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Pediatric Dental Trauma

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Nick Thome

on 24 March 2016

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Transcript of Pediatric Dental Trauma

Pediatric Dental Trauma
~Nick Thome~ DDS

Patient J.H.
Other Considerations
Initial Management
Where?

When?

How?

Was there a period of unconsciousness?

Is there any disturbance in the bite?

Is there any reaction in the teeth to cold and/or heat exposure?

Significant trauma to the oral-facial region, including the jaw,should be referred to an Emergency Room or oro-facial surgeon for evaluation.

Types of Trauma
&
Management

Concussion
Open Apex in Permanent Dentition
Resorption
Surface



Inflammatory



Replacement (Anklyosis)
1. Irrigate to remove blood and debris and to improve visualization
 
2. Examine soft tissues for edema, tenderness, and lacerations
 
3. Examine bony structures for pain or malocclusion
 
4. Assess patient’s ability to open the mouth and laterally deviate the jaw

5. Examine the tooth ridge for “step-offs”, which can indicate a
fracture of the underlying alveolar bone
 
6. Examine the teeth for tenderness and mobility
 
7. Account for all teeth and determine if injury has occurred to the
primary or permanent dentition

8 Radiographic examination: PA's, Occlusal images
Missing teeth should be accounted for!

Radiographs (soft tissue and chest X-rays) should be done to look
for missing teeth.

Subluxation
Luxations
Fractures


No mobility
No displacement
No gingival bleeding
Pain to percussion



Avulsion

Increased mobility and pain
No displacement of the tooth
Bleeding from the gingival sulcus
Displacement of the tooth
Partial or total separation of the periodontal ligament
Alveolar socket can be involved
Can be intrusive, extrusive, lateral
Common: apex of the tooth has been forced into the bone by the displacement, and the tooth is non-mobile
tooth is completely displaced out of its socket.
7-13% of primary teeth
J
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2015
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2015
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2015
12 year old female J.H.

No established dental home

Trauma to teeth #7-9 and #23-26

Initially seen at Minnesota Dental Care

#7 and 8 re-implanted and semi-rigid splint placed

Given Amoxicillin, Ibuprofen and referral to HCMC pediatric dental clinic

Calcium Hydroxide and Vitrebond placed to cover pulpal exposure of #9

Initial Visit
Comprehensive Treatment Plan
1. Initiate root canal treatment of #7 and 8 with CaOH in canal for 1 month

2. 2 week f/u for vitality testing of all involved teeth

3. Endodontic and oral surgery consult regarding intruded #9 with referral to U of M for orthodontic extrusion

4. Root canal as soon as possible for tooth #9 and definitive restoration (ie. composite vs. custom crown) in the future
Treatment Timeline
12/18-initiation of RCT's #7 and #8

12/28-Sinus tract assoc. #8

1/2-Re-instrumentation and CaOH dressing of #8

1/15-Dr.Leon at UMN Orthodontic clinic

1/18-#7,#8 RCT's finished

2/23-teeth #23-26 non responsive to cold minimal vertical movement of #9

4/2-RCT of #9 with placement of MTA after orthodontic extrusion

teeth #23-26 EPT test: Vital!
No treatment indicated
Soft food diet, 1 week
Monitor for pulp complications
Follow-up 1 week, 6-8 weeks and 1 year

**Permanent tooth: optional semi-rigid splint 2-4 weeks**
No treatment indicated
Soft food diet, 1 week
Monitor for pulp complications
Follow-up: 1 week, 6-8 weeks, 1 year

Reimplantation is NOT recommended for primary dentition
Account for all missing teeth

Soft food for 1 week

Follow-up:1 week, 6-8 weeks, 6 months, and 1 year
**Permanant tooth: reimplantation, 4-6 week splint, tetanus check, antibiotics, RCT w/in 7-10 days for tooth with closed apex
Spontaneous repositioning: If there is no occlusal interference
Repositioning: When there is occlusal interference
Extraction: For teeth with severe displacement
Soft food for 1-2 weeks
Follow-up 1 week, 4 weeks,8 weeks, 6 months, and 1 year
**Permanant tooth: semi-rigid splint 4-8 weeks
Orthodontic, surgical or spontaneous eruptions with RCT w/in 4 weeks**
Ellis Class I (White)-enamel only
Ellis Class II (
Yellow
) enamel and dentin, painful
Ellis Class III (
Red
) involve pulp, painful
Alveolar fracture indication: several teeth typically will move as a unit when mobility is checked.


Treatment:
restorations, pulp cap, partial pulpotomy
Crown/Root fractures: Extraction
Alveolar fractures: Reposition, Stabilize the segment with splint for 4 weeks. Monitor teeth in the fracture line
Follow-up 1 week, 3-4 weeks 6-8 weeks and 1 year then yearly until exfoliation

**Permanant dentition: above treatment, RCT, extrusion, decoronation
MEDICAL AND DENTAL HISTORY
CLINICAL EXAMINATION
AVULSION MANAGMENT
Inspect tooth for debris

Cleanse with milk, saliva, saline

Re-implant tooth and apply pressure
Storage:
Hank's balanced salt solution
Milk
Water
Vestibule/Under tongue
THANK YOU!
REFERENCES
ORTHODONTIC TREATMENT PLAN
Initial Plan: Orthodontic extrusion with palatal holding arch and hook for elastic attachment w/ 1mm of movement per week

Alteration: Banding U6's and bracketing U3's with labial archwire (rectangular 16x22 SS)

Ballista loop (NiTi) appliance for vertical movement & mesial root tipping

Activated NiTi archwire for extrusion using CEJ as reference point

Lingual retainer for 6 months to 1 year

Guideline on Management of Acute Dental Trauma. AAPD Reference Manual 2007;Vol 30(7): 175- 183.

Flores et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66–71.

Flores et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dental Traumatology 2007; 23: 130–136.

Flores et al. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dental Traumatology 2007; 23: 196–202.

Kazemi, H.R. (2014). A Road to Managing Dental Trauma with Predictable Results [Powerpoint slides]. Received from www.slideshare.net/drkazemi/ppt

Management of Dental Trauma in children. Information on emergencies, Paediatrics Dental Health,2008.
AVULSED TOOTH
EOT < 60min; monitor for 3-4 months, if pathology observed; apexification

EOT >60min; start apexification immediately

Evaluate every 3-4 weeks

Goal:
Allow for possible revascularization of immature tooth

*The longer the EOT, the higher the change of devitalization of the tooth and periodontium
Dental injuries are very common in the pediatric population

Occurs most often during 2-4 years old.

Dental injuries become common again at ages 8-10 years old

Overall, tooth injury is more common in males (2:1 ratio)

Almost half of all children will incur some type of tooth damage by the time they reach adolescence

Luxations and fractures are the most common

Anterior teeth are the most involved
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Special thanks to:
HCMC Dental Assistants
Dr. Avendano
Dr. Fulling
Dr. Jithendranathan
Dr. Leon Salazar
Dr. Zarbano

Dr. Zarbano
Dr. Jithendranathan
Dr. Fulling
&
Dr. Avendano
Removal of PDL
Saucer shaped cavity
Lateral Luxations
Related to infection
Loss of tooth if not treated
Damage to PDL
Anchored to alveolar socket
Adolescents: rapid loss (1-5 years)
Adults: may remain functional
Full transcript