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MANAGEMENT OF TRAUMATIC INJURY OF PRIMARY DENTITION

Dr. Akash Ardeshana Department of paedodontics and preventive dentistry

contents

Introduction Objective of management Management of traumatic dental injury

of the primary teeth Injuries to the hard dental tissues and

the pulp: Infraction Enamel fracture Enamel dentine fracture Enamel dentine pulp fracture

Injuries to the hard dental tissues, the pulp, and the alveolar process: Crown-root fracture without pulpal involvement Root fracture with without pulpal involvement Alveolar fracture

Injuries to the periodontal tissues: Concussion Subluxation Luxation injuries:

Lateral luxation I ntrusive luxation Extrusive luxation Avulsion

sequelae of acute dental trauma in the primary dentition.

sequelae in permanent dentition after trauma in primary dentition.

Conclusion Bibiliography

In preschool children, head and facial nonoral injuries make up as much as 40% of all somatic injuries .

In the age group 0–6 years, oral injuries are ranked as the second most common injury covering 18% of all somatic injuries (1–3).

Introduction

Traumatic injuries to the primary dentition present special problems and the management is often different as compared with the permanent dentition.

Trauma to the oral region occurs frequently and comprises 5% of all injuries for which people seek treatment .

Objectives……

1. Recognize the various trauma entities.

2. Recognize the risk of concomitant to the permanent dentition.

3. Determine treatment option that will reduce the risk of developmental disturbances of permanent dentition.

4. Determine risk profile for primary tooth that present a significant risk for the permanent dentition.

The primary goal is to optimize periodontal and pulpal healing in the primary dentition provided that no further injury is transmitted to the developing permanent successors.

Treatment principle

Factors influence on selection of treatment plane

Infraction

Treatment No treatment necessary

Follow-up No follow-up is needed for infraction injuries

unless they are associated with a luxation injury or other fracture types involving the same tooth.

Enamel fracture

Treatment Smooth sharp edges. In patients with lip or cheek lesions

it is advisable to search for tooth fragments or foreign material.

Follow-up No followup required.

Enamel-dentin fracture

Treatment If possible, seal completely the involved

dentin with glass ionomer to prevent micro leakage.

In case of large lost tooth structure, the tooth can be restored with composite.

Follow-up Clinical control at 3-4 weeks.

Enamel-dentin-pulp fracture

(Complicated crown fracture)

Treatment If possible, preserve pulp vitality by partial

pulpotomy. Calcium hydroxide is a suitable material for such

procedures. A well-condensed layer of pure calcium hydroxide paste can be applied over the pulp, covered with a lining such as reinforced glass ionomer. Restore the tooth with composite.

The treatment is depending on the child's maturity and ability to cope. Extraction is usually the alternative option.

Partial pulpotomy

Cervical pulpotomy

Pulpectomy

Extraction

Follow-up Clinical after 1 week. Clinical and radiographic after 6-8

weeks and 1 year.

radiograph of the maxillary primaryincisors of a 3-year-old child, 3 hours after injury.

Three-month follow-up radiograph showing the development of a dentin bridge at the site of the partial pulpotomy.

Two-year follow-up

Clinical photograph of a 27-month-old child who had sustained a complicated crown fracture that was not treated. The child appeared 6 weeks later with a parulis above the involved tooth. The tooth was extremely mobile

Crown-root fracture without pulp involvement

Localization of fracture line The fracture involves the crown and

root of the tooth and is in a horizontal or diagonal plane.

A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion

treatment Depending on the clinical findings, two

treatment scenarios may be considered. Most of these may be deferred to later treatment.

Fragment removal onlyIf the fracture involves only a small part of the root and the stable fragment is large enough to allow coronal restoration, remove the mobile fragment.

ExtractionExtraction in all other instances.

Patient instructions Soft food for 10-14 days.

Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week.

This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.

Parents should be further advised about possible complications that may occur, like swelling, increased mobility or fistula.

Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up In case of fragment removal only:

Clinical :after 1 week. Clinical and radiographic :after 3-4 weeks. Clinical : after 1 year.

In case of tooth extration: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

Crown-root fracture with pulp involvement (Complicated

crown-root fracture)

Treatment Depending on the clinical findings, two

treatment scenarios may be considered. Fragment removal only if the fracture involves

only a small part of the root and the stable fragment is large enough to allow coronal restoration.

Extration in all other instances.

Follow-up In case of fragment removal only:

Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

In case of tooth extration: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

Root fracture

In the primary dentition, root fractures are as rare as about 2-4% (1, 4, 5), due to the plasticity of the developing alveolar bone.

They are most frequent at the age of 3-4 years where physiologic root resorption has begun, thereby weakening the root

Treatment No treatment

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

ExtractionIf the coronal fragment is displaced, repositioning and splinting might be considered.

Otherwise extract only that fragment. The apical fragment should be left to be

resorbed.

These root fractures occurred at the age of 4 years. Due to severe displacement, both coronal fragments were extracted. The root tips remained in situ and where resorbed normally

Patient instructions Soft food for 10-14 days.

Follow-up Clinical control after 1 week. Clinical

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

In case of tooth extration: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

Title Conservation of root-fractured primary teeth--report of a case.

Author Liu X1, Huang J, Bai Y, Wang X, Baker A, Chen F, Wu LA.

Journal Dent Traumatol. 2013 Dec;29(6):498-501. Level of evidence

Iv

abstract A 3.5-year-old girl presented to our clinic experiencing pain in her maxillary central incisors following traumatic injury during a fall. Radiographic examination revealed both primary maxillary central incisors with mid-root and apical third horizontal root fractures, respectively. Splinting with orthodontic brackets and stainless steel wire was performed. At 2 weeks, resorption of the apical fragments in both injured teeth was observed, and after 3 months, almost complete resorption was noted on radiographs. Tooth mobility at this point was back to physiologic levels and the splint was removed. After 2.5 years, the primary maxillary incisors were replaced by permanent incisors demonstrating normal tooth color, position, and root development. Although this case illustrated the favorable prognosis of two primary teeth with root fractures and severely mobile coronal fragments by a conservative approach, more scientific evidences are needed and frequent recalls are necessary when primary root fractures are attempted to be managed with splinting.

Radiograph taken 2 weeks after injury showing root resorption of the apical fragments

After 10 month

Concussion

treatment objectives There is no need for treatment.

Treatment No treatment is needed only

observation.

Patient instructions Soft food for 1 week.

In a clinical study, endodontic treatment was performed on 48 primary incisors with dark-gray discoloration of the crowns.

Pulp necrosis was found in 37 discolored teeth, without presenting tenderness to percussion, increased mobility, and periapical osteitis

Title Long-term effect of different treatment modalities for traumatized primary incisors presenting dark coronal discoloration with no other signs of injury.

Author Holan G1.Journal Dent Traumatol. 2006 Feb;22(1):14-7.Level of evidence

IIB

aim The aim was to compare the long-term outcomes of root canal treatment with that of follow-up-only in traumatized primary incisors in which dark discoloration is the only sign of injury.

Method Root canal treatment was performed in 48 dark discolored asymptomatic primary incisors following trauma. Twenty-five of them [root canal treatment (RCT) group] were followed till eruption of their permanent successors. Ninety-seven dark discolored asymptomatic primary incisors were left untreated and invited for periodic clinical and radiographic examination. Of these, 28 [follow-up (FU) group] were followed till eruption of their permanent successors.

Result Chi-square test was used for statistical analysis. Seven of 25 (28%) of the RCT group and 32% (nine of 28) of the FU group required early extraction. Five of 25 (20%) of the RCT group and 21% (six of 28) of the FU group showed early or delayed eruption of the permanent successors. Sixteen of 25 (64%) of the RCT group and 79% (22 of 28) of the FU group showed ectopic eruption of the permanent successors. Enamel hypopcalcification or hypoplasia in the permanent successors was equally found (36%) in both groups (nine of 25 in the RCT group and 10 of 28 in the FU group). None of differences was statistically significant.

Conclusion

It can be concluded that more than 50% of the primary incisors that retain their dark coronal discoloration acquired after dental injuries remain clinically asymptomatic till the eruption of the permanent successor even if they present accelerated root resorption. Asymptomatic traumatized primary incisors that retain their dark coronal discoloration may develop a sinus tract and inflammatory root resorption years after the injury. There is still a dilemma: which treatment is better for dark discolored primary incisors: early endodontic treatment or follow-up with the risk of development of infection and root resorption that may require extraction?

Title Development of clinical and radiographic signs associated with dark discolored primary incisors following traumatic injuries: a prospective controlled study.

Author Holan G1.

Journal Dent Traumatol. 2004Oct;20(5):276-87.Level of evidence

III

aim The purpose was to evaluate late complications of asymptomatic traumatized primary incisors with dark coronal discoloration.

Method The clinical and radiographic signs of 97 teeth of the study group were recorded along a follow-up period that ranged between 12 and 75 months (mean >36 months). Children's age at time of injury ranged between 18 and 72 months (mean 40). The control group consisted of 102 non-discolored maxillary primary central incisors in 51 children older than 54 months with no history of dental trauma.

Result In 50 teeth (52%) the color faded or became yellowish and in 47 (48%) it remained dark. Clinical signs of infection, that were diagnosed 5-58 months after the injury, were associated significantly more with dark than yellowish hues (83 and 17%, respectively). Teeth that had changed their color to become yellow presented more PCO than teeth with black/gray/brown coronal discoloration (78 and 6%, respectively). Arrest of dentine apposition was found in 15 teeth, one had yellow coronal discoloration and the remaining 14 had a dark shade. Eleven teeth showed inflammatory root resorption all with dark discoloration. Two atypical types of root resorption were observed: a surface resorption restricted to the lateral aspects of the apical half of the root while the root length remained unchanged and in the other expansion of the follicle of the permanent successor was observed. Expansion of the dental follicle was observed in 72% of all teeth with no significant difference between the various types of coronal discoloration but only half of the cases were associated with resorption of the root of the primary incisor. The various pathologic findings observed in the study group were either absent or rarely seen in the control group.

Conclusion

Root canal treatment of primary incisors that had change their color into a dark-gray hue following trauma with no other clinical or radiographic symptom is not necessary as it does not result in better outcomes in the primary teeth and their permanent successors.

Unfavorable Outcome Dark discoloration of crown. No treatment is needed unless

apical periodontitis develops

Subluxation

Meadowet al. reported subluxations to occur at an incidence of 40% of all trauma.

Andreasen noted this type of injury to occur at a frequency of 12% in all traumatized primary teeth.

Treatment objective No treatment is needed.

Patient instructions Soft food for 1 week.

Unfavorable Outcome Transient red/ gray discoloration or

yellow discoloration indicates pulp obliteration and has a good prognosis

Lateral luxation

Treatment Spontaneous repositioning

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

RepositioningWhen there is occlusal interference local anesthesia should be applied where after the tooth should be repositioned by gentle combined labial and palatal pressure.

ExtractionFor teeth with severe displacement in a labial direction, extraction is the treatment of choice. Extraction is indicated in these cases because of the collision between the primary tooth and the permanent tooth germ.

Slight grindingIn cases with minor occlusal interference, slight grinding is indicated.

From a prospective study of 104 lateral Luxated teeth,99%were realigned within the 1st year.

In an observational study, it was found that of 52 teeth that were left for spontaneous reposition, almost 60%did not disclose any complication.

However, repositioning of lateral luxation was associated with an increased risk of developing pulp necrosis.

Patient instructions Soft food for 10-14 days.

Follow-up Clinical control after 1 and 2-3

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

intrusion

Intrusive luxation has been defined as dislocation of a tooth in an axial direction into the alveolar bone.

This dislocation is considered complete when the tooth is enveloped by surrounding tissues or partial when the incisal border of the crown is visible

-(Andreasen, 1984).

intrusion

Intrusion comprises 8–22% of all luxation injuries of primary anterior teeth (Andreasen and Ravn, 1972).

Other authors have reported prevalence rates as 15.3% (Soporowski et al., 1994), 21% (Onetto et al., 1994), 34% (Garcia-Godoy et al., 1987), and 54% (Robertson et al., 1997).

The degree of intrusion can be divided into 3 grades (Von Arx, 1995)

Grade I. Mild partial intrusion in which more than 50% of the crown is visible.

Grade II. Moderate partial intrusion in which less than 50% of the crown is visible.

Grade III. Severe or complete intrusion of the crown

Management of an intruded primary incisor depends on the following variables:

1. Direction of intrusion,

2. Degree of intrusion,

3. Presence of alveolar bone fracture.

In a retrospective study of 172 intruded teeth, the apices of more than 80% of the teeth were pushed labially.

It was found that most of them re-erupted and survived with no complications for more than 36months post trauma, even in cases of complete intrusion and fracture of the labial bone plate.

Whenever the intrusion is moderate or severe (grade II or III), the tooth rarely reerupts and may become necrotic, indicating the need for extraction (Ravn, 1968; Wilson, 1995).

If signs of reeruption are not evident after 4–8 weeks, ankylosis should be suspected, and extraction should be considered (Harding and Camp, 1995; Borum and Andreasen, 1998).

(A) Complete intrusion of tooth 61in a1-year-old girl. (B) The intruded tooth appears shorter than its contralateral in the periapicalX-ray. (C) In the lateralX-ray, the apex of the intruded tooth is displacedthrough the labial bone plate. (D) Clinical appearance 1month later. (E) Re-eruption at 3months. (F) One year later.

Follow-up 1 week C 3–4 weeks C + R 6–8 weeks C 6 months C+R 1 year C+R and (C*)

Extrusion

Extrusion Partial displacement of the tooth out of its

socket. An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth.

The alveolar socket bone remains intact. In addition to axial displacement, the tooth usually will have some protrusive or retrusive orientation.

Treatment The treatment choice should be based on the

degree of displacement, mobility, root formation and the ability of the child to cope with the emergency situation.

For minor extrusion (< 3mm) in an immature developing tooth, either careful reposition the tooth or leave the tooth for spontaneous alignment.

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

Patient instructions Soft food for 1 week.

Follow-up Clinical control after 1 weeks. Clinical

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

Avulsion

Replacement of avulsed tooth…. May displace a coagulum in to the

follicular space of developing incisor.

Periapical inflammation

External root resorption

Treatment It's not recommended to replant avulsed primary

teeth.

A the initial examination make sure that all avulsed teeth are accounted for.

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

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

Tsukibosi M. treatment planing for traumatize teeth 1st edition , quintessence boo, 2000.

Title Replantation of an avulsed maxillary primary central incisor and management of dilaceration as a sequel on the permanent successor.

Author Sakai VT1, Moretti AB, Oliveira TM, Silva TC, Abdo RC, Santos CF, Machado MA.Author information

Journal Dent Traumatol. 2008 Oct;24(5):569-73.Level of evidence

IVa

Abstract This case report outlines the sequel and possible management of a permanent tooth traumatized through the predecessor, a maxillary right primary central incisor that was avulsed and replanted by a dentist 1 h after the trauma in a 3-year-old girl. Three years later, discoloration and fistula were present, so the primary tooth was extracted. The patient did not come to the scheduled follow-ups to perform a clinical and radiographic control of the succeeding permanent incisor, and only returned when she was 10 years old. At that moment, the impaction and dilaceration of the maxillary right permanent central incisor were observed through radiographic examination. The dilacerated permanent tooth was then surgically removed, and an esthetic fixed appliance was constructed with the crown of the extracted tooth. Positive psychological influence of the treatment on this patient was also observed.

Alveolar fracture

A fracture of the alveolar process which may or may not involve the alveolar bone socket.

Teeth associated with alveolar fractures are characterized by mobility of the alveolar process; several teeth typically will move as a unit when mobility is checked.

Occlusal interference is often present.

Radiographic findings:

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. The horizontal fracture line may run at any level in regard to the permanent tooth germs.

Treatment

Treatment of fracture of the alveolar process includes reduction and immobilization

After administration of local anesthesia, the alveolar fragment is repositioned with digital pressure.

In this type of fracture, apices of involved teeth can often be locked in position by the vestibular bone plate.Andreasen J O, Andreasen F M, Andersson L. Textbook and Color Atlas of

Traumatic Injuries to the Teeth. 4th ed. Munksgaard: Blackwell publication Co. 2007.

Splinting of alveolar fracture can be achieved by means of acid-etch/ resin splint or arch bars.

Intermaxillary fixation is not required provided that a stable splint is used.

Fixation period of 4 week is usually recommended.

In child this period can be reduced to 3 weeks.

Andreasen J O, Andreasen F M, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Munksgaard: Blackwell publication Co. 2007.

Follow-up Splint removal and clinical and

radiographic control after 4 weeks. Clinical control after 1 week. Clinical and radiographic control and

splint removal after 3-4 weeks. Clinical and radiographic control after 

6-8 weeks and 1 year then yearly untill exfoliationh.

Sequele Of Acute Dental Trauma In The Primary

Dentition.

Pulpitis: Pulpitis is the initial response of the tooth to

trauma and it accompanies almost every injury.

Signs include sensitivity to percussion and capillary congestion, which may be clinically apparent from the lingual surface of the tooth using transillumination.

Pulpitis may be reversible in minor injuries or may progress to irreversible pulpitis and pulp necrosis.

Pulp Necrosis

Injured pulps may lose their vitality either because of damage to the vascular tissue at the apex and the resulting ischemia or because of necrosis of exposed coronal pulp tissue.

If the necrotic pulp becomes infected with oral microorganisms either because of luxation of the root and ingress through the lacerated PDL or via an exposed pulp, pain and root resorption can occur.

McTigue DJ. Managing injuries to the primary dentition. Dent Clin North Am. 2009 Oct;53(4):627-38.

Tooth Discoloration

Injuries to the primary incisors frequently cause tooth discoloration .

Blood vessels within the pulp chamber can rupture, depositing blood pigment in the dentinal tubules.

This blood may desorbed completely or can persist to some degree throughout the life of the tooth.

McTigue DJ. Managing injuries to the primary dentition. Dent Clin North Am. 2009 Oct;53(4):627-38.

Teeth that discolor are not necessarily necrotic, particularly when the color change occurs within a few days of the injury.

A yellowish discoloration of both primary and permanent teeth may occur if they undergo pulp canal obliteration

pulp canal obliteration

The entire pulp chamber and canal appear radiopaque in radiographs and the crown may have a yellowish color.

The process of accelerated dentinal apposition in PCO is not well understood, but primary teeth with PCO tend to resorb normally.

Pulp necrosis is rare in teeth with PCO and root canal treatment is rarely indicated in either the primary or permanent dentitions.

McTigue DJ. Managing injuries to the primary dentition. Dent Clin North Am. 2009 Oct;53(4):627-38.

Sequelae In Permanent Dentition After Trauma In

Primary Dentition.

Enamel hypoplasia: This includes discoloration of the

enamel and or defects of the enamel surface.

Discoloration usually ranges from white to yellowish-brown staining.

The hypoplasia normally affects the labial crown surface and ranges from tiny spots to large areas.

Fig. 1.-Enamel discoloration of 31 and 32 in a 9-year-old boy after trauma to their predecessors at 2.5 years of age.Fig. 2.-Buccal enamel defect of 1 1 in an 8-year-old boy after partial luxation of 51 at 1.5 years of age.Fig. 3.-Combined enamel defect and discoloration of 12 in a 9-year-old boy after partial luxation of 52 at 2 years of age.Fig. 4.-Extended enamel hypoplasia of 41 in a 7-year-old boy after partial luxation of 81 at 11 months of age.form

Crown dilaceration

A traumatic displacement of already formed hard tooth substance in relation to the developing soft tissues leads to a deviation of the crown in relation to the long axis of the tooth.

A minor dilaceration consists of a circular enamel defect.

The severe type includes a complete palatal deviation of the crown with additional enamel hypoplasia

Fig. 5a.-Crown dilacerations of 21 and 22 in a 9-year-old boy after partial luxations of 61 and 62 at 2 years of age.

Fig. 5b.-Palatal deviations of the crowns of 21 and 22.

Odontome-like teeth Heavy trauma to the permanent tooth germ at an

early stage of odontogenesis may lead to complete tooth deformation.

Odontome-like disturbances of permanent teeth may develop especially after intrusive or luxation of primary teeth.

On radiographs such malformed teeth present as a conglomeration of hard tissues resembling a complex odontome.

As a rule such malformed teeth do not erupt and must be removed surgically.

Root malformation

Trauma to the epithelial root sheath of Hertwig during root development may lead to root dilaceration or to an arrest of root formation

In the latter case a very short root may develop and tooth eruption will be delayed or completely disturbed.

Other, but very rare, malformations include root duplication and lateral or vestibular root angulation

root dilaceration of 11 with pulpal calcification in a7-year-old girl after partial luxation of 51 at 5 years of age.

Summary…

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