Trauma: Section F

Favourable vs Unfavourable Outcomes

• After dental trauma, frequent clinical and radiographic monitoring is essential for identifying unfavourable changes
• Favourable signs include asymptomatic presentation, normal crown colour, no pulp necrosis/infection signs, and continued root growth in immature teeth
• Unfavourable signs include symptomatic presentation, crown discolouration, pulp necrosis/infection, sinus tract, gingival swelling/abscess, increased mobility, no further root development, positional changes, and negative impacts on permanent successor development

Enamel Fracture

• Defined as a fracture that only involves the enamel and causes loss of tooth structure
• Clinically presents with enamel loss, no exposed dentine, no tenderness to percussion (TTP), and normal mobility
• Radiographs are not typically recommended
• Treatment involves smoothing sharp edges using a rainbow or soflex disc
• For patients with lip or cheek lesions, examine for tooth fragments
• Requires no specific clinical or radiographic follow-up

Enamel-Dentine Fracture

• Defined as a fracture involving both enamel and dentine, causing loss of tooth structure
• Characterized by visible loss of enamel and dentine, with no visible pulp exposure, and no TTP or mobility
• Radiographs are optional, in some cases can be used to identify imbedded objects
• Management includes cleaning with water, saline, or CHX, and providing emergency coverage using GIC or composite
• Follow-up includes a clinical examination at 6-8 weeks, with radiographic follow-up if clinical findings suggest pathosis
• Prognosis after one year: Tooth loss: 5.5%, Pulp necrosis: 5.6%, Pulp canal obliteration: 2.8%

Complicated Crown Fracture

• Defined as a fracture involving enamel and dentine, with pulp exposure
• Clinically presents with visible loss of enamel and dentine, exposed pulp, possible tenderness, and normal mobility
• Radiographic evaluation is recommended using occlusal and periapical views to assess displacement or root fracture signs, and to identify embedded fragments in lips/cheeks/tongue
• Radiographic findings show enamel-dentine loss extending into the pulp chamber
• Treatment aims to preserve pulp vitality using pulp capping or pulpotomy, based on patient age and cooperation
• Extraction is an alternative if the patient can't tolerate long treatment
• Pulpectomy can be considered where tooth loses vitality, and the patients can comply
• Follow-up includes clinical review at one week and 6-8 weeks if pulp capping or pulpotomy is performed
• Clinical and radiographic follow-up is annually completed
• After extraction, clinical follow-up is required at 1 week

Uncomplicated Crown-Root Fracture

• Defined as a fracture involving enamel, dentine, and cementum, but not involving the pulp
• Clinically characterized by a crown fracture extending below the gingival margin, potentially split into mobile fragments, accompanied by tenderness to percussion
• Radiographs can establish a baseline of occlusal and periapical
• Reveals an Apical extension of fracture not usually visible
• During laterally positioned fracture, the location of this fracture may be monitored with regards to the gingival margin
• Extent of fracture dictates the treatment plan
• Treatment: if a stable fragment has minor root involvement: remove the mobile fragment and cover exposed dentine with GIC
• If the child is uncooperative, or cannot be restored then extract the tooth
• Post- fragment removal: a clinical checkup is required after 1 week, 6-8 weeks and 1 year
• Radiographic follow up is indicated after 1 year

Complicated Crown-Root Fracture

• Defined as a fracture involving enamel, dentine, cementum, and pulp
• Characterized by crown fracture that extends below the gingival margin, presence of 2 or more tooth fragments, tenderness to percussion
• Radiographs are recommended using occlusal and periapical views for baseline assessment
• Apical extension of the fracture is usually not visible
• In a laterally positioned tooth, The fracture in relation to gingival margin can be directly observed
• If fracture line ABOVE crestal bone, a coronal restoration, perform partial pulpotomy or pulpectomy based on stage of root development and fracture level
• If not restorable or child is uncooperative, extract the tooth
• Followfragment removal and partial/full pulpectomy with clinical review after 1 week, 6-8 weeks and annually
• Use radiographic analysis after 1 year
• Extracted teeth require a 1 week follow up

Root Fracture

• Defined as a fracture that involves dentine, pulp, and cementum, and is classified by location in the apical, mid, or coronal third of the root
• Coronal segment more commonly mobile and may be displaced and Crown discolouration: red or grey
• An occlusal and periapical radiograph should be completed to establish a baseline
• Fracture usually found on the middle or apical third of the root
• For teeth with no displacement or mobility, no treatment
• For slight displacement with minimal mobility, allow the coronal fragment to spontaneously reposition
• For excessive mobility or occlusal interference: reposition, or extract
• Reposition the tooth using local anesthesia, cleanse with water spray, saline or chlorhexidine, and stablize with gentle pressure and stabilize with a flexible splint for 4 weeks if it's unstable
• Extract the loose coronal fragment while preserving the apical fragment
• When there is no mobility or displacement, schedule clinical reviews for 1 week, 6-8 weeks, along with a yearly clinical review for the lifespan of the tooth
• Use radiographs to determine the pathosis and if the tooth is being adequately repositioned with splinting

Concussion (PDL Injury)

• Defined as an injury to the tooth and its supporting structures, indicated by tenderness to percussion (TTP), without mobility, displacement, or gingival bleeding
• Clinical features: TTP, no mobility, and no displacement
• Radiographs are not recommended
• Management includes observation: no treatment required
• Clinical reviews are required after 1 week and 6-8 weeks
• Use radiographs only when pathosis is likely

Subluxation (PDL Injury)

• Injury to tooth and its supporting structures, indicated by tenderness to percussion (TTP), increased mobility, without displacement, and gingival bleeding
• Clinical features: TTP, Gingival bleeding upon initial assesment, Mobility with no displacement
• Radiographs by occlusal or periapical; look for root or displacement
• No treatment needed, clinical follow up at week 1, 6-8
• Look for pathosis, can use radiographs to check status
• Enamel Loss occurs 25% of the time with these injuries

Extrusive Luxation

• Defined as partial axial displacement of the tooth from the socket with partial or complete PDL separation while the alveolar socket remains intact
• Tooth appears lengthened, Axial displacement, can be retruded or protrude, Possible tooth mobility, TTP and intact alveolar socket
• Radiographic analysis is recommended: occlusal or periapical to screen for displacement or root fracture indications
• Radiographic shows: Increased PDL space apically
• If displacement is less than 3mm without functional interference, monitor and allow spontaneous repositioning
• If greater than 3mm, extract, particularly if the function or mobility is impaired
• With Spontaneous positioning, 1 week, 6-8 weeks and 1 year clinical checks
• 30% disturbance to the permanent successor

Lateral Luxation

• Displaces to the lingual, labial and partial separation w/PDL and or alveolar socket fracture
• Common Features: displacement toward or away from tooth bud, occlusal interferance, Ankylotic metallic sounds on percussion and Non Mobility of tooth
• In radiograph asses if tooth relationship and or fractures
• Findings: increased PDL apically
• Manage w: Minimal displacement, or Extract tooth
• Follow up at week 1,6-8 months, or annual with pathosis check

Intrusive Luxation

• Definition of displacement to the alveolar socket followed with fracture on the socket
• Clinical: tooth displaced axial with alveolar, metallic sounds, no movement and may be bleeding from the nose * Penetrating fracture in the cavity that may happen.
• Use Occulal/Periaparical Views and Lateral View if cavity perforations can result
• Findings = Apical tip location that is either shorter or longer/stretched
• Treatment= Monitor Spontaneous positioning or remove tooth after 6 months!
• 70% disturbance to the permanent successor

Avulsion

• Avulsion occurs when Displacement of tooth from Socket
• Socket is empty and/or filled with blood.
• Check radiographs for intrusion.
• Aspiration is a possibility.
• NO IMPLANT on a primary tooth.
• Follow up:
  • Clinical follow up is 6-8 weeks with age 6 checks for constant teeth
• Radiogrpahs is only completed pathosis is expected or indicated
• 50% disturbance to the permanent successor.

General advice Following alveoral Dento Trauma

• Keep a soft diet within 1 week
• Keep proper brushing habits
• Avoid contact sports