Dento -alveolar surgery in pediatric patients

Causes of Trauma - intentional or un-intentional

Domestic violence
Sporting activities contact sports, bicycle or horse riding
Others RTA,falls or coolision ,assaults. Handicapped children
Epidemiology
Incidence 30% chidren school-trauma to primary Dentition
20% permanent dentition
So about 50% children will sustain a traumatic dental injury before leaving school
Site Ant. Teeth Maxillary cntral incisors
71% trauma involve mx central incisors 3 times more than lateral incisors
Out of this 56% ,crown fracture without pulp involvement ,13 % with pulp
involvement and 3% with root fracture
Sex same incidence between the age 4-5 yrs
In permanent dentition similar sex distribution until 9yrs upto 11yrs boys are
twice more prone than girls in permanent dentition
WHO classification
873.60 . Enamel fracture
873.61. Crown frc involving E and Dentin without pulp exposure
873.62 . Crown frc with pulp exposure
873.63. root frc
873.64. Crown -root frc
873.66. luxation
873.67. intrision or extrusion
873.68. avulsion
873. 69 other injuries like soft tissue injuries
 International classification
Injuries to the teeth
1. E. Frc N502.50
2.E. Frc Uncomplicated crown fracture N502.50
3. E. Dentin Frc uncomplicated crown frc- N502.51
4.Comlicated crown frc N502.52
5. root Frc N 502.53
6. Uncomplicated crown-root fracture N502.54
7. complicated crown-root fracture N502.54
Injuries to the Periodontal tissues
1. Concussion- N503.20
2. Subluxasion- N503.20
3. Extrusive Luxasion- N503.20
4. Lateral luxasion- N503.20

5. Intrusive luxasion- N503.20

6. Avulsion- N503.20
 Descriprtive classification
Identify the exat problem
Injuries to the tooth Crown crack or craze
Fracture of the crown involving enamel dentin or pulp
Fracture of the crown and root involving cementum and may or may not
have pulpal involvement.
Rooty- apical one third , middle one-third, and coronal one-third
Involving the whole tooth
Concussion, subluxation
Displacement/luxation
Intrusion, extrusion ,labial lingual/palatal, lateral,
avulsion
Trauma to the supporting bone Frac. Of alveolar socket
Socket wall fracture; Frac. Of
alveolar process, Frac. Of
maxilla, Frac. Of mandib le

Etiology Direct or indirect

18 months to 2 yrs
Children are adventurous and inquisitive primary teeth injury
usuaily results in displacement or avulsion rather than frac.
Frac. Of tooth rarely observed due to
vertical placement of tooth , better lip protection and more pliable
alveolar bone.
2 5 yrs -- learning to walk and very much unsteady on their feet ,
fall injury to ant. Teeth. Common injury because of swing,which I is
usually at the level of the childs teeth the child stands in front of a
moving swing and receives a blow from the moving swing
5-10 yrs Play ground accident
>10 yrs -- Due to contact sports, horse riding and RTA etc.
Battered Child Syndrome should be considered
Features
Under 3 yrs children, presents some hrs or days after accident, oral trauma does not
coinside with C/F, multiple bruising over the body differing in shade, Facial scarring burns
of bite marks other features

Predisposing Factors
1. Accident prone profile Class II div 1 malocclusion, Cl I type 1 maloc, in adequate lip
coverage dental injury will be twice
Frequency of injury
Normal OJ (0-3mm)14.2%
OJ (3.1-6mm) is 28.4%
Extreme OJ ( >6mm) is 38.6%
2. Handicapped children CP ,MR or epilepsy- abnormal muscle tone proclin mx ant.
Tooth, Poor skeletal muscle coordination subjected to frequent fall
3. Dental anomalies and caries
Mechanical factors energy of impact, Resilency of impacting object, Shape of the
impacting object angle of direction of impacting force
Prevention
1 Legislation compulsory use of mouth guard, seat belt, hamlet etc.
2. Education
3. Early recognition and treatment of predisposing factors

Management
Obtaining history
Clinical examination Providing First aid
Treatment of the injury
O H-- Personal data
Complaint and its history
Relevant medical history and H/O tetanus prophylaxis
Previous dental history
Neurological History
Clinical Examination -- assessment of injury-- Position of the child on the
mothers lap and exam --

Extra-oral exam.
Haemmorhage, Laceration, Deviation of the path of the mandible, leakage of
straw coloured fluid from nose
Intra-oral exam-- Soft tissue exam
Hard tissue exam-- - occlusal abnormalities, palpation of maxilla and
mandible , displacement of the teeth , mobilty of teeth , root fracture
Vitality test-- Healthy pulp responds to electrical stimuli of 150 micron AMP
from a monopolar pulp tester and > 200 micron Amp may excite
periodontal nerves
Recommended pulp testing immediately 2wks, 1m, 2m, 3m, 12months and
then at yearly interval for next 3 yrs
 Providing First Aid
Profuse bleeding into the oropharynx and nasopharynx
creating respiratory obstruction maintain the airway.
if needed ET intubation or tracheostomy
Deep cut ,laceration sutured
Fluid replacement avoid hypovolumic shock
Adequate debridement, gentle cleaning and irrig with N/S
reduce the amount of dead tissue and risk of anaerobic
condition
Topical antiseptics use
 Treatment planning according to C/F
Why treatment to traumatized primary teeth?
Enamel fracture
Rough enamel margin disked and smoothened
Large enamel fracture - composite resin restoration
Enamel and dentin fracture exposed dentin calcium hydroxide or GI then
with acid etch composite resin restoration
Fracture involving pulp rare in primary dentition
Vital tooth FC pulpotomy
non vital pulpectomy final restoration with celliloid crown matrix or SS crown wirth
composite facing
Root Fracture primary tooth root frac without dislocation and excessive
mobility -normal exfoliation anticipad
Apical 1/3 good prognosis
Middle 1/3 and coronal 1/3 extraction
c
Concussion -- free from occlusion, observation
Mobility -- avoid eating, follow-up observation
Intrusion -- Contacting permanent tooth bud- ext.
No contacting and is labially placed allowed to erupt
Extrusion and lateral luxation serious damage to PDL splinting
Avulsion --
 Tetanus prophylaxis

Immunization completed previously Booster dose within 12 months No TT .

IM completed within previous 10 yrs Adm 0.5 ml fluid TT Boostered I/M

IM completed > 10 yrs last Booster within previous 10 yrs Adm 0.5 ml fluid TT

IM completed > 10 yrs previously no booster received within last 10 yrs wound
cleaned , treated promptly and adequately, 0.5ml TT
given I/M

IM completed > 10 yrs previously no Booster received within last 10 yrs

wound tetanus prone Adm 0.5 ml TT and 250 ml tetanus immune human
globulin

No history of immunization wound not clean treated promptly 250- 500 units
tetanus immune humal globilin and 0.5ml absorbed T.T prophylactic use of
penicllin should also be advised