D ental trauma in children

1. Dental trauma in children

2. Introduction • Peak incidences are found at 2-3 years of age, motor coordination is developing.

3. Pathogenesis • Surrounding bone is less dense and less mineralised. • A tooth can easily displaced instead of fractured. • Frontal trauma is quite frequent —> lateral luxation

4. Etiology • Falls • Accidents • Child abuse • Self-inflicted ora-dental

5. Goals Prevent the occurrence of sequelae in the permanent dentition. The ways which may damage permanent dentition 1. Direct displacement toward the permanent tooth bud 2. Infection caused by bacteria invasion to the injury site 3. Extraction, Repositioning, or Pulp treatment

6. History taking • Loss of consciousness ? • Tetanus innoculation • How injury occurred ?… • normal or abnormal • Who reported?

7. Clinical examination • Extra-oral • Intra-oral • Tooth mobility and alignment

8. Extra-oral examination • facial asymmetry • swelling of the lips • skin laceration • scars (previous injuries) • bleeding from nostrils • mouth opening

9. Intra-oral examination • Surrounding soft tissue • lips, oral mucosa, gingiva, and frenum • Submucosalhaemorrhage • upper lip / under tongue • Bleeding from sulcus

10. Radiographic examination AAPD guideline recommends size 2 film for 1. 90° horizontal view 2. Occlusal view 3. Extra-oral lateral view

11. Radiographic examination Apex is displaced toward permanent tooth germ Apex is displaced toward labial bone Elongation Foreshortening

12. Radiographic examination Extra-oral lateral radiograph • the relationship between the apex of the displaced tooth and permanent tooth bud • Rarely adds extra information

13. Radiographic examination Radiographic examination for soft tissue lesion Indication: a penetrating lip lesion Marking with lead foil or clip

14. Treatment principle • To minimise the risk to the permanent teeth • Implies a conservative approach • Child: Behaviourmanagement • Parents: Empathy and support their minds

15. Treatment principle • Traumatic injuries to primary teeth - Lack of scientific data • Factors related to treatment selection 1. Shedding time 2. A child’ maturity and compliance 3. The close proximity of the root of primary tooth to permanent tooth bud

16. Crown fracture Enamel-dentin Enamel Enamel-dentin-pulp Partial pulpotomy with calcium hydroxide Extraction Seal with GIC Restoration Smooth sharp edges

17. Crown-root fracture with or without pulp involvement • Fragment removal and restoration +/- pulp treatment • Extraction

18. Root fracture • Repositioning and splinting • Extraction

19. Alveolar fracture Repositioning and splinting for under G.A.

20. Luxation injuries

21. Extrusion • Treatment based on degree of displacement and root formation Minor extrusion (< 3 mm.) in an immature tooth • Repositioning • Leaving for spontaneous reposition Severe extrusion in mature tooth • Extraction

22. Lateral luxation Labial luxation Palatal/lingual luxation • no occlusal interference • Observe • minor interference • Grinding • severe interference • Repositioning Extraction

23. Intrusion Apex is displaced toward labial bone Apex is displaced toward permanent tooth germ Extraction Spontaneous reposition

24. Intrusion • Spontaneous eruption normally take place within 3 months • However some cases (25%) were not fully erupted after 1 year of trauma

25. Intrusion • complications during the re-eruption phase • acute inflammation around the displaced tooth • gingiva : swelling • pus from gingival crevice Immediate extraction and antibiotic therapy

26. Avulsion • Alternative trauma scenarios should be explored • deeply intrusion ? • Avulsed primary tooth should not be replanted • may displace a coagulum into the follicle of permanent incisor • pulp necrosis may cause mineralization disturbance

27. Avulsion • Tooth must be found to ensure that it has notbeenaspirated. Leith et al., Aspiration of an avulsed primary incisor: a case report Dental Traumatology 2008; 24: e24–e26. Coughing or breathing problems are the most common symptoms

28. Chin trauma • Crown and crown-root fractures may occur in molar regions • Treatment depend on the severity of fracture • If extraction is the treatment of choice, space maintainer should be considered

29. Complicationsin the primary dentition How to evaluate ? • Color changes • Radiographic findings • Clinical findings : abscess

30. Color changes • After luxation injuries • Pink / Yellow / Gray

31. Color changes Gray discoloration • Transient —> Permanent yellow discoloration • Permanent —> frequently associated with pulp necrosis

32. Color changes More than 50% of the primary incisors with dark coronal discoloration remain clinically asymptomatic.

33. Pulp necrosis • Related factors • age • degree of displacement • presence of crown fracture

34. Pulp necrosis Diagnosis Conclusive clinical symptoms • fistula • swelling and abscess formation + Radiographic evidence • a periapical rarefaction • lack of root formation Crown discolouration

35. Instructions to parents • Keep an affected area clean • Soft toothbrush • Swab with chlorhexidine • No pacifiers and nursing bottle • โอกาสเกิด trauma ซ้ำ

36. Trauma ครั้งนี้จะมีผลอะไรต่อฟันแท้ได้บ้าง ? • Crown discolouration with or without enamel hypoplasia • Malformation or dilaceration of the crown • Cessation of root development • Odontoma-like formation • Disturbance in eruption

37. Conclusion