1he art and sc|ence of manag|ng

traumat|c |n[ur|es to pr|mary teeth

8amesh v
Denta| 1raumato|ogy 2011 27 293299
Poward L needleman
onLenLs
Wntroduct|on
WCompar|son of 1rauma management gu|de||nes for |n[ur|es to permanent
and pr|mary teeth
DncompllcaLed crown fracLure
ompllcaLed crown fracLure
rown rooL fracLure
8ooL fracLure
Alveolar fracLure
oncusslon
SubluxaLlon
lnLruslon
LxLruslon
LaLeral luxaLlon
Avulslon
Wenera| cons|derat|ons |n manag|ng denta| |n[ur|es to pr|mary teeth
9aLlenL facLors
8ehavloral managemenL
uevelopmenLal lssues
9arenLal facLors
9sychosoclal
uenLlsL facLors
AnaLomlc and occlusal facLors
W|terature rev|ew
WConc|us|on
lnLroducLlon
rt sklll aL dolng speclflc Lhlng Lyplcally one
acqulred Lhrough pracLlce
Sc|ence knowledge coverlng general LruLhs or
general laws obLalned and LesLed Lhrough
sclenLlflc meLhods
arL sclence
arL sclence
arL sclence
DDL-LS ICk M-LML-1 CI
1kDM1C -DkLS 1C kMk -D
LkM-L-1 1LL1n
ermanent tooth r|mary tooth
Dncomp||cated crown #
an enamel fracLure or an
enameldenLln fracLure LhaL
does noL lnvolve Lhe pulp
WragmenL avallable bond
WSmall # smooLhen sharp
edges
WLarge # resLore LooLh
sLrucLure
do
ermanent tooth r|mary tooth
Comp||cated crown #
an enameldenLln fracLure
wlLh pulp exposure
WlmmaLure LooLh pulp
capplng or parLlal
pulpoLomy
WMaLure LooLh 8@ /
pulpcapplng or pulpoLomy
WMore Llme elapsed 8@
Wueclslons are based on llfe
expecLancy of Lhe prlmary
LooLh
W@reaLmenL alLernaLlves are
pulpoLomy / pulpecLomy /
exLracLlon
ermanent tooth r|mary tooth
Crown koot #
an enamel denLln and
cemenLum fracLure wlLh or
wlLhouL pulp exposure
( Same as compllcaLed
crown # )
Wln addlLlon aLLempLs aL
sLablllzlng loose segmenLs
of Lhe LooLh by bondlng
WSurglcal or orLhodonLlc
exLruslon for preparaLlon
for permanenL resLoraLlon
WLxLracLlon
Ware musL be Laken Lo
prevenL ln[ury Lo
permanenL successor
ermanent tooth r|mary tooth
koot #
a denLln and cemenLum
fracLure lnvolvlng Lhe pulp
W8eposlLlon check x ray
SLablllze wlLh flexlble spllnL
for 4 weeks
Wlf fracLure near cervlcal
area sLablllze 4 monLhs
WMonlLor pulp sLaLus for 1
year
Wlf Lhe coronal fragmenL ls
dlsplaced exLracL only LhaL
fragmenL @he aplcal
fragmenL should be lefL Lo
resorbed
W8eposlLlonlng x
ermanent tooth r|mary tooth
|veo|ar # W8eposlLlon and SpllnL
WSLablllze for 4 weeks
W8eposlLlon and spllnL
WCA
ermanent tooth r|mary tooth
Concuss|on
ln[ury Lo Lhe LooLh
supporLlng sLrucLures
wlLhouL abnormal
loosenlng or dlsplacemenL
of Lhe LooLh
Wno 8x needed
WMonlLor pulpal sLaLus for
1 year
Wno 8x needed
WobservaLlon
ermanent tooth r|mary tooth
Sub|uxat|on
ln[ury Lo LooLhsupporLlng
sLrucLures wlLh abnormal
loosenlng buL wlLhouL
LooLh dlsplacemenL
WA flexlble spllnL Lo sLablllze
Lhe LooLh for paLlenL
comforL can be used for up
Lo 2 weeks
Wno 8x needed
WobservaLlon
ermanent tooth r|mary tooth
Lxtrus|ve uxat|on
parLlal dlsplacemenL of Lhe
LooLh axlally from Lhe
sockeL parLlal avulslon @he
perlodonLal llgamenL
usually ls Lorn
W8eposlLlon by genLle
relnserLlon and use
flexlble spllnL for 2
weeks
WMonlLor pulpal sLaLus
WMlnor exLruslon (3mm)
allow sponLaneous reposlLlon
or reposlLlon and allow
heallng
WSevere exLruslon moblllLy
exfollaLlng LooLh exLracLlon
ermanent tooth r|mary tooth
atera| uxat|on
dlsplacemenL of Lhe LooLh
ln a dlrecLlon oLher Lhan
axlally @he perlodonLal
llgamenL ls Lorn and
conLuslon or fracLure of Lhe
supporLlng alveolar bone
occurs
W8eposlLlon wlLh forceps
Lo dlsengage lL from lLs
bony lock and genLly
reposlLlon lL lnLo lLs
orlglnal locaLlon
WMonlLor pulpal sLaLus
Wno occlusal lnLerference
allow sponLaneous reposlLlon
WCcclusal lnLerference
reposlLlon by comblned
palaLal and lablal pressure
under LA
WSever dlslocaLlon LooLh
nearlng exfollaLlon exLracLlon
ermanent tooth r|mary tooth
ntrus|ve uxat|on
aplcal dlsplacemenL of
LooLh lnLo Lhe alveolar
bone @he LooLh ls drlven
lnLo Lhe sockeL
compresslng Lhe
perlodonLal llgamenL
WlmmaLure rooL allow
sponLaneous
reposlLlonlng lf no
movemenL for 3 weeks
orLhodonLlc reposlLlonlng
WMaLure rooL reposlLlon
and spllnL for 4 weeks
8@ wlLhln 3 weeks of
Lrauma
WApex dlsplaced Lowards lablal
bone allow sponLaneous
reposlLlon
WApex dlsplaced lnLo
developlng LooLh germ
exLracL
ermanent tooth r|mary tooth
vu|s|on
compleLe dlsplacemenL of
LooLh ouL of sockeL @he
perlodonLal llgamenL ls
severed and fracLure of Lhe
alveolus may occur
Wlean Lhe LooLh
reposlLlon and spllnL
WSpllnL for 2 Lo 4 weeks
Wuo noL replanL
ollowup guldellnes
Ceneral onslderaLlons LhaL affecL Lhe
guldellnes
W at|ent Iactors
llnlclan noL only manage Lrauma buL also Lhe
behavlor of chlld before durlng and afLer 8x
omplex LreaLmenL / very uncooperaLlve chlld /
chlld wlLh speclal needs conslder exLracLlon
SuspecL of hlld abuse ? 8eporL Lo approrlaLe
agenL
ehav|ora| Management
9hyslcally LraumaLlzed chlld ls more dlfflculL Lo
manage
non pharmacologlcal behavlor managemenL
Lechnlques can be used
nC analgesla (mlnlmal/moderaLe/deep)sedaLlon
or Ceneral AnesLhesla can be used
8lsk lnvolved Vs 9oLenLlal beneflL of LreaLmenL
Deve|opmenta| ssues
Agenesls of 9ermanenL successor long Lerm success of
LreaLmenL Lo prlmary LooLh ls lmporLanL
earller Lhe sLage of Lhe succedaneous LooLh's developmenL
more llkely LhaL poor LreaLmenL ouLcomes
W arenta| Iactors
sychosoc|a| and I|nanc|a|
sychosoc|a|
9arenLs brlng Lhelr own seL of fears
emoLlonal lmpacL of ln[ury Lo chlld lmpacL on ||sten|ng
ab|||ty of parents Lo selecL approprlaLe LreaLmenL
lmporLance of denLal care varles
cosmeLlcs are noL a concern Lo younger chlldren LxL?
parents fee| gu||ty of Lrauma
I|nanc|a|
cosL of LreaLmenL should be consldered
LreaLmenL cosL noL covered by 3
rd
parLles ?
Dent|st Iactors
denLlsL musL be conversanL wlLh Lhe compleLe
armamenLarlum of behavloral modlflcaLlon Lechnlques
cllnlclan should be comforLable wlLh access Lo
pharmacologlcal Lechnlques such as nC sedaLlon or CA
9edlaLrlc denLlsLs are ldeal for LreaLlng chlldren wlLh
LraumaLlc ln[urles
natom|c and Ccc|usa| Iactors
Culdellnes for permanenL LeeLh prlmary LeeLh 8uL
natomy
Larger pulp chambers
Lhlnner enamel and denLln
rooL canals Lhlnner and LorLurous pulp exLrlpaLlon dlfflculL
longer and flarlng rooLs posslblllLy for fracLure of rooL apex
9roxlmlLy of succedaneous LooLh Lo rooL of prlmary LooLh
smaller Lhe dlsLance more llkely for developmenLal dlsLurbance Lo
permanenL LooLh
More llkely for pulpal exposure
Ccc|us|on
ln luxaLlon ln[urles lf dlsplaced LooLh ls ln crossblLe reposlLlon
or exLracLlon
mlldly luxaLed LooLh LhaL are noL ln crossblLe allow sponLaneous
reposlLlon
chlld wlLh oral hablLs llke dlglL or paclfler sucklng reposLlons
naLurally
Literature Review
LCn- kMk 1LL1n W1n 10 CkMDL LkCkDL uavld P 8ranLley uuS
kaLheryn 9 8arnes 8uP van 8 Paywood uMu leJlottlc ueotlstty 2J6 2001
@ooLh dlscoloraLlon ls not a lndlcaLlve of pu|p status
lf Lhere were no cllnlcal sympLoms of paln or moblllLy and no radlographlc
slgns of perlaplcal radlolucencles or resorpLlon Lhen b|each|ng was lndlcaLed
wheLher or noL Lhe LooLh LesLed vlLal or nonvlLal
@here ls llLLle concern of |ngest|on for Lhe mlnlmal amounL of maLerlal used
durlng Lhls LreaLmenL slnce Lhls 10 carbam|de perox|de maLerlal has been
used ln newborn lnfanLs for LhroaL lnfecLlons
Lxtract|on as a treatment a|ternat|ve fo||ows repeated trauma |n a severe|y
hand|capped pat|ent @sal @9 ueotol 1toomotoloqy 2001 17 1J9142
Pandlcapped paLlenLs wlLh proLrudlng maxlllary lnclsors are prone Lo
repeaLed denLal Lrauma onslderlng lnadequaLe conLrol of selzure
dlsorder llLLle ablllLy of Lhe paLlenL Lo recelve comprehenslve
orLhodonLlc LreaLmenL poor prognosls of resLoraLlons and posslble
fuLure ln[urles Lhe removal of nonfuncLlonal non esLheLlc Lrauma
suscepLlble lnclsor LeeLh can be [usLlfled as an alLernaLlve Lo LooLh
preservaLlon
Management of 1rauma of r|mary 1ooth keport of ntrus|on Case kyoko
n|rata otJ 1lssoe 8loloqy14(4) ltoceeJloqJ61J62 2005
AlLhough Lhe lnLruslon of prlmary anLerlor LooLh ls ofLen happened Lhe
LreaLmenL procedure for lL has noL been esLabllshed yeL
ulab eL all descrlbed LhaL when Lhe LooLh was lnLruded compleLely Lhe
tooth shou|d be extracted because reerupLlon could noL be expecLed
Polan eL al reporLed 108 of 123 |ntruded teeth were reerupted
spontaneous|y
Cur resulLs supporL LhaL case of lnLruslon ln lnfanLs aged 1 Lo 3 years old
should be observed lnsLead of surglcal LreaLmenLs unLll some sympLom
perlaplcal perlodonLlLls radlographlcally and alveolar abscess formaLlon
reveals
uependlng on Lhe severlLy of Lhe lnLruslon Lhe Amerlcan Academy of 9edlaLrlc
uenLlsLry recommends elLher exLracLlon or sponLaneous reerupLlon for Lhe
prlmary LooLh @hls case reporL provldes a brlef lnslghL lnLo surglcal reposlLlonlng
as an alLernaLlve LreaLmenL opLlon for Lhe managemenL of lnLruded prlmary LooLh
ln a 4yearold glrl
Management of |ntrus|ve |uxat|on |n the pr|mary dent|t|on by surg|ca|
repos|t|on|ng an a|ternat|ve approach Pv Shanmugam* 9 Aranganna
AusLrallan uenLal !ournal 2011 36 207211
uxat|on |n[ur|es |n pr|mary teeth a retrospect|ve study |n ch||dren ass|sted at an
emergency serv|ce Luclana 8elcherL da Sllva 8raz Cral 8es 2011 Mar
Apr23(2)1306
ln general Lhe prevalence of luxaLlon ln[urles decreased wlLh lncreaslng
age 8oys suffered from denLal Lrauma slgnlflcanLly more ofLen Lhan glrls
alllng as a resulL of walklng or runnlng was Lhe mosL common eLlologlc
facLor SubluxaLlon was Lhe mosL common Lype of Lrauma @reaLmenL
usually occurred wlLhln Lhe flrsL 13 days afLer Lhe ln[ury uesplLe Lhe
severlLy of Lhese ln[urles monlLor only" was Lhe mosL common
LreaLmenL
VDSC- CI kMk 1LL1n SLDLL C- 1nL LkM-L-1 SDCCLSSCkS
C-1DD- S1DD Mlchele Machado Lenzl ulana 8lbelro !acomo vlvlan
arvalho and vera ampos 8razlllan !ournal of uenLal @raumaLology (2011) 2(2)
8084
8esulLs of Lhe sLudy shows LhaL avulslon was Lhe 2
nd
most frequent Lype
of Lrauma ln prlmary denLlLlon
D|sco|orat|on of ename| and]or ename| hypop|as|a were Lhe mosL
frequenL sequelae ln successors
@he mosL sequelae occurred when avulslon happened ln 23 year old
chlldren
kep|antat|on of vu|sed r|mary nc|sors k|skenef|t ssessment Lrlca L
Zamon 8Sc oo ueot Assoc 2001 67J86
@he sLudy descrlbe longLerm ( 1 year) ouLcomes for 8 replanLed lnclsors
(maxlllary and mandlbular) @hese lnclsors were all spllnLed followlng
replanLaLlon uenLal pulps were lefL ln all buL one lnclsor desplLe lschemlc
perlods ln excess of 30 mlnuLes
4 lnclsors were subsequenLly exLracLed due Lo abscess or
paLhologlcal rooL resorpLlon
3 exfollaLed physlologlcally and
1 was reLalned
Cne permanenL lnclsor had an enamel defecL
nypop|as|a of a ermanent nc|sor roduced by r|mary nc|sor ntrus|on
Case keport ceyhon 4/tun uu5 lbu /in en/ik uu5 lbu 1o/qo likret
1tm uu5 lbu !uA Aptll 2009 vol 75 No J
W8eLween 18 and 69 of lnLruslve ln[urles Lo Lhe prlmary denLlLlon
cause anomalous developmenL of Lhe permanenL LeeLh
WSuch alLeraLlons ln denLal paLhology can lnclude
WwhlLe or yellowbrown dlscoloraLlon or
Wclrcular enamel hypoplasla
Wcrown dllaceraLlon
WrooL dupllcaLlon
WvesLlbular or laLeral rooL angulaLlon or dllaceraLlon
WparLlal or compleLe arresL of rooL formaLlon
WsequesLraLlon of Lhe permanenL LooLh germ
WdlsLurbed erupLlon
ntrus|on |n[ur|es of pr|mary |nc|sors art Lffects on the permanent
successors ulab M el8adrawy PL ;olotesseoce lot 2000 J1(6)J7784
Wh|te d|sco|orat|on ls caused by Lhe acce|erated m|nera| depos|t|on LhaL
resulLs from Lrauma durlng Lhe maLuraLlon sLage of enamel developmenL
whereas ye||owbrown dlscoloraLlon ls caused by the |ncorporat|on of
hemog|ob|n products from bleedlng ln Lhe perlaplcal area and enamel
hypoplasla ls caused by Lhe desLrucLlon of ameloblasLs ln Lhe acLlve enamel
eplLhellum
u|p cana| ob||terat|on |n an unerupted permanent |nc|sor fo||ow|ng
trauma to |ts pr|mary predecessor a case report kaLzSagl P MoskovlLz
M Moshonov ! Polan C ueot 1toomotol 2004 20(J)181J
kaLzSagl and oLhers found unusua| ob||terat|on of the pu|p cana| ln a maxlllary
cenLral lnclsor and crown ma|format|on ln Lhe ad[acenL unerupLed cenLral lnclsor
afLer Lrauma Lo Lhe assoclaLed prlmary LooLh
8asslouny MA Clannlnl 9 ueem L ermanent |nc|sors traumat|zed
through predecessors seque|ae and poss|b|e management llo leJlott
ueot 200J 27(J)22J8
8asslouny and oLhers also reporLed a case of tota| and part|a| pu|p ob||terat|on
of Lhe maxlllary cenLral lnclsors afLer Lrauma Lo Lhelr assoclaLed prlmary LeeLh
@hls sLudy has suggesLed LhaL paLlenLs may noL comprehend Lhe acLual
slgnlflcance of denLal ln[urles and Lhe complexlLy of LreaLmenL ln Lhe
same way as denLal professlonals and Lhls may explaln Lhe wlde varlaLlon
ln cooperaLlon wlLh longLerm managemenL of denLal ln[urles
oung peop|e's percept|ons of photographs of denta| trauma !ennlfer
Lmlly uenLal @raumaLology 2011 27 109112
@hls sLudy has found LhaL 11 Lo 12yearold chlldren aLLrlbuLe negaLlve
personallLy characLerlsLlcs Lo oLher chlldren wlLh vlslble lnclsor Lrauma
ln vlew of Lhe poLenLlal for adverse psychosoclal effecLs and llfe ouLcomes
every efforL should be made Lo provlde Llmely and aesLheLlc denLal care
for young paLlenLs wlLh LraumaLlzed lnclsors
Soc|a| [udgment made by ch||dren |n re|at|on to v|s|b|e |nc|sa| trauma
Pelen chrls baker uenLal LraumaLology 2010 28 28
oncluslon
8eferences
Management of |ntrus|ve |uxat|on |n the pr|mary dent|t|on by surg|ca|
repos|t|on|ng an a|ternat|ve approach Pv Shanmugam* 9 Aranganna AusLrallan
uenLal !ournal 2011 36 207211
kep|antat|on of vu|sed r|mary nc|sors k|skenef|t ssessment Lrlca L
Zamon 8Sc oo ueot Assoc 2001 67J86
LCn- kMk 1LL1n W1n 10 CkMDL LkCkDL uavld P 8ranLley
uuS kaLheryn 9 8arnes 8uP van 8 Paywood uMu leJlottlc ueotlstty 2J6 2001
Lxtract|on as a treatment a|ternat|ve fo||ows repeated trauma |n a severe|y
hand|capped pat|ent @sal @9 ueotol 1toomotoloqy 2001 17 1J9142
8eferences
nypop|as|a of a ermanent nc|sor roduced by r|mary nc|sor ntrus|on
Case keport ceyhon 4/tun uu5 lbu /in en/ik uu5 lbu 1o/qo likret
1tm uu5 lbu !uA Aptll 2009 vol 75 No J
Management of 1rauma of r|mary 1ooth keport of ntrus|on Case kyoko
n|rata otJ 1lssoe 8loloqy14(4) ltoceeJloqJ61J62 2005
uxat|on |n[ur|es |n pr|mary teeth a retrospect|ve study |n ch||dren ass|sted
at an emergency serv|ce Luclana 8elcherL da Sllva 8raz Cral 8es 2011 Mar
Apr23(2)1306
VDSC- CI kMk 1LL1n -D SLDLL C- 1nL LkM-L-1
SDCCLSSCkS C-1DD- S1DD Mlchele Machado Lenzl ulana 8lbelro
!acomo vlvlan arvalho and vera ampos 8razlllan !ournal of uenLal
@raumaLology (2011) 2(2) 8084
8eferences
Lmergency management of denta| trauma @ony SkapeLls 8uS AusLralaslan
Lmergency nurslng !ournal (2010) 13 3034
u|de||nes for the management of traumat|c denta| |n[ur|es Iractures and
|uxat|ons of permanent teeth LC8LS M@ AnuL8SSCn L uenLal @raumaLology
2007 23 6671
u|de||nes for the management of traumat|c denta| |n[ur|es vu|s|on of
permanent teeth LC8LS M@ AnuL8SSCn L uenLal @raumaLology 2007 23
130136
u|de||nes for the management of traumat|c denta| |n[ur|es vu|s|on of
permanent teeth LC8LS M@ AnuL8SSCn L uenLal @raumaLology 2007 23
196202