Management of traumatic lesions to primary dentition
Management of traumatic lesions to primary dentitionDr. Masar Mohammed
Management of traumatic lesions to primary dentition Etiology Epidemiology Classification History and examination Injuries to the primary dentition
Etiology of traumatic injuries to the teeth1. Falls due to incomplete coordination.2. Sports activities.3. Road accidents.4. Domestic violence and abuse5. Fights and assaults
Etiology of traumatic injuries to the teeth6. Mental retardation, epilepsy.7. Developmental defect in enamel and dentine.8. Class II Division 1 Malocclusion9. Overjet 3-6mm or more
Epidemiology Traumatic dental injuries (TDIs) occur with great frequency in preschool, school age children and young adults comprising 5% of all injuries for which people seek treatment. The traumatic lesion to the primary teeth occurs between 2 and 4 years of age and from 7 to 10 in the permanent dentition. Boys are affected twice as often girls in both dentition
Epidemiology The anterior teeth are the most affected in both dentition. In Primary dentition concussion and luxation are the most common injury. In the permanent dentition uncomplicated crown fractures are the most common injury.
ClassificationEllis classificationClass I: Simple fracture of the crown,involving little or not dentinClass II: Extensive fracture of the crowninvolving considerable dentin but not the pulp
Classification Class III: Extensive fracture of the crown involving considerable dentin and exposing the dental pulp Class IV: The traumatized tooth where amputation of the crown in mass occur Class V: Root fracture with or without loss of crown structure
Classification Andreasen’s classificationInjuries to the hard Injuries to the Injuries todental tissues and hard dental periodontal tissuesthe pulp tissues: The pulp and alveolar processEnamel infraction Crown root fracture ConcussionEnamel fracture Root fracture SubluxationEnamel – dentin Fracture of the jaws Extrusive luxationfracture alveolar socket wallComplicated crown Fracture of the jaws Lateral luxationfracture alveolar process Intrusive luxation Avulsion
Classification Andreasen’s classificationInjuries to gingiva or oral mucosaLaceration of gingiva or oral mucosaContusion of gingiva or oral mucosaAbrasion of gingiva or oral mucosa 10
World Health Organization (WHO) ClassificationInjuries to the Injuries to the Injuries to the Injuries to gingivahard dental tiss. & period. tissues supporting bone or oral mucosapulpEnamel infraction Concussion Comminution of Laceration of gingiva jaws alveolar or oral mucosa socket wallEnamel fracture Subluxation Fracture of jaws Contusion of gingiva alveolar socket wall or oral mucosaEnamel-dentin Extrusive Fracture of jaws Abrasion of gingivafracture luxation alveolar process or oral mucosaComplicated crown Lateral luxation Fracture offracture mandible or maxillaUncomplicated Intrusive luxationcrown-root fractureComplicated Avulsioncrown-root fractureRoot fracture 11
History and examinationExamination of a patient with a dental trauma injury Clean the face and the oral cavity with water or saline. Make a short medical and dental historyDental history:should indicate previous dental traumas, information which may explain radiographic findings such as pulp canal obliteration or apical pathology. 12
Questions relating to the injury When did the injury occur? Where did the injury occur? How did the injury occur? Was there a period of unconsciousness? headache, vomiting , nausea or amnesia. Is there any disturbance in the bite? Is there any reaction in the teeth to cold and/or heat exposure?
History and examinationMedical History Congenital heart disease, rheumatic fever or severe immunosuppressant? Bleeding disorder? Allergies? Tetanus immunization status?
History and examination Extraoral examinationwe should look for:1.Signs of shock (pallor, cold skin, irregularpulse, hypotension)2.Facial Swelling, bruises or lacerations3.Limitation of mandibular movement4.Foreign body in the lips
5. Sighs of head injury suggesting brainconcussion or maxillofacial fracturesSuch asAltered or loss of consciousness.Bleeding from nose and ears.Disorientation.Prolonged headache.Nausea, vomiting, amnesia.
Seizures or convulsions. Speech difficulties. Altered vision or unilateral dilated pupil.
History and examinationIntraoral examination Laceration, hemorrhage and swelling of the oral mucosa and gingiva Abnormalities of occlusion Mobility or displacement of the teeth. Reaction to percussion Color of tooth Reaction to sensitivity test
History and examinationRadiographic examination Periapical x-ray Occlusal x-ray Panoramic x-ray
Radiographic examination of soft tissue lesions:In the presence of a penetrating lip lesion, a soft tissue radiograph is indicated in order to locate any foreign bodies.
Injuries To The Primary DentitionA. Uncomplicated crown fracture1. Enamel infraction(crack)An incomplete fracture of the enamel without loss of tooth structure.
No treatment necessary No follow-up is needed for infraction injuries unless they are associated with a luxation injury or other fracture types involving the same tooth.
2. Enamel fracture:A fracture confined to the enamel with lossof tooth structure. Treatment: Grinding or restoration with composite resin depending on the extent and location of the fracture if cooperation is satisfactory .
In patients with lip or cheek lesions it is advisable to search for tooth fragments or foreign material. Follow-upClinical control at 3-4 weeks.
3. Enamel-dentin fracture: fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp.
Treatment: Smooth sharp edges. If possible, the tooth can be restored with glass ionomer or composite resin depending on the extent and location of the fracture
B. Complicated crown fracture Enamel-dentin-pulp fractureA fracture involving enamel and dentin withloss of tooth structure and exposure of thepulp.
Treatment:In very young children with immature, stilldeveloping roots and if the patient iscooperative it is advantageous to preservepulp vitality by pulp capping or partialpulpotomy
This treatment is also the choice in young patients with completely formed roots. Calcium hydroxide is a suitable material for such procedures. Both treatments should be considered whenever possible, otherwise extraction is indicated. A dentin bridge is expected to be seen on a radiograph within 4-6 weeks
C. Crown root fracture1. Crown-root fracture without pulpinvolvementCrown fracture extending below gingivalmargin. The crown is split into two or morefragments, one of which is mobile.
Treatment: Fragment removal only 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. Extraction Extraction is inevitable in very deep crown-root fractures
2. Crown-root fracture with pulp involvement Treatment Extraction is recommended. Care must be taken to prevent trauma to the subjacent tooth germ.
D. Root fracture:Treatment No treatment If the coronal fragment is not displaced no treatment is required but If the coronal fragment becomes non vital and symptomatic then it should be removed.
Extraction If the coronal fragment is displaced, extract only that fragment. The apical fragment should be left to be resorbed.
E. Alveolar fracture A fracture of the alveolar process which may or may not involve the alveolar bone socket.
Treatment Manual repositioning or repositioning using forceps of the displaced segment. Stabilize the segment with flexible splinting for 4 weeks.
Injuries To The Primary Dentition1. Concussion: An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion and without gingival bleeding.
2. Subluxation An injury to the tooth supporting structures resulting in increased mobility and pain to percussion, but without displacement of the tooth. Bleeding from the gingival sulcus is evident if the child is seen shortly after the accident.
Treatment No treatment is needed. Observation Soft food for 1-2 week. good oral hygiene. Brush with a soft brush after every meal
3. Extrusion Partial displacement of the tooth out of its socket resulting in loosening and displacement of the tooth
Treatment minor extrusion (< 3mm) in an immaturedeveloping tooth either careful repositionthe tooth or leave the tooth for spontaneousalignment. Extraction for severe extrusion in a fullyformed primary tooth.
4. Lateral luxationDisplacement of the tooth accompanied byfracture of either the labial or thepalatal/lingual alveolar bone.
Treatment1.Spontaneous repositioningIf there is no occlusal interference, as is incase of anterior open bite2.RepositioningWhen there is occlusal interferencerepositioned by gentle combined labial andpalatal pressure.
3. Extraction For teeth with severe displacement in a labial direction
5. Intrusive luxationDisplacement of the tooth into the alveolarboneThe most common type of injury.
Treatment1. Spontaneous eruptionIf the apex is displaced toward or throughthe labial bone plate, the tooth should be leftfor spontaneous repositioning.Most re-eruption occurs between 1 and 6 months, and if it doesn’t occur the ankylosis may happen and extraction is necessary
2. Extraction If the apex is displaced into the developing tooth germ the tooth should be extracted to minimize the damage done to the permanent successor.
6. AvulsionThe tooth is completely displaced out of its socket. Clinically the socket is found empty or filled with a coagulation.
Dental avulsion injuries occur most frequentlyin children between the ages of 7 and 9, anage when the alveolar bone surrounding thetooth is relatively resilient.Treatment Replantation of avulsed primary teeth is not recommended.
Sequelae of injuries to primary dentition 1. Pulpal necrosis 2. Pulpal obliteration 3. Root resorption 4. Injuries to developing permanent teeth: Intrusive luxation causes most disturbances
Others Sequelae1. Odontoma-like malformation2. Root duplication3. Partial or complete arrest of root formation4. Sequestration of permanent germs5. Disturbance in eruption
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