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Trauma to children’s teeth is a very common event.1 The
prevalence of these injuries varies depending on the population
studied and the types of injuries reported. Studies indicate that
as many as 46% of children sustained traumatic injuries
to their primary or permanent teeth during childhood.2-4 Approximately
2% of children sustain such injuries annually.5 The
majority of the injuries occur to the maxillary incisors due to
their prominence in the dentition. Displacement injuries are more
common in the primary dentition, because supporting bone in younger
children is more flexible and pliable, while fractures are more
common in the permanent dentition.
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Several factors influence the child’s individual risk
of sustaining traumatic injuries to the orofacial complex. Males
are more likely to sustain injuries,6 while the
frequency and type of injuries varies with age.7 The
greatest incidence of trauma to the primary dentition occurs at
2 to 3 years of age, when motor coordination is developing.8 The
incidence peaks again between the ages of 8 and 10 years, which
poses a risk to the maxillary anterior teeth.8 Children
who are very active, such as those with attention deficit hyperactivity
disorder (ADHD)6,9 or those with poor motor coordination
such as with cerebral palsy,10 have greater risk
of trauma. Socioeconomic status can also affect the risk of trauma
to the dentition.6,11 Being a member of a non-nuclear
family (ie, without two parents) will increase the risk of trauma.12 Children
who are overweight12 and those with protrusive
maxillary incisors13 are at greater risk of trauma.
Individuals who have undergone general anesthesia with endotracheal
intubation can experience “silent trauma” to their
incisors (fractured or traumatized incisors during intubation).14 Failure
to treat fractured teeth can impact a child’s daily performance,
specifically in smiling, laughing, and showing teeth without embarrassment.15
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The most common injuries to permanent teeth occur secondary to
falls, violence, traffic accidents, and sports.4 Most
sporting activities have an associated risk of orofacial injuries
due to falls, collisions, and contacts with hard surfaces or other
players. There are numerous preventive measures to decrease these
risks, such as wearing protective intraoral mouthguards and helmets
during many activities. The Centers for Disease Control estimates
that universal use of helmets would prevent 45,000 craniofacial
injuries and 55,000 maxillary and mandibular injuries annually.16 Two
types of mouthguards are recommended, depending on the stage of
the child’s dentition. The “boil and bite” mouthguard
(eFig. 375.1) is inexpensive and can be adapted
to the child’s mouth by the parent. These types of mouthguards
are especially helpful during the mixed dentition, when primary
teeth are exfoliating and permanent teeth are erupting, as they
require frequent replacement. The custom-made mouthguard (eFig. 375.2) is preferred due to its excellent
fit but is more expensive, since it requires dental impressions
and laboratory fees for fabrication. Early orthodontic intervention
to reduce a severe protrusion of the maxillary incisors also has
shown to decrease trauma to these teeth.17
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In all instances of trauma and infection in an otherwise stable
patient, a careful medical history, including tetanus vaccination,
should be obtained.18 The skull, facial bones,
and mandible should be palpated to assess any areas of ecchymosis,
paresthesia, crepitus, or pain, which may point to a concomitant
facial bone fracture. In addition, a subsequent cranial nerve function
test should be performed. Finally, to rule out aspiration in cases
of a tooth fracture or avulsion, where the tooth or fragment cannot
be located, immediate chest and abdominal radiographs should be
obtained.18
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Orofacial trauma, including trauma to the dentition, is common
in cases of child abuse and neglect.19-22 Dental
trauma may be an important marker for child abuse, because craniofacial,
head, face, and neck injuries occur in approximately 65% of
recorded cases of child abuse.21 This can be attributed
to the fact that the mouth is the source of yelling or crying and
is readily accessible, and the face represents “the self.” Trauma
in children is often caused by an adult violently striking the child’s
lips and teeth with a hand. If the hand or associated object is
directed forcefully and upward, the maxillary frenum may be torn
and the lips and teeth may be damaged.23 Injuries
that have typical shapes and patterns, human bite marks, adult handprints,
or bilateral injuries indicate possible abuse.
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Typical oral injuries include lacerations, especially of the
maxillary labial frenum (Fig. 375-1); fractured,
luxated, or avulsed teeth; jaw and facial fractures; oral burns;
oral and facial bruises; and tissue scarring from previous trauma.
Teeth may be discolored
or abscessed from
previous trauma. Sexually transmitted oral lesions such as condyloma
acuminata (eFig. 375.3) in prepubertal children
should raise suspicion of sexual abuse. Oral trauma from sexual
abuse can also result in petechiae or bruising at the junction of
the hard and soft palate (Fig. 375-2). Burns
and bruising on the lips may also be present and could be the possible
sequelae of forced feeding.24
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Trauma to the soft tissues of the oral cavity can be caused by
physical, chemical, or electrical insults. Soft tissue injuries
consist of abrasions, lacerations, contusions, ecchymoses, hematomas,
and burns. Oral lacerations should be examined carefully for the
presence of foreign bodies, especially in the presence of fractured
teeth (eFig. 375.4A,B).
A radiograph of the lesion should be done to rule out foreign bodies,
as visual inspection and palpation alone are usually not sufficient
(eFig. 375.5A,B).
Lip lacerations require careful management to provide an esthetic
closure, especially if the laceration is deep or extends through
the vermilion border. Full-thickness lacerations require suturing
in layers. Careful attention to anatomic alignment of the vermilion
border is important. Through and through lacerations result in communication
between the skin and oral environment and are frequently contaminated. Suturing
of the intraoral laceration should precede skin suturing, and the
patient should be placed on a course of antibiotics effective against
staphylococcal organisms. Tongue lacerations are commonly seen in
children and usually result from a fall or blow to the chin. The
tongue has a profuse blood supply, and injury can result in copious
bleeding. Most tongue lacerations with approximating borders will heal
without suturing; however, tears that leave unapproximated borders,
such as at the tip or along the lateral borders, require suturing.
Gingival degloving occurs when both the gingival tissue and periosteum are
pulled away from its normal position around the tooth, exposing
underlying bone (Fig. 375-3). These injuries
require careful repositioning of the gingival tissue and stabilization
with sutures.
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Electrical burns of the mouth are an infrequent but serious event
with varied interdisciplinary treatment approaches.25 One
study documented that approximately 3.5% of referred burns
involved the mouth and commissure.26 These injuries,
which affect children mostly under the age of 3, typically occur
when a child sucks on the end of an extension cord or bites through
the insulation of a live wire. The best way to avoid these accidents
is to take preventive measures against them by using safety caps
on all electrical outlets and heavy, solid insulation on all electrical
cords. Immediate treatment should address systemic complications such
as shock and hemorrhage. The wound requires careful daily débridement
of the necrotic tissue, approximation of the wound edges with adhesive
straps, and topical antibiotics. Complications may result from electrical
burns of the oral commissure such as bacterial infection, disfiguration,
microstomia, and discoloration of teeth.27 Labial
artery bleeding is a late complication of oral commissure burns.27 If
the oral commissure is involved, using an intraoral splint (eFig. 375.6A,B)28 to
prevent labial adhesions and to limit the oral opening can decrease
the need for commissuroplasty.29
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Injuries to teeth can be divided into fractures and displacements.
The International Association of Dental Traumatology has established
guidelines for their evaluation and management.30 Fractures
of teeth are classified by the extent of the lost tooth structure.
Most of these injuries require a thorough extra- and intraoral examination
as well as dental radiographs. Both intraoral and extraoral radiographic
evaluation is important to fully evaluate the extent of the injury.
In addition, a baseline radiograph is essential for comparison to
later radiographs to evaluate healing and the status of the periapical tissues,
should symptoms of pulpal necrosis arise.
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Uncomplicated fractures are limited to the enamel and dentin
of the tooth’s crown. If only the enamel is affected, the
fractured edge appears white (Fig. 375-4).
However, if both the enamel and dentin are involved,
the fractured edge appears yellow in the center (Fig.
375-5). These relatively superficial fractures
are nonurgent. Treatment consists of either smoothing the rough
edges if limited to the enamel or restoring the fracture with a
tooth-colored resin if cosmetics are an issue. When the dentin is
exposed, the tooth may be sensitive to thermal changes. The exposed
dentin needs to be covered within a few days with a temporary resin “bandage” to
diminish the irritation of the pulpal tissues, which can lead to
pulpal necrosis if left untreated. The tooth can be restored completely
at a later time by bonding a complete resin restoration to the fracture
site (eFig. 375.7A,B). If the fractured segment
is available, bonding of the two segments is possible and can result
in excellent esthetics (eFig. 375.8A–C).
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Complicated fractures extend beyond the dentin and need immediate
referral to a dentist. These fractures extend into the pulpal tissues
and/or root of the tooth, as evidenced by a red area visible
near the center of the fracture (Fig. 375-6). Pulpal/endodontic
therapy (partial or total root canal treatment) should be instituted
to avoid necrosis of the pulp and eventual alveolar abscess formation.
The final restoration of the fracture is accomplished at a later time.
Root fractures can be diagnosed by excessive mobility of the tooth
with radiographic signs of a fracture anywhere along the root (Fig. 375-7 and eFigs. 357.11B–D).
The fractured segments must be stabilized with a splint fabricated
by attaching the involved tooth to the adjacent uninvolved teeth
using resin and orthodontic wire (eFig. 375.9).
Splints should remain in place for at least 4 weeks, and root canal
therapy may be necessary if there is necrosis of the pulp.
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Displacement injuries to teeth include (1) concussion—where
the tooth is tender to percussion because of edema or inflammation
of the periodontal ligament; (2) subluxation—the tooth
is not displaced but is mobile within its socket; (3) luxation—the
tooth is displaced from its alveolar socket (either intruded, extruded,
or laterally displaced; Figure 375-8); and
(4) avulsion—the tooth is totally displaced from its socket.
The goal of treatment for displacement injuries is normal reattachment
of the periodontal ligament to both the tooth and the alveolar bone.
This is best accomplished by reducing the displacement and stabilizing
the tooth for 2 to 4 weeks, depending on the type of displacement;
maintaining good oral hygiene of the surrounding soft tissues; performing chlorhexidine
oral rinses; and minimizing chewing with the involved tooth or teeth
during this healing period. Normal reattachment is usually complete
at 3 weeks, and the prognosis for pulpal survival can be made 3
months after trauma. Pulpal survival varies in likelihood, depending
on the severity of displacement. Intrusions and avulsions have the
highest likelihood of needing root canal therapy. The ultimate prognosis
of displacement injuries is good if treatment is both prompt and
appropriate, with close follow-up for at least 1 year. Alveolar
fractures involve the displacement of multiple teeth along with
a bony segment (Fig. 375-9 and eFig. 375.10)
and need reduction with local anesthesia and splinting for at least
4 weeks. The risk of pulpal necrosis of the involved teeth is extremely
high with the need for root canal therapy almost guaranteed.
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The survival of an injured tooth depends on the normal reattachment
of its periodontal ligament to the surrounding bone and on the preservation
of the vitality of its pulpal tissues. Abnormal reattachments of a
tooth to its alveolar bone include resorption of the root surface,
which results in increased tooth mobility, and ankylosis of the
root surface, which results in decreased tooth mobility. Some of
these abnormal reattachments are often irreversible and can result
in loss of the tooth. Devitalization and infection of the pulp may
be manifested clinically as discoloration of the crown (eFig. 375.11), pain, excessive mobility,
and/or alveolar abscess formation (eFig.
375.12). If the dental pulp becomes nonvital, root canal therapy
is the treatment of choice with an excellent prognosis.
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Permanent teeth that are avulsed should be reimplanted immediately.
Radiographic examination is vital to ensure that the missing tooth
is not totally intruded rather than avulsed or that part of the
tooth still remains in the socket. Avulsed primary teeth should
not be reimplanted because of the risk of infection to both the
primary tooth and the developing permanent dentition. In addition,
the complex treatment that is required is contraindicated in the
very young child, and the primary incisors are not critical to the
developing dental arch.
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The protocol for immediate on-site reimplantation of avulsed
permanent teeth is as follows:
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1. The tooth should always be held by the crown and
not the root to avoid damage to the periodontal ligament.
2. If uncontaminated, the tooth is gently but firmly placed back
into the socket with digital pressure. If contaminated, the tooth should
be rinsed with running water or saline before reimplantation. If
resistance is met in reimplanting the tooth or if the child will
not cooperate, the tooth should be stored in appropriate storage
media such as Hank’s balanced salt solution (Save-A-Tooth
Kit, Phoenix-Lazerus, Pottstown, PA; www.save-a-tooth.com)
or milk until seen by a dentist. Alternative storage media include
saline or saliva. If the patient is able, they can keep the tooth
in their oral vestibule.
3. The replanted tooth should be stabilized by having the patient
bite on gauze or another readily available material until seen by
a dentist.
4. The patient should be transferred either to a hospital emergency
room with dental staff coverage or a dental office for immediate
splinting.
5. Antibiotics should be prescribed and tetanus immunization
status should be reviewed.
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The prognosis for the reimplanted permanent tooth is based on
the extra-alveolar period, since the cells of the periodontal ligament
usually are unable to survive for more than 10 to 15 minutes out
of a physiological solution. Immediate reimplantation at the injury
site is critical to minimize this extra-alveolar period. Since Hank’s
solution is not readily available in most situations, milk can be
used as a storage media, since it also can maintain the vitality
of the periodontal ligament of the tooth. Alternatively, placing
the tooth in saline or back in the patient’s oral cavity
can help to maintain the ligament’s vitality. Once reimplantation
is complete, stabilization and root canal therapy are required.
Prognosis for the avulsed tooth is favorable if the reimplantation has
been completed within 30 minutes of the avulsion or if the tooth
has been stored in the appropriate medium before reimplantation.
If the extra-alveolar period is greater than 30 minutes and the
periodontal ligament is allowed to dry, the prognosis is extremely
poor. More than 90% of these teeth become irreversibly
ankylosed (fused to the bone) and eventually require extraction
due to continued growth of the surrounding teeth with relative submergence
of the affected tooth (eFig. 375.13).
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Sequelae of trauma to primary teeth can result in a myriad of
clinical presentations. The primary tooth’s crown can change
color: gray indicates either extravasation of blood into the crown
or necrosis of the pulpal tissues, yellow-opaque indicates calcification
of the pulpal contents, and pink indicates internal resorption (eFig. 375.14). Periapical infections can
result in premature root resorption and excessive mobility of the
tooth. Conversely, the tooth may become ankylosed and lose its normal
mobility.
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The traumatic incident itself or post-trauma sequelae can result
in damage to the primary tooth’s succedaneous permanent
tooth. These defects include hypoplasia to the crown (Turner’s
hypoplasia; Fig. 375-10), root
deformities, and/or disturbances of eruption (accelerated,
delayed, and/or ectopic; eFig. 375.15).
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