History, Examination, Diagnosis and Treatment Planning
To provide a framework for assessing patients presenting after trauma.
After studying this chapter the reader should have a raised awareness of trauma aetiology, and be able to assess patients who have suffered trauma.
This book largely focuses on children in whom the majority of dental injuries occur and where management is evidence-based. However, most issues also translate to the management of trauma to permanent teeth in older people.
Trauma to children’s teeth occurs quite frequently. Previous studies in the UK (Todd and Dodd, 1985) suggested that the incidence of trauma to teeth was increasing, but more recent studies have indicated a fall in incidence (O’Brien, 1994). It is suggested that this may be related to a more sedentary lifestyle for children, with less active participation in organised sport and more recreational interest in computer games. It is evident from the world literature however that dental trauma is a global entity. At the age of five years some 31–40% of boys and 16–30% of girls will have suffered dental trauma. By the age of 12 years, the corresponding figures are 12–33% of boys and 4–19% of girls. Traumatic injuries are twice as common in boys in both the permanent and the primary dentitions.
The majority of dental injuries in the primary and permanent dentitions involve the anterior teeth – in particular, the maxillary central incisors. The mandibular central incisors and maxillary lateral incisors are less frequently involved. Concussion, subluxation, and luxation are commonest in the primary dentition, while uncomplicated crown fractures are commonest in the permanent dentition.
The most accident-prone times are between two and four years for the primary dentition and seven and 10 years for the permanent dentition. In the child in the primary dentition, coordination and judgement are incompletely developed and the majority of injuries are due to falls in and around the home – in particular as the child becomes more adventurous and explores its surroundings. In the permanent dentition most injuries result from 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 teenage years and are commonly associated with contact sports such as soccer, rugby, ice hockey and basketball.
Injuries related to road traffic accidents and assaults are most commonly associated with the late teenage years and adulthood, and are often closely related to alcohol abuse.
One form of injury in childhood that must never be forgotten is child physical abuse or non-accident injury (NAI). This topic will be covered in Chapter 12.
The exact mechanisms of dental injuries are largely unknown and without experimental evidence, but injuries can be the result of either direct or indirect trauma. Direct trauma occurs when the tooth itself is struck. Indirect trauma is seen when the lower dental arch is forcefully closed against the upper, e.g. a blow to chin. Direct trauma implies injuries to the anterior region, while indirect trauma favours crown or crown-root fractures in the premolar and molar regions, as well as the possibility of jaw fractures in the condylar regions and symphysis. The factors which influence the outcome, or type of injury, are a combination of:
energy of impact
resilience of impacting object
shape of impacting object
angle of direction of the impacting force.
Increased overjet, with protrusion of upper incisors, and insufficient lip closure are significant predisposing factors to traumatic dental injuries. Injuries are almost twice as frequent among children with protruding incisors. The number of teeth affected in a particular incident is also increased by an increased overjet.
The second major group of children predisposed to traumatic injuries are the accident-prone. These children sustain repeated trauma to their teeth. Frequencies have been reported to range from 4–30%.
Another group that has recently been shown to have a higher incidence of dental injuries are those children who are overweight. It is thought that the cause is their lack of athleticism during falling.
The classification of dento-alveolar injuries based on the World Health Organization (WHO) system is summarised in Table 1-1.
|Injuries to the hard dental tissues and the pulp|
|Enamel infraction||Incomplete fracture (crack) of enamel without loss of tooth substance|
|Enamel fracture||Loss of tooth substance confined to enamel|
|Enamel-dentine fracture||Loss of tooth substance confined to enamel and dentine not involving the pulp|
|Complicated crown fracture||Fracture of enamel and dentine exposing the pulp|
|Uncomplicated crown-root fracture||Fracture of enamel, dentine, and cementum but not involving the pulp|
|Complicated crown-root fracture||Fracture of enamel, dentine, and cementum and exposing the pulp|
|Root fracture||Fracture involving dentine, cementum and pulp. Can be subclassified into: apical, middle and coronal (gingival) third|
|Injuries to the periodontal tissues|
|Concussion||No abnormal loosening or displacement but marked reaction to percussion|
|Subluxation (loosening)||Abnormal loosening but no displacement|
|Extrusive luxation (partial avulsion)||Partial displacement of tooth from socket|
|Lateral luxation||Displacement other than axially with comminution or fracture of alveolar socket|
|Intrusive luxation||Displacement into alveolar bone with comminution or fracture of alveolar socket|
|Avulsion||Complete displacement of tooth from socket|
|Injuries to supporting bone|
|Comminution of mandibular or maxillary alveolar socket wall||Crushing and compression of alveolar socket. Found in intrusive and lateral luxation injuries|
|Fracture of mandibular or maxillary alveolar socket wall||Fracture confined to facial or lingual/palatal socket wall alveolar socket wall|