Dental Trauma in children I.

5DM PEDO

Childhood is a risky period of life considering trauma (high risk and incidence of injuries)

Injuries to the teeth can severely harm a child in these aspects:

functional

esthetic

psychological

Epidemiology of injuries

30% of children experience trauma of MD

22% of children experience trauma of PD

main incidence in MD - 1. – 3. year of life

main incidence in PD - 8. – 11. year of life

up to 3 y. there is no difference between sexes

after 3rd year 2–3x more frequent in boys

in 90% of trauma - maxillary teeth

in 70% of trauma - incisors

most frequently one tooth is injured 60%

two teeth 30%

ETIOLOGY

• direct trauma to the dentition – collision with hard object, stick, fist

• indirect trauma – sudden forceful closure of the mouth – Mn teeth against Mx – blow to the chin during fall, fight, car accident

• most common places – home, school

Epidemiology of injuries in milky dentition

walk, run....

falls from chair, table, pram

battered child syndrome

Epidemiology in permanent dentition

swings, climbs – falls on playgrounds

falls from: bike, scate, in-lines

fight

car accidents

other

PREDISPOSING FACTORS FOR DENTAL TRAUMA

1. Age (8-10years)

2. Sex (boys 12% - 32% ; girls 4% - 19%)

3. Maloclusions – Angle class II with protrusion

4. Handicaped individuals

5. Refractive defect of the eye

6. Dental anomalies – quantitative defect of enamel

7. Season (spring, summer)

Battered child syndrome

• in some cases the oral injury can be a result battered child syndrome

• small child is subject to continuous physical abuse from one or both parents

• attemps to silence screaming/crying child • discrepancy between history and clinical findings • Multiple bruises in different stages of healing • Signs of old fractures on x-rays • Scars, cigarette burns, etc. • has to be reported

Patient record after injury

ANAMNESIS:

- name, surname, address, insurance

- name of accompanying person, wittness, address

- description of an accident

HEALTH STATUS:

-General (hemorhagic diatesis, epilepsy...)

- status after trauma (whether the patient remembers circumstances – problem with small children, unconsciousness, nausea, vomiting, pain)

WHEN ACCIDENT HAPPENED (record time)

ADMINISTERED MEDICAMENTS

Examination of trauma patient

Extraoral

-deformities, colour, haemorrhage,hematomas, abrasions, lacerations, penetrative wounds, abrasions, contusion – face, head, neck (+limbs visible part)

- examination by palpation

- mobility of fragments

Intraoral – set of order 1. soft tissue examination 2. hard tissue examination 3. hard dental tissue examination

Examination of trauma patient

Intraoral

- dental status

- lines of fracture

- mobility

- hematoma

- bleeding

- dislocation

- vitality test, percussion

- status of mucosa (and other tissues of oral cavity)

Examination of trauma patient

Auxilliary examinations

- x-ray ! (i.o., e.o., OPG)

-every injury, forensic reasons also

- blood tests ( APTT, Trc, etc. – blood cloting) vitality testing – just following trauma may be false

negative – little significant...must be repeated after 1 months and 6 months

photography - usefull

SEQUELAE OF TRAUMA TO PRIMARY

TEETH

• Infection in periodontal ligament • Pulpitis • Pulp necrosis • Pulpal obliteration • Inflammatory resorption • Ankylosis • Coronal discoloration • Complications following intrusion • Complications following avulsion

• Injuries to developing permanent dentition.

CLASSIFICATION OF DENTAL TRAUMA

By WHO 1979, modified by Andreasen in 1981

A) Fracture of crown

B) Fractures of roots

C) Combination of crown and root fracture

D) Luxations: contussion

subluxation

intrusion

extrusion

avulsion

E) Trauma of the facial soft tissues: contusion, abrasion, laceration

F) Trauma of jaws (bones): fractures of alveolar socket

fr. of alveolar bone

fr. of jaws (Mx,Mn)

CLASSIFICATION OF DENTAL TRAUMA – Andreasen

(detailed)

A) Crown fracture

• Enamel infraction

• Enamel fracture

• Fracture of the enamel and dentin

• Fracture of the enamel and dentin near the pulp

• Fracture of the enamel and dentin with pulp exposure

• Fracture of the enamel and dentin with pulp overlap

CLASSIFICATION OF DENTAL TRAUMA

B) Fracture of the root

• fracture in the coronal third

• fracture in the middle third

• fracture in the apical third

• vertical fracture

CLASSIFICATION OF DENTAL TRAUMA

C) Combined fracture of the crown and the root

• Fracture of the crown and the root with no complication

• Fracture of the crown and the root with exposed pulp

CLASSIFICATION OF DENTAL TRAUMA

D) Injuries to the tooth supporting tissues

• Concussion

• Subluxation

• Intrusion – Intrusive luxation

• Extrusion – Extrusive luxation

• Luxation – Lateral luxation

• Avulsion

Infraction of the enamel

Cl.picture

- infraction only in enamel, visible fracture line on the surface of the

tooth

- an incomplete fracture (crack) of the enamel without loss of tooth

structure

- Percussion test – not tender

- Mobility test - normal mobility

- Sensibility pulp test - usually positive (important in assesing future

risk of healing complications)

- RTG - periapical view, no radiographic abnormalities.

Infraction of the enamel

Th:

- no treatment or only impregnation with NaF or Bond system

(to prevent discoloration of the infraction lines)

Follow-up

• Not needed (only if combined with other type of injury)

Fracture in the enamel

Cl. picture

- fracture confined to the enamel with loss of tooth structure, esthetic change of crown shape

- small pain to irritation, sharp margin irritates lip or tonque

- dentin not exposed

- Percussion test – not tender

- Mobility test - normal mobility.

- Sensibility pulp test - usually positive

- RTG – loss of enamel.

Fracture in the enamel

Th:

- DD – trimming(cutting), impregnation

- PD- trimming, impregnation

conservative treatment with compomer or composite

If a tooth fragment is available, it can be bonded to the tooth.

Follow-up

Clinical and radiographic control at 6-8 weeks and 1 year.

Fracture in the enamel and the dentin

A fracture confined to enamel and dentin

with loss of tooth structure, but not involving the pulp.

Cl. picture (1)

- small pain on irritation

- Visible loss of enamel and dentin. No visible sign of exposed pulp tissue.

- Percussion test - not tender. If tenderness is observed evaluate the tooth for possible luxation or root fracture injury.

- Mobility test - normal mobility.

• Sensibility pulp test - usually positive.

The test may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made.

Fracture in the enamel and the dentin

RTG - enamel-dentin loss is visible

Radiographs recommended - periapical, occlusal and eccentric exposure – rule out displacement or root fracture

If the fragment is not found - Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material.

Fracture in the enamel and the dentin

Th:

If a tooth fragment is available, it can be bonded to the tooth.

- DD- trimming, impregnation, GIC filling, compomer filling

- PD- conservative treatment with compomer or composite filling (definitive)

Follow-up

Clinical and radiographic controls after 6 – 8 weeks, 1 year

Fracture in the enamel and the dentin

(near the pulp)

Cl. Picture (2)

- patient feels pain to irritation

- Vitality: usually positive

Th: PD

- indirect pulp capping with Ca(OH)2

- protective celluloid crown with GIC for 8 weeks

- after temporary treatment if the pulp is vital:

definitive filling (compomer/composite)

Fracture in the enamel and the dentin

near the pulp

Th:

YPT- definitive tretment only after apex closure

Vitality examination:

1., 2., 6. week, 1 year

DD- indirect pulp capping and protective celluloid crown

- Pulpotomy or extraction

Complications:

- pulp inflammation, necrosis, gangrene

Fracture in the enamel and the dentin with

pulp exposure

A fracture involving enamel and dentin

with loss of tooth structure and exposure of the pulp.

Cl. picture

- painfull, bleeding from pulp

- Percussion test - not tender. If tenderness is observed evaluate the tooth for luxation or root fracture injury

- Mobility test - normal mobility.

- Sensibility test - usually positive. The test is important in assessing risk of future healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.

Fracture in the enamel and the dentin with

pulp exposure

• RTG – loss of enamel and dentin visible, pulpal cavity exposed

• Periapical, occlusal and eccentric exposure.

(They are recommended in order to rule out displacement or the

possible presence of a luxation

or a root fracture.)

• Radiograph of lip or cheek lacerations

to search for tooth fragments

or foreign material

Fracture in the enamel and the dentin with

pulp exposure

Th: possibilities PD

- depend on the size of pulp exposure, time, infection, stage of tooth development

1. Direct pulp capping: small pulp exposure, cooperative patient, time ≤6 h, no infection

Fracture in the enamel and the dentin with

pulp exposure

Working procedure

• Cleen the tooth with Fys.solution, dry, direct pulp capping

• GIC and definitive filling or GIC and protective crown ,

• Sterile instruments, dry operative field

Prognosis:

• After 4 weeks- line of odontoblasts

• After 8 weeks- new dentin

Vitality examination:

• - 1., 2., 4., 6. week

.

Fracture in the enamel and the dentin with

pulp exposure

2) Vital amputation: immature permanent tooth/permanent tooth

• Greater perforation

• Time more than 6 h.

• Infection

• Damage of periodontal tissues

Working procedure:

• Sterille pulp amputation in the region of pulp and papilla, controll bleeding,

• Capping with Ca(OH)2, GIC, definitive filing

Prognosis:

• Dentin bridge after 2-3 month

Irreversible damage of dental pulp:

• Extirpation and endo th (PD) or extraction (YPT if mesodermal papila damaged irreversibly)

Fracture in the enamel and the dentin with

pulp exposure

Treatment in deciduos dentition:

• Dental pulp has lower biological value, lower defensiveness

Th:

• vital amputation (less success)

• vital extirpation

• extraction

Fracture of the crown with pulp

overlap:

Cl. Picture

• painfull,

• dental pulp overlap fracture aperture – pulp capping impossible

Th:

• YPT - Deep vital amputation

• PD - Vital extirpation

• DD - Vital extirpation/Extraction

Fracture of the crown and root non

complicated (without pulp involvement)

Cl. picture:

• Fracture line crosses crown and root

• A fracture involving enamel, dentin and cementum with loss of tooth structure, but not involving the pulp.

• Visual signs - crown fracture extending below gingival margin.

• Percussion test - tender.

• Mobility test - coronal fragment mobile.

• Sensibility pulp test - usually positive for apical fragment.

Fracture of the crown and root non

complicated (without pulp involvement)

• RTG – Apical extension of fracture usually not visible.

• Radiographs recommended - periapical, occlusal and eccentric exposures.

Fracture of the crown and root non complicata

Th: PD

• Fragment removal and gingivectomy (sometimes ostectomy) Removal of segment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy, ostectomy with osteoplasty. This treatment option is indicated in crown-root fractures with palatal subgingival extension.

Fracture of the crown and root non complicata

Th:

• Orthodontic extrusion of apical fragment Removal of the segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown.

• Surgical extrusion Removal of the mobile fractured fragment with subsequent repositioning of the root in a more coronal position. A rotation of the root (90 or 180) may offter a better position for periodontal ligament healing.

Fracture of the crown and root non complicata

Th:

• YPT: apexification, definitive endodontic treatment, prosthodontic treatment

• DD: extraction

Fracture of the crown and root

complicata (involving pulp)

Cl. picture:

A fracture involving enamel, dentin, and cementum with loss of tooth structure, and involving the pulp.

• transverse fracture more than 4 mm subgingival

Fracture of the crown and root

complicata

Percussion test - tender.

Mobility test - coronal fragment mobile

Sensibility tet - usually positive for apical fragment.

Radiographs recommended - periapical and occlusal exposure.

Fracture of the crown and root

complicata

• Fragment removal and gingivectomy

(sometimes ostectomy)

Removal of segment of the fractured fragment

with subsequent endodontic treatment and

restoration with a post-retained crown. This

procedure should be preceded by a

gingivectomy and sometimes ostectomy with

osteoplasty. This treatment option is only

indicated in crown-root fractures with palatal

subgingival extension.

Fracture of the crown and root

complicata

• Orthodontic extrusion of apical fragment

Removal of the segment of the fractured

fragment with subsequent endodontic treatment

and orthodontic extrusion of the remaining root

with sufficient length after extrusion to support a

post-retained crown.

Fracture of the crown and root

complicata

• Surgical extrusion

Removal of the fractured fragment with

subsequent repositioning of the root in a more

coronal position. A rotation of the root (90 or

180) may offter a better position for periodontal

ligament healing.

Fracture of the crown and root

complicata

• Extraction

Extraction with immediate or delayed implant-

retained crown restoration or a conventional

bridge. Extraction is inevitable in very deep

crown-root fractures, the extreme being a

vertical fracture

• Th DD

- extraction

Fractures of the root

• fracture in the coronal third

• fracture in the middle third

• fracture in the apical third

• vertical fracture

Root fracture in coronal third

Cl. picture:

• mobility 2.-3. degree, most in trauma direction and in long axis

• supraocclusion

• pain to pressure

• marginal gingiva damage

• decreased reaction to cold

Root fracture in coronal third

Th:

• Subgingival fracture: gingivectomy, prosthodontic treatment with pin (exstirpation, endo th, intrapulpal post)

• Cross line under alveolus and communication with oral cavity: extraction

• Transversal fracture: conservative and ortodontic treatment (endodontic treatment, pin in root, 4 weeks root extrusion with orthodontic appliance, 6 weeks stabilisation in new position

Root fracture in middle third

Cl. picture:

• mobility of the tooth

• pain during function

• apical fragment is stabile

• decreased reaction to cold

Root fracture in middle third

Th:PD

• Pulp damage: endodontic treatment

• No dislocation: splinting for 3.-4. months with wire and composite

• With dislocation: reposition, splinting for 3 - 4 months, endodontic treatment with intraradicular pin

• Extraction

Root fracture in apical third

Cl. picture:

• mobility, I. degree

• pain to percussion

• reaction to cold or no reaction to cold

Th:PD

• Splinting for 2-3 months

• Necrotic pulp: endodontic treatment and apex amputation

Root fracture in apical third

Th:DD

• Extraction

• Leave apical third (erupting permanent

tooth will resorb remaining apical part of

root

Alveolar fracture

• A fracture of the alveolar process; may or may not involve the alveolar

socket.

• Teeth associated with alveolar fractures are characterized by mobility of

the alveolar process; several teeth typically will move as a unit when

mobility is checked. Occlusal interference is often present

• Displacement of an alveolar segment. An occlusal change due to

misalignment of the fractured alveolar segment is often noted.

Alveolar fracture

• Percussion test – tender

• Mobility test - entire segment mobile and moves as a unit.

• Vitality test – usually negative

• RTG - The vertical line of the fracture may run along the PDL or in

the septum. The horizontal line may be located apical at the apex or

coronal to the apex. An associated root fracture may be present.

• Occlusal, periapical and eccentric exposure and OPG

Alveolar fracture

Treatment

• Manual repositioning or repositioning using forceps of the displaced

segment.

• Stabilize the segment with splinting for 4 weeks

Patient instructions

• Soft food for 1 week

• Good healing following an injury to the teeth and oral tissues

depends, in part, on good oral hygiene. Brushing with a soft brush

and rinsing with chlorhexidine 0.1 % is beneficial to prevent

accumulation of plaque and debris.

Follow-up

• Splint removal and clinical and radiographic control after 4 weeks.

• Clinical and radiographic control after 6-8 weeks, 4 months, 6

months, 1 year and yearly for 5 years

Jaw fracture

• A fracture involving the base of the maxilla or mandible

and often the alveolar process. The fracture may or may

not involve the alveolar socket.

• Usually displacement between two alveolar segments

within the dental arch.

• Percussion test – tender

• Mobility test – mobility in fracture line

• Vitality test – maybe positive or negative

• RTG - The vertical line of the fracture line may run along

the PDL or in the septum. Periapical, OPG, skull

projections (AP, lateral, Clementschich)

Jaw fracture

Treatment

• Manual repositioning and stabilization of the fracture with splint

using intermaxillary immobilization for 4 weeks.

• An alternative treatment is surgical repositioning and stabilization

using plating. In this case intermaxillary splinting can usually be

avoided.

Patient instructions

• Good healing if good oral hygiene. Brushing with a soft brush and

rinsing with chlorhexidine 0.1 %

Follow-up

• Splint removal and clinical and radiographic control after 4 weeks.

• Clinical and radiographic control after 6-8 weeks, 4 months, 6

months, 1 year and yearly for 5 years.