Mgt of dental trauma


Published on

Published in: Health & Medicine, Business
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Mgt of dental trauma

  2. 2. OUTLINE PART 1  introduction  Aetiology of traumatic injuries  Epidemiology  Classification of traumatic injuries PART 2  clinical evaluation of patients  History of the trauma  Medical history  Dental history
  3. 3.  Examination general examination extra-oral intra-oral  Sensibility evaluation  Radiographic evaluation  Clinical photography PART 3…TREATMENT PROTOCOLS FOR VARIOUS DENTAL TRAUMATIC INJURIES IN PRIMARY AND YOUNG PERMANENT DENTITION
  4. 4. Hard tissue injuries  enamel infraction  uncomplicated crown fracture  complicated crown fracture  root fracture Supporting tissue injuries  concussion  subluxation  luxation; intrusive, extrusive, lateral  avulsion
  6. 6. INTRODUCTION Dental trauma is one of the most common presentation in the paediatrics clinic. The fears and anxiety of these patients make management difficult. If improperly managed, it could affect the patient self-esteem and quality of life
  7. 7. AETIOLOGY The most accident prone times include; 2-4 years for primary dentition 7-10 yrs for permanent dentition Aetiological factors include; 1. Falls 2. Collision 3. Playing and running 4. Contact sports 5. Road traffic accident 6. Child abuse; ESPN Emotional-Sexual-Physical-Neglect
  8. 8. PREDISPOSING FACTORS 1. Angle class 11 div 1 2. Increased overjet; 3-6mm..double the risk >6mm….triple the risk 3. Incompetent lip closure 4. Improperly fitted mouthguard..twice the risk
  9. 9. DIRECT AND INDIRECT TRAUMA Direct trauma;  involves the tooth directly  favours anterior teeth Indirect trauma  seen when the lower arch forcefully close against the upper arch  favours crown and crown-root fracture of the premolar and molar region
  10. 10. EPIDEMIOLOGY Dental trauma is common in childhood and adolescence. By 5 yrs; boys-- 31-40% girls….16-30% and At 12 years; 12-33% of boys and 4-19% of girls would have suffered dental trauma boys : girl; 2:1 in both dentitions
  11. 11. In primary dentition;  anterior segment is commonly affected especially the maxillary central incisor,  concussion, subluxation, and luxation are the commonest In permanent dentition;  luxation and fracture injuries are the commonest  Maxillary central incisor>maxillary lateral incisor>mandibular incisor
  12. 12. CLASSIFICATION Several classifications have been proposed for easy diagnosis and treatment need of various traumatic dental injuries(TDI). E.G 1. Ellis classification 2. WHO 1978 3. Garcia-Godoy 1968…for primary and permanent dentition 4. Andreasen 1981..modification of WHO
  13. 13. ANDREASEN’S CLASSIFICATION A. Dental Hard Tissue and Pulp Only  Crown infraction  Uncomplicated crown  Complicated crown  Uncomplicated crown-root  Complicated crown-root  Root fracture
  14. 14. B. Periodontium  Concussion  Subluxation(loosening)  Luxation intrusive(central dislocation) extrusive(peripheral dislocation, partial avulsion) lateral  Exarticulation(complete luxation/avulsion)
  15. 15. C. SURROUNDING BONE  Comminution of alveolar socket  Fractures of facial or lingual alveolar socket wall  Fractures of alveolar process -/+ involvement of the socket  Fractures of the mandible or maxilla -/+ involvement of the tooth socket
  16. 16. D. SOFT TISSUE  Laceration  Contusion  Abrasion
  17. 17. PART 2: CLINICAL EVALUATION OF PATIENTS 1. History of the trauma’ HOW;  to know extent of injury; direct or indirect  to rule out head injury involvement  Discrepancy between history and clinical findings raises suspicion of physical abuse. Where;  whether contaminated soil or not; which may be an indication for tetanus prophylaxis or not
  18. 18. When;  time interval between injury and presentation would determine treatment option and prognosis Is the tooth fracture or not; chest radiograph ..if not found possible reattachment if found Any neurological symptoms
  19. 19. 2. Medical history  Congenital heart diseases  Epilepsy  Bleeding disorders  Allergies 3.Past dental history  Regular attenders are more likely to be cooperative 4. Immunization status.  refer to physician for TT injection if trauma occurred in a contaminated soil and patient had not receive a booster dose for the past 5 yrs.
  20. 20. EXAMINATIONS A. General exam; a quick head-to-toe examination is done to r/o other injuries. Signs of shock and head injury must be excluded. B. Extra-oral exam; observe and palpate for;  Swelling, bruises, laceration  Limitation of mandibular movement  Mandibular deviation on opening and closing  Bony step deformity  Are wounds clean or contaminated
  21. 21. C. intra-oral exams;  Laceration, haemorrhage and swelling  Assess the occlusion, tooth displacement, fractured crowns, or cracks in the enamel.  Assess mobility;  horizontal and vertical direction  suspect ‘enblock alveolar process fracture if several teeth move at the same time.  excessive mobility…root fracture or displacement
  22. 22. Reaction to percussion; the sensitivity and the sound on percussion are important.  to assess PDL inflammation  luxated teeth are always tender  duller note indicate a root fracture Colour of the teeth; early colour change associated with pulpal breakdown is visible on the palatal surface ,in the gingival third of the crown
  23. 23. SENSIBILITY ASSESSMENT  Usually to ascertain nerve and blood supply  not reliable in children  More of a diagnostic tool in permanent dentition  Unreliable in erupting permanent and teeth with open apices  Positive response after a traumatic injury is more valuable than negative response although none should be trusted
  24. 24.  Commonly used are; EPT, thermal test(heat or cold). Other include; carbon dioxide snow, laser Doppler flowmetry
  25. 25. RADIOGRAPHIC EVALUATION Indication for radiograph; 1. To detect root fracture 2. Ascertain extent of root development 3. To determine resorption 4. To detect foreign body in soft tissue 5. To detect jaw fracture 6. To note position and stage of development of permanent teeth 7. To detect size of pulp chamber 8. To r/o periapical radiolucency 9. For follow-up evaluation
  26. 26.  Take two radiographs at different angles to detect a root fracture.  If access and co-operation are difficult then one anterior occlusal radiograph rarely misses a root fracture.  Periapical films positioned behind lips can be used to detect foreign bodies.  Lateral anterior view with an occlusal radiograph position by patient side could help detect extent of intrusive luxation.  Request for OPG if jaw injury is suspected
  27. 27. DOCUMENTATION PHOTOGRAPH  Take a pre and post treatment photograph for proper documentation  To assess outcome of treatment  For medicolegal purpose  Always obtain a written consent
  28. 28. TREATMENT OPTIONS FOR DENTAL TRAUMATIC INJURIES Dental trauma to primary dentition Most common is subluxation, intrusive luxation and avulsion. Crown and root fracture are rare. NB; large marrow spaces and pliability of the alveolar bone.
  29. 29. SUBLUXATION Diagnosis; mobile tooth -/+ sulcular bleeding X-ray; nil abnormality Treatment; clean associated soft tissue injury with 0.2% chlohexidine with gauze swabs twice daily. Slight mobility; place on soft diet for 2 wks Marked mobility; extract Follow-up; after 1 month to assess mobility Prognosis; usually good
  30. 30. INTRUSIVE LUXATION Tooth displace towards the socket, compressing the PDL and crushing the alveolar bone. Diagnosis; not mobile, not tender, appear shortened or in severe cases would seem missing Investigation; lateral anterior radiograph. Aim is to ascertain r/ship of apex of intruded tooth with the permanent tooth bud
  31. 31.  Treatment; a. if apex is displace labially, allow for spontaneous re-eruption b. if displaced palatally; extract the tooth Follow-up; Review should be weekly for a month then monthly for a maximum of 6 months. Most re-eruption occurs between 1 and 6 months and if this does not occur then ankylosis is likely and extraction is necessary to prevent ectopic eruption of the permanent successor
  33. 33. Prognosis; 90% of cases re-erupt b/w 2-6months. In dome cases ankylosis could occur leading to a delay of eruption of the permanent tooth. Extrusive luxation Partial avulsion as PDL is severely torn/damaged Diagnosis; tooth appear elongated and mobile X-ray; increased PDL space apically Treatment; mild extrusion<3mm allow tooth to reposition spontaneously and heal if tooth is immature. when do I need to extract? a. Severe extrusion/mobility
  34. 34. b. Tooth near exfoliation c. Child not cooperating d. Tooth fully mature Follow-up; if repositioned take x-ray to determine reduction in the PDL space apically
  35. 35. LATERAL LUXATION Tooth displaced in any position other than axially Diagnosis; tooth appear displace, not mobile nor tender X-ray; shows increased PDL space and displaced tooth apex Treatment; if apex is displace buccally and there is no gagging of occlusion, allow spontaneous realignment. extract if apex is displaces towards the permanent tooth bud.
  36. 36. prognosis; If tooth is repositioned, there is risk of pulpal necrosis compare to spontaneous eruption. Note the occlusal interference
  37. 37. AVULSION Diagnosis; Tooth is out of the socket X-ray; do a chest x-ray if tooth can’t be accounted for Treatment; do not re-implant due to risk of damaging the permanent tooth bud. Though space maintenance is not necessary, a fixed or removable be fabricated to allay aesthetic concerns Follow-up; permanent tooth eruption could be delay for 1-2yrs due to formation of fibrotic band
  38. 38. AVULSION
  39. 39. HARD TISSUE INJURIES UNCOMPLICATED CROWN FRCATURE; Enamel -/+ dentine # without pulpal involvement. Diagnosis; evidence of loss of tooth structure X-ray; soft tissue radiograph to locate tooth fragment Treatment;  aim is to preserve pulp vitality and restore aesthetics.  small fracture: smoothen rough margins/edges  large fracture: for large enamel fracture restore with acid- etch-composite resin
  41. 41. if dentine is involved; protect the pulp using acid resistant calcium hydroxide or GIC restore with acid-etch composite COMPLICATED CROWN FRACTURE Is uncommon in primary dentition Diagnosis; loss of tooth structure with pulp exposure clinically and on radiograph X-ray; to r/o fragment in soft tissue
  42. 42. Treatment options; Depends on  patients cooperation  vitality of the tooth  stages of root development formocresol pulpotomy; if tooth is vital pulpectomy with zinc oxide and eugenol  non-vital tooth  3/4th of the root must be formed  1-2mm short of the apex extraction; if child is uncooperative tooth is non-vital
  43. 43. Final restoration; depends on amount of tooth structure remaining  composite resin if remnant can support the composite restoration  stainless steel crown with composite veneering if small fragment remains Prognosis; depends on concomitant injury to the PDL.
  44. 44. ROOT FRACTURE; Diagnosis; mobile coronal segment -/+ displaced Radiograph;  take at least 2 views  reveal radiolucent line b/w fragment  succedaneous tooth could obscure root fragment Treatment; depends on level of fracture: at apical 1/3rd and with minimal mobility, observe. Take serial radiograph of the tooth.
  46. 46. If the coronal fragment becomes non-vital and symptomatic then it should be removed. The apical portion usually remains vital and undergoes normal resorption. At the middle and cervical 3rd, tooth should be extracted.
  47. 47. TRAUMA TO YOUNG PERMANENT TEETH Prompt and accurate diagnosis is invaluable in the success of treatment. Aims and objective of treatment; 1. Emergency/immediate; to  retain vitality of fracture and displaced tooth  treat exposed pulp tissue;  reduction and immobilization of displaced teeth  antiseptic mouthwash, +/- antibiotics and tetanus prophylaxis.
  48. 48. 2. Intermediate: (a) pulp therapy; (b) minimally invasive crown restoration. 3. Permanent: (a) apexogenesis/apexification; (b) root filling + root extrusion; (c) gingival and alveolar collar modification; (d) semi or permanent coronal restoration.
  49. 49. HARD TISSUE INJURIES AND MANAGEMENT Enamel infraction; Incomplete fracture in the enamel Examination; reveal craze lines on transillumination Treatment; observe to ensure tooth integrity and pulp vitality. Uncomplicated crown fracture Loss of enamel -/+ dentine fracture without pulp involvement Diagnosis; clinical and radiographic evidence of loss of tooth structure
  51. 51. , Treatment;  for small fracture use fine disk to smoothen the margins  for larger loss, protect the pulp with calcium hydroxide or GIC then restore with acid-etch composite.  Enamel and dentine bonding agents have also been used to protect the pulp from thermal irritants and bacterial ingress.
  52. 52. COMPLICATED CROWN FRACTURE; Factors that influence choice of treatment:  vitality of expose pulp  time elapse since the exposure  degree of root maturation of the fracture tooth  restorability of the fracture crown Aim of treatment; to preserve pulp vitality
  54. 54. Treatment options;  direct pulp capping(DPC)  pulpotomy; partial or complete  pulpectomy carry out DPC ;  when exposure is pin-point  when exposure is just of few hours>24hrs  when the apex is open  as an emergency measure even pulpotomy is to be done
  55. 55.  Review after a month, then 3 months, and eventually at 6 monthly intervals for up to 4 years to assess pulp vitality.  Take periodic radiograph  On the radiograph check the following: • root is growing in length; • root canal is maturing (narrowing); • Compare with previous x-rays. If growth is not occurring the pulp should be assumed to be non-vital.
  56. 56. When to do pulpotomy:  pulpal exposure for longer hours >24hrs  larger pulpal exposure  immature open apices Aim of treatment; to eliminate inflamed pulp tissue and preserve vital radicular pulp aiding complete root development(apexogenesis) Vital(full) pulpotomy or partial(Cvek) pulpotomy could be done depending on the level of inflammation and extent of bleeding on amputation
  57. 57.  Review after a month, 3 months, 6 monthly intervals for up to 4 years to assess pulp vitality.  Do periodic radiograph.  If vitality is lost, non-vital pulp therapy should be undertaken whether or not there is a calcific bridge Prognosis; success rates for partial (Cvek) pulpotomies are quoted at 97%. Those for coronal pulpotomies at 75%.
  58. 58. Pulpectomy as an option; done  in non-vital pulp  pulp with closed apex  when permanent restoration need a post build up an apical root end closure(apexification) is done, but dentinal wall is left fragile and easily fracture
  59. 59. first month, then 3 mths, then 6 mths Do periodic radiograph to check evidence of calcific barrier formation. This will normally take b/w 9-24 mths final treatment; these include  Definitive canal obturation  composite restoration  porcelain veneer and crown  post-retained crown
  60. 60. Treatment options; 1. Apexification 2. Apical barrier technique; using  generic tricalcium phosphate(g-TCP)  synthetic hydroxyl apatite  bioceramic glass  freeze-dried bone 3. Retrograde root canal filling
  61. 61. Root fracture. Diagnosis; clinically mobile teeth and 1 or more radiolucent lines separating fracture segments Aims of treatment;  to reposition and stabilise coronal segment  encourage healing of PDL and vascular supply  to restore aesthetics and function Treatment; reposition segment and immobilise for 2-3mths (preferably fixed splint composite resin a better choice; but why?)
  62. 62. Decision to splint; this depend on the level of fracture and whether long term stability of the tooth depends on it Apical 1/3rd fracture; no need to splint except there is an associated subluxation Middle and cervical 1/3rd; splint if tooth is to be retained Internal splints have ranged from hedstroem files to nickel- chromium points, screwed and cemented into position.
  63. 63. Final treatment 1. If coronal segment is extracted for cervical fracture, root portion is extruded surgically or via orthodontic mean and pulp therapy done. A post-retained crown is planned 2. Both fragments could be extracted and prosthesis planned. follow-up  assess pulp vitality  assess stability of tooth
  64. 64. Prognosis this is best for apical 3rd fracture becomes poorer in middle and cervical fracture
  65. 65. This involve damage to supporting structures of the teeth i.e PDL and alveolar bone. Primary objective is to maintain vitality of the PDL which is important in the long term prognosis of the luxated teeth.
  66. 66. CONCUSSION Diagnosis; tooth is firm, tender to pressure and percussion Radiograph; usually no abnormality Aim of treatment; to encourage healing of PDL and maintain pulp vitality Treatment; soft diet for 2wks, relieve it from occlusion if there is complain of pain Follow-up; vitality test foe 1, 3 and 6 month the yearly. Radiograph to assess root development Prognosis; usually good, but necrosis in 3-6% of cases
  67. 67. Subluxation Diagnosis; tooth is mobile. Bleeding at the marginal gingival, tender to percussion Radiology; the PDL space is widened Aim of treatment; allow healing of the PDL and ensure vascular supply Treatment; stabilize and relieve from occlusion. For comfort use flexible splint(<2wks) if apex is fully formed and extremely tender.
  68. 68. Prognosis; mature teeth with closed apices are at risk of pulpal necrosis hence, close monitoring is required.
  69. 69. LATERAL LUXATION Diagnosis; tooth is displaced crown may be palatal or labially displaced ; not mobile nor tender Radiology; PDL space is increased apex is displaced labially
  70. 70. Treatment;  reposition tooth with gentle and firm digital pressure  use flexible splint 3-8wks  place on antibiotics and TT(if indicated)  use 0.12% chlohexidine mouth wash Follow-up; do periodic radiograph to monitor DPL re- attachment. Prognosis; tooth with closed apices could become necrotic(start root canal trt) and have the canal obliterated
  71. 71. Diagnosis; teeth appear shortened, or in severe cases could appear missing, not mobile nor tender Radiograph; root apex is displaced apically PDL space is non-continuous Treatment; depends on: 1. stage of root development: open or close 2. severity of injury; mild <3 mm, moderate (3-6 mm); or severe (>6 mm).
  72. 72. OPEN APEX ; Mild intrusion <3 mm.  Excellent eruptive potential.  Treat conservatively and review.  If no movement in 2-4 months move orthodontically. Moderate Intrusion 3-6 mm. Disimpact (with forceps if necessary) and either allow to erupt spontaneously for 2-4 months before extruding orthodontically or apply orthodontic forces early.
  73. 73. Severe intrusion >6 mm. Orthodontic repositioning may be impossible and disimpaction followed by surgical repositioning under either LA, LA/sedation, or GA is appropriate. Functional splint for 2-3 weeks.
  74. 74. Follow-up.  Monitor pulpal status clinically and radiographically at regular intervals during the first 6 months after injury, and then 6 monthly, and start endodontics if necessary:  Non-setting calcium hydroxide in root canal does not preclude against orthodontic movement. Once apexification has occurred and orthodontic movement has ceased.  obturate canal with gutta percha.
  75. 75. CLOSED APEX ; Mild intrusion <3 mm. Orthodontic extrusion is probably indicated straight away although some authors have advocated conservative treatment. Moderate intrusion 3-6 mm. Orthodontic extrusion is indicated straight away.
  76. 76. Severe intrusion >6 mm. Surgical repositioning. Functional splint for 2-3 weeks
  77. 77. Follow-up; for closed apices carry out root canal as early as possible to guide against external root resorption. Prognosis;  mature closed apex have higher risk of pulp necrosis(96%), root resorption and ankylosis  immature apex have 60% risk of necrosis and 56% risk of resorption  teeth treated early enough have better prognosis
  78. 78. Tooth displace axially from the socket Diagnosis; clinically appear longer and is mobile On radiograph; PDL space is increased apically treatment; reposition tooth with gentle and firm digital pressure splint for 2wks Follow-up; closed apex are at risk of necrosis hence, pulp therapy is indicated after splinting
  79. 79. As a rule all avulsed teeth should be re-implant. Diagnosis; clinically and radiological evidence show absence of tooth in the socket in case complete intrusion is been suspected. Management; 1. Give first aid if you receive a phone call 2. On arrival in clinic the following is done;
  80. 80. Considerations; 1. Extra-oral time 2. Stage of root development
  81. 81. First aid for avulsed tooth  1. Do not touch the root of the tooth. Handle the tooth by the crown only.  2. Rinse the tooth off only if there is dirt covering it. Do not scrub or scrape the tooth.  3. Attempt to reimplant the tooth into the socket with gentle pressure, and hold it in position.  4. If unable to reimplant the tooth, place it in a protective transport solution, such as Hank's solution, milk or saline.
  82. 82.  This will hydrate and nourish the periodontal ligament cells which are still attached to the root. A  small container of Hank's Balanced Salt Solution can be purchased in dental emergency kit form at many  drug stores. Contact lens solution is not an acceptable storage medium.  5. The tooth should not be wrapped in tissue or cloth. The tooth should never be allowed to dry.
  83. 83.  6. Take the child to a dentist or hospital emergency room for evaluation and treatment.  7. Radiographs may need to be taken of the airway, stomach, and mouth if the tooth cannot be found .  8. Tetanus prophylaxis should be considered if the dental socket is contaminated with debris.
  84. 84. 1. For A Mature Tooth With A Closed Apex: If the extra-oral dry time is <60 minutes, reimplant as soon as possible. If the extra-oral dry time is >60 minutes, soak in citric acid or curette the root; then soak in stannous fluoride(2%) for 10 minutes. Rinse with saline. Perform root canal therapy one week following the trauma.
  85. 85.  If the extra-oral dry time is <60 minutes, soak in doxycycline (1mg/20 ml saline) for 5 minutes. If the extra -oral dry time is >60 minutes, provide the same treatment as for a closed apex.  Apply a flexible, functional splint for 7 to 10 days. If an alveolar fracture is present, provide a very rigid splint for 4-6 weeks.
  86. 86.  suture any laceration  place on antibiotics and analgesics  prescribe 0.12% chlohexidine mouthwash  check TT status
  87. 87. Open apex; EOT < 60min; monitor for 3-4 mths, if pathosis sets in start apexification EOT >60min; start apexification immediately Closed apex; provide traditional pulp treatment and obturate Remove splint after 7-10days Continue review every 3-4wks
  88. 88. If tooth eventually become discoloured, noon-bleaching could be done.
  89. 89. In primary dentition;  Pulpitis; reversible or irreversible  Pulp canal obliteration  Pulp necrosis  Resorption; inflammatory and replacement  Injury to developing permanent teeth; hypoplasia, hypomineralisation, crown dilacerations, arrested root development, odontoma-like formation
  90. 90. Trauma dental injuries is common among toddlers and adolescence. Due to the instability of children in their developmental stage they become prone to it. Mouth guard use in contact sport can greatly reduce the incidence and severity. Effort should be made if possible to preserve a traumatise tooth considering the aesthetics and functional role they play.
  91. 91. 1. Richard Welbury et al, 2005. paediatric dentistry (3rd ed) Oxford University Press. 2. Cameron A and Widmer R, Handbook of paediatrics Dentistry, 5:95-102 3. Andlaw AL and Rock WP, 1999. Manual of Paediatrics Dentistry(4th edn)27-29:203-239 4. Pinkham JR et, Paediatrics Dentistry; infancy through adolescence. 15:213-234, 34;531-546 5. Management of Dental Trauma in children. Information on emergencies, Paediatrics Dental Health,2008
  92. 92. 6. Flore MT et al , Guidelines For the Management of Traumatic Dental injuries part II avulsion of permanent teeth; dental traumatology 2007:130-136 7. Kapil L et al2010. A proposal for classification of tooth fractures based on treatment need Journal of Oral Science, Vol. 52, No. 4, 517-529 8. Elisa B. Bastone, Terry J. Freer, John R. McNamara Epidemiology of dental trauma: A review of the Literature; Australian Dental Journal 2000;45:(1):2-9
  93. 93. Thanks for your time