MANAGEMENT OF TRAUMATIC DENTAL INJURIES IN CHILDREN dental... · Class 9 Traumatic injuries of primary teeth . ... Injury to hard dental tissues Injury to periodontal tissues Injury

NAHDA UNIVERSITY

MANAGEMENT OF TRAUMATIC DENTAL INJURIES IN CHILDREN

Dr. AHMAD ABDEL HAMID ELHEENY

2019

Faculty of Dentistry, Minia University, Egypt

Dr. AHMED ABDEL HAMID ELHEENY Page 2 of 19

I. Epidemiology, Etiology and Predisposing Factors

For primary dentitions

For permanent dentitions

Peak age 2 to 4 years 7 to 14 years

Frequently

affected teeth

Maxillary incisors

Maxillary incisors

Gender Nearly boys are equal to girls Boys more than girls

Common type of

tooth injury

Luxation injuries

Crown fractures

Etiology

Children are developing

mobility skills

Accidents

Child abuse

Children with seizures and

cerebral palsy

Falls during play

Contact sports

Children with seizures and

cerebral palsy

Predisposing

factors

Class II division 1 and

increased the anterior overjet

Inadequate lip coverage

Dental anomalies

As in primary dentition

II. Classification of Trauma to Anterior Teeth

1. Classification by Ellis and Davey (1970)

Class 1 Simple fracture of the crown-involving little or no dentin

Class 2 Extensive fracture of the crown involving considerable dentin, but not the

pulp

Class 3 Extensive fracture of the crown involving considerable dentin, and exposing

the dental pulp

Class 4 The traumatized tooth which becomes nonvital with or without loss of

crown structure Class

Class 5 Teeth lost as a trauma

Class 6 Fracture of the root with or without loss of crown structure Class

Class 7 Displacement of the tooth-without fracture of crown or root

Class 8 Fracture of the crown en masse and its replacement

Class 9 Traumatic injuries of primary teeth


2. Clinical classification of traumatic dental injuries (TDI) including codes of the

WHO International Classification of Diseases to Dentistry and Stomatology

Injury to hard dental tissues

Injury to periodontal tissues

Injury to supporting bone

Injury to soft tissues

III. History of Injury

Sometimes, the dental treatment cannot be started immediately because other

injuries have higher priority. The force strong enough to fracture, intrude, or avulse a

tooth is also strong enough to result in cervical spine or intracranial injury. The dentist

must be particularly alert to such potential problems, be prepared ahead of time to

make a neurologic assessment, and make appropriate medical referral when indicated

without delay

1. Patient’s name, age, sex, address, and telephone number

2. WHEN did injury occur?

3. WHERE did injury occur?

4. HOW did injury occur?

5. Treatment elsewhere

6. History of previous dental injuries

7. General health of the child


1. Patient’s name, age, sex, address, and telephone number

For legal aspects, communication/behaviour management concerns and periodic

follow-up

2. WHEN did injury occur?

For diagnosis and treatment plan concerns

3. WHERE did injury occur?

4. HOW did injury occur?

Provide the dentist with information regarding

Severity

Prediction in regard to the consequences of the injury (e.g. a blow under chin

may cause subcondylar fracture and/or fractures of premolars)

5. Previous Treatment

Such as immobilization, reduction or replantation of teeth, should be

considered before further treatment is instituted

It is also important to ascertain how the avulsed tooth was stored, e.g. tap

water, sterilizing solutions, or dry

6. History of previous dental injuries

Repeated injuries to their teeth can influence pulpal sensibility and

recuperative capacity of the pulp and/or periodontium

7. Medical History

1. Congenital heart disease may need prophylaxis against infectious

endocarditis

2. Bleeding disorders

3. Allergies such as penicillin allergy which need a shift toward another

medication

When the most recent dose

Child has a completed primary tetanous dephteria series

Wound assessementContaminated with dirt, feces,soil and puncture

wounds

Yes

If wihtin the past 5 years, No need

for vaccine

If more than 5 years, Vaccine

today

NO/Unknown

Vaccine and TIG immediately


4. Seizures disorders

5. Tetanus immunization status was discussed above

IV. Examination

1. Extra-oral Examination

Neurological assessment

1. Episodes of amnesia, unconsciousness, drowsiness, vomiting or headache

indicate cerebral involvement

2. Shock signs (pallor, cold skin, irregular pulse, hypotension), symptoms of

head injury suggesting brain concussion, or maxillofacial fractures

3. Bleeding or discharge of clear fluid from ears and nose

4. Facial swelling, bruises, or lacerations may indicate underlying bony and tooth

injury

5. Subconjunctival hemorrhage may indicate fracture of zygomatic complex

6. Quick evaluation of cranial nerves through

Extraocular muscles are intact and functioning appropriately; that is, the

patient can track a finger moving vertically and horizontally through the

visual field with the eyes remaining in tandem

Pupils are equal, round, and reactive to light with accommodation

Sensory function is normal as measured through light contact to various

areas of the face

Symmetry of motor function is present, as assessed by having the patient

frown, smile, move the tongue, and perform several voluntary muscular

movements

7. Limitation of mandibular movement or mandibular deviation on opening or

closing the mouth indicate either jaw fracture or dislocation

8. Crown fracture with associated swollen lip

2. Intraoral Examination

2.1 Soft tissues examination Laceration of gingiva, labial/buccal mucosa, tongue and floor of the mouth

Presence of embedded tooth fragments

Hematoma in the floor of the mouth may indicate mandibular fracture

2.2 Hard tissues examination

2.2.1 Bone

2.2.2 Tooth

The following should be recorded:

Displacement (laxative injury)

Discoloration indicates the dental pulp condition (e.g. dark color may indicate

necrotic pulp tissues, reddish color may indicate pulp hyperaemia)

Abnormalities of occlusion may be due to fractured dentoalveolar portion or

displacement of the teeth

Mobility may be in horizontal or vertical direction. If two or more teeth move

at a time, alveolar fracture must be suspected


Pain with percussion or palpation with finger tapping may indicate injury to

ligaments. A useful clinical test is to apply finger pressure to the tooth and

check the child’s response by watching the eyes

Fiberoptic transillumination for cracks and pulp vitality

Dyes for cracks as methylene blue or india ink

3. Pulp testing

Pulp testing of recently traumatized tooth may not be reliable. The pulps of

these teeth, however, may still be vital as their blood vessels remain intact or have

revascularized. It may take 8 weeks, or longer, before a normal pulpal response can be

elicited. A more accurate assessment of pulp vitality would be made by determining

the presence of a functioning blood supply, thus allowing the healing potential to be

evaluated at an earlier stage

3.1. Thermal pulp testing

Traumatized tooth

Sock wave “injury to nerve fibers

Thermal or EPT may give false negative

Cold tests

• Ice cones

• Ethyl chloride (-41°C)

• Dichlorodifluoromethane (DDM) (-0°C)

• Dry ice (-72°C)

Hot tests

• Heated gutta-percha

• Hot water


3.2. EPT Requirements

Tooth isolation

Plastic strip interperoximally

Don’t place the current on metallic restoration, ortho. Appliance or crowned

tooth

Electric pulp tests and thermal tests are of limited value because of Varied responses as roots mature.

Unreliable responses from children because of fear, management problems,

and inability to understand or communicate accurately

Consequently, most diagnoses are made on observation of clinical symptoms and

radiographic evidence of pathosis

3.3. Laser Doppler Flowmeter LDF Source of laser: Helium Neon (633nm) or

Diode Laser (780-810 nm)

The technique utilizes a beam of infrared light produced by a laser that is directed into

the tissue. As light enters the tissue, it is scattered and adsorbed by moving red blood

cells and stationary tissue elements

4. Radiographic examination

4.1 Conventional two-dimensional Radiographic techniques

4.1.1 Indications

Recent pre- operative radiographs are requisites to pulp therapy in primary and young

permanent teeth

Proximity of fracture line from the pulp (not pulp exposure)

Periapical or interradicular bone radiolucenies

Widening of PMS

Pulp calcification

Detect presence or absence of IRR and/or ERR

Detect the degree of root development

Relation between injure tooth and its successor

Degree of root resorption of primary teeth

Root fracture (vertical or horizontal and its level)

4.2 Types of Conventional Radiographs

4.2.1 Periapical radiograph

Reproducible 'long cone technique' periapicals are the best for accurate diagnosis and.

Two radiographs at different angles may be essential to detect a root fracture.

Periapical films positioned behind lips can be used to detect foreign bodies. However,

if access and co-operation are difficult then one anterior occlusal radiograph rarely

misses a root fracture

4.2.2 Occlusal Radiograph

To detect root fractures when used intraorally and foreign bodies within the soft tissue

when used extraorally


4.2.3 Orthopantogram

Essential ill all trauma cases when underlying bone injury is suspected

4.3 Three- dimensional Imaging

Modern 3D imaging techniques provide the third dimension that may not be clinically

obvious chair-side. Traumatic dental injuries are often more complex and involve

several tissues, besides the dental structures. The utilization of 3D imaging helps

define the complexities, and reveal this otherwise hidden information, which may

assist in understanding the type of injuries sustained and the treatment(s) needed

4.3.1 Cone Beam Computed Tomography (CBCT) While there is no debate regarding the benefits of CBCT in dental and maxillofacial

trauma, all clinicians should be aware of, and apply the principles of ALARA (As

Low As Reasonable Achievable) for recommended radiologic exposures when using

CBCT or any other imaging technique. To minimize radiation exposure while

maximizing diagnostic information, clinicians should consider the use of CBCT only

when the need for information cannot be obtained adequately by lower dose

conventional dental radiography or alternate imaging modalities

V. Management of Hard Dental Tissues injures of Young Permanent Incisors

1. Enamel infractions

1.1 Clinical Findings

Crazing within the enamel substance which do not cross the DEJ junction

An incomplete fracture (crack) of the enamel without loss of tooth structure.

Not tender. If tenderness is observed evaluate the tooth for a possible luxation

injury or a root fracture.

Fiber optic light sources are also very useful in detecting infractions.

The presence of infraction lines should draw attention to the possible presence of

associated injuries, especially to the supporting structures

1.2 Radiographic Findings

No radiographic abnormalities

Radiographs recommended: a periapical view. Additional radiographs are

indicated if other signs or symptoms are present

1.3 Treatment

In case of marked infractions, etching and sealing with resin to prevent discoloration

of the infraction lines. Otherwise, no treatment is necessary

1.4 Flow-up Period

Clinical and radiographic examination at 6-8 weeks and 1 year

2. Enamel Fracture

2.1 Clinical Findings A complete fracture of the enamel

Loss of enamel.

No visible sign of exposed dentin

Not tender. If tenderness is observed evaluate the tooth for a possible luxation

or root fracture injury

Normal mobility


Sensibility pulp test usually positive


Enamel loss is visible

Radiographs recommended: periapical, occlusal and eccentric exposures. They

are recommended in order to rule out the possible presence of a root fracture

or a luxation injury.

Radiograph of lip or cheek to search for tooth fragments or foreign materials.

2.3 Treatment

Smoothing the rough, jagged tooth structure

If the tooth fragment is available, it can be bonded to the tooth.

Contouring or restoration with composite resin depending on the extent and

location of the fracture.

2.4 Flow-up Period


3. Enamel-Dentin Fracture

3.1 Aim of Immediate Treatment Protection

Restoration

Maintaining

3.2 Clinical Findings A fracture confined to enamel and dentin with loss of tooth structure, but not

exposing the pulp

Percussion test: not tender

If tenderness is observed, evaluate the tooth for possible luxation or root

fracture injury

Normal mobility

Sensibility pulp test usually positive


Enamel-dentin loss is visible and the rest as mentioned in enamel fracture

3.4 Treatment

If a tooth fragment is available, it can be bonded to the tooth. Otherwise

perform a provisional treatment by covering the exposed dentin with glass

Ionomer or a more permanent restoration using a bonding agent and composite

resin, or other accepted dental restorative materials

Fragment Reattachment Technique

A trial seated to confirm a precise fit of the fragment

The exposed dentin of the fractured tooth was covered with a thin layer of

hard setting calcium hydroxide that was allowed to remain as a sedative

dressing between the tooth and the restored fragment.

A portion of the dentin in the fragment was removed to provide space for the

calcium hydroxide dressing

The fragment was then soaked in etchant, and the fractured area of the tooth

was also etched well beyond the fracture site

After thorough rinsing and drying of all etched enamel, the fragment and the

etched portion of the tooth dentin bonding agent is used

The selected shade of composite resin was used to fill the prepared void in the

fragment, and it was then carefully seated into its correct position and held

firmly while the material was cured with the light


A small amount of external enamel had been lost, which left a defect about 1

mm in diameter on the labial surface. This defect was also filled with the

composite resin, and a second layer of sealant was painted over all margins

and cured

3.5 Flow-up Period


4. Crown Fracture with Pulp Exposure


A fracture involving enamel and dentin with loss of tooth structure and

exposure of the pulp

Normal mobility Percussion test: not tender. If tenderness is observed,

evaluate for possible luxation or root fracture injury.

Exposed pulp sensitive to stimuli


Enamel-dentin loss is visible and the rest as mentioned in enamel fracture

4.3 Treatment

Factors Affecting treatment choice

1. Vitality

2. Time

3. Size

4. Degree of root maturation

5. Restorability

6. Physical condition

Treatment details were discussed in details in nanagement of deep caries in

children lecture

4.4 Flow-up Period


5. Crown-Root Fracture without Pulp Exposure


A fracture involving enamel, dentin and cementum with loss of tooth structure,

but not exposing the pulp. Crown fracture extending below gingival margin

Percussion test: Tender

Coronal fragment mobile

Sensibility pulp test usually positive for apical fragment


Radiographs recommended: periapical, occlusal and eccentric exposures. They

are recommended in order to detect fracture lines in the root

CBCT

5.3 Treatment

5.3.1 Emergency treatment

Dentin protection as mentioned before

As an emergency treatment a temporary stabilization of the loose segment to

adjacent teeth can be performed until a definitive treatment plan is made

5.3.2 Non-Emergency Treatment

Alternatives Fragment removal only

Removal of the coronal crown-root fragment and subsequent restoration of the

apical fragment exposed above the gingival level


Fragment removal and gingivectomy (sometimes ostectomy)

Orthodontic extrusion of apical fragment

5.4 Flow-up Period


6. Crown-Root Fracture with Pulp Exposure


A fracture involving enamel, dentin, and cementum and exposing the pulp

Percussion test: tender

Coronal fragment mobile


As mentioned in crown root fracture without pulp exposure

6.3 Treatment

Pulp protection discussed in crown fracture with pulp exposure

Fragment management discussed in crown root fracture without pulp exposure

6.4. Flow-up Period


7. Root Fracture


The coronal segment may be mobile and or displaced

The tooth may be tender to percussion

Bleeding from the gingival sulcus

Sensibility testing may give negative results initially

Monitoring the status of the pulp is recommended

Transient crown discoloration (red or grey) may occur

7.2 Radiographic Findings The fracture involves the root of the tooth and is in a horizontal or oblique

plane

Fractures that are in the horizontal plane can usually be detected in the regular

periapical 90˚ angle film with the central beam through the tooth. This is

usually the case with fractures in the cervical third of the root

If the plane of fracture is more oblique which is common with apical third

fractures, an occlusal view or radiographs with varying horizontal angles are

more likely to demonstrate the fracture including those located in the middle

third

7.3 Treatment

7.3.1 Healing of the root fracture: According to Andresen

Calcified tissue: (Bridge of dentin and cementum); healing occurs by calcified

tissue

Interposition of connective tissue

Interposition of bone and connective tissue

Interposition of granulation tissue

7.3.2 Steps

Reposition, if displaced, the coronal segment of the tooth as soon as possible

Check position radiographically

Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near

the cervical area of the tooth, stabilization is beneficial for a longer period of

time (up to 4 months)


It is advisable to monitor healing for at least one year to determine pulpal

status

If pulp necrosis develops, root canal treatment of the coronal tooth segment to

the fracture line is indicated to preserve the tooth

7.4 Flow-up Period

Clinical and radiographic examination at 2, 4 and 6-8 weeks,4 months, 6

months,1 year and up to 5 years

VI. Management of Periodontal Tissue injures of Young Permanent Incisors

1. Concussion


Injury to the tooth-supporting structures without abnormal loosening or

displacement of the tooth

The tooth is tender to touch or tapping; it has not been displaced and does not

have increased mobility



1.3 Treatment

No treatment is needed

Monitor pulpal condition for at least one year

1.4 Flow-up Period


2. Subluxation


Injury to tooth-supporting structures with abnormal loosening but without

tooth displacement

The tooth is tender to touch or tapping and has increased mobility; it has not

been displaced

Bleeding from gingival crevice may be noted

Sensibility testing may be negative initially indicating transient pulpal damage

Monitor pulpal response until a definitive pulpal diagnosis can be made



2.3 Treatment

Normally no treatment is needed; however a flexible splint to stabilize the tooth for

patient comfort can be used for up to 2 weeks

2.4 Flow-up Period

Clinical and radiographic examination at 2, 4 and 6-8 weeks, 6 months and 1 year

3. Lateral luxation


Displacement of the tooth in a direction other than axially

It will be immobile and percussion usually gives a high, metallic (ankylotic)

sound

Fracture of the alveolar process present

Sensibility tests will likely give negative results


3.2 Radiographic Findings Increase in periodontal ligament space and displacement of apex toward or though the

labial bone plate

3.3 Treatment

To reposition as soon as possible and then to stabilize the tooth in its

anatomically correct position to optimize healing of the periodontal ligament

and neurovascular supply while maintaining esthetic and functional integrity.

Repositioning of the tooth is done with digital pressure and little force.

A displaced tooth may need to be extruded to free itself from the apical lock in

the cortical bone plate.

Splinting an additional 2 to 4 weeks may be needed with breakdown of

marginal bone

3.4 Flow-up Period

Clinical and radiographic examination at 2, 4 and 6-8 weeks, 6 months,1 year and up

to 5 years

4. Extrusive Luxation


Partial displacement of the tooth axially from the socket

Tooth appears elongated and is mobile



Increase periodontal ligament space apically

4.3 Treatment

Reposition as soon as possible which may be accomplished with slow and steady

apical pressure to gradually displace coagulum formed between root apex and floor of

the socket. Splint for up to 2 weeks

4.4 Flow-up Period


to 5 years

5. Intrusive Luxation


Apical displacement of tooth into the alveolar bone. The tooth is driven into

the socket, compressing the periodontal ligament and commonly causes a

crushing fracture of the alveolar socket

Tooth appears to be shortened or, in severe cases, it may appear missing

The tooth’s apex usually is displaced labially toward or through the labial

bone plate.

The tooth is not mobile or tender to touch



The periodontal ligament space may be absent from all or part of the root

The cemento-enamel junction is located more apically in the intruded tooth

than in adjacent non-injured teeth, at times even apical to the marginal bone

level

5.3 Treatment

5.3.1 Teeth with incomplete root formation

Allow eruption without intervention

If no movement within few weeks, initiate orthodontic repositioning


If tooth is intruded more than 7mm, reposition surgically or orthodontically

5.3.2 Teeth with complete root formation

Allow eruption without intervention if tooth intruded less than 3mm

If no movement after 2-4 weeks, reposition surgically or orthodontically

before ankylosis can develop

If tooth is intruded 3-7 mm, reposition surgically or orthodontically

If tooth is intruded beyond 7mm, reposition surgically

The pulp will likely become necrotic in teeth with complete root formation

Root canal therapy using a temporary filling with calcium hydroxide is

recommended and treatment should begin 2-3 weeks after repositioning

Once an intruded tooth has been repositioned surgically or orthodontically,

stabilize with a flexible splint for 4 weeks

5.4 Flow-up Period


to 5 years

6. Avulsion

Avulsion of permanent teeth is seen in 0.5‐3% of all dental injuries

There are also individual situations when replantation is not indicated (e.g.

severe caries or periodontal disease, noncooperating patient, severe medical

conditions (e.g. immunosuppression and severe cardiac conditions) which

must be dealt with individually

Replantation may successfully save the tooth, but it is important to realize that

some of the replanted teeth have lower chances of long term survival and may

even be lost or extracted at a later stage

6.1 Treatment objectives To replant as soon as possible and then to stabilize the replanted tooth in its

anatomically correct location to optimize healing of the periodontal ligament and

neurovascular supply while maintaining esthetic and functional integrity

6.2 Treatment

6.2.1 First Aid of Avulsed Tooth at the place of Accident

Immediate replantation is the best treatment at the Place of accident

The tooth has the best prognosis if replanted immediately

Keep the patient calm

Find the tooth and pick it up by the crown (the white part). Avoid touching the

root

If the tooth is dirty, wash it briefly (max 10s) under cold running water and

reposition it then bite on a handkerchief gently to hold tooth in place

If this is not possible (e.g. patient is unconsciousness), place the tooth in

suitable storage medium and bring the patient to emergency clinic

Storage Media

If the tooth cannot be replanted within 5 minutes, it should be stored in a

medium that will help maintain vitality of the periodontal ligament fibers

The best (ie, physiologic) transportation media for avulsed teeth include (in

order of preference) Viaspan™, Hank’s Balanced Salt Solution (tissue culture

medium), and cold milk.

Next best would be a non-physiologic medium such as saliva (buccal

vestibule), physiologic saline, or water


6.2.1.1 Tooth has been replanted before patient’s arrival at clinic

Leave tooth in place

Clean the area with saline or CHX

Suture gingival lacerations, if present

Verify normal position of replanted tooth clinically and radiographically

Apply flexible splint for 2 weeks

Administer systemic antibiotics

Check tetanus prophylaxis

Give patient instructions

Initiate RCT 7-10 days after replantation and before splint removal

6.2.1.2 Tooth was in physiologic storage media/Extra-oral time less than 60

minutes

Administer L.A

Irrigate the socket with saline

Examine the alveolar socket. If fractured reposition the fractured wall with

suitable instrument

Replant the tooth slowly with slight digital pressure







Initiate RCT 7-10 days after replantation and before splint removal

6.2.1.3 Dry tome more than 60 minutes

Remove attached non-viable soft tissue carefully

Perform RCT before replantation or 7-10 days

Administer L.A

Irrigate the socket with saline

Examine the alveolar socket. If fractured reposition the fractured wall with

suitable instrument

Replant the tooth slowly with slight digital pressure







To slow down osseous replacement, the root of avulsed tooth is placed into

2% sodium fluoride before replantation


The goal for replanting still‐developing (immature) teeth in children is to allow

for possible revascularization of the pulp space. The risk of infection related root

resorption should be weighed up against the chances of revascularization. Such

resorption is very rapid in teeth of children. If revascularization does not occur,

root canal treatment may be recommended

6.3 Antibiotic Considerations

Topical antibiotics (minocycline or doxycycline,1mg per 20ml of saline for 5

minutes soak) appear experimentally to have a beneficial effect in increasing

the chance of pulpal space revascularization and periodontal healing and may

be considered in immature teeth

For systemic administration tetracycline is the first choice in appropriate dose

for patient age and weight the first week after replantation. The risk of

discoloration of permanent teeth must be considered before systemic

administration of tetracycline in young patients

In many countries tetracycline is not recommended for patients under 12 years

of age. A penicillin phenoxymethylpenicillin (Pen V,) or amoxycillin, in an

appropriate dose for age and weight the first week, can be given as alternative

to tetracycline

Endodontic Considerations

If root canal treatment is indicated (teeth with closed apex), the ideal time to

begin treatment is 7–10 days post replantation. Calcium hydroxide is

recommended as an intra‐canal medication for up to 1 month followed by root

canal filling with an acceptable material

If the tooth has been dry for more than 60 min before replantation. The root

canal treatment may be done extraorally prior to replantation

In teeth with open apexes, which have been replanted immediately or kept in

appropriate storage media prior to replantation, pulp revascularization is

possible

The risk of infection related root resorption should be weighed up against the

chances of obtaining pulp space revascularization. Such resorption is very

rapid in teeth of children

For very immature teeth root canal treatment should be avoided unless there is

clinical or radiographic evidence of pulp necrosis

6.4 Patient Instructions

Avoid participation in contact sports.

Soft diet for up to 2 weeks. Thereafter normal function as soon as possible

Brush teeth with a soft toothbrush after each meal

Use a chlorhexidine (0.12%) mouth rinse twice a day for 1 week

6.5 Splinting

6.5.1 Requirement of Ideal Splint

Allow periodontal ligament reattachment and prevent the risk of further

trauma or swallowing of a loose tooth

Easily applied and removed without additional trauma or damage to the teeth

and surrounding soft tissues

Stabilize the injured tooth/teeth in its correct position and maintain adequate

stabilization throughout the splinting period


Allow physiologic tooth mobility to aid in periodontal ligament healing

Not irritate soft tissues

Allow pulp sensibility testing and endodontic access

Allow adequate oral hygiene

Not interfere with occlusal movements

Preferably fulfil aesthetic appearance

Provide patient comfort

6.5.2 Different Types of Splint

1. Composite resin splint

2. Composite resin splint and wire

3. Orthodontic bracket and wire splint

4. Titanium trauma splint

5. Fibre splint

6. Acrylic splint

7. Thermoplastic splint

VII. Management of Hard Dental Tissues injures of Primary Incisors

1. Cracks and Fractures of Enamel and Dentin without Pulp Exposure

As mentioned in young permanent teeth

The fractured crown can be restored as discussed in restorative dentistry in

children section

2. Enamel and Dentin with Pulp Exposure

Pulpotomy, Pulpectomy as discussed in management of deep caries in children

section

Extraction may be indicated

3. Crown Root Fracture

Fragment removal only if the fracture involves a small part of the root and the

stable fragment is large enough for coronal restoration. Otherwise, extraction

is indicated

4. Root Fracture

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

If the coronal fragment is displaced, repositiong and splinting might be

considered. Otherwise extract only that fragment. The apical fragment should

be left to be resorbed

VIII. Management of Supporting Tissue Structure injure of Primary Incisors

1. Concussion and Subluxation

No treatment required and just follow-up, unless associated infection exists, no

pulpal therapy is indicated. Although there is a minimal risk for pulp necrosis

2. Lateral Luxation

No occlusal interference Allow the tooth for spontaneous repositioing

Mild occlusal interference Gentle repositiong

Sever occlusal interference Extraction


3. Extrusive Luxation

Treatment based on the degree of displacement, mobility and the ability of

child to cope with the emergency situation

If extrusion of immature developing toothis less than 3 mm reposining or

allowing the tooth for spontaneous repositioing

4. Intrusive Luxation

If root apex displaced labially Allow the tooth for spontaneous repositioing

If root apex displaced palatalkly Extraction

Radiographic Considerations

Reveal that the tooth appears displaced apically and the periodontal ligament

space is not continuous.

Determination of the relationship of an intruded primary tooth with the follicle

of the succedaneous tooth is mandatory.

If the apex is displaced labially, the apical tip can be seen radiographically

with the tooth appearing shorter than its contralateral.

If the apex is displaced palatally towards the permanent tooth germ, the apical

tip cannot be seen radiographically and the tooth appears elongated.

An extraoral lateral radiograph also can be used to detect displacement of the

apex toward or though the labial bone plate

5. Avulsion

Not recommended for primary teeth

X1. Reaction of Tooth to Trauma

1. Coronal Discoloration

Occurs as a result of internal haemorrhage of pulp capillaries and leaving of

blood pigments in the dentinal tubules

In mild cases, blood is resorbed and very little discoloration occurs. In more

sever cases, discoloration persists

Discoloration can be diagnose by transillumination

Discoloration Comments

1. Pink Appears shortly after trauma due to capillary haemorrhage

2. Reddish hue Usually due to internal resorption in pulp chamber

3. Yellow Calcific metamorphosis

4. Dark Dark refers to shades of black, brown and gray

It is controversial

When associated with swelling or fistula, this indicates pulp

necrosis

2. Inflammatory Resorption

2.1 Internal Root Resorption

Destructive process occurs due to odontblastic activity

Rate of progression may be slow or rapid causing crown or root perforation

2.2. External Root Resorption

Damage to periodontal ligaments with or without pulp involvement


3. Replacement Resorption

Also known as “Ankylosis” occurs after injury to the periodontal ligaments

Alveolar bone directly contacts and fuses with the root surface

4. Pulp Necrosis

Little relationship exists between the type of injury to the tooth and the

reaction of the pulp and supporting tissues. A severe blow to a tooth causing

displacement often results in pulpal necrosis. The blow may cause a severance

of the apical vessels, in which case the pulp undergoes autolysis and necrosis.

In a less severe type of injury the hyperemia and slowing of blood flow

through the pulpal tissue may cause eventual necrosis of the pulp. In some

cases the necrosis may not occur until several months after the injury

A necrotic pulp in an anterior primary tooth may be successfully treated if no

extensive root resorption or bone loss has occurred

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MANAGEMENT OF TRAUMATIC DENTAL INJURIES IN CHILDREN dental... · Class 9 Traumatic injuries of primary teeth . ... Injury to hard dental tissues Injury to periodontal tissues Injury