- 30% of preschoolers suffer dental injury
- At this age there is no difference between boys and girls.
- 23% males age 6-20 years and 13% females suffer dental injuries
- Prevalence and incidence peak at 2-4 years and 8-10 years
- The way the tooth is injured is related to the activity level at each age.
- Patients with chronic conditions and mobility problems
- Altercations
- Abuse
- Most commonly injured teeth
- Maxillary central incisors
- Protruding teeth
History: important information to get regarding the injury
- Incidents surrounding injury
- Any other injuries
- How long ago the injury occurred
- Last time the patient ate
Physical Examination
Extraoral
- Inspection
- Asymmetry
- Nasal or orbital malalignments
- Lacerations, hematomas, foreign bodies
- Open and close mouth to evaluate for deviation during function
- Lip competency
- Palpation
- TemporoMandibular joint
- Equal movements
- Orbital rim intact
- Nose for crepitus
- Note parasthesias or numbness
Intraoral
- Inspection
- Color and quality of gums and mucosa
- Note hematomas
- Examine teeth
- Color, chips, cracks, bleeding, absent
- Palpation
- Tongue
- Mobility of teeth
- Tooth percussion
Imaging
- Moderate and severe dental trauma
- 4 views: maxillary anterior and 3 periapical
- Facial Series
- Panorex (mandible)
Principles of Management by Type of Injury
Crown Fractures
Ellis Class I
- Minor fracture of the tooth enamel
- Rarely painful
- Does not require immediate treatment
- Rough edges may need filing
Ellis Class II
- Enamel and dentin involvement
- Entry of bacteria into tooth
- Can see yellow or pink color of dentin
- Exposed dentin needs to be covered
- Apply calcium hydroxide paste
- Subsequent composite repair
- Antibiotics
- Prolonged exposure
- Dirty wound
Ellis Class III
- A true dental emergency
- Dental pulp is exposed
- Red tinge or bleeding
- Extremely painful
- Exposed pulp will become infected
- More likely if exposed > 6 hours
- Primary tooth
- May need to extract to prevent further injury
- Permanent tooth
- Calcium hydroxide paste
- Root canal for prolonged exposure
- Antibiotics
Root Fractures
- Crown luxation, pain, excessive mobility, malocclusion
- Confirm location with radiographs
- Primary tooth
- Extraction
- Permanent tooth
- Splint
- Length of splinting depends upon integrity of remaining root fragment
Periodontal Structural Injuries
Concussion
- Trauma to the supporting structures of the tooth
- Inflammation
- No displacement or mobility
- Tenderness to percussion
- No bleeding
- Management same for primary and permanent
- No acute intervention required
- Analgesia as needed
- Need dental follow up to monitor tooth vitality
Subluxation
- Mobility of the tooth without displacement
- Blood may be present in gingival sulcus
- Pain with percussion
- Primary Teeth
- Mobile teeth may need splinting
- Dental follow-up in 24 hours due to potential for pulp necrosis
- Soft diet
- Permanent Teeth
- Possible splinting
- Dental follow-up in 24 hours due to potential for pulp necrosis
- Soft diet
Lateral Luxation
- Displacement of tooth laterally in socket
- Buccal, lingual, labial, or lateral
- Lingual displacement is most common
- Periodontal ligament is torn
- Usually accompanied by alveolar fracture
- Primary Teeth
- Often no intervention necessary
- Passive repositioning
- Gentle repositioning
- Splint or extraction
- Laterally displaced or extreme mobility
- Refer for dental follow-up
- Permanent Teeth
- Immediate dental referral
- Repositioning
- Splinting
Intrusion
- Tooth is driven into socket
- Crown height is shortened
- Periodontal ligament is lacerated
- Bleeding usually present
- Root & alveolar fractures may occur
- Must determine if the tooth is truly intruded and not fractured
- Primary teeth
- Less than 50% intruded
- Will usually re-erupt in 3-4 weeks
- If 100% intruded
- May contact with underlying tooth bud
- Extraction
- Need dental follow up
- Monitor for potential damage to underlying tooth bud
- Dental emergency
- Urgent referral
- Monitor for injury to root structures & neuro-vascular supply
- Allow tooth to re-erupt
- Re-positioning and splinting
Extrusion
- Tooth is vertically displaced out of bony socket
- Periodontal ligament is torn
- Primary Tooth
- Urgent dental referral
- Extract if very mobile or nearly avulsed
- Permanent Tooth
- Immediate dental referral for re-positioning and splinting
Avulsion
- Tooth is completely detached from the socket
- Periodontal ligament severed
- Possible alveolar fracture
- Need to find the tooth!
- Rule out aspiration/intrusion/fracture
- Determine primary vs. permanent
Primary Teeth
- No replacement of tooth
- Children under 6 years of age
- Control bleeding
- Dental referral to evaluate potential injury to permanent tooth bud
Permanent Teeth
- True Dental Emergency
- Time is essential
- Best outcome if < 30 minutes to re-implant
- Viability dependent upon vitality of root
- Goal is to avoid further damage to periodontal ligament cells
- Re-implant tooth immediately
- If delay in re-implantation, place it in transport media
- Hank’s Balanced Salt Solution
- Fresh cold milk
- Saline
- Saliva (buccal vestibule)
- Water
- Minimize handling
- Do not scrub tooth
Extra-oral time < 1 hr:
- Rinse off debris and re-implant
- Immediate splinting by dentist
Extra-oral time > 1 hr:
- Soak in Hank’s Balanced Salt Solution or dental fluoride solution for 20-30 minutes
- Re-implant
- Immediate splinting
Disposition
When to see the dentist immediately
- Ellis II or III
- Root Fracture
- Primary
- 100% intrusion
- Permanent tooth
- Luxation
- Intrusion
- Extrusion
- Avulsion
When to see the dentist within 24 hours
- Ellis I
- Subluxation
- Primary
- Lateral luxation
- Intrusion
- Extrusion
- Avulsion
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