charles lekic ddm, msc, phd, frcd (c) may 2015 · classification of dental injuries tooth fractures...
TRANSCRIPT
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DENTAL TRAUMA
IN PEDIATRIC DENTISTRY
Charles Lekic DDM, MSc, PhD, FRCD (C)
May 2015
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Tooth injuries in children often have serious, long-
term consequences leading to change in tooth
colour, development of malformations and possibly
tooth loss
Trauma in the Child Patient
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Epidemiology of pediatric dental trauma
• Falls and sport are the most common cause of accidental injury.
• Maxillary incisors comprise 80% of all dental injuries, and of these 80-90% involve central incisor.
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History related to trauma
Patients with tooth
injuries are to be
treated as emergencies
and a careful medical
and dental history as
well as a thorough
clinical and
radiographic
examination are
mandatory
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Medical history
• Cardiac disease (necessity for antibiotic coverage ?)
• Bleeding disorders (possibility for prolonged or internal or external bleeding ?)
• Allergies to medications (penicillin in particular ?)
• Seizure disorders (trauma may trigger them ?)
• Medications (indicating an underlying medical condition ?)
• Status of tetanus immunization (vaccine valid for 5-10 years ?)
• Hospitalisation (revealing prior emergencies ?)
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History of a dental injury
When did the
injury occur?
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History of a dental injury (cont’d)
Where? This is to
determine the need for
tetanus prophylaxis
(particularly if
bleeding was
associated with the
injury)
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History of a dental injury (cont’d)
How did the accident
happen? To provide
information
regarding the
severity of the injury
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Clinical examination
Extraoral Examination
Examine and
palpate facial
skeleton, record
wounds and bruises.
Palpate TMJ joints
and check for eye
and mandibular
movements.
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Clinical examination
Radiographic Examination
Radiographs are mandatory and facilitate detection of root and bone fractures, presence of periapical radiolucencies, root resorptions, degree of displacement, position of the unerupted teeth, etc.
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Clinical examination (cont’d)
Intraoral ExaminationExamine oral soft tissues and each tooth.
Record:- wounds on soft tissue- tooth fracture- pulp exposure- tooth dislocation- mobility of the tooth - palpation and percussion
Note: pulpal vitality is not readily determined due to the questionable reliability of pulp vitality tests in young children.
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Classification of dental injuries
Tooth fractures
• Enamel infractions
• Fractures of enamel
• Fractures of enamel
and dentin only
• Enamel and dentin
fractures with open
pulp
• Root fractures (cervical,
mid or apical)
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Displacement (luxation) injuries
• Concussion - tooth not mobile and not displaced
• Subluxation - tooth loosened but not displaced
• Intrusion - tooth driven into its socket
• Extrusion – tooth centrally dislocated from its socket
• Lateral luxation - tooth displaced in a lateral direction
• Avulsion - tooth completely displaced from the
alveolus
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Treatment of tooth injuries
Due to the different characteristics of primary and
permanent teeth it is necessary to discuss treatment
procedures separately for both dentitions
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Wearing mouthguards when involved in contact
type of activities would make make the rest of the
presentation very short
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Treatment of tooth fractures in primary teeth
• Enamel infractions - no treatment required.
• Enamel fractures - disking of sharp edges, as required (arrow).
• Fractures of enamel and dentin - restore the tooth with a glass-ionomer'bandage‘/ composite resin/just disc sharp edges (arrows).
• Enamel and dentin fractures with open pulp –pulpotomy or pulpectomyand composite/ open face stainless steel crown/extraction
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Treatment of tooth fractures in permanent dentition
• Enamel infractions – etch and seal or apply topical fluorides or only observe. Prognosis is good with no developing sequel.
• Enamel fracture - contouring or placement of a composite resin restoration or observe.
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Treatment of tooth fractures in permanent
dentition (cont’d)
Fractures of enamel and dentin with closed pulp –
bevel, if closer to the pulp place calcium hydroxide
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Treatment of tooth fractures in permanent
dentition
Fractures of enamel and dentin (cont’d): etch, rinse
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Treatment of tooth fractures in permanent
dentition
Fractures of enamel and dentin (cont’d): place bond
and primer, light cure, prepare a celluloid crown
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Treatment of tooth fractures in permanent
dentition
Fractures of enamel and dentin (cont’d): fill the
crown, compress onto the tooth, remove excess
material, light cure, finish
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Treatment of tooth fractures in permanent
dentition
Enamel and dentin
fractures with open
pulp (arrow) - treatment
depends on:
• a) Size of pulp exposure
• b) Stage of root
formation
• c) Pulp vitality
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Treatment of tooth fractures in permanent
dentition
Enamel and dentin
fractures with open pulp
(cont’d):
a) direct pulp capping
b) pulpotomy
c) apexification
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Treatment of tooth fractures in permanent
dentition
Treatment objectives for
root fractures of
permanent teeth are
osseointegration of
fractured surfaces and to
maintain vital pulp:
a) Repositioning -
manually
b) Splinting - for 4 weeks
or longer if the fracture line
is in cervical area (up to 4
months)
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Treatment of displacement injuries in
primary teeth
• Concussion – Soft diet, Tylenol, follow-up examination monitor for color changes
• Subluxation – diet instructions and follow-up examinations
• Intrusion - allow to re-erupt, if it doesn’t extract - follow-up examination
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Treatment of displacement injuries in primary
teeth Cont’d)
Extrusion – extract
Lateral luxation - if possible reposition, when very mobile extract
Avulsion - do not replant
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Treatment of displacement injuries in permanent teeth
• Concussion – diet instructions, Tylenol, follow-up examination (for at least 1 year).
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Treatment of displacement injuries in permanent
teeth (cont’d)
• Subluxation – diet instructions, monitor closely and in a case of an increased mobility splint the tooth for 2 weeks. Splint should be:
a) Passive and atraumatic
b) Flexible
c) Permit endodontic access
d) Easy to apply and remove
e) Include if possible two teeth on each side of the injured tooth
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Treatment of displacement injuries in permanent
teeth (cont’d)
Intrusion - spontaneous
re-eruption with open
apex (if intruded 3mm
or less). Closed apex
consider orthodontic or
surgical extrusion (if
intruded 7mm or more).
Endodontic treatment
should be performed
after 2-3 weeks.
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Treatment of displacement injuries in permanent
teeth (cont’d)
Extrusion -repositioning of the tooth and splinting for 2 weeks. Endodontic treatment should be performed within 2-3 weeks following the injury.
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Treatment of displacement injuries in permanent
teeth (cont’d)
Note that bonding of the injured tooth is
done at the end
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Treatment of displacement injuries in permanent
teeth (cont’d)
Lateral Luxation - repositioning and splinting of the tooth for 4 weeks (do to the bone involvement).
Endodontic treatment to be performed in the case of pulpal necrosis.
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Treatment of displacement injuries in permanent teeth (cont’d)
• Note
If the mobility of the displaced tooth is 2 mm it needs to be treated as emergency. Prolonged time may contribute to further damage of injured periodontal tissues.
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Treatment of displacement injuries in permanent
teeth (cont’d)
Avulsion - important considerations:
• Time interval between injury and treatment
• Storage conditions for the avulsed tooth
• If the extra-alveolar time was <1 hour and the avulsed tooth stored under wet conditions (hopefully milk) tooth should be repositioned immediately and splinted for 2-3 weeks. Administer systemic antibiotics. Endodontic treatment to be performed within 7-10 days.
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Tooth avulsion - important considerations: Viability of periodontal ligament cells
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Protocol for the treatment of avulsed teeth
• Request immediate replantation of the avulsed tooth
• If not, request the tooth to be stored in cold milk and immediately transferred, with the patient, to the nearest dental office
• Treat this patient with outmost emergency. If the extra-oral time was <1 h replant the tooth. Then splint, prescribe antibiotics and a week after perform endodontic treatment
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Alternative treatment for ankylosed
teeth• Decoronation designed
to preserve the ridge and the vertical height:
• Raise flap and remove the crown
• Remove root filling allow the bleeding
• Reduce for 2mm the coronal part of the root (below the marginal bone)
• Suture
Malmgren,B. Journal of the California Dental Association2000.
Decoronation: How, Why and When?
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What would you, what would I do ?
J.B. age 5 presented with discolored tooth
#51, no mobility, X-rays showed no signs of
radiolocency
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What would you, what would I do ?
M.N. age 5 presented with fistula from tooth #61. X-
ray showed radiolucency and pathological root
resorption
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What would you, what would I do ?
M.M. age 3 presented with extrusive luxation injury of
teeth #52, #51, #61, #62. X-ray showed fracture of
anterior alveolar bone
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What would you, what would I do ?
S.A. age 10 presented with an intrusion injury of teeth
#21 and #22. Teeth were not mobile nor sensitive to
percussion.
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What would you, what would I do ?
C.J. age 11 presented with luxated tooth #21. Tooth
#21 was mobile (2 mm) and the X-ray showed widening
of the periodontal ligament on the lingual side.
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What would you, what would I do ?
W.P. age 11 presented with fractured crown and root
of tooth #11 and a fracture of enamel and dentin of
tooth #21. X-ray showed a split-in-half type of
fracture of tooth #11.
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What would you, what would I do ?
L.O. age 8 presented with an hour old fracture of enamel
and dentin and exposed pulp (teeth #11 and #21). X-rays
showed that root formation on teeth #11 and #21 has not
been completed.
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Thank you for your attention