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PEDIATRIC
DENTISTRY

DENT 444
DENTAL TRAVMATOLOGY
Epidemiology and etiology of
dental trauma
Case history and clinical examination of
traumatized patients

Prof.Dr. Senem SELVİ KUVVETLİ

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COURSE INFORMATON
Course Title Code Semester T+P+L Hours Credits ECTS
DENTAL TRAUMATOLOGY DENT 444 8. Spring: 1 1
1+0+0

Language of Instruction English

Course Level Undergraduate

Course Type Compulsory

Course Coordinator Assoc. Prof. Dr. Senem Selvi Kuvvetli

Prof. Dr. Senem Selvi Kuvvetli

Prof. Dr. Dilhan İlguy
Prof. Dr. Jale Tanalp
Instructors Prof. Dr. Esra Can
Assist.Prof.Dr. Ebru Özkan Karaca
Dr. Yunus Emre Özden
Prof.Dr. Ahmet Arslan
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The aim of the course is to provide competency in the diagnosis,

treatment and follow up procedures of traumatized primary and
GOALS
permanent teeth. With a multidisciplinary approach, the concept of
dental trauma is introduced from different perspectives.

The course is conducted by the collaboration of the Department of

Pediatric Dentistry, Dentomaxillofacial Radiology, Endodontics,
Restorative Dentistry, Prosthodontics and Oral and Maxillofacial Surgery.
CONTENT The course aims to provide competency in the diagnosis, treatment and
follow-up procedures of traumatized primary and permanent teeth and
is comprised of didactic lectures as well as practical portions where
teaching is conducted using a problem based approach.
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Learning Outcomes PEDIATRIC
DENTISTRY
1)Describe the principles of assessment and management of maxillofacial trauma.

2) Interpret radiological findings in traumatic dental injuries.

3) Identify the effects of trauma on dental hard tissues and oral soft tissues.

4) Perform urgent treatment and plan the appropriate treatment strategy for the traumatized teeth
in both dentitions and evaluate the need for referral to a specialist

5) Evaluate a trauma case from the standpoint of multiple disciplines and draw a treatment strategy
accordingly.

6) Draw a reasonable time schedule for further follow-ups after the treatment of a traumatic injury
to the dental tissues.

Teaching Methods: 1: Lecture, 2: Question-Answer, 3: Discussion, 4: Presentation, 5:Simulation, 6: Video, 7:

Applications, 8:Case Study

Assessment Methods: A:Written exam, B: Multiple choice , C:Filing the blank D:False and true, E: Oral Exam F:
Portfolio, G: Contribution of course activities H:Homework
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INTRODUCTION

Epidemiology
Etiology
History and examination
 Dental history
 Medical history
 Extra-oral examination
 Intra-oral examination
 Radiographic examination
 Photographic records
 DEPT. OF
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INTRODUCTION DENTISTRY

Dental trauma in childhood and adolescence is common.

In a Swedish study, 83% of all individuals with acute dental

trauma were found to be younger than 20 years of age.

Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic

tooth injuries in children and adolescents in the county of Västmanland,
Sweden. Swed Dent J 1996;20:15–28.
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INTRODUCTION DENTISTRY

Injuries to primary or permanent teeth can appear

rather severe, particularly when associated with
trauma to supporting tissues.
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INTRODUCTION DENTISTRY

A 3-year-old boy with swollen upper lip, lacerated frenulum,

gingival bleeding, and palatal luxation of the right central and
lateral incisors.
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INTRODUCTION DENTISTRY

The patient has had an impact where the force has been
transmitted through the upper lip to the teeth and the alveolar
process. Note the lip laceration and abrasion and the displacement
of the right central and lateral incisors.
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INTRODUCTION DENTISTRY

• The situation is distressing for both the child and

parents.

• It is important that the dentist and the other

members of the dental team are well prepared to
meet the many complex and challenging problems in
the care of dental emergencies.
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INTRODUCTION DENTISTRY
 DEPT. OF
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INTRODUCTION

Epidemiology
Etiology
History and examination
 Dental history
 Medical history
 Extra-oral examination
 Intra-oral examination
 Radiographic examination
 Photographic records
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EPIDEMIOLOGY DENTISTRY

• Trauma to the oral region occurs frequently and

comprises 5% of all injuries for which people seek
treatment.

• In preschool children, head and facial non-oral injuries

make up as much as 40% of all somatic injuries.
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EPIDEMIOLOGY DENTISTRY

• In the age group 0-6 years, oral injuires are ranked as

the -second most common injury covering 18% of all
somatic injuries.
• Of the oral injuries, dental injuries are the most
frequent, followed by oral soft tissue injuries.
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EPIDEMIOLOGY DENTISTRY

• The majority of dental injuries in the primary and

permanent dentitions involve the& anterior teeth,
especially the maxillary central incisors. to

1 may cont

Distribution of injuries of the most frequently injured

permanent teeth: 97% of all injuries affected the incisors.
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EPIDEMIOLOGY DENTISTRY

• A study from Denmark showed that 30% of children

had suffered traumatic dental injuries in the primary
dentition and 22% in the permanent dentition.

Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and
permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235–9.
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EPIDEMIOLOGY DENTISTRY

-
Primary Dentition 2 -4 years

Permanent Dentition
-
②
8-10 years
--

Skaare AB, Jacobsen I. Dental injuries in Norwegians aged 7–18 years.

Dent Traumatol 2003;19:67–71.
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EPIDEMIOLOGY DENTISTRY

• In the permanent dentition, the most accident-prone

time is between 8 and 10 years of age.

Skaare AB, Jacobsen I. Dental injuries in Norwegians aged 7–18 years.

Dent Traumatolgy 2003;19:67–71.
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EPIDEMIOLOGY DENTISTRY

• Boys appear to sustain injuries to permanent teeth

twice as often as girls.
• Even in preschool children, trauma in boys is reported
to outnumber cases in girls.
GIRLS
BOYS
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Most common injuries in:

Primary Dentition -
Concussion, Subluxation, Luxation

A 3-year-old child with a combination of injuries

to her upper anterior teeth
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Most common injuries in:

Permanent Dentition
=>
Uncomplicated
-
Crown Fractures
-

A fracture of the upper left central incisor

involving enamel and dentine
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INTRODUCTION

Epidemiology
Etiology
History and examination
 Dental history
 Medical history
 Extra-oral examination
 Intra-oral examination
 Radiographic examination
 Photographic records
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ETIOLOGY DENTISTRY

Etiological factors include:

 Falls
-

 Playing and running

-

 Sports accident
-

 Bicycle accident
-

 Road traffic accident

-

 Child abuse (emotional,

physical, neglect)
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ETIOLOGY DENTISTRY

Important aspects of child physical abuse;

• Most often the child is between 1 and 3 years.
• There is usually a significant delay between injury and
presentation at the clinic.
• There are often signs of multiple different bruises obviously
sustained over a period of time.
• Approximately half of the children have orofacial injuries.
• The child’s history differs from the parents’, or history given by
parents does not fit the clinical findings.
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ETIOLOGY DENTISTRY

• In the permanent dentition most injuries are caused by falls

and collisions
-
while playing and running, although bicycles
are a common accessory.

• The place of injury varies in different countries according to

local customs, but accidents in the school playground
remain common.

• Sports injuries usually occur in the teenage years and are

commonly associated with contact sports.
 DEPT. OF
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ETIOLOGY DENTISTRY

yatkınlaştırıcı
-
>
PREDISPOSING FACTORS
 Angle class II div 1
 Increased overjet
3-6 mm…. Double the risk
 >6 mm …..Triple the risk

 Incompetent lip closure

 Improperly fitted mouthguard….twice the risk
 DEPT. OF
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ETIOLOGY DENTISTRY

Accidental injuries can be the result of either

direct or indirect trauma.
Direct trauma Indirect trauma

Involves the--
tooth directly Seen when the lower arch forcefully
Favours anterior teeth close against the upper arch.
E
Favours --
crown and crown-root
fracture of the premolar and molar
region.
 DEPT. OF
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ETIOLOGY Indirect trauma DENTISTRY

Direct trauma
 DEPT. OF
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DENTISTRY

INTRODUCTION

Epidemiology
Etiology
History and examination
 Dental history
 Medical history
 Extra-oral examination
 Intra-oral examination
 Radiographic examination
 Photographic records
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DENTAL HISTORY DENTISTRY

When did the injury occur?

a
• The time interval between injury and treatment can influence
both the treatment procedure and the expected outcome.
Thus, optimal repositioning of an extruded permanent tooth
is difficult if treatment is delayed. The time factor is also very
critical for the prognosis of replanted teeth.
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DENTAL HISTORY DENTISTRY

Where did the injury occur?

• The place of accident also provides information on

the need for tetanus prophylaxis in replantation
cases.
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DENTAL HISTORY DENTISTRY

How did the injury occur?

• Physical abuse or neglect?

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DENTAL HISTORY DENTISTRY

Was there a period of unconsciousness?

• If so, for how long? Is there headache? Amnesia?

Nausea? Vomiting? Excitation or diffiulties in
focusing the eyes? These are all signs of brain
concussion and require medical attention.
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DENTAL HISTORY DENTISTRY

Is there any disturbance in the bite?

-
• Disturbance
-
in the occlusion can imply>
luxation injury,
alveolar fracture, jaw fracture, or luxation or fracture of
-

the temporomandibular joint.

• Limitations of mandibular movement or mandibular

deviation on opening or closing the mouth indicate that
the jaw might be fractured.
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DENTAL HISTORY DENTISTRY

Previous dental history?

• Previous trauma can affect pulpal sensibility tests and the

recuperative capacity of the pulp and/or periodontium.
Alternatively, are there suspicions of physical abuse?
Previous treatment experience, age, and parental/child
attitude will affect the choice of treatment.
 DEPT. OF
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MEDICAL HISTORY DENTISTRY

Congenital heart disease, a history of rheumatic fever, or

severe immunosuppression?

• These may be contraindications to any procedure that is

likely to require prolonged endodontic treatment with a
persistent necrotic/infected focus.

• Not all congenital heart defects carry the same risks of

bacterial endocarditis.
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MEDICAL HISTORY DENTISTRY

Bleeding disorders? Hemophilia?

• Very important if soft tissues are lacerated or teeth

are to be extracted.
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MEDICAL HISTORY DENTISTRY

Allergies?

• Penicillin allergy requires alternative antibiotics.

Tetanus immunization status?

• Referral for tetanus toxoid injection is necessary if there is soil

contamination of the wound and the child has not had a
‘booster’ injection within the last 5 years.
 DEPT. OF
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EXTRAORAL EXAMINATION DENTISTRY

 When there are associated severe injuries a general

examination is made with respect to signs of shock (pallor,
cold skin, irregular pulse, hypotension), symptoms of head
injury suggesting brain concussion, or maxillofacial fractures

 Antibiotics and/or tetanus toxoid may be required if wounds

are contaminated.
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EXTRAORAL EXAMINATION DENTISTRY

• Note is taken of swelling,

bruises, or lacerations to the
face and lips.

• Lacerations will require careful

debridement to remove all
foreign material and suturing.
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EXTRAORAL EXAMINATION DENTISTRY

• Crown fracture with associated

swollen lip and evidence of a
penetrating wound suggests
retention of tooth fragments within
the lip.

• Clinical and radiographic

examinations should be undertaken.
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DENTISTRY

A 12-year-old child presented with an enamel and dentine fracture of

the upper right permanent central incisor.
The lower lip was swollen with a mucosal laceration.
A lateral radiograph confirmed the presence of tooth fragments in the lip.
Fragments were retrieved from the lip under local anaesthesia.
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DENTISTRY
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INTRA-ORAL EXAMINATION DENTISTRY

• Laceration, haemorrhage, and swelling of the oral

mucosa and gingiva.
• Any lacerations should be examined for tooth
fragments or other foreign material.
• Lacerations of lips or tongue require suturing, but
those of the oral mucosa heal very quickly and may
not need suturing.
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INTRA-ORAL EXAMINATION DENTISTRY

• Abnormalities of occlusion, missing, displaced or

loosened teeth, fractured crowns, or cracks in the
enamel should be noted.

• The following signs and reactions to tests are

particularly helpful:
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INTRA-ORAL EXAMINATION DENTISTRY

Mobility

Degree of mobility is estimated in a horizontal and a

vertical direction. When several teeth move together en
bloc, a fracture of the alveolar process is suspected.
Excessive mobility may also suggest root fracture or
tooth displacement.
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INTRA-ORAL EXAMINATION DENTISTRY

Reaction to percussion

• In a horizontal and vertical direction compared with a

contralateral uninjured tooth.
• A duller note may indicate root fracture.
• Tenderness to percussion indicates damage to the
periodontal ligament.
• A high metallic tone implies that the injured tooth is
locked in bone.
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INTRA-ORAL EXAMINATION DENTISTRY

Colour of tooth

Early colour change associated with pulp breakdown is

visible on the palatal surface of the gingival third of the
crown. Discoloration may appear almost immediately
after the injury.
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INTRA-ORAL EXAMINATION DENTISTRY

Reaction to sensitivity tests

Thermal tests with warm gutta percha (GP) or ethyl

chloride (EC) are widely used. However, an electric pulp
tester (EPT) in the hands of an experienced operator is
more reliable.
 DEPT. OF
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INTRA-ORAL EXAMINATION DENTISTRY

• A positive response does not rule out later pulpal

necrosis.
• A negative response, while indicating pulpal damage,
does not necessarily indicate a necrotic pulp.
• The negative reaction is often due to a ‘shock-wave’
effect which damages the apical nerve supply. In such
cases the pulp may have a normal blood supply.
• In all sensitivity testing always include and document
the reaction of uninjured contralateral teeth for
comparison.
 DEPT. OF
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RADIOGRAPHIC EXAMINATION DENTISTRY

 Before a radiographic examination is carried out, a

clinical examination should establish the extent of the
trauma region.

 This area is then radiographed; ideally, the injury site

should be viewed from different angulations.
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DENTISTRY

(a) Clinical condition immediately after severe intrusive luxation of

the primary right central incisor.
(b) The occlusal exposure shows foreshortening of the intruded
tooth, indicating buccal displacement away from the permanent
follicle.
(c) This is evident in the lateral radiograph, since the apex of the
intruded incisor is forced through the buccal bone plate.
 DEPT. OF
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RADIOGRAPHIC EXAMINATION DENTISTRY

Periapical
 Reproducible ‘long-cone technique’ periapicals are
the best for accurate diagnosis and clinical audit.
 Two radiographs at different angles may be essential
to detect a root fracture.
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RADIOGRAPHIC EXAMINATION DENTISTRY

Occlusal

• This view detects root fractures when used inta-orally

and foreign bodies within the soft tissues when held
by the patient/helper at the side of the mouth in a
lateral view.
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RADIOGRAPHIC EXAMINATION DENTISTRY

Orthopantomogram
• This is essential in all trauma cases where underlying
bony injury is suspected.
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RADIOGRAPHIC EXAMINATION DENTISTRY

Photographic records

• Good clinical photographs are useful for assessing the

outcome of treatment and for medico-legal purposes.
Written consent must be obtained, and in the case of
digital images uncropped originals must be held in an
appropriately secure format and location.