Paediatric Trauma in Primary Dentition Flashcards
What is an enamel fracture?
Fracture of only enamel.
What is an enamel-dentine fracture?
Fracture involved enamel and dentine but not the pulp.
What is a complicated tooth fracture?
Fracture involves enamel, dentine and the pulp is exposed.
What is a crown-root fracture?
Fracture involves enamel, dentine and root, the pulp may nor may not be involved.
What is a root fracture?
Injury to the tooth where the root has fractured.
What is concussion?
Tooth tender to touch but has not been displaced.
Normal mobility and no bleeding into the gingival sulcus.
What is subluxation?
Tooth tender to touch, has increased mobility but not been displaced.
What is lateral luxation?
Tooth displaced usually in a palate-lingual or labial direction.
What is intrusion?
Tooth displaced through the labial bone plate, or it can impinge on the permanent tooth bud.
What is extrusion?
Partial displacement of tooth out its socket.
What is avulsion?
Tooth displaced completely out of the socket.
What is alveolar fracture?
Fracture involves the alveolar bone and may extend to the adjacent bone.
What are the 8 aspects of the trauma stamp?
Mobility
Colour
TTP
Sinus
Percussion note
EPT
Ethyl Chloride
Radiograph
What special investigations might you want to do?
Trauma stamp
Radiographs- PA, anterior occlusal, OPT, lateral pre-maxilla.
What are the paediatric trauma guidelines called?
International Association of Dental Traumatology guidelines
When might you undertake a Cvek Pulpotomy?
Partial pulpotomy
Might be done in an enamel-dentine-pulp fracture in a primary tooth.
Describe the procedure of a Cvek Pulpotomy.
- Local anaesthetic administration
- Isolation with dental dam
- Remove 1−3 mm of coronal pulp tissue (sterile excavator/high speed bur and copious irrigation)
- Irrigate wound surface with sterile saline or Ferric Sulphate depending on if it is a primary or permanent tooth and dry with a cotton pellet
- If haemostasis achieved place non-setting calcium hydroxide paste or calcium hydroxide powder mixed with sterile water over pulp exposure and use a sterile cotton pellet to apply pressure and adapt the medicament to the cavity. If haemostasis not achieved, remove more pulp until haemostasis is achieved but if haemostasis is not possible, proceed to a coronal pulpotomy
- Place non-setting calcium hydroxide paste, or calcium hydroxide powder mixed with sterile water, over the exposure and use a sterile cotton pellet to apply pressure and adapt the medicament to the cavity before covering with a layer of glass ionomer
- Restore tooth with composite resin/re-attach fractured tooth fragment, if available/appropriate
- Regular clinical and radiographic review1
If a partial pulpotomy has not been sufficient to achieve haemostasis, what would you do?
Carry out cervical pulpotomy.
Involves removing the entire coronal pulp.
What treatment would you do for an enamel fracture?
Smooth off edges
No follow up required
What treatment would you do for an enamel-dentine fracture?
Account for missing fragment
Baseline radiograph is optional but take a soft tissue radiograph if fragment cannot be accounted for.
Cover exposed dentine with GI or composite.
Review clinically 6-8 weeks later.
What treatment would you do for an enamel-dentine-pulp fracture?
Account for missing fragment.
Take PA size 0 sensor or AMO size 2 sensor.
Cvek pulpotomy first, then move to full pulpotomy if haemostasis cannot be achieved.
Follow up
- Clinically- 1 week, 6-8 weeks, 1 year.
Radiographically- 1 year.
What treatment would you do for a crown-root fracture?
Determine location of any missing fragments.
PA or AMO radiographs.
Remove loose fragments and determine restorability.
Pulp not exposed- remove all loose fragments and restore with GI or composite.
Pulp exposed- perform Cvek pulpotomy or RCT depending on stage of development.
If unrestorable- remove loose fragments and leave it or remove whole tooth.
Follow up
- Clinically- 1 week, 6-8 weeks, 1 year.
- Radiographically- 1 year.
What treatment would you do for a root fracture?
PA or AMO.
If loose fragment is not displaced- no treatment.
If loose fragment is displaced but not excessively mobile- leave coronal fragment to spontaneously reposition.
If coronal fragment is displaced, excessively mobile and interfering with occlusion
- Extract loose fragment and leave rest in place.
- Gently reposition the loose coronal fragment and splint for 4 weeks.
Follow up
- 1 week, 4 weeks, 8 weeks, 1 year.
- Radiographic follow up is only indicated if clinical symptoms arise.
What symptoms would suggest failure of treatment?
Colour change in crown
Symptomatic
SInus tract
Gingival swelling
Increased mobility
Peri-radicular radiolucency
No further root development in immature teeth
What clinical findings might suggest an alveolar fracture?
Segments of teeth moving in different directions and together
Mobility and dislocation of segment
Occlusal interference
If a patient had an alveolar fracture, what would you do?
PA or AMO radiographs
May benefit from a lateral radiograph
Reposition segment under LA and stabilise with flexible splint for 4 weeks.
Follow up
- 1 week, 4 weeks, 8 weeks, 1 year and again at 6yo to check development of permanent dentition.
- Radiographic follow up at 4 weeks and 1 year to assess impact on the permanent tooth germs
Warn patients and parents of unfavourable outcomes.
What signs would suggest a favourable outcome?
Asymptomatic
Normal crown colour
No signs of pulp necrosis and infection
Continued root development
Periodontal healing
What radiographs would you request to determine direction of intrusion?
PA or lateral pre maxilla
What radiographic signs would suggest that the intruded tooth has move towards or away from the developing tooth germ?
Can see apex and root appears shorter compared to contralateral tooth
- apex displaced away from dveveloping tooth germ and towards labial bone plate.
Cannot see apex and root appears longer compared to contralateral tooth
- Apex displaced towards developing tooth germ.
What consequences are there to the primary tooth following primary tooth trauma?
Discolouration
Discolouration and infection
Delayed exfoliation
What does discolouration mean in the primary dentition?
Yellow- pulp canal obliteration
Pink- Haemorrhage within the pulp chamber
Grey/brown/black- haemoglobin accumulation- hydrogen sulphate converted to iron sulphate.
What signs would suggest discolouration and infection?
Means the tooth is non-vital.
Sinus tract
Non physiological mobility
Periradicular pathology
Swelling
External inflammatory root resorption
TTP
No response to sensibility testing
How does delayed exfoliation influence dental development?
Can become ankylosed
Make successor ectopic
Delayed eruption of permanent successor
May require further treatment to expose permanent successor.
What is the most common injury in the primary dentition?
Luxation injury
Following trauma to the primary dentition, what effects can there be on the permanent successor?
Enamel defects- enamel hypoplasia, enamel hypomineralisation.
- Most common.
Abnormal crown/root morphology
Delayed eruption- up to 1 year because of thickened mucosa.
Ectopic tooth position
Arrested development
Complete failure of the tooth to form
Odontome formation
What is the difference between hypo mineralisation and enamel hypoplasia?
Hypomineralisation- qualitative defect of enamel
- usually white or yellow
Hypoplasia- quantitative defect of enamel
- usually yellow or brown
What would be the treatment for hypomineralisation and hypoplasia if it were to happen to a patient?
No treatment
Composite masking +/- localised removal
What abnormal crown/root morphology can occur following trauma to the primary dentition?
Dilaceration- abrupt deviation of the long axis of the crown or root portion of the tooth.
What radiograph would you request if a tooth is dilacerated?
Probably request OPT first because it will fail to erupt.
Then request Anterior maxillary occlusal
What are the treatment options for abnormal crown/root morphology?
Surgical exposure and orthodontic alignment
What radiograph would you request if there was delayed eruption?
Probably use parallax
- Either OPT and AMO or two PA at different horizontal positions.
What options are available for delayed eruption of teeth that haven’t erupted yet?
Surgical exposure and orthodontic alignment.
What are the options for treating an ectopic tooth?
Surgical exposure and realignment
Extraction
