Dental injuries

Dental trauma to baby teeth

Trauma to primary teeth commonly occurs between 2-4 years of age. This at a time when children begin to walk but are not very stable on their feet. The most commonly involved teeth are the primary maxillary central incisors.

So why it it important to seek dental help following dental trauma to primary teeth?

Injuries to primary teeth have the potential to disturb the development and health of the underlying permanent teeth. In order to achieve an optimal treatment outcome, a prompt assessment of the injury by a dentist is essential. The assessment would normally involve a thorough history, and detailed clinical and radiographic checks.
Paediatric dentists are skilled at saving injured primary teeth although they only do so provided there is no risk to the underlying permanent teeth, which have a lifelong functional and aesthetic importance.

Discoloured baby front teeth

Findings: Colour change is a common sign of primary tooth trauma and may range from yellow to grey to black.

Treatment objectives: Any colour change in a traumatized primary teeth indicates the necessity for clinical and radiographic assessment. Although colour changes do not necessarily require immediate treatment, discoloured primary teeth are more likely to undergo pathologic changes and should be kept under suprvision to ensure the best possible health of the developing permanent teeth.

Displaced Baby front teeth

The primary incisors may be displaced in several directions:
1) Intrusion: the tooth is pushed into the tooth socket and it looks shorter or absent.
2) Extrusion: the tooth is partly pushed out of its socket and it looks longer in length.
3) Lateral luxation: the tooth is displaced sideways, palatally or towards the lip.

Treatment objectives:

Intrusion injuries present a high risk of damage to the developing permanent tooth in the alveolar bone. Therefore the treatment options depend on the relationship between the root of the primary tooth and the crown of the developing permanent tooth. X-rays are necessary to determine this relationship. If there is no evidence of a compromise to the developing permanent tooth, the primary tooth may be left to spontaneously re-erupt. However, the tooth should be extracted if it has not re-erupted within six months.

If the intruded tooth appears to have compromised the developing tooth, it should be carefully extracted immediately, to avoid any further damage.

For extruded or laterally luxated teeth, the tooth should always be monitored even if there has only been a mild displacement. It may need to be extracted if the displacement is severe.

With any type of displacement, a long term clinical and radiographic follow-up is essential to monitor the vitality of these teeth and to ensure that there is no delayed infection of the root which can damage the developing permanent tooth.

Fractured baby front teeth

Findings: Fracture of primary tooth may occur in the crown or the root of the tooth. The crown fracture may involve the enamel, enamel and dentine or enamel, dentine and the nerve (pulp) of the tooth.

Treatment objectives: The rough edges of simple enamel fractures can be smoothed off. If there is enamel-dentine fracture, the crown of the tooth needs to be restored to protect the pulp of the tooth. If the fracture also involves the pulp of the tooth, then, depending on the stage of development of the primary tooth, the tooth may need to be extracted or have root canal treatment carried out.

Avulsed baby front incisors

Findings: This is complete displacement of a tooth out of its bony socket. There may be associated soft tissue injuries to the lips and gums.

Treatment objectives: Avulsed primary incisors SHOULD NOT be re-planted as this may cause damage to the developing permanent tooth underneath.

The alvusion of the primary tooth itself may cause damage to the developing permanent tooth underneath. This may be in the form of disturbance in enamel formation or disturbance in the eruption time of the permanent tooth.

Baby front tooth root fracture 

Findings: This is a rare occurrence, however when it occurs, the primary tooth may appear displaced or mobile.

Treatment objectives: If the coronal fragment is very mobile or severely displaced, then this require extraction. The remaining fractured root should be left undisturbed if deep in the bony socket. Attempts to remove deep apical fragments can damage the permanent tooth underneath. The apical fragment is usually resorbed physiologically.

Paediatric dental trauma – permanent teeth

Dental trauma most often occurs to upper incisors, usually between 8-12 years of age, and is more common in boys. These injuries are most commonly related to falls, fights, sporting injuries and road traffic accidents.

At this age the root development of the incisors is not yet complete, and prompt referral to a Paediatric Dentist is essential for immediate assessment and care. This is to optimise the survival of the nerves of teeth and therefore their continued development. If there has been damage to the nerve or blood supply of the tooth, long term follow-up with possible treatment may be necessary.

Avulsed permanent incisor

Findings: The tooth is completely displaced from the socket. Treatment objectives: To replace the tooth as soon as possible (unless this is contraindicated due to a compromising medical condition which would require antibiotic cover prior to any dental treatment).

The survival of avulsed teeth depends very strongly on the length of time the tooth is out of the mouth and how it is stored. The best survival outcome is for teeth that are replanted immediately. If the tooth is out of the mouth for more than 5 minutes, it must be kept moist to prevent further damage to the dental cells. The tooth may be stored in fresh cold milk, in the mouth, or in physiologic saline.

The tooth must not be handled by the root and should not be scrubbed to remove dirt. Holding the tooth by the crown, it can be gently washed with saline or sterile water followed by re-implantation. It should then be held in place by biting on a clean handkerchief and the patient taken to a dentist immediately.

This tooth should then be splinted for 7-10 days and the patient should be given appropriate antibiotics, a mouthwash and referred for a tetanus prophylaxis as required.

The follow-up treatment depends on the stage of root development of the tooth.

Displaced permanent incisors

Findings: Displacement of the tooth may be seen as one of the following;
a) Partial displacement of tooth out of bony socket (the tooth looks longer).
b) Partial displacement of tooth into the bony socket (the tooth looks shorter).
c) Displacement of the tooth sideways.

Treatment objectives: The main objectives are to re-position these teeth into the correct position and stabilize them to prevent further damage to the supporting structures, nerve and blood supply of the tooth/teeth.

The timing of the re-positioning may be immediate or delayed, and is dependent upon a number of factors.

The displaced teeth will require long term follow-up with X-rays and may require root canal treatment if there has been an irreversible damage to the nerve and blood supply of the teeth.

Fractured permanent incisors

Findings: The fracture may involve one or all of the following dental tissues: enamel, dentine, pulp (nerve) of the tooth.

Fracture of enamel and dentine, or enamel, dentine and pulp is usually associated with sensitivity to cold air and pain.

Treatment objectives: The main objective following this type of injury is to maintain the vitality of the pulp and prevent pain.

If the nerve of the tooth is not involved, then the tooth can be built-up with tooth-coloured filling material. If however, the nerve is exposed, depending on size of exposure and time since it occurred, the nerve will need to be treated.

In most cases, even if the nerve is removed, the tooth can be restored to almost the original shape. The aesthetics of these teeth are usually slightly compromised until the mid-teens when advanced restorative work can be carried out.

In the meantime all efforts should be concentrated on saving the traumatized tooth and monitoring the root development using X-rays.

Permanent tooth root fracture

Findings: The traumatized tooth may look normal, have increased mobility or the tooth may look displaced.

Treatment objectives: Multiple dental X-rays are necessary to assess the level and extent of the fracture.

Some root fractures require immobilization, and prompt treatment of such fractures increases the chance of healing and hence tooth survival.

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