Emergancy Treatment Of Dental trauma in Children

Examination and diagnosis Consider traumatic injuries as emergency, To relieve pain. Reduce psychological stress. Facilitate reduction of # or avulsion. For good prognosis.

Uncomplicated Crown Fracture Class 1 Fracture

If <2mm tooth structure is missing, no intervention is necessary No Emergancy treatment

Class 2 Fracture

Expose Dentine Dentine is more yellow compared to the peripheral enamel Patient feels thermal/tactile sensitivity

Complicated Fracture
Class III Fracture Fracture involves enamel and dentin and the pulp is exposed. The 3 angulations described in radiographic examination In young patients with immature (open apex) preserve pulp vitality : local anaesthetic pulp capping : pin piont expose

Mature teeth (close apex) : local anaesthetic Direct pulp capping : pin point exposure not more than 24 h Pulpectomy / vital Root canal treatment Restoration: temporary restoration or reattached fracture fragmen

Ad. Mahkota PilihSeluloid crown form: patokan size &

bentuk gigi sama pada kuadran ber><an Gunting bgn cervix crown form sesuai gingival margin 1mm dibwh free gingival margin Buat 2 lubang di lingual pd 1/3 bag. Incisal kelebihan komposite & udara dpt keluar Etch

Komposite masukkan crown form sedikit2 = gelembung udara Crown form+isi diselubungkan disinar Resin berlebih(lubang/cervikal) diambil Mahkota dibuka, iris bagian lingual (skalpel) Cek gigitan poles

Ad. SSC
Pilih ssc (size, form) disesuaikan bag. Cervic Prep = perlu kecuali kontak prox perlu bebas sedikit email di prox diambil Buat jendela di labial Mahkota disemen isi jendela dgn komposite SSC perlindungan max = tumpatan sementara of choice

Tumpatan sementara dibiarkan > 8 minggu = waktu yang perlu untuk pulpa menjadi normal

Class IV fracture
Emergancy treatment : Periodontitis : root canal treatment reduce occlusion Abscess :

Acute : drainage from pulp chamber keep it open for 24h antibiotic Cronic : root canal treatment

Management of the Avulsed Tooth / Class V fracture

Management of the Avulsed Tooth

Ultimate goal
PDL healing without root resorption

Most critical factor

Maintaining an intact and viable PDL on the root surface

Emergency Treatment
Replantation technique
Local anesthetic, if necessary Radiograph to verify position Check occlusion Physiologic splint

Emergency Treatment
Additional Considerations
Analgesics

Emergency Treatment
Additional Considerations
Analgesics Chlorhexidine

Emergency Treatment
Additional Considerations
Analgesics Chlorhexidine Tetanus

Refer to physician for tetanus prophylaxis prn

Rothstein RJ, Baker FJ. Tetanus: Prevention and treatment. J Am Med Assoc 1978;240:6756.

Emergency Treatment
Additional Considerations
Analgesics Chlorhexidine Tetanus Antibiotics

Antibiotics
Penicillin
500 mg qid for 4-7 days

Andreasen JO. Atlas of replantation and transplantation of Philadelphia: W.B. Saunders Co., 1992;57- 92. teeth.

Hanks Balanced Salt Solution

Proper pH and osmolality Reconstitutes depleted cellular metabolites Washes toxic breakdown products from the root surface

Recommended Storage Media

1. Socket (immediate replantation) 2. Cell culture medium 3. Milk 4. Physiologic saline 5. Saliva

Root Surface Manipulation

Extraoral dry time determines handling

Root Surface Manipulation

Extraoral dry time < 1 hr
PDL healing is still possible Handling recommendations

Keep root moist Do not handle root surface Gentle debridement

Root Surface Manipulation

Extraoral dry time > 1 hr
Loss of PDL cell viability inevitable Treatment recommendations

Remove tissue tags Soak in accepted dental fluoride solution for 20 min

Fluoride Treatment
1.0-2.4% topical fluoride solution
Sodium fluoride (Andreasen) Stannous fluoride (Krasner)

20 minute soak

Management of the Socket

Remove contaminated coagulum in socket
Irrigate with sterile saline

Management of the Socket

Examine socket If fracture is evident
Reposition fractured bone with a blunt instrument

Management of the Socket

Replant using light digital pressure

Types of Splints (flexible/physiologic)

Titanium Trauma Splint (TTS) Ortho wire with brackets Ortho wire with unfilled resin Monofilament line with unfilled resin Unfilled resin Suture(s) Ribbond

Splints for Stabilization

Round or rectangular wire

Monofilament line

Orthodontic brackets and wire

Splints for Stabilization

Ribbond

Titanium Trauma Splint (TTS)

Acid Etch Composite Splints

Interproximal composite

Acid Etch Composite Splints

Composite with arch wire

Acid Etch Composite Splints

Composite with monofilament nylon

Acid Etch Composite Splints

Functional Splint
20-30 lb monofilament nylon Bonded with composite Allows physiologic movement

Antrim DD, Ostrowski JS. A functional splint for traumatized teeth. J Endodon 1982;8:328-31.

Cross-Suture Splint
Indications
No adjacent teeth to splint to Unmanageable traumatized children

Cross-Suture Splint

Splinting Time
Effect of splinting time
7 days 30 days

Nasjleti CE, Castelli WA,

Caffesse RG. times

The effects of different splinting on replantation of teeth in monkeys. Oral Surg 1982;53:557-66.

Splinting Time
Recommended time
7 to 10 days

Nasjleti CE, Castelli WA,

Caffesse RG. times

The effects of different splinting on replantation of teeth in monkeys. Oral Surg 1982;53:557-66.

Class VI Fracture
Root fracture The coronal segment may be mobile and may be displaced. The tooth may be tender to percussion. monitoring the status of the pulp is recommended. Transient crown discoloration (red or grey) may occur

Emergency Management
Reposition coronal fragment

Emergency Management
Previous recommendation
Rigid splinting for 2-3 months

Emergency Management
Previous recommendation
Rigid splinting for 2-3 months

New recommendation
Splinting for 3 weeks

Class VII
Subluxation Definition: injury to tooth-supporting structures with abnormal loosening but without tooth displacement. Th/ : Permanent teeth: Stabilize the tooth and relieve any occlusal interferences. For comfort, a flexible splint can be used. Splint for no more than 2 weeks.

Lateral luxation Definition: displacement of the tooth in a direction other than axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs Emergancy treatment for Permanent teeth:
-

Local anasthetic to reposition as soon as possible and then to stabilize the tooth in its

Intrusion Definition: apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket Emergency treatment: - For immature teeth with more eruptive potential (root to / formed): Clean the wound with NaCl, H2O2

In mature teeth: Clean the wound with NaCl, H2O2 and anticeptic solution Local Anesthetic reposition the tooth with orthodontic or surgical extrusion (local anesthetic if nescessery) stabilize the tooth with a splint for up to 4 weeks in its anatomically correct

Extrusion Definition: partial displacement of the tooth axially from the socket; partial avulsion. The periodontal ligament usually is torn Permanent teeth:
-

Clean the wound with NaCl, H2O2 and anticeptic solution Give Local Anesthetic. Using fingers, grab extruded teeth and surrounding alveolus then

Class VIII: Crown and Root Fracture

Enamel, dentin, and cementum fracture with or without pulp exposure Emergency treatment : Permanent teeth:
-

Clean wound Local Anesthetic If the pulp is exposed, pulpal treatment alternatives are pulp capping, pulpotomy, and root canal

Emergency Treatment for dental trauma in primary Crown fracture with pulp involvement (vital) Teeth
Clean wound Local Anesthetic Perform Pulpotomy or pulpectomy Root fracture Apical third : observation Cervical third and midle third : Local anasthetic Extraction

Crown/root fracture : Local anesthetic The entire tooth should be removed unless retrieval of apical fragments may result in damage to the succedaneous tooth

Displacement
Lateral luxation Primary teeth:
-

to allow passive or spontaneous repositiong if there is no occlusal interference. When there is occlusal interference, local anestheticthe tooth can be gently repositioned or slightly reduced if the interference is minor.

Intrusion : Reeruption spontaneuly Dammage to premanent teeth extraction Extrusion Local Anesthetic reposition spontaneously or reposition and allow for healing for minor extrusion (<3 mm) in an immature developing tooth.