15.5.2 Primary dentition
15.5.2.1 Concussion
15.5.2.1.1 Clinical findings
- The tooth is tender to touch. It has normal mobility and no sulcular bleeding.
15.5.2.1.2 Radiographic findings
- No radiographic abnormalities. Normal periodontal space.
15.5.2.1.3 Treatment
- No treatment is needed. Observation.
15.5.2.1.4 Follow-up
1 week – Clinical examination.
6-8 weeks – Clinical examination.
15.5.2.2 Subluxation
15.5.2.2.1 Clinical findings
The tooth has increased mobility, but it has not been displaced.
Bleeding from gingival crevice may be noted.
15.5.2.2.2 Radiographic findings
- Radiographic abnormalities are usually not found. Normal periodontal space. An occlusal exposure is recommended in order to screen for possible signs of displacement or the presence of a root fracture. Furthermore, the radiograph can be used as a reference point in case of future complications.
15.5.2.2.3 Treatment
- No treatment is needed. Observation. Brushing with a soft brush and use of chlorhexidine 0.12% alcohol-free topically to the affected area with cotton swabs twice a day for one week.
15.5.2.2.4 Follow-up
1 week – Clinical examination.
6-8 weeks -Clinical examination.
Crown discoloration might occur. No treatment is needed unless a fistula develops. Dark discolored teeth should be followed carefully to detect signs of infection as soon as possible.
15.5.2.3 Extrusion
15.5.2.3.1 Clinical findings
Partial displacement of the tooth out of its socket.
The tooth appears elongated and can be excessively mobile.
15.5.2.3.2 Radiographic findings
- Increased periodontal ligament space apically.
15.5.2.3.3 Treatment
Treatment decisions are based on the degree of displacement, mobility, root formation and the ability of the child to cope with the emergency situation.
For minor extrusion (< 3mm) in an immature developing tooth, careful repositioning or leaving the tooth for spontaneous alignment can be treatment options.
Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth.
15.5.2.3.4 Follow-up
1 week – Clinical examination.
6-8 weeks – Clinical and radiographic examination.
6 months – Clinical and radiographic examination.
1 year – Clinical and radiographic examination.
Discoloration might occur. Dark discolored teeth should be followed carefully to detect signs of infection as soon as possible.
15.5.2.4 Lateral extrusion
15.5.2.4.1 Clinical findings
The tooth is displaced, usually in a palatal/lingual or labial direction.
It will be immobile.
15.5.2.4.2 Radiographic findings
- Increased periodontal ligament space apically is best seen on the occlusal exposure. Someties an occlusal exposure can also show the position of the displaced tooth and its relation to the permanent successor.
15.5.2.4.3 Treatment
If there is no occlusal interference, as is often the case in anterior open bite, the tooth is allowed to reposition spontaneously.
If minor occlusal interference, slight grinding is indicated.
When there is more severe occlusal interference, the tooth can be gently repositioned by combined labial and palatal pressure after the use of local anesthesia.
In severe displacement, when the crown is dislocated in a labial direction, extraction is the treatment of choice.
15.5.2.4.4 Follow-up
1 week – Clinical examination.
2-3 weeks – Clinical examination.
6-8 weeks – Clinical and radiographic examination.
1 year – Clinical and radiographic examination.
15.5.2.5 Intrusion
15.5.2.5.1 Clinical findings
- The tooth is usually displaced through the labial bone plate or can be impinging upon the succedaneous tooth bud.
15.5.2.5.2 Radiographic findings
- When the apex is displaced toward or through the labial bone plate, the apical tip can be visualized and appears shorter than its contra lateral. When the apex is displaced towards the permanent tooth germ, the apical tip cannot be visualized and the tooth appears elongated.
15.5.2.5.3 Treatment
If the apex is displaced toward or through the labial bone plate, the tooth is left for spontaneous repositioning.
If the apex is displaced into the developing tooth germ, extract.
15.5.2.5.4 Follow-up
1 week – Clinical examination.
3-4 weeks – Clinical and radiographic examination.
6-8 weeks – Clinical examination.
6 months – Clinical and radiographic examination.
1 year – Clinical and radiographic examination, clinical and radiographic monitoring until eruption of the permanent successor.
15.5.2.6 Avulsion
15.5.2.6.1 Clinical findings
- The tooth is completely out of the socket.
15.5.2.6.2 Radiographic findings
- A radiographic examination is essential to ensure that the missing tooth is not intruded.
15.5.2.6.3 Treatment
- It is not recommended to replant avulsed primary teeth.
15.5.2.6.4 Follow-up
1 week – Clinical examination.
6 months – Clinical and radiographic examination.
1 year – Clinical and radiographic examination, clinical and radiographic monitoring until eruption of the permanent successor.
15.5.2.7 Enamel fracture
15.5.2.7.1 Clinical findings
- Fracture involves enamel.
15.5.2.7.2 Radiographic findings
- No radiographic abnormalities.
15.5.2.7.3 Treatment
- Smooth sharp edges.
15.5.2.7.4 Follow-up
- No follow-up procedures needed.
15.5.2.8 Enamel-dentin fracture
15.5.2.8.1 Clinical findings
- Fracture involves enamel and dentin; the pulp is not exposed.
15.5.2.8.2 Radiographic findings
- No radiographic abnormalities. The relation between the fracture and the pulp chamber will be disclosed.
15.5.2.8.3 Treatment
- If possible, seal the involved dentin completely with glass ionomer to prevent microleakage. In case of large lost tooth structure, the tooth can be restored with composite.
15.5.2.8.4 Follow-up
- 3-4 weeks – Clinical examination.
15.5.2.9 Enamel-dentin-pulp fracture
15.5.2.9.1 Clinical findings
- Fracture involves enamel and dentin and the pulp is exposed.
15.5.2.9.2 Radiographic findings
- The stage of root development can be determined from one exposure.
15.5.2.9.3 Treatment
If possible, preserve pulp vitality by partial pulpotomy. Calcium hydroxide is a suitable material for such procedures. A well condensed layer of pure calcium hydroxide paste can be applied over the pulp, covered with a lining such as reinforced glass ionomer. Restore the tooth with composite.
The treatment is depending on the child’s maturity and ability to cope. Extraction is usually the alternative option.
15.5.2.9.4 Follow-up
1 week – Clinical examination.
6-8 weeks – Clinical and radiographic examination.
1 year – Clinical and radiographic examination.
15.5.2.10 Crown-root fracture without pulp involvement
15.5.2.10.1 Clinical findings
Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed.
Additional findings may include loose, but still attached, fragments of the tooth.
There is minimal to moderate tooth displacement.
15.5.2.10.2 Radiographic findings
- In laterally positioned fractures, the extent in relation to the gingival margin can be seen. One exposure is necessary to disclose multiple fragments.
15.5.2.10.3 Treatment
Depending on the clinical findings, two treatment scenarios may be considered:
Fragment removal only. If the fracture involves only a small part of the root and the stable fragment is large enough to allow coronal restoration.
Extraction in all other instances.
15.5.2.10.4 Follow-up
In cases of fragment removal only:
1 week – Clinical examination.
6-8 weeks – Clinical and radiographic examination.
1 year – Clinical and radiographic monitoring until eruption of the permanent successor.
15.5.2.11 Crown-root fracture with pulp involvement
15.5.2.11.1 Clinical findings
- Fracture involves enamel and dentin and the pulp is exposed.
15.5.2.11.2 Radiographic findings
- The stage of root development can be determined from one exposure.
15.5.2.11.3 Treatment
If possible preserve pulp vitality by partial pulpotomy. Calcium hydroxide is a suitable material for such procedures. A well condensed layer of pure calcium hydroxide paste can be applied over the pulp, covered with a lining such as reinforced glass ionomer. Restore the tooth with composite.
The treatment is depending on the child’s maturity and ability to cope. Extraction is usually the alternative option.
15.5.2.11.4 Follow-up
1 week – Clinical examination.
6-8 weeks – Clinical and radiographic examination.
1 year – Clinical and radiographic examination.
15.5.2.12 Root fracture
15.5.2.12.1 Clinical findings
The fracture involves the alveolar bone and may extend to adjacent bone.
Segment mobility and dislocation are common findings.
Occlusal interference is often noted.
15.5.2.12.2 Radiographic findings
The horizontal fracture line to the apices of the primary teeth and their permanent successors will be disclosed.
A lateral radiograph may also give information about the relation between the two dentitions and if the segment is displaced in labial direction
15.5.2.12.3 Treatment
Reposition any displaced segment and then splint.
General anesthesia is often indicated.
Stabilize the segment for 4 weeks.
Monitor teeth in fracture line
15.5.2.12.4 Follow-up
No displacement:
1 week – Clinical examination.
6-8 weeks – Clinical examination.
1 year – Clinical and radiographic examination, clinical and radiographic monitoring until eruption of the permanent successor each subsequent year until exfoliation.
Extraction:
- 1 year – Clinical and radiographic examination, clinical and radiographic monitoring until eruption of the permanent successor each subsequent year until exfoliation.
15.5.2.13 Alveolar fracture
15.5.2.13.1 Clinical findings
The fracture involves the alveolar bone and may extend to the adjacent bone.
Segment mobility and dislocation are common findings.
Occlusal interference is often noted.
15.5.2.13.2 Radiographic findings
The horizontal fracture line to the apices of the primary teeth and their permanent successors will be disclosed.
A lateral radiograph may also give information about the relation between the two dentitions and if the segment is displaced in labial direction
15.5.2.13.3 Treatment
Reposition any displaced segment and then splint.
General anesthesia is often indicated.
Stabilize the segment for 4 weeks.
Monitor teeth in fracture line
15.5.2.13.4 Follow-up
1 week – Clinical examination.
3-4 weeks – Splint removal, clinical and radiographic examination.
6-8 weeks – Clinical and radiographic examination.
1 year – Clinical and radiographic examination, clinical and radiographic monitoring until eruption of the permanent successor each subsequent year until exfoliation.