Traumatic injury to the primary dentition

Traumatic injuries to the
Primary dentition
Dr.Tinet Mary Augustine. BDS,MDS
Pediatric Dentist
Dr.Tinet’s Pedorayz, Pediatric And Early Age Orthodontic Dental Clinic
DR.TINET MARY AUGUSTINE.BDS,MDS 1

CHALLENGES

The treatment decision made not so much in terms of
primary tooth but on long term health of permanent
successors

EPIDEMOLOGY

 Less dense and mineralized alveolar bone
 Direction of impact
 Toy or pacifiers
PATHOGENESIS

Dilaceration/Turner’s Tooth

Focal Hypoplasia & Hypocalcification

 EXTRA ORAL EXAMINATION
 INTRAORAL EXAMINATION
 TOOTH MOBILITY
 TOOTH ALINGNMENT
EXAMINATION

RADIOGRAPHIC EXAMINATION

 REDUCE RISK
 PAIN CONTROL
 MAINTANENCE
TREATMENT REGIMEN

Primary (enamel fracture)
 Smooth enamel
 Check vitality in 6-8 weeks

Primary (dentin involved)
 IPT
 Restore
 Check in 6-8 weeks

Primary (pulp involved)
 Formocresol pulpotomy, at least(76%-FLAITZ 1989)
 Restore
 Check in 6-8 weeks

Primary (pulp necrotic)
 Formecresol Pulpectomy, in absence of significant internal
or external root resorption
 Extraction +/- space maintainer if endodontic treatment
not possible

Primary (avulsion)

Was the primary tooth actually avulsed;has it
been found?
Is there a possibility that the tooth is deeply
intruded? (Take a radiograph)
Has the tooth been inhaled? Have there been
any coughing or breathing problems subsequent
to the injury? (Refer for chest X-ray)

E ven if there is no intention to replant the
avulsed primary incisor, the tooth must be
found to ensure that it has not been
aspirated
If the tooth is not found, the child should be
referred to a pediatrician for further
examination.


Reimplantation(support)

Extraction followed by prosthesis

Primary (root fracture)
 Location of a root fracture in primary teeth usually
determines the outcome.
 The crown fragment appears loosened and usually
displaced in a coronal and oral direction.

Primary (displacement)
 Most frequent injury to primary dentition.
 Extraction?

 In concussion the tooth is sensitive to percussion
(performed with a ﬁnger tip).
 In subluxation the tooth appears loosened and may be
bleeding from the gingival crevice.
Concussion and subluxation

 No acute treatment apart from instructing the parents
 Maintain good oral hygiene to prevent bacterial
contamination through the PDL
 Application of chlorhexidine twice a day for 7 days
TREATMENT

 The tooth appears elongated and with the crown usually
displaced in lingual direction and there is usually a marked
loosening of the tooth.
Radiography
 A marked apical periodontal ligament space is seen.
Extrusion

 Soon after injury-reposition and stabilized for a short period
 If a blood clot has already become organized in the
alveolar socket and repositioning is no longer applicable,
the tooth can be left for spontaneous alignment or
extracted depending on the degree of extrusion and
mobility.
TREATMENT

The crown is usually tilted in the oral direction and
the tooth ﬁrm in its displaced position
Most of these luxations - crown displaced in lingual
direction and the apex with a labial bone plate
displaced in labial direction.
Lateral luxation

When child has fallen with an object in the mouth,
the opposite displacement direction can be found
and may have invaded the follicle.
These teeth should either be repositioned or
extracted.

 Through thin vestibular bone
 Evaluation-in comparison with adjacent teeth
Intrusion

Spontaneous eruption

Intrusion, Primary Teeth
18 months later
-allow 2-4 months for eruption

Primary - Coronal/Root Fracture
 Extraction is usually the only option

Alveolar bone fracture

IADT GUIDELINES

AVULSION


Reimplantation(support)

 Period : 6-8 weeks
 Colour change
 Radiographic evaluation
 Pulp testing methods
Complications to primary tooth

Colour changes

 3WEEKS
Radiographic findings

 The decisive factors
 Age of the patient (with the lowest frequency of necrosis
in the very young patients),
 The extent of displacement as well as the extent of
loosening of the luxated tooth
Pulp necrosis

 Isolation with a rubber dam without a clamp,
the pulp chamber is exposed from the palatal aspect of
the crown using a #330 tungsten bur on a high-speed
hand piece with water spray.
 Local anesthesia is not used if the pulp is considered to be
necrotic.
 If the patient complains of pain during insertion of the
broach, local anesthetic is injected directly into the root
canal.
Methodology for pulpal treatment

 The pulp is removed, root canal cleaned, washed with
hydrogen peroxide and saline and dried with paper
points.
 A resorbable paste is used to ﬁll the root canal with a spiral
lentulo on a slow-speed hand piece, and the tooth is
restored with a composite resin using the acid-etch
technique.
 A postoperative radiograph is taken to assess the extent of
root ﬁlling

Pulp canal obliteration

External root resoption

Internal root resorption

 DEPENDING ON THE STAGE-
MORPHOGENIC/ORGANIZING/FORMATIVE/MATURATION.
INJURIES TO DEVELOPING DENTITION

 White or yellow-brown discoloration of enamel
 White or yellow-brown discoloration of enamel with circular
enamel hypoplasia
 Crown dilaceration
 Odontoma-like malformation
 Root duplication
 Vestibular root angulation
 Lateral root angulation or dilaceration
 Partial or complete arrest of root formation
 Sequestration of permanent tooth germs
 Disturbance in eruption.
DIFFERENT DEVELOPMENTAL DEFECTS

 Classification according to anatomical and histological
deviation of developing tooth ( Andreasen )
Damage to the developing permanent
tooth bud
1.White or yellow brown
discoloration of enamel
2.White or yellow brown
discoloration of enamel
with circular hypoplasia

4.Crown dilaceration3.Odontoma like malformation
5.Partial or complete
arrest of root formation 6.Root dilaceration
7.Sequestration of permanent tooth germ 8.Disturbance in eruption

PREVALENCE

TYPE OF INJURY

AGE

JAW FRACTURE

 Contusion and displacement of the reduced enamel
epithelium and slight displacement of the hard dental
tissue in relation to the Hertwig’s epithelial root sheath
 After 6 weeks, metaplasia of the reduced enamel
epithelium into a thin stratiﬁed squamous epithelium took
place.
 In most cases,changes in morphology of the dentin
and/or enamel matrices were seen
CHANGES IN PERMENAT DENTION
ANIMAL STUDY

HUMAN STUDY

 These lesions appear as sharply demarcated, stained
enamel opacities, most often located on the facial
surface of the crown; their extent varies from small spots to
large ﬁelds
 BUT white enamel discolorations with a diameter of less
than 0.5mm are frequent in teeth without a history of
trauma
White or yellow-brown discolorations of
enamel

Mechanism

White or yellow-brown discoloration of
enamel with circular enamel hypoplasia

 It is an abrupt deviation of the long axis of the crown or
root portion of the tooth. This deviation originates from a
traumatic non-axial displacement of already formed hard
tissue in relation to the developing soft tissue
DILACERATION

DILACERATION

LARYNGOSCOPY

ODONTOME

Odontoma-like malformations

Root duplication

Vestibular root angulation

Lateral root angulation

Partial or complete arrest of root
formation

Sequestration of permanent tooth germs
– dentigerous cyst

MANAGEMENT

DILACERATION

Prevention of dental injuries

Face guards
Cage type guards that are attached to helmet or helmet straps
Prefabricated or custom made - clear polycarbonate plastic
Disadvantage :not applicable to all sporting activities
gives no protection if hit under the chin

Mouth guards((Shimada 2004)
 Soft and comfortable
 Firm enough to cushion traumatic impact
 Adaptable to the hard and soft tissues
 Minimal time for fabrication
 Retains form after prolonged removal from
the mouth
 Not interfere with speech and breathing
 not have offensive odour
 Non toxic
 Should provide proper occlusion

Advantages
•Effective in reducing severity and number of dental injuries
•Reduce the likelihood of brain concussion ,cerebral hemorrhage
and brain stem damage
Disadvantages
•Uncomfortable because of bulk
•Tissue reaction
•Maintenance

Types of mouth guard
•Stock mouth guard
•Mouth formed or boil and bite mouth guard
•Custom made mouth guard
Stock mouth guard
•Preformed rubber or polyvinyl type polymer
•Inexpensive and ready to use without modifications
•Also used during mixed dentition period and patients
wearing ortho brackets
•Least protective due to poor fit
•Less comfort to wear

Mouth formed or boil and bite mouth guard
Two types :
1. Preformed shell of semi-rigid polyvinyl with an inner lining
of silicon or plasticised acrylic gel
Disadvantage
•Inner lining may creep over time causing decreased retention
•Bulky

2.Preformed thermoplastic copolymer of polyvinyl acetate
•Prefabricated by softening for a few seconds in hot or boiling water and adapted in the mouth
•Bulky

Custom made mouth guard
•Fabricated on a cast
•Made of polyvinyl acetate or polyethylene
•Heated and vaccumed pressed on the cast
•Best available protection and most comfortable to the wearer
•Expensive
•Modification – multi laminated stock sheets that have harder
inserts to further support palatal side of the
incisors

Mouth protector
during laryngoscopy
Stock mouth guard for individuals
with orthodontic appliances
Neonatal protective plate supporting
an endotracheal tube

 Trauma to teeth is a common occurrence that every dental
surgeon must be prepared to assess, evaluate and treat when
necessary.
 Coupled with the dynamic panorama of sporting activity and
the significant increase in violence all over the world, tooth
trauma and its management has posed a major problem to the
dental professionals.
Summary and conclusion

 Tooth trauma leaves not only physical permanent scars but also
psychological impact on its victims.
 A simple enamel fracture to an avulsed tooth can be restored or
put back in it’s socket now with excellent post operative results.

 Understanding the basic principles and therapeutic protocols
can help to provide the appropriate treatment and prevent the
complication.

THANK YOU

Traumatic injury to the primary dentition

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