Dental trauma, treatments
The treatment of dental trauma in the primary dentition is different from the treatment indicated in the permanent dentition. The proximity of the root of the injured temporal tooth and the permanent tooth germ should be weighed. We must avoid with our treatment any damage that may affect the permanent teeth.
For the selection of the treatment for dental injuries in the pediatric patient, we will value, among other factors, the maturity of the patient and the time remaining for the replacement of the damaged tooth . All patients who have suffered a dental trauma, whether adult, child or adolescent, should undergo a clinical examination and oral x-rays for the diagnosis and evaluation of the damage suffered.
Uncomplicated coronary fracture
The fracture involves enamel or enamel and dentin; the pulp is not exposed. The treatment in temporary dentition as in the permanent dentition will consist in softening the cutting angles of the edges of the enamel fracture and restoring the tooth with a filling (composite). If the dental fragment is available, it can be used for rehabilitation using the adhesives and composite for material that we use for the fillings.
Complicated coronary fracture
The fracture involves enamel, dentin and the pulp or nerve.
- Temporary dentition : when the exposure of the pulp, the time elapsed since the injury and external contamination are considered minimal, a treatment called pulp capping can be performed, which consists in the application of a material called calcium hydroxide (classically used material). seal this exhibition. Later a reconstruction of the tooth will be made with a filling. In children with temporary teeth with immature roots and still in development, it is advantageous to preserve pulpal or nerve vitality to facilitate the development of the root. The techniques to be taken into account will be the nerve covering without removing the tissuevasculo-nervosa (pulp) or partial pulpotomy elimination of the tissue contained inside the pulp chamber, preserving the vasculo-nervous tissue from root canals. This treatment is also of choice in children with fully formed roots. These treatments should always be considered before extraction or extraction.
- Permanent dentition : in young patients with immature roots, in the process of formation, it is advisable to preserve the pulpal vitality by means of pulp-coating or partial pulpotomy . Treatments that we have just mentioned for temporary teeth. In adult patients, treatment of the root canal or endodontics (killing the nerve) may be the treatment of choice, although pulp lining or partial pulpotomy are also valid options. In extensive coronary fractures a decision must be made if another treatment other than extraction is feasible.
The fracture involves enamel, dentin and root structure; the pulp may or may not be exposed.
- Temporary dentition : Extraction is the recommended treatment. Care must be taken to avoid trauma to the underlying permanent tooth germs.
- Permanent dentition : the treatment recommendations are the same as for complicated fractures of the pulp capping crown and partial pulpotomy in patients with immature permanent teeth or endodontic treatment in adults, and tooth extraction as a last resort.
The coronary fragment is mobile and may be displaced.
- Temporary dentition : the fracture is usually located in the middle or apical third of the root. If the coronary fragment is displaced, extract only this portion of the tooth. The end fragment of the root or apical must be left so that it is physiologically reabsorbed.
- Permanent dentition : reposition, if displaced, the coronary segment as soon as possible. Stabilize the tooth with a flexible splint (joining the tooth to neighbors, with glass fibers or wire and composite) for 4 weeks. If the radicular fracture is near the cervical area or neck of the tooth, stabilization is beneficial for a longer period of time (up to 4 months). And follow up for a year.
The fracture compromises the alveolar bone. The segment that contains the tooth is mobile and generally displaced. Interference is often noticed, that is, a dental stop is perceived in lateral movements of the mouth. Both in the temporary and permanent dentition, any displaced fragment must be repositioned and splinted. Stabilize the segment for 4 weeks.
Supportive tissue injuries
Concussion and subluxations, in both situations no special treatment is required, it will be enough to keep the tooth at rest, avoiding contact with the opposite when closing the mouth or biting. If necessary, the tooth will be touched up by polishing the contact surface. Follow-up by the dentist. They can also be splinted or stabilized for 2 weeks in the case of subluxations.
The tooth appears elongated and is excessively mobile.
- Temporary dentition : careful reduction or leaving it for spontaneous alignment, are considered acceptable treatment options. In a severe extrusion in a fully developed temporary tooth, extraction is the treatment of choice.
- Permanent dentition : reposition the tooth by reinserting it gently into the alveolus. Stabilize the tooth with a flexible splint for 2 weeks. Subsequent assessment of endodontic treatment if vascular-nervous tissue injury occurs and may manifest itself with a change in tooth color.
The tooth is displaced, usually towards the inside of the mouth. Often it will be immobile.
- Temporary dentition : if there is no occlusal interference, the tooth is allowed to reposition spontaneously. When there is occlusal interference, with the use of local anesthesia, the tooth can be gently repositioned by pressure from the outside of the mouth inward. In severe displacements, when the crown is dislocated in a labial position, extraction is the treatment of choice. If there is minor occlusal interference, slight wear is indicated.
- Permanent dentition : reposition the tooth with forceps and reposition it gently in its original location. Stabilize the tooth with a flexible splint for 4 weeks. Observation of the vitality of the tooth (vascular-nervous tissue that has been injured in the dislocation). If there is significant involvement with necrosis, the endodontic treatment should be applied.
The tooth is frequently displaced through the bone table away from the mouth, it may be impacting the successor’s tooth germ in the event that it occurs in a temporary tooth. We talk about permanent dentition:
- Tooth with immature roots : allow spontaneous repletion to occur. If movement is not observed in the 3-week period, a rapid orthodontic replacement is recommended .
- Tooth with mature roots : The tooth must be repositioned orthodontically or surgically as soon as possible. The pulp will probably be necrotic (dead), so the endodontic treatment is necessary using a temporary filling with calcium hydroxide, which allows the natural resorption of the temporary teeth.
The tooth is completely out of the alveolus. The radiographic examination is essential to verify that the lost tooth is not intruded. It is not recommended to reimplant avulsed temporary teeth.
The prognosis of reimplantation of the tooth is bad when it is done after one hour and will end with the loss of the tooth. Immediate reimplantation has a better prognosis, being able to vary the vitality or not of the vasculo-nervous tissue, but the tooth will remain in the mouth producing an ankylosis by bone union of the tooth to the bone due to calcification of the periodontal ligament.
Reimplantation in less than an hour and with the tooth preserved in a moist environment has a prognosis between the two situations mentioned above. The subsequent reabsorption of the root that results in tooth loss may not occur.
- The tooth will be cleaned with serum and reimplanted in its place.
- It will stabilize with splinting of the tooth.
- The tetanus vaccine will be administered if it is not properly vaccinated.
- Antibiotic treatment, analgesics and use of topical antiseptics such as chlorhexidine on gum lesions.
- Soft diet to avoid use or trauma on the injured tooth.
In case of permanent teeth and mature roots if reimplantation is not immediate, the root canals and the pulp chamber of vascular-nervous tissue will be cleaned. waiting for a time that can be a year to end the endodontics with gutta-percha, material that replaces the pulp tissue.
In the same situation but with permanent teeth with immature roots, it will be observed that the pulp tissue was not necroseed, since this possibility exists. Otherwise, the same treatment will be performed as in the case of permanent teeth with mature roots.