be vital or non vital
Mild grey - Immediate discolouration may maintain vitality and can recede
Opaque/yellow - May indicate pulp obliteration
If no signs of pulp necrosis or infection then no treatment required and review per injury
What is pulp obliteration?
- Condition characterised by pronounce deposition of hard tissue along internal walls of root canal that fills most of pulp system leaving it narrowed and restricted
What to do when traumatic tooth presents with discolouration and infection?
Tooth is symptomatic and non-vital
- Sinus, gingival swelling, abscess
- Increased mobility
- Radiographic evidence of periapical pathology
- Extract or endodontic treatment
Consequences of delayed exfoliation?
Delayed exfoliation can cause ectopic eruption of permanent successor, delay eruption, prevent eruption
- Have consequences on occlusion and aesthetics and confidence of child
How are injuries to permanent teeth related to age of trauma in primary teeth?
- Intrusion shows most disturbance to permanent dentition
0-2years has 63% chance of injury to permanent
3-4 = 58%
5-6 = 24%
7-8 = 25%
What injuries can occur to permanent successor following trauma in primary dentition?
- Enamel defects (most common)
- Abnormal crown/root morphology
- Delayed eruption
- Ectopic tooth position
- Arrested development
- Complete failure of tooth to form
- Odontome formation
What is enamel hypomineralisation and how to treat?
- Qualitative defect of enamel i.e. normal thickness but poorly mineralised
- White/ yellow defect
Treatment - No treatment
- Composite masking with or without localised removal before composite mask
- Tooth whitening
What is enamel hypoplasia and how to treat it?
- Quantitative defect of enamel i.e. reduced thickness but normal mineralisation
- Yellow/brown defect
Treatment - No treatment
- Composite masking
What is Dilaceration?
- Abrupt deviation of long axis of crown or root portion of the tooth
What are crown dilaceration management options?
- Surgical exposure and orthodontic realignment
- Improve aesthetics restoratively
What are root dilaceration/angulation/duplication management options?
- Combined surgical and orthodontic approach
How to manage delayed eruption due to traumatic primary dentition?
- Premature loss of a primary tooth can result in delayed eruption of around 1 year due to thickened mucosa
- Radiograph if > 6 month delay compared to contralateral tooth
- Surgical exposure and orthodontic alignment may be required
How to manage ectopic tooth position?
- Surgical exposure and orthodontic realignment
- Extraction
How to manage arrested development due to traumatic primary dentition?
- Endodontic treatment
- Extraction
How to manage complete failure of tooth to form due to traumatic primary dentition?
- Tooth germ may sequestrate spontaneously
- Or require removal
What is an odontome?
- Growth in which both epithelial and mesenchymal cells exhibit complete differentiation with result that functional ameloblasts and odontoblasts form enamel and dentin
- Only option is surgical removal
What sensibility tests can you do on detailed intro-oral exam of trauma?
Thermal - Ethyl chloride (ECL) or warm Gutta-Percha
Electrical - Electric pulp tester (EPT)
- Compare to adjacent non-injured tooth
- Test on adjacent and opposing teeth as they can receive direct or indirect concussive injuries
- Continue sensibility tests at least 2years after
What does complicated and non complicated mean?
Complicated - pulp involved
Non-complicated - pulp not involved
What does prognosis of the tooth depend on?
- Presence of infection
- Time between injury and treatment
- If PDL is also damaged
- Type of injury
- Stage of root development
General aim of emergency treatment?
- Retain vitality of any damaged or displaced tooth by protecting exposed dentine by an adhesive ‘dentine bandage’
- Treat exposed pulp tissue
- Reduction and immobilisation of displaced teeth
- Tetanus prophylaxis
- Antibiotics?
General aim of intermediate treatment?
- +/- Pulp treatment
- Restoration (Minimally invasive e.g. acid etch restoration)
General aim of permanent treatment following trauma?
- Apexigenesis (vital pulp therapy procedure performed to encourage phsysiological development and formation of root)
- Apexification (induce a calcific barrier in root with incomplete formation or open apex of tooth with necrotic pulp)
- Root filling +/- root extrusion
- Gingival and alveolar collar modification if required
- Coronal restoration
How to manage enamel-dentine fracture?
- Account for fragment
- Either bond fragment to tooth or place composite bandage
- Take 2 periapical radiographs to rule out root fracture or luxation
- Radiograph any lip or cheek lacerations to rule out embedded fragment
- Sensibility testing and evaluate tooth maturity
- Definitive restoration
- Follow up 6-8weeks/6months/1year
Prognosis - 5% risk of pulp necrosis at 10years
How to manage enamel-dentine-pulp fractures?
Evaluate exposure
- Size of pulp exposure
- Time since injury
- Associated PDL injuries
Choose either
- Pulp cap
- Partial pulpotomy
- Full coronal pulpotomy
Avoid full extirpation unless tooth clearly non-vital
When and how to perform a direct pulp cap?
- If tiny exposure 1mm within 24hour period
- Trauma sticker and radiographic assessment
- Should be non-TTP and positive to sensibility tests
- LA and rubber dam
- Clean area with water then disinfect with sodium hypochlorite
- Apply calcium hydroxide (Dycal) or MTA white to pulp exposure
- Restore tooth with quality composite restoration
- Review 6-8weeks/6months/1 year
When and how to perform partial pulpotomy?
- Larger exposure >1mm or 24hrs+ since trauma
- Trauma sticker and radiographic assessment
- LA and dental dam
- Clean area with saline then disinfect with sodium hypochlorite
- Remove 2mm of pulp with hi-speed round diamond bur
- Place saline soaked CW pellet over exposure until haemostasis acheived
- If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy
- Apply CaOH then GI then restore with quality composite
Follow up 6-8weeks/6months/1year
When and how to perform full coronal pulpotomy?
- Begin with partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton wool
- If hyperaemic or necrotic proceed to remove all coronal pulp
- Place calcium hydroxide in pulp chamber
- Seal with GIC lining and quality coronal restoration
Follow up - 6-8weeks/6months/1year
What is the aim of pulpotomy?
- To keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine
How to manage root treatment for immature incisors?
- If tooth non-vital then full pulpectomy required
Clinical problem - no apical stop to allow obturation with GP
Options
- CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification)
- MTA/BioDentine placed at apex of canal to create cemenet barrier
- Regenerative Endodontic technique to encourage hard tissue formation at apex
What is the technique for Pulpectomy?
- Rubber dam
- Gain access
- Haemorrhage control (LA/sterile water)
- Diagnostic radiographic for WL
- File 2mm short of estimated WL
- Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
- Glass ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
Place CaOH no longer than 4-6weeks after identified as non vital as problems with CaOH apexification
- MTA plug and heated GP obturation
Final coronal restoration
- Once obturation complete
- Consider bonded composite short way down canal as well as in access cavity
- Bonded core
- Try to avoid post crown
What are the treatment options for crown-root fracture no pulp exposure?
- Fragment removal only and restore
- Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
- Extraction
- Decoronation (Preserve bone for future implant)
- Surgical extrusion
- Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
What are the treatment options for crown-root fracture with pulp exposure?
- Can be temporised with composite for up to 2weeks
- Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
- Extraction
- Decoronation (Preserve bone for future implant)
- Surgical extrusion
- Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
What other structures can injury have an impact on?
- Surrounding bone
- Neurovascular structure
- Root surface
How can the nature of the trauma be described?
- Separation injury
- Crushing injury
