Traumatic Dental Injuries PDF Spring 2024

TRAUMATIC DENTAL INJURIES Spring 2024 Epidemiology: Prevalence: About 30% of school children suffer traumatic dental injury in the primary dentition, and 22% in the permanent dentition. In Egypt, the prevalence of traumatic dental injuries represents 10% fo...

TRAUMATIC DENTAL INJURIES Spring 2024 Epidemiology: Prevalence: About 30% of school children suffer traumatic dental injury in the primary dentition, and 22% in the permanent dentition. In Egypt, the prevalence of traumatic dental injuries represents 10% for primary dentition and 14.6% in permanent dentition. Sex: The prevalence of traumatic dental injury among boys and girls does not differ to a great extent until the age of` 9 years. After this age, boys show higher prevalence than girls. The ratio was found to be 1.5:1, this is probably because of active participation of boys' in contact sports. Age: Peak incidence of dental injuries at 2-4 and 8-11 of age Teeth: The majority of injuries to the dentition occur to the anterior teeth and in particular the maxillary central incisors of both primary and permanent dentition. Injuries usually affect only one tooth, and 25% of the patients treated for dental trauma will very likely repeat the experience. Repeated episodes: The upper central incisors had the highest frequency of injury (89.7%), and enamel fracture was the most frequent type (51.8%) If trauma occurs early before 9 years, there is 8- fold increase in risk of new trauma, with increased risk for trauma to the same tooth Etiology of traumatic dental injuries: Include general factors, systemic factors and dental factors General factors 1. Sports activities as contact sports, bicycle or horse riding. 2. Falls and collisions: Due to lack of motor coordination, i.e. during the first year of life as due to fall when the child learns to walk. 3. Road accidents: Traffic accidents include bicycle and car related injuries. Wearing modified helmets significantly reduce the risk of facial injuries 4. Fight injuries 5. Inappropriate use of teeth: Like opening bottles, fix electronic equipment, cut or hold objects Domestic violence: Child abuse and neglect Systemic factors 1 1. Mentally handicapped individuals or children suffering from repetitive seizures where violent contact with objects may be unavoidable. 2. Cerebral palsied children due to poor tone, high incidence of malocclusion and 30% suffered epilepsy 3. Hyperactivity: Particularly in children with attention deficit hyperactivity disorder (ADHD) Dental factors 1. A class II, division 1 malocclusion with protruding upper incisors and incompetent lips. Dental trauma is as twice as frequent in those children. Early orthodontic treatment may prevent a great deal of traumatic injuries. 2. Hypoplasia, extensive caries or any structural defects of enamel that results in weakening of the tooth structure, can cause fracture of the crown under even slight trauma. Treatment needs: Insufficiently met in most countries Classification of trauma to anterior teeth: Several classifications have been advocated by several authors. 1. Ellis and Davey classification: Class 1: simple crown fracture with little or no dentin. Class 2: extensive crown fracture, involving considerable amount of dentine without pulp exposure. Class 3: extensive crown fracture involving considerable amount of dentine with pulp exposure. Class 4: non-vital traumatized tooth with or without loss of crown structure. Class 5: loss of the tooth. Class 6: root fracture with or without crown fracture. Class 7: tooth displacement without crown or root fracture. Class 8: fracture of crown enmass Class 9: traumatic injuries of deciduous teeth. 2 2. Descriptive classification: Injuries to the tooth: Crown Crack or craze of enamel Fracture of crown involving enamel dentine or pulp Fracture of crown and root involving cementum which may or may not have pulp involvement. Root May be horizontal or oblique:, Apical third fracture, Middle third fracture, Coronal third fracture Involving the whole tooth Concussion: sensitivity of the tooth due to trauma without abnormal loosening or mobility. The tooth may be sensitive to percussion usually caused due to mild blow. Subluxation: loosening of the tooth without displacement, due to a more severe blow resulting in injury to periodontal ligament. Displacement/luxation:  Intrusion: displacement of a tooth in an apical direction. Tooth is pushed into the socket, causing fracture of the bone at the floor of the socket in most of the cases.  Extrusion: displacement of a tooth in a coronal direction. Tooth is seen extruded partially of the socket ,  Lateral: displacement of a tooth in a mesial or distal, labial or lingual direction.  Avulsion: the tooth is totally displaced out of the socket Diagnosis 1. Personal History: It should include the patient's name, age, sex, address, source of referral if any, and reason for attendance. It is important for legal aspects, behavior management concerns and follow up of the patient. 2. Medical History: Routine data on the patient’s general health should be obtained particularly those relevant to dental injuries. Cardiac disease which would necessitate prophylaxis against subacute bacterial endocarditis. Bleeding disorders Allergies to medication Seizure disorders 3  Current medications The child’s current tetanus immunization status which is particularly important if the child suffers from a dirty wound. Children acquire active immunity through a series of injections of heat-denatured tetanus toxoid. Tetanus immunization protocol is usually: - Primary doses (DPT) booster dose at 18 months - Second booster dose at 5 years - A booster every 10 years 3. Dental History: Previous dental history: Information can be obtained on the frequency of dental visits type of treatment performed such as extraction or conservative procedures. The type of anesthesia used for the procedures and the cooperation of the child can be determined. History of the injury: Histories should be short and to the point. Only three questions need to be asked to obtain maximum information: When, Where, and How did the injury occur? When did the accident occur? In cases of oral trauma with damage to the teeth, time elapsed since trauma is very important especially in cases of avulsion or tooth fracture with pulp involvement. The shorter the time between accident and treatment the better will be the prognosis. Where did the accident occur? If the accident occurred in a particularly dirty environment, prophylactic tetanus treatment is indicated. 4 How did the injury happen? 1. Provide the dentist with information regarding severity of injury 2. Prediction in regard to the consequences of the injury; a direct blow under the chin may cause a fracture in the condyle and fracture of crowns of molars and premolars. 3. For young children, when there is a marked discrepancy in clinical findings and the history given, child abuse should be suspected. History of pain in injured tooth: Pain caused by thermal changes is indicative of pulpal inflammation. Pain while a tooth in contact is indicative of injury to periodontal ligament and supporting structures. 4. History of previous dental injuries Repeated injuries to their teeth can influence pulpal sensibility and recuperative capacity of the pulp and/or periodontiu II. Clinical Examination: 1. Extra-oral Examination: The extra-oral examination begins immediately when the patient enters the office Neurological assessment 1. Episodes of amnesia, unconsciousness, drowsiness, vomiting or headache indicate cerebral involvement 2. Shock signs (pallor, cold skin, irregular pulse, hypotension), symptoms of head injury suggesting brain concussion, or maxillofacial fractures 3. Bleeding or discharge of clear fluid from ears and nose All these may indicate cerebrospinal injury and immediate referral Other assessment 4. Facial swelling, bruises, or lacerations may indicate underlying bony and tooth injury 5. Subconjunctival hemorrhage may indicate fracture of zygomatic complex 7. Limitation or any asymmetries of mandibular movement or mandibular deviation on opening or closing the mouth indicate either jaw fracture or dislocation 8. Crown fracture with associated swollen lip may indicate imbedded fragment 5 9. Soft tissue injury: Lacerations, abrasions, and contusions on the face, head, neck and exposed limbs can be noted visually. Extra-oral wounds should be inspected for foreign bodies. 2. Intraoral Examination: It includes: the soft and hard tissues. 1. Soft-tissue Examination: Note any laceration of the tongue, gingiva, labial and buccal mucosa or penetrating wounds. Soft tissue injuries may be: a. Abrasion: A superficial wound produced by rubbing or scraping of mucosa leaving a raw bleeding surface. b. Laceration: A shallow or deep wound in the mucosa resulting from a tear usually produced by a sharp object. The presence ofembedded tooth fragments should always be suspected in this case c. Contusion: A bruise usually produced by a blunt object and not accompanied by break of continuity in the mucosa, causing submucosal hemorrhage. d. A hematoma in the floor of the mouth indicates mandibular fracture e. Loss of tissue/Tissue avulsion is very rare (associated with bite injuries). I. Management of Soft tissue injuries: A. Determination of child immunization status: The dentist should check the immunization status of the child: Tetanus Prophylaxis in Wound Management: 1. Assess patient’s immunization history Determine number of tetanus-containing vaccine previously given ❖ Examination: - The lacerated tongue should be examined for any foreign bodies like : crown fractures pieces of teeth restorations fragments. N.B: These fragments can be revealed by a radiographic examination with an exposure time 25% of normal exposure time. 6  - We should examine the airway for any obstruction due to hemorrhage (high blood supply) or swelling of the tongue. When to suture: - Wounds larger than 2 cm. - When hemorrhage is a concern. - Large gaping wounds with tongue at rest. - Anterior split tongue. - - Parents should be advised about possible complications that may occur, such as swelling, infection or tearing of suture. - - Referral to specialist when any complication occur. - Laceration of frenum - The tear will heal in about seven days B. Debridement, suturing and/or hemorrhage control of open soft tissue wounds, remove tooth fragment; if present and when indicated refer the child to family physician C. Antibiotic is indicated in: 1. Heavily contaminated wounds 2. Wound debridement has been delayed (>24hrs) 3. Penetrating lesions through the full substance 4. Open reduction of jaw fracture 5. General defense of patient is compromised 6. Human or animal bite wound 2. Hard-tissue Examination: a. Displacement: Teeth may suffer labial, lingual, palatal, or lateral displacement as well as intrusion, extrusion or avulsion. Visually determine and note any displacement. b. Mobility: If two or more teeth are seen to move, an alveolar fracture should be suspected. Degree or grade of mobility is recorded as: Grade 0 = no mobility Grade +1 = less than 1mm of horizontal movement 7 Grade +2 = more than 1mm of horizontal movement Grade +3 = more than 1 mm of horizontal movement and depressible within the socket Recently, Periotest™ has been introduced to evaluate tooth mobility C-Percussion: This test is first carried out on non-traumatized teeth so that the patient fully understands the purpose of this test Tooth percussion should initially be performed using a gentle touch with the fingertip, followed by a light percussion with the fingertip. If no pain is elicited, the next test is with a mirror handle, tapping laterally and then vertically on the tooth crown. E- Color change: Non-vital teeth often appear discolored. This is due to an interruption in the blood supply of the tooth. The blood already present in the pulp chamber undergoes a normal breakdown process, but the products are unable to dissipate. This results in tooth discoloration varying from gray-brown to black. -Reddish crown indicates pulpal-hyperemia. -Pink spot indicates internal resorption Pulp sensibility tests: ❖ Unreliable due to a transient lack of neural response or undifferentiation of A delta nerve fibers in young teeth ❖ The temporary loss of sensibility is a frequent finding during post- traumatic pulp healing, especially after luxation injuries. Thus, the lack of a response to pulp sensibility testing is not conclusive for pulp necrosis in traumatized teeth. BUT it should be performed initially and at each follow-up appointment in order to determine if changes occur over time. 8 EPT requires tooth isolation, plastic strip interperoximally Electrode shouldn’t be placed on metallic restoration, orthodontic appliance or crowned tooth The main disadvantages is unreliable responses from children because of fear, management problems, and inability to understand or communicate accurately. Consequently, most diagnoses are made on observation of clinical symptoms and radiographic evidence of pathosis Laser Doppler Flowmeter (LDF) Source of laser: Helium Neon (633nm) or Diode Laser (780-810 nm) The technique utilizes a beam of infrared light produced by a laser that is directed into the tissue. As light enters the tissue, it is scattered and adsorbed by moving red blood cells and stationary tissue elements Rules: to be considered during pulp testing Test teeth in immediate area & those in opposing arch Record normal reading, of tooth in opposite side, first Retest the tooth after a week or 10 days IV. Radiographic Examination: All traumatized teeth should be radiographed to investigate the following: 1. The stage of root formation. 2. The presence of any root fracture. 3. The presence of periapical radiolucencies. 4. Injuries to the supporting periodontal membrane, such as the degree of intrusion or extrusion of the tooth. 5. The size of the pulp chamber. 6. Presence of tooth fragments or foreign bodies in the soft tissues. Treatment of Traumatic Dental Injuries As a rule: Diagnose from outside to inside and treat from inside to outside.i.e. Treat affected tooth first then soft tissue and lastly extraoral tissues Check IADT GUIDELINES I sent you 9 A-treatment guideline for avulsed permanent teeth with closed apex: 10 Treatment of Traumatic Dental Injuries in the primary dentition Primary teeth are more likely to be displaced than fractured because of: a. The thinner and more elastic alveolar bone b. Teeth are more vertically position on dental arch c. Smaller crown root ratio The effect of injury in the deciduous dentition falls into two categories: direct effect on the primary teeth (displacement or fracture) or indirect effect on the unerupted permanent teeth (Turner’s hypoplasia, hypomineralization, dilacerations…….) Treatment of fractured primary teeth: 1. Enamel fractures: smooth sharp edges. 2. Enamel and dentin fracture: acid etch composite. 3. Fractures involving pulp: pulp therapy or extraction Treatment for non-vital anterior tooth following trauma is pulpectomy and filing with resorbable root canal filling material 11 4. Fractures of root of primary tooth: extraction Treatment of displaced primary teeth: a. Lateral displacement check the contact between a displaced primary tooth and its permanent successor by a radiograph, then follow-up. b. Intrusion: The prevalence of primary tooth intrusions is about 9-10%, and of those injuries, partial intrusion is more common than complete intrusion. International Association of Dental Trauma (IADT) guidelines, advocate extraction of the intruded primary tooth if there is clinical and/or radiographic evidence of displacement into the developing permanent tooth germ. In almost all instances of intrusion, reassurance and observation are all that is required. Most intruded primary teeth will re-erupt over a period of few months. Only if there is clear evidence that the intruded tooth is in contact with the underlying successional tooth consideration should be taken for removing the intruded tooth. The decision to leave or extract intruded tooth is depends on many factors 1. Degree of intrusion; Type I (>50% of the crown is exposed; type II,due to risk of damaging the permanent successor. If you decide to leave the tooth, the parents should be assured and informed about possibility of tooth ankylosis or necrosis and possibility of damage to permanent successor. c. Extrusion: The extruded primary tooth is usually extracted. Repositioning and splinting when possible otherwise such tooth may be extracted to avoid damage to the underlying permanent tooth. d. Avulsion: Avulsed primary teeth are not replanted. The tooth should be discarded. Providing adequate splint to support the repositioned tooth may be difficult in a very young child. Reaction of the pulp to trauma Pulp Hyperemia A trauma of even a so-called minor nature is immediately followed by a condition of pulpal hyperemia. The hyperemic condition with a single outlet of veins leads to an increased danger of strangulation of the vessels. Congestion of the blood within the pulp chamber a short time after the injury can often be detected in the clinical examination (the coronal portion of the tooth will often appear reddish as compared with the adjacent teeth). The 12 color change may be evident for several weeks after the accident and is often indicative of a poor prognosis. i.Internal Hemorrhage: The dentist will occasionally observe temporary discoloration of a tooth after injury. Hyperemia and increased pressure may cause the rupture of capillaries and the escape of red blood cells with subsequent breakdown and pigment formation. The extravasated blood may be reabsorbed before gaining access to the dentinal tubules, color change is noticeable and it is temporary in nature. In more severe cases there is pigment formation in the dentinal tubules. The change in color is evident within 2 to 3 weeks after injury, and the reaction is reversible to a degree that the crown of the injured tooth retains some of the discoloration for an indefinite period of time. Discoloration that becomes evident for the first time months or years after an accident, however, is evidence of a necrotic pulp. ii. Calcific Metamorphosis (Dystrophic Calcification): Calcific metamorphosis is a degenerative pathologic process that ultimately leads to obliteration of the pulp chamber and root canal. The reaction is considered to be a physologic repair response of the pulp and once initiated, it may continue until the pulp is completely replaced with a dentine like calcified tissue. Such teeth, Their clinical crowns may have a yellowish, opaque color and will not show any response to various pulp tests. Primary teeth will undergo normal physiologic resorption, and permanent teeth will often be retained indefinitely. iii. Inflammatory resorption: Inflammatory resorption can occur externally and/or internally (pink spot). It commonly arises following luxation injuries when the periodontal ligament is inflamed and the pulp is necrotic. Odontoclastic activity can occur so rapidly that the teeth are destroyed in a matter of weeks. Immediate treatment of inflammatory resorption is essential. As soon as this process is detected radiographically, the pulp tissue in the tooth is thoroughly extirpated. Copious irrigation with sodium hypochlorite assists in the dissolution of organic debris in the canal. In permanent teeth, calcium hydroxide is placed in the canal, here the objective is not to induce apical closure but to create an environment unfavorable for the resorption process. Depending upon the severity of the inflammatory resorption, calcium hydroxide may need to be retained in the tooth for 6-24 months. Repeated applications may be necessary if the resorption progresses. When radiographs confirm that the process is not continuing, gutta percha is placed as the final filling material. 13 iv. Replacement Resorption (Ankylosis): Replacement resorption occurs most commonly following severe luxation injuries like avulsion or intrusion, in which periodontal ligament cells are destroyed. Alveolar bone directly contacts cementum of the involved tooth and becomes fused with it. Then as the bone undergoes its normal, physiologic, osteoclastic, and osteoblastic activity, the root is resorbed or replaced with bone, which may cause a mechanical lock or fusion between alveolar bone and root surfaces. Clinical evidence of ankylosed tooth is being appear at a lower incisal plane than its adjacent teeth, as they continue to erupt while the ankylosed tooth remain fixed to surrounding structures. This type of resorption cannot be treated once the tooth is firmly immobilized by the process. In young children with rapid bone turnover, teeth are completely resorbed in 3-4 years. In adults, the process may take up to10years. Replacement resorption can be prevented only by prompt and appropriate treatment of luxation injuries v. Pulp Necrosis: Little relationship exists between the type of injury to the tooth and the reaction of the pulp and supporting tissues. A severe blow to a tooth causing displacement often results in pulp necrosis; the blow may cause a severance of the apical vessels, in which case the pulp undergoes autolysis and necrosis. In a less severe type of injury the hyperemia and slowing of blood flow through the pulpal tissue may cause eventual necrosis of the pulp. In some cases the necrosis may not occur until several months after the injury. Therefore , the effect of trauma on a tooth may be: I. Direct effect: A. Immediate effect 1. Enamel infarction 2. Enamel fracture 3. Enamel and dentine fracture 4. Enamel, dentine and pulp fracture (complicate crown fracture) 5. Uncomplicated C/R fracture 6. Complicated C/R fracture 7. Root fracture (apical, middle, cervical- oblique / horizontal). Delayed effect (reaction of the pulp to trauma 1. Hyperemia 2. Internal hemorrhage 3. Internal resorption 4. External resorption 5. Calcification of the pulp Pulp necrosis 14 6. Ankylosis 7. Dilaceration II.Indirect effect (trauma to primary tooth affecting its successor): 1. Hypoplasia; Turner’s hypoplasia 2. Hypomineralization 3. Dilacerations either of the crown or roo 15