Primary Tooth Trauma Flashcards
Most common aetiologies for primary tooth trauma
- Falls
- 0-4 year old infants learning to walk
- Bumping into objects
- Non-accidental injury
- Patients with disability eg epilepsy, CP
Predisposing factors to primary tooth trauma
- Epilepsy
- Hyperactivity
- Protrusion of upper incisors
- Increased overate and insufficient lip cover
- Poor motor coordination
- Anterior open bite
What teeth are most commonly affected during primary tooth trauma
-Maxillary centrals
What type of trauma is most common
Luxation most common
Name the different types of injuries in order of most common to least common
- Luxation- 65%
- Avulsion- 10%
- ED#- 10%
- EDP#- 10%
- CR#- 10%
- Root #- 4%
- Enamel infraction- 2%
How to manage a patient as they walk into clinic with a primary tooth fracture
- History
- Examination
- Diagnosis
- Emergency treatment
- Advise parent of sequelae to permanent teeth
- Further treatment and review
What types of questions should be answered in the history of trauma
- Presenting complaint
- When,
- How
- Where
- Who
- Has tx been provided elsewhere
- Has there been previous trauma
- Are teeth/frsgments all accounted for
- If avulsed how long in storage medium and what storage medium
- Previous dental trauma
- MH
- Any systemic signs
- Swallow?
- MEchanism of injury (fall, bicycle, sport, assault)
What should you look for during the extra oral examination
- General appearance
- Facial asymmetry
- Laceration
- Contrusion (crowding)
- Bruising
- Abrasion
- Swelling
- TMJ Assymmetry
- Fracture of facial skeleton
- Foreign body/tooth fragment
- Palpate bony borders of both maxillae and mandible
- Soft tissue lesions
What should be looked for during intra oral examination
- Gingival injury
- OH
- Tooth missing
- Type of injury
- Crown fracture (E/D/P)
- Discolouration
- Sinus/swelling
- Percussion
- Mobility
- TTP
- Response to EC
- Response to EPT
What should be looked for during rx of primary trauma case
- Root fracture
- Root development
- Permanent successor
- Crown fracture proximity to pulp
- Foreign body
What should you always be suspicious about and why
- Orofacial signs such as bruises and abrasions from non accidental injuries
- Discrepency between trauma history provided by parents and injuries found on examination or delay in presentation should arouse suspicions
What social history must you consider
- Living with parents
- Age
- FrankL score
- Type of school
- Behaviour
- Siblings
- Habits eg. use of dummies
What medical history points are important
-Loss Of consciousness , cardiac conditions, bleeding disorders and allergies
What special investigations would you ideally like to do in children trauma cases?
But what realistically can you actually do
Ideally:
- Colour
- TTP
- EPT
- EC
- Percussion
- Sinus
- Mobility
Realistically:
- Colour
- Sinus
- Mobility
- TTP
Classify types of dental trauma injuries
- Avulsion
- Alveolar fracture
- Root fracture
- Extrusion
- Lateral luxation
- Intrusion
- Subluxation
- Concussion
- Crown-Root fracture
- Crown fracture
- None
Describe how you could diagnose a intrusion injury
- Partial displacement of tooth from socket
- No mobility
- Tooth appears intruded rather than proclaimed/retroclined
Describe how you could diagnose a crown fracture
- No displacement of the tooth
- No loosening/mobility
- Not TTP
- Fracture does not go beyond the gingival margin
Describe how you could diagnose a extrusion injury
- Partial displacement of tooth from socket
- Mobility on a single tooth
- No X ray signs of a root fracture
Describe how you could diagnose a lateral luxation injury
- Partial displacement of tooth from socket
- No mobility
- Procliniation/retroclination of tooth
Describe how you could diagnose an avulsion injury
-Complete displacement of tooth from socket
Describe how you could diagnose a crown root fracture
- No displacement of tooth from socket
- No mobility or loosening
- Not TTP
- Fracture below gingival margin
Describe how you could diagnose a concussion injury
- No displacement of tooth from socket
- No loosening of tooth
- TTP
Describe how you could diagnose a subluxation
- No displacement of tooth
- Loosening of tooth
Describe how you could diagnose an alveolar fracture
- Displacement of tooth
- Mobility of multiple teeth as a unit on palpation
Describe how you could diagnose a root fracture
- Partial displacement of tooth from socket
- Mobility of tooth
- X ray evidence of root fracture
Aims of treatment planning
- Relieve pain
- Maintain vitality
- Prevent infection
- Prevent damage to permanent successor
- Maintain function, aesthetics, speech and mastication
- Maintain arch space- prevent tilting/drifting/over-eruption
- Maintain tooth in the arch
Common advice to all types of dental injuries
- Soft diet
- Pain relief
- OHI- tooth cleaning
- Topical chlorhexidine by parent twice daily for one week
- After initial treatment review 1,3 or 6 monthly taking rx if possible 6 monthly
Treatment for enamel or enamel dentine fractures
- Smooth sharp edges
- Restore with composite
- Cover exposed dentine
- Consider GIC if compliance is poor for composite
What is a complicated crown fracture and how would you treat
- EDP fracture
- Treatment dependent on behaviour
- Pulp therapy (partial pulpotomy or RCT) is very difficult
- Extract possible
Treatment for a crown root fracture and root fracture
- Monitor
- If tooth is reasonably firm then leave it
- If the tooth and there is risk of infection, extract it
- Extract the coronal fragment potentially
- Do not Dig for apical portion of root as can cause damage to successor
- Should resorb physiologically
Treatment for an alveolar fracture
- Manual repositioning or repositioning using forceps of the displaced segment
- General anaesthesia often indicated
- Usually managed in a hospital setting
- Stabilize segment with flexible splinting for 4 weeks
- Monitor the teeth in the fracture line
Difference between subluxation and concussion and treatment for each
- Neither are displaced
- Concussion is more of a shock. There is no mobility or discolouration. May be TTP. No Tx required
- Subluxation may present with gingival bleeding at the sulcus. Discoloration may also be present. It may be tender and mobile
-For both, just monitor
Rx evidence of lateral location and tx
- Increased PDL space apically
- If no occlusal interference, allow to position spontaneously
- If occlusal interference, reposition
- Otherwise, extract the tooth
Rx and description for intrusion
- Tooth is usually displaced through the labial bone
- Can impinge upon permanent tooth bud
- USO or PA required
- If apical tip appears shorter than its contralateral then it has been displaced towards or through the buccal plate
- If apical tip is indistinct and the tooth appears elongated then apex is displaced towards permanent tooth germ
Tx guideline for intrusion
- If labial, away from the tooth germ. Leave to re-erupt. If no progress after 6 months then extract
- If palatal towards the permanent tooth germ then extract
Tx plan for extrusion
-Extract
Tx plan for avulsion
- Rx to confirm complete avulsion
- Do not replant
What does prognosis of primary tooth fracture depend on
- Age of child
- Mature or immature tooth
- Type and severity of injury
- Associated injuries
- Time between injury and treatment
- Presence of infection
Long term effects of primary dental trauma on primary and permanent successors
Primary Teeth:
- Discolouration
- Infection
- Delayed exfoliation
Permanent teeth
- Enamel defects
- Abnormal tooth/root morphology
- Delayed eruption possible
How would discolouration progress from immediate to long term colour changes of the tooth
Immediate:
-Reddish colour, may regress/remain and maintain vitality
Intermediate (weeks)
-Brown/black pulp breakdown products in tubules- non-vital
Long term (months) -yellow/opaque, pulp calcification
What does the time of discolouration tell you about vitality
- If immediate discolouration then it may still be vital
- If intermediate (weeks) then non vital
Problems in terms of exfoliation after primary tooth trauma
- May not resorb normally after trauma
- XLA may be necessary or permanent successor will erupt ectopically
- Premature loss of a primary tooth can result in delayed eruption of about 1 year due to thickened mucosa
When should you worry about a delay in tooth eruption
-if greater than 6 month delay compared with contralateral
Correlation between age of trauma and risk to permanent successor anomalies
-Higher percentage of anomalies on permanent teeth is observed when trauma occurred at an age less than 36 months
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