Pediatric Trauma: Free INBDE Prep Course
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The optimal treatment of dental trauma depends on many variables. Dental trauma is more commonly seen in male patients (2:1), and is more commonly associated with certain dental/skeletal profiles (e.g. Class 2 Div 1, with increased overjet). Trauma to the primary dentition may affect adult teeth which develop in close proximity to deciduous tooth roots. Dental trauma is common. By the age of 14, 30% of children have experienced trauma to their baby teeth, and 22% will have experienced trauma to their permanent teeth.
POSSIBILITY RESULTS OF DENTAL TRAUMA
- Pulpal hyperemia – may lead to ischemia and subsequent necrosis due to an increase in intrapulpal pressure.
- Internal hemorrhage – may be clinically visible as discoloration, potentially appearing weeks after the injury.
- Pulpal calcification, pulp chamber/canal obliteration (PCO) – radiographically the pulp chamber and canal system can appear partially or totally filled. The pulp often remains vital. Clinically this causes a yellow, opaque discoloration.
- Internal resorption – activation of osteoclastic activity from within the pulpal tissue leading to a “hollowing out” of the pulp chamber or canals. Externally this can sometimes be seen as a “pink spot” lesion when the hard structures are thinned out.
- Peripheral root resorption – damage of the cementum layer inside the periodontal ligament space causes a similar activation of osteoclastic activity. More likely in severe injury like lateral luxation or intrusion. External resorption can be further classified:
- surface resorption – radiographically normal PDL, occurs in small localized areas.
- replacement resorption – PDL space is eliminated, resorption plus the deposition of new bone, leading to ankylosis.
- inflammatory resorption – resorption plus ingress of granulation tissues. Radiographic radiolucency.
- Pulpal necrosis – damage to the pulpal blood flow leads to ischemia and pulpal necrosis. More likely in mature teeth with closed apices. It is useful knowing when each root finishes developing (see CALCIFICATION AND ERUPTION TIMES).
- Ankylosis – a fusion of the bone and tooth surface, often clearly visible by the difference in height of the teeth (ankylosed teeth is infra-occluded).
If the primary tooth is injured, it is possible to see hypocalcification, hypoplasia, or dilaceration in the adult tooth. The succedaneous adult tooth usually sits lingual to its deciduous counterpart, so damage is likely on the labial surface. When a fractured tooth presents with lip laceration you should check the soft tissue for a foreign body. If there is a piece of tooth embedded in the soft tissue a radiograph at one quarter exposure should pick it up.
TRAUMA ASSESSMENT
The following is the suggested patient assessment for a trauma case.
- Medical history – including any medications, drug sensitivities, cardiac or coagulation problems etc.
- Tetanus status – may need an antitoxin if not covered, or booster if immunization is outdated. A booster is usually needed every 4 or 5 years after age 10.
- Neurological assessment – take note whether there was a loss of consciousness, nausea, vomiting, drowsiness, amnesia or blurred vision. Assess any head or neck pain or paraesthesia. If there is doubt, refer to the emergency room.
- Dental history – the what, where and why regarding dental trauma.
- General assessment – check for fractures, review the occlusion to see if something has shifted. Check mobility, percussion, discoloration, swelling, pain, bleeding, soft tissue damage etc.
- Radiographs – taking note not only of the injured tooth but neighbors and opposing teeth.
- Diagnostic tests – thermal and electric vitality could be unreliable in deciduous teeth.
DENTAL INJURY CLASSIFICATION AND TREATMENTS
An injury to the tooth can be classified according to the extent of damage to the periodontal ligament, supporting structures and blood supply.
- A (dental) concussion is an injury to the periodontal ligament space (PDL) without any displacement or mobility.
- In the case of subluxation there is mobility but no displacement, with possible bleeding from the gingival sulcus. Treatment is usually not required, though if the tooth is very mobile or causing discomfort it can be splinted (for a maximum of 2 week). A soft diet is recommended for about a week to avoid traumatizing the soft tissue, and maintaining good oral hygiene is important. A chlorhexidine or hydrogen peroxide rinse will help. Normal recall.
- A lateral luxation injury sees the tooth displaced in a non-axial direction. The PDL is torn, there is often bleeding from the gingival sulcus, and depending on the size of displacement, can present with alveolar fracture. The tooth is usually not mobile, with increased periodontal space. For deciduous teeth that have been displaced, it would be best to allow it to passively reposition. Though this might not be possible due to patient discomfort, in which case extraction is likely the best option. An adult tooth should be repositioned under local anesthesia as quickly as possible and stabilized with a splint for 2-4 weeks (longer if a bony fracture has occurred). There is a high risk of pulpal complications and root resorption.
- Intrusion describes a luxation injury where the tooth is displaced into the socket. If a baby tooth is intruded it may damage the developing adult tooth. There has been debate about whether to leave this tooth and allow it to erupt again, or remove it. Probably best to leave it be, unless the primary tooth was displaced into the developing follicle above it, in which case the tooth should be extracted. An intrusion injury to an adult tooth often causes irreversible pulpal trauma. There is a high risk of an associated crushing bony fracture. The adult tooth is often freed, manipulated and splinted (3 weeks) into its original position under local anesthetic. Root therapy treatment is started after 3 weeks.
- Extrusion injuries often lead to extensive damage to the supporting structure of the tooth. If a baby tooth is extruded the long term prognosis is poor and it should be removed. If a permanent tooth is extruded, it can be replaced and splinted (3 weeks) similar to an intrusion injury. There is a high risk of pulpal necrosis.
- In the case of a tooth avulsion, treatment is highly dependent on the status of the cells on the outside of the tooth root surface. The time the tooth spent outside the mouth and medium it was kept in will determine what to do. For extra-oral time of less than 30 minutes, replantation, splint (1-2 weeks), soft diet and antibiotics. The tooth has the best chance of success if stored in a medium like Viaspan, Hank’s solution, cold milk, saliva (isotonic), or saline. Root canal therapy will be required but resorption may be avoided. Primary teeth are not replaced if avulsed.
An injury can be classified according to the damage to tooth structure.
- Uncomplicated enamel fractures (Ellis Class I) only involve the outer enamel area. It is appropriate to simply smooth the area, but patients may demand a small aesthetic restoration. Follow up appointments at 1, 2 and 6 months due to possible concussive injury.
- Uncomplicated enamel-dentin fractures (Ellis Class II) do not involve the pulp, and are either polished or more commonly restored with a direct restoration. It is possible to recement the lost portion of the tooth back on after rehydrating it.
- Complicated enamel-dentin fractures (Ellis Class III) involve the pulp. For deciduous teeth with vital pulp tissue, pulpotomy and restore. For necrotic pulp, extirpation or extraction. For an adult tooth, the treatment depends on the status of the pulp. A direct pulp cap or partial pulpotomy are options, but routine root canal may be required. Cryotherapy also appears promising (sterile shaved ice over tooth before pulpal therapy).
- Root fractures (Ellis class IV) on primary teeth are rare (flexible bone), and extraction would be the treatment of choice. In the case of permanent teeth treatment depends on the size, position, and extent of the fracture, as well as the health of the pulp above and below the fracture. If the entire crown is lost, the restorability of the tooth may be questionable.
Primary teeth may discolor after an injury, but 80% of primary teeth that discolor continue to be asymptomatic. No treatment is required. Dental trauma is further explored in the module Endodontics.
Splinting is used to stabilize one or multiple teeth that are mobile or have been displaced after trauma. It is important to use non-rigid splints that permit a little movement to avoid ankylosis. Light gauge stainless steel orthodontic wire (0.016 x 0.022) or 0.018 round wire, monofilament nylon, or resin reinforced fibers are all appropriate. The wire must be passive and is usually bonded with composite or flowable composite. For dental injuries a splint is removed after 7-14 days. For cases that include alveolar fracture, 3-4 weeks. In the case of a root fracture, a rigid heavy gauge wire (0.032 to 0.036) is used, and the splint remains for 2-3 months.
A follow up assessment should be made at predetermined intervals after the traumatic incident, usually 1, 2 and 6 months. A clinical assessment is completed which includes testing mobility, percussion, presence of discoloration, pain, swelling, vitality testing, and a radiographic assessment.
PEDIATRIC MANDIBULAR FRACTURE
20-50% of all childhood fractures are mandibular fractures. They are more common in boys. These patients could also have intra-abdominal, neurocranial, or orthopedic injuries. As the child ages, the likelihood of fracturing the condyle decreases, and likelihood of fracturing the body or angle of the mandible increases. If a mandibular fracture is diagnosed in a pediatric patient it is likely treated conservatively (most likely a greenstick fracture). This prevents muscular atrophy, ankylosis, and allows for better oral hygiene. Surgical treatment options include various splinting techniques (e.g. interdental wiring) or open reduction and internal fixation (plates, screws).
