Title Page
Copyright Page
Foreword
Chapter 1 History, Examination, Diagnosis and Treatment Planning
Aim
Outcome
Introduction
Aetiology
Classification
History and Examination
Dental History
Medical History
Extraoral Examination
Intraoral Examination
Radiographic Examination
Periapical
Occlusal
Photographic Examination
Treatment Planning
Record Keeping
Behaviour Management of Trauma Cases
Key Points
Further Reading
Chapter 2 Prevention
Aim
Objective
Introduction
Primary Prevention
Playground Surfaces
Early (Mixed Dentition) Treatment of Large Overjets
Provision of Mouth Protection in Sports
Criteria for Mouthguard Construction
Mouthguard Design
Types of Mouthguards
Mouth-formed
Custom-made
Care of Mouthguards
Life of Mouthguards
Special Considerations in Mouthguard Design
Secondary Prevention
Tertiary Prevention
Key Points
Further Reading
Chapter 3 Intraoral Soft Tissue Injuries
Aim
Outcome
Aetiology
Diagnosis
Treatment
Specific Injuries
Lips
Fraenum
Mucosa
Palate, soft palate and fauces
Tongue
Floor of mouth
Gingiva
Non-accidental injury – physical child abuse
Prognosis
Key Points
Further Reading
Chapter 4 Primary Dentition Injuries
Aim
Outcome
Aetiology
Diagnosis
Treatment
Soft Tissue Injuries
Tooth Injuries
Crown and Root Fractures
Uncomplicated crown fracture
Complicated crown fracture
Crown-root fracture
Root fracture
Concussion, Subluxation, and Luxation Injuries
Concussion
Subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation
Exarticulation (avulsion)
Assessment and Review
Complications Involving Primary Teeth
Pulpal Necrosis
Pulpal Obliteration
Root Resorption
Injuries to the Developing Permanent Tooth
Treatment Options for Injuries to the Permanent Dentition Secondary to Primary Dentition Injuries
Yellow-brown discoloration of enamel with or without hypoplasia:
Crown dilaceration
Vestibular root angulation
Odontoma malformation, root duplication, arrest of root development
Disturbance in eruption
Injuries to Supporting Alveolar Bone
Prognosis
Key Points
Further Reading
Chapter 5 Permanent Dentition: Uncomplicated Crown and Crown-root Fractures: Infractions, Enamel Fractures, Enamel-dentine Fractures, Enamel-dentinecementum Fractures
Aim
Outcome
Aetiology
Diagnosis
Treatment
Infractions
Enamel Fractures
Enamel-dentine Fractures
Enamel-dentine-cementum Crown Root Fractures (not involving pulp)
Assessment and Review
Prognosis
Key Points
Further reading
Chapter 6 Permanent Dentition: Complicated Crown Fractures: Enamel-dentine-pulp Fractures, Enamel-dentine-pulp-root Fractures
Aim
Outcome
Aetiology
Diagnosis
Treatment
Enamel-dentine Pulp Fractures
Vital Pulp Therapy
Non-vital Pulp Therapy
Vital pulp therapy – pulp capping
Pulp capping – assessment and review
Vital pulp therapy – pulpotomy
Technique (Fig 6-2)
Pulpotomy – assessment and review
Non-vital pulp therapy – pulpectomy
Technique (Fig 6-3)
Pulpectomy – assessment and review
Techniques for Obturation
Cold Lateral Condensation Obturation (Figs 6-4b and 6-5)
Thermoplastic Obturation (Fig 6-4b)
Alternatives to the Root-end Closure Procedure
Complicated Crown-root Fracture (Involving Pulp)
Prognosis
Key Points
Further Reading
Chapter 7 Permanent Dentition: Root Fractures and Splinting
Aim
Outcome
Aetiology
Diagnosis
Treatment
Complicated Crown-root Fracture
Root Fracture
Extraction of the coronal fragment and retention of the remaining root
Internal splinting
Extraction of the two fragments
Assessment and Review
Prognosis for Root Fractures
Splinting
Types and Methods of Constructing Splints
Composite resin/acrylic and wire splint
Approximal composite/acrylic resin splint
Orthodontic brackets and wire
Foil/cement splint
Technique
Laboratory splints
Key Points
Further Reading
Chapter 8 Permanent Dentition: Concussion, Subluxation, Lateral Luxation, and External Resorption
Aim
Outcome
Aetiology
Diagnosis
Treatment
Concussion and Subluxation
Pulpal Necrosis and Root Resorption
Lateral Luxation
Pulpal Necrosis and Root Resorption
Assessment and Review
Prognosis for Luxation Injuries
Resorption
Surface (transient) root resorption
External inflammatory resorption
External replacement resorption (ankylosis)
Key Points
Further Reading
Chapter 9 Permanent Dentition: Intrusive and Extrusive Luxations
Aim
Outcome
Intrusive Luxations
Aetiology
Diagnosis
Treatment
Open Apex
Follow-up management
Closed Apex
Follow-up management
Pulpal Necrosis and Root Resorption
Assessment and Review
Extrusive Luxations
Aetiology
Diagnosis
Treatment
Pulpal Necrosis and Root Resorption
Assessment and Review
Key Points
Further Reading
Chapter 10 Permanent Dentition: Avulsion and Reimplantation
Aim
Prognosis
Aetiology
Diagnosis
Treatment
Extra-alveolar Dry Time (EADT) <1 hour
Advice on phone (to teacher, parent, etc.)
Treatment
Review
Extra-alveolar Dry Time (EADT) > 1 hour
Treatment
Review
Prognosis of Reimplanted Teeth
Key Points
Further Reading
Chapter 11 Permanent Dentition: Dento-alveolar Fractures
Aim
Prognosis
Aetiology
Diagnosis
Treatment
Pulpal Necrosis and Root Resorption
Assessment and Review
Prognosis for Dento-alveolar Fracture Injuries
Key Points
Further Reading
Chapter 12 Child Physical Abuse
Aim
Objectives
Introduction
Prevalence
Aetiology
Identification
Types of Orofacial Injuries in Child Physical Abuse
Bruising
Human hand marks
Bizarre bruises
Abrasions and lacerations
Burns
Bite marks
Tooth trauma
Eye injuries
Fractures
The Role of the Dental Professional in Child Protection
Key Points
Further Reading
Quintessentials of Dental Practice – 24
Endodontics – 3
British Library Cataloguing-in Publication Data
Welbury, Richard
Managing dental trauma in practice. - (Quintessentials of dental practice; 24. Endodontics; 3)
1. Teeth -Wounds and injuries 2. Periodontium - Wounds and injuries 3. Dental therapeutics 4. Traumatology
I. Title II. Gregg, Terry
617.6′044
ISBN 1850973407
Copyright © 2005 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN 1-85097-340-7
Dental trauma is invariably distressing and painful for the patient, and a challenge for the clinicians to manage in such a way as to give the best possible opportunity of a good, aesthetically pleasing medium to long term clinical outcome. Managing Dental Trauma in Practice, Volume 24 in the highly rated Quintessentials series, is a most welcome addition to the current dental literature. In common with all other volumes in the series, this book has been planned and prepared as a succinct, easy-to-read, well-illustrated text, convenient for practitioners and students wishing to update their knowledge and understanding in a specific aspect of clinical practice. The extensive guidance on diagnosing and treating different forms of dental trauma is both up to date and of immediate practical relevance. In addition, this book is not just about managing traumatised teeth, great emphasis is placed on the comprehensive care of patients and their damaged teeth, following trauma involving the dentition and associated soft tissues. The inclusion of a chapter on the part dentists may play in identifying cases of child abuse is especially welcome.
The management of dental trauma will continue to be an integral element of everyday clinical practice, fuelled, amongst other factors, by increasing violence in society and individuals of an ever-increasing age range risking dental trauma in sporting and other physical activities. As a consequence, practitioners will need to continue to be abreast of current thinking in the management of dental trauma. This book is targeted to meet this need.
Nairn Wilson
Editor-in-Chief
Dedicated to Peggy and Heather
To provide a framework for assessing patients presenting after trauma.
After studying this chapter the reader should have a raised awareness of trauma aetiology, and be able to assess patients who have suffered trauma.
This book largely focuses on children in whom the majority of dental injuries occur and where management is evidence-based. However, most issues also translate to the management of trauma to permanent teeth in older people.
Trauma to children’s teeth occurs quite frequently. Previous studies in the UK (Todd and Dodd, 1985) suggested that the incidence of trauma to teeth was increasing, but more recent studies have indicated a fall in incidence (O’Brien, 1994). It is suggested that this may be related to a more sedentary lifestyle for children, with less active participation in organised sport and more recreational interest in computer games. It is evident from the world literature however that dental trauma is a global entity. At the age of five years some 31–40% of boys and 16–30% of girls will have suffered dental trauma. By the age of 12 years, the corresponding figures are 12–33% of boys and 4–19% of girls. Traumatic injuries are twice as common in boys in both the permanent and the primary dentitions.
The majority of dental injuries in the primary and permanent dentitions involve the anterior teeth – in particular, the maxillary central incisors. The mandibular central incisors and maxillary lateral incisors are less frequently involved. Concussion, subluxation, and luxation are commonest in the primary dentition, while uncomplicated crown fractures are commonest in the permanent dentition.
The most accident-prone times are between two and four years for the primary dentition and seven and 10 years for the permanent dentition. In the child in the primary dentition, coordination and judgement are incompletely developed and the majority of injuries are due to falls in and around the home – in particular as the child becomes more adventurous and explores its surroundings. In the permanent dentition most injuries result from falls and collisions while playing and running, although bicycles are a common accessory. The place of injury varies in different countries, according to local customs, but accidents in the school playground remain common.
Sports injuries usually occur in teenage years and are commonly associated with contact sports such as soccer, rugby, ice hockey and basketball.
Injuries related to road traffic accidents and assaults are most commonly associated with the late teenage years and adulthood, and are often closely related to alcohol abuse.
One form of injury in childhood that must never be forgotten is child physical abuse or non-accident injury (NAI). This topic will be covered in Chapter 12.
The exact mechanisms of dental injuries are largely unknown and without experimental evidence, but injuries can be the result of either direct or indirect trauma. Direct trauma occurs when the tooth itself is struck. Indirect trauma is seen when the lower dental arch is forcefully closed against the upper, e.g. a blow to chin. Direct trauma implies injuries to the anterior region, while indirect trauma favours crown or crown-root fractures in the premolar and molar regions, as well as the possibility of jaw fractures in the condylar regions and symphysis. The factors which influence the outcome, or type of injury, are a combination of:
energy of impact
resilience of impacting object
shape of impacting object
angle of direction of the impacting force.
Increased overjet, with protrusion of upper incisors, and insufficient lip closure are significant predisposing factors to traumatic dental injuries. Injuries are almost twice as frequent among children with protruding incisors. The number of teeth affected in a particular incident is also increased by an increased overjet.
The second major group of children predisposed to traumatic injuries are the accident-prone. These children sustain repeated trauma to their teeth. Frequencies have been reported to range from 4–30%.
Another group that has recently been shown to have a higher incidence of dental injuries are those children who are overweight. It is thought that the cause is their lack of athleticism during falling.
The classification of dento-alveolar injuries based on the World Health Organization (WHO) system is summarised in Table 1-1.
| Injuries to the hard dental tissues and the pulp | |
| Enamel infraction | Incomplete fracture (crack) of enamel without loss of tooth substance |
| Enamel fracture | Loss of tooth substance confined to enamel |
| Enamel-dentine fracture | Loss of tooth substance confined to enamel and dentine not involving the pulp |
| Complicated crown fracture | Fracture of enamel and dentine exposing the pulp |
| Uncomplicated crown-root fracture | Fracture of enamel, dentine, and cementum but not involving the pulp |
| Complicated crown-root fracture | Fracture of enamel, dentine, and cementum and exposing the pulp |
| Root fracture | Fracture involving dentine, cementum and pulp. Can be subclassified into: apical, middle and coronal (gingival) third |
| Injuries to the periodontal tissues | |
| Concussion | No abnormal loosening or displacement but marked reaction to percussion |
| Subluxation (loosening) | Abnormal loosening but no displacement |
| Extrusive luxation (partial avulsion) | Partial displacement of tooth from socket |
| Lateral luxation | Displacement other than axially with comminution or fracture of alveolar socket |
| Intrusive luxation | Displacement into alveolar bone with comminution or fracture of alveolar socket |
| Avulsion | Complete displacement of tooth from socket |
| Injuries to supporting bone | |
| Comminution of mandibular or maxillary alveolar socket wall | Crushing and compression of alveolar socket. Found in intrusive and lateral luxation injuries |
| Fracture of mandibular or maxillary alveolar socket wall | Fracture confined to facial or lingual/palatal socket wall alveolar socket wall |
| Fracture of mandibular or maxillary alveolar socket wall | Fracture of the alveolar process, which may or may not involve the tooth sockets alveolar process |
| Fracture of mandible or maxilla | May or may not involve the alveolar socket |
| Injuries to gingival or oral mucosa | |
| Laceration of gingival or oral mucosa | Wound in the mucosa resulting from a tear |
| Contusion of gingival or oral mucosa | Bruise not accompanied by a break in the mucosa, usually causing submucosal haemorrhage |
| Abrasion of gingival or oral mucosa | Superficial wound produced by rubbing or scraping the mucosal surface |
A history of the injury followed by a thorough examination should be completed in any situation.
When did the injury occur? The time interval between injury and treatment significantly influences the prognosis of avulsions, luxations, crown fractures with or without pulpal exposures, and dento-alveolar fractures.
Where did the injury occur? May indicate the need for tetanus prophylaxis.
How did the injury occur? The nature of the accident can yield information on the type of injury expected. Discrepancy between history and clinical findings raises suspicion of child physical abuse.
Lost teeth/fragments? If a tooth or fractured piece cannot be accounted for when there has been a history of loss of consciousness then a chest X-ray should be obtained to exclude inhalation.
Concussion, headache, vomiting or amnesia? Brain damage must be excluded, with referral to a hospital for further investigation being organised as indicated.
Previous dental history? Previous trauma can affect pulp sensitivity tests and the recuperative capacity of the pulp and/or periodontium.
Is the child injury prone or are there suspicions of child physical abuse?
Previous treatment experience, age, and parental/child attitude will affect the choice of treatment.