Primary Teeth
Dental Management of Traumatic Injuries to the Primary Dentition
Clifton O. Dummett, Jr., DDS, MSD, MEd
Copyright 2000 Journal of the California Dental Association.
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There is considerable information on traumatic injury management of permanent teeth. However, there are no conclusive guidelines for treating traumatized primary teeth. This article will summarize a number of issues relative to primary dentition trauma and provide a system for treatment.
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There is considerable information on traumatic injury management of permanent teeth along with specialty-generated treatment guidelines and protocols. In spite of numerous epidemiological studies and excellent review articles on primary tooth trauma,1,2 there are no conclusive guidelines for treating traumatized primary teeth. The purpose of this article is to summarize a number of issues relative to primary dentition trauma and provide a system for treatment.
Epidemiologic Trends
Frequencies of primary tooth trauma range from 4 percent to 36 percent depending on the nature of the study and the country in which it was conducted.3,4 Falls account for the majority of such injuries.2 Soporowski and colleagues reported that 70 percent of lateral luxations in their sample were caused by falls.5 Peak indices for primary tooth trauma have been reported to occur between 1 and 2 years of age.6,7 Developmentally, children at this age are learning to walk and lack the coordination to minimize falls and avoid stumbling into furniture and other hard objects.
Boys are more likely to sustain primary tooth trauma than are girls, with frequency ratios ranging from 1.8-to-1 to 1.3-to-1.7,8 Maxillary primary incisors have the highest predisposition for traumatic injury. Soporowski and colleagues determined that the existence of class II primary molar occlusion did not increase the risk of luxation injury to the primary dentition. However, mean overjet values of greater than 4 mm increased the risk of primary tooth intrusion.5
Studies consistently demonstrate that most primary tooth trauma results in displacement injury.5,8,9 Borssen and colleagues, in their primary tooth sample, found that 74 percent demonstrated luxation injury in contrast to only 6.5 percent with coronal fracture and 1.5 percent with root fracture.8 The frequency of the types of luxation injuries in primary teeth differ somewhat among investigators with the combined categories of lateral luxation and subluxation being the most frequent (Table 1).
The major concern with primary tooth trauma is the potential for damage to the underlying permanent successor.11 This may occur directly from the injury or from the residual infection associated with the traumatized primary tooth.12 Andreasen and Ravn found that the child’s age at the time of injury was the most significant factor influencing the development of defects in succedaneous permanent teeth.13 They found that 60 percent children younger than 4 with traumatized permanent incisors demonstrated clinical and radiographic anomalies in their permanent successors.13 Intrusion and lateral luxation of primary teeth had the highest likelihood of damage to the underlying permanent teeth. Andreasen has listed a number of possible permanent tooth sequela from primary tooth trauma with localized enamel hypoplasia having the highest frequency:12
* Enamel hypoplasia (Figures 1 and 2);
* Crown dilaceration;
* Odontoma-like malformation;
* Bifid root;
* Vestibular root angulation;
* Lateral tooth angulation or dilaceration (Figure 3);
* Partial or complete arrest of root formation;
* Sequestration of permanent tooth germ; and
* Disturbance in eruption.
Comprehensive Assessment Issues
Assessment for the child who has sustained either primary or permanent tooth injury should be comprehensive and systematic so that a diagnosis can be made and treatment provided as efficiently as possible. A detailed history and the time elapsed since injury are important components in evaluating the involved tissues and degree of luxation. The parents are critical resources in this history-taking process because they are more reliable providers of information than are the children themselves.
The past medical history is imperative to determining the existence of chronic diseases or medical complications that could affect dental treatment. Central nervous system involvement must be ruled out by means of a simplified neurologic assessment as advocated by Croll and Schneider.14,15 Abnormal symptoms include loss of consciousness, nausea, vertigo, alteration in motor activity, rhinorrhea, headache, change in pupil size, change in reflexes, and alteration in sensory function. Completion of the tetanus inoculation series should be confirmed with the parents. If it is unclear whether the child is up to date with this series, he or she should be referred to a pediatrician for the administration of the appropriate tetanus booster.
The possibility of child abuse should also be ruled out. Mouden found that orofacial trauma was present in 65 percent of documented child abuse cases.16 Oral manifestations typically associated with child abuse include lacerated maxillary frenums, fractured teeth, luxated teeth, and avulsed teeth. The dentist may be one of the first in a series of health professionals to detect evidence of child abuse, particularly in dental trauma incidents. He or she is legally obligated to report such suspicions to social and legal authorities.
The dental examination should be comprehensive and its focus should extend beyond the dental injury. The possibility of facial fractures should be ruled out. Lacerated soft tissues should be cleaned of debris and blood to facilitate determining the extent of involvement. Deep lacerations may require suturing if wound tissue cannot be adequately approximated. Resistant behavior during assessment and treatment may require restraint by the parent in a knee-to-knee arrangement with the dentist or through the use of a restraining device such as a papoose board. Documentation of the status of all hard and soft tissues affected by the injury as well as tooth involvement is critical to the evaluation process. Wilson provided a systematic list of resources to be included in the evaluation and documentation process:2
* Parental information and consent regarding the possible need for restraint;
* Clinical evaluation;
* Radiographic evaluation;
* Photographic injury documentation;
* History with emphasis on elapsed time of injury occurrence;
* The ruling out of child abuse and neurologic involvement;
* Determination of the degree of behavioral cooperation;
* Notation of caries experience, history of previous trauma, and presence of habits; and
* Assessment of parental compliance indicators.
Pulp testing in the clinical evaluation process is of little value due to its poor correlation with histologic status and the difficulty of the young child to provide reliable responses. Radiographic examination tends to be the best source of information in diagnosing the extent of the traumatized hard tissues as well as a good means of documenting the post-treatment outcomes of traumatic injury management. Maxillary and mandibular periapical radiographs are important in identifying the presence of post-traumatic dystrophic changes in afflicted teeth such as pathologic root resorption and calcific metamorphosis (Figure 4). Parental and/or physical restraints can be effective adjuncts with the precommunicative or behaviorally difficult child. A lateral anterior X-ray film oriented parallel to the sagittal plane and perpendicular to the central ray is an excellent resource for determining the anterior-posterior relationship of an intruded or laterally luxated primary incisor relative to its underlying permanent successor (Figure 5).
Tooth Fractures
Enamel fractures in primary teeth are managed by either smoothing the sharpened margins of the fractured areas or restoring the missing tooth portion with composite resin. These teeth should be monitored for clinical and radiographic signs of pathology. Discoloration is a significant clinical entity associated with traumatized primary teeth. Borum and colleagues noted that 51.4 percent of 395 primary teeth discolored after being traumatized.9 Yellow discoloration was the most frequently seen in this group and was commonly associated with pulp canal calcification (Figure 4). Permanent gray discoloration had the highest correlation with pulp necrosis9 (Figure 6). Soxman and colleagues histologically evaluated discolored primary anterior teeth that were traumatized and found no correlation between coronal shade and histologic pulp status. Furthermore, they found that 78 percent of the discolored teeth had pulps with irreversible dystrophic changes.17 Traumatized primary teeth with discoloration should therefore be closely monitored for increased potential for development of pulpal pathology.
Enamel-dentin fractures in primary teeth are managed by sealing the exposed dentin tubules with either a glass ionomer or dentin-bonding agent in conjunction with composite resin restoration. With instances of extensive crown loss, the afflicted tooth can be restored with a full-coverage restoration such as a composite resin "strip" crown. Another alternative is a stainless steel crown with esthetic modifications such as open-faced composite resin window or esthetic veneer to the labial metal surface. As previously mentioned, postoperative monitoring for clinical and radiographic pathology is also indicated.
Complicated coronal fracture management depends on the extent of pulpal and hard tissue involvement. Coronally fractured primary teeth that have sustained pulp exposures with roots that have been resorbed to a greater extent than one half the total root dimension should be extracted. Conservation of radicular pulp tissue with varying degrees of coronal pulp tissue removal followed by sealing against microleakage is the ultimate treatment goal in primary teeth that are not eminent of exfoliation. In spite of strong opinions against direct pulp capping in primary teeth, Jeppsen, Kopel, and the American Academy of Pediatric Dentistry Guidelines on Pulp Therapy have supported treatment of clean pinpoint exposures with this technique in selected cases.18-20 Ram and Holan reported short-term success with a partial pulpotomy technique for a primary central incisor that sustained a complicated coronal fracture in a 14-month-old child.21 The procedure consisted of removing 1 to 2 mm of pulp tissue at the exposure site, followed by placing calcium hydroxide and restoring the tooth. Cvek has shown this technique to have the highest success rate of all vital pulp therapy techniques in permanent teeth.22 Similar outcomes for primary teeth based on controlled studies, however, have yet to be demonstrated.
Coronal pulpotomy is the most widely advocated treatment for exposed primary pulps because of its consistently reported higher success rates when compared with direct pulp capping.23 In instances when the exposed pulp has been contaminated from extensive crown loss or treatment time intervals greater than 24 hours, complete pulpectomy or extraction may provide the best insurance against residual infection (Figure 7). The complete pulpectomy in primary teeth differs from conventional permanent tooth endodontics in that the canals must be obturated with a resorbable material such as zinc-oxide-eugenol, calcium hydroxide, or iodoform-containing pastes to facilitate the normal exfoliation process.
Crown-root fractures in primary teeth are best treated by extraction unless pulp therapy procedures can be implemented, protection against bacterial leakage achieved, and the tooth adequately restored. Traumas of a great enough magnitude to cause crown-root fractures usually produce luxation injuries as well, which further compromise vital and nonvital pulp therapy success (Figure 8).
Root fractures in primary teeth, particularly those occurring in the apical third of the root, can be monitored if there is no mobility. If there is mobility or if the fracture occurs in the coronal third of the root, extraction is the treatment of choice. When extracting teeth with apical root fracture, the clinician must evaluate the difficulty in gaining access to the apical fragment. Iatragenic trauma to the underlying permanent tooth must be avoided. In those instances where access is difficult, apical fragment removal should not be attempted12 (Figure 9). These root portions can be expected to resorb as part of the normal exfoliation process.
Periodontal Trauma/Displacement Injury
The predominant treatment goal for luxated primary teeth focuses on protecting the periodontal ligament and pulp from bacterial infection. Avoidance of developmental damage to the underlying permanent tooth is the ultimate desired outcome. Because of the questionable ability to achieve this goal in most instances, extraction is the appropriate treatment
Subluxation in primary teeth has been found by Fried and Erickson to occur at a frequency of 66.2 percent with central incisors and 33.3 percent with lateral incisors.4 They noted that 80.2 percent of the subluxated teeth in their sample did not require treatment.4 This finding supports the monitoring of afflicted teeth on a regulated basis for the first year as opposed to immediately instituting invasive treatment. In instances of excessive mobility, short-term splinting of seven to 10 days using acid-etched resin attachment of a light orthodontic wire should be considered if the child’s behavior is not a deterrent. If behavior is a major deterrent to accomplishing splinting techniques, and the clinician judges the tooth’s mobility excessive enough to place it at risk for being lost with potential aspiration, the tooth should be extracted. Equilibrating opposing teeth to reduce repeated hyperocclusion trauma to the afflicted teeth can also enhance stabilization.
Extruded primary teeth can be repositioned in instances of minimal coronal displacement. Teeth with incisal displacement of greater than 2 mm should be extracted to avoid the elevated potential of persistent periradicular infection and subsequent adverse effects on the underlying permanent teeth (Figure 10).
Intruded primary teeth were found by Soporowski and colleagues to have the highest correlation with hypoplastic defects in underlying permanent tooth successors (17.4 percent) when compared with lateral luxation (7.1 percent) and avulsion (5.7 percent).5 Repositioning intruded primary teeth resulted in less pulp necrosis than repositioning laterally luxated teeth.5 The most prevalent treatment recommendation is to allow the intruded tooth to re-erupt, provided it is positioned facially away from the developing permanent tooth bud12 (Figure 11). Re-eruption should occur within one to six months with incisal movement being evident in four weeks.12 If incisal movement is not evident within this time or if the intruded primary tooth is displaced in a palatal direction toward the underlying permanent tooth, it should be extracted.12 Intruded primary teeth that re-erupt should be monitored closely for signs of pulp degeneration that necessitate either a pulpectomy procedure or extraction.
Lateral luxation of primary teeth can be treated by repositioning and short-term splinting in cases of minimal horizontal displacement. For excessive tooth displacement accompanied by alveolar fracture, gingival laceration, and resistant behavior, extraction is the preferred treatment. Soporowski and colleagues noted that repositioning laterally luxated primary teeth was associated with an increased prevalence of pulp necrosis, which supports the extraction option5 (Figure 12).
Avulsion of primary teeth has been somewhat confounding with respect to treatment recommendations (Figure 13). There are specific guidelines for avulsed permanent teeth, which involve elaborate protocols for replantation techniques.24 The predominant opinion, however, is that primary teeth should not be replanted because of the elevated potential for chronic infection and subsequent dystrophic changes that could occur with the developing teeth.2,12 The pragmatic issue of behavioral cooperation with splinting and subsequent nonvital pulp therapy is also a potential deterrent to a favorable outcome.
A number of case reports identify success in replanting avulsed primary teeth as long as principles of case selection criteria include teeth with an extraoral dry time of less than 30 minutes and periodontal ligament cell maintenance through an appropriate tooth storage medium. They describe primary tooth replantation success with short-term splinting, followed by pulp canal obturation with zinc-oxide-eugenol and calcium hydroxide medicaments.25-27 However, until more controlled studies become available to confirm successful outcomes with replanting avulsed primary teeth, this technique is not recommended.
Summary
This article has reviewed the various primary tooth injuries associated with dental trauma. Protection of the pulp and the periodontal ligament from bacterial infection along with efforts to avoid any residual damage to underlying permanent tooth successors is the desired treatment objective. The types of primary tooth injuries along with recommended treatment are summarized in Table 2.
Author
Clifton O. Dummett, Jr., DDS, MSD, MEd, is a professor in and head of the Department of Pediatric Dentistry at Louisiana State University School of Dentistry in New Orleans.
References
1. Fried I, Erickson P, Anterior tooth trauma in the primary dentition: Incidence, classification, treatment methods, and sequalae: A review of the literature. J Dent Child 62:256-61, 1995.
2. Wilson CFG, Management of trauma to primary and developing teeth. Dent Clin N Am 39:133-67, 1995.
3. Hargreaves JA, Sleaton-Jones PE, et al, Trauma to primary teeth of South African preschool children. Endod Dent Traumatol 15:73-6, 1999.
4. Fried I, Erickson P, et al, Subluxation injuries of maxillary primary anterior teeth: epidemiology and prognosis of 207 traumatized teeth. Pediatr Dent 18:145-51, 1996.
5. Soporowski NJ, Allred MS, Needleman HL, Luxation injuries of primary anterior teeth -- prognosis and related correlates. Pediatr Dent 16:96-101, 1994.
6. Galea H, An investigation of dental injuries treated in an acute care general hospital. J Am Dent Assoc 109:434-9, 1984.
7. Garcia-Godoy F, Garcia-Godoy F, Garcia-Godoy FM, Primary teeth traumatic injuries at a private pediatric dental center. Endod Dent Traumatol 3:126-9, 1987.
8. Borssen E, Holon A-K, Traumatic dental injuries in a cohort of 16-year-olds in northern Sweden. Endod Dent Traumatol 13:276-80, 1997.
9. Borum MK, Andreasen JO, Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol 14:31-44, 1998.
10. Schatz JP, Joho JP. A retrospective study of dentoalveolar injuries. Endod Dent Traumatol 10:11-4, 1994.
11. von Arx T, Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J 38:1-10, 1993.
12. Andreasen JO, Andreasen FM, Textbook and color atlas of traumatic injuries to the teeth, 3rd ed. Munksgaard, Copenhagen, 1994, pp 457-94.
13. Andreasen JO, Ravn JJ, The effect of traumatic injuries to primary teeth on their permanent successors. II. A clinical and radiographic follow-up study of 213 teeth. Scand J Dent Res 79:284-94, 1971.
14. Croll TP, Brooks EB, et al, Rapid neurologic assessment and initial management for the patient with traumatic dental injuries. J Am Dent Assoc 100:530-4,1980.
15. Schneider PE, Dental trauma and central nervous system injury. Quintessence Int 17:749-53, 1986.
16. Mouden LD, Bross DC, Legal issues affecting dentistry’s role in preventing child abuse and neglect. J Am Dent Assoc 126:1173-80, 1995.
17. Soxman JA, Nazif MM, Bouquot J, Pulpal pathology in relation to discoloration of primary anterior teeth. J Dent Child 51:282-4, 1984.
18. Jeppsen K, Direct pulp capping on primary teeth -- a long-term investigation. J Int Assoc Dent Child 2:10, 1971.
19. Kopel HM, Considerations for the direct pulp capping procedure for primary teeth. J Dent Child 59:141-9, 1992.
20. AAPD Reference Manual, Guidelines for pulp therapy in primary and young permanent teeth. Pediatr Dent 21:62, 1999-00.
21. Ram D, Holan G, Partial pulpotomy in a traumatized primary incisor with pulp exposure: case report. Pediatr Dent 16:46, 1994.
22. Cvek M, A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod 4:232-7, 1978.
23. Matthewson RJ, Primosch RE, Fundamentals of pediatric dentistry, 3rd ed. Quintessence Publishing, Chicago, 1995, p 255.
24. Treatment of the Avulsed Permanent Tooth: Recommended Guidelines of the American Association of Endodontists. American Association of Endodontists, Chicago, 1995.
25. Kawashima Z, Pineda LFR, Replanting avulsed primary teeth. J Am Dent Assoc 123:90-1, 1992.
26. Filippi A, Pohl Y, Kirschner H, Replantation of avulsed primary anterior teeth: Treatment and limitations. J Dent Child 64:272-5, 1997.
27. Weiger R, Heuchert T, Management of an avulsed primary incisor. Endod Dent Traumatol 15:138-43, 1999.
To request a printed copy of this article, please contact/Clifton O. Dummett, Jr., DDS, MSD, MEd, LSU Health Sciences Center, School of Dentistry, 1100 Florida Ave., New Orleans, LA 70119-2799 or at CDumme@lsusd.lsumc.edu.
Table 1. Frequency of Luxation Categories in Primary Teeth
Table 2. Treatment of Primary Tooth Injuries
Figures
Figure 1. Opaque hypoplastic defect in enamel of maxillary central incisors as a result of primary tooth trauma.
Figure 2. Severe hypoplastic defect extending into dentin of the maxillary left central incisor as a result of primary tooth trauma.
Figure 3. Root dilaceration of the maxillary left central incisor as a result of primary tooth trauma.
Figure 4. Pulp canal calcification (calcific metamorphosis) of the maxillary primary central incisors as a result of trauma.
Figure 5. Lateral anterior radiograph demonstrating proximity of intruded maxillary primary central incisors to the developing underlying permanent successors.
Figure 6. Grey discoloration of the maxillary right primary central incisor as a result of traumatic injury.
Figure 7. Periapical radiograph demonstrating complicated coronal fractures of the maxillary primary central and left lateral incisors. Also note crown root fracture of the maxillary right lateral incisor.
Figure 8. Crown root fractures extending below cementoenamel junction of maxillary primary central incisors.
Figure 9. Periapical X-ray of primary right central incisor with root fracture in the apical one-third area.
Figure 10. Extrusion of maxillary primary central incisors. These teeth should be extracted.
Figure 11. Intruded maxillary left primary central incisor. This tooth should be closely monitored for re-eruption within one to six months.
Figure 12. Lateral luxation of the left maxillary primary central incisor with root apex protruding through the labial alveolar bone. This tooth should be extracted.
Figure 13. Avulsed maxillary primary central incisors. These teeth should not be implanted.
