05 Pediatric Dental Traume

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

Dental Trauma in Pediatric Dentistry Dental trauma may affect very small children in their efforts to crawl, sit and in the attempts to walk and run.

Capítulos

Atualizado e Ilustrado

1. Introduction and Approaches a. Anamnese b. Exame Clínico c. Exames Complementares

2. Classificação a. Lesões de Tecidos Moles b. Lesões ao Tecido Dental c. Lesões ao Tecido Periodontal

3. Tratamento 4. Recomendações a.Dos Tecidos Moles Gerais aos b. Dos Tecidos de Responsáveis Sustentação c. Dos Tecidos Duros Página 5 do dente e da polpa

Página 1

5. Terapêutica Sistêmica

6. Referências e Créditos

Página 5

Página 5 e 6

Página 2 Página 2

•

1. Introduction

Investigate:

unconsciousness,

migraine, amnesia, nausea and Children who belong to the

!

vomits.

risk group of dental trauma are 1 to

•

3 years old and boys are more prone

the tooth?

to trauma. The upper incisors, especially the central, are the most impaired teeth in both arches. There is a high prevalence of multiple

Trauma common among children and adolescents

traumas in two or more teeth.

Several causes may be associated to consequent absence of lip protection. dental trauma in the deciduous This ledge can be observed in Class I dentition: falls, traffic accidents, patients with damaging habits or beaten child syndrome, traumas in Angle Class II division 1. practicing sports, etc.

There are circumstances that predispose trauma in the head and neck: !

deciduous teeth in vertical position, curiosity and recklessness.

-

Malocclusion:

anterior

Approaches in trauma in the deciduos dentition

protrusion

deciduous

teeth

of and

•

Brief medical history

•

Case

history:

•

Clean the area with water, saline solution, neutral soap or 0.12% chlorexidine.

•

Assess soft tissues, teeth and bone tissue. Check for coronal fracture, pulp exposure and observe the tooth position as to the adjacent teeth, signs of root

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of bloody or torn lesions, foreign bodies and bone fractures in the important

questions: HOW, WHEN AND WHERE trauma occurred?

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b. Cinical examination

fractures. Observe the presence

a. Case history

- Head bigger than the body,

Was there a previous lesion in

alveolar ridge, hematomas or edemas.

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c. Complementary examinations

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Enamel fracture

•

Enamel and dentin fracture without pulp exposure (non complicated coronal fracture)

!

Radiographic examination:

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Enamel and dentin exposure with pulp exposure (complicated coronal fracture)

•

Occlusal Rx with periapical film

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Coronal root fracture

•

Periapical Rx with positioner

•

Root fracture

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Lateral Rx with periapical film

Obs.:

The

radiographic

examination

is

not

tridimensional but it is possible to observe: • •

Root fractures Developing root

•

Pulp chamber dimension

•

Periapical radiolucency

•

!

Internal and external resorptions

c. Periodontal Tissue Lesions: •

Concussion / commotion

•

Subluxation

•

Lateral luxation

•

Extrusive Luxation

•

Intrusive luxation

•

Avulsion

Percussion and vitality tests:

SENSITIVITY AND DIFFICULTY IN OBTAINING

3. Treatment of Traumatic Dental Lesions

TRUE RESULTS.

a. Soft Tissues

DO NOT PERFORM VITALITY TEST DUE TO

Obs.: Procedures according to each type of traumatic dental lesion will be discussed later.

LACERATION: shallow or deep wound resulting from tissue laceration produced by cutting object.

Treatment:

2. Classification of Traumatic Dental Lesions

•

the impaired region, the flap is repositioned and sutures are applied if necessary.

a. Soft Tissue Lesions: • •

Laceration

•

Bruising

•

Abrasion

After cleaning and removal of foreign bodies from

Gingiva and mucosa minor lacerations require no sutures.

The use of 0.12% chlorexidine may help in tissue repair.

In doubt of a high contamination rate, antitetanus prophylaxis and antibiotic therapy are indicated.

b. Dental Tissue Lesions: •

Enamel crack

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CONTUSION:

wound

produced

by

impact with a non-cutting object, causing submucosa hemorrhage - ecchymosis.

!

Control In the cases of concussion and subluxation, color

alteration in the dental crown may be present.

However, this may not indicate pulp necrosis. The color

Treatment: •

•

No treatment because bleeding is locally resorbed.

alteration may recede. Endodontic treatment may be done, as well as a composite veneer for esthetic reasons.

If the color alteration is followed by fistula, pulp

ABRASION: it is the superficial lesion caused by mucosa scaling leaving a bruised and hemorrhagic surface.

Treatment: •

LATERAL LUXATION: Eccentric tooth displacement

Treatment is symptomatic. Gauze soaked with anodyne

necrosis has occurred and it is necessary to perform endodontic treatment.

solution

containing

benzocaine

(Ex.:

Cepacaína®, Gingilone®) may be used to relieve pain when eating.

b. Supporting Tissues

with socket crushing. It may have or not an increase of the periodontal space.

Treatment: •

Hygiene and removal of damaging habits

•

Digital replacement

•

Retention or extraction (if late)

CONCUSSION: lesion in the supporting structures of teeth. Hemorrhage and edema of the periodontal

EXTRUSIVE LUXATION: It is the partial displacement

ligament without mobility but sensitive to percussion.

of the tooth out of its socket. It is not common in

Treatment:

deciduous teeth. It is mainly seen in cases of decreased root as the small size of the tooth favors its peripheral

•

Hygiene and removal of damaging habits

displacement.

•

Observation (control)

Treatment:

•

Occlusal interference relief

!

•

Observation of periodontal tissues

•

Pasty food

Therapy includes two possibilities and the

choice depends on the severity of the lesion and the development stage of the next permanent tooth. Tooth repositioning and retention for 15 up to 21 days; extraction when there is risk of germ lesion in the permanent tooth during the repositioning process of the

SUBLUXATION: lesion in the supporting structures of

impaired deciduous tooth or when the pronounced

teeth, ligament fibers tearing, loosening without

degree of mobility of the deciduous tooth shows the

displacement. Light bleeding in the gingival groove.

risk of aspirating it.

Treatment: •

Hygiene and removal of damaging habits

•

Occlusal relief

•

Pasty food for 2 weeks

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INTRUSIVE LUXATION: It is the tooth displacement to the interior part of its socket. It may be associated to compression or alveolar process fracture and mucosa lesions.

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Treatment: !

The therapy is clinical and radiographic

surveillance of the tooth eruption that in 95% of the cases occurs in 6 months, or extraction under the following conditions: contact between the deciduous tooth root and the permanent germ, fistula or periapical radiolucency, bone fracture, defect in eruption, severe resorption of the deciduous tooth after eruption or anchylosis during eruption.

followed by fluoride application. When enamel is impaired, there is indication of composite restoration.

CORONAL FRACTURE OF ENAMEL AND DENTIN WITHOUT PULP EXPOSURE: Lesion that involves enamel and dentin with loss of dental structure but no pulp impairment.

Treatment: •

Crown restoration with composite resin.

AVULSION: It is the total traumatic expulsion of the tooth to the exterior part of the socket.

Treatment: !

There are controversies as to the need and

advantages of reimplanting an avulsed deciduous tooth. We should consider the physical and biological

CORONAL FRACTURE OF ENAMEL AND DENTIN WITH PULP EXPOSURE: Fracture involving enamel, dentin and pulp.

Treatment: •

Pulp treatment followed by coronal reconstruction.

•

In teeth with INCOMPLETE ROOT FORMATION

aspects of space maintenance in the anterior segment of the child’s dental arch. Repositioning of the deciduous tooth can be done under favorable conditions: young

there

is

indication

to

direct

pulp

capping,

accident, adequate transportation of the tooth, region

pulpotomy or pulpectomy depending on the pulp condition and case history (time elapsed from

and tooth without contamination to minimize infection

trauma).

child, time elapsed (less than 30 minutes) after the

and intact alveolar bone.

•

In teeth with COMPLETE ROOT FORMATION, pulpectomy should be indicated.

c. Hard Tissues and Pulp Tissue CROWN ROOT FRACTURE:

Fracture involving

ENAMEL CRACKS: It is the incomplete enamel

enamel, dentin and cementum. When it reaches pulp

fracture without dental structure loss.

tissue it is called complicated. If it is restricted to hard

Treatment: Although it does not require specific treatment, there is indication of an initial X-ray, after 3 months and one year from trauma.

tissues, it is called “non complicated”.

Treatment: When dental structure loss is not so large, dentin and pulp protection is performed or endodontic treatment,

CORONAL FRACTURE OF THE ENAMEL: It is the fracture restricted to enamel with loss of dental structure.

Treatment: Therapy is simple. In some cases it is enough to finish rough margins with Vaseline sand disc

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health

as it was said in the previous item, and restoration later on.

When the fracture line extends to 4 or 5 mm below the gingival margin and diagnosis is unconvincing, extraction is the treatment of choice.

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U P D A T I CN G L O FU T BH E E B A S IDC OA R A L SC A ER E Q N OU T EÓB OI O KA 2 0 1 2 FOUSP - MINISTRY OF HEALTH, BRAZIL

ROOT

FRACTURE:

Root

fracture

IN ALL CASES OF TRAUMA IN THE DECIDUOUS

involving dentin, cementum and the pulp

DENTITION, RADIOGRAPHIC FOLLOW-UP OF THE

may be longitudinal, transverse or oblique. In deciduous teeth the transverse are more frequent and

PHISIOLOGIC RESORPTION OF THE DECIDUOUS TOOTH AND ERUPTION OF THE PERMANENT

may occur in the apical, middle or cervical third.

TOOTH IS MANDATORY!

Treatment: !

In the apical and middle transverse fractures the

treatment consists of approximating the fragments if they are displaced. Retention is necessary for 7 to 14

6. References 1.

CHELLOTTI,

A.;

VALENTIM,

C.;

days when the middle third is involved and the tooth

PROKOPOWITSCH, I.; WANDEERLEY, M.T. Lesões

showing great mobility. Stabilization cannot be rigid, it must allow a slight dental movement decreasing the

traumáticas em dentes decíduos e permanentes jovens.

In: GUEDES-PINTO, A.C. – Odontopediatria. São

possibility of ankylosis.

Paulo: Ed. Santos, 2003. p.650-687.

In the cervical transverse fracture or middle third

2. COSTA, L.R.R.S; CORRÊA, M.S.N.P.; RIBEIRO, R.A.

severe fracture, extraction is preferred to conservative

Traumatismo na dentição decídua. In: CORRÊA,

approach. During extraction, if the removal of the apical

M.S.N.P. Odontopediatria na primeira infância. São Paulo: Ed. Santos, 1998 p.527-547.

root fragment will impair the dental germ, this is left in the socket and it will be resorbed.

3. DUARTE, D.A.; BÖNECKER, M.J.S.; SANT'ANNA, G.R.; SUGA, S.S. Princípios básicos da prevenção aos

4. General recommendations to responsible people Recommend a pasty diet in the first days

•

Removal of damaging habits

•

Instruct about local hygiene. Usually a toothbrush

Tratamento dos traumatismos dentários da infância à adolescência.

In:

RODE,

S.M.;

GENTIL,

S.N.

cannot be used. Utilize gauze soaked with diluted

Atualização em Odontologia (Odontopediatria). 23o.

Congresso Internacional de Odontologia de São

hydrogen peroxide for one week. Afterwards use

Paulo. São Paulo: Artes Médicas; 2005. Capítulo 9. p.

the regular toothbrush.

197-240.

Warn about the importance of clinical, radiographic and photographic periodical control.

Credits: Updating of the Primary Health Care Notebook - Oral Health, n. 17 F O U S P - M I N I S T R Y O F H E A L T H , B R A Z I L 2012:

5. Systemic therapy !

traumatismo na dentição decídua. São Paulo: Ed. Santos; 2001. cap. 3, p.11-2.

4. PERCINOTO, C.; CUNHA, R.F.; PUGLIESE, D.M.C.

•

•

traumatismos. In: Caderno de Odontopediatria –

Systemic

therapy

with

analgesic/

antinflammatory drugs may be prescribed in case of

Profa. Luciana Butini Oliveira - SLMandic Profa. Márcia Turola Wanderley - FOUSP

important trauma when the child has pain, fever or discomfort. Antibiotic therapy and anti-tetanus prophylaxis are indicated when there is a possibility of wound contamination by microorganisms.

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