printttjurnal
Post on 06-Apr-2018
216 Views
Preview:
TRANSCRIPT
-
8/3/2019 printttjurnal
1/7
REVIEW
Clinical practice
Dental trauma
Katarzyna Emerich & Jacek Wyszkowski
Received: 30 November 2009 /Accepted: 8 December 2009 /Published online: 8 January 2010# Springer-Verlag 2009
Abstract Approximately 50% of children under the age of 15
are victims of various kinds of injuries in the orofacial region.
Post-traumatic complications may occur, including crowndiscolouration, cervical root fracture, ankylosis, root resorp-
tion and tooth loss. The most severe complication after dental
injury in primary dentition can affect the developing perma-
nent tooth germ, and various consequences may be seen
several years later when the permanent tooth erupts. In the
permanent dentition, the most severe dental injury affects the
surrounding alveolar bone structure and will lead to loss of
the tooth. Current literature emphasises that awareness of
appropriate triage procedures following dental trauma is
unsatisfactory and that delay in treatment is the single most
influential factor affecting prognosis. What should a paedia-
trician know, and more importantly, how should he/she advise
parents and caretakers? In an emergency situation such as
tooth avulsion, reimplantation within 30 min is the best
treatment option at the site of the accident. If reimplantation of
the tooth is impossible, milk, saline or even saliva are the
preferred transport media. The prognosis for an avulsed tooth
depends upon prompt care, which is a determinant factor for
successful treatment of the traumatised tooth. In all other
dental trauma cases, it is important to refer the child to a
paediatric dentist, to follow up the healing process and reduce
late post-traumatic complications. With timely interventions
and appropriate treatment, the prognosis for healing
following most dental injuries is good. In conclusion, it
is important that paediatricians are able to inform parents
and caretakers about all possible and long-lasting con-sequences of different dental injuries.
Keywords Dental injury . First-aid
Introduction
The paediatrician, more than any other child health profes-
sional, should have the knowledge required to provide parents
with professional advice in all aspects concerning a childs
health. This should include basic knowledge about the most
common orofacial injuries. From the day the child starts
walking, different dental injuries can occur. Older children
participating in different activities, e.g. sports, are also prone
to various injuries. Dental trauma can have serious con-
sequences that are not only physical, but also economic, social
and psychological. The paediatrician, being the doctor of first
choice for most parents and caretakers, has a responsibility to
advise them competently in cases of dental injury affecting the
teeth and jaws. The paediatrician should know how to
competently direct the procedure to be followed for a victim
of an accident. As timing is frequently a decisive factor
for the success of long-term treatment, it is important
that paediatricians have a clear path to follow when they
are unexpectedly faced with such stressful situations.
Epidemiology
The largest group receiving dental injuries are children and
adolescents. Very often, due to lack of experience, they are
not aware of the consequences of different activities and
thus cannot predict the possibility of an accident. Research
K. Emerich (*)
Department of Paediatric Dentistry,
Medical University of Gdansk,
ul. Orzeszkowej 18,
80-208 Gdansk, Poland
e-mail: emerich@gumed.edu.pl
J. Wyszkowski
Private Dental Clinic,
Gdynia, Poland
Eur J Pediatr (2010) 169:10451050
DOI 10.1007/s00431-009-1130-x
-
8/3/2019 printttjurnal
2/7
indicates that approximately 50% of children under the age
of 15 receive various kinds of injuries to the orofacial
region [8, 15]. Dental injuries are the commonest type of
orofacial injury [12].
The consequences of dental trauma can vary from simple
tooth fractures to complicated tooth avulsion. In the
literature, however, the most frequently described conse-
quences are crown fractures, representing up to 79% of alldental injuries [11]. The most complex injury is the
complete dislocation of the tooth from its alveolus. Tooth
avulsion, a real emergency in dentistry, represents up to
21% of all dental injuries [7, 11, 19].
Aetiology
Age predilection is as follows:
Toddlers especially 12-year-oldfalls, child abuse
Kindergarten children especially 5-year-olds
hyper-activity, running, jumping
Schoolchildren especially boys 811-year-olds
playground accidents, cycling
Adolescentssports activities, assault, motor vehicle
and motorcycle collisions
Local predisposing factors are as follows:
Anterior overbite >4 mm, increased overjet, protrusion
of upper incisors
Incompetent or short upper lip, mouth breathing
Definition
One of the most remarkable and relevant problems regarding
dental traumatology is the wide range of existing diagnostic
classification systems. Over 50 distinct classification systems
have been identified in the literature [9]. One of the simplest
is the WHO classification, which forms the basis for several
other, more detailed, classifications [21]. The WHO classi-
fication divides dental trauma into ten categories:
1. Fracture of enamelthe tooth is usually non-tender
and without visible colour change but has rough edges
(Fig. 1d).
2. Crown fracture without pulp involvementthe frac-
ture involves the enamel and the dentin layer (Fig. 1a).
The tooth is typically tender to the touch and to air
exposure.
3. Crown fracture with pulp involvementthe fracture
involves the enamel, dentin and pulp. The tooth is tender
and has a visible area of pink, red or even blood at the
centre of the fractured tooth crown (Fig. 1b).
4. Root fracturethe fracture can be seen only on X-ray.
The treatment and the prognosis depend on the
fracture run and location.
5. Crown and root fracturethis is a very complicated
case, and most such fractures need tooth extraction.
6. Fracture of tooth unspecified.
7. Luxation of toothincreased mobility of a tooth
following trauma.8. Intrusion or extrusion of toothintruded tooth is forced
into the socket in an axial (apical) direction, at times to
the point of being buried and not visible. Tooth presents
decreased mobility and resembles ankylosis (Fig. 1c).
Extruded tooth is partially displaced from the socket
along the long axis. Such teeth have greatly increased
mobility, and radiographs show displacement.
9. Avulsion of toothcomplete extraction of the tooth
(crown and root).
10. Other injuries including laceration of oral soft tissues
(Fig. 1d).
Complications
These depend on whether the injury affects the primary or
permanent dentition. In the primary dentition, fractures are
less common than avulsion and different types of luxation
including intrusion and extrusion.
Primary teeth injury outcomes are as follows:
& Failure to continue eruption due to abnormal root
development
& Colour changes in the crown (grey if the pulp becomes
necrotic, yellowish if the pulp chamber becomes
obliterated, pink if internal resorption develops)
& Infection of the necrotic pulp leading to periapical infection
& Abscess as a result of pulp necrosis andperiapical infection
& Loss of space in the dental arch due to tooth loss in the
early years of life
& Ankylosis, leading to prolonged retention of the
primary teeth, mostly as a result of intrusion injury
& Damage to the permanent tooth germ as a result of
intrusion injury at the time when the primary root is
fully developed and the tooth germ is situated near to
the primary tooth root apex (usually injuries between 2
and 4 years of age)
& Abnormal exfoliation due to pathological root resorption
& Delayed eruption of permanent tooth due to scar tissue
development after primary tooth loss or pathological
development of permanent tooth germ.
The most severe complications after dental injury in the
primary dentition can affect the developing permanent tooth
germ, which will become apparent several years later when
1046 Eur J Pediatr (2010) 169:10451050
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?- -
8/3/2019 printttjurnal
3/7
the permanent teeth erupt. Depending on the stage of tooth
germ development, injury in the primary dentition can affect
the crown, the root or the whole permanent tooth (Fig. 2).
Permanent teeth injury outcomes are as follows:
& Colour changes in the crown (grey if the pulp becomes
necrotic, yellowish if the pulp chamber becomes
obliterated, pink if internal resorption develops)
& Infection of the pulp leading to periapical infection and
different abscesses
& Loss of space in the dental arch especially in children
with dental crowding
& Ankylosis mostly as a result of intrusion injury or late
reimplantation after avulsion
& Resorption of the root structure (especially replacement
resorption) due to periodontal ligament damage
(Fig. 3b)
& Reinclusion of the tooth as a result of root replacement
resorption and ankylosis (Fig. 3a, b)
& Abnormal root development due to injury to erupting
tooth without a fully developed root.
The most severe complications after dental injury in
permanent dentition can affect the surrounding bone structure,
which will lead to loss of the tooth and alveolar bone.
It is important that paediatricians are able to inform
parents and caretakers about all possible and long-lasting
consequences of different dental injuries.
Traumatic dental injuries are time-consuming and costly
to treat [14]. They can impair the quality of life, affecting
various aspects of life, including function, appearance and
interpersonal relationships [13]. With timely interventions
and appropriate treatment, the prognosis for healingfollowing most dental injuries is good.
Treatment indications
Primary dentition injuries
The majority of primary dentition injuries, involving
different kinds of luxation, only require observation, good
Fig. 1 a Crown fracture within
enamel and dentin. b Crown
fracture with pulp involvement.
c Intruded central incisor on the
left hand side. d Enamel fracture
on the left hand side central
incisor and soft tissue laceration
Fig. 2 Different developmental
anomalies in permanent denti-tion due to primary tooth injury:
a abnormal root development,
b enamel hypoplasia,
c abnormal crown and
root development
Eur J Pediatr (2010) 169:10451050 1047
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?- -
8/3/2019 printttjurnal
4/7
oral hygiene and a soft diet for 12 weeks. In crown
fractures, which are observed quite rarely, extraction is
usually the treatment of choice. If the child is cooperative,
root canal treatment followed by crown restoration is
possible. It is very important to monitor primary teeth at
least annually after dental trauma until the permanent
successors erupt because different complications such as
pulp necrosis or periapical inflammation may occur several
weeks, months or years after the injury. X-ray examination
may be required to assess the signs of pulpal or periodontal
complications. Soft tissue injuries should be monitoredweekly until they are healed.
The parents should be informed that the risk of damage
to permanent successors in primary tooth trauma is high.
Permanent dentition injuries
It is known that the prognosis for traumatic dental injuries
depends on the time between the accident and initiation of
treatment [1, 18]. Paradoxically, the literature highlights the
tendency to delay presentation for dental treatment [11, 20].
All crown fractures may be easily restored, but if the
pulpal tissue is involved, treatment should be performedwithin several hours from the injury to save the vitality of
the tooth. In crown fractures, it is essential to find the piece
of the tooth because it can be reattached (Fig. 4). In root
fractures and crown/root fractures, the prognosis depends
on the fracture run and location.
Different injuries to the periodontal tissues (luxation and
extrusion) may loosen the tooth or even lead to tooth
avulsion. The severity of the periodontal ligament damage
will determine the healing outcome. The general outcome is
dependent upon stage of root formation and type of injury.
Thus, pulpal and periodontal ligament healing complica-
tions are the most frequent in cases with completed root
formation vs. incomplete root formation [3]. If the tooth is
loose, it should be splinted [16].
Tooth avulsion, being a complex injury affecting
multiple tissues, should be considered a real emergency
requiring prompt and appropriate management to signifi-
cantly improve the prognosis [6]. Immediate reimplantationwithin 30 min after injury or maintenance of the avulsed
tooth in storage media compatible for the survival of
periodontal ligament cells before reimplantation is funda-
mental for successful healing [2, 4, 6]. The longer the time
elapsed between tooth avulsion and reimplantation, the
greater the risk of replacement resorption or inflammatory
root resorption [4, 5]. If the root surface is contaminated, it
should be gently cleaned with a stream of saline or even
cold tap water before reimplantation. To avoid periodontal
ligament damage, the tooth should be held by the crown [5,
17]. A temporary splint comprised of aluminium foil,
available in every kitchen or from any chocolate bar, can be used until dental intervention [10] (Fig. 3c). Alterna-
tively, if immediate reimplantation is impossible, an
avulsed tooth should be placed in physiological saline,
milk or even saliva (between the cheek and the lower
molars). Providing one of the procedures indicated above is
applied, the patient should be seen by the dentist at his/her
earliest convenience.
Fig. 3 a Reinclusion of right
central incisor caused by root
ankylosis and replacement
resorption 2 years after
reimplantation; b X-ray of case
A; c temporary splinting with
aluminium foil
Fig. 4 Crown fracture without pulpal involvement: a clinical status after dental trauma; b fractured pieces of both incisors; c clinical status after
crown restoration
1048 Eur J Pediatr (2010) 169:10451050
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?- -
8/3/2019 printttjurnal
5/7
Guidelines
Conflict of interest The authors received no extra funding forpreparation of this manuscript and believe that there is no relationship
that can lead to any conflict of interests relevant to the content of this
article.
References
1. Adair SM, Durr DP (1991) Practical clinical applications of sports
dentistry in private practice. Dent Clin North Am 35:757770
2. Andersson L, Bodin I (1990) Avulsed human teeth replanted
within 15 min: a long-term clinical follow-up study. Endod Dent
Traumatol 6:3742
3. Andreasen FM, Andreasen JO (1993) Luxation injuries. In:Andreasen JO, Andreasen FM (eds) Textbook and color atlas of
traumatic injuries to the teeth. Munksgaard, Copenhagen, pp 315
378
4. Andreasen JO, Andreasen FM, Andersson L (2007) Textbook and
color atlas of traumatic injuries to the teeth. Chapter: Avulsion,
4th edn. Blackwell Munksgaard, Oderr, pp 444479
5. Andreasen JO, Andreasen FM, Bakland LK, Flores MT (2003)
Traumatic dental injuriesa manual, 2nd edn. Blackwell Munks-
gaard, Odder, pp 5053, 6869
6. Andreasen JO, Andreasen FM, Skeie A et al (2002) Effect of
treatment delay upon pulp and periodontal healing of traumatic
dental injuriesa review article. Dent Traumatol 18:116128
7. Andreasen JO (1970) Etiology and pathogenesis of traumaticdental injuries. A clinical study of 1, 298 cases. Scand J Dent Res
78:329342
8. Bakland LK, Andreasen JO (2004) Dental traumatology: essential
diagnosis and treatment planning. Endodontic Topics 7:1434
9. Feliciano KMPC, de Franca Caldas A Jr (2006) A systematic
review of the diagnostic classifications of traumatic dental
injuries. Dent Traumatol 22:7176
10. Fuss Z (1985) Successful self-replantation of avulsed tooth with
42-year follow-up. Dent Traumatol 1:120122
11. Gabris K, Tarjan I, Rozsa N (2001) Dental trauma in children
presenting for treatment at the Department of Dentistry for
Children and Orthodontics, Budapest, 19851999. Dent Trauma-
tol 17:103108
12. Gassner R, Bosch R, Tuli T, Emshoff R (1999) Prevalence of
dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
87:2733
13. Gift HC, Redford M (1992) Oral health and quality of life. Clin
Geriatr Med 8:673683
14. Glendor U (2009) Aetiology and risk factors related to traumatic
dental injuriesa review of the literature. Dent Traumatol 25:19
31
15. Glendor U (2008) Epidemiology of traumatic dental injuriesa
12 year review of the literature. Dent Traumatol 24:603611
16. Hinckfuss SE, Messer LB (2009) Splinting duration and periodontal
outcomes for replanted avulsed teeth: a systematic review. Dent
Traumatol 25(2):150157
Type of injury Recommendationshow to proceed
Primary dentition injuries
Different fractures Refer to paediatric dentist as soon as possible
Luxation, intrusion and extrusion
Avulsion Monitor the healing process and inform the parents about the need for dental consultation
Soft tissue lacerationPermanent dentition injuries
Crown fracture within enamel or
enamel/dentin
Instruct the parents to find the tooth piece. Refer to a dentist. In most cases a delayed treatment approach
(i.e. even after more than 24 h) is realistic
Crown fracture with pulp
involvement
Instruct the parents to find the tooth piece. Refer to a dentist. In most cases a subacute treatment
approach (i.e. within 24 h) should be recommended
Other fractures Refer to a dentist as soon as possible
Luxation and intrusion Refer to a dentist. In most cases a subacute treatment approach should be recommended
Extrusion and lateral luxation Refer to a dentist. In most cases an acute treatment approach (i.e. within a few hours) should be
recommended
Avulsion First-aid procedureinstruct the parents how to act
1. Find the tooth as quickly as possible
2. Hold the tooth only by the crown and rinse it with cold tap water3. Immediately reimplant the tooth in its socket
4. Immobilise the tooth (e.g. with aluminium foil)
5. If the tooth cannot be reimplanted, keep it wet at all times. Place the tooth in milk, saline or even
salivaplace the tooth between the cheek and the gums
6. See a dentist as soon as possible
If the tooth is not reimplanted at the time of injury an acute approach is recommended; otherwise
subacute
Soft tissue laceration Monitor the healing process and inform the parents about the need for dental consultation
Eur J Pediatr (2010) 169:10451050 1049
-
8/3/2019 printttjurnal
6/7
17. International Association of Dental Traumatology. http://www.iadt-
dentaltrauma.org/web/index.php?option=com_content&task=
view&id=28&Itemid=43 Accessed Oct 10, 2009
18. Kumomoto DP, Winters JE (2000) Private practice and
community activities in sports dentistry. Dent Clin North Am
44:209220
19. Marcenes W, Alessi ON, Traebert J (2000) Causes and
prevalence of traumatic injuries to the permanent incisors of
school children aged 12 years in Jaragua do Sul, Brazil. Int
Dent J 50:8792
20. Rajab LD (2003) Traumatic dental injuries In children presenting
for treatment at the Department of Pediatric Dentistry, University
of Jordan, 19972000. Dent Traumatol 19:611
21. World Health Organization (1978) Application of the International
Classification of Diseases to Dentistry and Stomatology (ICD-DA).
WHO, Geneva, pp 8889
1050 Eur J Pediatr (2010) 169:10451050
http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43 -
8/3/2019 printttjurnal
7/7
Copyright of European Journal of Pediatrics is the property of Springer Science & Business Media B.V. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.
top related