Patient Story
A 9-year-old boy presents to his pediatrician after suffering trauma to his face 45 minutes ago while jumping on a trampoline (Figure 37-1). The mother presents with a tooth folded in a wet napkin. There are no signs or symptoms of trauma to other craniofacial structures nor signs of neurological trauma. Upon examination, a fully rooted permanent tooth is noted to have been lost from its socket and the adjacent tooth is fractured. He is diagnosed with avulsion of the maxillary right central incisor. After a call to the child’s dentist, the pediatrician reimplanted the tooth as directed (Figure 37-2). The boy was then sent directly to the dentist for evaluation and stabilization.
Introduction
Epidemiology
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Dental trauma is most common among children with a slight male predilection; the most commonly traumatized teeth are the maxillary central incisors.1
Etiology and Pathophysiology
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Most incidents of trauma are caused by accidents in or around the home or at school.
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The impact of the injury may cause damage to the hard tissue of the tooth, the pulpal tissue within the tooth, the periodontal ligament which holds the tooth in the arch, the alveolar bone, intraoral soft tissue, the maxilla/mandible, or other craniofacial structures.
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Dental trauma, or delayed treatment of a traumatized tooth, may cause necrosis of the pulp tissue within the tooth necessitating root canal therapy or inflammation of the periodontal ligament, which can result in resorption of the root.
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After ruling out neurological and damage to other craniofacial structures, referral to a dentist is necessary for a thorough clinical and radiographic intraoral examination.
Risk Factors
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Malocclusion of maxillary/mandibular teeth.
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Lower socioeconomic status.
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Risk-taking children.
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Children being bullied or under emotionally stressful conditions.
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Children with obesity or ADHD.2
Diagnosis
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Tooth fractures:
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Enamel fracture—Fracture confined to the outer enamel surface without exposing the underlying dentin. Normally asymptomatic, although fracture site may be rough to the touch.
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Enamel/dentin fracture—Fracture involving the outer enamel and inner, more yellow-colored dentin. Normally moderate to severely sensitive to heat or cold (Figure 37-3).
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Enamel/dentin/pulp fracture—Fracture involving the enamel and dentin, which exposes the underlying vascular pulp tissue. Symptoms may range from no symptoms to sensitivity to heat and cold (Figure 37-4).
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Tooth displacement injuries:
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Concussion/subluxation—Injuries to a tooth resulting in tooth mobility and/or sensitivity without displacement from the socket. Teeth may be sensitive to touch or abnormally loose, but the tooth remains in its prior position.
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Luxation—Displacement of a tooth from its position in its socket. Teeth may be luxated laterally from the socket, intruded into the socket, or extruded partially out of the socket. These injuries are often associated with damage to the supporting alveolar bone (Figures 37-5 and 37-6).
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Avulsion—Complete loss of tooth from socket. Tooth will be lost and a blood clot will form in the socket (Figure 37-1).
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Intraoral soft tissue trauma:
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Laceration, abrasion, contusion of gingival, labial or lingual tissue, visible upon clinical examination (Figure 37-7).
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