Dento- alveolar...2020/03/23 · Dento-alveolar trauma: In children is distressing for both child...

Dento-

alveolar

trauma

Dento-alveolar trauma:

In children is distressing for both child and

parent.

Often difficult for the dentis.

It is important that the dentist (all members

of the dental team) are well prepared to

meet the many complex and challenging

problems in the care of dental

emergencies.

Is one of the most common reason young

children to visit a pediatric dentist.

This concerns especially for cases whit little

children \toddler\.

History

When the patient is received for treatment, the first step is to get an initial impression of the extent of the injury.

Has a tooth been knocked out?

Is the patient’s general condition affected?

Is there a need for immediate medical care?

History of

the

Dental Injury

Three important questions are asked in gathering the dental history:

When?

Where?

How did the accident occur?

Dental history

When did the injury occur?

The time interval between injury and treatment can influence both the treatment procedure and the expected outcome.

Optimal repositioning of an extruded permanent tooth is difficult if treatment is delayed.

The time factor is also very critical for the prognosis of replanted teeth.

Dental

history

Where did the injury occur ?

This information is important for insurance and social security purposes.

The place of accident also provides information on the need for tetanus prophylaxis in replantation cases.

Dental history

How did the injury occur?

The nature of the blow may provide

information about the type of injury,

which can be expected.

When a blow hits the chin, the

mandibular arch is forced against

the maxillary arch.

As possible resulting injuries:

Jaw fracture

Сrown-root fracture in the

premolar or molar regions

Dental history

Was there a period of unconsciousness?

If so, for how long?

Is there а headache? Amnesia? Nausea? Vomiting?

Excitation or difficulties in focusing the eyes?

These are all signs of brain concussion and require medical attention.

Head injury

Between 25% and 50% of all

accidents in children up to 14 years

involve the head.

If there is any suggestion that a

head injury has been sustained, the

child should be immediately

medically assessed.

Signs of closed head injury

● Altered or loss of consciousness.

● Bleeding from the head or ears.

● Disorientation.

● Prolonged headache.

● Nausea, vomiting, amnesia.

● Altered vision or unilateral

dilated pupil.

● Seizures or convulsions.

● Speech difficulties.

Dental history

Is there any disturbance in the bite?

Disturbance in the occlusion can imply:

luxation injury

alveolar fracture

jaw fracture or luxation

or fracture of the temporomandibular

joint.

Limitations of mandibular movement or

mandibular deviation on opening or

closing the mouth indicate that the jaw

might be fractured.

Medical history

A short medical history should

reveal

Possible allergies

Blood disorders – very important if

soft tissues are lacerated or teeth

are to be extracted

Congenital heart disease

Other information about

conditions that could interfere

with treatment.

Clinical

examination

Extraoral

examination

The facial skeleton should be palpated to determinediscontinuities of facial bones.

Extraoral wounds and bruises should be recorded.

Deep lip wounds are examined closely with respect to tooth fragments or other foreign bodies.

Extraoral examination

The temporomandibular joints should be palpated, and any swelling, clicking, or crepitus should be noted.

Mandibular function in all excursive movements should be checked.

Any stiffness or pain in the child's neck necessitates immediate referral to a physician to rule out cervical spine injury.

Intraoral examination

All soft tissues should be examined and any injuries

recorded.

The presence of foreign matter in lacerations of the

lips and cheeks, such as tooth fragments or soil,

should be identified.

Removal at the initial appointment will eliminate

chronic infection and disfiguring fibrosis.


It is important to examine all teeth within a

traumatized area;

In close bite situations;

Also teeth in the opposite jaw;

Each tooth in the mouth should be examined

Particular note is taken of the following

factors:

Intraoral

examination

Displacement.

The direction as well as the extent (in mm) of displacement should be recorded.

Minor displacement can be difficult to detect.

In such cases it is helpful to examine the occlusion as well as radiographs taken at various angulations.


Mobility

The degree of mobility is assessed

in a horizontal and vertical

direction

keeping in mind that immature

permanent teeth and primary

teeth undergoing root

resorption have quite extensive

physiologic mobility.

When several teeth move

together en bloc, a fracture of

the alveolar process is suspected.


Reaction to percussion.

The handle of a mouth mirror is

tapped gently against the

teeth in a horizontal and

vertical direction.

Tenderness to percussion

indicates damage to the

periodontal ligament.

A high metallic tone implies

that the injured tooth is locked

in bone.

Intraoral

examination

Color of the tooth

Discoloration may appear

almost immediately after the

injury.

Special attention should be

paid to the palatal surface in

the gingival third of the crown.


Reaction to sensibility tests

It is usually not possible to obtain reliable information from a young, frightened child.

In the permanent dentition electrometric sensibility testing should be performed whenever possible.

It gives important information about the neurovascular supply to the pulp.

Provides a baseline value for comparison at follow-up examination.

Reaction to sensibility tests

The contralateral uninjured tooth or another comparable tooth serves as a control.

The most reliable response is obtained when the electrode is placed upon the incisal edge.

It is important to explain the purpose of the test and the type of reaction to be expected.

Radiographic

examination

Is mandatory in order to get an

impression:

Of the injury to the supporting

tissues

The stage of root development

In the case of primary tooth

injuries, the relation to

permanent successors

The injury site should be viewed

from different angulations.

Diagnosis

A diagnosis is based on

information from the

clinical and radiographic

examination.

The injury is classified as a

guide to the treatment

required.

We use the classification,

recommended by the

World Health Organization

(WHO).

Classification of dento-alveolar injuries (WHO)

Injuries to hard dental tissues and pulp

Enamel infraction

Enamel fracture

Enamel – dentine fracture

Complicated crown fracture

Uncomplicated crown-root fracture

Complicated crown-root fracture

Root fracture


Injuries to the periodonal tissues

Concussion

Subluxation

Extrusive luxation (partial avulsion)

Lateral luxation

Intrusive luxation

Avulsion


Injuries to supporting bone

Comminution of mandibular or

maxillary alveolar socket wall

Fracture of mandibular or maxillary

alveolar socket wall

Fracture of mandible and maxilla


Injuries to gingiva or oral

mucosa

Laceration of gingiva or oral

mucosa

Contusion of gingiva or oral

mucosa

Abrasion of gingiva or oral

mucosa

Injuries to primary teeth. Clinical features, diagnosis and treatment

Epidemiology in primary dentition:

At 5 years of age

11 – 30 % of children suffer trauma to

primary dentition (31 – 40 % of boys and

16 – 30 % of girls)

The incidence of injuries to primary

teeth increases from 1 year of age –

peak incidence is at 2 – 4 years

Most traumas involve children younger

than 4 years of age.

In preschool children, trauma in

boys is more common than in girls.

Epidemiology:

Depending on the affected teeth:

The most frequently injured teeth in the primary

dentition are the maxillary incisors.

Primary molars are rarely injured - when injury

occurs it is usually due to indirect trauma

blows to the underside of the chin causing

the mandible to close forcefully against the

maxilla.

Epidemiology:

Depending on the kind of injury:

In the primary dentition luxation injuries are

more common than fractures due:

to the spongy nature of the bone in young children

to the lower root/crown ratio in comparison with

that of permanent teeth.

Concussion and subluxation – are the next

most injuries

Aetiology: In a young child learning to walk and to

run, muscle coordination and judgmentare incompletely developed and fallinginjuries frequently occur.

Predisposing factors:

Malocclusion – protrusion

Most injuries are caused by falls and play accidents.

Another major cause of dental injuries in young children is automobile accidents.

Child abuse is serious cause of dental injuries to young children.

- Physical abuse. - Emotional abuse.

- Neglect. - Sexual abuse.

Important!

The permanent incisor is located palatally during its early development and in close proximity to the apex of the primary incisor.

With any injury to primary teeth, the dentist must always be aware of possible damage to the underlying permanent teeth.

A primary incisor should always be removed if its maintenance will jeopardize the developing tooth bud.

Important!

A traumatized, retained primary tooth should

be assessed regularly for clinical and

radiographic sings of pulpal or periodontal

complications.

Every 3-4 months – for the 1. year

Then annually until tooth exfoliation

Soft tissue injuries should be assessed weekly

until healed

Injuries to

the

periodonal

tissues

Concussion – description:

An injury to the tooth-supporting structures:

without increased mobility

tooth is not displaced

but with pain to percussion

without gingival bleeding.

Concussion – etiology:

The neurovascular supply is usually intact

In a few areas bleeding edema

In most areas the periodontal ligament is without

damage

No damage to the follicle or permanent tooth

germ

Diagnostic signs

➢ The signs of concussion are transient. It is not possible to

diagnose concussion if the examination is done several days after

injury.

Visual signs

Percussion test

Mobility test

Pulp sensibility test

Radiographic findings

Radiographs

recommended

Not displaced.

Tender to touch or tapping.

No increased mobility.

Not reliable in primary teeth. Inconsistent results

No radiographic abnormalities. Normal

periodontal space.

An occlusal exposure is recommended in order

to screen for possible signs of displacement or

the presence of a root fracture. The radiograph

can be used as a reference point in case of

future complications.

Treatment Guidelines

There is no need for treatment.

Only observation is needed

Clinical control at 1 week, 6-8 weeks.

PATIENT

INSTRUCTIONS

Soft food for 1 week.

as far as possible - children do not bite with teeth

Good oral hygiene.

Brush with a soft brush after every meal and apply chlorhexidine 0.1% topically to the affected area with cotton swabs twice a day for one week.

This is beneficial to prevent accumulation of plaque and debris

PATIENT

INSTRUCTIONS

Parents should be further advised about possible complications that may occur, like:

swelling,

dark discoloration of the crown,

increased mobility or fistula.

Children may not complain about pain;

however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Subluxation

An injury to the tooth supporting structures

resulting in:

➢ increased mobility

➢ pain to percussion

➢ without displacement of the tooth.

Bleeding from the gingival sulcus is evident if the

child is seen shortly after the accident.

Subluxation – etiology:

Damage may have happened to the

neurovascular supply

In many areas separation of periodontal

ligament with interstitial bleeding and edema

Some areas have undamaged periodontal

ligament

No damage to the follicle or permanent tooth

germ

Diagnostic signs

➢ The signs of subluxation are transient. It is not possible to

diagnose it if the examination is done several days after injury.

Visual signs

Percussion test

Mobility test



Radiographs

recommended

Not displaced.

Tender to touch or tapping.

Increased mobility.


Normal periodontal space.

An occlusal exposure is recommended in order

to screen for possible signs of displacement or

the presence of a root fracture. The radiograph

can be used as a reference point in case of

future complications.


There is no need for treatment.

Only observation is needed

Clinical control at 1 week, 6-8

weeks.

Treatment GuidelinesPATIENT INSTRUCTIONS


as far as possible - children do not bite with teeth

Good oral hygiene.




swelling,




however, infection may be present, and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Extrusion

Partial displacement of the tooth out of

its socket

An injury to the tooth characterized by

partial or total separation of the

periodontal ligament resulting in

loosening and displacement of the

tooth.

The alveolar socket bone remains

intact.

In addition to axial displacement, the

tooth usually will have some protrusive

or retrusive orientation.

Extrusion

Severance of neurovascular pulp supply

Separation of periodontal ligament and

coronal exposure of root surface

Usually no damage to the follicle or

permanent tooth germ

Diagnostic signs

Visual signs

Percussion test

Mobility test



Radiographs recommended

Appears elongated.

Tenderness to percussion.

Excessively mobile


Increased periodontal ligament space apically

An occlusal exposure is recommended in order to evaluate the size of the displacement and rule out the presence of a root fracture. The radiograph can be used as a reference point in case of late complications.

Treatment

The treatment choice should be based on the:

degree of displacement

mobility

root formation

the ability of the child to cope with the emergency situation.

For minor extrusion (< 3 mm) in an immature developing tooth

either careful reposition the tooth

or leave the tooth for spontaneous alignment.

Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth.

Extrusion - repositioning

The area must be cleaned with water spray,

saline

Reposition tooth with finger

Extrusion - extraction

• The area must be cleaned with water spray,

saline

• Apply local anesthesia (if necessary)

• Extract tooth


PATIENT INSTRUCTIONS


Good oral hygiene.




swelling,







Follow-up

Clinical control after 1 week.

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

Once per year until physical exfoliation of the tooth

Lateral luxation

Displacement of the tooth other than

axially.

Labial, lingual, lateral direction

Displacement is accompanied by

comminution or fracture of either the

labial or the palatal/lingual alveolar

bone.

Palatal/lingual luxation of the maxillary

incisors may result in occlusal interference

expressed by premature contact with the

opponent teeth.

Lateral luxation

No collision with permanent

tooth bud

Collision with permanent tooth

bud

Lateral luxation - Retrusion

Rupture of the periodontal ligament

Rupture of the neurovascular supply and

entrapment of the apex in the bone

Possible damage to the permanent tooth

germ

Lateral luxation - Protrusion

Rupture of the periodontal ligament

Rupture of the neurovascular supply

and entrapment of the apex in the

bone

High risk of damage to the permanent

tooth germ

Diagnostic signs Lateral luxations are complicated by fracture of either

the labial or the palatal/lingual alveolar bone and a

compression zone in the cervical and sometimes the

apical area.

If both sides of the alveolar socket have been

fractured, the injury should be classified as an alveolar

fracture (alveolar fractures rarely affect only a single

tooth).

In most cases of lateral luxation the apex of the tooth

has been forced into the bone by the displacement,

and the tooth is frequently non-mobile.

Diagnostic signs

Visual signs

Percussion test

Mobility test

Sensibility test



Displaced, usually in a palatal/lingual or labial direction

Usually gives a high metallic (ankylotic) sound

Usually non-mobile.


Increased periodontal ligament space apically is best seen on the occlusal exposure

An occlusal exposure can sometimes show the position of the displaced tooth and its relation to the permanent successor.

Treatment

• If there is no occlusal interference, as is often the case in anterior open bites, the tooth should be allowed to reposition spontaneously.

Spontaneous repositioning

• Clinical control after 1 and 2-3 weeks.

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

• Once per year until physical exfoliation of the tooth

Follow-up

Treatment

Repositioning

When there is occlusal interference local anesthesia

should be applied where after the tooth should be

repositioned by gentle combined labial and palatal

pressure.

Follow-up

Clinical control after 1 and 2-3 weeks.

Clinical and radiographic control at 6-8 weeks and 1

year.

Once per year until physical exfoliation of the tooth

Treatment

Extraction (protrusion)

For teeth with severe

displacement in a labial direction,

extraction is the treatment of

choice.

Extraction is indicated in these

cases because of the collision

between the primary tooth and

the permanent tooth germ.



Soft food for 10 – 14 days.

Good oral hygiene.




swelling,





Intrusion - Intrusive luxation

Displacement of the tooth into

the alveolar bone.

This injury is accompanied by

comminution or fracture of the

alveolar socket.

Intrusion - Intrusive luxation

No collision with permanent

tooth bud

Collision with permanent tooth

bud

Intrusion

Contusion of the periodontal

ligament and bone

Rupture of the neurovascular supply

and fracture of the labial bone

Damage to the permanent tooth

germ is frequent

Diagnostic signs

The tooth is displaced axially into the alveolar

bone and frequently penetrating the labial bone

plate where it can be palpated.

The tooth may disappear completely in the tissues

resembling avulsion and root fracture with

complete extrusion of the coronal fragment.

In this case diagnosis is based on an occlusal

radiograph.

Penetration of the tooth into the nasal cavity can

be diagnosed by bleeding from the nose or simple

observation of the nostril.

Diagnostic signs

Percussion test

Mobility test

Sensibility test


Usually give a high metallic (ankylotic) sound; in severe intrusion cases - not always possible to perform.

The tooth is non-mobile.

Not reliable in primary teeth.

When the apex is displaced toward or through the labial bone plate the apical tip can be visualized and appears shorter than the unaffected contralateral tooth.When the apex is displaced toward the permanent tooth germ, the apical tip cannot be visualized, and the tooth appears elongated.

Treatment

Spontaneous re-eruption

Follow-up


Clinical and radiographic control at 3-4 weeks, 6-8 weeks, 6-month, 1 year and yearly clinical and radiographic control until eruption of the permanent successor.

If eruption has not yet begun after 4 weeks an ankylosis may be present

Indication for extraction at a later day

Treatment

Extraction

If the apex is displaced into the

developing tooth germ.

Other indications are:

signs of swelling, spontaneous

bleeding, abscess and fever

Follow-up

Clinical and radiographic control

at 1 year

Yearly until eruption of the

permanent successor.




Good oral hygiene.




swelling,





Intrusive LuxationPrimary Teeth

One of the most dangerous

injuries to the developing

tooth bud

Management: Minimize

damage by assessing

displacement of permanent

bud

Discoloration of Primary ToothPost Trauma

Color may change 2-4 weeks

after trauma

May retain/regain vitality

and return to near normal

color within 6 months

Monitor. Esthetics may be a

concern if color does not

resolve

Color may be pink, purple,

grey or brown

Pulpal Obliteration

History of Trauma

Tooth darker-usually yellowish

Radiograph shows pulpal space

narrowing or obliterated

Radiographic

Abscess

Note:

resorption

post trauma.

Avulsion

The tooth is completely

displaced out of its

socket.

Clinically the socket is

found empty or filled

with a coagulum.

Damage to the follicle

of the permanent tooth

germ is frequent

Diagnostic signs

• Visual signs

Radiographic

findings

Radiographs

recommended

The tooth is removed from its socket.

The alveolar socket will be empty. If the

avulsed tooth is not present a

radiographic examination is essential to

ensure that the missing tooth is not

intruded.

An occlusal exposure is recommended

in order to screen for the presence of

root fragments and to make sure that

the missing tooth is not intruded.

TreatmentReplantation is contraindicated

In the initial examination all avulsed teeth are accounted for.

If not, it is recommended to make a radiographic examination in order to ensure that the missing tooth is not a case of complete intrusion or root fracture with loss of the coronal fragment.

If the avulsed tooth has not been found refer the child to the pediatrician to exclude aspiration.

TreatmentPatient instructions


Good oral hygiene.

Inform the parent about possible complications in the development of the permanent successor

especially following avulsion injuries sustained in children under 3 years of age.

Follow-up

Clinical control after 1 week

Clinical and radiographic control after 6 months and 1 year.

Yearly clinical and radiographic controls until eruption of the permanent successor.

Injuries to

hard

dental

tissues and

pulp

Enamel infraction

An incomplete fracture

(crack) of the enamel without

loss of tooth structure.

Fracture lines in the enamel

No damage to the permanent

tooth germ

Diagnostic signs

Visual signs

Percussion test

Mobility test




A visible fracture line on the surface of the tooth

Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.

Normal mobility.


No radiographic abnormalities.

Treatment

No treatment necessary

Follow-up

No follow-up is needed for

infraction injuries unless they are

associated with a luxation injury

or other fracture types involving

the same tooth.

Enamel fracture

A fracture confined to the

enamel with loss of tooth

structure.

Fracture restricted to enamel

No damage to the



tooth germ

Diagnostic signs

Visual signs

Percussion test

Mobility test




Visible loss of enamel. No visible sign of exposed dentin.

Not tender. If tenderness is observed evaluate the tooth for a possible luxation or a root fracture.

Normal mobility.


The enamel loss is visible

Treatment

Smooth sharp edges.

In patients with lip or cheek

lesions it is advisable to search

for tooth fragments or foreign

material.

Clinical and radiographic

controls after 3-4 weeks

Follow-up

No follow up required.

Enamel-

dentin fracture

A fracture confined to enamel

and dentin

with loss of tooth structure

not involving the pulp.

No damage to the



tooth germ

Diagnostic signs

Visual signs

Percussion test

Mobility test



Visible loss of enamel. No visible sign of exposed pulp tissue.

Not tender. If tenderness is observed evaluate the tooth for a possible luxation or a root fracture.

Normal mobility.


The enamel loss is visible. The distance between the fracture and the pulp chamber can be evaluated.

Treatment

Clean the area with water spray,

saline

As an emergency treatment GIC can

be applied as temporary coverage

Restore with composite after 1 month

(GIC must be removed)

Follow up

Clinical and radiographic controls

after 6-8 weeks and 1 year

Complicated

crown fracture

A fracture involving enamel and dentin

with loss of tooth structure and exposure

of the pulp.

No damage to the neurovascular supply

No damage to the permanent tooth

germ

Diagnostic signs

Visual signs

Percussion test

Mobility test




Visible loss of enamel and dentin and exposed pulp tissue

Not tender. If tenderness is observed evaluate the tooth for a possible luxationinjury or a root fracture.

Normal mobility.


The loss of tooth structure is visible.

An occlusal exposure is recommended in order to screen for possible signs of displacement or the presence of a root fracture. The radiograph can be used as a reference point in case of future complications.

Treatment

Pulp capping

Partial pulpotomy

Extraction

❑ The treatment is depending on the child's maturity and ability to cope.

❑ Extraction is usually the alternative option.

Follow-up

➢ Clinical after 1 week.

➢ Clinical and radiographic control after 6-8 weeks and 1 year.

Crown-root fracture without pulp involvement

A fracture involving enamel, dentin and

cementum with loss of tooth structure

but not involving the pulp.

Enamel-dentin fracture extending below

the gingival margin



germ

Diagnostic signs

Visual signs

Percussion test

Mobility test




Crown fracture extending below gingival margin. The crown is split into two or more fragments, one of which is mobile.


At least one coronal fragment is mobile. Because of mobility during mastication there might be transitory pain.


Apical extension of fracture usually not visible. In laterally positioned fractures, the extent in relation to the gingivalmargin can be seen.

An occlusal exposure.

Treatment

• Most of these may be redirected to later treatment.

Depends on the clinical

findings - two treatment

scenarios may be considered.

• If the fracture involves only a small part of the root

• The stable fragment is large enough to allow coronal restoration,

• Remove the mobile fragment.

Fragment removal only

• Extraction in all other instances.Extraction

Treatment



Good oral hygiene.




swelling,





Treatment

Follow-up

❑ In case of fragment removal only:


Clinical and radiographic control after 3-4 wks.

Clinical control after 1 year.

❑ In case of tooth extraction:

Clinical and radiographic control at 1 year

Every year until eruption of the permanent successor.

Crown-root

fracture with

pulp involvement

Enamel-dentin fracture with pulp

involvement extending below the

gingival margin



Diagnostic signs

Visual signs

Percussion test

Mobility test




Crown fracture extending below gingival margin. The crown is split into two or more fragments, one of which is mobile.


At least one coronal fragment is mobile. Because of mobility during mastication there might be transitory pain.


Apical extension of fracture usually not visible. In laterally positioned fractures, the extent in relation to the gingival margin can be seen.

An occlusal exposure.

Treatment

Extration:

Follow-up



Root fracture

A fracture confined to the root of the

tooth involving cementum, dentin, and

the pulp.

The neurovascular supply is usually intact

at tooth apex


germ

Rupture of neurovascular supply at

fracture line

Separation of PDL and exposure of root

surface

Diagnostic signs

Visual signs

Percussion test

Mobility test




The coronal segment is usually mobile and may be displaced. Transient crown discoloration (red or grey) may occur.

The tooth may be tender.

The coronal segment is usually mobile


The fracture is usually located mid-root or in the apical third.

An occlusal or periapical exposure.

Treatment

No treatment

If the coronal fragment is not displaced no treatment is required.

Extraction

If the coronal fragment is displaced - extract only that fragment.

The apical fragment should be left to be resorbed.

Root FracturesPrimary Teeth

Apical 1/3

Most teeth maintain vitality and are

minimally mobile

Apical fragment should

resorb normally

Monitor with radiographs

Root FracturesPrimary Teeth

Middle or Cervical 1/3

Most teeth mobile.

Extraction indicated

Gently attempt to retrieve apical

fragment

If not successful, monitor

Don’t disrupt permanent tooth

bud

Treatment



Good oral hygiene.




swelling,





Treatment

Follow-up


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

In case of tooth extraction:



Alveolar fracture

A fracture of the alveolar process

which may or may not involve the

alveolar bone 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.

Dento- alveolar...2020/03/23 · Dento-alveolar trauma: In children is distressing for both child...

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Transcript of Dento- alveolar...2020/03/23 · Dento-alveolar trauma: In children is distressing for both child...