Root tip is displaced towards buccal cortical plate or vertical INTRUSION INJURIES: RECOMMENDATIONS

Primary Dentition No

All treatment is ideal and assumes patient has manageable behavior. Recommendations also assume radiographs ( periapical and lateral anterior taken where appropriate).

(REFERENCE: AAPD Handbook of Pediatric Dentistry)

Yes

Allow 6 months for spontaneous re-eruption. Advise parents of potential damage to adult tooth Extract if root tip is displaced into permanent tooth bud Follow up in 4 weeks: Advise parents of possible injury / damage to permanent teeth

Intrusive Luxation

 Most common in upper primary incisors  Management: allow to re-erupt or extract

Tooth Not Retrieved Post Trauma  Confirm Intrusion with Periapical  Monitor up to 6 months for re-eruption

Intrusive Luxation

Primary Teeth

 Consider antibiotic therapy - monitor for infection  Tetanus immunization current?

 Extract if there are signs of swelling, spontaneous bleeding, abscess and fever Day of the Trauma 2 weeks Post Trauma

Intrusive Luxation

Primary Teeth  One of the most dangerous injuries to the developing tooth bud  Management: Minimize damage by assessing displacement of permanent bud

 Ideally, a lateral film should be taken to confirm that intruded tooth has not displaced permanent tooth bud. If so, extraction recommended

Lateral Anterior Radiograph for Intruded Primary Tooth    Angulation of intruded tooth Occlusal or size 4 extraoral film next to child’s cheek and perpendicular to radiographic beam Exposure time is doubled

Intrusion Luxation: Re-eruption of Primary Tooth 2 months after injury 3 months after injury 1 year after injury

ROOT FRACTURES : RECOMMENDATIONS

Primary Dentition

Fracture located in coronal 1/3 of root or segment is aspiration risk All treatment is ideal and assumes patient has manageable behavior.

Recommendations also assume appropriate pre-operative radiographs .

(Source: AAPD Handbook of Pediatric Dentistry)

No Yes

Extract coronal segment. Leave apical segment if not visible/easily removed Clinical and radiographic follow up in 4 weeks: Advise parents of possible injury / damage to permanent teeth.

NO SPLINT IS INDICATED

Root Fractures Primary Teeth   Radiograph

Apical 1/3

- Most teeth maintain vitality and are minimally mobile - Apical fragment should resorb normally - Monitor with radiographs

Root Fractures Primary Teeth   Radiograph

Middle or Cervical 1/3

- Most teeth mobile. Extraction indicated - Gently attempt to retrieve apical fragment If not successful, monitor Don’t disrupt permanent tooth bud

Avulsion:

Primary Teeth

 Radiograph  Do not re-implant!

 Space loss may not occur if primary canines are present  Permanent tooth eruption may be delayed due to scar tissue/bone

Parents Question:

Will the permanent teeth be damaged?

 May not be able to be determined until the teeth erupt and can be evaluated clinically  The accident has happened we can’t reverse it  Monitor clinically and radiographically

Complications of Trauma

 Permanent teeth malformation:  hypomineralization  hypoplasia  dilaceration  arrested development

History of Intrusive Luxation

Primary Teeth  Hypomaturation/Hypomineralization #8

History of Intrusion Luxation of Primary Tooth  Severe dilaceration of Root

History of Avulsion #E :

Prior to Eruption of Primary Canines

 Space maintainer not possible for pre-coop tot with incisors only  Ortho/space regaining will be needed

Acknowledgements

 Photos and Diagrams taken from:  Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4 th edition: J.O. Andreasen (2007)  Pediatric Dentistry, 4 th edition; Pinkham (2005)  Odontologia Para o Bebe’: Walter L.R.F. (1996)  University of Iowa, Department of Pediatric Dentistry

Competency Exam

Answer the following questions on your worksheets

Case #1 “Anna”

  Anna is a 4 y.o. girl who fell against the edge of a table about 2 hours ago Her mother has given her children’s Tylenol and is at your office for evaluation  The upper incisors are tender, but non-mobile.

 Her mother raises her lip to show you a 2 mm tear in the labial frenum area  Anna is cooperative

Case #1: “Anna”

 What other clinical procedures do you need to perform? List at least 3.

“Anna’s” Pedo Occlusal

 Is this radiograph within normal limits, or do you see any abnormalities or pathology?

Case #1 “Anna”

 What is your plan for treatment and followup care for Anna?

 What are your care instructions for mother?

Case #2: “Bart”

 Bart is a 2 y.o. boy who fell against the edge of the bathtub about 1 hour ago  Mother felt his tooth “completely broke off at the gumline”, but could not find the piece  Clinically there are no additional findings

“Bart”

 What radiographs are indicated for Bart?

Pedo Occlusal for “Bart”

 Bart was not cooperative for further radiographs. What is your diagnosis based on this film?

Case #2 “Bart”

 What is your plan for treatment and followup care?

Case #3: “Charlie”

 Charlie is a healthy 3 y.o. boy who fell against the fireplace at home this morning  His father is with him  Clinical exam reveals enamel fracture #E and dentin fracture #F  No excessive mobility, no luxation  Occlusion is normal  Charlie is cooperative , but impatient and wiggly

Charlie’s Clinical Appearance

( photo is a representation of the injury, not an actual photo of this patient)  What radiographs would you order for Charlie?

Pedo Occlusal for “Charlie”

Case #3 “Charlie”

 What is your plan for treatment and followup care for Charlie?

Case #4 “Davonne”

 Davonne is a 12 year old boy with a non contributory Health History  He and his parents are at your office for comprehensive care.

 The chief complaint is “discolored lower front teeth.”

Davonne Clinical Photo

Davonne

 What most likely caused this discoloration?

 What are treatment options?

Competency Exam

Answer Discussion

Case #1 “Anna”

  Anna is a 4 y.o. girl who fell against the edge of a table about 2 hours ago Her mother has given her children’s Tylenol and is at your office for evaluation  The upper incisors are tender, but non-mobile.

 Her mother raises her lip to show you a 2 mm tear in the labial frenum area  Anna is cooperative

Case #1: “Anna”  What other clinical procedures do you need to perform? List at least 3.

 Periapical radiograph (pedo occlusal)  Mobility check  Percussion check  Occlusion check  Complete hard and soft tissue assessment

“Anna’s” Pedo Occlusal  Is this radiograph within normal limits, or do you see any abnormalities or pathology?

Answer: Within Normal Limits

Case #1 “Anna”   What is your plan for treatment and followup care for Anna?

 Do not suture  Observe clinically and radiographically What are your care instructions for mother?

 OTC pain meds prn  Soft diet for about 1 week  Tooth may discolor, but this may reverse  Periodic reassessment needed

Case #2: “Bart”

 Bart is a 2 y.o. boy who fell against the edge of the bathtub about 1 hour ago  Mother felt his tooth “completely broke off at the gumline”, but could not find the piece  Clinically there are no additional findings

“Bart”

 What radiographs are indicated for Bart?

 Periapical (pedo occlusal)  Lateral

Pedo Occlusal for “Bart”  Bart was not cooperative for further radiographs. What is your diagnosis based on this film?  Intrusion. No fracture detected.

Case #2 “Bart”  What is your plan for treatment and followup care?

 Monitor for re-eruption  Consider antibiotic therapy and assess tetanus immunization  Explain signs and symptoms of infection.

 Re-assess in 2 weeks

Case #3: “Charlie”

 Charlie is a healthy 3 y.o. boy who fell against the fireplace at home this morning  His father is with him  Clinical exam reveals enamel fracture #E and dentin fracture #F  No excessive mobility, no luxation  Occlusion is normal  Charlie is cooperative , but impatient and wiggly

Charlie’s Clinical Appearance  What radiographs would you order for Charlie?

 Periapical (pedo occlusal)

Pedo Occlusal for “Charlie”

Case #3 “Charlie”  What is your plan for treatment and followup care for Charlie?

 Smooth #E  GI “Bandaid “ #F or composite if cooperation allows  Periodic clinical and radiographic followup

Case #4 “Davonne”

 Davonne is a 12 year old boy with a non contributory Health History  He and his parents are at your office for comprehensive care.

 The chief complaint is “discolored lower front teeth.”

Davonne Clinical Photo

Davonne  What most likely caused this discoloration?

 History of primary tooth trauma/intrusion  What are treatment options?

 No treatment  Cosmetic bonding