Transcript Pediatric Trauma - updated - Clinical Jude

History
 1. Patient name, age etc
 2. When did the occur?
 3. Where did injury occur?
4. How did injury occur?
5. Previous treatment
History
 6. Medical history
 7. Subjective complaints:
 a. Did trauma causes amnesia, un-con. vomiting or headache.
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b. Is there any disturbance in bite which imply: tooth luxation,
alveolar fracture , jaw fracture, or fracture of the TMJ.
c. Reaction to thermal or other stimuli.
Clinical examination :
Provides all information necessary to make correct
diagnosis and design an appropriate treatment plan
 Before initiating the C.E. the areas should
be cleaned of all debris and blood.
Clinical Examination should
include:
 1: Injury to the soft tissues. (Intra & Extra)
 2: Presence of foreign material or tooth
structure.
2: Presence of foreign material or
tooth structure
Clinical Examination should
include
 3: Bony fracture
 4: Hemorrhage into floor of the mouth J Fra.
 5: Cracks and Craze lines, fracture, pulp
exposure
 6: Displacement of the tooth in any direction
Clinical Examination should
include:
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7: Abnormal, horizontal and vertical mobility.
8: Injury to PDL.
9: Abnormalities in the occlusion.
10: Percussion test
11: Reaction of teeth to sensibility testing:
11: Reaction of teeth to sensibility testing:
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1. Heat
 2. Cold, ethyl chloride, carbon dioxide snow -78,
dichlorodifluoromethane -28.
 3. Electric pulp tests:
 Before initiating vitality testing, the following factors should be
considered:
 A. erupting non-injured teeth
 B. testing should be conducted away from the gingival area
 C. splinted and crowned teeth.
 D. since pt. adapt sustained E C, pain threshold should be determined
by rapid, steady increase in current rather than slow, gradual increase.
Radiographic Examination
1. Four films
Some points to be considered
 1. Four films
 2. Fracture Line are usually obliquely positioned.
10-15 apical or coronal.
 3. A bend in a film Tracing P ligament around the
root.
 4. After six week another x-ray.
Root Fracture
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Complex healing pattern, E,D,P,C,PDL
After age of 10 years ( incomplete root, resilient supportive structure )
Types of fracture
Healing events depends on :pulp cut off, bacteria invasion
Types of healing events
Treatment include repositioning and splinting
Prognosis depends on degree of displacement of the coronal fragment
and the stage of root development
Concussion and Subluxation
 Concussed Tooth is tender to percussion due to edema and
Hemorrhage in PDL
 Subluxated Tooth is tender to percussion and abnormally loose due to
rupture of PDL , gingival hemorrhage around the gingival margin
 Treatment:
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adjustment of occlusion
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soft diet
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splinting for the comfort of the pat. Does not prompt healing
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repeated sensibility testing
Extrusive luxation
 E xtrusive Luxation :Partial displacement of the tooth out of its socket
 X-ray: revealed increased P L space at peri-apical region
 Clinical findings:
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extrusive tooth appear elongate
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bleeding from PL
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percussion is dull
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increase mobility
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tenderness to percussion
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sensibility test is -ve
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pulp necrosis 15%-59%
Lateral Luxation
 Lateral lux: eccentric displacement of the tooth accompanied with
comminuted fracture or fracture of the alveolar socket
 X-ray findings: reveals P space apically only by occlusal view
 Clinical findings:
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crown displaced palataly
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usually of socket wall and root apex locked
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percussion test metallic sound
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little mobility
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pulp necrosis 58%
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temporary breakdown of the marginal bone within 2-4 weeks, extend
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splinting 2 months
Intrusion Luxation
 Displacement of the tooth deeper into the alveolar bone with
comminuting or fracture of the alveolar bone.
 Clinical findings:
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the affected tooth appears shorter than the contra lateral tooth
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high metallic sound in percussion
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no mobility
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x-ray: PL space partially or totally disappears
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pulp necrosis 63% in immature teeth and 100% in mature ones.
Diagnosis
Treatment
Concussion −Tooth is tender to percussion(TTP) but is
not displaced or mobile; no radiographic abnormalities.
Monitor pulpal status for 1 year.
Subluxation −Tooth is TTP and has increased mobility
but is un-displaced. Radiographic abnormalities not
normally found.
Flexible splint for up to 2 weeks.
Extrusive Luxation –Tooth displaced axially out of
alveolar bone with mobility monitor pulpal status. but
still retained within socket. Radio-graphically tooth
appears elongated with increased apical PDL space.
Reposition, flexible splint for 2 weeks,
Lateral Luxation –Tooth is horizontally displaced,
usually in palatal/lingual direction. Immobile, and usually
gives high, metallic note on percussion.
Reposition with finger pressure, disengaging from bony lock
with forceps applied to the crown if required, flexible splint
for 4 weeks, monitor pulpal status.
Intrusive Luxation –Tooth displaced axially into
alveolar bone. Tooth is immobile and may give high,
metallic sound on percussion. PDL space may be
absent from all or part of the root on radiographs. Can
be subdivided into mild, moderate and severe intrusion
Incomplete root formation − Allow spontaneous reeruption; if no movement in 3 weeks, rapid orthodontic
repositioning. Complete root formation − Reposition
orthodontically or surgically as soon as possible. Extirpate
and dress with non-setting calcium hydroxide paste.
avulsion
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Maxillary incisors (prominent)
Children 7-10 years old
Success rate 4-50%
Two important aspects in the successful treatment:
A. the condition under which the tooth has been preserved.
B the time interval between the injury and the treatment
The following condition to be considered before R.A.T:
A. The avulsed tooth should be without advanced P.diseas
B. The alveolar process should be intact to provide a seat
C. Their should be no orthodontic contraindication
D. The stage of root development should be evaluated
 To provide the best chance of success, the PL cells should
be kept in the most physiologically healthy status as
possible.
 If the avulsed tooth does not replanted within 60-120 min.,
the PL cells undergo necrosis then root resorption begins
and leads to the loss of pre-cementum layer. Because PL
cells deprived from its blood supply and depletion of the
stored cell metabolites.
Storage media
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Water and saline are damaging to PL cells (one hour)
Milk (low fat) limited in benefit (two hours)
Hank’s Balance Saline Solution (HBSS) (Save-A-tooth sys)
Gingival fluid storage media not available commercially
Emdagon is an enamel matrix derivative gel Promote
regeneration of periodontal ligament cells (60 minutes).
Time
Mature root
Immature root
>15 m
Clean with HBSS
5% doxycycline 5 minutes
15 m-24H
(G.M) Implant immediately 5% Doxy. 5 minutes
15 m-24 H
(B.M) HBSS 30 minutes
HBSS 30 m then 5% Doxy 5 m
<24 H
Dry media
Shaving PL
30 m Sod.Hyp
Endo. Treat
Citric acid 3 m
5% Doxy 5m
Canal dried then Ca(OH)2
Replanted
Gatta P. months filling
The same as mature root
Complication of primary teeth
injuries on developing permanent
teeth
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white or brown discoloration of the permanent tooth with or without
hypoplastic defects;
dilaceration of the crown of the tooth causing eruption disturbance or
failure .
dilaceration of the root of the tooth causing eruption disturbance or
failure; odontome-like formation.
partial or total failure of root development;
total failure of tooth development .