MANAGEMENT OF DENTAL TRAUMATIC INJURIES IN PAEDIATRIC PATIENTS

Aghimien AOUniversity of Benin Dental School

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OUTLINE PART 1 introduction Aetiology of traumatic injuries Epidemiology Classification of traumatic injuries PART 2 clinical evaluation of patients History of the trauma Medical history Dental history

Examination general examination extra-oral intra-oral Sensibility evaluation Radiographic evaluation Clinical photographyPART 3…TREATMENT PROTOCOLS FOR VARIOUS DENTAL TRAUMATIC INJURIES IN PRIMARY AND YOUNG PERMANENT DENTITION

Hard tissue injuries enamel infraction uncomplicated crown fracture complicated crown fracture root fractureSupporting tissue injuries concussion subluxation luxation; intrusive, extrusive, lateral avulsion

FOLLOW UP PROGNOSIS COMPLICATION OF TRAUMATIC DENTAL

INJURIES CONCLUSION REFERENCES

INTRODUCTIONDental trauma is one of the most common presentation in the paediatrics clinic. The fears and anxiety of these patients make management difficult. If improperly managed, it could affect the patient self-esteem and quality of life

AETIOLOGY The most accident prone times include;2-4 years for primary dentition 7-10 yrs for permanent dentitionAetiological factors include;1. Falls2. Collision3. Playing and running4. Contact sports5. Road traffic accident6. Child abuse; ESPN Emotional-Sexual-Physical-Neglect

PREDISPOSING FACTORS1. Angle class 11 div 12. Increased overjet; 3-6mm..double the risk >6mm….triple the risk3. Incompetent lip closure4. Improperly fitted mouthguard..twice the risk

DIRECT AND INDIRECT TRAUMADirect trauma; involves the tooth directly favours anterior teeth

Indirect trauma seen when the lower arch forcefully close

against the upper arch favours crown and crown-root fracture of

the premolar and molar region

EPIDEMIOLOGY Dental trauma is common in childhood and adolescence.By 5 yrs; boys-- 31-40% girls….16-30% and At 12 years; 12-33% of boys and 4-19% of girls would have suffered dental traumaboys : girl; 2:1 in both dentitions

In primary dentition; anterior segment is commonly affected

especially the maxillary central incisor, concussion, subluxation, and luxation

are the commonestIn permanent dentition; luxation and fracture injuries are the

commonest Maxillary central incisor>maxillary

lateral incisor>mandibular incisor

CLASSIFICATION Several classifications have been proposed for easy diagnosis and treatment need of various traumatic dental injuries(TDI). E.G1. Ellis classification2. WHO 19783. Garcia-Godoy 1968…for primary and

permanent dentition4. Andreasen 1981..modification of WHO

ANDREASEN’S CLASSIFICATIONA. Dental Hard Tissue and Pulp Only Crown infraction Uncomplicated crown Complicated crown Uncomplicated crown-root Complicated crown-root Root fracture

B. Periodontium

Concussion Subluxation(loosening) Luxation intrusive(central dislocation) extrusive(peripheral dislocation, partial avulsion) lateral Exarticulation(complete

luxation/avulsion)

C. SURROUNDING BONE Comminution of alveolar socket Fractures of facial or lingual alveolar

socket wall Fractures of alveolar process -/+

involvement of the socket Fractures of the mandible or maxilla

-/+ involvement of the tooth socket

D. SOFT TISSUE Laceration Contusion Abrasion

PART 2: CLINICAL EVALUATION OF PATIENTS

1. History of the trauma’HOW; to know extent of injury; direct or

indirect to rule out head injury involvement Discrepancy between history and

clinical findings raises suspicion of physical abuse.

Where; whether contaminated soil or not;

which may be an indication for tetanus prophylaxis or not

When; time interval between injury and

presentation would determine treatment option and prognosis

Is the tooth fracture or not; chest radiograph ..if not found possible reattachment if foundAny neurological symptoms

2. Medical history Congenital heart diseases Epilepsy Bleeding disorders Allergies3.Past dental history Regular attenders are more likely to be

cooperative4. Immunization status. refer to physician for TT injection if trauma

occurred in a contaminated soil and patient had not receive a booster dose for the past 5 yrs.

EXAMINATIONSA. General exam; a quick head-to-toe

examination is done to r/o other injuries. Signs of shock and head injury must be excluded.

B. Extra-oral exam; observe and palpate for;

Swelling, bruises, laceration Limitation of mandibular movement Mandibular deviation on opening and

closing Bony step deformity Are wounds clean or contaminated

C. intra-oral exams; Laceration, haemorrhage and swelling Assess the occlusion, tooth

displacement, fractured crowns, or cracks in the enamel.

Assess mobility; horizontal and vertical direction suspect ‘enblock alveolar process

fracture if several teeth move at the same time.

excessive mobility…root fracture or displacement

Reaction to percussion; the sensitivity and the sound on percussion are important. to assess PDL inflammation luxated teeth are always tender duller note indicate a root fractureColour of the teeth; early colour change associated with pulpal breakdown is visible on the palatal surface ,in the gingival third of the crown

SENSIBILITY ASSESSMENT Usually to ascertain nerve and blood supply not reliable in children More of a diagnostic tool in permanent

dentition Unreliable in erupting permanent and teeth

with open apices Positive response after a traumatic injury is

more valuable than negative response although none should be trusted

Commonly used are; EPT, thermal test(heat or cold). Other include; carbon dioxide snow, laser Doppler flowmetry

RADIOGRAPHIC EVALUATIONIndication for radiograph;1. To detect root fracture2. Ascertain extent of root development3. To determine resorption4. To detect foreign body in soft tissue5. To detect jaw fracture6. To note position and stage of

development of permanent teeth 7. To detect size of pulp chamber8. To r/o periapical radiolucency9. For follow-up evaluation

Take two radiographs at different angles to detect a root fracture.

If access and co-operation are difficult then one anterior occlusal radiograph rarely misses a root fracture.

Periapical films positioned behind lips can be used to detect foreign bodies.

Lateral anterior view with an occlusal radiograph position by patient side could help detect extent of intrusive luxation.

Request for OPG if jaw injury is suspected

DOCUMENTATION PHOTOGRAPH Take a pre and post treatment

photograph for proper documentation To assess outcome of treatment For medicolegal purpose Always obtain a written consent

TREATMENT OPTIONS FOR DENTAL TRAUMATIC INJURIES

Dental trauma to primary dentitionMost common is subluxation, intrusive luxation and avulsion. Crown and root fracture are rare.NB; large marrow spaces and pliability of the alveolar bone.

SUBLUXATION Diagnosis; mobile tooth -/+ sulcular bleedingX-ray; nil abnormalityTreatment; clean associated soft tissue injury with 0.2% chlohexidine with gauze swabs twice daily.Slight mobility; place on soft diet for 2 wksMarked mobility; extractFollow-up; after 1 month to assess mobilityPrognosis; usually good

INTRUSIVE LUXATION Tooth displace towards the socket, compressing the PDL and crushing the alveolar bone.Diagnosis; not mobile, not tender, appear shortened or in severe cases would seem missingInvestigation; lateral anterior radiograph. Aim is to ascertain r/ship of apex of intruded tooth with the permanent tooth bud

Treatment; a. if apex is displace labially, allow for spontaneous re-eruption b. if displaced palatally; extract the tooth

Follow-up; Review should be weekly for a month then monthly for a maximum of 6 months. Most re-eruption occurs between 1 and 6 months and if this does not occur then ankylosis is likely and extraction is necessary to prevent ectopic eruption of the permanent successor

NOTE GINGIVAL DISPLACEMENT, INDICATING INTRUSION

Prognosis; 90% of cases re-erupt b/w 2-6months. In dome cases ankylosis could occur leading to a delay of eruption of the permanent tooth.

Extrusive luxationPartial avulsion as PDL is severely torn/damagedDiagnosis; tooth appear elongated and mobileX-ray; increased PDL space apicallyTreatment; mild extrusion<3mm allow tooth to reposition spontaneously and heal if tooth is immature. when do I need to extract?a. Severe extrusion/mobility

b. Tooth near exfoliationc. Child not cooperatingd. Tooth fully matureFollow-up; if repositioned take x-ray to determine reduction in the PDL space apically

LATERAL LUXATIONTooth displaced in any position other than axiallyDiagnosis; tooth appear displace, not mobile nor tenderX-ray; shows increased PDL space and displaced tooth apexTreatment; if apex is displace buccally and there is no gagging of occlusion, allow spontaneous realignment. extract if apex is displaces towards the permanent tooth bud.

prognosis; If tooth is repositioned, there is risk of pulpal necrosis compare to spontaneous eruption.

Note the occlusal interference

AVULSION Diagnosis; Tooth is out of the socketX-ray; do a chest x-ray if tooth can’t be accounted forTreatment; do not re-implant due to risk of damaging the permanent tooth bud.Though space maintenance is not necessary, a fixed or removable be fabricated to allay aesthetic concernsFollow-up; permanent tooth eruption could be delay for 1-2yrs due to formation of fibrotic band

AVULSION

HARD TISSUE INJURIESUNCOMPLICATED CROWN FRCATURE;

Enamel -/+ dentine # without pulpal involvement.Diagnosis; evidence of loss of tooth structure X-ray; soft tissue radiograph to locate tooth fragment Treatment; aim is to preserve pulp vitality and restore

aesthetics. small fracture: smoothen rough margins/edges large fracture: for large enamel fracture restore with acid-etch-composite resin

FRACTURE EDGES CAN BE DISKED

if dentine is involved; protect the pulp using acid resistant calcium hydroxide or GIC restore with acid-etch composite

COMPLICATED CROWN FRACTUREIs uncommon in primary dentitionDiagnosis; loss of tooth structure with pulp exposure clinically and on radiographX-ray; to r/o fragment in soft tissue

Treatment options; Depends on patients cooperation vitality of the tooth stages of root development formocresol pulpotomy; if tooth is vital pulpectomy with zinc oxide and eugenol non-vital tooth 3/4th of the root must be formed 1-2mm short of the apex extraction; if child is uncooperative tooth is non-vital

Final restoration; depends on amount of tooth structure remaining composite resin if remnant can

support the composite restoration stainless steel crown with

composite veneering if small fragment remains

Prognosis; depends on concomitant injury to the PDL.

ROOT FRACTURE;Diagnosis; mobile coronal segment -/+ displacedRadiograph; take at least 2 views reveal radiolucent line b/w

fragment succedaneous tooth could obscure

root fragmentTreatment; depends on level of fracture: at apical 1/3rd and with minimal mobility, observe. Take serial radiograph of the tooth.

MIDDLE 3RD FRACTURE

If the coronal fragment becomes non-vital and symptomatic then it should be removed. The apical portion usually remains vital and undergoes normal resorption.At the middle and cervical 3rd, tooth should be extracted.

TRAUMA TO YOUNG PERMANENT TEETHPrompt and accurate diagnosis is invaluable in the success of treatment.Aims and objective of treatment;1. Emergency/immediate; to retain vitality of fracture and displaced

tooth treat exposed pulp tissue; reduction and immobilization of displaced

teeth antiseptic mouthwash, +/- antibiotics and

tetanus prophylaxis.

2. Intermediate: (a) pulp therapy; (b) minimally invasive crown restoration. 3. Permanent: (a) apexogenesis/apexification; (b) root filling + root extrusion; (c) gingival and alveolar collar modification; (d) semi or permanent coronal restoration.

HARD TISSUE INJURIES AND MANAGEMENT

Enamel infraction;Incomplete fracture in the enamelExamination; reveal craze lines on transilluminationTreatment; observe to ensure tooth integrity and pulp vitality.Uncomplicated crown fractureLoss of enamel -/+ dentine fracture without pulp involvementDiagnosis; clinical and radiographic evidence of loss of tooth structure

UNCOMPLICATED # E AND D

,Treatment; for small fracture use fine disk to

smoothen the margins for larger loss, protect the pulp with

calcium hydroxide or GIC then restore with acid-etch composite.

Enamel and dentine bonding agents have also been used to protect the pulp from thermal irritants and bacterial ingress.

COMPLICATED CROWN FRACTURE;

Factors that influence choice of treatment: vitality of expose pulp time elapse since the exposure degree of root maturation of the

fracture tooth restorability of the fracture crownAim of treatment; to preserve pulp vitality

NOTE PULP EXPOSURE, DO A CVEK

Treatment options; direct pulp capping(DPC) pulpotomy; partial or complete pulpectomy

carry out DPC ; when exposure is pin-point when exposure is just of few hours>24hrs when the apex is open as an emergency measure even pulpotomy

is to be done

Review after a month, then 3 months, and eventually at 6 monthly intervals for up to 4 years to assess pulp vitality.

Take periodic radiographOn the radiograph check the following: • root is growing in length; • root canal is maturing (narrowing); • Compare with previous x-rays. If growth is not occurring the pulp should be assumed to be non-vital.

Follow-up

When to do pulpotomy: pulpal exposure for longer hours >24hrs larger pulpal exposure immature open apicesAim of treatment; to eliminate inflamed pulp tissue and preserve vital radicular pulp aiding complete root development(apexogenesis)

Vital(full) pulpotomy or partial(Cvek) pulpotomy could be done depending on the level of inflammation and extent of bleeding on amputation

Review after a month, 3 months, 6 monthly intervals for up to 4 years to assess pulp vitality.

Do periodic radiograph. If vitality is lost, non-vital pulp therapy should be

undertaken whether or not there is a calcific bridge

Prognosis; success rates for partial (Cvek) pulpotomies are quoted at 97%. Those for coronal pulpotomies at 75%.

Follow-up

Pulpectomy as an option; done in non-vital pulp pulp with closed apex when permanent restoration need a post

build up an apical root end closure(apexification) is done, but dentinal wall is left fragile and easily fracture

first month, then 3 mths, then 6 mthsDo periodic radiograph to check evidence of calcific barrier formation. This will normally take b/w 9-24 mths

final treatment; these include Definitive canal obturation composite restoration porcelain veneer and crown post-retained crown

Follow-up;

Treatment options;1. Apexification2. Apical barrier technique; using generic tricalcium phosphate(g-TCP) synthetic hydroxyl apatite bioceramic glass freeze-dried bone3. Retrograde root canal filling

Managing immature non-vital teeth with open apex

Root fracture.Diagnosis; clinically mobile teeth and 1 or more radiolucent lines separating fracture segmentsAims of treatment; to reposition and stabilise coronal segment encourage healing of PDL and vascular supply to restore aesthetics and functionTreatment; reposition segment and immobilise for 2-3mths (preferably fixed splint composite resin a better choice; but why?)

Apical 3rd

Decision to splint; this depend on the level of fracture and whether long term stability of the tooth depends on itApical 1/3rd fracture; no need to splint except there is an associated subluxationMiddle and cervical 1/3rd; splint if tooth is to be retainedInternal splints have ranged from hedstroem files to nickel-chromium points, screwed and cemented into position.

Flexible assisted splinting, root fracture needs undisturbed splinting

Final treatment1. If coronal segment is extracted for cervical

fracture, root portion is extruded surgically or via orthodontic mean and pulp therapy done. A post-retained crown is planned

2. Both fragments could be extracted and prosthesis planned.

follow-up assess pulp vitality assess stability of tooth

Prognosis this is best for apical 3rd fracture becomes poorer in middle and cervical fracture

This involve damage to supporting structures of the teeth i.e PDL and alveolar bone.Primary objective is to maintain vitality of the PDL which is important in the long term prognosis of the luxated teeth.

Luxation injuries in permanent dentition

CONCUSSION Diagnosis; tooth is firm, tender to pressure and percussionRadiograph; usually no abnormalityAim of treatment; to encourage healing of PDL and maintain pulp vitalityTreatment; soft diet for 2wks, relieve it from occlusion if there is complain of painFollow-up; vitality test foe 1, 3 and 6 month the yearly. Radiograph to assess root developmentPrognosis; usually good, but necrosis in 3-6% of cases

Subluxation Diagnosis; tooth is mobile. Bleeding at the marginal gingival, tender to percussion Radiology; the PDL space is widened Aim of treatment; allow healing of the PDL and ensure vascular supplyTreatment; stabilize and relieve from occlusion. For comfort use flexible splint(<2wks) if apex is fully formed and extremely tender.

Note sulcular bleeding

Prognosis; mature teeth with closed apices are at risk of pulpal necrosis hence, close monitoring is required.

LATERAL LUXATIONDiagnosis; tooth is displaced crown may be palatal or labiallydisplaced ; not mobile nor tenderRadiology; PDL space is increased apex is displaced labially

Note labially displaced crown

Treatment; reposition tooth with gentle and firm

digital pressure use flexible splint 3-8wks place on antibiotics and TT(if indicated) use 0.12% chlohexidine mouth washFollow-up; do periodic radiograph to monitor DPL re-attachment.Prognosis; tooth with closed apices could become necrotic(start root canal trt) and have the canal obliterated

Diagnosis; teeth appear shortened, or in severe cases could appear missing, not mobile nor tenderRadiograph; root apex is displaced apically PDL space is non-continuousTreatment; depends on: 1. stage of root development: open or close 2. severity of injury; mild <3 mm, moderate (3-6 mm); or severe (>6 mm).

INTRUSIVE LUXATION

OPEN APEX ; Mild intrusion <3 mm. Excellent eruptive potential. Treat conservatively and review. If no movement in 2-4 months move

orthodontically. Moderate Intrusion 3-6 mm. Disimpact (with forceps if necessary) and either allow to erupt spontaneously for 2-4 months before extruding orthodontically or apply orthodontic forces early.

Severe intrusion >6 mm. Orthodontic repositioning may be impossible and disimpaction followed by surgical repositioning under either LA, LA/sedation, or GA is appropriate. Functional splint for 2-3 weeks.

Follow-up. Monitor pulpal status clinically and

radiographically at regular intervals during the first 6 months after injury, and then 6 monthly, and start endodontics if necessary:

Non-setting calcium hydroxide in root canal does not preclude against orthodontic movement. Once apexification has occurred and orthodontic movement has ceased.

obturate canal with gutta percha.

CLOSED APEX ;Mild intrusion <3 mm. Orthodontic extrusion is probably indicated straight away although some authors have advocated conservative treatment. Moderate intrusion 3-6 mm. Orthodontic extrusion is indicated straight away.

Severe intrusion >6 mm. Surgical repositioning. Functional splint for 2-3 weeks

.

Partially intruded with ortho disimpaction

Follow-up; for closed apices carry out root canal as early as possible to guide against external root resorption.

Prognosis; mature closed apex have higher risk of pulp

necrosis(96%), root resorption and ankylosis immature apex have 60% risk of necrosis and

56% risk of resorption teeth treated early enough have better prognosis

Tooth displace axially from the socketDiagnosis; clinically appear longer and is mobileOn radiograph; PDL space is increased apicallytreatment; reposition tooth with gentle and firm digital pressure splint for 2wksFollow-up; closed apex are at risk of necrosis hence, pulp therapy is indicated after splinting

EXTRUSIVE LUXATION

Note teeth appearing longer

As a rule all avulsed teeth should be re-implant.Diagnosis; clinically and radiological evidence show absence of tooth in the socket in case complete intrusion is been suspected.

Management;1. Give first aid if you receive a phone call2. On arrival in clinic the following is done;

AVULSION/EXARTICULATION

avulsion

Considerations;1. Extra-oral time2. Stage of root development

First aid for avulsed tooth1. Do not touch the root of the tooth. Handle

the tooth by the crown only.2. Rinse the tooth off only if there is dirt

covering it. Do not scrub or scrape the tooth.3. Attempt to reimplant the tooth into the

socket with gentle pressure, and hold it in position.

4. If unable to reimplant the tooth, place it in a protective transport solution, such as Hank's solution, milk or saline.

Handling an avulsed tooth

This will hydrate and nourish the periodontal ligament cells which are still attached to the root. A

small container of Hank's Balanced Salt Solution can be purchased in dental emergency kit form at many

drug stores. Contact lens solution is not an acceptable storage medium.

5. The tooth should not be wrapped in tissue or cloth. The tooth should never be allowed to dry.

6. Take the child to a dentist or hospital emergency room for evaluation and treatment.

7. Radiographs may need to be taken of the airway, stomach, and mouth if the tooth cannot be found .

8. Tetanus prophylaxis should be considered if the dental socket is contaminated with debris.

1. For A Mature Tooth With A Closed Apex: If the extra-oral dry time is <60 minutes, reimplant as soon as possible. If the extra-oral dry time is >60 minutes, soak in citric acid or curette the root; then soak in stannous fluoride(2%) for 10 minutes. Rinse with saline. Perform root canal therapy one week following the trauma.

TOOTH REIMPLANTATION GUIDELINES

If the extra-oral dry time is <60 minutes, soak in doxycycline (1mg/20 ml saline) for 5 minutes. If the extra -oral dry time is >60 minutes, provide the same treatment as for a closed apex.

Apply a flexible, functional splint for 7 to 10 days. If an alveolar fracture is present, provide a very rigid splint for 4-6 weeks.

. For An Immature Tooth With An Open Apex:

suture any laceration place on antibiotics and analgesics prescribe 0.12% chlohexidine mouthwash check TT status

Open apex; EOT < 60min; monitor for 3-4 mths, if pathosis sets in start apexification EOT >60min; start apexification immediatelyClosed apex; provide traditional pulp treatment and obturateRemove splint after 7-10daysContinue review every 3-4wks

Follow -up

If tooth eventually become discoloured, noon-bleaching could be done.

In primary dentition; Pulpitis; reversible or irreversible Pulp canal obliteration Pulp necrosis Resorption; inflammatory and replacement Injury to developing permanent teeth;

hypoplasia, hypomineralisation, crown dilacerations, arrested root development, odontoma-like formation

Complication of trauma dental injuries

Trauma dental injuries is common among toddlers and adolescence. Due to the instability of children in their developmental stage they become prone to it. Mouth guard use in contact sport can greatly reduce the incidence and severity.Effort should be made if possible to preserve a traumatise tooth considering the aesthetics and functional role they play.

conclusion

1. Richard Welbury et al, 2005. paediatric dentistry (3rd ed) Oxford University Press.

2. Cameron A and Widmer R, Handbook of paediatrics Dentistry, 5:95-102

3. Andlaw AL and Rock WP, 1999. Manual of Paediatrics Dentistry(4th edn)27-29:203-239

4. Pinkham JR et, Paediatrics Dentistry; infancy through adolescence. 15:213-234, 34;531-546

5. Management of Dental Trauma in children. Information on emergencies, Paediatrics Dental Health,2008

References

6. Flore MT et al , Guidelines For the Management of Traumatic Dental injuries part II avulsion of permanent teeth; dental traumatology 2007:130-136

7. Kapil L et al2010. A proposal for classification of tooth fractures based on treatment need Journal of Oral Science, Vol. 52, No. 4, 517-529

8. Elisa B. Bastone, Terry J. Freer, John R. McNamaraEpidemiology of dental trauma: A review of theLiterature; Australian Dental Journal 2000;45:(1):2-9

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