The art and science of managing traumatic injuries to primary teeth

Introduction Comparison of Trauma management guidelines for injuries to permanent and primary teeth
Uncomplicated crown fracture Complicated crown fracture Crown root fracture Root fracture Alveolar fracture Concussion Subluxation Intrusion Extrusion Lateral luxation Avulsion

Contents

General considerations in managing dental injuries to primary teeth

Patient factors Behavioral management Developmental issues Parental factors Psychosocial Dentist factors Anatomic and occlusal factors

Literature review Conclusion

Introduction
Art skill at doing specific thing, typically one acquired through practice
Science knowledge covering general truths or general laws obtained and tested through scientific methods

GUIDELINES FOR MANAGEMENT OF TRAUMATIC INJURIES TO PRIMARY AND PERMANENT TEETH

Permanent tooth
Uncomplicated crown #
an enamel fracture or an enamel-dentin fracture that does not involve the pulp. Fragment available bond Small # - smoothen sharp edges Large # - restore tooth structure.

Primary tooth
- do -

Permanent tooth Complicated crown #

an enamel-dentin fracture with pulp exposure Immature tooth pulp capping or partial pulpotomy Mature tooth RCT / pulpcapping or pulpotomy More time elapsed - RCT

Primary tooth
Decisions are based on life expectancy of the primary tooth. Treatment alternatives are pulpotomy / pulpectomy / extraction.

Permanent tooth Crown Root #

an enamel, dentin, and cementum fracture with or without pulp exposure. ( Same as complicated crown # ) In addition, attempts at stabilizing loose segments of the tooth by bonding. Surgical or orthodontic extrusion for preparation for permanent restoration.

Primary tooth
Extraction Care must be taken to prevent injury to permanent successor.

Permanent tooth Root #

a dentin and cementum fracture involving the pulp. Reposition check X ray Stabilize with flexible splint for 4 weeks If fracture near cervical area - stabilize 4 months. Monitor pulp status for 1 year

Primary tooth
If the coronal fragment is displaced, extract only that fragment. The apical fragment should be left to resorbed. Repositioning - X

Permanent tooth
Alveolar # Reposition and Splint Stabilize for 4 weeks

Primary tooth
Reposition and splint. GA

Permanent tooth Concussion

injury to the toothsupporting structures without abnormal loosening or displacement of the tooth No Rx needed. Monitor pulpal status for 1 year

Primary tooth
No Rx needed. observation

Permanent tooth

Primary tooth

Subluxation
injury to tooth-supporting structures with abnormal loosening but without tooth displacement.

A flexible splint to stabilize No Rx needed. the tooth for patient observation comfort can be used for up to 2 weeks.

Permanent tooth Extrusive Luxation

partial displacement of the tooth axially from the socket; partial avulsion. The periodontal ligament usually is torn Reposition by gentle reinsertion and use flexible splint for 2 weeks. Monitor pulpal status.

Primary tooth
Minor extrusion (<3mm)allow spontaneous reposition or reposition and allow healing. Severe extrusion, mobility, exfoliating tooth - extraction

Permanent tooth
Lateral Luxation
displacement of the tooth in a direction other than axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs. Reposition with forceps to disengage it from its bony lock and gently reposition it into its original location Monitor pulpal status.

Primary tooth
No occlusal interference allow spontaneous reposition. Occlusal interference reposition by combined palatal and labial pressure under LA Sever dislocation, tooth nearing exfoliation - extraction

Permanent tooth
Intrusive Luxation
apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament Immature root allow spontaneous repositioning. If no movement for 3 weeks orthodontic repositioning Mature root reposition and splint for 4 weeks. RCT within 3 weeks of trauma.

Primary tooth
Apex displaced towards labial bone allow spontaneous reposition. Apex displaced into developing tooth germ extract

Permanent tooth Avulsion

complete displacement of tooth out of socket. The periodontal ligament is severed and fracture of the alveolus may occur. Clean the tooth, reposition and splint. Splint for 2 to 4 weeks

Primary tooth
Do not replant

Follow-up guidelines

General Considerations that affect the guidelines :

Patient Factors :
Clinician not only manage trauma, but also the behavior of child before, during and after Rx. Complex treatment / very uncooperative child / child with special needs consider extraction Suspect of Child abuse ? Report to approriate agent

Behavioral Management : - Physically traumatized child is more difficult to manage. - non pharmacological behavior management techniques can be used - NO analgesia, (minimal/moderate/deep)sedation or General Anesthesia can be used. - Risk involved Vs Potential benefit of treatment

Developmental Issues:
- Agenesis of Permanent successor long term success of treatment to primary tooth is important.

- earlier the stage of the succedaneous tooths development more likely that poor treatment outcomes.

 Parental Factors:
Psychosocial and Financial

Psychosocial:
- Parents bring their own set of fears. - emotional impact of injury to child impact on listening ability of parents to select appropriate treatment. - importance of dental care varies. - cosmetics are not a concern to younger children Ext? - parents feel guilty of trauma .

Financial :
- cost of treatment should be considered

- treatment cost not covered by 3rd parties ?

Dentist Factors:
- dentist must be conversant with the complete armamentarium of behavioral modification techniques. - clinician should be comfortable with access to pharmacological techniques such as NO sedation or GA.

- Pediatric dentists are ideal for treating children with traumatic injuries.

Anatomic and Occlusal Factors: Guidelines for permanent teeth = primary teeth. But
Anatomy: Larger pulp chambers thinner enamel and dentin

More likely for pulpal exposure

root canals thinner and torturous pulp extripation difficult longer and flaring roots possibility for fracture of root apex.

Proximity of succedaneous tooth to root of primary tooth smaller the distance more likely for developmental disturbance to permanent tooth.

Occlusion:
- In luxation injuries if displaced tooth is in crossbite reposition or extraction.

- mildly luxated tooth that are not in crossbite allow spontaneous reposition.
- child with oral habits like digit or pacifier sucking repostions naturally.

Literature Review

BLEACHING PRIMARY TEETH WITH 10% CARBAMIDE PEROXIDE David H. Brantley, DDS Katheryn P. Barnes, RDH Van B. Haywood, DMD. Pediatric Dentistry 23:6, 2001

-Tooth discoloration is not a indicative of pulp status. - If there were no clinical symptoms of pain or mobility, and no radiographic signs of periapical radiolucencies or resorption, then bleaching was indicated whether or not the tooth tested vital or non-vital. - There is little concern of ingestion for the minimal amount of material used during this treatment, since this 10% carbamide peroxide material has been used in newborn infants for throat infections.

Extraction as a treatment alternative follows repeated trauma in a severely handicapped patient. Tsai T-P. Dental Traumatology 2001; 17: 139142

Handicapped patients with protruding maxillary incisors are prone to repeated dental trauma. Considering inadequate control of seizure disorder, little ability of the patient to receive comprehensive orthodontic treatment, poor prognosis of restorations, and possible future injuries, the removal of non-functional, non esthetic, trauma susceptible incisor teeth can be justified as an alternative to tooth preservation.

Management of Trauma of Primary Tooth: Report of Intrusion Case. Ryoko Hirata, J.Hard Tissue Biology.14(4) Proceeding,361-362, 2005 Although the intrusion of primary anterior tooth is often happened, the treatment procedure for it has not been established yet. Diab et all described that when the tooth was intruded completely, the tooth should be extracted because re-eruption could not be expected. Holan et al reported 108 of 123 intruded teeth were re-erupted spontaneously. Our results support that case of intrusion in infants aged 1 to 3 years old should be observed instead of surgical treatments until some symptom, periapical periodontitis radiographically and alveolar abscess formation, reveals.

Management of intrusive luxation in the primary dentition by surgical repositioning: an alternative approach. HV Shanmugam,* P Aranganna Australian Dental Journal 2011; 56: 207211
Depending on the severity of the intrusion, the American Academy of Pediatric Dentistry recommends either extraction or spontaneous re-eruption for the primary tooth. This case report provides a brief insight into surgical repositioning as an alternative treatment option for the management of intruded primary tooth in a 4-year-old girl.

Luxation injuries in primary teeth: a retrospective study in children assisted at an emergency service. Luciana Reichert da Silva. Braz Oral Res. 2011 MarApr;25(2):150-6

In general, the prevalence of luxation injuries decreased with increasing age. Boys suffered from dental trauma significantly more often than girls. Falling as a result of walking or running was the most common etiologic factor. Subluxation was the most common type of trauma. Treatment usually occurred within the first 15 days after the injury. Despite the severity of these injuries, monitor only was the most common treatment.

AVULSION OF PRIMARY TEETH & SEQUELAE ON THE PERMANENT SUCCESSORS: LONGITUDINAL STUDY Michele Machado Lenzi, Diana Ribeiro Jacomo, Vivian Carvalho and Vera Campos. Brazilian Journal of Dental Traumatology (2011) 2(2): 80-84.

-Results of the study shows that avulsion was the 2nd most frequent type of trauma in primary dentition. -Discoloration of enamel and/or enamel hypoplasia were the most frequent sequelae in successors. -The most sequelae occurred when avulsion happened in 2-3 year old children.

Replantation of Avulsed Primary Incisors: A RiskBenefit Assessment. Erica L. Zamon, B.Sc. J Can Dent Assoc 2001; 67:386

The study describe long-term (> 1 year) outcomes for 8 replanted incisors (maxillary and mandibular). These incisors were all splinted following replantation. Dental pulps were left in all but one incisor despite ischemic periods in excess of 30 minutes. - 4 incisors were subsequently extracted due to abscess or pathological root resorption, - 3 exfoliated physiologically and - 1 was retained.
One permanent incisor had an enamel defect.

Hypoplasia of a Permanent Incisor Produced by Primary Incisor Intrusion: A Case Report . Ceyhan Altun, DDS, PhD; Elin Esenlik, DDS, PhD; Tolga Fikret Tzm, DDS, PhD. JCDA April 2009, Vol. 75, No. 3.

Between 18% and 69% of intrusive injuries to the primary dentition cause anomalous development of the permanent teeth. Such alterations in dental pathology can include white or yellowbrown discoloration, or circular enamel hypoplasia; crown dilaceration; root duplication; vestibular or lateral root angulation or dilaceration; partial or complete arrest of root formation; sequestration of the permanent tooth germ disturbed eruption.

Intrusion injuries of primary incisors. Part III: Effects on the permanent successors. Diab M, elBadrawy HE. Quintessence Int 2000; 31(6):37784.

White discoloration is caused by the accelerated mineral deposition that results from trauma during the maturation stage of enamel development, whereas yellow-brown discoloration is caused by the incorporation of hemoglobin products from bleeding in the periapical area and enamel hypoplasia is caused by the destruction of ameloblasts in the active enamel epithelium.

Pulp canal obliteration in an unerupted permanent incisor following trauma to its primary predecessor: a case report. Katz-Sagi H, Moskovitz M, Moshonov J, Holan G. Dent Traumatol 2004; 20(3):1813.
Katz-Sagi and others found unusual obliteration of the pulp canal in a maxillary central incisor and crown malformation in the adjacent unerupted central incisor after trauma to the associated primary tooth.

Bassiouny MA, Giannini P, Deem L. Permanent incisors traumatized through predecessors: sequelae and possible management. J Clin Pediatr Dent 2003; 27(3):2238.
Bassiouny and others also reported a case of total and partial pulp obliteration of the maxillary central incisors after trauma to their associated primary teeth.

Young peoples perceptions of photographs of dental trauma. Jennifer, Emily Dental Traumatology 2011; 27: 109112;

This study has suggested that patients may not comprehend the actual significance of dental injuries and the complexity of treatment in the same way as dental professionals, and this may explain the wide variation in cooperation with long-term management of dental injuries.

Social judgment made by children in relation to visible incisal trauma. Helen, chris baker. Dental traumatology. 2010 28: 2-8

This study has found that 11- to 12-year-old children attribute negative personality characteristics to other children with visible incisor trauma. In view of the potential for adverse psychosocial effects and life outcomes, every effort should be made to provide timely and aesthetic dental care for young patients with traumatized incisors

Conclusion

References
Management of intrusive luxation in the primary dentition by surgical repositioning: an alternative approach. HV Shanmugam,* P Aranganna Australian Dental Journal 2011; 56: 207211 Replantation of Avulsed Primary Incisors: A RiskBenefit Assessment. Erica L. Zamon, B.Sc. J Can Dent Assoc 2001; 67:386

BLEACHING PRIMARY TEETH WITH 10% CARBAMIDE PEROXIDE. David H. Brantley, DDS Katheryn P. Barnes, RDH Van B. Haywood, DMD. Pediatric Dentistry 23:6, 2001

Extraction as a treatment alternative follows repeated trauma in a severely handicapped patient. Tsai T-P. Dental Traumatology 2001; 17: 139142

References
Hypoplasia of a Permanent Incisor Produced by Primary Incisor Intrusion: A Case Report . Ceyhan Altun, DDS, PhD; Elin Esenlik, DDS, PhD; Tolga Fikret Tzm, DDS, PhD. JCDA April 2009, Vol. 75, No. 3. Management of Trauma of Primary Tooth: Report of Intrusion Case. Ryoko Hirata, J.Hard Tissue Biology.14(4) Proceeding,361-362, 2005 Luxation injuries in primary teeth: a retrospective study in children assisted at an emergency service. Luciana Reichert da Silva. Braz Oral Res. 2011 MarApr;25(2):150-6

AVULSION OF PRIMARY TEETH AND SEQUELAE ON THE PERMANENT SUCCESSORS: LONGITUDINAL STUDY Michele Machado Lenzi, Diana Ribeiro Jacomo, Vivian Carvalho and Vera Campos. Brazilian Journal of Dental Traumatology (2011) 2(2): 80-84.

References
Emergency management of dental trauma. Tony Skapetis, BDS. Australasian Emergency Nursing Journal (2010) 13, 3034 Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. FLORES MT, ANDERSSON L. Dental Traumatology 2007; 23: 6671 Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. FLORES MT, ANDERSSON L. Dental Traumatology 2007; 23: 130136 Guidelines for the management of traumatic dental injuries. III. Avulsion of permanent teeth. FLORES MT, ANDERSSON L. Dental Traumatology 2007; 23: 196-202