1. Dental trauma 4 - primary teeth

2. Lecture outline Introduction
Management of injuries to the dental tissues
Management of injuries to the periodontal tissues
Management of alveolar fracture
Sequelae of injuries to the primary dentition

3. Introduction
Oral injuries make up 17% of all bodily injuries in preschool children.
The majority of oral injuries at that age occur due to falls in/around the home.
Reported peak incidence for primary dentition is 2-4 years.
The young age of presentation frequently limits the approaches available for injury management.

4. Introduction
Permanent incisors develop palatally and in close proximity to the apices of the primary incisors.
In instances of trauma to the primary teeth, there is a risk of damage to the underlying permanent successors.

5. Management of injuries to the dental tissues

6. Infraction Treatment: No treatment necessary Follow-up
No follow-up is needed

7. Enamel fracture Treatment: Smoothen sharp edges.
In patients with lip or cheek lesions it is advisable to search for tooth fragments or foreign material.
Follow-up
No follow-up required.

8. Enamel dentin fracture
Treatment:
Glass ionomer bandage as an emergency treatment to prevent microleakage.
Remover GI bandage after a few days and restore the tooth with composite.

9. Enamel dentin fracture
Follow-up:
Clinical control at 3-4 weeks.

10. Enamel-dentin-pulp fracture
Treatment:
Preserve pulp vitality by performing pulpotomy followed by composite restoration.
This requires a cooperative patient, vital pulp, and healthy radicular pulp.
If performing a pulpotomy is not possible, extraction is the alternative option.

11. Enamel-dentin-pulp fracture
Follow-up:
Clinical after 1 week.
Clinical and radiographic control after 6-8 weeks and 1 year.

12. Crown-root fracture Treatment:
Depending on the clinical findings, two treatment scenarios:
If the fracture involves only a small part of the root and the stable fragment is large enough to allow coronal restoration, remove the mobile fragment.
In all other instances, including when pulp is exposed, extraction is necessary.

13. Crown-root fracture Instruct the patient to:
have soft foods for days.
Preserve good OH by brushing with a soft toothbrush and application of 0.1% chx twice a day for a week.
Alert parents to possible complications: swelling, increased mobility or fistula. Children may not report pain.

14. Crown-root fracture Follow-up: Fragment removal only: Extraction:
Clinical control after 1 week.
Clinical and radiographic control after 3-4 weeks.
Clinical control after 1 year.
Extraction:
Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

15. Root fracture Treatment:
If the coronal fragment is not displaced, no treatment is required.
If the coronal fragment is mildly displaced and patient cooperation allows, consider repositioning the tooth fragment.
In all other cases, extract the coronal fragment and leave the apical fragment to resorbed.

16. Root fracture Instruct the patient to: have soft foods for 10-14 days.
Preserve good OH by brushing with a soft toothbrush and application of 0.1% chx twice a day for a week.
Alert parents to possible complications: swelling, increased mobility or fistula. Children may not report pain.

17. Root fracture Follow-up:
Clinical control after 1 week. Clinical and radiographic control after 6- 8 weeks and 1 year.
In case of tooth extrcation: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

18. Management of injuries to the periodontal tissues

19. Concussion Treatment Instruct the patient to:
have soft foods for days.
Preserve good OH by brushing with a soft toothbrush and application of 0.1% chx twice a day for a week.
Alert parents to possible complications: swelling, increased mobility or fistula. Children may not report pain.

20. Concussion
Follow-up
Clinical control at 1 week, 6-8 weeks.

21. Subluxation Treatment Instruct the patient to:
have soft foods for days.
Preserve good OH by brushing with a soft toothbrush and application of 0.1% chx twice a day for a week.

22. Subluxation
Alert parents to possible complications: swelling, increased mobility or fistula. Children may not report pain.
Follow-up:
Clinical control at 1 week, 6-8 weeks.

23. Extrusion
Treatment:
The treatment choice should be based on the degree of displacement, mobility, root formation and the ability of the child to cope with the emergency situation.

24. Extrusion
For minor extrusion (< 3mm) in an immature developing tooth, either careful repositioning of the tooth or leave it for spontaneous alignment.
Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth.
Patient instructions: soft diet, OH, monitor complications.

25. Extrusion Follow-up: Clinical control after 1 weeks.
Clinical and radiographic control at 6-8 weeks, 6 months, and 1 year.

26. Lateral luxation
If the crown is displaced palatally, its unlikely that there was a collision with the permanent tooth bud.
If the crown is displaced labially, its likely that there was a collision with the permanent tooth bud

27. Lateral luxation Treatment:
If there is no occlusal interference, the tooth should be allowed to reposition spontaneously.
In cases with minor occlusal interference, slight grinding is indicated.
When there is occlusal interference local anaesthesia should be applied where after the tooth should be repositioned by gentle combined labial and palatal pressure.

28. Lateral luxation
When there is severe displacement in a labial direction, extraction is the treatment of choice.
Give the patient instructions: soft diet, OH, monitor complications.
Follow-up:
Clinical control after 1 and 2-3 weeks. Clinical and radiographic control at 6-8 weeks and 1 year.

29. Intrusion
Might result in collision with the permanent tooth bud, depending on intrusion direction and severity.
The injury type most likely to cause disturbances in the developing permanent successors.

30. Intrusion
When the apex is displaced toward the labial bone plate the apical tip can be visualized and appears shorter than the unaffected contralateral tooth.
When the apex is displaced toward the permanent tooth germ, the apical tip cannot be visualized and the tooth appears elongated.

31. Intrusion
Treatment:
If the apex is displaced toward or through the labial bone plate, the tooth should be left for spontaneous repositioning. In order to evaluate re- eruption, the degree of intrusion should be assessed by measuring the distance between the incisal edge of the intruded tooth and that of adjacent unaffected teeth.
If the apex is displaced into the developing tooth germ the tooth should be extracted to minimize the damage done to the permanent successor.

32. Intrusion
Give the patient instructions: soft diet, OH, monitor complications.
Inform the parents of a likely disturbance to permanent successor (especially if the trauma occurred before the age of 3)
Follow-up:
Clinical control after 1 week.
Clinical and radiographic control at 3-4 weeks, 6-8 weeks, 6 month, 1 year and yearly until eruption of the permanent successor.

33. Avulsion
It's not recommended to replant avulsed primary teeth, to prevent any complications that are likely to cause a disturbance to the permanent tooth bud.
A the initial examination make sure that all avulsed teeth are accounted for.

34. Avulsion
If you cant account for the avulsed teeth, it is highly recommended to make a radiographic examination in order to ensure that the missing tooth is not a case of complete intrusion or root fracture with loss of the coronal fragment.
If the avulsed tooth has not been found refer the child to the paediatrician to exclude aspiration.

35. Avulsion
Treatment:
Give the patient instructions: soft diet, OH, monitor complications.
Follow-up:
Clinical control after 1 week
Clinical and radiographic control after 6 months and 1 year.
Yearly clinical and radiographic controls until eruption of the permanent successor.

36. Management of alveolar fracture

37. Alveolar fracture
Reposition the displaced segment manually or using forceps (General anaesthesia is often indicated).
Stabilize the segment with flexible splinting for 4 weeks.
Give the patient instructions: soft diet, OH, monitor complications.

38. Alveolar fracture Follow-up: Clinical control after 1 week.
Splint removal and clinical and radiographic control after 4 weeks.
Clinical and radiographic control after  6-8 weeks and 1 year then yearly until exfoliation.

39. Sequelae of injuries to the primary dentition

40. Sequelae of injuries to the primary dentition
Trauma to the primary teeth can result in damage to the pulp, periodontal tissues or developing permanent dentition.

41. Pulpal necrosis Most common complication of primary trauma. Diagnosis:
1. Tooth discoloration
Temporary and mild grey discolouration following trauma might be due to pulpal bleeding and doesn't necessarily mean the pulp is necrotic.
Grey tooth discolouration following trauma that is persistent.
2. Periapical inflammation
Noted as a radiographic radiolucency, abscess, fistula.

42. Pulpal necrosis Treatment:
Extraction of the offending tooth to prevent damage to the permanent successor.

43. Pulpal obliteration
Hard tissues are deposited along the wall of the root canal and fill most of the pulp canal.
A common reaction to dental trauma.
Clinically the tooth becomes yellow/opaque.

44. Pulpal obliteration
No intervention is necessary, as teeth normally exfoliate as usual.
In some cases periapical inflammation might develop, hence, annual radiographic follow-up is necessary with extraction of the offending tooth if inflammation develops.

45. Root resorption
Different types as discussed in the previous lecture: inflammatory (internal, external, cervical); replacement.
Any signs of any type of pathological root resorption indicate the extraction of the offending tooth.

46. Injuries to the developing permanent teeth
Reported to occur in 12-69% of primary tooth trauma.
The type, location, and severity of the disturbance will depend on the age at which the injury happened in addition to the type and severity of the trauma.
Intrusion is the most likely to cause a disturbance.
Avulsion can cause damage if the apex of the primary tooth moved towards the developing tooth bud before the avulsion.

47. Injuries to the developing permanent teeth
Most likely to occur if the trauma happens under the age of 3 with the crowns of the permanent incisors still developing.
Changes in mineralization and morphology of the crown are the most common
Later injuries (after three years of age), can lead to radicular anomalies.

48. Enamel hypomineralization/hypoplasia
White or yellow-brown discolouration of enamel with or without an area of hypoplasia.
History of an injury before the age of 3, although in some up to the age of 7 years.
Treatment options: bleaching, microabrasion, composite restorations, veneers, full coverage crowns

49. Dilaceration
An abrupt deviation in the long axis of the tooth crown or root.
A result of a traumatic displacement of hard tissues that have already been formed in relation to the tissues still developing.
Crown dilacerations occurs mostly when trauma is below the age of 3, root dilacerations when it occurred at 2-5 years of age.

50. Dilaceration Closely related to dilaceration is Angulation:
Angulation: a curvature of the root resulting from a gradual change in the direction of root development, without evidence of abrupt displacement of the tooth germ during odontogenesis. This may be vestibular (labiopalatal), or lateral (mesiodistal).
Angulation is possibly created when the erupting tooth meets an obstacle such as scar tissue during eruption.

51. Dilaceration
Can usually be noticed on radiographs within the first year following the trauma.
May lead to delayed or failed eruption.

52. Dilaceration

53. Dilaceration Treatment: Crown dilaceration: Root dilaceration:
Surgical exposure and orthodontic realignment.
Removal of the dilacerated part of the crown and temporary restoration
Permanent restoration (full coverage crown).
Root dilaceration:
- Surgical exposure and orthodontic realignment

54. Disturbances in eruption
Could be due to:
Thick connective tissue formation over the permanent tooth germ.
Ectopic location due to lack of eruptive guidance.
Presence of a tooth structure malformation preventing eruption

55. Other disturbances
Odontoma-like malformations (Injury at <1-3 years).
Rare.
Reported cases are confined primarily to maxillary incisors.
Occur when the injury happens during early phases of permanent tooth odontogenesis.

56. Other disturbances Root duplication (Injury at 2-5 years).
A rare occurrence seen following intrusive luxation of primary teeth.
Result of an injury at the time when half or less of the crown is formed.
A traumatic division of the cervical loop occurs at the time of injury, resulting in the formation of two separate roots.
Radiographically, a mesial and distal root can be demonstrated, which extends from a partially formed crown.

57. Other disturbances
Partial or complete arrest of root formation (Injury at 5-7 years).
The injury displaces a developing successor in such a way that Hertwig’s epithelial root sheath has been partly or totally destroyed.

58. Other disturbances Sequestration of permanent tooth germs:
Exceedingly rare after injuries to the primary dentition.
Swelling, suppuration and fistula formation are typical clinical features that sometimes lead to spontaneous sequestration of the involved tooth germ.
Radiographic examination discloses osteolytic changes around the tooth germ, including disappearance of the outline of the dental crypt and expanded cortical alveolar bone.

59. Thank you