Teaching Module & Competency:

Primary

Tooth Trauma

Prepared by : Cynthia Christensen; DDS, MS Karin Weber-Gasparoni; DDS, MS, PhD University of Iowa 2008

Objectives

 Understand the incidence of primary tooth trauma  Understand how to triage primary tooth trauma  Understand clinical presentation of the most common types of primary tooth trauma and treatment options

Epidemiology of Tooth Trauma

 30% of children suffer trauma to primary dentition.

 Most injuries to primary teeth occur at 18-30 mo of age:

“…more traumatic dental injuries occur to younger children, probably because the children are gaining mobility and independence, yet lack full coordination and judgment.”

Garcia-Godoy

et al.

Clinical Examination

 Intra/ extra oral soft tissues  Swelling  Fractured, luxated, or missing teeth  Pulp exposures  Occlusion  Deviation on opening

TRIAGE

: Occlusion Indicates Fractured Alveolus or Mandible  Immediate referral to Oral Surgeon or ER  Advise patient to be kept NPO

Radiographic Exam

For young children, parent or dental staff must hold Establish Baseline Detect root or alveolar injuries or pathosis

What about Sutures?

 Extraoral: Plastic/ENT surgeon best for esthetic outcome  Introral:  Small laceration = No sutures.  Larger lacerations = General Dentist or Oral Surgeon

Possibility: Foreign Body in Lip or Tongue

Checking for Tooth Fragment

 Palpate puncture/laceration  Soft tissue radiograph  ¼ the exposure time of nearest teeth

Common Injuries

Treatment Options

Concussion / Subluxation



Concussion

: injury to the tooth and ligament without displacement or mobility 

Subluxation

: tooth is mobile, but is not displaced

Concussion and Subluxation Management

    Periapical radiograph OTC pain meds prn Soft diet for 1 week Advise parent of possible sequelae  Follow-up, 2-4 weeks

Concussion/Subluxation

 Neurovascular bundle at apex may be crushed or severed  PDL may be torn  Prognosis for Recovery = Good

Discoloration of Primary Tooth Post Trauma  Color may change 2-4 weeks after trauma  May retain/regain vitality and return to near normal color within 6 months  Monitor. Esthetics may be a concern if color does not resolve Color may be pink, purple, grey or brown

Pulpal Obliteration/Calcific Metamorphosis    History of Trauma Tooth darker-usually yellowish Radiograph shows pulpal space narrowing or obliterated  NO TX-observe for normal exfolitation

All Teeth Do Not Recover: Abscess 6 Months Post Concussion  Note associated soft tissue swelling  Confirm Dx and check root structure with periapical radiograph

Radiographic Abscess #F

 

Note

: #E resorption post trauma. No Tx #F extraction indicated

LATERAL LUXATION / EXTRUSION INJURIES: RECOMMENDATIONS

Primary Dentition

Tooth is aspiration risk

Yes

Extract and advise parents of potential damage to permanent tooth

No

Tooth causing occlusal interference **All treatment is ideal and assumes patient has manageable behavior. Recommendations also assume appropriate radiographic survey.

(

Reference: AAPD Handbook of Dentistry)

Yes No

Allow for spontaneous re-positioning or re-position and splint or consider extraction Extract or reposition and splint Follow up in 2 weeks: Advise parents of possible injury / damage to permanent teeth

Extrusion and Luxation With Occlusal Interference

 Extraction is recommended most of the time due to risk of aspiration of mobile teeth and damage to permanent tooth bud 

**Key = Degree of Severity and cooperation

Extrusion and Luxation With Occlusal Interference

 Primary Teeth Reposition and Splinting RARE unless..

 Excellent Patient Cooperation  Excellent Recall Compliance

No

Pulp Exposed

No

Dentin Exposed

No

Rough Edge Present No further treatment required

Yes Yes

Treatment Planning Crown Fracture Injuries

Primary Dentition

Pulpectomy and full coverage crown (SSC or strip crown) All treatment is ideal and assumes patient has manageable behavior.

Recommendations also assume appropriate pre-operative radiographs

Reference: AAPD Handbook of Pediatric Dentistry

Composite or GI provisional restoration “band-aid” if symptomatic

Yes Yes

Smooth edge and if required restore with composite Clinical and radiographic follow up.

Advise parents of possible injury to permanent teeth and monitor for signs of pathology

Enamel Fx Dentin Fx Pulp Exposure Ellis Class I Ellis Class II Ellis Class III

Enamel Fracture in Primary Teeth: Ellis Class I

 Radiograph  Smooth Sharp Edges  GI or Composite Optional  Periodic Follow Up

Enamel and Dentin Fx: Ellis Class II  Radiograph  Protect Dentin  Glass Ionomer  Bonding Agents  Composite Ideal  Periodic Follow Up Dentin Exposed

Pulp Exposure: Ellis Class III  Radiograph  Pulpectomy  Extraction Pulp Exposed

Vertical Crown Fracture  RARE- more likely to luxate or intrude  Extraction