Trauma to temporary teeth and immature permanent teeth
EDUCATIONAL OBJECTIVES
-Diagnosis of the different types of trauma that can affect children with temporary and permanent teeth.
– Implement treatment strategies for each type of dental trauma.
1- Introduction
Nearly one in three children is affected by oral trauma before the age of 6. Often underestimated, trauma to the primary dentition, along with infections, constitutes a real emergency in Pediatric Dentistry.
2-Epidemiology
– More numerous than in permanent dentition but often ignored
– They affect 51% of children under 6 years old
Frequency peaks:
- 1st year (learning to walk)
- 3-4 years (the child acquires independence of movement)
- Male predominance + line
- 95% in the maxilla (Inc central +++)
- Predisposing factors: thumb sucking, pacifier sucking
- Accident in the family environment +++
- Tooth displacement more common than coronal fractures because:
Alveolar bone plasticity
Relative weakness of the periodontal ligament
Shorter root
Directional force of trauma rather vertical in the very young
- Sequelae on the underlying germ:
Direct: trauma itself
Indirect: complications of trauma
3- Etiopathogenesis of trauma
- Evaluate the Shock: hardness / size / shape / speed / force
- Soft object often causes dislocation, avulsion
- Hard objects (stones, etc.) often cause enamel fractures
- Absence of the cushioning reflex in young children
- Car accident, epilepsy
4- Risk factors
- Gender: boys > girls
- Dentofacial dysmorphosis:
-Labial gap (lip protection)
-Vestibulo-version of Inc max > 30°
-Overhang > 6 mm
-Oral ventilation: mandible and TMJ fragile in case of shock in open mouth
- High-risk sports
- Boxing, martial arts, rugby, hockey, handball, cycling, skateboarding/rollerblading
- Football, squash, basketball, skiing, gymnastics, horse riding
- Other factors:
– Tracheal intubation and endoscopy under GA
– Neurological accidents (epilepsy, Parkinson’s disease, cerebral palsy)
– Abuse
– Multi-ring fasteners: wounds
5- Etiologies
Several etiologies but often:
- Sports accident
- Domestic accident
- School accident
- Public road accident AVP
- Assault
6- The main classifications
7- Clinical examination of the traumatized young person
Parental help : reassuring, holding, talking
Provide sedative premedication and/or conscious sedation
Exorbuccal examination : Inspection of wounds, palpation of bone edges, measurement of the opening amplitude
Intraoral examination: Inspect soft tissues, static and dynamic occlusion , Examination of the dentition
EXAMINATION OF THE CAUSAL TOOTH
Three tests to perform are: Mobility, Percussion, Thermal Sensitivity
*Percussion is performed in vertical and horizontal directions using the mirror handle in adults and the finger in children. It allows sensitivity and sound to be assessed.
*The evaluation of thermal sensitivity is done:
-Either with dichlorofluoromethane, applied to the tooth using a cotton ball
-Either by means of a warmed gutta-percha.
They allow us to assess the state of the pulp after the trauma. These tests can be supplemented by electrical tests.
Radiological examination
- Radiation intensity reduced by 2/3 compared to adults
- Prefer occlusal film because it is easily accepted by the patient
- Assess the desmodontal space and the extent of displacement
- Retroalveolar child cliché with film holder
- Maxillary defilement : which gives:
position of the apex / germ
Fracture of the vestibular bone plate
- Ray parallel to the occlusal plane
Clinical observation and X-rays
- Size of the traumatized tooth:
- Symmetrical orientation of the underlying germ compared with the contralateral germ
Treatment
Depending on the child’s cooperation.
Insufficient endodontic treatment can have more harmful consequences on the germ (inflammation, periapical infection) than the trauma itself.
8-Diagnosis and therapeutic suitability of temporary tooth trauma:
- Coronary fractures
- Simple coronary fractures
Enamel fracture: Grinding and/or polishing + fluoride gel
Enamel-dentin fracture:
Minimal loss of substance: grinding + application of fluoride
Significant loss of substance: Composite, transparent molds (Pedo strip crown 3M®, etc.)
Gluing the fragment is not recommended: long, delicate technique, and difficult adhesion.
- Coronal fractures with pulp exposure
8-2 Coronal-radicular fractures
A- Not concerning the pulp:
* Attached and mobile fragment.
Sensitivity test: positive.
*Treatment:
-Extraction of the fragment.
-Supragingival coronal reconstruction.
B- Concerning the pulp:
* Attached and mobile fragment
* diagonal fracture line ending at the cervical third of the root with pulp exposure.
*Treatment:
Stage 1 or 2: pulpotomy and reconstruction by supragingival bonding.
Stage 3: Extraction
- Root fractures
A-Transverse root fractures
Avoid avulsion of an apical fragment: risk of damaging the germ.
Monitor its physiological resorption: x-ray every 6 months.
Restraint with difficulty in execution, see its necessity not clinically proven.
B -Longitudinal fracture : avulsion.
They are quite rare, and generally occur when the tooth is in stage II, mature.
C – Fractures of the apical 1/3 and the middle 1/3 of the root
Treatment: if there is no displacement or communication with the oral cavity → monitoring, otherwise, extraction of the coronary fragment.
D – Fractures of the 1/3 coronal root
Treatment: the coronary fragment is generally mobile , or even displaced → it is better to extract it to avoid the risk of infection.
Also extract the apical fragment if possible, otherwise monitor the physiological resorption of this fragment.
8-4 Dislocations
They affect temporary teeth at all stages . Bone fractures may also be associated with them, and will need to be reduced.
Reduction maneuvers of luxated teeth that risk traumatizing the underlying germ should be avoided.
Depending on its degree of mobility and maturation, the tooth will be monitored or extracted immediately.
Clinical monitoring of retained teeth is essential due to the risk of infectious complications.
- Concussion
Definition: Minor trauma to the periodontium, without displacement or mobility of the tooth.
The tooth may be sensitive to the touch. Nothing to report on the X-ray examination.
Treatment : monitoring.
- Subluxation
Definition: Damage to the periodontal structures, without movement of the tooth, accompanied by low mobility.
There may be bleeding at the gum line.
Treatment : monitoring.
- Extrusive dislocation
Definition: Extrusion is a partial axial displacement of the tooth out of the socket.
The tooth appears long and is mobile. It is sensitive to percussion and can interfere with occlusion.
On X-ray, there is ligament enlargement at the apical level.
Treatment : it depends on the degree of displacement, the stage of the tooth, and how quickly the patient arrives at the office.
– if the displacement is minor (< 3 mm) and the tooth is immature: the tooth can be gently repositioned or allowed to reposition spontaneously.
– if the tooth is mature, and/or if the displacement is significant (> 3 mm): it is extracted.
– If the tooth is retained, regular clinical and radiological monitoring is necessary at 1 week, 1 month, 2 months, 6 months and then every 6 months.
D- Lateral dislocation
Definition : The tooth is displaced from its axis, most often in a palatal or lingual direction. The tooth is generally immobile, stuck in its new position.
The tooth is sensitive to percussion and may interfere with occlusion.
On X-ray, ligament widening is noted (++ occlusal image).
Treatment :
– If the palatal luxation is mild and there is no occlusal interference, the tooth is allowed to reposition spontaneously; if there is interference, the tooth can possibly be gently repositioned, after local anesthesia, and a retention placed for 1-2 weeks if necessary (but difficult).
-In other cases, if there is damage to the germ, severe displacement of the tooth and/or a significant alveolar fracture: extraction is carried out.
-The course of action will most often depend on the degree of displacement, the stage of development of the tooth, the speed of arrival of the patient at the treatment center and the cooperation of the latter.
-Repositioning a mature tooth can put the underlying germ at risk.
E- Intrusive dislocation
Definition: Intrusion is a displacement of the tooth in the apical direction.
-The tooth appears buried in the mucosa, and may sometimes no longer be visible.
-X-rays are therefore essential for making a differential diagnosis with an expelled tooth.
-The X-ray will visualize the relationship of the intruded tooth with the underlying permanent tooth germ .
Treatment :
-If the apex is very close to the germ or if the germ is affected, it must be extracted.
-If the apex is vestibular, we monitor it because the tooth can reposition itself naturally in 2-3 months, most often within 3 weeks.
-If the tooth is retained, it is important to establish clinical monitoring at 1 month, 3 months, then every 6 months.
-Sucking habits should be avoided as they could prevent the tooth from spontaneously repositioning.
F- expulsion (total dislocation)
Definition: Total displacement of the tooth out of its socket.
-After the clinical examination, the radiographic examination will allow the differential diagnosis to be made with an intrusion if the tooth has not been found, to detect the possible presence of a foreign body in the alveolus and the mucous membranes, and to assess whether there is an attack on the underlying germ(s).
-Due to the risk of damage to the underlying germ and the difficulty of re-implanting in a young child, an expelled temporary tooth will never be re-implanted .
9- follow-up and complications
At the end of the first appointment, oral health advice should be given to patients, as it is important to maintain good oral hygiene during trauma:
– brushing with a soft toothbrush after each meal
– application of topical chlorhexidine to the affected area twice a day for 1 week
-When the damage is significant, a diet or soft food for 10 to 15 days is sometimes recommended.
-A prescription is written if necessary with: local care for wounds (antiseptic, Betadine), an analgesic depending on the pain (paracetamol), an antibiotic in cases of intraoral mucosal lesions, bone damage and depending on the general condition of the patient.
– Clinical monitoring must be established following trauma.
– Complications, such as discoloration, or necrosis and infection most often, can occur in temporary teeth affected by trauma.
-We will therefore see the child again at 2 weeks, 1 month, 3 months, then every 6 months.
-In the case of extracted temporary teeth, it will be necessary to consider the installation of a space maintainer depending on the child’s age, motivation and cooperation, but also depending on this need (harmony of the arches, available space, development of the palate, etc.).
-Post-traumatic staining is common, but it is not always a sign of necrosis of the traumatized tooth.
10-Diagnosis and therapeutic suitability of permanent tooth trauma:
-The notion of dental age is essential (mature/immature tooth) and influences our therapy.
– Dislocations and expulsions will be the most frequently found traumas for immature permanent teeth, while fractures will be the majority for mature permanent teeth.
-The goal is to preserve the traumatized tooth as best as possible, or at least to maintain optimal conditions for valid prosthetic rehabilitation.
-All dental and periodontal structures can be affected.
-The teeth in the anterior sector are the most affected.
- Coronary fractures
- Simple coronary fractures
The most common trauma to permanent incisors is enamel-dentin fracture. Signs include pain with temperature changes, chewing, and possible mobility if the ligament is damaged.
Pulp sensitivity tests are generally positive, sometimes negative initially.
Treatment: Depending on the extent of the lesion, the following treatment will be carried out:
● a coronary surgery
● bonding the fractured piece (if it has been preserved in milk or physiological serum) to the fluid composite
● a composite reconstruction
Then we will establish clinical monitoring at 3-4 weeks.
- Complicated coronal fractures: enamel-dentin with pulp invasion
Treatment depends on the stage of root development, the size of the exposure, and the time elapsed between the time of the trauma and the visit to the office.
*Mature tooth
-minimal and recent exposure: → direct capping → partial pulpotomy + CaOH2 or MTA
Composite reconstruction or bonding of the fractured piece.
Reserved prognosis and essential monitoring (vitality tests, X-rays)
-significant or old exposure: → total pulpectomy then obturation with gutta-percha (+ CaOH2 session to clean up)
* Immature tooth Apexogenesis
● depending on the exposure time → direct styling → pulpotomy
*Immature tooth , Apexification: when the trauma is old
On clinical examination, the tooth does not respond to vitality tests, and there may be the presence of an abscess or fistula.
- Coronal-radicular fractures
– they are rare.
-Complicated with damage to the pulp tissue, they affect the anterior teeth, but also the posterior teeth through indirect impact. The periodontal tissues are also affected.
-Most often, the fracture line is oblique, going from the vestibular incisal edge to the palatal or lingual cervical edge. It is sometimes vertical, it can be multiple.
– The pain is mainly related to chewing.
– Pulp exposure is common.
-On the radio, it is necessary to use images taken at different angles to visualize it well.
Treatment
-In the case of simple coronal-radicular fractures: without pulp exposure
-Depending on the subgingival depth of the fracture line, the fractured piece is extracted; then the tooth is reconstructed (after gingival resection if necessary).
-In the case of complicated coronal-radicular fractures: with pulp involvement
-If the fracture line extends too low and after extrusion the clinical root/crown ratio is not favorable → it is extracted.
-Otherwise, extraction of the fractured piece, then depending on the case:
● mature tooth → total pulpectomy then extrusion by orthodontic traction
● immature tooth → Apexogenesis treatment (capping or pulpotomy) then extrusion by orthodontic traction (light and continuous forces)
- Root fractures
-The most frequently affected teeth are the maxillary central incisors, and they are most often mature (immature teeth: more luxation and expulsion).
– More frequently the shock is horizontal, and causes a root fracture at the level of the middle third.
-On clinical examination, the coronary fragment may be displaced and mobility depends on the location of the fracture line.
– Vitality tests are random just after the trauma and must be repeated after 3 weeks.
– The tooth may also be very sensitive to percussion, and a transient pink or gray coloration may appear quickly.
-The radiographic examination requires several images: occlusal, retro-alveolar with several incidences.
- Dislocations
A- Concussion and subluxation
● Concussion : the tooth is sensitive to touch and percussion, pulp tests are positive, but the tooth is neither displaced nor mobile → monitoring
● Subluxation : the tooth is sensitive to touch and percussion, slightly mobile but not displaced; slight gingival bleeding can be observed, and pulp tests are positive.
→ retention according to mobility, and the patient must not use his tooth for a week.
Follow-up is established because the possible complications are: pulp obliteration and necrosis .
B-Extrusive dislocation
-After an oblique impact, the tooth is mobile, often extruded on the lingual/palatal side, the apex is forced towards the vestibular alveolar wall but fracture is rare. We sometimes speak of a long tooth.
-Immediate pulp tests are often negative.
-Treatment: → gentle manual repositioning and restraint
– Regular monitoring is established: the DPI often revascularizes, the teeth mature more rarely (endodontic treatment will then be carried out)
C- Lateral dislocation
-It affects all dental, periodontal and bone tissues.
-It causes lateral displacement of the tooth, vestibular or most often palatal/lingual, often with an associated alveolar fracture.
-The tooth is often immobile in this new position because it is blocked, hence the metallic sound produced when struck.
-Occlusion may be disturbed.
-Treatment: → repositioning of the tooth in its socket (manually, more or less with forceps) and retention
If the patient consults more than 48 hours after the shock → orthodontic repositioning
Regular monitoring is established, especially since revascularization is possible for DPI.
D – Intrusive dislocation
-The force of the shock is such that it causes an axial displacement of the tooth, which is buried and immobile in this new position, with a metallic sound on percussion.
-Sensitivity tests are often negative.
*MATURE TOOTH (rare)
● minimal displacement (< 3 mm) → natural re-eruption possible – Follow-up necessary because of significant risk of necrosis
● significant displacement → surgical or orthodontic extrusion – Retention and endodontic treatment
– Significant risk of ankylosis
*Immature tooth
● possible spontaneous re-eruption within a few weeks
● if after 4 weeks it has not descended → extrusion by orthodontic traction (light forces).
E- EXPULSION (TOTAL DISLOCATION)
The expulsion of permanent teeth mainly concerns immature teeth due to the short root and ligamentous laxity.
The prognosis depends on:
● extra-alveolar time before reimplantation (++ immediate reimplantation),
● the stage of root development (more favorable prognosis for immature teeth),
● the tooth transport medium, if it is not reimplanted immediately.
When a permanent tooth is ejected, there is a rupture of the periodontal ligament and the pulpal vascular-nervous bundle, but ligament cells remain on the root surface.
The aim of the treatments is therefore to preserve the vitality of these cells to have a new ligament attachment, and to limit pulp contamination in the hope of pulp revascularization in the case of immature permanent teeth (IPD).
Action to take
● retrieve the tooth, do not touch the root, hold it by the crown
● ask if immediate reimplantation of the permanent tooth is possible
● if not, keep it in milk (better iced milk) or physiological serum (+ in saliva / transport in water is not recommended), and come to the dental office as quickly as possible (more favorable prognosis if the extra-alveolar time is less than 60 minutes).
Follow up
The restraint is placed:
● 1 to 2 weeks, depending on the mobility of the tooth
● if there is a bone fracture: 3 weeks to 3 months, depending on the mobility of the bone tables.
-It is necessary to prescribe antibiotics for at least 7 days (Amoxicillin), painkillers and mouthwashes; and to give some postoperative advice.
– soft diet for 2 weeks
– brush your teeth with a soft brush after each meal
– mouthwash 2X/day for 1 week chlorexidine (0.1%)
Conclusion
The dentist must consider any trauma as an emergency. Their clinical forms are varied and each requires rapid and specific treatment. The child’s cooperation, the physiological stage of the temporary tooth, the nature of the trauma and the stage of development of the permanent tooth will guide the therapeutic decision, but priority will always be given to preserving the germ.
Bibliographies
- Sarah Chopineaux. Management of trauma in primary dentition: from emergency treatment to complication management. Life Sciences [q-bio]. 2019. ffhal-03297991f
- Avigaïl Saada. The impact of trauma to temporary teeth on permanent teeth and their management. Life Sciences [q-bio]. 2020. ffdumas-02903023
- K. VALLAEYS, V. CHEVALIER, R. ARBAB-CHIRANI; Dental trauma; emergency 2013.
Trauma to temporary teeth and immature permanent teeth
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