Primary Trauma

Question 1

Do you feel confident you can identify all 3?
a: E - ED - EDP (complicated crown fracture)

Answer 1

Yes or no

Question 2

Crown root fracture

Answer 2

Involves crown and root and is either complicated or uncomplicated (pulp involved or not)

Question 3

Concussion

Answer 3

Tooth tender to touch but has not been displaced

Question 4

Subluxation

Answer 4

Tooth tender to touch, has increased mobility, but has not been displaced

Question 5

Lateral luxation

Answer 5

Tooth displaced

Usually in a; palatal/lingual or labial direction

Question 6

Intrusion

Answer 6

Tooth usually displaced through the labial bone plate or it can impinge on the permanent tooth bud

Question 7

Extrusion

Answer 7

Partial displacement of tooth out its socket

Question 8

Avulsion

Answer 8

Tooth completely out of socket

Question 9

Alveolar fracture

Answer 9

Fracture involves the alveolar bone and may extend to the adjacent bone

Question 10

Most common injury in primary dentition

Answer 10

Luxation injury

Question 11

Trauma management

Answer 11

1. Reassurance
2. History
   a. Injury
   - when, where, how
   -any other symptoms/injuries
   -any lost teeth/fragments
   b. Medical History
   (not CI but may need appropriate extra management)
   -congential heart disease
   -rheumatic fever or immunosuppression
   -bleeding disorders
   -allergies
   -tetanus immunisation status
   c. Dental Hx
   -previous trauma
   -treatment experience
   -legal guardian
   -child attitude/cooperation
3. Examination (rule out facial/jaw fractures!)
   -E/O; lacerations, haematoma, haemorrhage, subconjunctival haemorrhage, bony step deformities, mouth opening
   -I/O; soft tissues, alveolar bone, occlusion, teeth
4. SI
   -trauma stamp
   -radiographs; periapical, anterior occlusal, lateral pre-maxilla, panoramic, soft tissue
5. Diagnosis; soft tissue and hard tissue diagnosis

Question 12

Supporting tissue injuries

Answer 12

Concussion
Subluxation
Lateral luxation
Intrusion
Extrusion
Avulsion
Alveolar fracture

Question 13

Hard tissue injuries

Answer 13

E
ED
EDP
C-R
R # (fracture)

Question 14

Emergency tx homecare advice

Answer 14

Analgesia
Soft diet 10-14 days
Brush teeth with soft toothbrush after every meal
Topical chlorhexidine gluconate 0.12% mouthrinse applied topically twice daily for one week
Warn against signs of infection; (swelling, pain, discoloration)

Question 15

E fracture

Answer 15

Smooth sharp edges

Question 16

ED fracture

Answer 16

Cover exposed dentine with GI or composite

Restore lost tooth structure with composite (immediately or at later visit)

Question 17

EDP fracture

Answer 17

Partial pulptotomy
Or
Extract

Question 18

C-R fracture

Answer 18

Remove any loose fragments and then determine if crown can be restored

A: if restorable
-no pulp exposed: cover exposed dentine with GI
-pulp exposed: pulpotomy or endodontic treatment

B: If unrestorable
- Extract loose fragments
- Don’t dig

Question 19

R fracture

Answer 19

Coronal fragment not displaced
- no treatment

Coronal fragment displaced but not excessively mobile
- leave Coronal fragment to spontaneously reposition even if some occlusal interference

Coronal fragment displaced, excessively mobile and interfering with occlusion
Option A: Extract only the loose Coronal fragment
Option B: reposition the loose Coronal fragment (+/- splint)

Question 20

Concussion tx

Answer 20

No treatment

Just observation

Question 21

Subluxation

Answer 21

No treatment

Just observation

Question 22

Lateral luxation

Answer 22

(If) minimal/ no occlusal interference: allow to reposition spontaneously

(If) severe displacement: extraction or reposition (+/- splint)

Question 23

Intrusion

Answer 23

Allow to spontaneously reposition irrespective of direction of displacement

Question 24

Intrusion radiograph

Answer 24

Periapical or lateral premaxilla (extra-oral film)

To determine direction of displacement, assess danger to permanent tooth and thus allow better counselling re - prognosis

Displacement is one of two ways:
Apex toward labial bone plate
(Tooth appears shorter compared to contralateral tooth and apical tip can be seen)
Apex toward permanent tooth germ
(Apex of intruded tooth cannot be visualised and tooth appears elongated compared to contralateral)

Question 25

Extrusion tx

Answer 25

If not interfering with occlusion, allow spontaneous repositioning If there's excessive mobility or the tooth is extruded >3mm Then extract

Question 26

Avulsion tx

Answer 26

Take radiograph to confirm avulsion Do not replant! (primary)

Question 27

Alveolar fracture tx

Answer 27

-Reposition segment -Stabilise with a flexible splint to the adjacent uninjured teeth for 4 weeks -teeth may need to be extracted after alveolar stability has been achieved

Question 28

Review trauma

Answer 28

Up to at least 5 years (IADT guidelines for each)

Question 29

Trauma complications

Answer 29

Warn parents of possible pathology to; traumatised primary tooth and the permanent successor Primary tooth; discoloration, discoloration and infection, delayed exfoliation Discoloration + asymptomatic (vital or non-vital) mild grey, yellow (pulp obliteration) No signs of pulp necrosis/infection then no treatment and review Discoloration and infection (symptomatic, non-vital): -sinus -gingival swelling -abscess -increased mobility -radiographic evidence of periapical pathology -TX: extract or endo tx Delayed exfoliation; consequences to developing occlusion -intrusion causes most disturbances Developing permanent tooth injuries; enamel defects, dilaceration, delayed eruption, ectopic tooth position, arrested development, complete failure of tooth to form, odontome formation

Question 30

Enamel hypomineralisation (+ tx)

Answer 30

Normal thickness but poorly mineralised Nothing, tooth whitening or composite masking +/- localised removal

Question 31

Enamel hypoplasia (+ tx)

Answer 31

Reduced thickness but normal mineralisation No treatment/ composite masking

Question 32

Dilaceration

Answer 32

Abnormal crown/root morphology Crown/root does not follow long axis of the tooth

Question 33

Dilaceration management

Answer 33

Crown dilaceration options: surgical exposure and orthodontic realignment or improve aesthetics restoratively Root dilaceration options: combined surgical and orthodontic approach

Question 34

Delayed eruption

Answer 34

Take a radiograph if >6 months compared to contralateral tooth Surgical exposure and orthodontic alignment may be required Premature loss of a primary tooth can result in delayed eruption of around 1 year due to thickened mucosa

Question 35

Ectopic tooth position

Answer 35

Options: - Surgical exposure and orthodontic realignment - Extraction

Question 36

Dull percussion note

Answer 36

May indicate root fracture

Question 38

Traumatic occlusion

Answer 38

Demands urgent tx

Question 39

Trauma sensibility testing

Answer 39

For at least 2 years after an injury

Question 40

Trauma prognosis factors

Answer 40

Stage of root development (Mature/immature) Presence of infection (Yes/no) Type of injury (Hard and supporting tissue) Is PDL damaged aswell (Yes or no) Time between injury and tx

Question 41

Emergency trauma case principles

Answer 41

-aim to retain vitality -treat exposed pulp tissue -reduction and immobilisation of displaced teeth -tetanus prophylaxis -antibiotics?

Question 42

Intermediate aims of trauma cases

Answer 42

+/- pulp treatment Restore hard tissues