Dental Trauma in children I. 5DM PEDO

Dental Trauma in children I. 5DM PEDO

Childhood is a risky period of life considering trauma (high risk and incidence of injuries) Injuries to the teeth can severely harm a child in these aspects: functional esthetic psychological

Epidemiology of injuries 30% of children experience trauma of MD 22% of children experience trauma of PD main incidence in MD - 1. 3. year of life main incidence in PD - 8. 11. year of life up to 3 y. there is no difference between sexes after 3rd year 2 3x more frequent in boys in 90% of trauma - maxillary teeth in 70% of trauma - incisors most frequently one tooth is injured 60% two teeth 30%

ETIOLOGY direct trauma to the dentition collision with hard object, stick, fist indirect trauma sudden forceful closure of the mouth Mn teeth against Mx blow to the chin during fall, fight, car accident most common places home, school

Epidemiology of injuries in milky dentition walk, run... falls from chair, table, pram battered child syndrome

Epidemiology in permanent dentition swings, climbs falls on playgrounds falls from: bike, scate, in-lines fight car accidents other

PREDISPOSING FACTORS FOR DENTAL TRAUMA 1. Age (8-10years) 2. Sex (boys 12% - 32% ; girls 4% - 19%) 3. Maloclusions Angle class II with protrusion 4. Handicaped individuals 5. Refractive defect of the eye 6. Dental anomalies quantitative defect of enamel 7. Season (spring, summer)

Battered child syndrome in some cases the oral injury can be a result battered child syndrome small child is subject to continuous physical abuse from one or both parents attemps to silence screaming/crying child discrepancy between history and clinical findings Multiple bruises in different stages of healing Signs of old fractures on x-rays Scars, cigarette burns, etc. has to be reported

ANAMNESIS: Patient record after injury - name, surname, address, insurance - name of accompanying person, wittness, address - description of an accident HEALTH STATUS: -General (hemorhagic diatesis, epilepsy...) - status after trauma (whether the patient remembers circumstances problem with small children, unconsciousness, nausea, vomiting, pain) WHEN ACCIDENT HAPPENED (record time) ADMINISTERED MEDICAMENTS

Examination of trauma patient Extraoral -deformities, colour, haemorrhage,hematomas, abrasions, lacerations, penetrative wounds, abrasions, contusion face, head, neck (+limbs visible part) - examination by palpation - mobility of fragments Intraoral set of order 1. soft tissue examination 2. hard tissue examination 3. hard dental tissue examination

Examination of trauma patient Intraoral - dental status - lines of fracture - mobility - hematoma - bleeding - dislocation - vitality test, percussion - status of mucosa (and other tissues of oral cavity)

Examination of trauma patient Auxilliary examinations - x-ray! (i.o., e.o., OPG) -every injury, forensic reasons also - blood tests ( APTT, Trc, etc. blood cloting) vitality testing just following trauma may be false negative little significant...must be repeated after 1 months and 6 months photography - usefull

SEQUELAE OF TRAUMA TO PRIMARY TEETH Infection in periodontal ligament Pulpitis Pulp necrosis Pulpal obliteration Inflammatory resorption Ankylosis Coronal discoloration Complications following intrusion Complications following avulsion Injuries to developing permanent dentition.

CLASSIFICATION OF DENTAL TRAUMA By WHO 1979, modified by Andreasen in 1981 A) Fracture of crown B) Fractures of roots C) Combination of crown and root fracture D) Luxations: contussion subluxation intrusion extrusion avulsion E) Trauma of the facial soft tissues: contusion, abrasion, laceration F) Trauma of jaws (bones): fractures of alveolar socket fr. of alveolar bone fr. of jaws (Mx,Mn)

CLASSIFICATION OF DENTAL TRAUMA Andreasen (detailed) A) Crown fracture Enamel infraction Enamel fracture Fracture of the enamel and dentin Fracture of the enamel and dentin near the pulp Fracture of the enamel and dentin with pulp exposure Fracture of the enamel and dentin with pulp overlap

CLASSIFICATION OF DENTAL TRAUMA B) Fracture of the root fracture in the coronal third fracture in the middle third fracture in the apical third vertical fracture

CLASSIFICATION OF DENTAL TRAUMA C) Combined fracture of the crown and the root Fracture of the crown and the root with no complication Fracture of the crown and the root with exposed pulp

CLASSIFICATION OF DENTAL TRAUMA D) Injuries to the tooth supporting tissues Concussion Subluxation Intrusion Intrusive luxation Extrusion Extrusive luxation Luxation Lateral luxation Avulsion

Infraction of the enamel Cl.picture - infraction only in enamel, visible fracture line on the surface of the tooth - an incomplete fracture (crack) of the enamel without loss of tooth structure - Percussion test not tender - Mobility test - normal mobility - Sensibility pulp test - usually positive (important in assesing future risk of healing complications) - RTG - periapical view, no radiographic abnormalities.

Infraction of the enamel Th: - no treatment or only impregnation with NaF or Bond system (to prevent discoloration of the infraction lines) Follow-up Not needed (only if combined with other type of injury)

Fracture in the enamel Cl. picture - fracture confined to the enamel with loss of tooth structure, esthetic change of crown shape - small pain to irritation, sharp margin irritates lip or tonque - dentin not exposed - Percussion test not tender - Mobility test - normal mobility. - Sensibility pulp test - usually positive - RTG loss of enamel.

Fracture in the enamel Th: - DD trimming(cutting), impregnation - PD- trimming, impregnation conservative treatment with compomer or composite If a tooth fragment is available, it can be bonded to the tooth. Follow-up Clinical and radiographic control at 6-8 weeks and 1 year.

Fracture in the enamel and the dentin A fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp. Cl. picture (1) - small pain on irritation - Visible loss of enamel and dentin. No visible sign of exposed pulp tissue. - Percussion test - not tender. If tenderness is observed evaluate the tooth for possible luxation or root fracture injury. - Mobility test - normal mobility. Sensibility pulp test - usually positive. The test may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made.

Fracture in the enamel and the dentin RTG - enamel-dentin loss is visible Radiographs recommended - periapical, occlusal and eccentric exposure rule out displacement or root fracture If the fragment is not found - Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material.

Fracture in the enamel and the dentin Th: If a tooth fragment is available, it can be bonded to the tooth. - DD- trimming, impregnation, GIC filling, compomer filling - PD- conservative treatment with compomer or composite filling (definitive) Follow-up Clinical and radiographic controls after 6 8 weeks, 1 year

Fracture in the enamel and the dentin (near the pulp) Cl. Picture (2) - patient feels pain to irritation - Vitality: usually positive Th: PD - indirect pulp capping with Ca(OH)2 - protective celluloid crown with GIC for 8 weeks - after temporary treatment if the pulp is vital: definitive filling (compomer/composite)

Fracture in the enamel and the dentin near the pulp Th: YPT- definitive tretment only after apex closure Vitality examination: 1., 2., 6. week, 1 year DD- indirect pulp capping and protective celluloid crown - Pulpotomy or extraction Complications: - pulp inflammation, necrosis, gangrene

Fracture in the enamel and the dentin with pulp exposure A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp. Cl. picture - painfull, bleeding from pulp - Percussion test - not tender. If tenderness is observed evaluate the tooth for luxation or root fracture injury - Mobility test - normal mobility. - Sensibility test - usually positive. The test is important in assessing risk of future healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.

Fracture in the enamel and the dentin with pulp exposure RTG loss of enamel and dentin visible, pulpal cavity exposed Periapical, occlusal and eccentric exposure. (They are recommended in order to rule out displacement or the possible presence of a luxation or a root fracture.) Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material

Fracture in the enamel and the dentin with pulp exposure Th: possibilities PD - depend on the size of pulp exposure, time, infection, stage of tooth development 1. Direct pulp capping: small pulp exposure, cooperative patient, time 6 h, no infection

Fracture in the enamel and the dentin with pulp exposure Working procedure Cleen the tooth with Fys.solution, dry, direct pulp capping GIC and definitive filling or GIC and protective crown, Sterile instruments, dry operative field Prognosis: After 4 weeks- line of odontoblasts After 8 weeks- new dentin Vitality examination: - 1., 2., 4., 6. week.

Fracture in the enamel and the dentin with pulp exposure 2) Vital amputation: immature permanent tooth/permanent tooth Greater perforation Time more than 6 h. Infection Damage of periodontal tissues Working procedure: Sterille pulp amputation in the region of pulp and papilla, controll bleeding, Capping with Ca(OH)2, GIC, definitive filing Prognosis: Dentin bridge after 2-3 month Irreversible damage of dental pulp: Extirpation and endo th (PD) or extraction (YPT if mesodermal papila damaged irreversibly)

Fracture in the enamel and the dentin with pulp exposure Treatment in deciduos dentition: Dental pulp has lower biological value, lower defensiveness Th: vital amputation (less success) vital extirpation extraction

Fracture of the crown with pulp overlap: Cl. Picture painfull, dental pulp overlap fracture aperture pulp capping impossible Th: YPT - Deep vital amputation PD - Vital extirpation DD - Vital extirpation/extraction

Fracture of the crown and root non complicated (without pulp involvement) Cl. picture: Fracture line crosses crown and root A fracture involving enamel, dentin and cementum with loss of tooth structure, but not involving the pulp. Visual signs - crown fracture extending below gingival margin. Percussion test - tender. Mobility test - coronal fragment mobile. Sensibility pulp test - usually positive for apical fragment.

Fracture of the crown and root non complicated (without pulp involvement) RTG Apical extension of fracture usually not visible. Radiographs recommended - periapical, occlusal and eccentric exposures.

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

Fracture of the crown and root non complicata Th: Orthodontic extrusion of apical fragment Removal of the segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown. Surgical extrusion Removal of the mobile fractured fragment with subsequent repositioning of the root in a more coronal position. A rotation of the root (90 or 180) may offter a better position for periodontal ligament healing.

Fracture of the crown and root non complicata Th: YPT: apexification, definitive endodontic treatment, prosthodontic treatment DD: extraction

Fracture of the crown and root complicata (involving pulp) Cl. picture: A fracture involving enamel, dentin, and cementum with loss of tooth structure, and involving the pulp. transverse fracture more than 4 mm subgingival

Fracture of the crown and root complicata Percussion test - tender. Mobility test - coronal fragment mobile Sensibility tet - usually positive for apical fragment. Radiographs recommended - periapical and occlusal exposure.

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

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

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

Fracture of the crown and root complicata Extraction Extraction with immediate or delayed implantretained crown restoration or a conventional bridge. Extraction is inevitable in very deep crown-root fractures, the extreme being a vertical fracture Th DD - extraction

Fractures of the root fracture in the coronal third fracture in the middle third fracture in the apical third vertical fracture

Root fracture in coronal third Cl. picture: mobility 2.-3. degree, most in trauma direction and in long axis supraocclusion pain to pressure marginal gingiva damage decreased reaction to cold

Root fracture in coronal third Th: Subgingival fracture: gingivectomy, prosthodontic treatment with pin (exstirpation, endo th, intrapulpal post) Cross line under alveolus and communication with oral cavity: extraction Transversal fracture: conservative and ortodontic treatment (endodontic treatment, pin in root, 4 weeks root extrusion with orthodontic appliance, 6 weeks stabilisation in new position

Root fracture in middle third Cl. picture: mobility of the tooth pain during function apical fragment is stabile decreased reaction to cold

Root fracture in middle third Th:PD Pulp damage: endodontic treatment No dislocation: splinting for 3.-4. months with wire and composite With dislocation: reposition, splinting for 3-4 months, endodontic treatment with intraradicular pin Extraction

Root fracture in apical third Cl. picture: mobility, I. degree pain to percussion reaction to cold or no reaction to cold Th:PD Splinting for 2-3 months Necrotic pulp: endodontic treatment and apex amputation

Root fracture in apical third Th:DD Extraction Leave apical third (erupting permanent tooth will resorb remaining apical part of root

Alveolar fracture A fracture of the alveolar process; may or may not involve the alveolar socket. Teeth associated with alveolar fractures are characterized by mobility of the alveolar process; several teeth typically will move as a unit when mobility is checked. Occlusal interference is often present Displacement of an alveolar segment. An occlusal change due to misalignment of the fractured alveolar segment is often noted.

Alveolar fracture Percussion test tender Mobility test - entire segment mobile and moves as a unit. Vitality test usually negative RTG - The vertical line of the fracture may run along the PDL or in the septum. The horizontal line may be located apical at the apex or coronal to the apex. An associated root fracture may be present. Occlusal, periapical and eccentric exposure and OPG

Alveolar fracture Treatment Manual repositioning or repositioning using forceps of the displaced segment. Stabilize the segment with splinting for 4 weeks Patient instructions Soft food for 1 week Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris. Follow-up Splint removal and clinical and radiographic control after 4 weeks. Clinical and radiographic control after 6-8 weeks, 4 months, 6 months, 1 year and yearly for 5 years

Jaw fracture A fracture involving the base of the maxilla or mandible and often the alveolar process. The fracture may or may not involve the alveolar socket. Usually displacement between two alveolar segments within the dental arch. Percussion test tender Mobility test mobility in fracture line Vitality test maybe positive or negative RTG - The vertical line of the fracture line may run along the PDL or in the septum. Periapical, OPG, skull projections (AP, lateral, Clementschich)

Jaw fracture Treatment Manual repositioning and stabilization of the fracture with splint using intermaxillary immobilization for 4 weeks. An alternative treatment is surgical repositioning and stabilization using plating. In this case intermaxillary splinting can usually be avoided. Patient instructions Good healing if good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % Follow-up Splint removal and clinical and radiographic control after 4 weeks. Clinical and radiographic control after 6-8 weeks, 4 months, 6 months, 1 year and yearly for 5 years.