Trauma to baby (primary) teeth commonly occurs between 2-4 years of age. This is at a time when children begin to walk but are not very stable on their feet. The most commonly involved teeth are the upper anterior teeth. Show
Why is it important to seek dental help following dental trauma to primary teeth?Injuries to baby teeth have the potential to disturb the development and health of the underlying permanent teeth. In order to achieve an optimal treatment outcome, a prompt assessment of the injury by a dentist is essential. The assessment would normally involve a thorough history and detailed clinical and radiographic checks. Paediatric dentists are skilled at saving injured primary teeth, although they only do so provided there is no risk to the underlying developing permanent teeth, which have a lifelong functional and aesthetic importance. DISCOLOURED PRIMARY INCISORSColour change is a common indication of primary tooth trauma and may range from yellow to grey to black. Any such colour change in a traumatised primary tooth needs to be investigated. Although colour changes do not necessarily require immediate treatment, discoloured primary teeth are more likely to undergo pathologic changes and should be kept under supervision to ensure the best possible health of the developing permanent teeth. DISPLACED PRIMARY INCISORSThe primary incisors may be displaced in several directions:
Intrusion injuries present a high risk of damage to the developing permanent tooth in the alveolar bone. Therefore the treatment options depend on the relationship between the root of the primary tooth and the crown of the developing permanent tooth. X-rays are necessary to determine this relationship. If there is no evidence of a compromise to the developing permanent tooth, the primary tooth may be left to spontaneously re-erupt. However, the tooth should be extracted if it has not re-erupted within six months. If the intruded tooth appears to have compromised the developing tooth, it should be carefully extracted immediately, to avoid any further damage. For extruded or laterally luxated teeth, the tooth should always be monitored even if there has only been a mild displacement. It may need to be extracted if the displacement is severe. With any type of displacement, a long-term clinical and radiographic follow-up is essential to monitor the vitality of these teeth and to ensure that there is no delayed infection of the root which can damage the developing permanent tooth. FRACTURED BABY TEETHFracture of the primary tooth may occur in the crown or the root of the tooth. The crown fracture may involve the enamel, enamel and dentine or enamel, dentine and the nerve (pulp) of the tooth. The rough edges of simple enamel fractures can be smoothed off. If there is an enamel-dentine fracture, the crown of the tooth needs to be restored to protect the pulp of the tooth. If the fracture also involves the pulp of the tooth, then, depending on the stage of development of the primary tooth it may need to be extracted or have root canal treatment carried out. It is not ideal to carry out root canal treatment on anterior primary teeth due to the close approximation of the root of these teeth to the permanent tooth developing underneath. AVULSED PRIMARY INCISORSThis is complete displacement of a tooth out of its bony socket. There may be associated soft tissue injuries to the lips and gums. Avulsed primary incisors SHOULD NOT be re-planted as this may cause damage to the developing permanent tooth underneath. The alvusion of the primary tooth itself may cause damage to the developing permanent tooth underneath. This may be in the form of disturbance in enamel formation or disturbance in the eruption time of the permanent tooth. The enamel may have a white or brown discolouration or an indentation, depending on the severity of the injury. Should there be a disturbance in the enamel formation, this will not become apparent until the permanent tooth has erupted. PRIMARY TOOTH ROOT FRACTUREThis is a rare occurrence, however, when it occurs, the primary tooth may appear displaced or mobile. Traumatic Dental Injuries: Examination, Diagnosis, and Immediate Care It is well documented that the majority of traumatic dental injuries occur in children. Thus, in a Swedish study, 83% of all individuals with acute dental trauma were younger than 20 years of age [1]. Injuries to primary or permanent teeth can appear rather severe, particularly when associated with trauma to supporting tissues (Figures 18.1 and 18.2). The situation is distressing for both the child and parents. It is important that the dentist and the other members of the dental team are well prepared to meet the many complex and challenging problems in the care of dental emergencies (Box 18.1). Figure 18.1 A 4‐year‐old boy with lateral luxation of three primary incisors and extensive gingival laceration. Figure 18.2 The patient has had an impact where the force has been transmitted through the upper lip to the teeth and the alveolar process. Note the lip laceration and abrasion and the displacement of the right central and lateral incisors. EpidemiologyTraumatic dental injuries are frequent. A Danish study showed that 30% of children had suffered traumatic dental injuries in the primary dentition and 22% in the permanent dentition [2]. The incidence of injuries to primary teeth increases from 1 year of age, and most traumas involve children younger than 4 years of age. In the permanent dentition, the most accident‐prone time is between 8 and 10 years of age (Figure 18.3). Boys appear to sustain injuries to permanent teeth twice as often as girls. Traumatic dental injuries usually affect one or two of the anterior teeth, and especially the maxillary central incisors (Figure 18.4) [3]. Figure 18.3 Percentage distribution of 1275 children with traumatic dental injuries related to age at the time of injury. Source: Skaare & Jacobsen 2003 [3]. Reproduced with permission of John Wiley & Sons. Figure 18.4 Distribution of injuries of the most frequently injured permanent teeth: 97% of all injuries affected the incisors. Source: Skaare & Jacobsen 2003 [3]. Reproduced with permission of John Wiley & Sons. EtiologyIn a young child learning to walk and to run, muscle coordination and judgment are incompletely developed and falling injuries frequently occur. Trauma to the orofacial area may also be part of child physical abuse. The characteristics of this unfortunate condition are presented in Box 18.2. A Norwegian study of children aged from 7 to 18 years reported that 48% of all dental traumas occurred during school hours and 52% during leisure time. Nearly half of the leisure‐time injuries occurred when children were playing. Ten percent happened in traffic, and half of these were bicycle accidents. Twenty‐five percent occurred while partying or visiting bars and clubs [4]. In contrast to common belief, only 8% of all injuries were sports related. Finally, in the age group 16–18 years, 23% of all orofacial injuries resulted from violence [4]. ExaminationTo ensure that all relevant data are recorded, a standardized trauma form is recommended [5]. This form serves as a checklist for the dentist at the initial visit and at subsequent appointments. HistoryWhen the patient is received for treatment, the first step is to gain an initial impression of the extent of the injury. Is there a need for immediate medical care? Is the patient’s general condition affected? If not, the following questions should be asked to end up with a correct diagnosis, and allow treatment planning:
Medical historyA short medical history should include information about medication, allergies, bleeding disorders, and other conditions that could interfere with treatment or prognosis. Ask also if the patient is covered by antitetanus vaccination. Extraoral examinationPalpation of the facial skeleton and mandible and note is taken of soft tissue swelling, bruises, or lacerations to the face and lips. Deep lip wounds are examined closely with respect to tooth fragments or other foreign bodies (Figure 18.5). Figure 18.5 (a) Crown fracture of mandibular lateral incisor and mandibular lip lesion. (b) A radiograph reveals the fractured tooth fragment hidden in the lip lesion. Intraoral examinationThe examination must be systematic and include the recording of:
It is important to examine all teeth within a traumatized area and, in close bite situations, also teeth in the opposite jaw. Particular note is taken of the following factors:
Radiographic examinationA detailed radiographic examination is mandatory in order to obtain an impression of the injury to the teeth, supporting tissues, the stage of root development and, in the case of primary tooth injuries, the relation to permanent successors (Figure 18.6). Before a radiographic examination is carried out, a clinical examination should establish the extent of the trauma region. This area is then radiographed; ideally, the injury site should be viewed from different angulations [6]. Figure 18.6 (a) Clinical condition immediately after severe intrusive luxation of the primary right central incisor. (b) The occlusal exposure shows foreshortening of the intruded tooth, indicating buccal displacement away from the permanent follicle. (c) This is evident in the lateral radiograph, since the apex of the intruded incisor is forced through the buccal bone plate. Permanent teethFor an injured anterior front with all incisors involved, four exposures should be taken (one occlusal and three bisecting angle exposures), where the central beam is directed interdentally between the incisors. This combination of radiographs results in each traumatized tooth being seen from different angulations, which increases the likelihood of diagnosing even minor dislocations (Figure 18.7). Figure 18.7 (a–c) Clinical appearance after lateral luxation of the right central incisor. (d–g) One occlusal and three periapical radiographs. Note that the occlusal exposure is optimal for showing the buccal displacement of the root. (h) The lateral radiograph illustrates where the fracture of the buccal bone plate has occurred (arrow). In deep lip wounds a soft tissue radiograph is essential to diagnose embedded tooth fragments or other foreign bodies. A film is placed between the lips and the alveolar process, and the exposure time should be approximately 25% of a dental exposure time. Primary teethA young child is often difficult to examine radiographically because of fear or lack of cooperation. However, with the parents’ help, it is usually possible to obtain a radiograph of the traumatized area (see also Chapter 8). In these instances an occlusal film held by the parents and a steep exposure angle should be used. This will normally show the position of the displaced tooth and its relation to the permanent successor. However, an extraoral lateral exposure may give additional information in case of suspicion of collision between the primary tooth and the permanent tooth germ. DiagnosisWith combined information from the clinical and radiographic examination, a diagnosis is made and the injury is classified as a guide to the treatment required. In this chapter the classification recommended by the World Health Organization (WHO) will be used. The code numbers are according to the International Classification of Diseases [7]. Injuries to the hard dental tissues and the pulp
Injuries to the hard dental tissues, the pulp, and the alveolar process
Injuries to the periodontal tissues
Injuries to gingiva or oral mucosa
The distribution of various dental diagnoses in the primary and permanent dentition is shown in Figures 18.8 and 18.9, respectively. In the permanent dentition uncomplicated crown fractures are very common [3]. In contrast, luxation injuries dominate in the primary dentition [8]. This is probably due to resilience of the alveolar bone in young children, favoring loosening or displacement rather than fractures of the hard dental tissues. Figure 18.8 Percentage distribution of diagnoses for traumatized primary teeth. Source: Heintz 1968 [25]. Reproduced with permission of Elsevier. Figure 18.9 Distribution of 2019 traumatized permanent teeth according to diagnosis in 1275 children aged 7–18 years. Source: Skaare & Jacobsen 2003 [3]. Reproduced with permission of John Wiley & Sons. Immediate care: primary teethDuring its early development, the permanent incisor is located palatally and in close proximity to the apex of the primary incisor (Figure 18.10). Consequently, with injuries to primary teeth, the dentist must always be aware of possible damage to the underlying permanent teeth. Figure 18.10 Schematic drawing illustrating developmental disturbance of permanent tooth bud at the age of 2 years. The crown of the primary incisor is displaced buccally, forcing the root into the crown of the developing permanent incisor. A young child is often unable to cooperate, and the following procedure is suggested for clinical examination (Figure 18.11):
Figure 18.11 Procedure for examination of a young child’s mouth (see text). In this way, a thorough examination of the oral structures can easily be done in a few minutes. With the assistance of a parent or another adult, it is also possible to obtain radiographs of the traumatized area. However, active treatment such as splinting of loosened teeth or endodontic therapy may be extremely difficult. Therefore, in the majority of cases, the dentist has to decide whether the traumatized tooth is best treated by extraction, or whether it can be maintained without any extensive treatment. A primary incisor should always be removed if its maintenance will jeopardize the developing permanent tooth bud, i.e., if the displaced primary tooth has invaded the follicle of the permanent successor [9]. If treatment is required in a young child, the use of conscious sedation should be considered (Chapter 9). Enamel and enamel–dentin fractureMost crown fractures consist of enamel or superficial enamel–dentin fractures. In both situations, slight grinding of sharp edges is sufficient. If the fracture is extensive, and the child cooperative, the tooth can be restored with glass‐ionomer cement or composite [9]. Complicated crown fractureNormally, extraction is the treatment of choice. However, if full cooperation of the child can be achieved, the same procedure as outlined for permanent teeth can be followed [9]. Crown–root fractureThese cases involve fracture of enamel, dentin, and cementum. Frequently, the pulp is also exposed. Restorative treatment is extremely difficult and the tooth is best extracted [9]. Root fractureIf the coronal fragment is severely dislocated, extraction is the treatment of choice. No effort should be made to remove the apical fragment, as such intervention might damage the underlying permanent tooth. After removal of the coronal fragment, uncomplicated resorption of the apical fragment should be expected (Figure 18.12). Without evident displacement, the coronal fragment may show little mobility, and no immediate extraction is required. The tooth should be kept under observation. Sometimes necrosis develops in the coronal fragment, whereas the apical portion nearly always remains vital. In these cases the coronal fragment only should be extracted [9]. Figure 18.12 (a) Fractured roots of both central incisors with dislocation of the coronal fragments. (b) Normal resorption of the apical fragments after removal of the coronal fragments. Luxation injuriesThese injuries dominate in the primary dentition. Most often, the patients also have extensive soft tissue damage such as swollen lips, lacerations, and hemorrhage of the oral mucosa and gingiva (Figure 18.13). The parents are instructed to clean the traumatized area gently with 0.1% chlorhexidine solution, using cotton swabs (twice daily for a week). Normally the soft tissue heals quickly. Swelling will usually subside within a week. Figure 18.13 Severe soft tissue damage with extensive hemorrhage. Both central incisors and the right lateral incisor are extruded and extremely mobile. ConcussionMost concussions are not seen by the dentist at the time of the accident. The parents may see no need to seek dental treatment, or they may not be aware of the injury until tooth discoloration appears. SubluxationThe parents are advised to keep the traumatized area as clean as possible, and to feed the child on a soft diet for a few days [9]. Mobility should diminish within 1–2 weeks. Extrusive luxationAn extruded tooth may be repositioned by digital pressure. However, if the tooth is severely displaced and shows considerable mobility, the tooth is best treated by immediate extraction [9]. Lateral luxation
Figure 18.14 (a) Severe palatal luxation of the right central incisor. No treatment other than observation was performed. (b) Two months later, the tooth is back in normal position due to tongue pressure. Figure 18.15 Clinical condition immediately after buccal displacement of the left central incisor in an 8‐month‐old girl. Intrusive luxationAn intruded tooth often shows severe displacement. Sometimes it will be completely intruded into the alveolar process and mistakenly assumed to be lost, until a radiograph shows the intruded position (Figure 18.16). With all intrusions, it is essential to clarify whether the root is forced in a palatal or buccal direction. The diagnosis should be based on a combined clinical and radiographic examination. Figure 18.16 (a) Clinical examination after trauma of an 18‐month‐old child. The parents assumed that the right central incisor was lost. (b) The radiograph reveals severe intrusive luxation. Additional radiographs should be taken to disclose the exact direction of the intrusion (see Figure 18.6). Clinical examinationDue to a buccal curve of the apex, the primary root tends to be displaced through the buccal bone plate. It is advisable to palpate the buccal sulcus. If part of the crown is visible, the tooth crown axes will also indicate the direction. Radiographic examinationA foreshortened appearance of the intruded tooth implies buccal displacement of the root and thus away from the permanent tooth germ, whereas an elongated image suggests palatal displacement towards the permanent successor (Figure 18.6). TreatmentIn most cases the root will be displaced in a buccal direction and the primary tooth can be left to re‐erupt spontaneously [9]. The parents are instructed to clean the traumatized area with 0.1% chlorhexidine solution for a week. During the re‐eruption phase, there is a risk of infection, and the patient should therefore be seen for follow‐up a week after the injury. Signs of infection include swelling, spontaneous bleeding, and abscess formation. There may also be a rise in body temperature. In these cases, the traumatized tooth must be removed and antibiotic therapy instituted. Without signs of infection, re‐eruption will generally take place within 2–6 months (Figure 18.17). If re‐eruption fails to occur, ankylosis should be suspected. If the ankylosed tooth interferes with eruption of the permanent successor, it must be removed [9]. Figure 18.17 (a) Condition immediately after intrusive luxation of both central incisors. (b) Re‐eruption is evident 6 months later. If the primary root is displaced palatally, into the follicle of the developing tooth germ, extraction is recommended [9]. Extraction is performed to minimize the risk of bacterial invasion into the follicle which could cause further damage to the developing permanent tooth. Elevators should never be used to luxate the intruded incisors. Forceps should be the only instrument employed for this purpose. The intruded tooth should be grasped mesiodistally and lifted out of its socket in an axial direction. Thereafter digital pressure should be applied to the buccal and palatal aspects of the socket to reposition the displaced bone plates. AvulsionA radiographic examination is essential to ensure that the missing tooth is not intruded (Figure 18.16). Replantation is contraindicated, as pulp necrosis is a frequent complication. Moreover, there is a risk of further injury to the permanent tooth germ by the replantation procedure, whereby the coagulum from the socket can be forced into the follicle [9]. Immediate care: permanent teethThe most common age of trauma to the permanent dentition is between 8 and 10 years (Figure 18.3). This implies that a traumatized tooth often has an open apical foramen, a wide root canal, and fragile dentinal walls in the cervical area. If pulp necrosis develops, no further dentin apposition occurs, and there is a considerable risk of spontaneous root fracture cervically with subsequent loss of the injured tooth (see Chapter 19). Consequently, the primary concern is to maintain pulp vitality to allow continued root formation including physiologic dentin apposition in the critical cervical area. The following recommendations for treatment of acute traumatic injuries is based on the treatment guidelines developed by the International Association of Dental Traumatology [10,11]. Crown fracturesIt is most important to diagnose concomitant periodontal injuries, since the risk of complications to crown fractures is significantly increased with an additional luxation injury (Figures 18.18 and 18.19) [12–14].
Figure 18.18 Uncomplicated crown fracture involving either mesial corners or entire incisal edge. The gingival bleeding indicates that intrusive luxation has also occurred in the right central incisor. Figure 18.19 (a) Both subluxation and uncomplicated crown fracture have occurred in the left central incisor. (b) The tooth is stabilized with a splint, and a temporary crown restoration is applied. Figure 18.20 (a) Enamel–dentin fracture of the left central incisor in an 8‐year‐old boy. (b) The fractured crown fragment. (c) Condition immediately after reattachment of the fragment. Figure 18.21 (a) A 12‐year‐old girl with enamel–dentin fracture of the left central incisor. (b) Condition shortly after the composite crown build‐up. Figure 18.22 Right central incisor with a small pulpal exposure, but with loosening and marked tenderness to percussion. Partial pulpotomy was decided to be the treatment of choice. Apr 26, 2017 | Posted by mrzezo in General Dentistry | Comments Off on 18: Traumatic Dental Injuries Which injury has occurred when the injured tooth has been forced into the alveolus?Intrusive luxation is one of the most severe forms of traumatic injuries in which the affected tooth is forced to displace deeper into the alveolus. As a consequence of this type of injury, maximum damage occurs to the pulp and all the supporting structures.
What is avulsion and luxation?Extrusion: tooth appears longer than normal and is mobile both vertically and horizontally. Lateral luxation: tooth crown is displaced in either a labial or palatal/lingual direction. Avulsion: intact tooth is totally displaced from its alveolus.
What is concussion injury of tooth?Concussion is characterized by an injury of the tooth support structures without increased tooth mobility or tooth displacement, but with reaction to the horizontal or vertical percussion, and may be associated with crown fracture 3 , 15 .
What happens when a tooth is avulsed?An avulsed tooth occurs when a tooth is completely dislodged from its socket. Avulsed teeth are dental emergencies and require immediate treatment. To save your tooth, try reinserting your tooth right away. Teeth treated within 30 minutes to one hour have the best chance of success.
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