Join me for Susan and Claire’s lecture looking at paediatric trauma and the orthodontic management
Background
Prevalence of trauma
Prevalence 12% 12 year olds CDH 2013
10.3% orthodontic population have trauma
Ortho implication
· Inform consent process
· Previous trauma, likely 2nd traumatic episode
Evidence
· Generally weak – unable
· Tooth SOS mobile app
· International association of the dental traumatology
· Guidelines for the orthodontic management of the traumatised tooth 2020 JO– Cara Sandler
Radiographs
· Baseline periapical
· Monitor injury dependent
· CBCT
Management of traumatised teeth
· Initial management
o Repositioning
o Splinting
· Future orthodontic implications
o Reducing forces – i.e. thermal NiTi wire
o Space closure – use undersized archwire
Mild injury
· Concussion
· Subluxation – gingival fibre and bleeding at gingival level
o 3 month wait prior to orthodontic forces
Moderate injury
· Intrusion – damage to vessel bundle
o Immature – spontaneous eruption preferred as less RR
o Mature – spontaneous / ortho up to 7mm, greater than 7mm surgical reposition – RCT 2-3 weeks after injury as will be non-vital from injury
o When reposition, consider incisal positioning as likely ankylosed, therefore relative intrusion less evident as patient grows
· Lateral luxation – displacement in a non-axial direction, frequent bony fracture
o Digital reposition and light archwire placed for 6-9 months
Avulsion
· Fixed appliances with passive archwire
Hard tissue injuries
· Crown root fracture – crown, cement +/- pulp
· Root fracture
o Apical area treated as vital root
o Cervical aspect treated non-vital
§ If orthodontic movement needed, likely loss of tooth
Rest periods prior to orthodontic active forces
· Minor damage – 3 months
· Moderate damage 6-12 months
· Severe – root fractures -12 months
Challenges
· Endodontically treated teeth
· No further RR during orthodontic treatment
o Advise re-radiograph 6-9 months of orthodontic forces
· Pulp canal obliteration
o 4-24% sequelae after trauma
o Usually occurs up to 1 year after injury
o Implies vitality of a tooth
o HOWEVER – increased risk of loss of vitality during orthodontic treatment
· Delayed presentation
o Avulsed immature central incisor tooth
§ Can re-implant however plan for loss
§ Or temporary prosthesis
o Safeguarding issues
o Root end closure
§ MTA
§ Regenerative endodontics
· Biologically increase root length and wall thickness
o However unpredictable
§ No longer apexification with CaOH, risk of fracture and significant time
Traumatised teeth of poor prognosis management
· Infection related resorption, ankylosed teeth
· Ankylosed tooth
o Decoronate – subgingival level
§ Maintains alveolar bone – prevents vertical bony defect
§ Temporary prosthesis
o Autologous tooth transplantation
§ Usually premolar teeth – width, size and root morphology
§ Half formed root at time of transplantation
§ Bony inductive property = long term option
§ However restorative and clinical burden high
o Space closure
Conclusion
o 10% of patients will have trauma – before or during orthodontic treatment
o Informed consent – fluid process
