this presentation talking about treatment traumatic teeth specially maxillary incisor and orthodontic treatment possibility after trauma . dr mohammad alkeshan

1. TRAUMATO THE PERMANENT MAXILLARY
INCISORS IN THE MIXED DENTITION AND
ORTHODONTICS
Pediatric Department .R2 Mohammad

2.  Introduction
 Common occurrence in young children.
 The prevalence of dental trauma 10.7 - 37.6%.
 The most commonly affected teeth are the permanent
maxillary central and lateral incisors.
 Management requires long-term monitoring of both pulp vitality
and root development.
early interceptive management of a malocclusion (increased
overjet) may be indicated to reduce the risk of trauma.

3. Aetiology of Dental Trauma
• Physical trauma the commonest cause of traumatic dental
injuries.
• Types of physical trauma include falls, collisions and
trauma during physical or sporting activities and traffic
accidents.
• physical traumatic dental injuries result as:
1. Enamel-Dentine fractures without pulpal involv(40%)
2. Enamel fractures (33.8%)
3. subluxation (8.4%)
4. luxation (6.7%)

4. Risk Factors for Dental Trauma
• Gender is an aetiological factor, males tend to incur
trauma to the permanent maxillary incisors more than
females 1.88 more likely
• The presence of an overjet above 3.5 mm increases the
risk of trauma.Traumatic dental injuries 1.6 times more
likely to occur if the overjet >5 mm.
• the presence of lip incompetency.
• Increase of the overjet and inadequate lip coverage acts
synergistically and substantially increases the risk of
trauma

5. • Incompetent lips
• An Increased overjet in the mixed
dentition

6. Prevention of Trauma
 Use of Mouthguards “shock absorber”
Mouthguards reduce the risk and severity of orofacial
trauma.
Trauma is 1.6–1.9 times more likely when mouthguards
are not worn
 the material properties of MG such as thickness and
resilience are thought to absorb traumatic forces and
reduce their transmission to the dentoalveolar complex
 Custom-made types made from ethylene vinyl acetate
are recommended (better tolerated, allow for normal
function breathing and speaking)

7.  Mouthguards can be worn when a
child is either in the mixed or
permanent dentition 7–8-year-olds.
 The retention of Mouthguards and
effectiveness may be compromised
during the mixed dentition due to
growth and development of the jaws
and further tooth eruption.
 Anticipation of these changes should
be incorporated in the design of
custom-made Mouthguards.
 the use of Mouthguards by young
children participating in sporting
activities is recommended
• Custom-made Mouthguard worn in
the mixed dentition

8. Early Orthodontic Treatment
• Interceptive orthodontic treatment to reduce an increased
overjet. Considered between 7 and 11 years of age (early
adolescence).
• Simple upper removable appliance and a functional
appliance can be reduce an increased overjet in the
mixed dentition.
• There was a significant reduction in the incidence of
trauma to the upper permanent incisors in patients who
underwent two-phase treatment.

9. Early Orthodontic Treatment

10. Management of Acute Traumatic Injuries
in the Mixed Dentition
• The aim in managing acute dental trauma in the mixed
dentition is to:
1. Restore form.
2. Restore function.
3. Preserve pulp vitality.
4. Support continued root formation.
5. Improve self-esteem.
6. Promote long-term sustainable biological outcomes for
the patient

11. Management of Acute Traumatic Injuries
in the Mixed Dentition
Fracture injuries can be categorised as:
• Uncomplicated crown fractures-enamel; enamel-dentine.
• Complicated crown fractures-enamel-dentine with pulp
exposure.
• Crown-root fractures-with or without pulp exposure
• Root fractures-involving the cementum; horizontal/oblique
Luxation injuries can be categorised as:
• • Concussion • Subluxation • Extrusion • Lateral luxation
• Intrusion • Avulsion

12. History of the Traumatic Incident
 Any loss of consciousness ( signs of a head injury such as
headache, amnesia, nausea or vomiting ).
 Sensibility testing can be useful in the long-term
monitoring ,immature teeth can give transient negative
results, and there may be false-negative responses for up
to 3 months after a trauma.
 Periapical radiographs are standard, but if there is a
suspicion of a root fracture, an upper occlusal radiograph
would help to diagnos the case.
 photographs are an important and a line diagram
outlining all of the soft tissue injuries can also help.

13. Fractures Injuries
• Uncomplicated crown fractures—enamel; enamel-dentine
 Direct build up with composite resin ASAP is indicated. If
no time , placing a temporary ‘bandage’ with GI is
acceptable.
• Complicated crown fractures—enamel-dentine with pulp
exposure
 preserve the vitality of the pulp to support continued root
formation.
 A Cvek pulpotomy, carried out under local anaesthesia
and rubber dam, is indicated
 built up with composite, or if the tooth fragment is
available it can be relocated.

14. Fractures Injuries

15. Fractures Injuries
• Crown-root fractures-with or without pulp exposure
 Uncomplicated crown- root fractures; include
reattachment of the coronal fragment, build up with
composite resin, surgical extrusion or orthodontic
extrusion.
 Complicated crown-root fractures are as above with
consideration of pulp management either with a Cvek
pulpotomy or RCT.
• Root fractures—involving cementum
the coronal fragment repositioned under LA and splinted
flexibly for 4 weeks in the apical and mid-third root
fractures and for 4 months in cervical third root fractures.

16. Luxation Injuries
• Concussion
 Tender to touch .No increase in mobility. NO need for any
active treatment.
• Subluxation
 Tender to touch, slightly increased mobility. Flexible
splinting can sometimes be benefit if patient demonstrate
considerable distress.
• Extrusion
 Teeth appear slightly longer than the adjacent teeth and
are mobile and there may be an occlusal interference.
Digital repositioning under local anaesthetic and flexible
splinting for 2 weeks is indicated.

17. Luxation Injuries
• Lateral luxation
Displaced palatally(most common)or labially.Palatally
displaced teeth may result in an occlusal interference.
Digital repositioning under LA and flexible splinting for 4
weeks is indicated.
• Intrusion
 Displaced apically into the socket, crown appears shorter
than the adjacent teeth. A high-pitched ankylotic sound is
elicited

18. Luxation Injuries

19. Luxation Injuries
• Avulsion
• Total displacement of a tooth out of its socket. Immediate
replantation of the tooth confers the best prognosis in the
long term.

20. Luxation Injuries
• Complications
The following complications may arise following traumatic
dental injuries in the mixed dentition:
• Pulp necrosis ± discolouration. Pulp canal obliteration ±
discolouration. Root resorption. Ankylosis. Infraocclusion
• Follow-Up
• RCT should be carried out if there are two signs or
symptoms of pulp necrosis such as; Pain, Swelling , Sinus,
Discolouration ,Increased mobility, Negative sensibility
tests (weak sign) , Periapical radiolucency on radiograph.

21. Orthodontic Movement of Traumatised
Teeth
 Orthodontic movement is not without possible risk.
 Application of orthodontic forces may increase the
chance of root resorption and non-vitality.
 The incidence of loss of vitality of traumatised
permanent incisors with application of orthodontic
movement 7.3 and 10.4%.
 little evidence that a history of previous trauma to the
incisors increases the risk of root resorption during
orthodontic treatment.
A period of observation/monitoring is often recommended
prior to the application of orthodontic forces

22. Orthodontic Movement of Traumatised
Teeth
• The duration of this observation period varies in relation to
the severity of the traumatic injury.
• Crown and crown-root fractures without pulpal
involvement (3 months)
• Crown and crown-root fractures with pulpal involvement
(3 months after coronal pulpotomy)
• Root fractures (12–24 months)
• Minor injuries including concussion, subluxation,
extrusion, minor lateral luxation (3 months)
• Moderate/severe injuries including avulsion and
replantation and moderate/ severe lateral luxation (12
months if ankylosis not present)

23. Orthodontic Movement of Traumatised Teeth

24. Case#1
• Name: 김*규
• File Number: 761893
• Age: 10 years 7months
• Gender: M
• PDH: -
• C/C: Broken of the ant teeth after hit
• Dx.
1. Mx prognathic tendency, Mn retrognathic tendency.
2. Deep OJ & OB
3. U1 protrusion . UL Protrusion LL Protrusion
4. Midline deviation
5. Uncomplicated Enamel-Dentine fracuters #11&# 21
• Tx: Class IV Resin Restoration with lingual
index

25. Case#2
• Name: 양*희
• File Number: 874543
• Age: 10 years
• Gender: F
• PDH: -
• C/C: Protruded Maxilla
Dx:
1. U1 protrusion , Labioversion/ L1 retrusion, linguovirsion
2. Lip incompetency
3. UL protrusion
4. OJ/OB: 13MM / 7MM
Tx plan:
1- Twin block
2- Re-eval -> Full fixed (permanent dention )
Lip sealing Emphasized