Trauma of Primary Teeth Flashcards
Which teeth are most commonly affected by trauma?
Upper central incisors
What are the types of trauma injuries?
Soft tissue:
- Loosening
- Displacement
Hard tissue: fractures
- Children have softer bones => less likely to fracture due to impact => hard tissue injury less common
What is the presentation of concussion?
- Tender to touch
- No displacement
- Normal mobility
- No sulcular bleeding
What is the management for concussion?
- Soft diet
- Monitor
- No radiograph needed
What is the presentation of subluxation?
- Tender to touch
- No displacement
- ↑ mobility
- Sulcular bleeding
What is the management for subluxation?
- Take baseline radiographs
- Clean patient up
- Soft diet
- Analgesics
- Monitor
What is the follow up management for teeth with concussion and subluxation?
Clinical examination after
- 1 week
- 6-8 weeks
What is the presentation of lateral luxation?
- Tooth is displaced (labial or palatally displaced)
- Tooth immobile
- Occlusal interference may be present
What is the treatment for lateral luxation?
Take baseline radiograph
Leave alone if:
- No interference with bite
- Stable
Extract if:
- Tooth pushed into developing tooth bud (tooth bud usually palatal to primary tooth)
- Occlusal interference + reposition not possible
- Excess mobility, increased risk of aspiration
Immediate repositioning
Describe the procedure for immediate repositioning
- Clean area w water spray/saline/CHX
- Apply LA
- Suture gingival lacerations, if any
- Reposition tooth w gentle combined
labial & palatial pressure - If tooth unstable, stabilise w flexible
splint for 4 weeks (take note: splint requires GA)
What is the follow-up management of teeth with lateral luxation injury?
Clinical examination after:
- 1 week
- 4 weeks (for splint removal, if splint placed)
- 6-8 weeks (8 weeks if had splint removed)
- 6 months
- 1 year
How do you determine the direction of the apex of a tooth radiographically?
- Shortened tooth => closer to source
=> root apex buccal - Elongated tooth => further from source
=> root apex palatal
What is the presentation of an intrusion?
- Tooth submerged into gum, can be palapted labially
- Tooth may be displaced through labial bone plate or impinging or permanent tooth bud
What may intrusion be mistaken for?
Avulsion or crown fracture with root left behind – important to have good history taking
Tooth may also be aspirated – high chance of pneumonia
What is the treatment for intrusion?
- History taking
- Radiographs (PA/occlusal) to rule out avulsion and aspiration, to confirm that tooth is embedded in soft tissues
Leave alone to spontaneously reposition unless:
- Infection
- Failure to re-erupt
What is the follow up management for intrusion?
Clinical follow ups at
- 1 week
- 6-8 weeks
- 6 months
- 1 year
Further follow up at 6 years of age is indicated for severe intrusion to monitor eruption of permanent tooth
What is the presentation for extrusion?
- Tooth is mobile
- Displaced out of socket
- Radiographically – increased PDL space
What is the treatment for extrusion?
If extrusion 1-2mm; no occlusal interference:
Monitor
If extrusion >3mm; occlusion affected: extract
What is the follow up management of teeth with extrusion?
Clinical follow up
- 1 week
- 6-8 weeks
- 1 year
What are the general guidelines for follow up management for all trauma injuries?
- If concerned that unfavourable outcome is likely, clinical follow-up every year until eruption of permanent teeth
- Radiographic follow-up only indicated where clinical findings suggestive of pathosis
What is the presentation of avulsion?
Tooth completely out of socket
What is the treatment for avulsion?
History taking:
- Location of missing tooth should be explored: could have been aspirated, ingested, or embedded in soft tissues
- If location of missing tooth not found, child should be referred for medical evaluation, esp if have respi symptoms (high risk of pneumonia)
Baseline radiograph – to rule out intrusion + determine if permanent tooth bud was displaced
Do NOT replant
What is the follow up management for avulsed primary teeth?
Clinical examination at 6-8 weeks.
Further follow up at 6 years of age to monitor eruption of permanent tooth
What are the types of traumatic hard tissue injuries?
- Root fracture
- Crown fracture
- Crown-Root fracture
- Alveolar fracture
How may a root fracture present?
Depending on location of fracture:
- Coronal fragment may be mobile and may be displaced
- Occlusal interference may be present
What is the treatment for root fracture?
- Baseline radiograph – fracture usually at mid-root or in apical 1/3
If stable – coronal fragment not displaced OR displaced but not excessively mobile: leave alone and monitor
If unstable – coronal fragment displaced, excessively mobile + interfering with occlusion:
1. Extract coronal segment and leave apical segment to be resorbed / pushed out when permanent tooth erupts OR
2. Reposition and splint for 4 weeks
What is the follow up management for crown fracture?
Clinical examination after
- 1 week
- 4 weeks (if splint placed to remove splint)
- 6-8 weeks
- 1 year
What are the types of crown fractures?
- Enamel fracture
- Enamel dentine fracture (with no pulp exposure)
- Complicated crown fracture (with exposed pulp)
What is the treatment for the different types of crown fractures?
Baseline radiograph (optional for enamel fracture) – PA or occlusal
If no pulp exposure (uncomplicated)
- Smoothen sharp edges
- CR restoration
If pulp exposure (complicated)
- Pulpotomy/pulpectomy
- Extraction (if non restorable)
What are the recommended follow up managements for the various types of crown fractures?
Enamel fracture: no F/U recommended
Enamel-dentine fracture: 6-8 weeks later
Complicated fracture: 1 week, 6-8 weeks, 1 year
How do crown-root fractures present?
Fracture involves enamel, dentin and root.
Pulp may or may not be exposed
Additional findings: loose but still attached fragments of tooth
What are the treatment options for crown-root fractures?
- Remove loose fragment
- Assess if crown can be restored
- If restorable + no pulp exposure: cover exposed dentine with GIC
- If restorable + pulp exposure: pulpotomy/RCT
- If unrestorable: extract
How does alveolar fracture present?
- Mobility and dislocation of the segment with several teeth moving together
- Occlusal interference usually present
What is the treatment for alveolar fracture?
Baseline radiographs (PA/occlusal) – other radiographs may be indicated
(done by pedodontist)
1. Reposition under GA
2. Stabilise segment with flexible splint for 4 weeks
3. Monitor teeth in fracture line
What are the post treatment instructions to parents after traumatic injury treatment?
- Soft diet: prevent further trauma to injured tooth
- OH measures to encourage gingival healing
- Advise about possible complications that may occur and when to bring child in for tx
- Inform about possible effects on permanent tooth
What are the OH measures for post-trauma instructions to parents?
- Support tooth when brushing
- Clean affected area w soft brush/cotton swab
- Topical application of alcohol-free 0.1% CHX m/w, x2/day for a week
What are 3 possible sequelae that parents should be informed of?
- Discoloration
- Loss of vitality (pulp necrosis & infection)
- Damage to permanent successor
What does grey tooth discolouration mean?
- Probably hemorrhage
- Usually happens quickly w subsequent gradual resolution
- In isolation => not sign of loss of vitality
- *grey discolouration alone insufficient to dx pulp necrosis, could be due to
haemosiderin by-products during healing => bruising within pulp chamber
What are clinical signs of loss in vitality?
- Pain
- ↑ mobility
- Sinus tract, gingival swelling, abscess
- Persistent dark grey discolouration w ≥1 sign of root
canal infection
What does yellow discolouration mean?
Pulp canal obliteration
What are radiographic signs of loss of vitality?
- Periapical pathology
- Infection-related resorption
In what kind of injuries is damage to permanent successors more commonly seen?
Intrusion or avulsion
Younger age trauma occurs => ↑ risk
What are possible effects that traumatic injuries can have on permanent successors?
- White/brown discolouration
- Dilaceration of crown/root (crown dilaceration requires exo)
- Odontome-like malformation (aka Turner’s hypoplasia)
- Failure of tooth dev: sequestration of permanent tooth germ => dissolves instead of calcifying
What are the aims of treating traumatic injury?
- Prevent further damage to permanent successor
- Treat pain
- Restore function
- Restore aesthetics
What are factors that influence the choice of treatment?
- Medical history
e.g child w congenital heart disease requires RCT to save & keep tooth
- BUT re-infection possible => risk of bacteraemia => infective endocarditis
- Exo w 100% success => better option - Severity of injury – restorable?
- Behaviour – affected by age (older children likely more cooperative)
- Parental choice
