Dental Trauma - Chapter 16-19 Student Copy PDF

Chapter 16 Dental Trauma Epidemiology (primary dentition) Maxillary Incisors ○ the most frequently injured teeth in the primary dentition Epidemiology (primary dentition) Primary incisors - tend to be luxated more than permanent teeth ○ this is due to the spongy nature of the bon...

Chapter 16 Dental Trauma Epidemiology (primary dentition) Maxillary Incisors ○ the most frequently injured teeth in the primary dentition Epidemiology (primary dentition) Primary incisors - tend to be luxated more than permanent teeth ○ this is due to the spongy nature of the bone in the young children and to the lower root/crown ratio in comparison with that of permanent teeth Crown fractures (mainly enamel fractures) the most common injuries to the primary teeth peaks at age of 2 to 4 years when children are developing mobility skills Crown fractures Children that are Class II (protrusion) are 2-3x more prone Another cause of dental injuries is automobile accidents History Taking (Questions to ask) When did the trauma occur? How did the trauma occur? Were there any other injuries? What initial treatment was given? Have there been any other dental injuries in the past? Are current immunizations up to date? Examination It is important to examine the whole body as the patient may present first to the dentist and other injuries may have occurred Extraoral Examination Battle sign or bruising of the mastoid region is associated with base-skull fracture The TMJ should be palpated Swelling, Clicking or Crepitus should be noted Stiffness or pain in the child’ s neck necessitates referral to the physician to rule out cervical spine injury Intraoral Examination All soft tissues should be examined and any injuries recorded Each tooth in the mouth should be examined for fracture Reaction to palpation and percussion should be recorded Pulp vitality test should NOT be performed 2 reasons to percuss: Sensitivity to percussion gives information about the extent of the apical tissues Determines the likelihood of ankylosis Transillumination Non-invasive technique to assess the presence of cracks and/or fractures Radiographic Examination For dental injuries All traumatized teeth should be checked for: ○ Stage of root development ○ Injuries to root and developing structures ○ Tooth fractures may involve crown and root Classification of Injuries to Teeth Fracture ○ Ellis and Davey classification of crown fracture is useful in recording extent of damage to crown Classification of Injuries to Teeth Fracture ○ Class I simple fracture of crown involving little or no dentin / enamel only ○ Treatment: smoothened rough edges to prevent irritation to the soft tissue Check vitality in 6-8 weeks Classification of Injuries to Teeth ○ Class II extensive fracture of crown involving considerable dentin but not dental pulp ○ Treatment: composite resin restorations Strip crowns preformed esthetic crowns open-faced steel crown Classification of Injuries to Teeth ○ Class III fracture of the enamel, dentin and involving the pulp ○ Treatment Pulpotomy - vital pulp RCT - nonvital pulp Extraction — space maintainer Classification of Injuries to Teeth ○ Class IV Loss of entire crown (non-vital) Classification of Injuries to Teeth ○ Class V Tooth lost because of trauma; avulsion Classification of Injuries to Teeth ○ Class VI Fracture of a root with or without loss of crown Classification of Injuries to Teeth Root Fracture ○ rare in children ○ attempt to remove the apical fragment should be avoided to prevent harm of the developing permanent successor Classification of Injuries to Teeth Root Fracture ○ apical fragments usually resorb as part of the physiologic process of tooth replacement ; exfoliation Classification of Injuries to Teeth ○ Class VII Displacement of a tooth without the fracture of a crown/root Classification of Injuries to Teeth ○ Class VIII Fracture of a crown en masse Classification of Injuries to Teeth ○ Class I – Enamel ○ Class II – Enamel + Dentin ○ Class III – Enamel + Dentin + Pulp ○ Class IV – Non-IVtal ○ Class V – aVulsion ○ Class VI – R66t ○ Class VII – Displace ○ Class VIII – Fracture Classification of Injuries to Teeth Luxation (Displacement) injuries are most common PDL = physiologic “hammock” that supports the tooth in the socket Primary objective = maintain the vitality of the pulp Classification of Injuries to Teeth 1.Concussion 2.Subluxation 3.Intrusion/ Intrusive luxation 4.Extrusion 5.Lateral Luxation 6.Avulsion Concussion The tooth is not mobile and is not displaced. The PDL absorbs the injury and is inflamed (+) Pain on biting, (+) Percussion No increased mobility Concussion (s/sx) a. the tooth is not mobile and is not displaced. b. symptoms include a painful tooth plus an elongate feeling of the involved tooth. c. radiographically, there may be thickening of the periodontal space due to the injury of the periodontal Concussion (Treatment) No treatment Monitor pulpal condition Thorough oral hygiene to prevent contamination to the PDL Subluxation The tooth is loosened (has mobility) but not displaced from its socket (+) percussion and (+) bleeding Subluxation (Treatment) Same treatment with concussion Intrusion Tooth is driven into its socket, compressed PDL and crushed alveolar socket Intrusion (treatment) Immediate removal of the primary tooth to relive the pressure and minimize damage to the permanent successor *Turner’s tooth Those that do not pose a risk can be left to re-erupt (2-3 weeks or 6 months) Lateral Luxation The tooth is displaced in labial, lingual, or lateral direction PDL is torn Contusion or fracture of the alveolar bone Lateral Luxation (treatment) Rinse the exposed part before repositioning Apply LA -> Reposition and then splint Severe cases = extraction Avulsion Complete displacement from the socket PDL is severed Fractures of alveolar bone may occur Avulsion (treatment) No replantation Color changes subsequent to trauma: Reddish-brown or pink discoloration ○is indicative of pulpal hemorrhage ○Internal resoption Color changes subsequent to trauma: Bluish-black color ○indicates pulpal necrosis ○Treatment: extraction or pulp therapy to prevent damage to the developing permanent tooth bud Treatment of Hard Tissue Fractures Hard tissue fractures ○ are present in about 60%of all injuries involving primary teeth ○ Treatment: determined by the extent of the fracture Treatment of Hard Tissue Fractures Hard tissue fractures ○ Treatment: if no pulp exposure exists, smooth sharp edges and continue to observe at future appointments Treatment of Hard Tissue Fractures If pulp is exposed, perform pulp therapy restoring the tooth with resin or SSC If extensive pulpal exposure is present, extraction is usually the best choice Treatment of Hard Tissue Fractures Alert parent to watch for color changes and infection Follow up with radiographics Treatment of Hard Tissue Fractures If associated with root fracture, extract all fracture segments without damage to developing permanent tooth bud. DO NOT chase apical third fragment Treatment of Hard Tissue Fractures Root fracture of primary teeth ○ extraction is almost always the treatment of choice Pathologic sequalae of Trauma to Teeth 1. Reversible Pulpitis The pulp’s initial response to trauma is pulpitis. Capillaries become congested Tender to percussion if the PDL is inflamed Can progress to irreversible one Pathologic sequalae of Trauma to Teeth 2. Coronal Discoloration After trauma, capillaries hemorrhage leaving blood pigments in the dentinal tubules Mild case = blood is resorbed, color becomes lighter Severe case = discoloration persists throughout life Pathologic sequalae of Trauma to Teeth Pink – intrapulpal hemorrhage Yellow – PCO Dark - necrosis Pathologic sequalae of Trauma to Teeth 3. Rapidly Progressing Root Resorption Can be ERR or IRR Pathologic sequalae of Trauma to Teeth 4. Replacement External Root Resorption Aka Ankylosis Results after irreversible injury to the PDL Fusion of alveolar bone and teeth MOST COMMON TEETH TO BE Reaction of the Tooth to Trauma Question: ○ Which has better prognosis, tooth receiving an injury with fracture or without crown fracture? Reaction of the Tooth to Trauma Answer: ○ A tooth receiving an injury that causes coronal fracture may have better pulpal prognosis than tooth that sustains severe blow without crown fracture. Why? Reaction of the Tooth to Trauma WHY? : ○ Part of the energy of the blow dissipated as the crown fractures rather than all the energy being absorbed by the tooth’s supporting tissues ○ Thus the periodontium & the pulp of the injured tooth sustain less trauma Reaction of the Tooth to Trauma Ankylosis : ○ PDL injury Inflammation osteoclastic activity fusion between bone and root surface Reaction of the Permanent Tooth Bud to injury most damaging sequelae of injuries to primary teeth are effect on the unerupted developing permanent teeth. anatomically, the permanent anterior teeth develop in close proximity to the apices of primary incisors Reaction of the Permanent Tooth Bud to injury Thus, periapical pathology that is due to necrotic pulps, intrusive injuries, or over instrumentation of primary root canals can irreversibly damage the permanent teeth. Position of Primary Teeth Reaction of the Permanent Tooth Bud to injury Disturbance of tooth eruption ○ premature exfoliation of primary teeth = delay of eruption of permanent tooth ○ unerupted intruded primary teeth may cause permanent teeth to erupt ectopically requiring extraction Localized Enamel Hypoplasia Trauma to the primary tooth can disturb enamel formation in the underlying permanent tooth, especially on the labial surface aka Turner's Hypoplasia Chapter 17 Dynamics of Change Dental Changes Primary teeth ○ 2 years of age - eruption completed ○ 3 years of age - root completed Dental Changes Morphologic Difference between primary and permanent teeth Dental Changes CROWN ○ primary anterior teeth are wider mesiodistally in comparison with their cervicoincisal length than the crowns of the permanent teeth Dental Changes Roots ○ primary anterior teeth are narrower mesiodistally ○ primary molars are more slender and longer than the roots of permanent teeth the flaring allows more room between the roots for the development of permanent tooth crowns Dental Changes CROWN AND ROOTS ○ primary molars are slender mesiodistally at the cervical third than those of the permanent molars Dental Changes CERVICAL RIDGE ○ primary molars, buccally, more pronounced especially on both the maxillary mandibular 1st molars Dental Changes BUCCAL AND LINGUAL SURFACES ○ primary molars are flatter above the cervical curvatures than those of the permanent molars Dental Changes COLOR ○ primary teeth are usually lighter in color than the permanent teeth Cognitive Changes Preschooler ○ 3-6 years ○ preoperational - Piaget’s cognitive intelligence ○ mental imagery - (pretend play) the child‘s mind acquires the ability to think symbolically with mental imaginary Cognitive Changes Classical conditioning ○ when 2 stimuli are paired together a reaction happens ○ especially when the stimuli are paired often enough e.g breastfeeding when paired with hearing a lullaby eventually leads to the infant initiating the sucking motion Cognitive Changes Operant conditioning ○ rewards and punishment in modifying behavior Positive punishment – addition of a reward Negative punishment – removal of a punishment Positive reinforcement – addition of a punishment Negative reinforcement – removal of a reward Cognitive Changes Description Example Positive Unfavorable Spanking for Punishment event to misbehavior weaken the response Negative Favorable event Taking away a Punishment is removed child’s video after a behavior game after occus misbehavior Positive Behavior is The bonus Reinforcement strengthened given by your by a reward manager increases Cognitive Changes Development Theory ○ By Jean Piaget ○ much intellectual development of the child from birth to age of 2 years results from the actions of the child objects in the environment Cognitive Changes Development Theory ○ By Jean Piaget ○ First 2 years of life is sensorimotor development ○ Piaget - during this time the child must develop knowledge in 3 areas Cognitive Changes Piaget Sensorimotor Development 1. Object Permanence objects continue to exist even when they aren’t perceived by the child 2.Casualty Objects have uses, and events have causes 3. Symbolic Play - one object may represent another Emotional Changes emotions ○ development of self-control ○ distraction method can be used during anesthetic solution deposition Emotional Changes emotions ○ can be discerned by observing behavioral reactions, measuring physiological responses, or ascertaining person’s thoughts and reactions In children, thoughts and reactions are of little or no value Emotional Changes emotions ○ As the child grows older they begin to express more emotions and they are ascertained more accurately by adults Emotional Changes infants and childhood ○ fear of strangers is almost universal for children older than 7 months to 12 months intensity varies from child to child ○ 16 to 18 months (peak) fear of separation of parents around 6 months can lead to stress Emotional Changes infants and childhood ○ Ainsworth concluded: children with strong relationship with their caregiver could that relationship as a place from which to venture into wider social circles converse can be said to be true Emotional Changes aggression ○ caused by the child’s inability to exert self- control 1. Instrumental aggression a. achieving a goal - taking a candy from a playmate 2. Hostile aggression b. to cause hurt or pain to another child Social Changes the first year ○ children — utterly dependent on the parents ○ Mothering is extremely important ○ The baby may smile or cry at parents and strangers ○ Expect first teeth to appear Social Changes the second year ○ advent of language skills allows the child to learn and relate to the family ○ Children - start to exert their will ○ Effective and consistent parenting strategies become very important ○ Role model observation highlighted and thus good role models are imperative Social Changes the second year ○ Maintenance of affection between parent and child ○ Discipline should be educational not punitive ○ Temper tantrums are natural and are best to be left unnoticed Social Changes the third year ○ Eating independently maybe late 2nd year or early 3rd year ○ Potty Training starts but depends on the child ○ “Terrible Twos” — tantrums, lots of frustration ○ No. No. NO!!!! ○ Why? ○ Stating observation without reservations ○ Increased communication skills Social Changes Oedipus complex ○ Freudian theory ○ emotions aroused in a young child, typically around the age of four, by an unconscious sexual desire for the parent of the opposite sex and wish to exclude the parent of the same sex ○ originally applied to boys ○ Electra complex - equivalent in girls Social Changes Oedipus complex and electra complex ○ Freudian theory ○ can be resolved by adopting a system of morality with the Superego or the code of moral values FRANKL BEHAVIOR RATING SCALE  Chapter 18 Examination, Diagnosis, and Treatment Planning EXAMINATION First step is obtaining medical and dental history. This should be done thoroughly and not in a hurry. The parent or guardian is the child’s historian. ANTERO-POSTERIOR PLANE First step is obtaining medical and dental history. This should be done thoroughly and not in a hurry. The parent or guardian is the child’s historian. 3 POINTS ON THE FACE Bridge of the nose Base of the upper lip Base of the base ANTERO-POSTERIOR PLANE When those 3 dots are connected, FACIAL PROFILE is determined CLASS 1 – STRAIGHT CLASS 2 – CONVEX CLASS 3 - CONCAVE VERTICAL FACIAL RELATIONSHIP Face is divided into thirds Upper third – hairline to bridge of nose Middle third – bridge of nose to base of upper lip Lower third – base of upper lip to the bottom of the chin VERTICAL FACIAL RELATIONSHIP LIP POSITION Assessed by drawing an imaginary line from the tip of the nose to the most anterior point on the soft tissue chin SPACES IN THE PRIMARY DENTITION 1. Primate space – BC / CD 2. Developmental Space – bw the remaining teeth 3. Leeway Space or Nance – CDE > 345 Mx: 1.8mm Mn: 3.4mm ANTEROPOSTERIOR DIMENSION Chapter 19 Dental Materials RESTORATIVE MATERIALS IN PEDIA 1.LINERS AND BASES To reduce marginal microleakage from the restoration To prevent sensitivity Materials Calcium Hydroxide Zinc Oxide-eugenol Glass Ionomer Zinc phosphate CALCIUM HYDROXIDE alkaline pH aids in preventing bacterial invasion (ph 11) Application process: -Placed only on dentin -Place directly over the deepest portion of the preparation. Properties of Calcium Hydroxide -High solubility(must not be left on enamel preparations, or on axial walls) Poor seal, low compressive strength, radiopaque ZINC OXIDE EUGENOL Contain eugenol oil which has sedative effects Powder- Zinc Oxide Liquid- Eugenol Because of the sedative effects & years of clinical success, remains the material of choice for the pulp chamber filling material, following pulpotomy and pulpectomy Not used as a base under resin-based composite resin because eugenol can inhibit the polymerization of the resin. GLASS IONOMER CEMENT commonly used basing agent Has the ability to create a physical bond to tooth structure and to release fluoride Demonstrated the inhibition of secondary caries formation. Can be used under composite restorations Powder: calcium aluminosilicate glass particles Liquid: polyacrylic acid ZINC PHOSPHATE CEMENT is the oldest of the luting cements used in dentistry. Composed of zinc oxide and magnesium oxide powder that is mixed with a solution of phosphoric acid and water Has thermal insulating qualities The mixed cement reaches 50% of its final strength within the first 10 minutes and reaches its final strength after about 24hours. ZINC PHOSPHATE CEMENT The compressive strength can vary from 95- 135MPa, while the tensile strength is about 3 5MPa. The cement is extremely brittle and is influenced by its very low tensile strength Zn phosphate cement has the highest modulus of elasticity among all cements that is why it is the most suitable under amalgam restorations. ZINC PHOSPHATE CEMENT pH of freshly mixed cement=1.3-3.6 So in deep cavities sub-base of Ca(OH)2 is placed under Zn-phosphate to prevent irritation of the pulp RESTORATIVE MATERIALS IN PEDIA 2. CAVITY VARNISH The purpose is to reduce microleakage at restoration margins and inhibit penetration of corrosion products from amalgam into dentin, thereby preventing tooth discoloration adjacent to restorations Indicated under amalgam restorations RESTORATIVE MATERIALS IN PEDIA 3. COMPOSITE RESINS possess durability and superior esthetic qualities Bulk Fill resins Conventionally, the maximum incremental thickness of resin-based composite that provided adequate light penetration and polymerization was defined as 2mm(layering technique) but for bulk fill you can go up to 4 mm. Marginal Adaptation Microleakage can be reduced by:  Using contemporary posterior resin-based composites, which contain a high volume of filler that decreases polymerization shrinkage  Using an enamel bevel  Using newer dentin-bonding agents and glass ionomer cements  Acid etching the enamel RESTORATIVE MATERIALS IN PEDIA 4. SEALANT