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DENTAL TRAUMA
IN PEDIATRIC DENTISTRY
Charles Lekic DDM, MSc, PhD, FRCD (C)
May 2015
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
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.
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
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 ?)
History of a dental injury
When did the
injury occur?
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)
History of a dental injury (cont’d)
How did the accident
happen? To provide
information
regarding the
severity of the injury
Clinical examination
Extraoral Examination
Examine and
palpate facial
skeleton, record
wounds and bruises.
Palpate TMJ joints
and check for eye
and mandibular
movements.
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.
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.
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)
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
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
Wearing mouthguards when involved in contact
type of activities would make make the rest of the
presentation very short
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
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.
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
Treatment of tooth fractures in permanent
dentition
Fractures of enamel and dentin (cont’d): etch, rinse
Treatment of tooth fractures in permanent
dentition
Fractures of enamel and dentin (cont’d): place bond
and primer, light cure, prepare a celluloid crown
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
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
Treatment of tooth fractures in permanent
dentition
Enamel and dentin
fractures with open pulp
(cont’d):
a) direct pulp capping
b) pulpotomy
c) apexification
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)
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
Treatment of displacement injuries in primary
teeth Cont’d)
Extrusion – extract
Lateral luxation - if possible reposition, when very mobile extract
Avulsion - do not replant
Treatment of displacement injuries in permanent teeth
• Concussion – diet instructions, Tylenol, follow-up examination (for at least 1 year).
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
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.
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.
Treatment of displacement injuries in permanent
teeth (cont’d)
Note that bonding of the injured tooth is
done at the end
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.
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.
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.
Tooth avulsion - important considerations: Viability of periodontal ligament cells
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
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?
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
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
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
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.
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.
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.
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.
Thank you for your attention
