emergency treatment of dental trauma in children

Emergancy Treatment Of Dental trauma in Children

• Examination and diagnosis

Consider traumatic injuries as emergency,

• To relieve pain.

• Reduce psychological stress.

• Facilitate reduction of # or avulsion.

• For good prognosis.

Uncomplicated Crown Fracture• Class 1 Fracture

– If <2mm tooth structure is missing, no intervention is necessary No Emergancy treatment

• Class 2 Fracture— Expose Dentine Dentine is more yellow compared

to the peripheral enamel— Patient feels thermal/tactile sensitivity— Usually >2mm of tooth lost but no ‘red pulp’ visible in

centre of fractureCa(OH)2 Temporary Restoration : GIC,

Orthodontic ring, SSC, Crown form (celluloid) or Reattached fragmen fracture or composite

filling

Complicated Fracture

• Class III Fracture – Fracture involves enamel and dentin and the pulp is exposed.– The 3 angulations described in radiographic examination

In young patients with immature (open apex) preserve pulp vitality : • local anaesthetic • pulp capping : pin piont expose• partial pulpotomy• PulpotomyCapping material : Calcium hydroxide and MTA (white) Temporary Restoration : GIC, Orthodontic ring, SSC, Crown

form (celluloid)

• Mature teeth (close apex) : – local anaesthetic– Direct pulp capping : pin point exposure not

more than 24 h – Pulpectomy / vital Root canal treatmentRestoration: temporary restoration or reattached

fracture fragmen

Ad. Mahkota SeluloidPilih crown form: patokan size & bentuk gigi sama pada kuadran ber><anGunting bgn cervix crown form sesuai gingival margin 1mm dibwh free gingival marginBuat 2 lubang di lingual pd 1/3 bag. Incisal kelebihan komposite & udara dpt keluarEtch

Komposite masukkan crown form sedikit2 = gelembung udaraCrown form+isi diselubungkan disinarResin berlebih(lubang/cervikal) diambilMahkota dibuka, iris bagian lingual (skalpel)Cek gigitanpoles

Ad. SSC

Pilih ssc (size, form) disesuaikan bag. CervicPrep = perlu kecuali kontak prox perlu bebas sedikit email di prox diambilBuat jendela di labialMahkota disemen isi jendela dgn komposite

SSC perlindungan max = tumpatan sementara “of choice”

Tumpatan sementara dibiarkan > 8 minggu= waktu yang perlu untuk pulpa menjadi normal

Class IV fracture

• Emergancy treatment : – Periodontitis : root canal treatment reduce

occlusion– Abscess :

• Acute : drainage from pulp chamber keep it open for 24h antibiotic

• Cronic : root canal treatment

Management of the Avulsed Tooth / Class V fracture

Management of the Avulsed Tooth

• Ultimate goal– PDL healing without

root resorption

• Most critical factor– Maintaining an intact

and viable PDL on the root surface

Emergency Treatment

• Replantation technique– Local anesthetic, if

necessary– Radiograph to verify

position– Check occlusion– Physiologic splint

Emergency Treatment

• Additional Considerations– Analgesics

Emergency Treatment

• Additional Considerations– Analgesics– Chlorhexidine

Emergency Treatment

• Additional Considerations– Analgesics– Chlorhexidine– Tetanus

• Refer to physician for tetanus prophylaxis prn

Rothstein RJ, Baker FJ.Tetanus: Prevention and

treatment.J Am Med Assoc 1978;240:675-

6.

Rothstein RJ, Baker FJ.Tetanus: Prevention and

treatment.J Am Med Assoc 1978;240:675-

6.

Emergency Treatment

• Additional Considerations– Analgesics– Chlorhexidine– Tetanus– Antibiotics

Antibiotics

• Penicillin– 500 mg qid for 4-7 days

Andreasen JO.Atlas of replantation and transplantation

of teeth.Philadelphia: W.B. Saunders Co.,

1992;57- 92.

Hank’s Balanced Salt Solution

• Proper pH and osmolality• Reconstitutes depleted cellular metabolites• Washes toxic breakdown products from the

root surface

Recommended Storage Media

1. Socket (immediate replantation)

2. Cell culture medium

3. Milk4. Physiologic saline5. Saliva

Root Surface Manipulation

• Extraoral dry time determines handling

Root Surface Manipulation

• Extraoral dry time < 1 hr– PDL healing is still possible– Handling recommendations

• Keep root moist• Do not handle root surface• Gentle debridement

Root Surface Manipulation

• Extraoral dry time > 1 hr– Loss of PDL cell viability

inevitable – Treatment

recommendations• Remove tissue tags• Soak in accepted dental

fluoride solution for 20 min

Fluoride Treatment

• 1.0-2.4% topical fluoride solution– Sodium fluoride

(Andreasen)– Stannous fluoride

(Krasner)

• 20 minute soak

Management of the Socket

• Remove contaminated coagulum in socket– Irrigate with sterile saline

Management of the Socket

• Examine socket If fracture is evident – Reposition fractured bone with a blunt instrument

Management of the Socket

• Replant using light digital pressure

Types of Splints(flexible/physiologic)

• Titanium Trauma Splint (TTS)• Ortho wire with brackets• Ortho wire with unfilled resin• Monofilament line with unfilled resin• Unfilled resin• Suture(s)• Ribbond®

Splints for Stabilization

Round or rectangular wire

Monofilament line

Orthodontic brackets and wire

Splints for Stabilization

Titanium Trauma Splint (TTS)

Ribbond®

1

Acid Etch Composite Splints

• Interproximal composite

Acid Etch Composite Splints

• Composite with arch wire

Acid Etch Composite Splints

• Composite with monofilament nylon

Acid Etch Composite Splints

• Functional Splint– 20-30 lb

monofilament nylon

– Bonded with composite

– Allows physiologic movement

Antrim DD, Ostrowski JS.A functional splint for traumatized teeth.J Endodon 1982;8:328-31.

Cross-Suture Splint

• Indications– No adjacent teeth to

splint to– Unmanageable

traumatized children

Cross-Suture Splint

Splinting Time

• Effect of splinting time– 7 days– 30 days

Nasjleti CE, Castelli WA, Caffesse RG.

The effects of different splinting times on replantation of

teeth in monkeys. Oral Surg 1982;53:557-66.

Splinting Time

• Recommended time– 7 to 10 days

Nasjleti CE, Castelli WA, Caffesse RG.

The effects of different splinting times on replantation of

teeth in monkeys. Oral Surg 1982;53:557-66.

Class VI Fracture

• Root fracture• The coronal segment may be mobile and may

be displaced.• The tooth may be tender to percussion.

monitoring the status of the pulp is recommended.

• Transient crown discoloration (red or grey) may occur

Emergency Management

• Reposition coronal fragment

Emergency Management

• Previous recommendation– Rigid splinting for 2-3 months

Emergency Management

• Previous recommendation– Rigid splinting for 2-3 months

• New recommendation– Splinting for 3 weeks

Class VII

• Subluxation Definition: injury to tooth-supporting structures with abnormal loosening but without tooth displacement.

Th/ : Permanent teeth: Stabilize the tooth and relieve any occlusal interferences. For comfort, a flexible splint can be used. Splint for no more than 2 weeks.

• Lateral luxation Definition: displacement of the tooth in a direction other than

axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs

Emergancy treatment for Permanent teeth: - Local anasthetic- to reposition as soon as possible and then to stabilize the tooth

in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. Repositioning of the tooth is done with digital pressure and little force. A displaced tooth may need to be extruded to free itself from the apical lock in the cortical bone plate.

- Splinting an additional 2 to 4 weeks may be needed with breakdown of marginal bone

• Intrusion Definition: apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket

Emergency treatment:- For immature teeth with more eruptive

potential (root ½ to ²/³ formed): Clean the wound with NaCl, H2O2 and

anticeptic solution spontaneous eruption

In mature teeth:• Clean the wound with NaCl, H2O2 and anticeptic

solution• Local Anesthetic • reposition the tooth with orthodontic or surgical

extrusion (local anesthetic if nescessery)• stabilize the tooth with a splint for up to 4 weeks in its

anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity.

• Extrusion Definition: partial displacement of the tooth axially from the socket; partial avulsion. The periodontal ligament usually is tornPermanent teeth:

- Clean the wound with NaCl, H2O2 and anticeptic solution- Give Local Anesthetic.- Using fingers, grab extruded teeth and surrounding alveolus

then reposition teeth and attached bone all together.- After repositioning, splint with attention to bite relationship

stabilize the tooth in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. Splint for up to 2 weeks

Class VIII: Crown and Root Fracture

• Enamel, dentin, and cementum fracture with or without pulp exposure

Emergency treatment :Permanent teeth: - Clean wound- Local Anesthetic- If the pulp is exposed, pulpal treatment alternatives are

pulp capping, pulpotomy, and root canal treatment.- Reattached fracture fragmen stabilize the coronal fragment.

or necessary gingivectomy; osteotomy; or surgical or orthodontic extrusion to prepare for restoration.

Emergency Treatment for dental trauma in primary Teeth

• Crown fracture with pulp involvement (vital)- Clean wound- Local Anesthetic- Perform Pulpotomy or pulpectomy• Root fracture ―Apical third : observation―Cervical third and midle third :

― Local anasthetic― Extraction

• Crown/root fracture :– Local anesthetic– The entire tooth should be removed unless

retrieval of apical fragments may result in damage to the succedaneous tooth

Displacement

• Lateral luxation Primary teeth:

- to allow passive or spontaneous repositiong if there is no occlusal interference.

- When there is occlusal interference, local anestheticthe tooth can be gently repositioned or slightly reduced if the interference is minor.

- When the injury is severe or the tooth is nearing exfoliation, local anesthetic extraction is the treatment of choice

• Intrusion : – Reeruption spontaneuly– Dammage to premanent teeth extraction

• Extrusion– Local Anesthetic– reposition spontaneously or reposition and allow

for healing for minor extrusion (<3 mm) in an immature developing tooth.

– Indications for an extraction include severe extrusion or mobility, the tooth is nearing exfoliation, the child’s inability to cope with the emergency situation