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Trauma in the Primary Dentition

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... and gingivae Remove any tooth ... the cementum What to Tell Parents Clean tooth under tap water Replant and maintain pressure for 5-10 minutes Bring child ... – PowerPoint PPT presentation

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Title: Trauma in the Primary Dentition


1
Trauma in the Primary Dentition

Dr.E.S.Jabbarifar.
2
Epidemiology(Permanent)
  • Boys gt Girls
  • 9-11 year olds
  • Maxillary central incisors
  • Class I fractures
  • Patients with increased overjet

3
Epidemiology(Primary)
  • Incidence - up to 30
  • Location - anterior teeth
  • 71 maxillary central incisors
  • Sex predilection - varies according to author and
    age.

4
Incidence in Sports
  • Soccer players are at increased risk of an
    orofacial injury than football players

Flanders, JADA, Vol.126, April 1995
5
Incidence in Sports
  • Basketball players risk is double that of a
    football player
  • Due to faceguards and mouth protectors that are
    mandatory in football.

6
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
7
Mouthguards
  • Aids in preventing condylar injuries
  • Aids in preventing against dental-alveolar
    injuries

8
Condylar Injuries
Without mouthguard
With mouthguard
Photos courtesy of Dr. Ray Padilla, D.D.S.
http//sportsdentistry.com
9
Types of Mouthguards
  • Stock
  • Boil and bite
  • Custom vacuum formed
  • Custom pressure laminated

10
Stock Mouthguards
11
Stock Mouthguards
12
Boil and Bite
13
Custom Mouthguard - Vacuum
14
Pressure Laminated
Photos courtesy of Dr. Ray Padilla, D.D.S.
http//sportsdentistry.com
15
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
16
Medical History
  • Take a full medical history
  • Pay particular attention to
  • drug sensitivities
  • congenital or acquired cardiac problems
  • coagulation disorders
  • Determine tetanus coverage

17
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
18
WHEN IN DOUBT REFER TO ER!!!
19
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

20
Reaction of the Tooth to Trauma
  • Pulpal hyperemia
  • Internal hemorrhage
  • Calcific metamorphosis
  • Internal resorption
  • Peripheral root resorption
  • Pulpal necrosis
  • Ankylosis

21
Pulpal Hyperemia
  • May lead to infarction and necrosis

22
Internal Hemorrhage
  • Capillary rupture due to increased pressure
  • Within 2-3 weeks

23
Internal Resorption
  • Due to osteoclastic action
  • Institute endodontic tx. immediately
  • "Pink spot" perforation may occur

24
Calcific Metamorphosis
25
Calcific Metamorphosis
26
Calcific Metamorphosis
27
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

28
Pulpal necrosis
  • Due to severing of apical vessels or prolonged
    hyeremia and strangulation
  • May not occur for several months

29
Ankylosis
  • PDL injury gt inflammation gt osteoclastic activity
    gt fusion between bone and root surface

30
Reaction of the Permanent Tooth Buds
  • Hypocalcification/hypoplasia (Turner's tooth -
    due to trauma, infection, or both)
  • Reparative dentin
  • Dilaceration
  • Sequelae of chronic infection

31
Position of Primary Teeth
32
Dilaceration/Turners Tooth
33
Dilaceration
34
Focal Hypoplasia Hypocalcification
35
Sequelae of chronic infection.
36
Dental History
  • How?
  • When?
  • Where?
  • Was there a previous injury to area?
  • Was there previous treatment to area?
  • Unconsciousness, headache, amnesia, nausia?
  • Bite disturbance?

37
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

38
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

39
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

40
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

41
Class I Primary (enamel fracture)
  • Smooth enamel
  • Check vitality in 6-8 weeks

42
Class II Primary (dentin involved)
  • Dycal
  • Restore
  • Check in 6-8 weeks

43
Class III Primary (pulp involved)
  • Formocresol pulpotomy, at least
  • Restore
  • Check in 6-8 weeks

44
Class IV Primary (pulp necrotic)
  • Formocresol pulpectomy, in absence of significant
    internal or external root resorption
  • Extraction /- space maintainer if endodontic
    treatment not possible

45
Extraction and Space Maintainer
46
Extraction and Space Maintainer
47
Extraction and Space Maintainer
48
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

49
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

50
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

51
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.

52
Splinting
  • .030 Stainless steel wire Composite (old)
  • .0175 Twist (Wildcat) Composite
  • Composite alone
  • Avulsion 7 days
  • Root fractures 1-3 months

53
Splinting (not good.)
54
Splinting
55
Class VI Primary (root fracture)
  • Extraction is almost always the treatment of
    choice

56
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

57
Intrusion, Primary Teeth
Intrusion of primary incisors
18 months later
Photos by the Dental Trauma Server, University of
Geneva
58
Lateral Luxation
Photos by the Dental Trauma Server, University of
Geneva
59
Lateral Luxation
Photos by the Dental Trauma Server, University of
Geneva
60
Lateral Luxation
Photos by the Dental Trauma Server, University of
Geneva
61
Class VIII Primary - Coronal/Root Fracture
  • Extraction is usually the only option

62
Class VIII Primary - Coronal/Root Fracture
  • Radiograph day of trauma

63
Class VIII Primary - Coronal/Root Fracture
64
Class VIII Primary - Coronal/Root Fracture
  • Radiograph one month later

65
Class VIII Primary - Coronal/Root Fracture
  • Tooth following extraction

66
Combination Trauma Case
  • 9 year 8 month male
  • Bike accident yesterday
  • History of asthma
  • Taking Ritalin (nausia, dry mouth, BP changes)

67
Combination Trauma Case
68
Combination Trauma Case
69
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
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