Trauma in the Primary Dentition

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Trauma in the Primary Dentition

Dr.E.S.Jabbarifar.
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Epidemiology(Permanent)

• Boys gt Girls
• 9-11 year olds
• Maxillary central incisors
• Class I fractures
• Patients with increased overjet

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Epidemiology(Primary)

• Incidence - up to 30
• Location - anterior teeth
• 71 maxillary central incisors
• Sex predilection - varies according to author and
  age.

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Incidence in Sports

• Soccer players are at increased risk of an
  orofacial injury than football players

Flanders, JADA, Vol.126, April 1995
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Incidence in Sports

• Basketball players risk is double that of a
  football player
• Due to faceguards and mouth protectors that are
  mandatory in football.

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Slam Dunking

• May cause serious dental injury
• Typical patient
• male
• 12 years old
• about 5 feet tall
• slam dunking on lowered backboard or raised take
  off area

Kumamoto, et al, JADA, Sep 1997
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Mouthguards

• Aids in preventing condylar injuries
• Aids in preventing against dental-alveolar
  injuries

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Condylar Injuries
Without mouthguard
With mouthguard
Photos courtesy of Dr. Ray Padilla, D.D.S.
http//sportsdentistry.com
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Types of Mouthguards

• Stock
• Boil and bite
• Custom vacuum formed
• Custom pressure laminated

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Stock Mouthguards
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Stock Mouthguards
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Boil and Bite
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Custom Mouthguard - Vacuum
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Pressure Laminated
Photos courtesy of Dr. Ray Padilla, D.D.S.
http//sportsdentistry.com
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Domestic Violence?

• 23 of patients with HNF injuries were victims of
  DV
• 94.4 of victimes of domestic violence had HNF
  injuries
• Patients with HNF injuries were 11.8 times more
  likely to be victims of DV
• Caution preliminary study, small sample size
  age 15 and older.

Ochs, et al, JADA, Vol. 127, June 1996
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Medical History

• Take a full medical history
• Pay particular attention to
• drug sensitivities
• congenital or acquired cardiac problems
• coagulation disorders
• Determine tetanus coverage

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Neurological Assessment

• Obtain information re loss of consciousness,
  neck or head pain, and numbness
• Ask about the event. amnesia?
• Other signs nausea, vomiting, drowsiness,
  blurred vision

Davis, et al JDC, March April 1995
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WHEN IN DOUBT REFER TO ER!!!
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Tetanus Coverage

• Uncovered children - antitoxin (tetanus immune
  human globulin)
• Children with previous but dated coverage -
  toxoid booster
• Active immunization
• 3 injections of DPT during 1st year
• booster at 1 1/2 and 3 years
• booster at 6 YOA and every 4-5 years

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Reaction of the Tooth to Trauma

• Pulpal hyperemia
• Internal hemorrhage
• Calcific metamorphosis
• Internal resorption
• Peripheral root resorption
• Pulpal necrosis
• Ankylosis

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Pulpal Hyperemia

• May lead to infarction and necrosis

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Internal Hemorrhage

• Capillary rupture due to increased pressure
• Within 2-3 weeks

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Internal Resorption

• Due to osteoclastic action
• Institute endodontic tx. immediately
• "Pink spot" perforation may occur

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Calcific Metamorphosis
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Calcific Metamorphosis
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Calcific Metamorphosis
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Peripheral Root Resorption

• Due to damage of peridontal structures
• Usually in severe injuries with displacement of
  the tooth
• Types
• surface - normal PDL, small areas
• replacement - ankylosis
• inflammatory - granulation tissue, radiolucency

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Pulpal necrosis

• Due to severing of apical vessels or prolonged
  hyeremia and strangulation
• May not occur for several months

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Ankylosis

• PDL injury gt inflammation gt osteoclastic activity
  gt fusion between bone and root surface

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Reaction of the Permanent Tooth Buds

• Hypocalcification/hypoplasia (Turner's tooth -
  due to trauma, infection, or both)
• Reparative dentin
• Dilaceration
• Sequelae of chronic infection

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Position of Primary Teeth
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Dilaceration/Turners Tooth
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Dilaceration
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Focal Hypoplasia Hypocalcification
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Sequelae of chronic infection.
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Dental History

• How?
• When?
• Where?
• Was there a previous injury to area?
• Was there previous treatment to area?
• Unconsciousness, headache, amnesia, nausia?
• Bite disturbance?

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Soft Tissue Injuries

• Examine lacerations and contusions of the face,
  lips, and gingivae
• Remove any tooth fragments or debris embedded in
  the tissue
• Gently cleanse the area to aid in visual
  examination (topical anesthetic, soaked gauze
  sponges)
• Develop treatment plan

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Hard Tissue Injuries

• Examine teeth and alveolar process
• Note extent of crown fracture, if any
• Check for displaced or avused teeth
• Note amount of mobility
• Check for pulp exposures
• Examine adjacent/opposing teeth for injury

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Radiographic Examination

• X-ray injured tooth, adjacent teeth, and opposing
  teeth
• Evaluate proximity of fracture to pulp
• Estimate root development
• Look for root and alveolar fractures
• Note any periapical pathology
• Note previous treatment

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Other Diagnostic Tests

• Wait at leat 2 weeks
• Electrical and thermal tests may be unreliable in
  primary teeth
• If a tooth is incompletely erupted or is being
  orthodontically treated, the tooth may be normal
  even if there is little sensitivity to EPT - 20
  of normals with 3/4 erupted teeth show no
  response to vitalometer

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Class I Primary (enamel fracture)

• Smooth enamel
• Check vitality in 6-8 weeks

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Class II Primary (dentin involved)

• Dycal
• Restore
• Check in 6-8 weeks

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Class III Primary (pulp involved)

• Formocresol pulpotomy, at least
• Restore
• Check in 6-8 weeks

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Class IV Primary (pulp necrotic)

• Formocresol pulpectomy, in absence of significant
  internal or external root resorption
• Extraction /- space maintainer if endodontic
  treatment not possible

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Extraction and Space Maintainer
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Extraction and Space Maintainer
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Extraction and Space Maintainer
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Class V Primary (avulsion)

• Poor prognosis
• If within 30 minutes, replant, splint if
  necessary, soft diet, follow with primary
  endodontic treatment
• Space maintainer if endodontic treatment not
  possible

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Cleaning an Avulsed tooth

• Saline to remove foreign bodies and bacteria
• Flush alveolus with saline to remove coagulum
  failure to do this increases chance of ankylosis
• Avoid scraping the root surface this removes
  periodontal fibers and denudes the cementum

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What to Tell Parents

• Clean tooth under tap water
• Replant and maintain pressure for 5-10 minutes
• Bring child to office immediately
• If parent can't replant, put tooth into a cup of
  milk

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Replantation

• "Periodontal Healing of Replanted Dog Teeth
  Stored in Viaspan, Milk, and Hank's Balanced Salt
  Solution" Trope, Endod Dent Traumatol, Jan-Feb,
  1993.
• Viaspan (a storage media used in organ
  transplants) and HBSS proved superior to milk for
  long term storage (gt6 hrs) of avulsed teeth.

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Splinting

• .030 Stainless steel wire Composite (old)
• .0175 Twist (Wildcat) Composite
• Composite alone
• Avulsion 7 days
• Root fractures 1-3 months

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Splinting (not good.)
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Splinting
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Class VI Primary (root fracture)

• Extraction is almost always the treatment of
  choice

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Class VII Primary (displacement)

• Labial, lingual, extrusion - reposition tooth,
  compress alveolar bone, stabilize if necessary,
  check periodically
• Intruded primary tooth
• allow 2-4 months for eruption
• if ankylosis occurs, may luxate and check in 1
  month, or remove

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Intrusion, Primary Teeth
Intrusion of primary incisors
18 months later
Photos by the Dental Trauma Server, University of
Geneva
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Lateral Luxation
Photos by the Dental Trauma Server, University of
Geneva
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Lateral Luxation
Photos by the Dental Trauma Server, University of
Geneva
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Lateral Luxation
Photos by the Dental Trauma Server, University of
Geneva
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Class VIII Primary - Coronal/Root Fracture

• Extraction is usually the only option

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Class VIII Primary - Coronal/Root Fracture

• Radiograph day of trauma

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Class VIII Primary - Coronal/Root Fracture
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Class VIII Primary - Coronal/Root Fracture

• Radiograph one month later

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Class VIII Primary - Coronal/Root Fracture

• Tooth following extraction

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Combination Trauma Case

• 9 year 8 month male
• Bike accident yesterday
• History of asthma
• Taking Ritalin (nausia, dry mouth, BP changes)

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Combination Trauma Case
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Combination Trauma Case
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Just for Baseball Fans
None of us, Mickey included, would want to be
held to account for every moment of our lives.
But how many of us could say that our best
moments were as magnificent as his? Bob
Costas