Dental trauma in children อ.ทญ.ดร. ศิริพร ส่งสิริประดับบุญ ภาวิชาทันตกรรมสำหรับเด็ก คณะทันตแพทยศาสตร์จุฬาลงกรณ์มหาวิทยาลัย

Introduction Peak incidences are found at 2-3 years of age, motor coordination is developing. อุบัติเหตุที่เกิดในเด็ก 0-6 ปี พบมี oral injuries ได้ถึง 18 % ของอุติเหตุที่เกิดขึ้นบริเวณร่างกานภายนอก โดยช่วงอายุที่พบอุยัติการณ์การเกิดได้บ่อนที่สุด คือช่วง 2-3 ขวบ เป็นวัยกำลังเดินได้ ชอบวิ่ง แต่กล้ามเนื้อยังพัฒนาไม่สมบูรณ์ การทำงานร่วมกันของกล้ามนื้อกับระบบสั่งการยังไม่สมบูรณ์

Pathogenesis Surrounding bone is less dense and less mineralised. A tooth can easily displaced instead of fractured. Frontal trauma is quite frequent —> lateral luxation ลักษณะเฉพาะของการเกิดอุบัติเหตุในเด็กเล็ก การสะสมแร่ธาตุ การสร้างกระดูกรอบๆฟันยังไม่หนาแน่นเหมือนเด็กโตหรือผู้ใหญ่ทำให้เมื่อเกิดอุบัติเหตุ ฟันจะมีการเคลื่อนตำแหน่ง มากกว่าการเกิดการหักของตัวฟันหรือรากฟัน แรงที่เกิดขึ้น

Etiology Falls Accidents Child abuse Self-inflicted ora-dental ทำร้ายตัวเอง

Goals The ways which may damage permanent dentition Prevent the occurrence of sequelae in the permanent dentition. The ways which may damage permanent dentition 1. Direct displacement toward the permanent tooth bud 2. Infection caused by bacteria invasion to the injury site 3. Extraction, Repositioning, or Pulp treatment

History taking Loss of consciousness ? Tetanus innoculation How injury occurred ?… normal or abnormal Who reported?

Clinical examination Extra-oral Intra-oral Tooth mobility and alignment

Extra-oral examination facial asymmetry swelling of the lips skin laceration scars (previous injuries) bleeding from nostrils mouth opening

Intra-oral examination Surrounding soft tissue • lips, oral mucosa, gingiva, and frenum Submucosal haemorrhage • upper lip / under tongue Bleeding from sulcus

Radiographic examination AAPD guideline recommends size 2 film for 1. 90° horizontal view 2. Occlusal view 3. Extra-oral lateral view

Radiographic examination Apex is displaced toward labial bone Apex is displaced toward permanent tooth germ Foreshortening Elongation

Radiographic examination Extra-oral lateral radiograph the relationship between the apex of the displaced tooth and permanent tooth bud Rarely adds extra information

Radiographic examination Radiographic examination for soft tissue lesion Indication: a penetrating lip lesion Marking with lead foil or clip

Treatment principle To minimise the risk to the permanent teeth Implies a conservative approach Child: Behaviour management Parents: Empathy and support their minds

Treatment principle Traumatic injuries to primary teeth - Lack of scientific data Factors related to treatment selection 1. Shedding time 2. A child’ maturity and compliance 3. The close proximity of the root of primary tooth to permanent tooth bud

Crown fracture Enamel Enamel-dentin Enamel-dentin-pulp Smooth sharp edges Seal with GIC Restoration Partial pulpotomy with calcium hydroxide Extraction

with or without pulp involvement Crown-root fracture with or without pulp involvement Fragment removal and restoration +/- pulp treatment Extraction

Root fracture Repositioning and splinting Extraction

Repositioning and splinting for under G.A. Alveolar fracture Repositioning and splinting for under G.A.

Luxation injuries Injuries Clinical findings Treatments Concussion tender to touch No treatment Subluxation increased mobility bleeding from gingival crevice

Extrusion Treatment based on degree of displacement and root formation Minor extrusion (< 3 mm.) in an immature tooth • Repositioning • Leaving for spontaneous reposition Severe extrusion in mature tooth • Extraction

Lateral luxation Palatal/lingual luxation Labial luxation Extraction no occlusal interference Observe minor interference Grinding severe interference Repositioning Extraction

Intrusion Apex is displaced toward Apex is displaced toward labial bone Apex is displaced toward permanent tooth germ Spontaneous reposition Extraction

Intrusion • Spontaneous eruption normally take place within 3 months • However some cases (25%) were not fully erupted after 1 year of trauma

Immediate extraction and antibiotic therapy Intrusion • complications during the re-eruption phase • acute inflammation around the displaced tooth • gingiva : swelling • pus from gingival crevice Immediate extraction and antibiotic therapy

Avulsion • Alternative trauma scenarios should be explored deeply intrusion ? • Avulsed primary tooth should not be replanted may displace a coagulum into the follicle of permanent incisor pulp necrosis may cause mineralization disturbance

Avulsion • Tooth must be found to ensure that it has not been aspirated. Leith et al., Aspiration of an avulsed primary incisor: a case report Dental Traumatology 2008; 24: e24–e26. Coughing or breathing problems are the most common symptoms

Chin trauma • Crown and crown-root fractures may occur in molar regions • Treatment depend on the severity of fracture • If extraction is the treatment of choice, space maintainer should be considered

Complications in the primary dentition How to evaluate ? Color changes Radiographic findings Clinical findings : abscess

Color changes • After luxation injuries • Pink / Yellow / Gray

Color changes Gray discoloration Transient —> Permanent yellow discoloration Permanent —> frequently associated with pulp necrosis

Color changes More than 50% of the primary incisors with dark coronal discoloration remain clinically asymptomatic.

Pulp necrosis Related factors age degree of displacement presence of crown fracture

+ Pulp necrosis Diagnosis Conclusive clinical symptoms • fistula • swelling and abscess formation + Crown discolouration Radiographic evidence • a periapical rarefaction • lack of root formation

Instructions to parents Keep an affected area clean Soft toothbrush Swab with chlorhexidine • No pacifiers and nursing bottle • โอกาสเกิด trauma ซ้ำ

Trauma ครั้งนี้จะมีผลอะไรต่อฟันแท้ได้บ้าง ? • Crown discolouration with or without enamel hypoplasia • Malformation or dilaceration of the crown • Cessation of root development • Odontoma-like formation • Disturbance in eruption

Conclusion