Paeds - Trauma to Permanent Teeth Flashcards
what is the most common trauma injury to the primary dentition?
luxation - bone is soft
when is the apex of adult teeth closed in paediatric patients?
9/9.5
what is the most common trauma injury to the adult dentition in children?
enamel dentine crown fractures
what information regarding the trauma should you gather during history taking? (5)
How did it happen?
When exactly did it happen?
Where did it happen?
Where are the lost teeth/fragments?
Have you got any other injuries?
what medical conditions require the child to undergo further treatment after trauma i.e. antibiotic cover? (3)
Rheumatic fever
Congenital heart defects
Immunosuppression
As well as examining the teeth after trauma what else should you examine? (3)
soft tissues - ensure no fragments/debris in the lip etc
alveolar bone - mobility/displacement
occlusion - is it traumatic?
what investigations should you do after trauma? (5)
radiographs
tooth mobility - if lots of teeth move could be a bone fracture
tactile test - identify fracture and pulpal involvement
sensibility test - Thermal, electric, percussion
occlusion - can the teeth go into ICP as before or is it traumatic
list the key points when testing sensibility in traumatised teeth (4)
Always compare the tooth to the adjacent non-injured teeth
Always compare teeth to the opposing teeth
Continue taking sensibility test for at least 2 years after an injury and they if all is well discharge from trauma care.
Never make judgements of sensibility testing alone - need ticks in several trauma sticker boxes
list the classifications of fractures. (6)
Enamel fracture
Enamel dentine fracture
Enamel dentine pulp fracture (could also be called complicated)
Root fracture - subcategorises further into apical, middle, coronal third.
Uncomplicated crown root fracture
Complicated crown root fracture (complicated = pulp involved)
what is a useful tool for monitoring trauma.
trauma stickers
how do we manage an enamel fracture to a child’s adult tooth? (3)
(Bond fragment to tooth - unlikely as its so small)
smooth sharp edges
etch, bond and Place composite
take periapicals to rule out root fracture and luxation
what is the follow up period for an enamel fracture to a child’s adult tooth?
6-8 weeks, 6 months and 1 year later.
how do we manage an enamel dentine fracture to a child’s adult tooth? (6)
Account for the missing fragments.
check the lip for residual tooth fragments
Place a composite bandage
Take periapicals to rule out root fracture and luxation
Carry out sensibility testing and evaluate tooth maturity
Place definitive composite
what is the follow up period for an enamel dentine fracture to a child’s adult tooth?
Follow up 6-8 weeks, 6 months and 1 year later using the trauma sticker
when taking a radiograph of a child’s traumatised tooth, what are we looking for? (3)
comparison with the other side
Root development - is the length is longer and walls of dentine thicker over time?
Internal and external inflammatory resorption
Periapical pathology
in terms of apex maturity, what teeth have a higher chance of the pulp surviving?
teeth with an immature apex (open)
how do we manage an enamel dentine pulp fracture to a child’s adult tooth? (2)
Evaluate the exposure:
Time since the fracture
Size of the fracture
PDL injury
Then either;
Pulp cap - 1mm exposure within 24 hours
Partial pulpotomy
Full coronal pulpotomy
when is pulp capping used in an EDP fracture?
Used for tiny exposures (1mm) within a 24 hour window.
describe how pulp capping is carried out. (6)
Trauma sticker carried out - should be TTP and positive to sensibility tests.
trauma sticker & Take radiograph to confirm
Give LA and rubber dam
Clean area with saline
disinfect with sodium hypochlorite
Apply calcium hydroxide or MTA white to the exposed pulp
Restore tooth with composite
what is the follow up period for a pulp capped tooth?
Follow up 6-8 weeks, 6 months and 1 year later using the trauma sticker
when is a partial pulpotomy used in an EDP fracture?
Used for larger exposures (>1mm) after 24 hour window.
describe how a partial pulpotomy is carried out. (8)
Trauma sticker carried out
Take radiograph
LA and rubber dam
Clean area with saline and disinfect with sodium hypochlorite
Remove 2mm of the pulp with high speed round diamond burr
Place saline soaked cotton wool peet over the exposure until haemostats is achieved
If no bleeding or if bleeding doesn’t stop = full coronal pulpotomy
Apply CaOH then GI/White MTA
Restore tooth with composite
what is the follow up period for a partial pulpotomy?
Follow up 6-8 weeks, 6 months and 1 year later using the trauma sticker
when is a full coronal pulpotomy carried out?
If there is no bleeding or if bleeding doesn’t stop after placing saline soaked CW peet over the exposure
describe how to carry out a full coronal pulpotomy.
Begin with partial pulpotomy
Assess for haemostsais after application of saline soaked cotton-wool and pressure
If hyperaemic or necrotic (no blood) = removal of all the coronal pulp
Place CaOH in the pulp chamber
Seal with GIC lining
Place coronal restoration
what is the prognosis for a partial pulpotomy after an enamel dentine pulp fracture?
97% success
what is the prognosis for a full coronal pulpotomy after an enamel dentine pulp fracture?
75% success
how do we root treat permanent teeth with an open apex in children?
we need to create an apical stop;
MTA/biodentine placed at apex of canal to create a cement barrier
what treatment options do we have for a crown and root fracture with no pulp exposure? (3)
- Fragment removal only and restore
- This is if the fracture hasn’t gone past the crestal bone and you can place dam and achieve the appropriate conditions for a restoration. - Fragment removal and gingivectomy
Remove part of the gum so that you can gain access to restore the area. - Orthodontic extrusion to gain access to the supra gingival part of the fracture
Pull the tooth down so that the fracture that was once unaccessible is now visible and able to be restored.
(Surgical extrusion- not recommended if the pulp is still vital.)
what treatment options do we have for a crown and root fracture with no pulp exposure but the fragment in non-restorable? (2)
Decoronation - useful for future implantation
Extraction
what treatment options do we have for a crown and root fracture WITH pulp exposure? (5)
(Temporised with composite for 2 weeks so that further investigations can be carried out.)
Fragment removal and gingivectomy paired with Endodontics treatment
Orthodontic extrusion to gain access to the supra gingival part of the fracture and endodontic treatment
Surgical extrusion of the tooth and Endodontics treatment
Decoronation
Extraction
how do we classify a root fracture? (3)
Position:
Apical 1/3rd = best prognosis
Middle 1/3rd
Coronal 1/3rd = Very Poor prognosis due to the small amount of PDL support keeping the crown in place during function.
Displacement of fragments
Displaced - ends of fragments do not meet
Undisplayed - ends of fragments still meeting
Stage of root development:
Mature - closed apex
Immature - open apex
what does the prognosis of root fractures depend on? (5)
Age - mature or immature apex
Degree of displacement
Associated injuries - crown fractures
Time between injury and treatment - especially important in displaced teeth since a blood clot forms between the two ends.
Presence of infection
how do we manage an apical/middle third root fracture? (3)
(LA not usually required)
Clean the area with water/saline/chlorhexidine
Reposition the tooth with digital pressure
Place a flexible splint for 4 weeks
what advice do we give to those who have a splint after root fracture? (2)
soft food diet for 1 week
Instruct on good OHI
what is the follow up period for a root fracture?
Review 6-8 weeks, 6 months, 1 year and 5 years later with radiographs.
how do we manage an coronal third root fracture? (3)
(LA not usually required)
Clean the area with water/saline/chlorhexidine
Reposition the tooth with digital pressure
Place a flexible splint for 4 MONTHS
How long do you splint an apical/middle third root fracture?
4 weeks
How long do you splint a coronal third root fracture?
4 months ++
how can you tell if there has been a successful healing outcome after a root fracture? (4)
calcified union along the fracture line- best outcome
connective tissue healing- Fracture still visible however the edges of the fracture line show signs of eburnation (rounding off of the edges)
both of the above
bone/osseous-
The separate parts of the root do not connect however each have their own PDL space
Bone is seen between the fractures.
how can you tell if there has been unsuccessful healing after a root fracture? (3)
Granulation tissues associated with a loss of vitality - 20% chance of pulp necrosis
Dark radiolucent area on radiograph surrounding the fracture line
what happens if a root fracture doesn’t heal?
20% chance of pulp necrosis
how do you treat an apical/middle third root fracture if it doesn’t heal and becomes non-vital? (4)
Extirpate to fracture line
Dress with non setting CaOH
Place MTA/biodentine coronal to the fracture line to create a barrier
Fill the remained of the root to the fracture line with GP
list the types of PDL injuries (6)
Concussion, subluxation Extrusive luxation Lateral luxation Intrusive luxation Avulsion Dentoalveolar fracture
define a concussion injury.
Injury to the tooth and supporting structures without; mobility, displacement or gingival bleeding.
list the signs of a concussion PDL injury. (4)
Pain on percussion - TTP
no mobility
no gingival bleeding
no displacement
define a subluxation injury.
Traumatic Injury to the PDL has causes increased mobility, gingival bleeding but NO displacement.
list the signs of a subluxation PDL injury. (3)
Pain on percussion - TTP
increased mobility
gingival bleeding
what is the follow up period for a concussion PDL injury?
4 weeks, 6-8 weeks, 1 year
what is the follow up period for a subluxation PDL injury?
2 weeks, 4 weeks, 6-8 weeks, 1 year
what advice do we give to patients who have experienced subluxation injuries? (3)
OHI with chlorhexidine gluconate - Gentle brushing
Soft diet - (after a few days) this includes food which encourages gentle biting too as this helps to simulate what a normal/healed PDL will be doing.
Avoid contact sports
define an extrusion PDL injury.
displacement of the tooth from Partial or total separation/tearing of the PDL
tearing
Alveolar socket is intact
wide periodontal ligament space on radiograph
list the signs of a extrusion PDL injury. (2)
TEARING
Alveolar socket is intact
wide periodontal ligament space on radiograph
how long do we splint extruded teeth?
2 weeks
what is the follow up period for an extrusion PDL injury?
After 4 weeks, 6-8 weeks, 6 months and every year for 5 years.
what is the 5 year pulpal survival for an extruded mature and immature tooth?
mature = 45%
immature = 95%
define a lateral luxation PDL injury. (2)
Displacement of the tooth other than axially with tearing and crushing injuries
paired with fracture to labial/lingual bone.
list the signs of a lateral luxation PDL injury. (2)
Displacement accompanied by fracture of either the labial or palatal/lingual bone
Increased PDL space on radiograph
how long do we splint laterally luxated teeth?
4 weeks
what is the follow up period for a lateral luxation PDL injury?
After 4 weeks, 6-8 weeks, 6 months and every year for 5 years.
what is the 5 year pulpal survival for a laterally luxated mature and immature tooth?
mature = 25%
immature = 95%
name PDL injuries that causes tearing
extrusion
Lateral luxation (tearing and crushing)
name PDL injuries that cause crushing (2)
intrusion
lateral luxation (+ tearing)
name a crushing and tearing injury.
lateral luxation
define an intrusion injury.
crushing injury where the tooth has been driven into the alveolar process due to axially directed impact.
how do we treat an immature (open apex) tooth with up to 7mm of intrusion?
spontaneous reposition
how do we treat an immature (open apex) tooth with MORE than 7mm of intrusion?
orthodontic repositioning
surgical repositioning
how do we treat an mature (closed apex) tooth with up to 3mm of intrusion?
spontaneous reposition
how do we treat an mature (closed apex) tooth with 3mm to 7mm of intrusion?
orthodontic repositioning
surgical repositioning
how do we treat an mature (closed apex) tooth with MORE than 7mm of intrusion?
surgical repositioning
how long do you splint an intruded tooth after surgical realignment?
4 weeks
what is the follow up period for an intruded PDL injury?
Monthly reviews to observe re-eruption
Measure progress against a fixed point i.e. incisal edges of fully erupted and non-displaced adjacent incurs.
what is the 5 year pulpal survival for an intrusion injury to a mature and immature tooth?
mature = 0% (100% resorption)
immature = 40%
how long after presenting with a MATURE INTRUSION injury do we want to endodontically treat?
within 7-10 days - pulp revascularisation is unlikely
define avulsion.
where the tooth is separated from the PDL and the root surfaces are exposed.
what factors determine the success of an avulsed tooth?
Extra-alveolar dry time - This is where the tooth is out of the mouth (in air - no storage medium etc)
Extra alveolar time
Amount of time its been out the mouth or also in a storage medium
Type of storage medium
what advice do we give to those who have an avulsed tooth?
Hold the tooth by the crown and rinse the root under cold running water for 10 secs max.
then;
Either replant the tooth in the socket and bite down on a tissue (best option)
Place the tooth in a glass of cold, fresh milk, saliva or ‘normal physiological’ saline.
Place tooth between cheek and gum
seek dental attention as soon as possible
if an avulsed tooth has been reimplanted by the patient, when would we consider removing it?
If there’s a lot of debris or if it was replaced in a contaminated area, remove and assess the tooth/socket.
what are the periodontal (4) and pulpal (3) healing outcomes after avulsion?
Periodontal outcomes:
Regeneration - occurs if replanted asap
PDL/cemental healing - partial healing
Bony healing - bones fuses up to the tooth
Uncontrolled infection = not healing = abscess etc
Pulpal Outcomes:
Regeneration - more likely with an open apex.
Controlled necrosis (elective disinfection) - take the live tissue out the tooth before it is starts to undergo necrosis.
Uncontrolled infection
What is the healing outcome of an avulsed tooth if the extra Alveolar time is < 60 minutes? (1)
there is a chance of cemental/PDL healing if the tooth was kept in an appropriate storage medium
What healing outcome do we aim to achieve in an avulsed tooth if the extra Alveolar time is > 60 minutes?
unlikely that the PDL will heal so we aim to achieve bony healing (ankylosis).
what healing do we aim for in an avulsed tooth with an extra alveolar time of > 60mins?
bony healing (ankylosis).
how do we TREAT a MATURE avulsed tooth with an extra alveolar time of < 60 mins? (8)
Give LA
Replant the tooth
Flexible splint for 14 days
Consider antibiotics and check tetanus status.
Carry out pulp extirpation from 0-10 days (ideally day 0)
Once extirpation and disinfection place antibiotic steroid paste within the canal and leave for 2 weeks.
After 2 weeks replace the antibiotic paste with non setting calcium hydroxide.
Obturate within 4 - 6 weeks.
Refer to specialist
how do we treat a immature avulsed tooth with an extra alveolar time of < 60 mins?
Give LA
Replant the tooth
Flexible splint for 14 days
Consider antibiotics and check tetanus status
You can decide whether to endodontically treat or to leave the tooth;
how do we treat a mature avulsed tooth with an extra alveolar time of > 60 mins? (6)
Scrub the root clean of dead PDL cells
Extra-oral endodontics on the avulsed tooth
Give LA
Once the tooth has been endodontically treated, replant the tooth
Flexible splint for 4 weeks
Consider antibiotic prescription
If extra-oral endodontics isn’t carried out;
Extirpate between 7-10 days
Place non-setting calcium hydroxide 4 weeks before obturation
how do we treat a immature avulsed tooth with an extra alveolar time of > 60 mins? (6)
Give LA Replant the tooth Flexible splint for 4 weeks Consider antibiotic prescription Check tetanus status Monitor closely for signs of necrosis and continued root development/
when would we never reimplant an avulsed tooth? (3)
Possibly if a very immature tooth has a EAT > 90 mins (replanting would still be the best option)
If child is immunocompromised
The child has other serious injuries - emergency treatment/ICU
deciduous Lower incisors in very young children (tooth will only last 6 months anyway)
what is the 5 year pulpal survival for avulsion to a mature and immature tooth?
mature = 0%
immature = 30%
how do we manage dento-alveolar fractures? (4)
Give LA
Reposition - Sometime apical lock can occur (can’t slide the segment back into it’s position) have to lift the socket up and replace.
Place a flexible splint for 4 weeks
Prescribe antibiotics
how long do we splint dento-alveolar fractures for?
4 weeks
what is the review period for DAF?
Review 2 weeks, 4 weeks, 8 weeks, 4 months, 6 months, 1 year and yearly for 5 years.
what advice do we give to patients with a DAF?
OHI with chlorhexidine gluconate mouthwash 0.1%
Gentle brushing
Soft diet for 7 days: (after a few days) this includes food which encourages gentle biting as this helps to simulate what a normal/healed PDL will be doing.
Avoid contact sports
when would you place a flexible splint for 2 weeks? (3)
Subluxation
Extrusion
Avulsion - open and closed apices EADT < 60 mins
when would you place a flexible splint for 4 weeks? (5)
Lateral luxation Apical/middle root fracture Intrusion Dento-alveolar fratures Avulsion - closed apex EADT > 60 mins
what types of splints are available? (6)
Composite and wire - the best choice
Acrylic and wire
Vacuum splint
Orthodontic bracket and wire (must be passive)
Acrylic URA - useful when there are few abutment teeth
Foil temporary splint cemented with Kalzinol
what are the long term affects on the permanent teeth after trauma to the primary dentition? (8)
Discolouration +/- infection Delayed exfoliation Enamel defects (most common) Abnormal morphology of crown/root of permanent tooth Delayed eruption Ectopic position Failure to form Odontome formation
what radiographic signs show an unsuccessful healing outcome after trauma? (5)
external inflammatory root resorption internal inflammatory root resorption presence of granulation tissue ?? arrested root formation ?? abscess formation ??
What is the prognosis of traumatised teeth dependant on? (5)
The stage of root development i.e. immature teeth more vulnerable
The type of injury
If the PDL is damaged
The time between injury and treatment
Presence of infection
What are the aims of emergency treatment? (5)
Retain vitality by protecting the dentine with a dentine bandage
Treat exposed pulp tissue
Reduction and immobilisation of displaced teeth (moved within their socket)
Tetanus prophylaxis - make sure it’s received and up to date
Antibiotics - use trauma guide to help make this decision
What are the aims of intermediate treatment? (2)
+/- Pulp treatment (partial/full)
Restoration enamel - i.e. in a dentine fracture take away composite bandage and replace with a permeant restoration.
