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Case Report - Paediatric Dentistry After a dental screening examination in a mobile clinic (school van), a 9 year old female

patient was referred to a dental officer for examination and restoration of 21 incisal fracture. The patient presented with her mother to the Oral Health Centre (school dental) for examination and treatment. Medical History No significant medical history was disclosed. The patient was currently on no medications, and didnt have any known allergies. Dental History The patient had suffered a traumatic dental injury in mid 2006 (approximately 1 year ago). This had occurred after the patient fell off her bike onto her driveway. Following the incident the patient had no medical/dental follow-up. After questioning, the patient had only suffered superficial soft tissue injuries and fractured her left central incisor (the fracture was found and disposed of). The patient hadnt suffered any loss of consciousness following the incident and only suffered slight pain associated with soft tissue injuries. The patient had no other history of dental trauma. Comprehensive Oral Examination Extraoral examination No abnormalities of significance were detected on palpation of the cervical lymph nodes, soft tissue, TMJs and the muscles of mastication. No evidence of facial scarring or asymmetry (from dental injury) were noted. Intraoral examination Mucosa: Overall health of mucosa was good. Saliva on presentation was bubbly and frothy with moderate flow. The importance of hydration on salivary flow and the oral environment was emphasized to both patient and parent. No other abnormalities were detected. Teeth/Periodontium: Teeth present: 16, 55, 54, 12, 11 46, 85, 84, 42, 41

21, 22, 64, 65, 26 31, 32, 73, 74, 75, 36

- Moderate generalised plaque with associated gingival marginal inflammation - Minimal anterior calculus - 11 buccal sinus tract with no abnormalities in tooth colour, mobility or probing depths. No decay or restoration clinically evident. - 21 uncomplicated incisal fracture (class II fracture- enamel and dentine). Fracture involved both mesial and distal incisal corners and no abnormalities in tooth colour, mobility or probing depths were noted. - Class I molar relationship with buccally palpable 13,23

- Increased anterior overbite (80%), normal overjet and 2mm diastema between 11 and 21. Tooth 21 crown angled mesially. Although the malalignment of 21 may be due to its natural eruptive path into the dental arch, the possibility that this is sequel of an untreated luxation injury (with subsequent bone healing) can not be ruled out. - No active caries activity noted clinically. Radiographic Examination: 1. Left and right bitewings (Appendix 1) No areas of decalcification/caries and periodontal status is good. 2. Periapical view of 11 and 21 (Appendix 2) Tooth 11 shows arrested root development with open apex (comparison made with 21). The tooth has a large periapical radiolucency and has no areas of decalcification. Periodontal bone height both mesially and distally is below the CEJ. The PDL space appears normal. Tooth 21 shows open apex with continued root development, with no periapical pathology or areas of decalcification/caries. Both periodontal bone height and PDL space appear normal. The fracture site is not in close proximity to the pulp. Other Diagnostic tests used to confirm vitality/non-vitality: Percussion: 12 -, 11 -, 21 -, 22 -. Cold Spray (ethyl chloride): 12 +, 11+, 21+, 22+ Cold spray can be an effective means of finding non-vitality, however in paediatric patients this is often unreliable and patients often give false positives.1 Gutta percha point into sinus tract and radiograph taken to confirm which toothThe GP point went into tooth 11. (Appendix 3) Diagnosis: Marginal generalised gingivitis 11 necrotic/non-vital tooth with arrested root development. 21 uncomplicated crown fracture with tooth vitality maintained. Treatment Plan: 1. Oral hygiene education- Reinforce brushing technique to allow better plaque removal and decrease marginal gingival information. Both patient and parent should be given diet/hydration advice. 2. Scale and Prophylaxis 3. Restore 21 incisal edge to replace aesthetics and function, using composite resin. Review tooth clinically and radiographically yearly. 4. Tooth 11- Apexification (using calcium hydroxide to form an apical hard tissue barrier) followed by root canal therapy. Apexification may take up to 18 months. Treatment Rationale: The management of patients following traumatic injury can be difficult, and it is therefore important that patients have immediate dental follow-up. The patient presented 1 year following dental injury and had no follow-up since the injury. Dental history was

thus obscured by time and many aspects of the injury couldnt be recalled. Upon examination, diagnosis of marginal generalised gingivitis, necrotic 11 with associated arrested root development, and uncomplicated crown fracture of 21 was made. The patients gingivitis was a result of inadequate cleaning of the gingival portion of teeth causing plaque accumulation and subsequent gingival inflammation.2 Through education and instructions on plaque removal, the patients gingival inflammation will resolve in approximately one week.2 Subsequent to the traumatic injury, tooth 21 had an uncomplicated crown fracture. As direct irritation of the pulp can occur via dentinal tubules, teeth with extensive proximal fractures and no coverage of dentine have a 54% chance of developing pulpal necrosis, whilst teeth with coverage of dentine have an 8% chance of necrosis.3,4 Despite dentine being exposed since the injury, the patient had not experienced any symptoms, clinical (swelling tenderness, mobility, sinus) or radiographic (boned loss, arrested root development) signs of infection or loss of vitality of 21.3,4,5 The aim of treatment was to seal dentinal tubules, as well as restoring both aesthetics and function.3 This can be achieved by using a direct method (eg. composite resin and liner) or an indirect method (eg. veneer or crown).6 Although the mechanical and aesthetic properties of veneers and crowns are superior to composite resins, in this case they are not viable options as the patient is too young and the gingival margin is yet to be finally established.6 After restoration of the tooth, follow up should be clinical and radiographic on a yearly basis.4 The long term prognosis of the composite restoration is questionable as differing results of aesthetics and durability have been published.1,7,8,9 Main reasons for failure have been bond failure, marginal leakage, fracture of composite, recurrent decay and further traumatic injury.1 However, newer generation of composites and adhesive systems are proving to have increased longevity.1,7 Following injury, tooth 11 has lost vitality leading to termination of radicular growth and therefore causing incomplete tooth formation.10 Although an exact diagnosis of the traumatic dental injury of 11 is not made, the basic pathological process is identified and the treatment is focused to arrest this process. The aims of treating 11 are to maintain the tooth in both function and aesthetics. This can be achieved by cleansing the pulp canal of debris, toxins and necrotic pulpal tissue and then sealing the pulp canal apically, periodontally and coronally.5,6 Apically, as this is an immature tooth, apexification is attempted to form an apical hard tissue barrier.6 Apexification involves accessing the root canal, removal of necrotic pulp, gently debriding the canal (excessive pressure may fracture the tooth) and irrigating using sodium hypochlorite.4 The canal is dressed with non-setting calcium hydroxide and temporised. Two weeks after the initial appointment, the canal is debrided, irrigated and dressed with a paste filler.4 The tooth should be reviewed every 3 months (both clinically and radiographically) until a complete apical barrier is formed. Following apexification, the tooth should be obturated using gutta percha, the operator should be careful to not apply undue pressure, as this may cause root splitting or breaking of calcific barrier.4 Calcium hydroxide is most commonly used for apexification and is successful in creating an apical closure of immature permanent teeth in 74-100% of cases.5,11 The long term prognosis of apexification and subsequent

obturation is good, however due to decreased root length and thickness, the tooth is at an increased risk of root fracture.1 Treatment undertaken: Since this patient came towards the end of semester one, I was unable to complete treatment. The patient was referred to another dental officer. Treatment undertaken by me: 1. OHE 2. Restored 21 3. 11- Extirpated necrotic pulpal tissue, debrided, irrigated (1% NaOCl) and dressed with non-setting calcium hydroxide.

Appendix 1: Left and right bitewings

Appendix 2: Periapical view of 11 and 21

Appendix 3: Gutta percha point into sinus tract to confirm tooth identification References: 1. Berman L, Blanco L, Cohen S. A clinical guide to dental traumatology. St. Louis : Mosby Elsevier; 2007. 2. Samaranayake L. Essential microbiology for dentistry 2nd. ed. Edinburgh, Churchill Livingstone, 2002. 3. Andreasen J, Andreasen F. Essentias of traumatic injuries of the teeth 2nd. ed. Copenhagen, Munksgaard; 2000. 4. Cameron A, Widment R editors. Handbook of Pediatric Dentistry. 2nd ed. Edinburgh: Mosby; 2003. 5. Mackie C, Hill F. A clinical guide to the endodontic treatment of non-vital immature permanent teeth. Br Dent J 1999; 186: 54-8. 6. Chestnutt I, Gibson J. Churchills pocketbook of clinical dentistry. 2nd ed. Edinburgh: Harcourt Publishers Ltd.; 2002. 7. Eid H, White G. Class IV preparations for fractured anterior teeth restored with composite resin restoration. J Clin Pediatr Dent 2003; 27;201-11. 8. Robertson A, Andreasen F, Andreasen J et al. Long-term prognosis of crownfractured permanent incisors: The effect of stage of root development and associated luxation injury. Int J Pediatr Dent 2000; 10:191-9. 9. Smales R, Gerke D. Clinical evaluation of four anterior composite resins over five years. Dent Mater 1992; 8:245-51. 10. Whittle M. Apexification of an infected untreated immature tooth. J Endod 2000; 26(4):247-7. 11. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth a review. Br Dent J 1997; 183: 241-6.