DANYLO HALYTSKIY LVIV NATIONAL MEDICAL UNIVERSITY

Pediatric Dentistry Department

Methodical works

for practical lessons

ON ORTHODONTICS

V Year, IX Semester

Lviv - 2014

Methodical works were developed by:

Chuhkray N.L., Assoc. Prof., Cand.Sci (Med)

Leshchuk S.E., Assist. Prof.

Skybchyk O.V., Assist. Prof.

Kostura V.L., Assist. Prof.

Morozova N.P., Assist. Prof.

Sementsiv Kh. G., Assist. Prof.

Chief Editor: Elvira V. Bezvushko, Assoc. Prof., Doct.Sci (Med)

Reviewed by: O. R. Ripetska., Assoc. Prof., Cand.Sci (Med)

O. Ya. Matvijchuk ., Assoc. Prof., Cand.Sci (Med)

L. Yu. Smolska, Assoc. Prof., Cand.P. S.(Med)

Considered and approved by the Methodical Commission of the Dentistry Faculty

(Head R.Z. Ohonovskiy), (protocol № from 24.12.14 )

THEMATIC PLAN

Practical Lessons on Orthodontics

(5th

Year, 10th

Semester)

№ Theme Hours

1.

Etiology of defects of teeth and dental arches in children, their frequency among

child’s population. Preventive measures. Peculiarities of examination of children with

defects of teeth and dental arches. The aim, clinical and biological substantiation of

prosthetics in children.

7

2.

Traumatic injuring of teeth in children, their classification and diagnostics.

Peculiarities of trauma in children, possible complications, orthopedic treatment.

Determination of the terms of orthopedic treatment and rationale constructions of

appliances. Constructions of dentures for children for restoration anatomical form of

teeth (inlays, pin teeth, peen cores and crowns). Indications for their application.

7

3.

Rationale constructions of bridge dentures in children. Peculiarities of their

fabrication. Importance of periodontal tissues state of the supporting teeth in

determination of the denture construction. Indications for partial removable dentures

fabrication in children. Peculiarities of their construction, methods of fixation, order

of replacement, possible complications and their causes. Requirements to materials,

which are used for making of child's prosthetic appliances.

Indications for complete removable dentures fabrication in children. Peculiarities of

their construction, methods of fixation, order of replacement, possible complications

and their causes. Requirements to materials, which are used for making of child's

prosthetic appliances.

7

4.

Etiology, pathogenesis, diagnostics and prevention of congenital face clefts.

Classification of congenital clefts of oro-facial region. Organization of preventive and

medical help for children with clefts of the upper lip, alveolar bone, hard and soft

palate. Role of orthodontic treatment and rehabilitation of such patients. Possible

complications and their prevention.

Method of orthodontic appliances fabrication in cases of clefts of lip, alveolar bone,

hard and soft palate (preformative correcting plate, floating obturator of complex

construction, orthodontic appliances).

7

5.

Orthodontic appliances, their classification. Peculiarities of construction of the

mechanical-active fixed appliances. Peculiarities brace-system application.

Peculiarities of construction of the mechanical-active removable appliances

(expanding appliance, Osadchyi’s appliance, Doroshenko’s appliance).

7

6.

Peculiarities of construction of the functional-directing appliances (Schwartz’s splint,

Bunin’s splint, removable appliance with occlusal plates). Their application.

Peculiarities of functional-active appliances construction (Andresen-Hauple

monoblock, Frankel’s regulator of functions I-IV, Balter’s bionator, twin-blocks,

Klampt’s activator). Their application. Preventive appliances. Trainers.

7

7. Clinical examination of orthodontic patients. Classification of malocclusions (Angle,

Kalvelis, Khoroshilkina, WHO). Six key of normal occlusion by Endrews. Estimation 7

of previous diagnosis. Filling in medical history. Functional methods of examination.

8.

Anthropometric method of investigation: craniometry, photometry, measuring of the

diagnostic models by Pont, Korkhaus. Determination indices by Tonn and

Dolgopolova. Measuring of the width and length of the dental arches, sizes of the

apical bases by Snagina. Determination of the space deficit in the dental arch for an

anomalously located tooth. Determination the segments of the dental arches by

Gerlah, drawing the diagram of Hawley-Herber-Herbst.

7

9.

Roentgenologic methods of investigation: intraoral roentgenography,

orthopantomography, hand-wrist X-ray. Teleroentgenography (Cephalometry).

Analyzing of the teleroentgenograms by Schwarz.

7

10. Summary module control 3

Whole 66

TYPES of SELF - WORK for students

and its control for MODULE № 3

on Orthodontics: “Prosthetics in children”

(5th

Year, 10th

Semester) (20 hours)

№

Тема занять

Hours

Types of

control

1. Preparation for the practical, seminar lessons (theoretical,

mastering of the practical skills)

Themes: №№ 1 - 20

16

On the

practical

lessons

2. Preparation for the summary module control (SMC) 4 Summary

Whole: 20

ТHEMATICAL PLAN OF LECTURES

Module №3. Prosthetics in children (4 hours)

№

Theme of lecture Hours

1.

Clinical and biological substantiation of the prosthetics in children. Causes of teeth

defects and defects of the dental arches in children, their prevention. Peculiarities of

determination of masticatory effectiveness. Fixed constructions of dentures for

children (crowns, inlays, pins, bridges), indications for their fabrication.

2

2.

Removable constructions of the dentures in children (partial and complete).

Indications for their application, peculiarities of their construction, types of their

fixation, terms of replacement, possible complications.

2

Methodical works №1

Causes of defects teeth and dental arches, their

frequency among children. Preventive measures.

Pecualiarities of examination of children with defects of teeth and dental arches. The aim of

childrens’ prosthetics, its clinical and biological substantiation.

The aim: to study students to reveale the defects of teeth and dental arches, to substantiate the

necessity to restore the crown of teeth and entire dental arch in children, to ptactice the methods of

examination of children with defects of teeth and dental arches.

Pre-study test questions:

1. The main causes of teeth defects formation.

2. Causes of premature loss of prmary teeth.

3. Morphological disturbances after loss of the primary teeth.

4. Functional disturbances after loss of the primary teeth.

5. Pathogenesis of secondary deformation occlusion formation in the case of dental arches

defects.

Content of the practical class.

At the beginning of class, the teacher points out that the complete dentition during all

period of primary dentition is important for physiological development of masticatory apparatus.

We know that children without teeth, especially in the frontal area, try not to laugh,cover their

mouth with the hand while talking. Defects of teeth and dental arches are found in all age periods

and characterized by different values and localization. The frequency of dental arches defects in

children increases with age and in 6-year-olds is 14,7%. In the 11-12 year-old children dental arches

defects cuased by to premature loss of the primary teeth are found in 37-40% of patients. The

frequency of teeth defects and defects of the dental arches depends on medical and geographical

conditions of the region residence.

The main reasons for defects of teeth and dental archesdentition are:

- dental caries and its complications - 78 %;

- traumatic injuries of teeth - 12 %;

- hypoplasia and fluorosis - 6 %;

- adentia - 3 %;

- inflammatory diseases and tumors of the jaws - 1%.

There are 4 stages of tooth destruction and disturbance of entire dental arches dentition :

1- partial defect of the tooth crown without damage of the pulp;

2 - significant or complete defect of the tooth crown with pulp damage as a result of dental caries

and its complications, severe forms of hypoplasia or dental fluorosis, trauma;

3 degree – defects of the dental arch with loss of 1-2 teeth;

4 degree - defects with loss of 3 or more teeth and a complete lack of teeth.

From carious destruction often suffer primary molars and first permanent molars. Defects

of chewing surfaces of the crowns lead to decreasing the occlusion height, dentoalveolar

enlongation of the antahonisys,

deviations in the region of the frontal teeth, changes of occlusion and periodontal tissues state.

Such diviations mostly appeared during the period of change of teeth, when the first permanent

molars hold the height of the occlusion height.

Destruction of the approximal surfaces of the crowns of primary and permanent molars leads to :

- mesial displacement of the teeth,

- shortening of the dental arch,

- incorrect position of individual teeth, their retention,

- malocclusion .

As a result of carious destruction of the frontal teeth children have problems with biting,

swallowing, speech, the child begins to lisp. After the early loss of primary molars the biodynamic

balance between the tongue and cheeks takes place, specific habits appears, including laying tongue

between the dental arches in the region of the defect, tongue sucking.

Interocclusal location of soft tissue holds eruption of the permanent teeth and can promote

development of deep bite. Loss of the primary teeth teeth more than 1 year prior to the period of

physiological change is considered as premature teeth loss. If the period of the defect appearance

and its replacement is longer, the deformation and functional deviation is more pronounced

abnormalities. Due to the active growth of child’s organisn developmental deviations of dento-

alveolar region occur in a short periods of time and are severe pronounced.

Timely sanation of the oral cavity in children is an important measure that prevents the

development of appearance and development of described disorders. Prevention of unfavourable

consequence

of tooth decay consist of the prevention of its development, restoration of the anatomical shape of

the teeth crowns with restorations, inlays, crowns. After the premature loss of teeth chosen method

of treatment: replacement dentition defect by prosthetic or orthodontic treatment , combined with

prosthetics .

Prevention of adverse consequences of dental caries is to prevent its development,

restoration of the anatomical shape of teeth crowns with fillings, inlays, crowns. After the

premature loss of teeth the method of treatment should be chosen: replacement of the dental arch

defect by prosthetic or orthodontic treatment, combined with prosthetics.

Prevention of consequences of the premature loss of permanent teeth

As discussed in the etiology of orthodontic irregularities, permanent first molars of poor quality and

uncertain prospects located in the lateral segment of the dentition are usually extracted. Decision as

to whether to extract these teeth or retain them in the arch should be made in time.

If permanent first molars in the crowding dentition are to be extracted at the age of 8 – 9

years, the basic irregularity of the dentition will usually improve. In addition, the permanent second

molar will erupt after the mesial shift without inclination into a contact with the second premolar.

At older age, it is suitable to extract permanent first molars if the crowding of the premolar segment

of the dentition is extensive. Erupting premolars will accommodate the place of the extracted

permanent first molar, and the permanent second molar will not be endangered by adverse mesial

inclination.

Unlike the above-mentioned knowledge, the extraction of permanent first molars is not

recommended in the following cases:

there is enough space in the dental arch,

the aplasia of the second premolar,

cover bite

The extraction of permanent first molars in the upper jaw is not suitable in the presence of edge-to-

edge bite or interocclusion. In such a case, the extraction of upper permanent first molars is

associated with a risk that the reverse bite will be formed or will deteriorate (if present) and that the

abnormal anteroposterior relationship of dental arches will become more distinct.

On the other hand, the extraction of lower permanent first molars is not recommended in

the case of normal occlusion and distal occlusion. This would deepen the occlusion and increase the

incisal ledge.

When a permanent tooth is lost, it is necessary to take into account the subsequent

extrusion of an antagonist, until the gap closes. Gap closure can be accelerated by the recontouring

of dental cusps adjacent to the gap, to make guiding surfaces which help the motion of teeth into the

gap, as required.

The early loss of permanent front teeth requires cooperation of paediatric dentist, practical

dentist and orthodontist and prosthetic technician.

In such cases, the therapeutic plan is developed before the eruption of the permanent

canine and is based on the gap closure by shifting adjacent teeth (which is more suitable for a

patient) or on the maintaining of the gap in the dental arch, if the permanent canine in the dentition

has already erupted.

With the former variant of the therapeutic procedure, the shifted teeth will be fitted with

full-cover crowns whose size and shape correspond to those of the teeth that are missing in the

dental arch and that were displaced by the shifted teeth.

In the latter variant, the gap is maintained using a spacer until the adult age where it is

treated using a prosthesis. In some clinics, removable plate spacers indicated for a period of the

development of the dentition are replaced with adhesive bridges after the eruption of permanent

canines.

When the development of the dentition is completed (i.e. after the eruption of permanent

second molars), it is advisable to replace the removable plate spacer for a removable spacer to

enable the dentomucosal transmission of chewing pressure. Such a spacer consists of a reduced

chromium-cobalt plate which bears artificial teeth and is attached to the dentition by means of

three-arm clamps.

An examination of children with teeth defects and and defects of the dental arches was

carried out by the generally accepted method. Particular attention is paid to the period of dentition,

the number of erupted teeth acoording to the age, determine how much time is left to the

physiological replacement of primary teeth by the permanent teeth. During damaging of the tooth

by caries process determine the size of the cavity, its location, the presence of inflammation in the

pulp and periodontium.

When the defect of the dental arch is present dentist pay attention to it:

- location;

- size ;

- the alveolar process in this area;

- the presence of deformation of the dental arches and occlusion.

Indications for dental prosthetics specify using X-ray examination of the alveolar process,

orthopantomography or radiography of jaws. Assess the location and extent of follicles of the

permanent teeth, availability of space for them in the dental arch, the possibility of it preservation or

creation.

The need to preserve primary teeth in children is necesary due to their important role in

occlusion formation, in particular:

- formation occlusion height;

- correct formation of the dental arches;

- providing the normal development of the jaws ;

- timely and proper eruption of thr permanent teeth, correct development of the next

functions - speech functions,chewing, swallowing;

- prevention of dento-alveolar deformations in the form of shortening of the dental arch,

dentoalveolar elongation, teeth inclination into the side of the defect.

Prevention of the teeth follicles movement plays an important role in the occlusion

formation. Thus, restoring the integrity of teeth and dental arches provides saving of the correct

function of dento-alveolar system and prevent deformation of occlusion. Timely prosthesis prevents

occurrence of bad habits and provides a physiological and harmonious formation of oro-facial area

of the child.

Comrehensive conrol

Causes of premature loss of dental hard tissues.

1. Causes of defects of dental arches in children.

2. The purpose of children prosthesis.

3. Describe the morphological deviationd in dento-aleolar region in the case of

loss of one tooth.

4. Describe the morphological deviationd in dento-aleolar region in the case of

loss of frontal teeth.

5. Describe the morphological deviationd in dento-aleolar region in the case of

loss of chewing teeth.

6. Describe the morphological deviationd in dento-aleolar region in the case of

complete adentia.

7. Prevention of defects of teeth and dental arches.

8. Peculiarities of examination of children with defects of tetth and debtal arches.

Tests

1. A 7,5-year-old boy came to dentist with complains on the mobility. During intraoral

examination it was revealed that 52 tooth is mobile due to the physiological resorbtion.

Dentist made a mistake. He made extraction of the 53 tooth beside the 52 tooth. What

changes can be expected in this case?

A. Asymmetry of the dental arch with shift of the upper central line to the right, anomaly of

position of the 13 tooth in the future

B. Changes won't be present

C. Asymmetry of the dental arch with shift of the upper central line to the left, anomaly of

position of the 13 tooth in the future

D. Shortening of the dental arch from the left, anomaly of position of the 13 in the future

E. Protrusion of the upper frontal teeth

2. Parents of a 9-year-old girl came to the dentist for the examination of their daughter. In the

medical card the dentist marked the next received data: the absence of the primary upper

first molars. What changes can be expected in this case?

A. Changes won't be present

B. Asymmetry of the dental arch

C. Disturbance of the form of the dental arch

D. Shortening of the dental arch

E. Protrusion of the upper frontal teeth

3. A 4,5-year-old girl came to visit the dentist. During examination the absence of the primary

lateral incisors was revealed. Primary canines and molars are intact. What morphological

changes can be expected in nearest future in this case?

A. Shortening of the dental arch

B. Disturbance of the form of the dental arch

C. Asymmetry of the dental arch

D. Morphological changes won't be present

E. Changing of the vertical size of the dental arch

4. A 4-year-old girl with infantile type of swallowing is on the clinical review of orthodontist.

Premature loss of what teeth can be the cause of this harmful habit?

A. Central and lateral primary incisors

B. Second primary molars

C. All primary molars

D. Primary canines

E. First primary molars

5. The 54 and the 55 teeth were extracted in a 5-year-old child. The rest of the teeth are intact.

For what morphological changes the premature extraction of these teeth can lead for?

A. Shortening of the dental arch

B. Elongation of the dental arches, the first permanent molars won't be in normal

relationship

C. Expansion of the dental arch

D. Delay of the jaw growth

E. Expansion of the dental arch, the first permanent molars won't be in normal relationship

6. During preventive examination in the kinder garden some children with missed primary

molars, canines and incisors were revealed. Thus some of children have other stomatological

diseases. Define, what from the enumerated is not contraindication for making prosthesis for

children.

A. Presence of carious cavity on the occlusal surface of the 54 tooth

B. Diseases of mucous membrane in the oral cavity

C. Psychical disorders in the child

D. Allergy to material of prosthetic appliance is made from

E. Multiple caries, complicated caries

7. The absence of the 54 and the 64 teeth was revealed in a 6-year-old girl. What possibilities

have teeth that are located from the both sides of the defect of the dental arch?

A. To move to the direct of the defect

B. To move in vestibular direction

C. To leave on their place for a long time

D. To turn around their own axis

8. The 9-year-old boy came to the dentist with his parents. During the intraoral examination

the absence of the 53, 64 and 75 teeth was revealed. Which complication can be expected in

a case of premature loss of these teeth in the child of such age?

A. Shortening of the dental arches changes in the relationship of the first permanent molars

B. Protrusion of the frontal upper teeth

C. Retrusion of the frontal upper teeth

D. Elongation of dental arches, changes in the relationship of the first permanent molars

E. Expansion of the dental arches

9. Parents of the 7-year-old girl came to the dentist with the aim of the preventive examination

of their daughter. Extraoral sighs are without changes. Data of intraoral examination:

premature extraction of the 64 and the 65 teeth is noted. What pathological changes will be

developed in the child without any treatment?

A. Mesial movement of the 26 tooth, extrusion of the 74 and the 75 teeth

B. Distal movement of the 26 tooth

C. Extrusion of the 74 tooth

D. Extrusion of the 75 tooth

E. Distal movement and vestibular position of the 26 tooth

10. Parents of the 9-year-old child came to the dentist with complaint on the partial defect of the

lower dental arch. What factors more often can lead to the premature loss of teeth?

A. Caries and its complications

B. Traumatic tooth injuring

C. Hypoplasia and fluorosis

D. Processes of inflammation character and tumors

E. Adentia

Literature:

1. P.S.Flis, S.І.Тril, V.P.Vosnul. Prostheti dentistry. - Kiev. –2010. – «Medicine». – P. 7-15;

40-65.

2. Bezvushko E.V., Chukhray N.L. Textbook of orthodontics (for 3rd

year course students). –

Lviv, 2008. – 87 p.

Methodical works №2

Traumatic injuring of teeth in children, their classification and diagnostics. Peculiarities of

trauma in children, possible complications, orthopedic treatment. Determination of the terms

of orthopedic treatment and rationale constructions of appliances. Constructions of dentures

for children for restoration anatomical form of teeth (inlays, pin teeth, peen cores and

crowns). Indications for their application.

The aim: to study classification of the traumatic injuring of teeth in children, terms of orthopedic

treatment and rationale constructions of appliances.

Pre-study test questions:

1. Anatomical peculiarities of primary teeth in children.

2. Terms of eruption of the primary teeth in children.

3. Terms of eruption of the permanent teeth in children.

4. Terms of root formation of the permanent teeth in children.

5. Periods of active growth of the jaw.

6. Morphological changes after loss of the primary teeth.

7. Functional changes after loss of the primary teeth.

8. Disturbances in dento-alveolar system after loss of the frontal teeth.

9. Disturbances in dento-alveolar system after loss of the posterior teeth.

Content of the practical class.

Injury to both the primary and permanent teeth and the supporting structures is one of the

most common dental problems occured in children.

Researchers have shown that 30% of school children suffer traumatic dental injury in the

primary dentition and 22% - in the permanent dentition. Therefore, just over 50% of children will

sustain a traumatic dental injury before leaving school.

Trauma to the dentition should always be considered an emergency situation. It occurs

frequently and results in functional and esthetic disturbances accompanied by concern from both the

patient and the parent. The dentist’s responsibility is to act objectively and efficiently in such a

situation.

Etiology

Trauma to the dentition can be either direct or indirect. Direct trauma occurs when the

dentition is struck by one of a variety of objects such as a hard ball, stick, or a fist. Indirect trauma

is produced by sudden forceful closure of the mandibular teeth with their maxillary opponents as

may follow a blow to the chin in a fall, a fight, or road accident.

The etiology of the various types of dental trauma is, to a large extent, dependent on age.

The age and the type of trauma experienced can be divided into well-defined sections.

Age 18 Months to 2 Years

The age from 18 months to 2 years is an important time in the child’s development. He is

discovering and exploring his environment. The ability to stand unsupported has not been perfected,

and locomotive movement is provided by crawling on hands and knees. Children at this age are

notoriously adventurous and inquisitive, resulting in many traumatic incidents, fortunately mostly

of a trivial nature. In the primary dentition, injury is usually confirmed to the supporting structures,

resulting in displacement or avulsion of the tooth rather than fracture of the crown or root.

Age 2 to 5: The Toddler Stage

At the beginning of the period between the age of 2 and 5, the child is just learning to walk

and is very unsteady on his feet. This may result in a fall injury to the anterior teeth. Quite often the

child is taken to a park where there are swings, slides, and the like. A common cause or dental

injury in this setting is the swing.

At this stage the child’s oral cavity is just about on the same level as the average swing seat.

Often, the child will stand in front or behind a moving swing and will receive the full force of the

blow at the level of the teeth, resulting in their fracture or displacement.

Between 5 and 10 Years

At the stage between the ages of 5 and 10, the child has reached school age, and playground

accidents are very common. These accidents tend to be falls, characterized by a high frequency of

crown fracture. Also, it is the time to learn to ride a bicycle, to roller skate, and to ice skate. Falls

from bicycles and skates cause multiple crown fractures with associated soft tissues injuries to the

upper lip and chin.

The Teenage Years

Injuries during the teenage years tend to be due sporting activities, especially contact sports

such as soccer, baseball, football, basketball, and hockey.

Road Traffic Accidents

Facial injury owing to road traffic accidents is frequently seen in the late teens. In such an

accident the passenger next to the driver is often thrown forward and may contact the windshield,

causing lacerations of the soft tissues of the lip and chin.

The driver and the front seat passenger are not most risk, especially if seat belts are not

worn. The trauma experienced is typified by soft tissue and bony injuries as well as damage to teeth

due to contact with the windshield, dashboard, or steering wheel. Young children in rear seats are

particularly at risk. If no restraint is worn, they can be thrown around the car interior in an accident,

resulting in severe total body injury.

Predisposing Factors to Dental Trauma

Mentally handicapped

A high proportion of mentally handicapped individuals sustain dental injuries. Many

mentally handicapped people also are epileptic and suffer from repetitive seizures, some of a violent

nature. During these seizes, violent contact with objects may be unavoidable, resulting in repetitive

trauma to the dentofacial complex.

Malocclusion

A class II, division I malocclusion on a skeletal II base with protruding upper incisors and

incomplete lip closure indicates that the upper front teeth are one of the most prominent features,

next to the nose, on the face and are especially prone to trauma in a fall or accident. Dental injuries

are twice as frequent in children with a protrusive malocclusion than those who have not. Early

orthodontic treatment for these children may prevent a great deal of traumatic distress.

Mechanical Factors

The energy of impact of an object is related to the mass and velocity. Tooth resiliency

depends on the nature and direction of the blow and whether it is transmitted through soft tissues.

The shape of the impacting object and the direction of the force it applies are other mechanical

factors determining the type and severity of the resultant injury. In general, a high-velocity, high

mass impact usually results in coronal fracture. Low-velocity, low-mass impacts usually give rise to

root fractures and subluxations.

Dental Anomalies and Caries

Hypoplasia, either chronologic or local, is a quantative defect of enamel that results in a

weakening of the crown structure of a tooth. Any trauma to a tooth can cause fracture of the crown

in the area of hypoplasia. Extensive caries can weaken tooth structure so much that even slight

trauma will result in fracture of the tooth through the line of weakness.

Injuries to the Tooth

Crown

A crack or craze of the enamel without loss of tooth structure can be horizontal or vertical

(Fig.1-A).

Fracture of the crown can be enamel only (Fig.1-B); involving enamel and dentine (Fig.1-

C); or enamel, dentine, and pulp Fig.1-D).

Fig. 1 (A) Enamel crazing. (B) Crown fracture involving enamel. (C) Crown fracture involving

enamel and dentine. (D) Crown fracture involving enamel, dentine and pulp.

The fracture can be either horizontal (Fig.2-A); vertical (Fig.2-B); or oblique (Fig.2-C).

Fig.2 A) Horizontal crown fracture (B) Vertical crown fracture. (C) Oblique crown fracture.

Fracture of the crown and root involving cementum may have pulpal involment

or no pulpal involment (Fig.3-A and B).

Fig. 3 (A) Crown root fracture involving cementum. (B) Crown root fracture involving cementum and

pulp.

Root

Fracture of the root can involve the apical third (Fig. 4-A), the middle third (Fig. 4-B), or the

cervical third.

Fig. 4 (A) Apical third root fracture. (B) Middle third root fracture. (С) Cervical third root fracture.

Fig.5 Root fracture (A) Horizontal root fracture. (B) Oblique root fracture

Entire tooth

Concussion. A mild blow to the teeth may result in injury only to the periodontal membrane, so

“concussion” the tooth. The tooth may be sensitive to touch and tender to percussion. No mobility or

displacement will be observed.

Subluxation. More severe blow may result in more drastic injury to the periodontal membrane

resulting in tooth mobility. Any displacement is not observed.

Displacement. Various types of displacement can result from trauma:

Intrusion—displacement of the tooth into the socket (Fig 6-A);

Extrusion—partial displacement of the tooth out of its socket (Fig 6-B);

Labial displacement—displacement of the tooth labially (Fig. 6-C);

Linguopalatal displacement—displacement toward the tongue/palate (Fig. 6-D);

Lateral displacement—displacement of the tooth mesially or distally (Fig. 6-E);

Avulsion—complete loss of the tooth from its socket (Fig. 6-F).

Fig. 6. (A) Intrusive tooth displacement. (B) Extrusive tooth displacement. (C) Labial tooth

displacement. (D) Linguopalatal tooth displacement. (E) Lateral tooth displacement. (F) Avulsion.

Classification of Traumatic Injuries to the Supporting Bone

Fracture of the alveolar socket due to tooth intrusion— a crushing injury to the bony socket

(Fig. 7-A).

Socket wall fractured either labially or lingually/palatally (Fig. 7-B).

Fracture of the alveolar process (Fig. 7-C).

Fracture of the maxilla

Fracture of the mandible

Fig. 7 (A) Crushing injury to bony socket. (B) Labial fracture of socket wall. (C) Alveolar fracture.

MEDICAL HISTORY, EXAMINATION, AND DIAGNOSIS

History taking and examination are fundamental aspects of clinical dentistry in making

diagnosis, but in the treatment of traumatic injuries to the dentition and supporting structures.

History taking begins at the interview and should include (1) personal data, (2) symptoms, (3)

relevant medical history, (4) previous dental history, (5) neurological assessment, and (6) history of

traumatic injury and accident details.

Personal Data

Personal data should include the patient's name, age, sex, address, source of making referral

if any, and reason for attendance.

Symptoms

Both general and local symptoms should be noted. There may be injury to other parts of the

body such as limb fracture or lacerations and contusions, which require specialized medical

treatment. Hence, inquiry into symptoms emanating from other parts of the body is essential.

Local symptoms may be elicited by specific questions:

(1)Is there any spontaneous pain from any of the teeth?

(2)Is there any sensitivity to pressure on eating or touch?

(3)Is there any mobility or change in the way the teeth are occluded?

(4)Do temperature or sweet or sour food cause pain?

Relevant Medical History

Routine history taking must include a good, accurate medical history to make the dentist

aware of any relevant facts that may necessitate modifying the treatment. Essential questions that

must be asked when taking a medical history follow.

Has the patient been under medical treatment recently or at the present time? This is a useful

question, because hopefully any medical problems can be elicited at this time. The historian may

miss something vital, hence, further probing is essential.

Has the patient ever suffered from rheumatic fever? A positive response to this question is

becoming increasingly rare in young people. Rheumatic fever may cause heart valve damage, and in

such cases prophylactic antibiotic therapy is needed for any blood-producing procedures. Also,

administration of antibiotics is necessary because of the trauma itself to reduce risk of bacterial

endocarditis. Consultation with the patient's physician is recommended.

Does the patient have any heart complaint? If valvular problems exist or there is a prosthetic

valve present, antibiotic prophylaxis is essential to prevent bacterial endocarditis. The patient's

physicain must be contacted to establish the severity of the problem, the need for antibiotic

prophylaxis, and relevant dosage and type.

Does the patient suffer from any allergies? In particular, it is essential to determine penicillin

allergy because this will affect the type of antibiotic given. Some children suffering from allergic skin

diseases such as eczema may be taking steroid medication. Long-term steroid therapy will cause

adrenal atrophy and a reduced stress tolerance. It is necessary to be aware of any steroid therapy and

the dosage and period of such therapy. In conjunction with medical advice, steroid cover may be

required in such cases to avoid adrenal crisis, especially after a stressful experience such as

dentofacial trauma.

Does the patient have any chest complaints? Many young people suffer from asthma, and

often steroids are prescribed for these patients. Additional steroid cover may be required to avoid

adrenal crisis.

Is the patient on any medication? The usage of tranquilizers and antidepressants is more

common in the adult than the child. The question is really aimed at determining whether the child is

on steroids or current course of antibiotics.

What is the child's current immunization status? If dirt has been introduced into a wound,

information on status of tetanus immunization is important. Tetanus cover (antitetanus toxoid)

should be given if booster shots are not up to date.

Does the child see a doctor regularly? Many patients are very poor historians. Only by

repetitive questioning will any relevant information be gained. If the patient and/or parent is

suspected of holding back information, the dentist must question repeatedly until satisfied that all

important information has been given.

Previous Dental History

Information can be obtained on the frequency of dental visits and the type of work performed

such as extractions and conservation. The type of anesthetic used for the procedures can be determined.

Any untoward complications should be noted, and the cooperativeness of the patient may be

determined.

If the patient regularly attends your office, all relevant information will be available in his or her

chart, and you should know your own patient very well.

Neurological Assessment Damage to the cranial nerves may be associated with both minor and major trauma to parts of

the craniofacial-oral complex. Before any definitive diagnosis or treatment, a quick initial patient

assessment, based on observation, must be made to determine whether neurological damage has

occurred. This can be done by observing the patient from the moment he or she enters the office.

A list of signs and symptoms suggestive of neurological damage is given in a table.

Table 1. Signs and Symptoms Suggestive of Neurological Damage

№ Signs and Symptoms Suggestive of Neurological Damage

1 Inability of the patient to walk or stand unsupported

2 The patient appears lethargic or confused

3 The presence of lacerations, abrasions or contusions

4 Facial discoloration, e.g., "black eye"

5 Unusual verbal response to questions

6 Nausea or vomiting

7 Headache

8 Bleeding or discharge of clear fluid from the ears or nose

9 Abnormal position and/or movements of the eyes

10 Perspiration on the forehead

11 Asymmetric or decreased reactions of the pupils

12 Abnormal respiration rate

A triad of symptoms can follow head injuries in young children: irritability, vomiting, and

lethargy. The symptoms may or may not be associated with loss of consciousness and usually subside

within 48 to 72 hours.

If there are any suggestions of neurological damage, a more detailed neurological

examination must be performed, which will require the child to be hospitalized. This must take

precedence over treatment of the dental trauma. Following the initial visual assessment, a detailed

history of the traumatic injury and accident details is taken. Such a verbal history also enables the

dental surgeon to see how well the child can recall the details of the trauma, thereby complementing

the neurological assessment.

History of Traumatic Injury and Accident Details

Histories should be short and to the point. Rambling accounts are to be avoided. Only three

questions need to be asked to obtain maximum information: when, where, and how?

When did the accident occur? In cases of oral trauma with damage to the teeth, time is very

important. If there is avulsion of the tooth or the need to resposition a tooth or treat a fractured crown

in which the pulp has been involved, the shorter the time between accident and treatment the better if

viability of the tooth is to be maintained.

Where did the accident occur? If the incident occurred in a particularly dirty environment,

prophylactic tetanus treatment is indicated. The whereabouts of the accident may be important if

liability for the accident has to be determined for legal purposes.

How did the injury happen? This information will give a guide as to what type of injury to

suspect, weapons that may have been used to produce the injury, and the possibility of child neglect,

for legal purposes. A child may fall while sucking an object and will possibly suffer dislocation of

the anterior teeth palatally. A direct blow under the chin may cause a fracture in the condylar region

and fracture of molar and premolar crowns. For young children, when there is a marked discrepancy

in clinical findings and the history given, then child abuse should be suspected.

Clinical Examination

Extraoral

The extraoral examination begins immediately the patient enters the office. Initial signs of

neurological involvement can be noted (Table). The general appearance of the patient, that is, height,

build and the way in which he or she moves, is easily observed. The patient may limp or give the

impression of being in pain. The presence of subconjunctival hemorrhage indicates a fracture of the

zeugmatic complex (Fig.).

Lacerations, abrasions, and contusions on the face, head, neck and exposed limbs can

visually be noted . Other notable points are lumps, bumps, and asymmetries including any deviation

in mandibular path on mouth opening. Extraoral wounds should be inspected for foreign bodies, and

the size and position of foreign objects in the body should be noted on a drawing for permanent

record if any questions arise, legally, when healing has occurred.

Leakage of straw-colored fluid from the nose indicates a middle third maxillary fracture. The

patient should be referred to a maxillofacial surgeon if fracture of the maxilla, zeugmatic complex, or

mandible is suspected.

Intraoral Examination

It must be remembered that children who have recently sustained traumatic injuries will be in

a state of emotional distress. When examining such a patient, it is important to record all relevant

findings in one attempt if at all possible. Repeated efforts will only increase the child's anxiety and

will make the examination procedure progressively more difficult.

The procedure for intraoral examination should follow the following set order: (1) the soft

tissues, (2) the hard tissues in general, (3) the hard tissues specifically.

4) gingivae, labial and buccal mucosa. Examine the tongue for penetrating wounds, usually in the

distal aspect. The presence of embedded tooth fragments should always be suspected in this case.

Move tongue to one side, and inspect the floor of the mouth. A hematoma in the floor of the mouth

indicates mandibular fracture. Note any bleeding from the periodontal membrane.

Hard-Tissue Examination in General. Note any occlusal abnormalities, and in addition

palpate the maxilla and mandible for firmness to determine the extent of any alveolar process or

mandible fracture. Also note any obvious caries, existing restorations, and the general overall

condition of the mouth. This gives an idea of the general dental awareness of the patient.

Hard-Tissue Examination Specifically. Here the results of the trauma to the teeth should be

described in detail.

Displacement. Teeth may suffer labial, lingual, palatal, or lateral displacement as well as

intrusion, extrusion, or avulsion. Visually determine and note any displacement. If an intrusion or

extrusion is measured, this should be done in millimeters to avoid any confusion.

Mobility—Horizontal and Vertical. To determine the presence of abnormal horizontal

mobility, place a mirror handle or finger on the labial aspect of the tooth. Place a finger on the palatal

aspect, and gently apply alternating pressure buccally and palatally. Determine vertical mobility by

applying gentle pressure to the incisal of occlusal surface of the tooth. Testing for horizontal mobility,

two or more teeth are seen to move, an alveolar fracture should be suspected.

Root Fracture. The presence of a root fracture is more difficult to determine clinically, and the

use of radiograph is mandatory for accurate diagnosis. To examine root fracture, place fingers against

the linguopalatal and buccolabial mucosa, and attempt to move the teeth. If independent movement of

crown and root is detected, then root fracture has occurred.

Type of Fracture. Note the type of fracture sustained by the teeth, using the descriptive

classification described previously.

Color Change. Nonvital teeth often appear discolored. This is due to an interruption in the

blood supply to the tooth. The blood, already present in the pulp chamber, undergoes the normal

breakdown process, but the products are unable to dissipate. This results in tooth discoloration

varying from gray-brown to black. Tooth discoloration post-trauma is indicative of nonvitality.

Special Investigations. Special investigations are used to confirm or re-enforce a clinical

diagnosis and should not themselves be used in isolation. Diagnosis from special investigations alone

is a mistake that is too commonly made. The most useful special investigative tool available to the

dental surgeon is the radiograph.

Radiographs

Teeth. All traumatized teeth should be radiographed. Radiographic investigation should reveal the

following:

the stage of root formation,

the presence of any root fracture,

the presence of periapical radiolucencies,

injuries to the supporting periodontal membrane, such as the degree of intrusion or extrusion of the

tooth,

the size of the pulp chamber,

presence of tooth fragments or foreign bodies in the soft tissues.

Three exposures should be taken to accurately diagnose dislocation of a permanent tooth. A

traumatized anterior region should be covered by one occlusal and three periapical exposures where

the central beam is directed between the lateral and central incisors and the two central incisors.

An ideal radiograph to identify root fracture is the occlusal view. Position the beam so that it

passes obliquely through the tooth and so in line with the fracture. However, the fracture will only be

visible if the central beam is within a maximum angular deviation of 15° to 20° from the fracture

place. If a fracture is suspected, take two more periapical views, one at an angulation of 15° more than

the original occlusal view and one 15° less. Often, root fractures can be missed on radiograph

immediately following trauma, possibly because of hemorrhage or soft tissue interposition. Mis-

direction of the central beam may cause an appearance of multiple or ellipsoidal root fractures. If a

misdiagnosis is suspected, take another radiograph at a different angulation. Actual multiple

fractures tend to show an irregular shape on radiograph rather than the smooth outline seen with a

beam misdirection.

Root fractures are usually obliquely positioned to the long axis, and the main beam should be

directed into the fracture line. A bend in the film will often give the impression of a root fracture

when there is none. To avoid this misdiagnosis the periodontal membrane should be traced, and any

interruption in continuity indicates a film fault. The view should be retaken.

Tooth fragments in the lip can be demonstrated by placing a film in the buccal or labial

sulcus using a short exposure time or low kilovoltage.

If teeth are missing and no accurate history of their whereabouts can be as certained, it is

advisable to refer the patient to a hospital for chest radiographs in case of inhalation.

If a jaw fracture is suspected, extraoral radiographs are indicated. The panoramic and lateral

oblique views are very useful and can be taken in the dental office. For more sophisticated

radiographic investigation, the patient should be referred to a hospital radiography department.

Vitality Testing

In order to obtain a full evaluation of the injury, vitality testing of the teeth must be

performed. The basic principle in this testing is the conduction of various stimuli to the pulp and the

subsequent reaction. A positive response indicates that the pulp is alive and well whereas a negative

response (e.g., no response) indicates pulp death. Vitality testing just following traumatic injury is

of little value because false responses often occur. The initial reading immediately post-trauma

should not be taken as a one-and-only guide to vitality. Further testing should be performed at

subsequent visits.

There are basically three types of vitality testing:

thermal,

electric,

mechanical.

Thermal. Thermal tests, that is, the use of hot and cold stimuli to elicit tooth vitality, have

been used for many years. The various methods include the use of :

ethyl chloride,

heated gutta percha,

Ice,

carbon dioxide snow.

Thermal testing, although relatively simple (not requiring sophisticated instruments), has some

disadvantages. (1) Thermal testing is not easily reproducible in terms of reaction intensity. (2) False

readings can be obtained. Thermal testing on nonvital teeth using heat as the reaction-producing

medium can cause expansion of fluids in the pulp space, producing pressure pain. Similarly, a

false-negative reaction can be obtained on vital teeth.

Types of Thermal Tests.

Heated gutta percha is one of the most common and inaccurate tests used. It is an easy,

convenient test, but false readings often occur. A review for thermal vitality testing that attempted

some standardization was advocated by Mumford.

A stick of gutta percha is held with 5 mm of one end resting in a flame. It is held there for 2

seconds, and then the heated end is applied to the buccal, middle third of the crown of the tooth

under investigation. Reaction to the test indicates a positive response and vitality of the tooth.

Ethyl chloride is a highly volatile anesthetic liquid. It takes its latent heat of vaporization

from its surroundings, producing a very cold area in its immediate vicinity. A pledget of cotton is

saturated with the liquid, and to help increase the rate of evaporation the cotton is circulated (wafted

around) in the air until a "frosting" appears. The cotton pledget is now cold enough to elicit a

response when placed on the buccolabial aspect of the crown of the tooth. The intensity of sensation

reported by patients is not reproducible, and inaccurate responses occur, although not as frequently

as with gutta percha.

Ice, as a test application, is not reliable. Reaction depends on time; that is, a period of 5 to 8

seconds can increase the sensitivity to this test. A cone of ice is applied to the buccolabial surface of

the crown of the tooth. A reaction indicates vitality of the tooth.

Carbon dioxide snow has a temperature in the region of — 78°C to — 108°F. This low

temperature makes testing with this substance reliable and consistent. Testing may also be done

through a splint or stainless steel crown. The low temperature has disadvantage in that small cracks

may be caused in the enamel.

Electrical Vitality Testing. An electric current is passed through the tooth under

examination, eliciting a painful response or uncomfortable feeling indicating vitality. The

instrument used for testing is essentially a rheostat so that a varying strength of current can be

delivered to the tooth.

The method of testing is as follows:

Inform the patient as to what sensations may be experienced and to indicate by raising a hand when

these sensations are felt.

Air dry the tooth and isolate it with cotton rolls.

Place the electrode as the tester on the tooth as far away from the gingivae as possible, that is, on the

incisal edge of the crown or incisal third of the buccolabial aspect of the crown. The circuit is

completed by touching the patient's mouth with a mouth mirror.

Advance the dial on the tester continuously until a response occurs.

Usually, the dial is calibrated numerically from 1 to 10, and the numeric value of the initial

response should be noted. Tolerance to stimulus does occur; hence, the increase in current must be

quick and continuous. Once the response occurs, stimulus duration should be as short as possible,

that is, the electrode should be removed immediately.

Response Considerations. In general, terms the more current (and therefore the higher

numeric value on the tester dial) that must be passed through the tooth before a response is observed

the poorer the prognosis. Immediately following trauma, the sensitivity response of a tooth

decreases, and this is especially so in cases of luxation. However, normality returns after a few weeks.

Teeth react differently at different stages of root formation, and quite often vitality testing of erupting

non-injured teeth can give a negative result until the erupting stage is complete or the root fully

developed. Also, teeth undergoing orthodontic movement can be hypersensitive. Regular vitality

testing of injured teeth is essential to accurately determine vitality or returning vitality.

Mechanical Vitality Testing. Cutting a test cavity in the tooth without local anesthetic

provides evidence of vitality. This method is, however, slightly drastic in its concept, because in

some cases, pain reaction is not noted until the pulp is nearly reached.

With crown fractures of the enamel and dentine, ran a probe over the exposed dentine, and

note the response. Similarly, if the pulp is involved, test vitality by gentle probing or placement of a

pledget of cotton soaked in saline on the exposure. Probing of exposed pulp is not really advised,

because quite possibly further damage can be caused.

If a logical sequence of events has been followed, (i.e., history taking and examination), a

clear diagnosis can now be reached, and the treatment for the injury in both short- and long-terms

can be planned.

TRAUMA TREATMENT (PERMANENT DENTITION)

Crown Fracture

A CRACK OR CRAZE OF THE ENAMEL WITHOUT LOSS OF TOOTH STRUCTURE

Horizontal or vertical crack or craze lines in enamel do not require immediate treatment. Injury to

the blood supply and supporting structures may have occurred, and so vitality testing should be

performed at regular intervals to monitor any changes.

FRACTURE OF ENAMEL ONLY

Horizontal, vertical, and oblique fractures of the crown involving enamel only or enamel and a

very small part of dentine can be treated either by leaving them alone or selective contouring. The

main objective is to smooth down any jagged edges to prevent irritation of the lips or tongue.

Maintain periodic vitality testing.

FRACTURES INVOLVING ENAMEL AND DENTINE

Immediate treatment of horizontal, vertical, or oblique fractures of the crown is required to

protect the pulp and restore esthetics and function.

It is necessary to cover the exposed dentine by a layer of hard-setting calcium hydroxide.

This is to encourage secondary dentine formation. Protection for this dressing can be achieved

temporarily using of a stainless steel crown, orthodontic band, or more permanently by acid-etch

composite resin.

Stainless Steel Anterior Crowns

Although not too esthetically pleasing, the stainless steel anterior crown restoration (Fig.1) is

extremely sturdy, durable, and a very good retainer for the calcium hydroxide dressing. For many

years the stainless steel crown was the only quick and effective restoration for a crown fracture

involving enamel and dentine on a semi- permanent basis. The crown has now largely been

superseded by the acid-etch composite resin restoration. The main drawback of the stainless steel

crown is esthetic. It is a useful restoration in cases where the fracture is close to the gingival margin

and isolation is difficult. When the fracture is horizontal and the restoration likely to be subjected to

occlusal stresses, the strength of the stainless steel crown is a great advantage.

Fig. 1 Stainless steel crown on an upper central incisor.

To improve esthetics a labial window can be cut with a diamond bur in an air turbine. Smooth the

edges with a green stone. Use a thin layer of composite material in the window (Fig.2). Conduct

regular testing to monitor vitality.

Fig. 2 Stainless steel crown with labial window. Immediately following trauma the tooth may give a negative vitality response. This can last

up to 7 months before a vital response is noted. The crown should remain in place until a vital

response is noted or for 8 weeks if a vital response is initially elicited. The crown can then be

replaced by a more permanent restoration.

Acrylic and Polycarbonate Crowns

Acrylic and polycarbonate crowns overcome the poor appearance of the stainless steel crowns. After

placement of the calcium hydroxide liner over the exposed dentine, select a suitable celluloid or

polycarbonate crown form, and trim and fit it. Fill the form with acrylic resin, fit it, and trim away

the excess. After polymerizing the crown remove and finish it. Perform cementation using either

zinc oxide eugenol or polycarboxylate cement.

Orthodontic Bands

Preformed orthodontic bands are useful as temporary matrixes for the dressing covering the

exposed dentine (Fig.3 ). Select the appropriate band, and cement it onto the tooth using zinc oxide

eugenol cement.

Fig.3 Orthodontic band as temporary matrix for a dressing

Acid-etch Composite Resin Restoration

Provided that adequate dentine protection has been obtained, there is no risk to the pulp from the

acid-etch technique, and hence, an acid-etch composite resin restoration can immediately be

inserted post-trauma. The temporary restorations described previously are becoming obsolete in

favor of the more permanent composite restoration.

The light-cured microfil composite resins are ideal for anterior restorations, having excellent

esthetic qualities. They have good color stability over the long-term and can be polished to a high

finish.

The Primary Dentition Fractures of the crown involving enamel and dentine in the primary dentition can usually be

treated by grinding any rough enamel edges. If considerable tooth structure has been lost, then

treatment with composite resin or stainless steel crown is advocated. Unfortunately, because of lack

of co-operation with child, choice treatment may be extraction.

Crown Fractures Involving Enamel, Dentine, and Pulp

PERMANENT DENTITION

The treatment of this type of fracture depends on:

the size of pulpal exposure;

the stage of development of the root apex;

the vitality of the pulp.

The main objects of treatment are to:

retain the tooth;

maintain its vitality, if at all possible, in order to allow root apex closure; and

ensure root apex maturity by chemical means.

The following procedures may be adopted to accomplish the preceding objectives: (1) pulp

capping, (2) pulpotomy, (3) pulpectomy, (4) apexification.

PULP CAPPING

Pulp capping involves placing a hard-setting calcium hydroxide over the pulp exposure. Pulp

capping is indicated in the following cases:

The exposure is confined to a small area.

Hemorrhage from the pulp has been minimal.

The pulp has not been exposed for more than a few hours.

Root fracture is not present.

Techinque. Isolate the tooth under a rubber dam, and cover the exposed pulp and dentine with

hard-setting calcium hydroxide. The tooth can now be restored with a stainless crown or acid-etch

composite resin.

Pulp capping is only suitable for small exposures, and there is some risk of failure. Even with a

minute exposure, infection of the pulp is inevitable, and pulp tissue varies from patient to patient in

the amount of inflammation it can withstand. However, patient co-operation can often make this the

only treatment feasible.

Fig. 4 Crown fracture involving enamel, dentine, and pulp in a tooth with an immature apex.

PULPOTOMY

When there is a large exposure of the pulp in a vital tooth with an immature apex (Fig. 4),

pulpotomy is the treatment of choice. This procedure removes infected pulp tissue, leaving vital,

noninfected pulp tissue capable of completing apex formation.

Technique. Using a traumatized incisor as an example, achieve conventional endodontic

access to the pulp chamber through the palatolingual aspect of the tooth. Rubber dam isolation is a

prerequisite. Remove the coronal pulp either by using a sharp currette or spoon excavator. Use of a

large, round bur, running slowly in reverse, has been advocated but may leave radicular pulp in an

inflamed state on completion of the amputation (personal communication). Control bleeding from the

amputated pulp by applying a cotton pellet for 30 to 60 seconds. When bleeding ceases, place calcium

hydroxide in contact with the pulp. Protect calcium hydroxide with a zinc oxide eugenol cement or

polycarboxylate cement (Fig. 5), and place a composite restoration to restore esthetics and function.

The purpose of pulpotomy is to retain vital radicular pulp tissue so that closure of an immature apex

can naturally occur. Pulpotomy should only be regarded as a first step to pulpectomy and root canal

filling. If the calcium hydroxide is left, there is a danger of dystrophic calcification.

Restoration of esthetics and function can be achieved by an acid-etch composite restoration.

Regular radiographic follow-up is essential to monitor apical closure or any pathologic changes that

may occur.

CALCIUM HYDROXIDE, ZINCOXIDE OR POLYCARBOXYLATE CEMENT

Fig. 5 Pulpotomy procedure.

APEXIFICATION

Should a crown fracture occur and expose a necrotic pulp, and if the tooth has an incomplete apex,

apexification must be initiated before permanent root filling can be achieved.

Technique. Obtain access to the pulp chamber under rubber dam isolation. Conduct

instrumentation of the canal to approximately 0.5 mm short of the radiographic apex. Fill the canal

with calcium hydroxide paste, which is usually supplied in commercially prefilled syringes. Insert the

needle into the canal to the working length, and inject the paste as the needle is slowly withdrawn

(Fig. 6).

Fig. 6 Apexification procedure.

Seal the canal with a cement such as poly-carboxylate cement over a cotton pledget. Changing

the calcium hydroxide every 3 months is recommended until apexification is achieved. When there is

radiographic evidence of closure, insert a permanent root filling. The various procedures for the en-

dodontic treatment of pulpally involved crown fractures are summarized in Table .

Endodontic Treatment of Incisors with Crown Fracture Involving the Pulp

Tooth status Treatment

Vital

Open apex Pulpotomy

Closed apex Pulp cap or root filling

Nonvital

Open apex Apexification

Closed apex Root filling

Treatment of Crown Root Fractures

Crown root fractures are those fractures involving the enamel, dentine, and cementum, with or without

pulp exposure. These fractures are some of the most frustrating and technically difficult to treat. This

type of fracture is usually caused by falls, road accidents, or foreign bodies striking the teeth. Most

commonly, the fracture occurs obliquely from the incisal edge to below the gingival crevice.

Displacement of the crown is minimal, which can easily cause the fracture to be overlooked.

In fractures of the crown and root where the fracture follows the long axis of the tooth, or the

coronal fragment is more than one-third the clinical root length, extraction is the only treatment.

CROWN ROOT FRACTURE WITHOUT PULPAL INVOLVEMENT

In crown root fractures without pulpal involvement where the fracture line of the crown extends

only about 2 mm below the marginal base level, a restoration is possible. Perform reattachment of

the periodontal membrane and deposition of cementum on dentine does occur in these cases.

Administer a local anesthetic, and isolate the crown fragment under rubber dam. Then remove the

crown fragment using a sharp scalpel to dissect the fragment from the attached periodontal

membrane. Some bleeding will occur, but it is easily arrested with pressure or adrenaline.

Cover the exposed dentine to the gingival crevice with hard-setting calcium hydroxide, and place a

temporary crown with its margin above gingival level. Alternatively, an acid-etch composite

restoration can be placed as a more permanent restoration but must be finished to above gingival

level. Approximately, 2 months are required for re-attachment of periodontal fibers.

CROWN ROOT FRACTURE WITH PULPAL INVOLVEMENT

Immature Tooth With an Open Apex. Pulpotomy is the treatment of choice. Using local

anesthetic isolate the tooth under a rubber dam, and fuse the mobile coronal segment to the stable part

of the tooth by acid-etch composite resin. Use conventional access to the pulp chamber, and perfom

a pulpotomy procedure.

Retention of the mobile coronal fragment is advocated rather than its removal for the

following reasons:

(1) When the fragment is removed, hemorrhage can obscure the operator's view.

(2) Isolation may be difficult because of lack of remaining tooth substance.

(3) The patient's own crown is used as a temporary restoration to minimize operating time and

maintain normal esthetics.

Regular radiographic review enables monitoring of these teeth. Once apex closure occurs,

insert a permanent root filling, and prepare the tooth for a post and crown as the final restoration.

Closed Apex. Essentially, the treatment for the closed apex is the same as for a tooth with an

open apex. After fixing the mobile coronal segment with an acid-etch composite resin, perform a

pulpectomy and root filling. An added reason to maintain the mobile segment of the crown rather

than its removal is to be able to use the whole crown as a reference point for reaming and filling

when performing endodontic therapy. After successful endodontic therapy, prepare the tooth for a

cast post and porcelain crown.

If the fracture extends substantially down the periodontal membrane, problems can occur in

providing the permanent restoration. In order to expose the fracture surface it may be necessary to

proceed with a gingivectomy and bone removal. A cast post can be constructed to compensate for

tooth substance loss and a porcelain crown inserted as a final restoration.

Treatment of Crown Fractures Involving Enamel, Dentine, and Pulp

in the Primary Dentition It must be remembered that trauma to the dentition of a child is traumatic not only to the

child but the parents as well. The incident may affect the parents far more seriously than the child.

With crown fractures involving the pulp in the primary dentition, root canal therapy and

restoration with composite resins are quite possible. A mummifying pulpotomy procedure is

advocated to prevent damage to the developing permanent tooth. However, patient co-operation

may be such that extraction of the traumatized tooth is the only treatment possible. Consideration

must also be given to the limited life of a primary tooth.

Treatment of Root Fractures Root fractures are unusual in the primary dentition, but when they occur, the patient's age is

usually 3 to 4 years, when resorption of the roots has begun.

In the primary dentition simple fractures of the apical third are left without treatment.

Fractures of the middle third can be splinted with composite to promote a cementum bridge. Teeth

with fractures of the coronal third should be removed with the root fragment.

In the permanent dentition root fractures mainly affect the maxillary central incisors and are

the most common in patients between the age of 11 and 20. Below 11 years of age, the root is in its

formative stage and more resilient to trauma.

The healing of root fractures occurs in one of four ways.

Healing by calcified tissue, a bridge of dentine and cementum (Fig. 7-A).

Interposition of connective tissue separating the two fragments (Fig. 7-B).

Interposition of bone and connective tissue (Fig.7-C).

Interposition of granulation tissue (Fig. 7-D).

Fig. 7 (A) Healing of root fractures by calcified tissue. (B) Connective tissue. (C) Bone and

connective tissue. (D) Granulationtissue

The approach to treating teeth with root fractures is essentially the same as that of treating

bony fractures; that is, the fracture is reduced and then fixed or stabilized until the healing process is

complete.

Fractures of the Apical and Middle Third Inevitably, with these types of fractures there will be displacement of the fractured crown-

root segment, usually palatally or lingually. Under local anesthetic, achieve reduction into position

by digital pressure, and stabilize the tooth or teeth in this position by splinting. Check the position

radiographically after reduction .

SPLINTING

The purpose of splinting is to stabilize the tooth in the arch in order to prevent further damage to

the pulpal and periodontal tissues. Splints can be fixed or removable. Properties of an ideal splint:

It should be quick and easy to produce.

It should be atraumatic to the teeth and gingivae.

There should be adequate stability throughout the healing period.

There should be access for endodontic therapy if needed.

The splint should be as esthetically pleasing as possible.

Fixed Splints. The acid-etch resin composite splint.

Clean the labial surface of the affected tooth and neighboring teeth as thoroughly as possible,

using cotton pledgets and a water spray so as not to further disturb the injured tooth.

Etch the incisal half of the labial surface of the tooth and neighboring teeth with an acidified

gel, as there may be gingival bleeding. Place unfilled resin bonder on the teeth, and polymerize the

resin. Place more filled resin on the labial surface of the teeth, and allow the resin to polymerize.

Finally, trim the material, smooth it, and leave it in place for 2 to 3 months. A rectangular

arch wire fitted to the arch form may be easily incorporated to give greater stability of the splint.

During this time the tooth must be observed radio-graphically and regularly vitality tested. If

symptoms of nonvitality become apparent, then initiate endodontic treatment immediately. With the

apical third fracture only, treat the coronal segment. Surgical removal of the apical fragment is usually

delayed until clinical or radiographic evidence of pathology is present. With the middle third fracture,

endodontic treatment of both fragments can be carried out, uniting the two together (Fig.8). If

treatment of both fragments is impossible, then endodontic treatment of the coronal part only and

subsequent removal of the apical segment, if and when pathology develops is an alternative (Fig. 9).

After removal of the apical segment, an endodontic implant can be considered to improve stability of

the tooth (Fig.10). These implants are prefabricated and used in conjunction with standard endodontic

canal instruments. The long-term prognosis for these implants is doubtful.

Other materials used in conjunction with the acid-etch technique are cold-cure acrylic resins

such as Serviton (AD International, DeTrey Division, Weybridge, England) and the epimine resins such

as Scutan and Protemp (ESPE, Selfeld, West Germany).

Fig. 8 Cervical third root

fracture united by endodontic

treatment.

Fig. 9 Endodontic treatment of

coronal part only

Fig. 10 Removal of apical

third with endodontic

implant.

Before application of any splinting material, exposed dentine must be protected by a hard-

setting calcium hydroxide cement. Instructions to the patient are to use the front teeth as little as

possible. Removal of the splint is by tapered fissure bur run at slow speed, thinning the resin and

cutting interproximally. Remnants can be flicked off. One of the advantages of Scutan is that it can

be removed relatively easily.

Other types of fixed splinting that can be considered are (1) orthodontic brackets and wire

splint (Fig. 11); (2) interdental wiring (Fig. 12); (3) arch wire and resin splint (Fig.13); and (4) full

arch, vacuum-moulded acrylic splint (Fig. 14).

One of the disadvantages of the full-mouth acrylic splint is that an impression must be taken.

This can dislodge the already loose tooth.

A technique for taking impressions to minimize the dislodging effect is to place a probe on

the incisal edge of the tooth, so maintaining the tooth in position. Alternatively, tin foil can be

placed on the crown. This acts as a temporary splint, and then the impression may be taken.

Fig.11 Orthodontic brackets and wire splint Fig. 12 Interdental wiring.

Fig. 13 Arch wire and resin splint Fig. 14 Full-arch vacuum-moulded acrylic splint

Silver Cap Splints. In the past silver cap splints were used extensively (Fig. 15), but now

there is very little indication for them except in case of fractured jaws.

Fig. 15 Silver cap splint.

Removable Splints: Sved Type. This splint is a removable appliance fabricated in acrylic. It

is constructed so that the acrylic extends over the occlusal or incisal surface of the tooth in question,

thereby fixing and stabilizing the tooth.

Fractures of the Coronal Third

For fractures of the coronal third, reduce and immobilize by splinting. If healing is

uneventful then no further treatment is required. Should pulp necrosis occur or failure to heal, one

must carry out endodontic treatment. The proximity of this fracture to the gingival crevice makes

pulpal infection more probable.

Remove the coronal segment, and complete the endodontic treatment. After removal of the

coronal segment, the remaining root will be difficult to restore, and so to improve the situation, vertical

orthodontic extrusion may be required.

ROOT EXTRUSION

Prepare the root canal for a post to be inserted in two-thirds of the canal length. Use heavy

orthodontic wire, cement it into the canal, and bend it in the form of a hook occlusally (Fig. 16 ).

Attach a horizontal wire to the labial surfaces of adjacent teeth by acid-etch enamel-bonded resin

directly or by orthodontic brackets. Place elastics under the hook and over the wire, resulting in a

vertical force (Fig. 17).

Fig. 16 (A) Hook cemented into root canal. (B) Clinical picture.

Fig. 17 (A) Force applied to the hook to provide vertical movement. (B) Clinical picture.

Check the patient regularly, and when the hook reaches the horizontal wire, stabilize the

extruded root for 8 weeks to allow the periodontal membrane to stabilize and reattach. Extrusion is

usually completed in 2 to 4 weeks.

The extruded root surface can occlusally be prepared for the final restoration of cast post and

porcelain crown.

If gingival overgrowth has occurred, performing a givectomy is necessary to restore gingival

contour before final restoration. Place a temporary crown, and bond it to adjacent teeth to maintain the

contour during the healing process. It must be remembered that the extruded surface available for the

final restoration will be smaller in diameter than is usual and must be compensated for in the final

restoration.

Treatment of Injuries to the EntireTooth

CONCUSSION

A mild blow to the tooth resulting in mild sensitivity requires slight or any treatment. Adjustment

to the occlusion might be made at time of examination with regular vitality testing at subsequent

visits.

Subluxation. With mobility of the tooth but without displacement, there is often hemorrhage

around the gingival margin of the tooth, and the tooth may be sensitive to percussion. The treatment

in the permanent dentition is similar to that of the concussed tooth. If mobility is extensive, splint

the tooth using the acid-etch splinting technique. Periodic reviews every 3 to 4 weeks are essential

to monitor for abscess formation and loss of vitality.

Displacement Intrusion. An intruded permanent tooth can be treated in one of three ways:

if immature, the tooth will erupt spontaneously;

immediate surgical repositioning, splinting, and endodontic therapy;

orthodontic extrusion and repositioning.

Complications such as external root resorption and loss of marginal bony support do occur in

surgically repositioned teeth. A far better success rate has been achieved with orthodontic

repositioning slowly over 3 to 4 weeks.

Adapt a wire to this noninjured tooth, and retain the wire by acid-etch composite resin. Bond a

bracket to the crown of the intruded tooth, and loop an elastic from wire to bracket, resulting in a

vertical force that extrudes the tooth. Endodontic therapy can be performed when there is adequate

crown available.

Extrusion. Reposition an extruded tooth by digital pressure on the incisal edge, returning the

tooth to its original position. Delay in treating the tooth may result in its being fixed in its extruded

position. After repositioning, maintenance of position is by splinting. If vitality of the tooth is lost,

begin root treatment immediately, placing calcium hydroxide in the canal for 6 months to 1 year

followed by more permanent filling.

Labial, Lingual, and Lateral Displacement

Supporting bone fractures are associated with labial, lingual, and lateral displacement. The

displacement must be reduced with digital pressure and splinted. Lacerated gingiva should be

repositioned around the necks of the teeth and sutured. If endodontic treatment becomes necessary,

fill the root canals with calcium hydroxide for 6 months to 1 year, and then place a permanent

filling.

Guidelines for the splinting period for displaced teeth are listed.

Isolated injury to the periodontal ligament: 2 to 3 weeks

Injury to the periodontal ligament plus bone fracture: 3 to 4 weeks

Large displaced bony fracture: 6 to 8 weeks

During the splinting period good oral hygiene must be maintained. Careful tooth brushing and

rinsing with an antiseptic mouthwash may be prescribed.

Treatment of the Avulsed Tooth Avulsion can occur both in the primary and permanent dentitions. In the permanent dentition

avulsion of the maxillary central incisors is the most common in the age group 7 to 10, during the

eruptive phase. The types of trauma causing avulsion tend to be fight and sport injuries while in the

primary dentition it is falls against hard objects.

There are two important factors to be considered in cases of avulsion:

(1) the time interval between injury and treatment,

(2) the conditions under which the tooth or teeth have been stored.

The treatment of choice, for permanent teeth, is immediate replantation or within 30 minutes

of injury. If this is not possible then replantation, after storage in a suitable medium, must be performed

within 1 hour of injury. The tooth must be kept moist to prevent irreversible damage to the periodontal

membrane. Replantation in the primary dentition is contraindicated because such procedure may

damage the permanent successor.

In many cases the initial patient contact is by phone. A disturbed parent will contact the dentist

reporting a traumatic incident and avulsion of a tooth. It is essential to advise the parent then and there

as to what procedures follow.

(1) The tooth should be located.

(2) The tooth should be rinsed under running tap water with the plug in the sink. Under any circumstances

should the root be scrubbed or scraped. Soap and alcohol as cleaning agents are contraindicated. It is

important to stress that the tooth should be handled by the crown only. Often, parents are not aware of

what the crown of a tooth looks like, so it should be described, that is, the short, white part, not the

long, pointed, yellow part with blood on it.

(3) After rinsing, insert the tooth back into the socket; it should be the mirror image of the contralateral

tooth.

(4) The patient should gently occlude on a gauze or handkerchief for stability and should be transferred to

the dental office as soon as possible.

If replantation is not possible for any reason, then a suitable storage medium should be found,

and the tooth should be placed in it. The suitability of the storage medium depends on pH and osmotic

pressure, which if correct will ensure the viability of the cells of the periodontium. The media to store

avulsed teeth, in order of preference, are: (1) milk, (2) saliva, (3) contact lens solution, (4) unsalted

water.

If no storage medium is available, other than saliva, the tooth should be placed in the mouth

between cheek and gum or under the tongue. Once at the dental office, replantation can be effected,

making sure that information on current tetanus immunization is obtained. Stabilization of the tooth in

the socket is obtained by acid-etch composite resin splint. It is desirable not to splint rigidly for an

extremely long period to avoid post-replantation ankylosis or resorption. One week is usually sufficient

to obtain adequate periodontal support.

In the permanent dentition if the avulsed incisor is nonretrievable, construct a partial prosthesis

initially to prevent space loss, pending more permanent bridging later. Regular monitoring of the

replanted tooth is desirable because root resorption is, unfortunately, a very common complication.

Types of Root Resorption With surface replacement a small area of

the root surface shows superficial resorption

which is self-limiting, showing spontaneous

repair (Fig. 18).

Fig. 18 Superficial root resorption

ANKYLOSIS

With ankylosis there is external

resorption of the root surface, characterized by a

loss of normal periodontal space and a

replacement of root surface by bone (Fig. 19).

This can be seen radiographically at 6 weeks to

4 months postreplantation. Clinically, the tooth

becomes mobile, and a high metallic sound may

be elicited on percussion.

Transient external resorption may occur

where the preceding findings are seen but

disappear in 6 months. Hence, teeth exhibiting

ankylosis should be observed for 1 year before

extracting.

Fig. 19 Replacement of root surface by bone.

Soft-tissue replacement is characterized

radiographically by the presence of bowl-shaped

radiolucencies where root resorption has

occurred and has been replaced by soft tissue

(Fig.20). This can be seen as early as 2 weeks

postreplantation. The tooth will be loose and

possibly extruded with a percussive sound

similar to that in ankylosis. There is no treatment

for these complications other than extraction of

the tooth.

Fig. 20 Replacement of root surface by soft tissue.

ROOT TREATMENT

Root treatment should always be performed on avulsed teeth with closed apices. The question

is whether to complete the treatment while the tooth is avulsed or replanted. Extraoral root

treatment has been shown to harm the periodontal membrane. Therefore, endodontic treatment

initiated 1 to 2 weeks after replantation is advocated in order to prevent postreplantation complica-

tions.

When the apex is open and replantation has occurred within 1 hour postinjury,

revascularization of the pulp may occur, and so waiting is justified. Radiographic monitoring will

show any root changes; if they occur, root treatment should be immediate, filling the canal with

calcium hydroxide. Timing is important because root resorption can rapidly progress .

Factors influencing root resorption are:

the length of time the tooth is out of the mouth,

the presence of periodontal tissue—the presence of tissue reduces the tendency of the root to resorp.

Unfortunately, 74% to 96% of replanted avulsed teeth undergo root resorption. With care,

however, some teeth will last and maintain their integrity and function.

Displacement Injuries in the Primary Dentition

Treatment for displacement injuries in the primary dentition depends on the degree of

mobility and interference with the occlusion. The range is from doing little to reducing and fixing to

extraction. With intrusion injuries teeth intruded over one-half their clinical crown length should be

extracted. With intrusion lengths less than this, teeth may be allowed to erupt spontaneously. In all

cases extraction may be the only treatment of choice due to unco-operation.

CONSEQUENCES OF TRAUMA IN THE PRIMARY DENTITION TO THE

PERMANENT DENTITION

Unfortunately, trauma to the primary dentition can have an adverse effect on the permanent

dentition ranging from white or brown marks on the permanent crown (Fig. 21); localized enamel

hypoplasia on the permanent crown (Fig.22); dilaceration of the root; odontomelike formations (Fig.

23); and partial reduplication (Fig. 24). All are caused by pressure from the primary root impinging

on the developing permanent crown.

Fig. 21 White patches on a permanent premolar. Fig. 22 Localized enamel hypoplasia

Fig. 23 Odontomlike crown formation. Fig. 24 Partial reduplication

Parents must be advised of the consequences of the trauma to their young child, and the

developing permanent dentition must regularly be monitored .

Electrical Burns of the Oral Cavity in Children

Electrical burns of the oral cavity in children constitute about 4% of burns experienced among

children. The burns are usually caused by young children, under the age of 3, chewing on electric

cables plugged into the various domestic appliances at home. The commissures of the mouth are

frequent sites of the burns and can unilaterally or bilaterally be affected. (Fig. 25).

Fig. 25 Unilateral electrical burn to commissure of the mouth. Sometimes the tongue and hard palate may be involved. Tissue is burned by thermal

changes at the exit and entrance of the current, and the heat can be in the range of 2,500 to 3,000°C.

The injury can be superficial or severe. Superficial burns involve mucosa, submucosa, and

some muscle. Severe burns include associated nerves and vascular tissue.

The burn has a coagulated or charred appearance of gray white tissue surrounded by a

narrow rim of erythema. Swelling in the area is evident for 7 to 10 days. The necrotic tissue can

slough off within a few days but it is usually complete within 2 to 4 weeks. Complications include

cardiac arrest, secondary shock, and bleeding from the labial artery. Bleeding can be controlled by

pressure or ligation. Bleeding may not occur until some time post-trauma. Therefore, hospitalizing

the patient until the necrotic tissue sloughs off is advisable. This type of burn is extremely

disfiguring and causes functional impairment. Studies have shown that the majority of patients

experience slightly or any pain after the initial injury but feelconsiderable discomfort due to loss of

control of the lip, resulting in drooling and inability to masticate efficiently.

Management of Electrical Burns

The management approach depends on the degree of tissue destruction, which is

interdependent on the quality, intensity, duration, and location of the electrical stimulus. Superficial

burns are usually treated conservatively, whereas surgical intervention is recommended for tissue

damage. There are two distinct schools of approaches about surgical intervention. Some surgeons

recommend primary excision of the necrotic wound material almost immediately with placement of

a skin graft. Others are more conservative and wait until the necrotic material sloughs off before

placement of the graft.

With either case, the major problem encountered is the scar contracture on healing, which

can lead to reduction in mouth-opening size either bilaterally or unilaterally. Cosmetically and

psychologically, this is extremely undesirable. To prevent or minimize this effect, and to avoid

esthetic problems and the need for repeat corrective surgery, splints designed to maintain tension on

the commissures of the mouth are inserted. The splints are usually inserted at the immediate postburn

stage to reduce burn contracture and maintain the area in optimal position, reducing complications

caused by contracture.

Splint Design

Two basic types of splints have been advocated, removable and fixed.

Removable Splints. Essentially, these are upper removable appliances fabricated to the

maxillary dentition with posts attached to the lateral buccal aspects, curling outward and back to

hold the commissures taut (Fig. 26). Impressions are usually taken while the patient is under general

anesthesia.

Fig.27 Removable wing-type splint To position the posts as accurately as possible, take measurements from the uninvolved

commissure to the midline. If both commissures are involved this measurement must be estimated.

The recommended length of time, the splint is worn varies among authorities.Continuous

wearing for 3 months, then only in the evening and night for 6 to 12 months has been advocated,

whereas others have advocated continuous wearing for 6 months followed by nocturnal wearing for

further year. The length of time seems to depend on the severity of the injury, there being no rigid

timetable.

Another type of removable appliance has been described utilizing a modified orthodontic

cheek retractor. This is kept in the place during waking for 3 hours, taken out for 1 hour, and then

replaced. It is left in the place while the patient sleeps.

Fixed Appliance. A fixed splint has been described that utilizes orthodontic bands on the

second primary molars. Cast a model with the bands in situe, and bend a stainless steel wire to the

arch form, with two loops corresponding to each commissure. Place acrylic around the loop in such

a position so as to exert tension on the commissures when inserted in the mouth. Solder the wire to

the bands, and cement the appliance.

The splinting of electrical burns of the lip commissures has been shown to offer an

alternative to surgery, when the burns are superficial and to minimize contraction when severe,

thereby helping to maintain esthetics and function. The treatment of these cases also offers an

opportunity for the plastic surgeon and dental surgeon to collaborate.

Comrehensive conrol

1. Classification of traumatic injurings in children.

2. Peculiarities of examination of children with trauma of teeth.

3. Clinical appearance and differential diagnostics of concussion of teeth in children.

4. Peculiarities of bone fragments fixation in children of different age periods (primary, mixed,

permanent dentition).

5. Types of splints applied for the immobilization.

6. Dispanserization and rehabilitation patients with teeth trauma.

7. Complications and consequences after trauma of teeth in children.

8. Indications for replacement tooth crown by inlay.

9. Indication for crown fabrication.

10. Indications for postpins fabrication.

Tests

1. Parents came with 4,5-year-old sun to the dentist with complains on the pain and black color

of teeth. Dentist revealed multiple caries with complications, after that it was carried out

treatment and patient was directed to the orthodontist. Orthodontist in diagnosis indicated

the first subclass by Kurilenko. What defects refer to the first subclass by Kurilenko's

classification?

A. Defects of the posterior teeth

B. Defects of the frontal teeth

C. Defects of all groups of teeth

D. Atypical cavities

E. Defects of the teeth with vital pulp

2. A 7,5-year-old boy came to dentist with complains on the mobility. During intraoral

examination it was revealed that 52 tooth is mobile due to the physiological resorbtion.

Dentist made a mistake. He made extraction of the 53 tooth beside the 52 tooth. What

changes can be expected in this case?

A. Asymmetry of the dental arch with shift of the upper central line to the right, anomaly of

position of the 13 tooth in the future

B. Changes won't be present

C. Asymmetry of the dental arch with shift of the upper central line to the left, anomaly of

position of the 13 tooth in the future

D. Shortening of the dental arch from the left, anomaly of position of the 13 in the future

E. Protrusion of the upper frontal teeth

3. Parents of a 9-year-old girl came to the dentist for the examination of their daughter. In the

medical card the dentist marked the next received data: the absence of the primary upper

first molars. What changes can be expected in this case?

A. Changes won't be present

B. Asymmetry of the dental arch

C. Disturbance of the form of the dental arch

D. Shortening of the dental arch

E. Protrusion of the upper frontal teeth

4. A 4,5-year-old girl came to visit the dentist. During examination the absence of the primary

lateral incisors was revealed. Primary canines and molars are intact. What morphological

changes can be expected in nearest future in this case?

A. Shortening of the dental arch

B. Disturbance of the form of the dental arch

C. Asymmetry of the dental arch

D. Morphological changes won't be present

E. Changing of the vertical size of the dental arch

5. An orthodontist indicated a post for the upper first premolar of the 11-year-old patient. The

patient feels an anxiety, has increased salivation. What peculiarities are not characteristic in

a case of prosthetics of the permanent teeth with posts in the period of mixed dentition?

A. It is possible to make preparation of whole length of the root

B. It leads to the adequate partition of functional load

C. It doesn't interfere the final root formation

D. It couldn't be the cause of pathological changes in periapical tissues

E. It allows to carry out changing of the covering crowns after complete tooth eruption

6. A 4-year-old child fallen down and due to this has trauma of the upper central incisors.

During examination dentist set following clinical diagnosis: intrusive luxation of the 61

tooth. What should be the dentist's tactic?

A. Extraction of the 61 tooth. Supervision over the self-eruption of the tooth during 9-12

months

B. Extraction of the 61 tooth

C. Extraction and replantation of the tooth

D. Orthodontic and endodontic treatment

E. Medicament and orthodontic treatment

7. A 5-year-old child received trauma of the upper jaw. During objective intraoral examination

it was revealed: crowns of the 51 and the 61 teeth are shorter from the neighbor teeth on half

of the crow height. Mucous membrane is hyperemic in the region of the 51 and the 61 teeth.

Apexes of roots of the 51 and the 61 teeth are situated in the spongy matters tissue of the

corpus of the upper jaw. What should be the doctor's tactic?

A. Extraction of the 51 and the 61 teeth

B. Splinting of the teeth with ligature

C. Reposition of the 51 and the 61 teeth

D. Replantation

E. Supervision for a long time

8. What teeth can be replantated?

A. All answers are correct

B. Teeth, which were knocked out as a result of acute trauma

C. When a surgeon extracted a tooth by mistake

D. Fracture of the toot root and luxation of the crown wreckage

E. Extracted teeth that were deep location in the alveolar bone a result of trauma

(orthodontic treatment with the aim of move the tooth on it place is impossible)

9. What does it mean commissure of a tooth?

A. Incomplete tooth fracture without tearing away it parts

B. It is complete separation of a part of the hard tissues of the tooth crown

C. Injuring due to what the tooth can be moved in different B. Injuring due to what the

tooth can be moved in differentdirects, and which partially or completely goes through

the level of the alveolar bone

D. Closed mechanical injuring of teeth and soft tissues without destroying anatomical form

of their crown

E. Such type of injuring when the tooth isn't moved, but only it takes place injuring of soft

tissues

10. For what period a splint should be fixated in a case of incomplete luxation of the permanent

tooth?

A. For 1 month

B. For 2 months

C. Don't carry out splinting

D. For 6 months

E. For 2 weeks

Literature:

1. P.S.Flis, S.І.Тril, V.P.Vosnul. Prostheti dentistry. - Kiev. –2010. – «Medicine». – P. 7-15;

40-65.

2. Andreasen, J.O.: Challenges in clinical dental traumatology. Endodont. Dent. Traumatol.,

7:45, 1985.