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Traumatic
Dental Injuries
By:
Mennat Allah Alkaram
Under supervision of:
Professor. Nagwa Khattab
Incidence & Gender predilection
Prevalence : 9.8%
Age: peak incidence at 2- 4 y and 8 – 11 year.
Sex : males more than females ( after 9 y).
Teeth : anterior
Predisposing factors
 Occlusal state “ Accident-prone
dental profile”
 Increase Overjet> 9 mm
 Cl II dev 1
 Lip Incompetence
 Ugly Duckling Stage
 Dental factors
 Amylogenesis imperfecta
 Dentinogenisis imperfecta
 Root canal treatment
 Carious tooth
 Systemic factors/ physical
factors
“Neurological disorders” Cerebral
Palsy, Epilepsy, down, mentally
retarded”
Etiology of Dental injuries
Pre- school Child:
 Fall injuries
 Child abuse
 Seizures or C.P (why)
School-age Child:
 Athletic injuries
 Fighting
 Accidents
Classification
Descriptive
classification
Tooth
Crown
Infarction
E,D or
pulp (H or
V)
C&R
involving
cementum
Root
Apical
Middle Coronal
Whole tooth
Concussion Subluxation Displacement
Intrusion
Extrusion
Lateral dis.
avulsion
Supporting structure
Modified Ellis and Davey classification
(1970)
 Class I [enamel fracture]
 Class II [enamel and dentin without pulp
involvement]
 Class III [fracture enamel and dentin with pulp
involvement]
 Class VI [fracture crown enemas]
 Class V [root fracture]
Mangement
Management
A- Diagnosis
History
Medical Dental
Examination
Extra Oral Intra oral
Soft tissue Hard tissue
B- treatment
History
Medical Dental
 Medical History : (vaccination State)
 Dental History: Previous teeth trauma
Examination
Extra Oral Intra oral
 Extra Oral: Neuralgic involvement, Laceration,
Asymmetries , TMJ involvement
 Intra Oral: 1) Soft tissue
2) Hard tissue (vitality test)
Radiographic examination
• Relation od displaced 1ry
tooth to its successor
• Root Fx
• Jaw / alveolar process Fx
• Proximity of pulp tissue to
the Fx
• Maturity of the tooth
• Displacement of tooth
into/out of its socket
Treatment:
Diagnosis:
 Extra Oral
 Intra Oral – soft
tissue
 Intra oral – Hard
tissue
Treatment:
 Intra oral – Hard
tissue
 Intra Oral – soft
tissue
 Extra oral
Infraction
Primary dentition:
No treatment + follow up
permanent:
No treatment + follow up
Long term + wide crack =
discoloration [require
sealing]
Sensitivity [more than 2
weeks] [require sealing]
Uncomplicated crown fracture Ellis class I ,II
Uncomplicated
crown
fracture
Enamel
No treatment required
Roundation of the
edges + flouride
application
composite restoration
Enamel + dentin
Shallow [away from
the pulp]
composite restoration
Deep [near the pulp]
indirect pulp capping
Fragment
restoration
Complicated crown fracture –Ellis Class III –
[ enamel + dentin + pulp]
Pulp
treatment
Vital
open apex
large
early
partial pulpotomy
complete pulpotomy
late
Small
early direct pulp capping
late
Partial pulpotomy [3-5
mm]
complete pulpotomy
[till the CEJ]
closed apex
large
early RCT
late RCT
small early direct pulp capping
late RCT
Apexogenisis
Apexogenisis
According to clinical judgement:
Pulpotomy or apexification.
Non-vital
Open apex
apexification
small
Revascularization
Closed apex RCT
Complicated crown fracture –Ellis Class
III – [ enamel + dentin + pulp]
Ellis class IV
Corwen
amputation
Subgingival +
supra bony
retraction cord
Pulp ttt +
restoration
Subgingival +
infra bony
if less than
2mm
osteotomy +
gingivectomy
if more than
2mm
orthodontic
extrusion
Root fracture
A. Vertical [ extraction]
B. Horizontal :
 Apical fracture( Most favorable )
No ttt required
 Middle root fracture, (repositioning
and splint for 4 – 6 w)
 Coronal fracture:
 Splinting 3-4 months [low success
rate]
 If not successful:
 remove coronal part, and then
extrude.
 Internally splint both fragments
 Extract both fragments
Concussion
 Trauma absorbed by PDL
causing edema within the PDL
but no rupture of the fibers.
 Diagnosis:
 Tender to percussion [periodontal
cells are affected]
 No mobility
 No displacement
 Treatment:
 Relife the occlusion.
 Soft dite for 7 days
 Follow up for any signs of tooth
necrosis
Subluxation
No displacement just looseness-
periodontal cells breakdown =
hemorrhage from gingival crevice.
Splint [1-2 weeks] + soft diet + out of
occlusion
Chlorohexidine MW twice daily
Follow up
Lateral luxation [ any direction but
apical]
Primary tooth or
permeant:
 Repositioning + splint
[2-3 weeks]
 Soft diet for 2 – 3 w
 Antibiotic and MW
Intrusion
In primary:
 Leave to re erupt
**Inform the parents about possibility of ankyloses ,
necrosis or damage for permanent successor
Intruded
permanent
tooth
Open apex
Allow to erupt for 2-
4w
No eruption occurs
Surgical extrusion +
splint for 1w + endo ttt
Orthodontic extrusion
over 3-4 w
Closed apex
Surgical traction
Orthodontic traction
Intrusion
RCT if
needed
Extrusion
 If primary = Reposition and splint with
composite
 If permanent replace and splint 2-3w
 Follow up
Avulsion
Tell the guardian to :
make sure it is a permanent tooth (primary teeth should not
be replanted).
 Find the tooth and pick it up by the crown
 Avoid touching the root.
 If the tooth is dirty, wash it briefly (10 seconds) under cold
running water and reposition it. Try to encourage the
patient / parent to replant the tooth.
 If this is not possible, place the tooth in a suitable storage
medium, e.g. a glass of milk
 Seek emergency dental treatment immediately.
Avulsion
Extra oral dry time less
than 60 min. The tooth
has been kept in
physiologic storage
media or osmolality
balanced media (Milk,
saline, saliva or Hank’s
Balanced Salt Solution)
.
 Clean the root surface.
 Administer local anesthesia
 Irrigate the socket with saline.
 Replant the tooth slowly.
 Suture gingival lacerations if
present.
 Verify normal position of the
replanted tooth both, clinically
and radiographically.
 Apply a flexible splint for up to
2 weeks.
 Administer systemic
antibiotics.
 Initiate root canal treatment 7-
10 days after replantation and
before splint removal.
 Extra oral dry
time
exceeding
60 min or
other
reasons
suggesting
non-viable
cells
Avulsion  Remove attached non-viable
soft tissue with gauze.
 Root canal treatment can be
performed prior to replantation,
or it can be done 7-10 days later.
 Administer local anesthesia
 Irrigate the socket with saline.
 Replant the tooth slowly.
 Suture gingival lacerations if
present.
 Stabilize the tooth for 4 weeks
using a flexible splint.
 Administer systemic antibiotics.
management of traumatic dental injuries in children.pptx

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management of traumatic dental injuries in children.pptx

  • 1. Traumatic Dental Injuries By: Mennat Allah Alkaram Under supervision of: Professor. Nagwa Khattab
  • 2. Incidence & Gender predilection Prevalence : 9.8% Age: peak incidence at 2- 4 y and 8 – 11 year. Sex : males more than females ( after 9 y). Teeth : anterior
  • 3. Predisposing factors  Occlusal state “ Accident-prone dental profile”  Increase Overjet> 9 mm  Cl II dev 1  Lip Incompetence  Ugly Duckling Stage  Dental factors  Amylogenesis imperfecta  Dentinogenisis imperfecta  Root canal treatment  Carious tooth  Systemic factors/ physical factors “Neurological disorders” Cerebral Palsy, Epilepsy, down, mentally retarded”
  • 4. Etiology of Dental injuries Pre- school Child:  Fall injuries  Child abuse  Seizures or C.P (why) School-age Child:  Athletic injuries  Fighting  Accidents
  • 6. Descriptive classification Tooth Crown Infarction E,D or pulp (H or V) C&R involving cementum Root Apical Middle Coronal Whole tooth Concussion Subluxation Displacement Intrusion Extrusion Lateral dis. avulsion Supporting structure
  • 7. Modified Ellis and Davey classification (1970)  Class I [enamel fracture]  Class II [enamel and dentin without pulp involvement]  Class III [fracture enamel and dentin with pulp involvement]  Class VI [fracture crown enemas]  Class V [root fracture]
  • 9. Management A- Diagnosis History Medical Dental Examination Extra Oral Intra oral Soft tissue Hard tissue B- treatment
  • 10. History Medical Dental  Medical History : (vaccination State)  Dental History: Previous teeth trauma Examination Extra Oral Intra oral  Extra Oral: Neuralgic involvement, Laceration, Asymmetries , TMJ involvement  Intra Oral: 1) Soft tissue 2) Hard tissue (vitality test)
  • 11. Radiographic examination • Relation od displaced 1ry tooth to its successor • Root Fx • Jaw / alveolar process Fx • Proximity of pulp tissue to the Fx • Maturity of the tooth • Displacement of tooth into/out of its socket
  • 12. Treatment: Diagnosis:  Extra Oral  Intra Oral – soft tissue  Intra oral – Hard tissue Treatment:  Intra oral – Hard tissue  Intra Oral – soft tissue  Extra oral
  • 13. Infraction Primary dentition: No treatment + follow up permanent: No treatment + follow up Long term + wide crack = discoloration [require sealing] Sensitivity [more than 2 weeks] [require sealing]
  • 14. Uncomplicated crown fracture Ellis class I ,II Uncomplicated crown fracture Enamel No treatment required Roundation of the edges + flouride application composite restoration Enamel + dentin Shallow [away from the pulp] composite restoration Deep [near the pulp] indirect pulp capping Fragment restoration
  • 15. Complicated crown fracture –Ellis Class III – [ enamel + dentin + pulp] Pulp treatment Vital open apex large early partial pulpotomy complete pulpotomy late Small early direct pulp capping late Partial pulpotomy [3-5 mm] complete pulpotomy [till the CEJ] closed apex large early RCT late RCT small early direct pulp capping late RCT Apexogenisis Apexogenisis According to clinical judgement: Pulpotomy or apexification.
  • 16. Non-vital Open apex apexification small Revascularization Closed apex RCT Complicated crown fracture –Ellis Class III – [ enamel + dentin + pulp]
  • 17. Ellis class IV Corwen amputation Subgingival + supra bony retraction cord Pulp ttt + restoration Subgingival + infra bony if less than 2mm osteotomy + gingivectomy if more than 2mm orthodontic extrusion
  • 18. Root fracture A. Vertical [ extraction] B. Horizontal :  Apical fracture( Most favorable ) No ttt required  Middle root fracture, (repositioning and splint for 4 – 6 w)  Coronal fracture:  Splinting 3-4 months [low success rate]  If not successful:  remove coronal part, and then extrude.  Internally splint both fragments  Extract both fragments
  • 19. Concussion  Trauma absorbed by PDL causing edema within the PDL but no rupture of the fibers.  Diagnosis:  Tender to percussion [periodontal cells are affected]  No mobility  No displacement  Treatment:  Relife the occlusion.  Soft dite for 7 days  Follow up for any signs of tooth necrosis
  • 20. Subluxation No displacement just looseness- periodontal cells breakdown = hemorrhage from gingival crevice. Splint [1-2 weeks] + soft diet + out of occlusion Chlorohexidine MW twice daily Follow up
  • 21. Lateral luxation [ any direction but apical] Primary tooth or permeant:  Repositioning + splint [2-3 weeks]  Soft diet for 2 – 3 w  Antibiotic and MW
  • 22. Intrusion In primary:  Leave to re erupt **Inform the parents about possibility of ankyloses , necrosis or damage for permanent successor
  • 23. Intruded permanent tooth Open apex Allow to erupt for 2- 4w No eruption occurs Surgical extrusion + splint for 1w + endo ttt Orthodontic extrusion over 3-4 w Closed apex Surgical traction Orthodontic traction Intrusion RCT if needed
  • 24. Extrusion  If primary = Reposition and splint with composite  If permanent replace and splint 2-3w  Follow up
  • 25. Avulsion Tell the guardian to : make sure it is a permanent tooth (primary teeth should not be replanted).  Find the tooth and pick it up by the crown  Avoid touching the root.  If the tooth is dirty, wash it briefly (10 seconds) under cold running water and reposition it. Try to encourage the patient / parent to replant the tooth.  If this is not possible, place the tooth in a suitable storage medium, e.g. a glass of milk  Seek emergency dental treatment immediately.
  • 26. Avulsion Extra oral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank’s Balanced Salt Solution) .  Clean the root surface.  Administer local anesthesia  Irrigate the socket with saline.  Replant the tooth slowly.  Suture gingival lacerations if present.  Verify normal position of the replanted tooth both, clinically and radiographically.  Apply a flexible splint for up to 2 weeks.  Administer systemic antibiotics.  Initiate root canal treatment 7- 10 days after replantation and before splint removal.
  • 27.  Extra oral dry time exceeding 60 min or other reasons suggesting non-viable cells Avulsion  Remove attached non-viable soft tissue with gauze.  Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.  Administer local anesthesia  Irrigate the socket with saline.  Replant the tooth slowly.  Suture gingival lacerations if present.  Stabilize the tooth for 4 weeks using a flexible splint.  Administer systemic antibiotics.