Section 1 Dental Trauma

#### **Chapter 1**

## Perspective Chapter: Dental Emergency and Conditions

*Navneet Kaur*

#### **Abstract**

Dental emergencies are related to dental pain, bleeding and orofacial trauma-like conditions should be attended by dental practitioners. Even the jaw fracture requires the attention of oral and maxillofacial surgeons. Dental pain may be of odontogenic or non-odontogenic in origin, and in some cases, it may be idiopathic in nature. Bleeding in the soft tissues of the oral cavity may occur due to the infection from the microbial flora or inflammation and trauma. The management of these conditions should be based on the cause of the condition that may require the antibiotic prophylaxis along with root canal treatment or extraction of the tooth. Most of the dental conditions can be prevented by visiting to the dentists regularly and minimize the risk of oral trauma.

**Keywords:** management, emergencies, trauma, pulpitis, inflammation

#### **1. Introduction**

Any dental emergency such as an injury to the hard tissue and soft tissues (teeth or gingiva) can be potentially serious and should not be ignored. Ignoring a dental problem may enhance the risk of permanent damage of the hard and soft tissue structures and also more extensive and expensive treatment is required to correct the problem later on.

An acute oral disorder requiring dental and/or medical care, including fractured, loose, or avulsed teeth caused by traumas, any pathology (infections and inflammation) of the soft tissues of the oral cavity; and complications of oral surgery, such as dry tooth socket, fracture jaw and swelling in the jaw.

A dental emergency is basically determined by health care staff which includes any dental condition that require immediate diagnostic evaluation and treatment which is necessary to prevent severe or long-term illness, or to reduce or lessen severe pain. Some of the examples of dental emergencies are acute oral and maxillofacial conditions such as trauma, infection, pain, swelling, or bleeding that are likely to remain acute or will worsen if not provided with immediate intervention and treatment.

Some of the conditions that always require dental emergencies include, but are not limited to like Airway/breathing difficulties occurring mostly from oral infection, A swift spread of oral infection, such as Ludwig's angina, cellulitis which is

characterized by severe swelling on the floor of the mouth, with elevation of the tongue and acute abscess which includes an abscess at root end or a gingival abscess.

Maxillofacial injury or trauma to the jaws or dentition that put on to decrease the loss of airway.

By presuming the shock due to oral infection or trauma, Uncontrolled or spontaneous severe bleeding from the oral cavity, Head injuries (including stabbing or gunshot wounds) that involve maxillary or mandibular jaw along with its dentition, Moderate to severe dehydration associated with altered response in masticatory function due to any infection or trauma, Clear signs of physical distress, (e.g., respiratory distress), related to infection or injury to the jaws or dentition, Suspected or known fractures involving the nasal bones, mandible, zygomatic arch, maxilla and zygoma, Acute Temporomandibular Joint (TMJ) pain, "closed-lock" TMJ, or dislocation of the TMJ, Aspiration or swallowing of a tooth/teeth or foreign object that threatens loss of airway, Acute, severe, debilitating pain due to suspected oral infection, oral trauma, bleeding disorders of oral mucosa, oral ulceration or other dental-related conditions. Infections, including infected third molars, (Pericoronitis) and acute infections with a fever of 101° F or above, infections not responsive to antibiotic therapy, and acute pulpitis. Injuries from trauma, such as an avulsed tooth, or fractured tooth. Postoperative complications including alveolar osteitis, bleeding or infection. Restorative Dental Emergencies include Pain management, Infections and soft tissue problems, Crack, fracture and mobility of teeth and dental restorations, Fractured and loose implants, Fractures and swallowing of removable prostheses.

According to the General Dental Council's 'Standards for Dental Professionals', 2009, registered dentists are expected to:


#### **2. Dental pain (pulpitis)**

Dental pain is the commonest dental emergency and it may occur due to various etiological factors. It is delineated as 'an unpleasant sensory and emotional expertise related to actual or potential tissue damage, or described in terms of such damage. It is one of the most common reasons that why patients seek dental treatment and further to note that various diseases or pathological conditions may be responsible for the initiation of pain. However, pain arising from nondental sources corresponds to myofascial inflammation, cephalalgia headache, maxillary sinusitis, nasal tissues, ears, temporomandibular joints, and neuralgias continually should be thought of and excluded [1].

Odontogenic pain is a pain initiating from the teeth or their supporting structures, the mucosa, gingivae, maxilla, mandible or periodontal membrane.

The major cause of dental pain is inflammation of the dental pulp, most commonly as a result of dental caries (tooth decay), most commonly worldwide, affecting 60–90%

#### *Perspective Chapter: Dental Emergency and Conditions DOI: http://dx.doi.org/10.5772/intechopen.105495*

of school children. The second most common infection similar to chronic mycobacterial infections is Periodontal disease (gum disease for example Leprosy, is painless. The periodontal pathogens appear to be singularly and odds-on to cause aggressive periodontal disease. Both *Porphyromonas gingivalis* and *A. actinomycetemcomitans*, along with multiple deep pockets, severe clinical attachment loss is linked with resistance to standard traditional treatments for soft tissues (gingiva). Other risk factors which include smoking and also there is a genetic predisposition responsible to develop this silent painless disease, which may be the leading cause of tooth loss, and is found in almost 5–400% of middle-aged adults.

Initially, dental caries is asymptomatic. Pain does not occur until the decay caused by bacteria reaches near the pulp, and an inflammatory process starts developing. Reversible pulpitis is defined as mild inflammation of the tooth pulp which is caused by caries encroaching on the pulp. Pain is generally triggered by hot, cold, and sweet stimuli which lasts for a few seconds, and resolves spontaneously. If we talk about the treatment then it includes removal of the caries and placement of a dental restoration, or filling. But if the carious lesion persists, it will progress towards irreversible pulpitis, which is a severe inflammation of the pulp. Pain becomes very severe, spontaneous, and persistent in nature, and is poorly localized. The only way to definitively treat irreversible pulpitis is root canal treatment along with appropriate analgesia such as a nonsteroidal anti-inflammatory drug (NSAID).

A severely inflamed pulp will eventually undergo necrosis which may lead to apical periodontitis, which is inflammation around the apex of the tooth. Pain is severe, spontaneous, and persistent, but unlike that of irreversible pulpitis, localizes to the affected tooth. The tenderness to percussion is positive. Management is root canal treatment or extraction. The patient should be referred to a dentist as soon as possible along with prescription of analgesics (**Figure 1**).

Apical abscess is a localized and purulent form of apical periodontitis. Clinically it presents as a fluctuating buccal or palatal swelling, with or without a draining fistula. If pus can drain out from the fistula, the pain is usually not severe in nature. Antibiotics are unnecessary unless concomitant cellulitis is present. Incision and drainage of a fluctuating area should be performed by qualified physician. Definitive treatment is root canal treatment or extraction. Patients should be recalled back to dentist within one or two days and also analgesics should be prescribed.

#### **Figure 1.**

*The stages and characteristics of pulpal pain.*

Cellulitis may follow apical periodontitis if the infection spreads to the surrounding tissues and also to the areas of facial space which can lead to facial space infections. Diffuse, tense and painful swelling of the affected tissues may occur. Diagnostic evaluation should focus on determining whether cellulitis remains localized or has spread regionally. Outpatient treatment of patients with localized cellulitis should be treated by the physician with oral antistreptococcal antibiotics, such as oral penicillin 500 mg three times a day in adults or 50 mg/kg/day in children [2].

In case of patient is allergic with penicillin, erythromycin or clindamycin (Cleocin) may be prescribed. In addition, analgesics should be prescribed. Definitive treatment is root canal treatment or extraction, which may be delayed until swelling subsides. Patients should be evaluated by a dentist within one or two days but patient should also advice to return sooner if swelling or pain worsens. If infection spreads into the deep spaces of the head and neck presented with significant swelling, increased risk of life-threatening complications like there is extensive airway involvement. As a general rule, these patients should be hospitalized for a surgical and infectious consultation. Broad-spectrum Intravenous antibiotic therapy should be started immediately and should include coverage for anaerobes.

#### **3. Periodontal origin**

Periodontitis can be described as an inflammatory disease of supporting tissues of teeth which is caused by the specific microorganisms or groups of specifics microorganisms which results in progressive destruction of the periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession or both. The main etiological factor is bacterial plaque and calculus. Patients with chronic periodontal disease or patients who have a foreign object impinge in the gingiva may present with an acute periodontal abscess. A gingival abscess is basically a localized, painful and rapidly expanding lesion which involves the marginal gingival or interdental papilla and sometimes in a previously disease-free area. It usually occurs as an acute inflammatory response to foreign substances which has been forced into the gingiva. In its early stage it appears to be a red swelling with a smooth, shiny surface. Within 24 to 48 hours, the lesion is usually fluctuant and pointed, with a surface orifice from which purulent exudates may be seen. If not hindered and allowed to progress, the lesion generally ruptures spontaneously. Acute periodontal abscess presents as a Localized red, ovoid swelling, Periodontal pocket, Mobility, Tooth elevation in socket, Tenderness to percussion or biting, Exudation, Elevated temperature and regional lymphadenopathy.

If it is not treated on time, the abscess may rupture or progress to cellulitis. Oral intervention is incision and drainage within 24 hours of patient referral and debridement of the infected periodontal area. Antibiotics are not prescribed if debridement is successful, because their use remains controversial in these cases.

However, Penicillin is the first drug of choice in the treatment of periodontal abscesses in the UK, being used by 57% of surveyed dentists, followed by amoxicillin (21%) and metronidazole (14%). Amoxicillin, 500 mg (because amoxicillin exhibits an excellent ability to penetrate into both normal and pathologic periodontal tissues and is highly active against many periodontal pathogens) 1.0-g loading dose, then 500 mg three times a day for 3 days. Re-evaluation after 3 days to determine if there is any need for continued or adjusted antibiotic therapy.

*Perspective Chapter: Dental Emergency and Conditions DOI: http://dx.doi.org/10.5772/intechopen.105495*

#### **4. Pericoronitis**

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted third molar*.* It occurs when bacterial plaque and food debris accumulate beneath the flap of soft tissue covering the partially erupted third molar. Inflammatory edema, most commonly complicated by trauma from the opposing tooth, which may result in swelling of the flap, pain, tenderness, and a bad taste caused by pus oozing from beneath the flap. Lymphadenopathy is common, and cellulitis and trismus may occur. In severe cases, the oral airway can be compromised. If pericoronitis is well localized, chlorhexidine mouthwashes and irrigation with normal saline and povidone iodine can resolve symptoms in the majority of cases. Localized cases that do not respond to mechanical therapy and more severe untreated cases with spreading cellulitis should be treated with prescribing antibiotic like penicillin and analgesics like NSAIDs prescribed as medication. Patient can be diagnosed in case of symptomatic treatment and refer to the dentists as soon as possible. The intervention of pericoronitis is surgical removal of soft tissue called as operculectomy. If the tooth is impacted, in that case surgical extraction is recommended.

#### **5. Exposed cementum and dentin**

Dentinal sensitivity is one of the most common dental emergency conditions. It is characterized by short, sharp pain arising from exposed dentine in response to stimuli, typically thermal, tactile, osmotic or chemical and which cannot be attributed to any other dental defects or pathological conditions. The tooth is having sensitivity from cold fluids or from air which directly affects the pulp of the tooth. The etiological factors are gingival recession, scaling and root planning or wasting disease such as erosion (tooth wear) due to a high acid diet or gastric reflux, the patient may experience generalized dentinal hypersensitivity. The root surface comprised of a thin layer of cementum overlying dentine which may be exposed to oral environment due to aggressive or using wrong tooth brushing technique. Dentine underlying the enamel layer comprised of minute tubules which are fluid filled and connects to the nerve ending in the dental pulp directly. The recent postulate for dental pain includes the osmolality theory, whereby the dentine fluids initiates an action potential within the A delta and C fibers in the pulp when stimulated by mechanical stimulation.

The use of a desensitizing toothpaste and a reduction in acid in the diet will help resolve the symptoms of root sensitivity. Modification and accurate tooth brushing habits along with use of fluoride toothpaste may also reduce the tooth sensitivity symptoms is also recommended. In the case of dental caries, a lost filling or fractured tooth, coverage of the exposed dentine with a temporary restoration will usually relieve the symptoms.

#### **6. Fractured tooth/dental trauma**

Dental trauma is most commonly seen in children with a peak age of 12 years old and having a primary tooth. Injury to the teeth and their supporting structure may lead to fractures, lateral or extrusive luxation in which loosening and displacement of the tooth, intrusion where displacement of the tooth vertically into the alveolar

bone), and avulsion is a complete displacement of the tooth out of its socket [3]. Tooth fracture may occur on the crown, root or both and in some cases, it may cause exposure to the pulp. Fractures exposing the pulp are often painful, and patients with this condition require timely referral to a dentist. If the crown of a tooth is fractured by trauma and the broken fragment is available, it should be stored in a physiological medium (milk) until a dentist can assess the patient. Definitive treatment may involve root canal therapy or extraction. Coverage of exposed dentine on the fractured crown with a temporary restoration is desirable to protect the underlying pulp tissue [4].

Fracture of the root usually require radiograph and treatment may involve root canal therapy, splinting, or extraction, depending on the exact nature of the root fracture. In case of luxation of tooth if the primary dentition is traumatized and teeth are so loose and are in danger of being aspirated then immediate referral to a dentist for extraction is required [3]. If permanent teeth are involved the dental referral is required for repositioning, splinting, or root canal therapy, along with long term follow-up.

Avulsed teeth are one of the true dental emergency conditions. Primary teeth are never reimplanted [3]. In case of permanent teeth involvement, Immediate on-scene reimplantation is the preferred method of treatment. If the tooth is contaminated, it should be gently rinsed in cold running tap water and then reimplanted. Care should be taken not to touch, rub, or clean the root because it may remove the periodontal ligament fibers and reduce the chance of successful reimplantation. The patient should immediately report to dentist for splinting and antibiotic prophylaxis [5].

#### **7. Placement of temporary restorations**

Although it is dubious that general medical practitioners will have temporary filling materials available in their surgeries. Dentine that has been exposed due to caries, a lost filling or tooth fracture can be treated relatively easily by using glass ionomer cement (GIC) or zinc oxide eugenol (ZOE) materials. Mostly GIC materials are available in capsules but a hand-mixed material is also available which consists of a powder, liquid and conditioner. Firstly, the surface of the cavity is painted with the conditioner followed by rinsing and drying and then finally placement of the filling is done. Zinc oxide eugenol materials consist of a powder and liquid (oil of cloves) that are mixed to a putty-like consistency before placement in the tooth.

#### **8. Alveolar osteitis**

After extraction, the most common complication is a 'dry socket' in which the clot formation within the socket fails at 3–5 days. It occurs due to the disruption of the clot within the socket. The socket may be filled with food debris along with saliva. Pain usually initiates within 24–72 hours after the extraction of tooth. Pain may vary in frequency and intensity and radiates to the ear and neck which may cause headache, insomnia and dizziness may be present. Redness, swelling, fever or pus formation is uncommon but edema of the surrounding gingiva and regional lymphadenitis is usually present. There is marked halitosis and foul taste. Smoking is a major predisposing environmental factor as it reduces the blood supply. The tissue around the socket appears to be tender and white necrotic bone is exposed in the socket. The incidence of dry socket may vary from 1 to 9%.

*Perspective Chapter: Dental Emergency and Conditions DOI: http://dx.doi.org/10.5772/intechopen.105495*

Irrigation of the socket using saline or chlorhexidine or powdered sodium perborate and then placement of medicated dressing soaked in bacteriostatic solution (alvogyl paste, bismuth iodoform paraffin paste (BIPP), cotton wool or gauze soaked in iodoform) on ribbon gauze and metronidazole and lidocaine ointment. Analgesics should be prescribed as a short course of non-steroidal anti-inflammatory drug to narcotic based like codeine. Immediate pain relief is usually attained and patients rarely re-present for additional treatment. Patients should be instructed to irrigate the area regularly. If the patient returns with ongoing pain, then osteomyelitis should be excluded and localized bony sequestrate should be excluded.

However, the rate of occurrence is unavoidable. Dry socket condition can only be prevented by copious use of irrigation, antibiotic medicated dressings and maintenance of oral hygiene.

#### **9. Maxillary sinusitis 'mimicking' toothache**

Recurrent maxillary sinusitis can result in extensive maxillary tooth pain. When lying down or bending over, the discomfort tends to get worse. On the affected side, there is frequently a sensation of 'fullness.' The discomfort is usually one-sided, dull, throbbing, and constant. Frequently, the patient is sick in general and has a temperature. In temporomandibular disorders (TMD) or neuropathic pain, it might mimic the symptoms of maxillary sinusitis. Unless misdiagnosed, many dental disorders rarely cause chronic discomfort.

Inflammation of the maxillary sinuses is best treated with local and systemic decongestants, and antibiotics may be administered if the condition persists10. Sinus pain is caused by a build-up of pressure in the sinuses. Sinus drainage can be aided by decongestants. In moderate situations, antibiotics are likely to play only a minimal influence. The patient is sent to an otorhinolaryngologist.

Acute necrotizing ulcerative gingivitis is a type of gingival infection that produces ulceration of the interdental gingival papillae. It has the potential to cause widespread devastation. Typically, young to middle-aged adults with low infection resistance are afflicted (diabetes, HIV infection, chemotherapy). Males are more likely to be impacted than females, with predisposing factors including stress, smoking, and poor oral hygiene. Important indications include halitosis, spontaneous gingival bleeding, and a 'punched-out' appearance of the interdental papillae. Patients frequently complain of significant gingival tenderness, which causes pain when eating and brushing their teeth. The ache is dull, profound, and unrelenting. Gums can bleed on their own, and there's an awful taste in the mouth as well as visible halitosis.

Because the infection is anaerobic, treatment is based on surgical principles and comprises superficial debridement, chlorhexidine mouthwashes, and a course of metronidazole pills. A recurrence should be avoided if the causative causes are addressed.

#### **Which tests can assist in diagnosis?**

There are several simple tests that may assist in diagnosis of dental pain.

1.**Pulp sensitivity test:** On the cervical third (neck region) of the tooth crown, dry ice on a cotton bud or an ordinary ice stick (made in a plastic or glass tube) is placed. The pulpal tissue is capable of sending nerve impulses and is vital if it responds to the stimuli (pain is the only sensory response from the dental pulp). The absence of a response could imply pulp necrosis.



#### **Table 1.**

*Most common dental emergencies.*

inferiorly below the mylohyoid muscle leading to dermal sinuses that are often mistaken for skin lesions remaining immune to routine dermatological remedies

7.**Radiographic examination:** If it's possible to get a screening radiograph, like an orthopantomography, this could help in diagnosis and pinpointing the explanation for the pain. The radiograph shows clearly the apical, periapical and associated structures and tissues. The connection of the maxillary molars and premolars to the ground of the sinus are often examined, and radiographs may reveal recurrent caries or periapical radiolucency's related to a long-time infection (**Table 1**).

#### **10. Conclusion**

It has been estimated that one or two life threatening emergencies will occur in the lifetime practice of a general dentist so prompt recognition and efficient management of dental emergencies by a well-prepared dental team can increase the likelihood of a satisfactory outcome. With proper training, thorough preparation, and regular practice, the staff of the dental office will be able to provide appropriate dental care whenever the need arises. To improve access and the quality-of-life care indeed it is essential to identify the need of the use of emergency dental services.

#### **Author details**

Navneet Kaur National Dental College and Hospital, Derabassi, Punjab, India

\*Address all correspondence to: kaurparneet1963@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Okeson JP, Falace DA. Nonodontogenic toothache. Dental Clinical in North America. 1997;**41**:367-383

[2] Goldberg MH, Topazian RG. Odontogenic infections and deep fascial space infections of dental origins. In: Topazian RG, Goldberg MH, Hupp JR, editors. Oral and Maxillofacial Infections. 4th ed. Philadelphia: Saunders; 2002. pp. 158-187

[3] McTigue DJ. Diagnosis and management of dental injuries in children. Pediatrics Clinic in North America. 2000;**47**:1067-1084

[4] Auld DN, Wright GB. The initial management of dento-alveolar trauma in general dental practice. Dental Update. 2010;**37**(5):286-288

[5] Andreasen JO. Traumatic Dental Injuries: A Manual. Copenhagen: Munksgaard; 1999. pp. 34-39

#### **Chapter 2**

## Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19

*Khairul Bariah Chi Adam, Haszelini Hassan, Pram Kumar Subramaniam, Izzati Nabilah Ismail, Nor Adilah Harun and Naziyah Shaban Mustafa*

#### **Abstract**

Traumatic dental injuries are emergencies that must be treated promptly and properly to reduce the suffering, costs, and time for patients and parents. However, since the coronavirus disease 2019 (COVID-19) outbreak was declared a pandemic on March 11, 2020, most dental care facilities in the affected countries have been completely closed or have been only providing emergency treatment. This can partly be a result of the lack of universal protocol or guidelines regulating the dental care provision during such a pandemic, especially in the management of dental trauma. This lack of guidelines has the potential to both promote the spread of nosocomial COVID-19 through oral health care facilities and deny people in need of immediate treatment. Moreover, ceasing dental care provision during such a period will incense the burden on hospitals' emergency departments that are already struggling with the pandemic. Therefore, this chapter elaborates on the importance of early management of dental trauma by sharing local guidelines and experience with a proposed algorithm for the early management of dental trauma during the emergence of COVID-19.

**Keywords:** management, dental trauma, COVID-19, guidelines in the management of TDI, algorithm for management of TDI

#### **1. Introduction**

Even before the pandemic, dental trauma is one of the world's leading oral health problems that is often neglected [1] leading to a global burden of disease amounting to a US\$2—5 million per 1 million inhabitants annually [2]. When the world was hit with a deadly coronavirus in late 2019, the whole world is in a massive total economic and social lockdown to focus on controlling the spread of the infection. The impact it had on the health services is detrimental enough to negatively affect not only the treatment and monitoring of dental trauma patients but also intensify the challenges in new findings and further scientific contributions to dentistry [3, 4].

Before coronavirus disease 2019 (COVID-19), the reported prevalence of dental trauma had varied widely as they depend on various factors such as age, etiology, region, environment, and gender. These injuries may be caused by road traffic accidents, bicycle accidents, assaults, falls, sports, industrial accidents, as well as iatrogenic causes from intraoral procedures. The prevalence of dental trauma in overall groups of patients were ranging from 15% to 30% [2] with an incidence rate of roughly 1—3 per 100 person-years [5, 6]. It was thought that approximately 900 million people had at least one dental trauma in the year 2016 with 1 in 4 adults and one in 6 adolescents having had a history of traumatic dental injuries [1]. The types of dental trauma reported include orofacial soft tissue injuries, maxillomandibular injuries, as well as traumatic dental injuries, in which the majority of the cases were contributed by traumatic dental injuries.

#### **2. Dental trauma and COVID-19: the incidence**

The pattern of dental trauma affecting different age groups has been relatively constant for the past many years, with the majority of the cases being contributed by pediatric patients. It was reported that 25% of the dental trauma was affecting the primary dentition, whereas 33% of the dental trauma was found in permanent dentition with the majority of the injuries occurring before the age 1 of 9 [2, 7]. Different age groups were known to have different etiologic factors leading to the presentation of dental trauma. A most common cause of dental trauma in preschool children is due to accidental falls, whereas in school-age children ranging from 7 to 12 years, sports and school fights were the main etiologic factors [2]. Assaults and road traffic accidents are more common etiologic factors among adolescents and adults [6]. This characteristic pattern of etiological factors is significantly affected when the world is hit by the COVID-19 pandemic. Due to the restricted movement order by most government authorities in the world, the changes in the epidemiology of dental trauma were very challenging to acquire for many reasons including the limited oral health emergency services available, as well as the restrictions in the data collection for the epidemiological studies.

Because of the COVID-19 pandemic, school closures, travel restrictions, and cessation of social events have changed the character of dental injuries. It significantly reduced the reported cases of dental trauma during the pandemic period. Few studies done were done in China, India, the UK, and Europe had described a significant reduction in the presentation of dental trauma in the primary and emergency dental services when they compared the dental attendances during a similar period before COVID-19 [8–10]. Some studies in China and the UK even showed that during the pandemic, there was a relatively higher case of dental trauma among preschoolers aged below 6 years, followed by adults [4, 8]. This pattern was different before covid-19 where the majority of the dental trauma cases were contributed by the adults. However, in Europe, it was found that most of the dental trauma was from the adults, with the age group of 20—29 years contributing to more than half of the adult patients [9, 10].

The global lockdown had led to a reduction in road traffic, social violence, group sports, and other school activities. This led to a reduction of dental trauma cases contributed by the mentioned activities. Nonetheless, reports on dental trauma during the pandemic showed that there was a significant increase in accidental falls and bicycle accidents leading to the dental and maxillofacial trauma ranging from 52% to

#### *Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.105992*

68% of presentations [8, 9, 11, 12]. This is further followed by interpersonal violence, occupational accidents, and road traffic accidents. A report in the UK also found that assaults from interpersonal and domestic violence had also increased considerably during the pandemic lockdown amounting to approximately 6% compared to a 2.6% prevalence before the pandemic [8]. It is no doubt that the socioeconomic gap that is present in some societies may have contributed to more interpersonal violence when the authority employed the social distancing measure and enforced the "stay-athome" guidance to flatten the infection curve [13].

Dental trauma can present as an isolated injury or in association with a multisystem traumatic injury. The trend of cases seen in the emergency setting since the COVID-19 emerged has also drastically transformed from a higher number of polytrauma seen in road traffic accidents to a more isolated injury. Soft-tissue facial injuries and traumatic dental injuries caused by the accidental falls were prominent in comparison to maxillomandibular fractures [9, 12]. Since children aged below 6 are those mainly contributing to the number of cases during COVID-19, the diagnosis of traumatic dental injuries was reported to be mainly dentoalveolar injuries which include concussion, luxation, and intrusion injuries to the anterior teeth that may range from 20% to 28% [8, 12]. However, in young adults with permanent dentition, the type of dental trauma presented during the pandemic was reported to be tooth fracture which mainly includes complicated crown fractures ranging from 62% to 75% [8, 9]. Depending on the impact of force from trauma caused by accidental falls or assaults, direct injury mechanisms can contribute to soft tissue injuries usually presenting with a laceration of the lip or chin [14].

The accidental falls with the chin falling first contributed to the indirect forces on the mandibular teeth against the maxillary dentition. The impact of this force often results in complicated crown fractures. The upper central incisors were reported to be most frequently injured [8] regardless of permanent or primary dentition. This trauma is usually accompanied by a condylar and/or mandibular symphysis fracture and intraoral soft tissue and submental laceration. Alveolar fractures were the least number of cases presented during the pandemic phase.

Throughout this unfortunate pandemic phase that had claimed millions of lives, a conclusion can be drawn to the pattern of dental trauma epidemiology which was highly influenced by the social and economic factors. The presentation of dental trauma in the emergency dental services during the COVID-19 pandemic was more likely to be caused by the lower energy injuries caused by falls and assaults that were more likely to be sustained in the home due to the restricted movement and quarantine orders governed by the authorities. Soft-tissue facial injuries accompanied by isolated traumatic dental injuries to the anterior dentition predominated the epidemiology of dental trauma during the COVID-19 pandemic. There is a significant reduction during the pandemic in the more complex dental trauma caused by the high kinetic injuries that would occur outside the homes, such as road traffic accidents and sports injuries.

#### **3. Early management of dental trauma**

Initial management when dental trauma occurs on the day of injury has a great influence on healing and the prognosis of the affected teeth. Correct diagnosis and a well-timed treatment will improve outcomes when managing dental trauma, especially in children and adolescents due to growth spurt consideration. Timeliness of treatment provided is a crucial indicator to salvaging the tooth provided an

appropriate assessment is conducted and treatment is done according to recommended established guidelines [15–17].

#### **3.1 Dental trauma emergencies**

Avulsion, luxation, displaced root fractures, and alveolar fractures require immediate dental treatment. Avulsion of permanent teeth requires timely management, particularly in the first 15 minutes after the traumatic injury [16]. Immediate tooth replantation is strongly advised, however, if this is not possible, the avulsed tooth should be placed in a medium able to preserve the periodontal ligament.

Complicated crown-root fractures (fractures with pulp exposure) should be treated within 24 hours [15]. If tooth fragments are available, they can be reattached once conservative pulp therapy has been completed. However, it is recommended to immerse it in distilled water or saline for 30 minutes before reattachment for rehydration. This process will increase its bonding strength particularly if the fragment is kept dry for long period.

Uncomplicated crown fractures, subluxation, and tooth concussions are not classified as dental emergencies. However, all exposed dentine should be covered promptly within 24 hours, as the patient will experience discomfort due to the sensitivity of exposed dentine. It is crucial to prevent bacterial penetration into the dentinal tubules, thus affecting its long-term prognosis.

Soft tissue injuries also need priority care, and appropriate referral should be made according to the severity of the soft tissue injuries especially in deep through and through lesions and when it involves anatomical aesthetic consideration.

#### **3.2 Assessment checklist**

A checklist is recommended to ensure that detailed information regarding the patient and injury is obtained, including [18]:


*Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.105992*

10.If the patient is experiencing associated pain in the adjacent teeth, jaw, or temporomandibular joint area

The injury must always be thoroughly assessed by both extraoral and intraoral clinical examination and radiographic investigation. The current American Association of Endodontists (AAE) guidelines recommend taking one occlusal and two periapical radiographs with different lateral angulations for all dental injuries, including crown fractures. If cone-beam computed tomography is available, it should be considered for more serious injuries, such as crown/root, root, and alveolar fractures, as well as all luxation injuries.

Additionally, sensitivity tests should be conducted on all teeth involved, including opposing teeth. Cold testing is recommended over electric pulp testing in young patients. Both testing methods should be considered, however, especially when there is no response to one of the two. The pulp might be nonresponsive for several weeks after a traumatic injury, so a pulp test should be done at every follow-up appointment until a normal response is obtained.

#### **3.3 Clinical management**

Dental trauma can be categorized into two groups: fractures and luxation injuries. Fractures are further divided by type: crown, crown-root, and root fractures. Any dental tissue injuries that lead to pulp exposure, is considered a complicated fracture. However, if the pulp is not exposed to the oral environment, it is an uncomplicated fracture.

Tetanus prophylaxis administration should be considered for contaminated wounds even though the patient may have had previous immunization history. Broadspectrum antibiotics against gram-positive organisms such as penicillin, and cephalosporin, are the drugs of choice for soft tissue injuries with oral cavity communication.

#### **4. Barriers to early management of dental trauma during COVID-19**

Traumatic dental injury (TDI) can occur even via a low-kinetic trauma which can happen anywhere relating to falls, sports, and collisions with objects and people. Hence, it is the most common type of dental-related trauma to occur. TDI is also a condition that requires urgent attention, being more so since its management can be more daunting if the case involves young patients with primary dentition or mixed dentition stage [19]. This form of trauma despite not being life-threatening in most cases can cause significant distress to the patient as well as their parents as there are substantial physical, aesthetical, and psychological consequences. In the urgent setting, dental trauma care revolves around the tenet that it is intended to stop the pain, and restore oral function and esthetics whilst reducing dental anxiety [20]. In the long-term setting, the treatment should avoid infection propagation and smooth progression of growth to permanent dentition if the situation involves young children group.

The proper steps of management are essential to mitigate the undesired short- and long-term consequences [21]. Even in cases of properly reviewed young patients with a history of severe dental trauma during the deciduous or mixed dentition stage may present with consequences years later leading to issues with permanent dentition succession problems [22, 23]. Despite clear guidelines being spelled out for the

management of TDI; COVID-19 concern takes precedence which indicates that the usual standard of care may not be the feasible option. In a situation, with the COVID-19 pandemic still being rampant amongst the population, many barricades impact the ideal provision or acquisition of care for dental trauma. These barriers are represented at many points including dental healthcare regulation policy, patients' concerns, dental service providers' concerns, dental amenities issues as well as other limitations.

Some studies have reported that patients are more than hesitant to obtain dental care due to fear of COVID-19 transmission [9, 24]. This concern is very much allayed by the fact that most dental treatment revolves around the implementation of aerosolgenerating procedures (AGP). Hence the risk of transmission is increased [25, 26]. During dental AGP several thousand droplets are aerosolized where larger droplets gravitate quickly to surfaces whilst smaller droplets tend to evaporate allowing dry microscopic pathogens to remain air-borne and freely circulating via air convection [26]. The basic understanding of COVID-19 in terms of its novel and rapid transmission instills this dread even more amongst the public [4]. A study done in Nigeria by Ajayi and Arigbede [27] implies that patients choose to defer from seeking treatment for dental-related emergencies as it is their perception that such ailments are not life-threatening, hence it would simply resolve them on their own. Ahmad et al. [28] also communicated that patients' refusal for seeking urgent dental treatment includes dental fear, perception of need, sterilization concerns, lack of awareness, and discomfort at the long wait in the emergency or dental outpatient clinic. This is due to the notion that the emergency waiting area could be harboring active COVID-19 patients. Hence, this cavalier approach of wait and see by the patient towards dental trauma is not just limited to the population with limited access to health care provisions.

Additionally, many do believe in the notion that if there are no symptoms or if the symptoms resolve, no further treatment is necessary after the dental trauma. In some other situations, it is the patient's concern about the high treatment cost incurred upon seeking dental trauma treatment, especially since COVID-19 has diminished livelihood and devastated job opportunities. Another report suggests that the reluctance of patients even in developed nations to seek treatment for trauma or non-trauma-based dental condition is due to the loss of the employer-sponsored dental insurance coverage caused by the pandemic [29]. Even in the post-lockdown phase, the impact of COVID-19 has far-reaching consequences as there is an opinion considering younger patients are not able to comply with the period of preoperative and postoperative isolation that might be required in tandem with dental trauma management due to their commitments towards their employment, children at school or care for elderly family members [30]. Dental trauma care for elderly patients is also another concern as they are at greater risk of developing severe reactions and morbidities related to the COVID-19. This opinion is supported by a recently cited United Kingdom study have noted a reduction of TDI cases in patients aged range of 50 years of age [9].

The next loci impeding the management of dental trauma revolves around the dental service provider force as well as the amenities that are involved in the treatment. One concern is the limitation of available dental care providers as many dental staffs may have redeployed to the frontline for COVID-19 testing or triaging roles as well as being furloughed thus limiting access to dental care [29]. A web-based survey done in Brazil divulged that many dentists who attended emergency or dental trauma patients proceeded so without auxiliary dental staff support to minimize infection spread and due to manpower restrictions [31]. From another viewpoint, limiting the number of dental personnel during AGP is essential to minimize the propagation of

#### *Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.105992*

COVID-19 though this is likely to draw the procedure time even longer than the usual. In the private sector, dental practitioners are burdened by financial issues resulting from reduced working hours and limited dental procedures that could be performed. On the other hand, public health workers including dental practitioners have experienced stress and depression during the pandemic period caused by increased workload, constant changes in the infection control protocols, social distancing, selfisolation, and caring for deteriorating patients [32]. These conditions could impede their standard of care during the management of dental trauma as well. In addition, older dental practitioners and staffs are more cautious when dealing with dental trauma cases since they are in the more susceptible age group in terms of COVID-19 severe reaction [33]. Younger dental practitioners reported lower anxiety in the same manner whilst the older dental practitioners face greater family and job concerns as well as financial considerations [33].

Next, the adjoining dental amenities can also be a barrier in the treatment of dental trauma as will be expounded here. The use of an intraoral radiograph to assess dental trauma for conditions like an intrusion, lateral luxation or crown-root fracture is ideal during the initial treatment phase for such conditions. It is one of the most common forms of radiographic technique in dental imaging. However, the use of intraoral radiographs involves placement of the radiograph film inside the mouth leading to stimulation of salivary secretion and activation of gag reflex leading to etching and coughing [3, 29]. This is undoubtedly not suitable as the dispersion of droplets and bioaerosols will be increased. This situation is made worse by the fact that most dental procedures are the aerosol-generating type as the tools used as air-driven handpieces, ultrasonic scalers, piezotomes, cautery units as well air-water syringes [25]. Dental avulsion, intrusion, and luxation injuries routinely require the placement of splint using composite resin requires the use of air-drying syringe while removing the splints requires bur cutting and suctioning. Hence the issue of minimizing the use of such tools during the management of dental trauma would be a barrier to providing sound treatment.

Based on the UK Office for National Statistics, dental practitioners and auxiliary staff deal with their patients in proximity inferring the possibility of increased exposure to general disease and COVID-19 [34] due to splashback of saliva or bioaerosols. Efforts to minimize and reduce the salivary viral load are another concern that could hinder the treatment of dental trauma in patients with a high risk of COVID-19 especially the routine mouthwash such as chlorhexidine may not be effective against COVID-19 [35, 36]. Disinfection of tools and surfaces of the dental clinical surfaces for COVID-19 includes a waiting period to allow the aerosols generated in the previous session to dissipate. This means an increase in waiting time and further delays in the provision of treatment, especially in healthcare facilities with high trauma case flow [29]. Additionally, the use of fumigation is not considered a practical option in dental surgery as it will further increase the waiting time for starting the procedure [3]. Additionally, methods to minimize follow-up for dental trauma management are also a hindrance as a treatment for such condition usually requires frequent follow-up to ensure no morbidities ensues.

Next, the limitation in healthcare facilities and policies are identified as potential blockades in the provision of dental trauma emergency care during the COVID-19 pandemic. It is not unusual to observe that during budget deductions in hospital or emergency services; dental benefits or dental treatment budgets are among the first service to receive cuts [29]. This is likely to hamper further the effort in providing sound dental care for trauma cases. Additionally, most dental healthcare facilities

can be under great strain to provide personal protective equipment (PPE) for their staff and to stay ahead of the curve in the evolving infection control policies regarding COVID-19 [9]. The next challenge includes the availability of a negative pressure room for dental trauma procedures which will be very ideal; however, most if not all dental facilities still lack such options as most dental operatories are clustered in open spaces without physical barriers. Other limitation includes the availability of teledentistry in most dental healthcare centers as well as emergency centers. Teledentistry is a viable tool for triaging and follow-up assessment by dental practitioners without direct contact with patients [37]. Some challenges may still ensue in the implementation of teledentistry in all dental healthcare facilities as there is the need for dental personnel to acclimatize to this new technology, whilst managing, sharing, and disseminating personal-medical information on their patients.

Overall, the hindrance or limitations mentioned above must be addressed expediently to minimize the delay of comprehensive dental trauma treatment secondary to COVID-19 limitations as it will inevitably create a backlog of cases. Health issues in the oral cavity will most likely occur in such cases especially if regular follow-ups and care are not available. In addition, the consequence of substandard dental trauma treatment will flare up, especially in cases involving children with deciduous or mixed dentition as it could affect permanent dentition and thus increase the need for further dental care in the future. Finally, the current implementation of biosafety in clinical dental practices may compromise the cost of dental consultation and reduce the consultation time.

#### **5. Guidelines in the management of dental trauma during COVID-19**

#### **5.1 Available guidelines and proposed algorithm in the management of traumatic dental injuries**

In the era of the early COVID 19 pandemic, most dental practices were forcibly closed and it was uncertain whether dental services in the hospitals would be able to cope with patients suffering from dental trauma. However, research also has revealed that patients are hesitant to go to a hospital out of worry for the potential risk of contracting COVID-19 [9]. Therefore, it is important to weigh the benefit of managing traumatic dental injuries to the primary dentition and minimizing the risk of transmission of COVID-19 to patients and staff. In published interim guidance for the provision of essential oral health services during the COVID-19 pandemic, it was advised that routine non-essential oral health care to be delayed until there has been sufficient evidence of control in COVID-19 transmission rates at the national, sub-national, or local level [38–42]. This is mainly due to the prolonged duration and the proximity of dental healthcare workers to the patient's facial region. The dental procedures involve close contact and exposure to saliva, blood, and handling sharp instruments; stratifying the dental healthcare workers as high risk of being infected with COVID-19 or passing the infection to patients.

Multiple guidelines were written in conjunction with this cause on resuming general dental services and principles for acute care during the pandemic such as the new 2020 IADT trauma guidelines [20, 38–42]. The focus of the updated guideline was mainly on general information in certain sections, and a table of complications with the recommendation of longer follow-up (yearly till 5 years and beyond). In intrusive injuries, for example, the current recommendation is only to observe and review as

#### *Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.105992*

opposed to extraction of the primary teeth. More emphasis is placed on conservative treatment rather than pulpotomy or extraction in injuries such as crown fractures and luxation [20].

While the new IADT guideline advocates conservative treatment options following traumatic injuries to the primary dentition during the COVID-19 pandemic, the British Society of Paediatric Dentistry (BSPD) and Dental Trauma UK suggest treatment options should focus on either observation or extraction [43]. This approach minimizes the number of face-to-face contacts and reduces aerosol-generating procedures. The BSPD has published consensus guidelines on the management of dental trauma concerning the COVID-19 pandemic, including acute management of traumatic injuries and follow-up care. Remote consults are recommended during follow-up to assess oral hygiene, healing, and complications. If deemed necessary, the patient is seen in the clinic for detailed assessment and treatment. All follow-ups could be made through remote consults for root fractures 1 week, 4 weeks, and 1-year intervals after the injury. For enamel-dentine fractures, the follow-up could also be remote, and the recommended time is 8 weeks.

In supporting tissue injuries, for example in lateral luxation and intrusion, which have higher risks of sequels and require more frequent follow-ups, the guideline recommends that remote consult be performed. Remote consult for review at 1-week for all supporting tissue trauma and, depending on the type of trauma, at 8 weeks, 6 months, and 1 year of follow-up are required. Post-injury advice should include care not to further traumatize the injured teeth while eating and encouraging the patients to return to normal function as soon as possible; oral hygiene instructions that include cleaning the affected area with a soft brush or cotton swab combined with an alcoholfree chlorhexidine gluconate mouth rinse.

In the meantime, the Scottish Dental Clinical Effectiveness Programme published a guide on the management of acute dental problems during the COVID-19 pandemic [44]. In the cases of dental injuries that don't require urgent medical attention, patients are advised to clean the affected area with mild antiseptic and to apply ice packs and pressure on the injured soft tissue to stop bleeding. Urgent care is recommended for avulsed, luxated, or fractured teeth. In the case of the avulsed primary tooth, they should not be re-implanted, instead, it is recommended for self-help and consultation that include appropriate analgesia followed by advice on a soft diet.

In tandem with guidelines by the BSPD and Dental Trauma UK as well as the Scottish Dental Clinical Effectiveness Programme, the King's College Hospital has published new standard operating procedures specifically for the COVID-19 pandemic, published by Ilyas et al. [45] in June 2020. This guideline is also recommended on telephone advice only or a dental visit to perform extraction as management of primary tooth trauma during the pandemic. Telephone advise only is given for all cases of dental trauma that does not interfere with occlusion/airway risk. Only enamel-dentine fractures and pathological mobility, causing occlusal interference/ airway risk are recommended to be seen urgently for treatment.

The Royal College of Surgeons of England also published the recommendations for pediatric dentistry during the COVID-19 pandemic of COVID-19 [46]. These guidelines recommended that no routine dentistry should be provided for children during this pandemic and treatment should be deferred to minimize the risk of transmission of the disease to patients, staff, and the public. They also recommended that urgent management is only indicated in pulp exposure or severe luxation that carries a potential airway risk or is severely interfering with occlusion for primary teeth. To reduce the need for AGP, extraction may be the preferred treatment option for children with pulpal symptoms.

The aim of trauma management should be to minimize the number of visits required and the number of AGPs provided. Outcomes should be optimized by giving evidence-based initial management with a low risk of complications requiring further intervention.

In Malaysia, a guideline or standard operating procedures were published urgently in view of the pandemic in early 2020. During the early phase of COVID-19, all dental clinics in Malaysia were to suspend their services except for emergency dental treatment including dental trauma. Therefore, all dental trauma cases were channeled to hospitals for urgent management. Following that, more revised protocols focusing on PPE and patient screening were published to allow the opening of dental services again with restrictions. The ministry of health published the guideline on "Management of COVID-19 screening in dental clinics" and circulated

**Figure 1.**

*Proposed algorithm for management of TDI during COVID-19.*

#### *Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.105992*

it in January 2020 concerning the Interim Guidelines Novel Coronavirus (nCov) in Malaysia. This document mainly addressed the concerns on the identification and handling of positive COVID-19 patients or Person Under Investigation (PUI) at the point of screening/triage prior to dental treatment. Several amendments had been made to the protocols to ensure it is updated and kept abreast with other international guidelines given their rapid change of management.

In summary, there are some similarities observed in published guidelines during the pandemic. Regarding treatment options for example, although some guidelines recommended conservative treatments (i.e., pulpotomy, composite build-ups, root canal treatment, and repositioning and splinting) during the COVID-19 pandemic, BSPD Dental Trauma UK, The Royal College of Surgeons of England as well as King's College Hospital protocol, however, suggest treatment options should focus on either observation or extraction. These guidelines recommended that a more definitive treatment, such as tooth extraction, may avoid recurring visits to the dental office and thus reducing the risk of exposure to COVID-19. Following an acute injury, most of the guidelines are encouraged remote consultation (e.g., telephone, photographs, or video conferencing) that can help clinical teams to clarify a provisional diagnosis and treatment. An effective remote consultation may also reduce the face-to-face time in the clinic, thereby maximizing the potential use of the clinic and minimizing PPE usage. Only selected cases may require an initial face-to-face consultation to ensure an accurate diagnosis where remote consultation is not possible, or diagnosis is uncertain. Follow-up appointments are necessary to assess healing, oral hygiene, and complications in the intervals of 1 week up to 5 years of the review were recommended with the intervals of remote and face-to-face consultation. Beginning a road to recovery will require "new normal" management. As part of the recovery, clinicians are recommended to completely re-evaluate how services are prioritized and delivered. Relieving children of pain must take priority over routine dental care services [47]. These guidelines are likely to evolve as dental services return to normal, at which point this guide will be withdrawn in preference for the new 2020 IADT trauma guidelines.

Below is the summary of the proposed management algorithm for dental trauma during the pandemic following various guidelines worldwide (**Figure 1**).

#### **6. Conclusions**

Traumatic dental injuries are among the dental emergencies that must be addressed as early as possible to ensure the survival of the tooth with good treatment outcomes and a better prognosis. In a long run, this reduces the number of visits, number of treatments, and cost as well as the time of treatment needed in the future. During the COVID-19 pandemic, the etiology of the injury has also shifted to accidental falls, and interpersonal and domestic violence since most countries implemented the movement restriction orders, school closure, and travel restrictions—all accounting for to stay home policy. The incidence of TDI across many countries has shown a change in age predilection and the characteristics of dental injury.

Special management protocols for immediate dental trauma management have been forwarded by many guidelines and various modified measures have been suggested to reduce and regulate droplet and aerosol contamination in the emergency dental setting has been discussed. This includes the screening of the patients before procedures, reduction or avoidance of droplet/aerosol generation in emergency dental situations, the disinfection of the treatment field, application of a rubber dam, and

pre-procedural antiseptic mouth rinse, and the dilution and efficient removal of contaminated air utilizing the air filter. Some cases are even consulted via teledentistry to reduce the face-to-face contact between the dental healthcare worker and patients during pandemics.

With the available guidelines for treating dental diseases during the COVID-19 pandemic time, some dental practices can safely return and restart operations, other practices may choose to remain closed or limit services to only those critical or emergency procedures that cannot be delayed due to expected risks and existing safeguards.

#### **Acknowledgements**

This work was supported by International Islamic University Malaysia.

### **Conflict of interest**

All named authors have no conflict of interest, financial or otherwise.

### **Notes/thanks/other declarations**

We declare no conflicts of interest in any of the related issues.

#### **Author details**

Khairul Bariah Chi Adam\*, Haszelini Hassan, Pram Kumar Subramaniam, Izzati Nabilah Ismail, Nor Adilah Harun and Naziyah Shaban Mustafa Department of Oral Maxillofacial Surgery and Oral Diagnosis, Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan, Malaysia

\*Address all correspondence to: bariah@iium.edu.my

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Early Management of Dental Trauma in the Era of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.105992*

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#### **Chapter 3**

## Perspective Chapter: Update and Making-Decisions in Dental Traumatology

*Blanca del Carmen Migueláñez Medrán, Nuria Delgado Castro, Elena Riad Deglow and Álvaro Zubizarreta Macho*

#### **Abstract**

Dental traumatology is highlighted as an unexpected emergency event which can occur at any moment, age, sex, and gender. Crown fractures account for most traumatic injuries occurring in the permanent dentition. A complete radiographic examination is considered essential in order to assess the state of the pulp, the degree of root development, and the existence of any pathologies affecting the supporting tissues. These examinations also provide a useful tool for subsequent comparisons with those conducted after treatment, ensuring adequate clinical follow-up. Additionally, avulsion of permanent teeth has been highlighted as one of the most relevant dental injuries; therefore, the prognosis of this traumatic event has been directly related to the treatment decision-making process and the time passed since the accident. In addition, dental trauma is also one of the most frequent emergency situations seen in Pediatric Dentistry; moreover, the dental injury of the temporary teeth could also affect to the permanent teeth; hence, it is necessary to perform an exhaustive clinical and radio diagnostic exam to allow a correct diagnosis and a predictable treatment plan. Therefore, the creation of action protocols makes it possible to simplify and facilitate decision-making under stressful situations for patients and clinicians.

**Keywords:** dental fracture, dental traumatology, permanent dentition, primary dentition, tooth avulsion

#### **1. Introduction**

Avulsion of permanent teeth has been highlighted as one of the most relevant dental injuries; it has been reported to make up between 0.5 and 16% of all dental injuries [1, 2]. Additionally, the prognosis of this dental injury is directly related to the treatment decision-making process and the time passed since the accident [3–6]; it is therefore essential to inform society and keep professionals updated so that the decisionmaking chain is as optimal as possible and leads to a predictable prognosis [7, 8]. Currently, dental replantation is the treatment of choice; however, certain scenarios prevent it from being carried out immediately, including extensive caries, periodontal disease, uncooperative patients, immunosuppression, or heart disease, which require

individualized treatment procedure. Additionally, the final decision must be made with the consent of the parents. Therefore, the creation of action protocols makes it possible to simplify and facilitate decision-making under stressful situations for patients and clinicians. For this reason, guides developed by scientific societies are published in the most popular media, so that they might reach the majority of society and clinicians. 2. Treatment guidelines and decision-making for dental fractures.

#### **1.1 Crown fractures**

Crown fractures account for most traumatic injuries occurring in the permanent dentition. The most common etiology of this type of injury is accidental falls, contact sports, traffic accidents, or accidents at work.

A complete radiographic examination is considered essential in order to assess the state of the pulp, the degree of root development and the existence of any pathologies affecting the supporting tissues. These examinations also provide a useful tool for subsequent comparisons with those conducted after treatment, ensuring adequate clinical follow-up [9].

#### *1.1.1 Enamel fissures (enamel infraction)*

These types of fractures are located on the vestibular surface of the anterior teeth and may go unnoticed because there is no loss of tooth structure. Clinically, they appear as fissures that do not cross the amelo-dentinal junction [10, 11], and they are usually revealed when light is targeted perpendicular to the major axis of the tooth (transillumination).

Vitality tests are usually positive3, although they may be temporarily negative after any impact [9].

The presence of crack lines in the enamel should alert the clinician to the possibility of injury to the surrounding supporting structures (e.g. luxation). In such cases, there may visible changes in dental color.

Fissures limited to enamel generally do not require treatment. In selected cases, to avoid potential staining by external agents, the enamel surface can be sealed [9, 11].

The long-term prognosis of this type of lesion is very good, with tooth survival approaching rates of 100%.

#### *1.1.2 Fracture without pulp exposure (uncomplicated crown fracture)*

Fortunately, this type of fracture occurs more frequently than those with pulp involvement.

On initial examination, thermal tests may be negative for a certain period of time (primarily if the lesion coexists with a luxation), but with this type of fracture there is usually sensitivity to thermal changes due to dentine exposure (more prevalent in younger teeth due to the larger diameter of the dentin tubules and the proximity of the fracture to the pulp), pressure changes, and dehydration [9, 11].

Just like with enamel fissures, the surrounding tissues should be routinely examined to exclude other pathologies that might affect the supporting tissues.

The primary goal of treatment is to achieve adequate esthetics and function. Nowadays, with composite resins [12] and the use of adequate bezels to mask the fracture line, it is possible to attain very satisfactory results [13].

Another therapeutic option involves the fixation of the detached crown segment with a total acid etching technique and the application of composite resins at the

#### *Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

fracture line. This type of fixation is more predictable the larger the fragment is, and if it is a single fragment (smaller and multiple fragments have a worse prognosis) [9]. Before being bonded to the remaining tooth structure, the fragment must be rehydrated [11].

According to different authors, failures in this type of restorations can be attributed to:


3.Color instability.


#### *1.1.3 Crown fracture with pulp exposure (complicated crown fracture)*

In this case, visible loss of tooth structure is evident, and a slight hemorrhage can be observed at the site of pulp exposure. In cases in which there is a delay in treatment, and particularly in young teeth, a pulp polyp may be observed.

Due to this pulp exposure, the teeth are often sensitive to thermal and pressure changes.

Radiographs are very useful for diagnosis, mainly to assess the extent of the lesion and to determine the degree of root development, in order to choose the most appropriate treatment option for each individual case.

The primary objective of treatment is the preservation of pulp vitality without inflammation, to achieve the formation of a hard tissue barrier [9, 13].

The prognosis of treatment will depend on:


Treatment of teeth with an open/immature apex should be as conservative as possible, trying to maintain pulp vitality. The therapeutic options that can be considered are as follows:

• *Direct pulp capping*: This is used in small pulp exposures in which treatment can be carried out in less than 24 h and the bleeding stops when pressure is applied with cotton wool.

Pulp capping, which may consist of applying glass ionomer cement (GIC) or mineral trioxide aggregate (MTA) before placing the restoration to prevent bacterial invasion [14].

• *Partial pulpotomy* (*Cvek pulpotomy*): The treatment of choice if the trauma occurred more than 24 h before. It consists of removal of the damaged tissue until clinically healthy pulp is available [15].

Depending on the size of the pulp exposure, it may be performed partially or coronally. This treatment be used in both mature and immature teeth.

After removal of the affected pulp and controlling the bleeding, Calcium Hydroxide (CaH) or MTA is placed. Zinc oxide eugenol or another cement can be placed on top. After 3 months, if appropriate sensitivity has been preserved and a dentin barrier can be observed via radiographic examination, definitive reconstruction can be carried out.


As in the previous cases, bleeding must be controllable (hemostatic agents can be used). The material of choice is CaH [9], although calcium silicate–based cement is also used [18].

Despite advances in both technique and materials used, it is particularly difficult to assess the state of the pulp in root canals, so the prognosis of this therapeutic option remains controversial.

• *Non-vital teeth*: Teeth with complete root formation can be treated with standard endodontic procedures, producing a predictable outcome.

Teeth without complete root formation have a poorer prognosis, as cessation of the neurovascular supply leads to incomplete apex closure, thinner root walls, and, in some cases, even an unfavorable crown-root ratio [19].

The apexification procedure allows for complete root development by forming an apical hard tissue barrier [20].

This was traditionally carried out using CaH, which induced apex closure until complete apical closure was achieved, enabling conventional endodontic treatment. Nowadays, MTA is used to achieve apical closure in a single step [19], and even platelet-rich plasma is used in combination with MTA [21].

If CaH is used, endodontic reopening of the tooth is performed when the clinician observes the desired apical closure radiographically, and the existence of the apical barrier is checked with a file.

If MTA is used, after proper opening and cleaning of the canal, the MTA is loaded into a dental plate holder and placed at the apex with the aid of a thick paper tip 1–2 mm shorter than the estimated working length and a thick stripper until a 4– 5 mm thick plug is formed. When the plug is deemed to be adequate, a radiographic check of the plug is necessary, and once the MTA has set, the root canal can be filled [9].

#### **1.2 Intra-alveolar root fractures**

These represent a much lower percentage than coronal fractures. Furthermore, they are much less common in the primary dentition and in teeth with immature apexes (these tend to dislocate rather than fracture). These types of fractures can be located horizontally or vertically with respect to the major axis of the tooth and involve enamel, dentine, and cementum [9, 13]. Vertical fractures usually have a worse prognosis, the tooth is not usually restorable, and often the only option is to extract the tooth.

Horizontal fractures, depending on their location, can affect the coronal, middle, or apical third.

Clinically, the affected teeth will appear as if they were extruded. As the trauma usually comes from the vestibular side, we will often also find the tooth is slightly lingually inclined, in addition to exhibiting mobility, bleeding from the gingival sulcus, and positive percussion. In terms of vitality, both fragments may be necrotic, or the coronal fragment may be endodontically treated and the apical fragment may still be vital.

The diagnosis of an intra-alveolar fracture is sometimes complicated by the small separation of fragments at the time of impact. This separation usually increases over the following days, which often makes diagnosis easier as the fracture line can be seen on the radiographic scan if the beam is directed at approximately the same angle as the fracture line. This is usually easier when the fracture is more horizontal rather than oblique. Therefore, in a patient with a possible intra-alveolar fracture, several radiographs should be taken, changing the degree of angulation [9]. If the radiographic projections do not give us the information we need, it is advisable to perform a CBCT (Cone Beam Computed Tomography) to determine the location, extension, and trajectory of the fracture [12].

The different types of scarring between fragments were first classified by Andreasen and Hjorting-Hansen [22] into four different categories (**Table 1**).


#### **Table 1.**

*Types of scarring observed in fragments [22].*


#### **Table 2.**

*Sequelae of intra-alveolar fractures [9].*

In addition, intra-alveolar fractures present four types of sequelae, which are summarized in **Table 2**.

The treatment and prognosis of the tooth will depend largely on the location of the root fracture: whenever possible, it is advisable to reduce the fracture by repositioning the coronal fragment in an appropriate position. If it is very mobile, it should be splinted passively and flexibly (semi-rigid) [23].

If the fracture affects both the crown and the root but there is no pulp exposure, the fractured fragment should be reconstructed [12].

In the case of an intra-alveolar fracture, it should be noted that vitality tests may initially be negative. If the diagnosis of loss of vitality is confirmed, or if it is confirmed that the root of an immature tooth is not continuing to develop, endodontic treatment should be carried out. Depending on the case, treatment of both fragments can be carried out in several ways:


#### **2. Introduction of the treatment guidelines and decision-making for avulsed permanent teeth**

#### **2.1 Patient recommendations**

Traumatic events occur suddenly and unexpectedly, and first aid responses for an avulsed permanent tooth is usually performed by a guardian, teacher, or parents, who call the dental clinic asking for instructions on how to respond to the traumatic event. Afterwards, it is necessary to confirm that it is a permanent tooth that has been avulsed, as a primary tooth should not be replanted. Subsequently, clinicians should provide the following recommendations [24]:

1.Keep the patient and the guardian, teacher, and/or parents calm.


In addition, the International Association of Dental Traumatology (IADT) has developed the free app "ToothSOS", which provides useful information for patients affected by dental injury.

#### **2.2 Management and decision-making for avulsed permanent teeth**

Once the patient arrives to the dental clinic, the clinician should ask whether or not it was possible to replant the avulsed permanent tooth. If the tooth was replanted on the alveolus, the clinician should verify that the tooth has been replanted correctly by comparing the angulation and incisal border with respect to the adjacent teeth, as well as by using a periapical radiograph. However, if the tooth could not be successfully replanted on the alveolus, the clinician should first analyze the condition of the periodontal ligament fibers according to the classification of the IADT in order to obtain useful information regarding the prognosis of the avulsed permanent tooth [28]:

Most of the periodontal ligament fibers are viable, since the tooth was replanted immediately or within the first 15 min after the accident.

The periodontal ligament fibers are damaged, as the extra-oral dry time did not exceed 60 min, despite being stored in a wet medium.

Most of the periodontal ligament fibers are non-viable, as the extra-oral dry time exceeded 60 min.

Regardless of treatment prognosis, replantation should be the treatment of choice; that being said, the stage of development of the avulsed permanent tooth is an important factor.

#### *2.2.1 Management of avulsed permanent teeth with closed apex*

Three different scenarios can occur, depending on the replantation site and length of extra-oral dry time:

#### *2.2.1.1 Mature permanent tooth replanted immediately at the accident site*

If the avulsed permanent tooth with closed apex has been replanted at the injury site, the clinician should follow the following recommendations:


#### *2.2.1.2 Avulsed permanent tooth stored in wet medium for less than 60 min*

The medium used to store depends on the accident location; however, tissue culture media such as milk or HBSS are recommended to preserve the viability of periodontal ligament cells.

	- 1.Gently rinse the avulsed permanent tooth with a saline solution or milk to remove any dirt, taking care not to apply heavy pressure to avoid damaging the periodontal ligament.
	- 2.Leave the tooth hydrated in a moist environment while you examine the patient and take their medical history.
	- 3.Administer local anesthesia, preferably without a vasoconstrictor.
	- 4.Gently irrigate the socket with saline, removing the coagulum for easier replantation of the avulsed tooth.

#### **Figure 1.**

*(A) Avulsed permanent tooth held by the dental crown, (B) replantation procedure, (C) root canal treatment after 15 days, and (D) 6 months follow-up after replantation.*


Three different scenarios can also occur here, depending on the replantation site and length of extra-oral dry time:

#### *2.2.2.1 Immature permanent tooth replanted immediately at the accident site*

If the avulsed permanent tooth with closed apex has been replanted at the injury site, the clinician should follow the following recommendations:


*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*


#### *2.2.2.2 Avulsed immature permanent tooth stored in wet medium for under 60 min*

The medium used to store depends on the accident location; however, tissue culture media such as milk or HBSS are recommended to preserve the viability of periodontal ligament cells.


#### *2.2.2.3 Extra-oral dry time longer than 60 min*


#### **3. Introduction of the treatment guidelines and decision-making for traumatic dental injuries (TDI) in temporary teeth**

Dental trauma is one of the most frequent emergency situations seen in Pediatric Dentistry, especially in notable hospitals or dental clinics, or those linked to schools or sports centers. Dental trauma often happens in the schoolyard or in sports facilities where children practice some sport without the presence of the parents, who are notified by the institution, go to pick up their child, and come to us bewildered, nervous, and scared regardless of the severity of the blow.

#### *Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

The situation is one of tension, anguish, and chaos, further exacerbated by the presence of blood, crying, having to dental fragments or missing teeth... Therefore, when these situations reach us, we must prioritize their attention and transmit our sense of calm to the patient and their family members. In addition, in cases of multiple traumas, time is essential for the best possible prognosis and evolution of the case.

Once the anamnesis and medical history have been taken, we collect data on the accident, how it happened, where, how long ago, whether it is the first time the area has been hit, whether there is pain, bleeding, dental dyschromia, changes in bite, or if you have had any neurological symptoms that force us to prioritize another type of medical assessment by professionals from another specialty.

Then, once in the clinical area, we must wash the patient's face and thoroughly clean the injured areas with saline solution and gauze pads, using 5-ml syringes for areas that are difficult to access, such as the back of the vestibule. Often once this cleaning has been carried out, the diagnosis is nothing more than the most banal of injuries, despite the initial appearance of the blow (**Figure 2**) [32–40].

It is important to highlight that when a tooth suffers a trauma, no matter how slight, the neurovascular bundle that innervates it and supplies it with nutrients through the apical foramen is always involved. This can undergo compression or stretching that may well evolve without any complications, or it may evolve to necrosis that requires treatment. For this reason, it is essential that we monitor the evolution of the pulp over time and that we follow up on the signs and symptoms that may appear, sometimes several months after the trauma [41].

With regard to this evolution of the pulpal state of a tooth that has suffered a trauma, any change in color or darkening of the tooth become especially important. Many traumas give rise to a more or less immediate darkening of the color of the tooth due to internal bleeding that enters through the dentinal tubules, resulting in dyschromia. This tone lightens in the days after the trauma, although it does not usually disappear completely, but it does not indicate any pulpal degenerative processes at all. It is important that we note the color of the tooth during the initial exploration of the trauma, assessing whether there has been a change in shade or not; if the darkening of the tooth occurs gradually, becoming increasingly darker over time, this would be a sign of pulpal degeneration and necrosis (**Figure 3**) [42–45].

**Figure 2.** *Trauma in temporary teeth prior to thorough cleaning of the area.*

**Figure 3.** *(A) Dyschromia of 61 caused by internal bleeding at the time of injury and (B) dyschromia of 51 and 61 caused by pulp necrosis.*

Essentially, when assessing our case, we must classify injuries according to the tissues affected: soft tissues, periodontal ligament, dentin-pulp complex, and bone tissue, doing our best to explain to the parents that each tissue has a unique healing capacity and rhythm requiring different types of care and/or treatment. As a general rule, soft tissues heal in 3–4 days when following the specific guidelines for their care, the periodontal ligament in 7–10 days, depending on the degree of severity, and the pulp can suffer direct effects that require immediate treatment to avoid potential long-term complications, a condition that we will diagnose later if observed during the follow-up appointments that we schedule after the trauma.

Dental trauma can affect both primary and permanent dentition, and many times traumas that occur in temporary dentition can even affect permanent dentition regardless of the age at which they occur, given the intimate contact between the roots of temporary incisors and the germs of permanent incisors. In fact, the younger the patient is when a primary tooth suffers trauma, the more severe the consequences may be for the future permanent tooth, given the immaturity of its formation at the time of the trauma. These possible consequences of injuries must be kept in mind when writing the accident damage report, as it is often the insurance companies that bear the cost of immediate treatment, follow-up appointments to assess their evolution, and treatment of any complications or sequelae should they occur [46–49].

#### **3.1 Dental tissue injuries involving pulp**

#### *3.1.1 Crown infraction*

This is an incomplete fracture of the enamel without any loss of dental substance. They are small fissures that can be vertical, horizontal, or diagonal, generally diagnosed because the hemorrhage itself deriving from the soft tissues stains the surface of the dental crown, making crown infractions evident. It can also be diagnosed using transillumination, aiming the light beam from the palatal position to be able to visualize the fracture lines on the buccal surface of the crown. Treatment for this type of injury depends on the case, ranging from a simple supply of fluoride to remineralize the area to polishing of the fissure and application of fluoride, or even sealing of the fissure if so required.

However, the most important thing that we must not overlook is that at the moment of the blow, the neurovascular bundle suffers, and the evolution of the pulp must be monitored after 1, 3, and 6 months to monitor the evolution of the pulp.

#### *Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

Given that vitality tests in children are uncertain, we will base our pulp monitoring on assessing the absence of clinical signs over time, such as darkening of tooth color, appearance of fistulae or swelling of the attached gingiva at the level of the dental apex, and/or mobility. Radiographically, we must also ensure that the root development of the tooth continues to advance over time, narrowing the lumen of the canal and thickening the dentin of its walls, as well as ensuring the absence of atypical root resorption or apical focus.

#### *3.1.2 Uncomplicated fracture of the crown*

This is a fracture limited to enamel or enamel and dentin in which there is already loss of substance. Treatment depends on the affected tissues and can range from application of fluoride, if it is only a small loss of enamel, to rounding and polishing of sharp edges and application of fluoride if the loss of enamel is greater or damages the tongue or lip of the patient. If there is exposed dentin, it is always necessary to reconstruct, either with composite materials or by replacing the fragment, although in temporary dentition this latter option is not very frequent (**Figure 4**).

Again, the most important thing that we must not forget is the neurovascular bundle. It is necessary to monitor evolution at 1, 3, and 6 months to monitor the evolution of the pulp. Assess pulp vitality at these appointments, controlling for the absence of clinical signs over time, such as darkening of tooth color, appearance of fistulae or swelling of the attached gingiva at the level of the dental apex, and/or mobility. Radiographically, we must also ensure that the root development of the tooth continues to advance over time, narrowing the lumen of the canal and thickening the dentin of its walls, as well as ensuring the absence of atypical root resorption or apical focus. It is not uncommon for these injuries to lead to pulpal necrosis in the long term, requiring a pulpectomy of the tooth to be carried out later (**Figure 5**).

**Figure 4.** *Enamel and dentin fracture of a 51 without pulp exposure.*

#### **Figure 5.**

*Uncomplicated fracture of tooth 61 in a 3-year-old patient. Reconstruction with preformed crown and composite resin.*

#### *3.1.3 Complicated crown fracture*

This is a fracture of enamel and dentin with pulp exposure. In these cases, if the tooth is restorable and the physiological resorption is still slight, pulp treatment can be carried out, generally a pulpectomy and restoration with composite materials. If pulp exposure was minimal (<1 mm) and recent (<1 h), direct pulp capping (DPR) could be carried out with bioactive materials such as MTA or Biodentine™ before restoration with composite materials. If the tooth is not restorable or the physiological resorption is already very advanced, extraction would be the treatment of choice (**Figures 6** and **7**).

#### **Figure 6.**

*Complicated crown fracture of tooth 52. Pulpectomy with iodoform paste and reconstruction with composite resin in tooth 52.*

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

#### **Figure 7.**

*Complicated fracture of tooth 61 with presence of pulp polyp in a 2-year-old patient. X-ray of teeth 51–61. Tooth extraction of tooth 61.*

#### *3.1.4 Uncomplicated crown and root fracture*

This is a fracture of enamel, dentin, and cement without pulp exposure. These fractures are difficult to diagnose; pain may appear when chewing. To tailor the treatment, it will be necessary to remove the coronal fragment under local anesthesia and assess whether it is possible to restore it or not. If restoration is not possible, extraction will have to be carried out.

#### *3.1.5 Complicated crown-root fracture*

This is a fracture of enamel, dentin, and cementum with pulp exposure. In primary dentition, they often follow the longitudinal axis of the tooth. In this case, and when the fracture covers more than a third of the clinical root, the treatment of choice is extraction. When the fracture covers less than a third of the clinical crown, after extracting the coronal fragment under local anesthesia, the possibility of restoration is assessed. If it is restorable, a pulpectomy and reconstruction with composite materials is carried out (**Figure 8**).

It is very common to find this type of fracture in maxillary primary first molars as a result of the violent closure of the mandible against the maxilla after a contraction injury caused by trauma to the chin. For this reason, with this type of trauma it is very important to examine the crowns of the upper molars, always trying to separate their cusps with the probe in order to diagnose them. If we do not take this precaution, the most common outcome is that the fracture goes unnoticed and the patient arrives at the consultation weeks after the trauma presenting with pain and inflammation in one

**Figure 8.** *Complicated crown-root fracture and extraction of tooth 61.*

#### **Figure 9.**

*Complicated crown-root fracture of tooth 64. Using the probe to separate the cusps. Extraction of tooth 64. Healed injury on the chin.*

side of the face and an almost healed lesion on the chin. By exploring the upper molars, we can identify the fracture (**Figure 9**).

#### *3.1.6 Root fracture*

This is a dentin and cement fracture with pulp involvement that can affect the apical third, middle third, or coronal third. Clinical experience tells us that most root fractures are diagnosed as incidental findings over time; this is because only 20–44% of root fractures result in pulpal necrosis. For this reason, we must take a preventative approach, monitoring the evolution of the case with a follow-up appointment at 1, 3, and every 6 months to assess the pulpal response. In most cases, obliteration of the duct occurs as a reparative response, without any associated clinical symptoms. If necrosis occurs, the treatment would involve the extraction of the coronal fragment; the apical fragment must be left so as not to damage the germ of the permanent tooth. A vital apical fragment is usually resorbed without problem. There are times when the root fracture is very apical and we can perform a pulpectomy up to the fracture line and restore with composite materials, subsequently monitoring the evolution of the case (**Figure 10**) [50–66].

#### **3.2 Periodontal tissue injuries**

#### *3.2.1 Concussion*

This is an incomplete rupture of the periodontal fibers, with hemorrhage and edema of the same but without mobility or displacement of the tooth. There may be percussion tenderness but no radiological signs.

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

#### *3.2.2 Subluxation*

This is damage to the supporting tissue, which results in mobility but not displacement of the tooth. Sensitivity to percussion and occlusal forces is increased, and upon radiographic examination, an increase in the space of the periodontal ligament can be seen.

The treatment for both concussion and subluxation is to recommend resting the area to allow the damaged periodontal fibers to heal. Depending on the child's age, emphasis must be placed on reducing the use of bottles and pacifiers, limiting the use of teethers, following a bland diet, following extreme hygiene measures, and once again, scheduling a follow-up appointment at 1, 3, and 6 months to monitor pulpal evolution as any trauma, no matter how slight, can damage the neurovascular bundle and lead to long-term pulpal complications. During these follow-up appointments, the color of the tooth becomes important, because while darkening of the clinical crown is a very noticeable sign for parents and can alert us to pulpal necrosis, it is common in this type of trauma; at the time of the blow, a small internal hemorrhage occurs, resulting in immediate dental darkening. It is important not to confuse this dyschromia with that caused by pulpal necrosis, and for this reason, care must be taken to note the color of the tooth in the first assessment or to ask the parents about the color change. When it comes to staining due to hemorrhage immediately after trauma, the color tends to lighten over time, unlike in cases of necrosis, in which the color darkens over time (**Figure 11**) [41].

#### **Figure 11.**

*Injuries 2 years ago to teeth 51–61 in a 4-year-old patient with no prior dental assistance. X-ray of teeth 51–61, apical focus with pulp necrosis. Pulpectomy of teeth 51–61 at a very early stage of root development. Evolution 1 year after treatment.*

#### *3.2.3 Intrusive luxation*

This is the movement of the tooth into the socket. It is associated with a comminuted fracture of the alveolar bone. Sometimes we see part of the tooth in the intraoral examination and it is easy to diagnose, and other times the tooth completely disappears inside the socket and an X-ray is needed to diagnose it because the parents believe that it has been lost and they simply have not found it at the site of trauma. In temporary dentition, the treatment will be to monitor the evolution over time, as it is common for the tooth to re-erupt to its position in the arch. Clinical and radiographic controls must be performed at 1, 3, and 6 months. During these followup evaluations, it is most common to see that the tooth is advancing on the path towards re-eruption, being closer to the occlusal plane, and it is usually almost complete at 6 months. In addition to monitoring the eruption, as in the previous cases, pulp vitality must also be monitored. If after 6 months of follow-up, the tooth has not undergone any progress or has been the origin of an infectious process while still in the place of inclusion, we must schedule the extraction of the piece (**Figures 12**–**14**) [50, 67].

**Figure 12.** *X-ray. Intrusion of tooth 61.*

**Figure 13.** *Intrusion of teeth 52–51–61–62. Clinical photos and radiography.*

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

**Figure 14.** *Intrusion of 51–61. 1-, 3-, and 6-month follow-up.*

**Figure 15.** *Extrusive luxation of tooth 51–61. Tooth extraction.*

#### *3.2.4 Extrusive luxation*

Movement of the tooth out of the alveolus as a result of a sharp blow. Radiographic examination always shows the increase in the periodontal space. The neurovascular bundle may be completely ruptured. In temporary dentition, we should not reposition the tooth in the alveolus due to the risk of damaging the germ of the permanent tooth in formation, so the treatment of choice is extraction (**Figure 15**).

#### *3.2.5 Lateral luxation*

This is a lesion to the supporting tissue of the tooth with its deviation in an axial direction. The most frequent cause is a horizontal impact that forces the crown towards the palatal wall and the apex towards the vestibular wall, resulting in occlusal interference and bleeding through the groove. It is always accompanied by a fracture of the alveolar process, so there is no mobility since the tooth is impacted on the cortical bone. Upon radiographic examination, the widening of the periodontal space

#### **Figure 16.**

*Intrusion of tooth 51–61 and palatine luxation of tooth 62 with occlusal interference. Bite lifts on tooth 74–84 to physiologically correct the luxation of tooth 62. Follow-up at 1 week.*

#### **Figure 17.** *Palatine luxation of tooth 61 in an 18-month-old baby.*

is visible. In temporary dentition, we should never reposition the tooth in its original position due to the danger of damaging the germ of the permanent tooth in formation, but if the displacement is small, we can keep the tooth in the mouth and relieve the occlusion by placing bite lifts to gently reposition it spontaneously with the help of the tongue. If the displacement of the tooth is larger, tooth extraction is recommended (**Figures 16** and **17**) [50–66].

#### *3.2.6 Avulsion*

This is the complete expulsion of the tooth from the alveolus. In temporary dentition, we should never replant an avulsed tooth due to the danger of damaging the permanent tooth in formation. There are different fixed or removable therapeutic procedures to replace lost pieces early in the deciduous dentition (**Figure 18**) [49].

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

#### **4. Bone tissue injuries**

#### **4.1 Comminuted fracture of alveolar bone**

Internal breakage of the alveolar bone that usually occurs as a result of an intrusion or lateral dislocation.

#### **4.2 Fracture of the alveolar wall**

This can be a fracture of the facial or lingual wall (**Figure 19**).

#### **4.3 Alveolar process fracture**

A fracture of the alveolar process may also include the alveolus.

In this type of bone fractures, we need to splint for consolidation, often with 0.12– 0.14 braided wire anchored to the teeth with composite. On many occasions, the teeth that we use to anchor the splint have to be extracted, but first we use them as anchors. We let them consolidate and heal the bone fracture, and after that is when we plan the corresponding dental extractions. In conclusion, we must prioritize bone healing and never extract a tooth when there is a fracture of the wall or alveolar process until it has consolidated (**Figures 20**–**22**).

### **5. Gum or oral mucosa injuries**

#### **5.1 Laceration of gum or oral mucosa**

Superficial or deep injury to the epithelium that is usually produced by a sharp instrument. For treatment, the wound must be irrigated with saline. If the edges can be approximated, we suture and close by first intention; if they cannot be approximated, we will control the bleeding with compression and close by second intention. We must always give recommendations to the patient and their parents for exhaustive

#### **Figure 19.**

*Superior maxillary vestibular alveolar wall fracture between tooth 61 and 62 and palatine luxation of 52. 1-day follow-up.*

**Figure 20.** *Fracture of the superior alveolar process in an 18-month-old patient.*

**Figure 21.** *Alveolar process fracture in a 5-year-old patient. Splinting and suture. 1-month follow-up.*

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

#### **Figure 22.**

*Avulsion of tooth 61, luxation of tooth 51, superior alveolar process fracture with occlusal interference and foreign body in upper lip of a 5-year-old patient. Radiographic control. Soft tissue and periapical radiography. Splinting and bite lifts on teeth 74–84.*

cleaning of the area, application of chlorhexidine gel, analgesic and anti-inflammatory treatment, and antibiotic therapy if necessary, depending on whether the injury occurred in a dirty environment or depending on the condition of the instrument that caused the injury (**Figure 23**).

**Figure 23.** *Laceration on the internal side of the lip in a 5-year-old patient. 10-day follow-up.*

**Figure 24.** *Four days post-injury with fibrin at the edge of the lesion as a result of lip traction and new tearing.*

If we suture the inner area of the lips, we must remember that they should not be revealed to visualize the wound because it is very likely that the margins of the injury will tear again and end up healing by secondary intention (**Figures 24**–**27**).

#### **5.2 Contusion of gum or oral mucosa**

This is an injury caused by blunt force trauma with blunt surfaces. It causes edema and hematoma of the subcutaneous tissue, while the skin and mucosa remain intact. Generally, this type of injury only requires analgesic anti-inflammatory treatment, and we recommend the application of a cold compress. We must remember that it is important that when we see an injury of this type on the chin, the crowns of the upper molars must be examined very thoroughly, as it is very common for fractures to occur *Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

**Figure 25.** *Upper lip laceration in a 4-year-old patient. Suture.*

**Figure 26.** *Tongue laceration in a 4-year-old patient. Suture.*

due to the counterblow, and we do not inspect carefully, we will not be able to diagnose these until the appearance of later complications (**Figure 28**).

#### **5.3 Abrasion of the gum and oral mucosa**

This occurs due to friction trauma. It removes the reticular and papillary layer of the epidermis, exposing the bleeding reticular layer of the dermis. There is continuity of the tissue and it is painful given the nerve endings of the dermis. A thorough

**Figure 27.** *Laceration of upper lip brace in a 4-year-old patient.*

**Figure 28.**

*Contusions on the skin and mucosa of the lip and chin.*

cleaning of the area must be carried out to avoid the retention of dirty particles that can lead to infections or permanent discoloration. It scars by secondary intention, and as treatment recommendations we must insist on cleaning the area, application of chlorhexidine gel, analgesic anti-inflammatory treatment, and antibiotic and antitetanus prophylaxis (**Figures 29**–**31**) [50–66].

#### **6. Affectation of the permanent teeth as a consequence of injuries to the temporary dentition**

As we discussed previously, trauma to the primary dentition may have consequences for the permanent dentition. These consequences may be due to:

	- a. Displacement of the tooth inside the bone, altering its eruption trajectory in the future. The permanent tooth may erupt out of place, have delayed eruption, or even fail to erupt.

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

**Figure 29.** *Gum abrasion on teeth 51–52 in a 4-year-old patient.*

**Figure 30.** *Upper lip abrasion in a 7-year-old patient.*

**Figure 31.** *Extraction of teeth 51 and 61 involved in a trauma with abrasion of the gum. Periapical radiography.*

#### **Figure 32.**

*Ulectomy. Eruptive delay of 11 by intrusion of 51 after 2 years. 48-hour and 7-day follow-up. Alteration in the structure and dyschromia due to impaction of the apex of tooth 51. Esthetic restoration of tooth 11, 6 years after the causing trauma.*

	- a. Accelerate resorption of the primary tooth root and alter the timing of tooth replacement.
	- b. Alter the odontogenesis of the permanent tooth, producing circumscribed chromatic lesions or structural alterations on the buccal surface of the crown of the permanent incisors (**Figure 32**) [35, 46–49].

#### **7. Discussion**

Crown fractures, regardless of the degree of involvement of the tooth, are the most common fractures in the permanent dentition. They are usually caused by contact sports or accidental falls.

In all cases, a radiographic examination should be carried out to provide an idea of the best therapeutic option in each case and to evaluate the surrounding tissues for any associated soft tissue lesions [9].

Treatment in cases of fissures limited to enamel usually consists of simply observing and monitoring the tooth or some authors even suggest sealing the enamel surface [9].

If the lesion affects enamel and dentine but there is no pulp involvement, there are several therapeutic options: if the fragment is available, it can be bonded to the tooth surface with the help of composite resins [9, 12] or the fractured segment can be directly restored with reconstructions made of composite resins [13, 14].

Finally, in the most complicated cases in which pulp tissue exposure occurs, it is necessary to evaluate whether the camera pulp or healthy root pulp can be maintained in those cases in which complete root development has not finalized [9, 14]. For this purpose, there are available different therapeutic options, depending on the pulp involvement, which are as follows:


In those clinical situations in which the pulp is necrotic, the degree of root development will also be assessed, so that in teeth with an open apex, apexification with CaH or MTA [18–20] will be chosen, and in teeth with a closed apex, the relevant endodontic treatment will be carried out.

Intra-alveolar root fractures occur much less frequently than coronary fractures and even less frequently in the primary dentition or teeth with immature apex. They can be horizontal (better prognosis) or vertical (worse prognosis).

As with coronal fractures, it is essential to carry out a correct radiographic examination, modifying the degree of angulation of the fracture in multiple shots [9, 13]. Currently, CBCT (Cone Beam Computed Tomography) is also used for a correct diagnosis by image, which helps us to locate the fracture and even the direction and extent [12].

The treatment of intra-alveolar fractures depends mostly on the location of the fracture, but in any case, when possible, semi-rigid splinting of the fragments should be attempted [23]. Since vitality tests can be confusing at first, the treatment options available for intra-alveolar fractures are as follows:


The most relevant factors related to the prognosis of the avulsed teeth are the storage medium and the extra-oral dry time; therefore, previous studies have been conducted in order to assess the management procedures and behavior that are most recommendable in this scenario [63]. Zeissler-Lajtman et al. reported that cling film possibly could be used as an alternative transport medium for a storage period of up to 6 h [64]. However, De Brier et al. reported that although milk was shown to extend the periodontal ligament cell viability before replantation compared with saline or tap water, Hank's balanced salt solution, propolis, oral rehydration salts, rice water, and cling film media have also demonstrated efficacy at preserving the cell viability [65]. Additionally, Adnan et al. concluded that milk is the most recommended storage medium individually, based not only on PDL cell viability, but also practical considerations [66].

Moreover, the management procedures and making decisions after the accident comprising dental avulsion are also relevant for the long-term prognosis of these teeth. Therefore, some approaches have been performed in order to improve the attachment of the periodontal cells. Parthasarathy et al. performed an interdisciplinary approach to regenerate the osseous defect including the placement of PRF membrane around the root surface [68]. However, Schjøtt et al. analyzed the efficacy of Emdogain to promote regeneration of the periodontal tissues of avulsed teeth and reported that the teeth were all extracted, the ankylosis sites removed and the root and socket treated with Emdogain. After 6 months all teeth showed recurrence of ankylosis and concluded that Emdogain was not able to prevent or cure ankylosis [69]. Recently, Aksel et al. analyzed cell- or stem cell-based regenerative medicine and concluded that this approach has a promising future for the regeneration of periodontal regeneration of avulsed teeth [67].

Currently, studies agree that the highest prevalence of trauma in primary dentition is subluxation, followed by lateral dislocation and avulsion. This is due to the fact that, in children, the resistance capacity of the bone and the periodontal ligament is high given their elasticity and absorbs most of the energy of the impact, in addition, anatomically, the primary teeth have small crowns and short roots, trait that may favor dislocations over fractures.

It is important to know and establish an appropriate follow-up and/or treatment guideline in each case according to the complexity of the trauma. In fact, most of the sequelae derived from trauma are the consequence of inadequate treatment, lack of follow-up or not having acted within the necessary period of time.

Many times, this delay in the time of action is a consequence of the patient not coming to our consultations until a few weeks after the trauma. We must make parents and caregivers aware that in the event of any dental trauma, professional attention should be sought, since early diagnosis and treatment is essential, as well as monitoring the evolution of the case over time, to avoid unfavorable prognoses.

The international guidelines for dental traumatology agree that the early diagnosis and treatment of traumatisms will frequently determine the medium and long-term prognosis of the teeth involved in the trauma. For this reason, it is essential to have a clear action protocol that facilitates the dentist's decision-making to achieve an adequate immediate or deferred treatment based on the evidence, as well as a follow-up that allows early detection of an unfavorable evolution of the case, establishing a change in the mode of action. This will be the basis for the success of the treatment.

It should not be forgotten that even the slightest trauma to the primary dentition can have direct or indirect consequences on the permanent dentition given the close relationship between the apex of the root of the primary teeth and the permanent tooth in formation, and that these consequences they will be even more severe the younger the patient is at the time of impact due to the degree of immaturity in the formation of the permanent tooth germ. It is another of the key points that parents,

caregivers and other health professionals must be made aware of so as not to downplay dental trauma in young patients [70].

#### **8. Conclusions**

In both types of fractures, a complete radiographic examination is essential for a proper diagnosis and treatment of the lesion. The surrounding tissues should always be evaluated regardless of the type of injury. In addition, one of the most decisive characteristics in terms of treatment is the degree of root development of the tooth and whether or not there is pulp exposure, characteristics which in most cases are what will indicate which treatment option will be more accurate.

It is recommended to maintain the avulsed teeth in a wet storage medium; preferably milk, Hank's Balanced Salt solution (HBSS), saliva, or saline solution and visit a dentist under 60 min after injury.

Dental trauma is the result of the interaction of many factors, so the success of treatment is unpredictable. Most professionals follow the general guidelines of the IADT to perform treatments on traumatized teeth, although clinical experience, good behavior management and continuous updating on the knowledge of trauma are essential for the dentist when it comes to treat and monitor these injuries.

Prevention and information on how to act at the scene of the accident by people close to the child is essential to carry out a favorable treatment, as well as instilling in the population the importance of going to a qualified professional whenever a fall or a blow is involved the oral cavity.

In this chapter we have tried to capture in a simple way the recommendations, most frequent situations and the most effective way of proceeding when dealing with trauma in primary dentition, as a result of the clinical experience of professionals in a reference center for diagnosis and treatment. of dental trauma emergencies and supported by the most current bibliography.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Blanca del Carmen Migueláñez Medrán<sup>1</sup> , Nuria Delgado Castro<sup>2</sup> , Elena Riad Deglow<sup>3</sup> and Álvaro Zubizarreta Macho3,4\*

1 Faculty of Health Sciences, Alfonso X el Sabio University, Madrid, Spain

2 Department of Pediatric Dentistry, San Rafael Hospital, Madrid, Spain

3 Faculty of Health Sciences, Department of Implant Surgery, Alfonso X el Sabio University, Madrid, Spain

4 Faculty of Medicine, University of Salamanca, Department of Surgery, Spain

\*Address all correspondence to: alvaro.zubizarreta@usal.es

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Update and Making-Decisions in Dental Traumatology DOI: http://dx.doi.org/10.5772/intechopen.106195*

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#### **Chapter 4**

## Perspective Chapter: Teeth Avulsion

*Manal Abdalla Eltahir, Randa Fath Elrahman Ibrahim and Hanan Alharbi*

#### **Abstract**

Tooth avulsion refers to total displacement of the tooth out of its alveolar socket. This chapter discusses the causes of avulsion for both primary and permanent dentition in addition to the prevalence of avulsion comparing it between before and during COVID-19 era. Successful outcomes depend on procedure conduction with immediate replantation of the avulsed tooth and good handling of the tooth keeping the tooth in suitable available storage media till a professional service is obtainable. Management of this type of dental trauma necessitates awareness and collaboration between the lay personal at the site of injury in addition to the important role of different dental professional. After replantation of the avulsed tooth, it should be kept immobile with preservation of the functional (physiological) mobility by application of suitable splint. There are adjunctive therapies including antibiotics, analgesics, mouth washes, and tetanus vaccines. Endodontic therapy should be initiated within 7–10 days from the time of avulsion, where the outcomes generally might be favorable or unfavorable. Newly emergent teledentistry played important role in the treatment of tooth avulsion, especially during COVID-19 period.

**Keywords:** avulsion, replantation, storage media, antibiotic, splinting, open apex, closed apex, trauma, dental emergency, teledentistry, tooth replantation

#### **1. Introduction**

Tooth avulsion is a very serious traumatic dental injury (TDI) as tooth loss may remarkably compromise the patient in both functional and psychological aspects [1, 2].

Among all dental traumas, avulsion of the permanent tooth accounts for up to 16% of all dental injuries and constitutes the most serious one. It is considered as one of the few emergency situations in dentistry [3]. By definition, tooth avulsion refers to the total displacement of the tooth out of its alveolar socket (**Figure 1**) [4]. Presence of the tooth outside the socket leads to deterioration of the pulp and periodontal ligaments (PDLs) due to the lack of blood and nerve supply to their cells in addition to the unfavorable external environment such as dryness and possible contamination [5]. This may end up with periodontal attachment damage, pulp necrosis, and eventually tooth loss [6]. The maxillary central incisors are the most frequently involved teeth; boys and the age group of 7–11 years old are more susceptible to this type of trauma [7].

**Figure 1.** *Tooth avulsion refers to the total displacement of the tooth out of its alveolar socket.*

#### **1.1 Epidemiology of avulsed teeth before and during COVID-19 pandemic**

The prevalence and incidence of reported traumatic dental injuries (TDIs) have significantly been affected during COVID-19 pandemic. In a retrospective analysis conducted at King's College Hospital Dental Institute in London, UK, there was around 46% reduction in presented cases with TDIs during the COVID-19 compared to the year before for the same period of time [8]. With respect to avulsion injuries, the study revealed a remarkable decline in cases by around 93%. It also showed an increase in the mean delay in presentation following TDIs from 2.4 days the year before to 5.3 days during COVID-19 [8]. The reasons behind these changes were mostly related to the lockdown and forcible closure of dental practices during the pandemic. Although the urgent dental cares services in hospitals were mostly available worldwide, patients were hesitant to reach out to such centers due to the perceived fear of acquiring viral infections. Other studies also showed the same steep reduction in reported TDIs and traumatic injuries generally during COVID-19 [8–10].

According to previous studies, demographic data of reported cases has not differed between COVID-19 and years before except having less admitted cases in group age older than 70-year-old [8].

#### **1.2 Causes**

The etiology of tooth avulsion varies according to the type of dentition. Avulsion in primary dentition is typically a result of hard objects hitting the teeth, whereas avulsion in permanent dentition is generally a result of falls, fights, sport injuries, automobile or bicycle accidents, and domestic abuse. In permanent and primary dentition, *Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

avulsion generally occurs in the maxilla, and the most affected teeth are the maxillary central incisors (**Figure 2**). Increased overjet and incompetent lips were identified as potential etiological factors in such avulsion cases [11–13]. In rare cases, iatrogenic teeth avulsion during other procedures might happen and were reported in the literature [14–17].

#### **2. Management of the avulsed tooth**

Several factors should be considered [18], when treating a patient with an avulsed permenant tooth (**Figure 3**):

1.Patient's age


**Figure 2.** *Maxillary central incisors are the most frequently involved teeth in avulsions.*

**Figure 3.** *Factors should be considered in the treatment of tooth avulsion.*


7.Damage associated with the avulsed tooth

#### **2.1 Emergency treatment/management (at the site/and at the clinic)**

Multidisciplinary approach in avulsion injuries is essential and considered a cornerstone during the management process. Though the management of avulsions is highly dependent on the early actions taken following the trauma and the time spent till reaching out healthcare services, this is furthermore affected during COVID-19 pandemic due to international lockdowns and restricted accessibility to hospitals. Such times clearly signify the importance of public awareness of first-aid measures in TDIs, especially avulsion.

International guidelines have been proposed to address TDIs and avulsions injuries. According to the International Association of Dental Traumatology (IADT) guidelines [19–21] and the European Society of Endodontology position statement [22], certain systematic approach has to be adopted to treat teeth avulsions. Obviously, tooth avulsion leads to necrosis of disrupted pulp which requires endodontic treatment.

We will be talking about the management for teeth avulsion and treatment choices during COVID-19. Best approach to treat an avulsed permanent tooth is immediate replantation. Whether the case is admitted to emergency clinic or people at trauma site are instructed on phone, the following steps are to be considered:


History: Review patient history in case of any other injury (potentially more serious) is involved, simultaneously. If any vomiting, headache, unconsciousness, or drowsiness are reported, this should be further investigated at the hospital, and also, if there is a previous injury to the teeth or the alveolar bone or if the occlusion has further changed.

*Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

How, when, and where the trauma/accident happened are all questions that should be answered. This will further help in evaluating the trauma for legal and insurance purposes. Any suspected abuse should be reported to local authority.

Anesthesia: administering local anesthesia is always recommended, preferably without vasoconstrictor [20].

Recent guidelines have detailed the plan on replanting tooth according to two main factors:

1.Extra-oral dry time: being less or more than 60 min.

2.Root maturation: closed or open apex.

For extra-oral dry time, it is used to assess periodontal ligament (PDL) cells' viability. The soonest the tooth is replanted, within 15 min, the most likely PDL cells are viable. When the extra-oral dry time exceeds 60 min, it is more likely that PDL cells are nonviable. In all situations, it is recommended to replant the tooth acknowledging that prognosis is best when replantation is within 15 min and poorest when it is after 60 min [20]. Ankylosis-related (replacement) root resorption is an expected outcome in cases of late tooth replantation [18, 20, 24].

#### **2.2 Factors might influence the success of replantation**

These factors are the patient's general health, the maturity of the root, the time the tooth is out of its socket, storage medium [11, 25–27], extra-alveolar permanence period, means of preservation, contamination, manipulation, and conditions of the avulsed tooth [28], and also relevant factors such as type of splint used and time of permanence (**Figures 4** and **5**).

#### **2.3 Storage media**

.

Successful healing after replantation may occur only if the damage to the PDL cells was minimal. Immediate replantation of the avulsed tooth into the socket at the site of the trauma has been suggested to prevent further damage to the PDL cells left on the root surface from desiccation. As this is not always attainable since the lay person at the trauma site may lack the skill and the willingness to try this procedure. In such situations, it is recommended to put the avulsed tooth temporarily in a storage medium capable of preserving PDL cells viability. Thus, the extra-alveolar dry time and the type of storage medium are the most critical factors. Prolonging the duration of dry storage causes necrosis of the PDL cells after 30–60 min and decreases greatly the chances of healing after replantation [29].

#### *2.3.1 Characteristics of the ideal storage medium [29]*


#### **Figure 4.**

*Factors might influence the success of tooth replantation.*

**Figure 5.** *Potential complications following tooth replantation.*


#### *2.3.2 Types of storage media*

In their quest for an ideal storage media, a wide variety of materials have been tested by a lot of researchers for their role as potential storage media. The recent guidelines of IADT recommend in descending order of preference, milk, HBSS (Hanks' Balanced Salt Solution), saliva, or saline as suitable and convenient storage mediums. Water is considered a poor medium but is better than dry storage. Other materials, some with promising results, include ViaSpan, propolis, and egg white [20, 30].

#### *2.3.2.1 Milk*

Many authorities recognized milk as the most recommended storage medium for avulsed teeth. The ease of obtaining it at accident sites makes it a practical choice. The physiological properties of milk are significantly better than other solutions, and pH (6.5–7.2) and osmolality (270 mOsm/kg) are compatible with PDL cells. Milk contains a combination of nutritional substances such as amino acids, carbohydrates, and vitamins capable of maintaining PDL cell viability. In addition, the presence of epithelial growth factor stimulates the proliferation and regeneration of epithelial cell rests of Malassez and activates the alveolar bone resorption. Hence, the bone tissue may be isolated from the tooth and decreases the chances of ankylosis [30, 31]. However, it should be noted that few reports argued that replanted teeth stored in milk were subject to ankylosis [32–34].

#### *2.3.2.2 HBSS (Hanks' Balanced Salt Solution)*

The HBSS is a sterile, isotonic, and physiologically balanced standard saline solution which is used in biomedical research to support the growth of many cell types. It is a nontoxic solution, biocompatible with PDL cells; its pH (7.2) and osmolality (320 mOsm/kg) are balanced and considered almost ideal. It is composed of glucose, sodium, calcium, potassium, and magnesium ions.

HBSS is highly recommended for its ability to provide long-term preservation of PDL cells viability and proliferation capacity. Its ingredients may further help to reconstitute the depleted cellular components of the PDL. HBSS is commercially available as "Save-A-Tooth." However, it is not found at most of the accident sites; this makes it an impractical storage medium [20, 29, 31, 32, 34].

#### *2.3.2.3 Saliva*

The only advantage of saliva as a storage media is its ease of availability immediately on almost all accident sites. However, it presents a possible source of bacterial contamination for PDL cells. Its osmolality (60–70 mOsm/kg) is considerably lower than the physiological osmolality; thus, cells stored in saliva show swelling and membrane damage. Saliva is better than tap water or dry storage, but it can be used only for very short storage time [29–31].

#### *2.3.2.4 Saline*

Normal saline, a 0.90% NaCl solution, has a physiological osmolality of 280 mOsm/kg which is compatible with the PDL cells. However, it is deficient in the essential nutrients, such as glucose, magnesium, and calcium which are needed to the normal metabolic functions of the cells of the PDL. Moreover, the hypotonic properties of saline induce rapid cellular lysis. Therefore, saline is not a good storage media unless for short periods only [29, 31].

#### *2.3.2.5 Viaspan*

Viaspan is a cell culture media widely used for storing and transporting organs to be transplanted. It has 320 mOsm/kg osmolality and 7.4 pH which favors cell growth and viability of the PDL cells. It is nearly an ideal material for storage of avulsed teeth for long periods. However, its high cost, short vitality expiration, and the limited access to it especially at the accident sites make it difficult to find and use this storage medium [31, 35].

#### *2.3.2.6 Egg white*

Egg white is considered a good storage media because of its high protein content, vitamins, and water. It is easily accessible and lacks microbial contamination with a pH of 8.6–9.3 and osmolality of 258 mOsmol/kg. Thus, it favors PDL cells viability and healing and presents a suitable choice for extended storage time [29, 31].

#### *2.3.2.7 Tap water*

Tap water has an approximate osmolality of 30 mOsm/kg and a pH of 7.4–7.79. It is not considered a suitable storage medium for avulsed teeth. It has bacterial contamination; its hypotonicity and nonphysiologically pH and osmolality favor the PDL cell lysis. Cells stored in water did not maintain their viability. However, it is better than dry storage and should be used only when there are no other alternatives (**Table 1** and **Figure 6**) [29, 31].


#### **Table 1.**

*Characteristics of storage media.*

#### **2.4 Splinting**

After replantation, the treatment of choice is splinting [2]. By definition, splinting is an assembly to protect, stabilize, and immobilize loosened, fractured, replanted, and traumatized teeth [3]. Also splinting is defined by American Association of Endodontists as "a rigid or flexible device or compound used to support, protect, or immobilize teeth that have been loosened, replanted, fractured, or subjected to certain endodontic procedures" [36].

To allow immobilization of the teeth during the initial period, it is mandatory using the so-called splint which is essential for the repair of periodontal ligament [37]. The use of semirigid splint is more indicated than the rigid one, considering that the long period of splinting is not recommended due to its expected complications namely substitutive resorption or ankylosis [38, 39]. One of the adverse healing outcomes of splinting is that forceful placement of the splint may cause additional trauma to the already affected pulp of the avulsed tooth [40].

#### *2.4.1 Types of splints*

Many different splinting techniques have been described [41]:

Wire-composite splint, orthodontic splint, titanium trauma splint (TTS) splint, resin splint, Kevlar/fiberglass splint (fiberglass), self-etching and bonding material, and suture splint.

Kahler et al. also described splint types [42]:


#### **Semirigid/flexible (physiologic**) [43]:


In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks.

Cap splints and orthodontic bands were associated with a greater frequency of pulp necrosis and pulp canal obliteration when compared with acid etch resin splints and no splinting [44].

These splinting techniques were used prior to the development of a passively


Stabilize the tooth for 2 weeks using a passive flexible splint such as wire of a diameter up to 0.016″ or 0.4 mm bonded to the tooth and adjacent teeth. Keep the composite and bonding agents away from the gingival tissues and proximal areas. Second option is nylon fishing line (0.13–0.25 mm) which can be used to create a flexible splint, using composite to bond it to the teeth. Nylon (fishing line) splints are not recommended for children with mixed dentition, since the status of the other teeth may result in instability or loss of such splint.

#### *2.4.2 Management of the soft tissues and surrounding alveolar bone*

Tooth-supporting tissue injuries and lip injuries may be associated with avulsion [45]. Soft tissue tearing of the socket gingiva associated with avulsed tooth should be noted [46].

There are three benefits may be gained from the tight stitching of such tearing [47]:

1.Stop of the bleeding.

2.Avoid the penetration of microorganism into periodontium.

3.Allow the primary healing of the wound.

In addition to the soft tissue, the socket itself needs to be manipulated before replantation of the root, if the alveolar bone has collapsed, attempts should be made to reconstruct its wall [48].

#### **2.5 In clinic treatment**

#### *2.5.1 Root canal treatment in avulsed teeth*

#### *2.5.1.1 Closed apex*

It is mandatory to initiate root canal treatment within 2 weeks of tooth replantation [20, 22]. Root canal treatment should start with intracanal medication; calcium hydroxide or antibiotic-corticosteroid paste dressing for 2 weeks up to 1 month or 6 weeks [49, 50] is followed by root canal filling.

#### *2.5.1.2 Open apex*

No root canal treatment is performed at first, but a close follow-up is needed to detect any clinical or radiographic signs of pulp necrosis. The aim is to re-establish blood supply of open apices and maintain root development which could happen spontaneously after replantation.

Radiographic and clinical examination is indicted after 2 weeks, 4 weeks, 6– 8 weeks, 3 months, 6 months, 1 year, and yearly thereafter for at least 5 years. If there is any sign of external infection-related root resorption, endodontics intervention is advised whether it is apexification, root canal treatment, or regenerative endodontic procedures (REPs) [20, 22, 48].

#### *2.5.2 Regenerative/revitalization procedures and avulsions*

REPs have been proposed based on translational studies. In 2016, American Association of Endodontists and European Society of Endodontology have proposed clinical considerations and position statement; respectively, discussing REPs [51]. In avulsion injuries, REPs are only indicated in cases of immature root with open apex and signs of pulp necrosis. The clinical protocol is the same that have been proposed previously in the mentioned guidelines. A recent report implemented this approach to treat avulsed tooth and showed successful outcome with a 30-month follow-up [52]. The key is using biocompatible materials that would recruit stem cells to build hard tissue barriers and allow physiological growth of roots. Biocompatible materials could be MTA or tricalcium silicate cements, e.g. bioceramicsm that revealed successful outcomes in several reports [53].

#### **3. Adjunctive therapy**

#### **3.1 Antibiotic use**

Antibiotics given at the time of replantation to prevent the infection may occur due to tooth contamination or may be present in the storage media. Also, it can be prescribed prior to endodontic treatment. It is theoretically effective in preventing bacterial invasion of the necrotic pulp and; further, it may prevent the inflammatory resorption (**Figure 7**) [54].

In all cases, appropriate dosage for the patient's age and weight should be calculated.

Amoxicillin or penicillin remains the first choice due to their effectiveness on oral flora and low incidence of side effects. Alternative antibiotics should be considered for patients with an allergy to penicillin [55].

The effectiveness of tetracycline administered immediately after avulsion and replantation has been demonstrated in animal study [56, 57]. Specifically, doxycycline is an appropriate antibiotic to use because of its antimicrobial, anti-inflammatory, and anti-resorptive effects. But still doxycycline exerted no effect on the occurrence of complete pulp revascularization in replanted teeth [58]. Tetracycline or doxycycline is generally not recommended for patients under 12 years of age to avoid the risk of discoloration of permanent teeth [20, 56, 57].

#### *3.1.1 Indications of antibiotics in patients with avulsed tooth*

By searching the literature so far, there are some indications of antibiotic prescribed for the patient with avulsed tooth (**Figure 8**).

1.Replanted tooth with possibly contaminated root and/or storage media [20, 54] for medically compromised patient.

#### **Figure 7.**

*Adjunctive therapies in the treatment of avulsed tooth.*

#### **Figure 8.**

*Indication of antibiotics in patient with avulsed tooth.*


#### **3.2 Analgesic**

Prescription of analgesic is case-dependent; accordingly, it should be assessed individually. The use of stronger pain killer is unlikely [20, 48].

#### **3.3 Mouth wash**

Chlorhexidine (CHX) is a commonly used antiseptic mouthwash and is available over the counter (OTC); the use of adjunctive short-term of CHX can enhance oral hygiene by managing dental plaque [60].

The recent recommendation is to use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks (during the entire period of splinting).

#### **3.4 Tetanus vaccine**

The possibility of environmental contamination of the injury can justify the administration of tetanus vaccine [19].

The patient should be sent to a physician for consultation regarding a tetanus booster within 48 h of the initial visit [20].

#### **4. Alternative treatment**

#### **4.1 Decoronation**

In cases of severe replacement resorption (RR) and ankylosis, decoronation can be considered as an alternative treatment with good clinical outcomes for children and adolescents to the age when an appropriate implant is possible. If carried out at the right time; it helps to preserve the bucco-palatal dimensions of the alveolar bone and at the same time allows for vertical bone growth. This enables for future implant insertion without the need for the costly and invasive procedure of alveolar ridge augmentation. However, this approach still needs solid studies to verify it [61, 62].

Timing of the decoronation is crucial and should be planned for each individual case with regard to the patient's age, growth intensity, and growth pattern. In young patients, it is advantageous to retain an ankylosed tooth, if possible, to act as a space maintainer. However, it is very necessary to intervene before the effect of infraposition causes significant arrested alveolar bone growth that makes a final prosthetic solution difficult. When ankylosis is diagnosed before the age of 10 years, there is a high risk of severe infraposition, and the tooth should be carefully monitored every 6 months. There is also a risk of severe infraposition during the pubertal growth spurt which varies in time from one person to another and thus needs also careful monitoring [63].

Clinically, the procedure is simple. Under local anesthesia and a full-thickness flap, the crown of the ankylosed tooth is sectioned earlier the cementoenamel junction. The root is cleaned with a K-file and washed with saline, and the canal is allowed to fill with blood and then the flap is repositioned. Subsequently, esthetics is maintained using an adhesive bridge [62].

#### **4.2 Autotransplantation**

Autotransplantation of an immature maxillary premolar to replace an ankylosed tooth is considered a highly successful alternative technique and is particularly indicated when crowding requires extraction of a premolar. To achieve pulpal revascularization and successful periodontal healing of the donor tooth, the ideal root should develop to three-fourths of the complete root length. In such cases, the whole root of the ankylosed tooth must be extracted, and a premolar will be transplanted in its place. The transplant tooth with its sound periodontal ligament will induce new bone formation, have continued root development, and even maintain its vitality. An esthetic restoration and orthodontic treatment will follow the transplant [64, 65].

#### **4.3 Partial prosthesis/dental implant**

#### *4.3.1 Prognosis and outcomes*

The long-term prognosis of replanted avulsed teeth shows great variability; the observed outcomes are greatly heterogeneous ranging from healing without symptoms to inflammation and rapid tooth loss. Many studies had shown a relatively low survival rate of replanted avulsed teeth, compared to other types of traumata, ranging from 50% to 83.3% [66]. Under favorable conditions, replanted teeth may be retained for 5 or 10 years and even few of them for a lifetime. However, some may fail very soon after replantation.

#### *4.3.2 Factors associated with unfavorable outcomes and low survival rate [65]:*


After replantation of the tooth, the prognosis commonly remains uncertain. Replacement resorption and inflammatory resorption are probable adverse outcomes in comparison with the more favorable functional healing (FH): [66]

#### • **Functional healing**

The damaged tissues including the cementum and dentin are being resorbed by multinuclear giant cells. In regions with minor damage, the ruptured periodontal fibers are being rebuilt (regeneration). In case of small resorption cavities, the denuded root surface is being recolonized by neighboring cementoblasts and these deposit the cementum in which the new periodontal fibers are anchored. This process represents healing with physiologic function (functional healing, FH) [66, 67].

#### • **Inflammatory (infection-related) root resorption**

Root surfaces affected by the trauma are quickly colonized by multinuclear giant cells. If these cells are continuously stimulated by microbial products from an infected root canal, not adequately treated, infection-related resorption (IRR, formerly named inflammatory resorption) will result. Provided the tooth is still restorable, adequate endodontic treatment might stop the progression of IRR.

#### • **Replacement resorption (ankylosis)** (**Figure 9**)

Replacement resorption is a special form of root resorption, and it follows serious luxation or avulsion injury. It is a common sequela of delayed replantation and/or dry storage. Due to excessive drying before replantation, the damaged periodontal ligament cells will start an inflammatory response over extended areas on the root surface. The resulting large resorption cavities may not be entirely covered by the cementoblasts in time. Regenerating alveolar bone will be attached directly onto the root surface. In time, through physiologic bone remodeling, the root cementum and dentin will be replaced by bone; a process termed replacement resorption (RR) or ankylosis-related root resorption [65–67].

If revascularization does not occur or appropriate endodontic therapy is not performed after tooth replantation, pulpal necrosis will occur. The combination of microbes in the root canal and the external surface of the root results in aggressive resorption and can lead to rapid tooth loss [20, 65].

In a growing patient and/or tooth with open apices, the ankylosed tooth shows severe and progressive infraocclusion. The alveolar bone will stop advancing in a coronal direction with the rest of the jaw leaving a big bone defect when the tooth is eventually lost causing major esthetic and functional challenges when it is time for the final replacement [48, 67].

**Figure 9.** *Replacement root resorption (ankylosis).*

#### **5. Follow-up**

Mature replanted teeth need clinical and radiographic monitoring at 2 weeks (with splint removal), 4 weeks, 3 months, 6 months, 1 year, and hence yearly for at least 5 years. For teeth with open apices where spontaneous pulp revascularization might occur, clinical and radiographic monitoring should be more frequent due to the high risk of infection-related (inflammatory) and/or ankylosis-related (replacement) root resorption. Therefore, replanted teeth with open apices should have clinical and radiographic monitoring at 2 weeks (with splint removal), 1 month, 2 months, 3 months, 6 months, 1 year, and hence yearly for at least 5 years [20].

Evaluation may include the following outcomes:

#### **5.1 Favorable outcomes**

The replanted tooth is


Pulp canal obliteration is expected and can be recognized radiographically sometime during the first year after the trauma.

#### **5.2 Unfavorable outcomes**


#### **6. Avulsion of primary teeth**

A relatively recent meta-analysis showed trauma of primary dentition to be as common as 22.7% [68] with variable prevalence of avulsion from 7 to 13% [69]. In general, avulsed primary teeth should not be replanted (according to the recommendations of the IADT) [19]. Nevertheless, there are case reports with varying degrees of success after replantation of primary teeth, whereas others reported negative results to the replanted primary tooth and its permanent successor. One systematic review concluded that here is a lack of high-quality studies to support this approach [69].

Such a severe injury to the primary tooth may have negative impact on the development and/or eruption of its permanent successor. Premature loss of avulsed primary teeth might sometimes lead to space loss, masticatory, speech, and esthetic problems; this may also cause negative impact on their behavior, pschological, and social well-being. Removable or fixed appliances present valid treatment options to minimize space loss and improve esthetics when necessary. Furthermore, movement of the tooth during avulsion and the proximity between the primary tooth and the germ of its developing successor may interfere with its further growth and maturation leading to the occurrence of enamel defects and tooth malformations. The risk of sequelae in the permanent successor after avulsion of primary teeth is higher when the injury occurs in young children (<2 years), when the trauma is of greater magnitude such as when more teeth are involved and lower jaw is affected [70, 71].

Sequelae to the permanent successor include (**Figure 10**) [70]:

#### 1.Malformations


#### 2.Enamel defects

• white/cream or yellow/brown demarcated opacities,

#### **Figure 10.**

*Sequelae of primary tooth avulsion.*


4.Combinations

#### **7. The role of teledentistry in the treatment of avulsed teeth**

Teledentistry can be used to monitor those traumatic injuries cases remotely. Teledentistry combines dentistry and telecommunications simultaneously with clinical information and images over remote distances for dental consultation and treatment planning [72].

In cases of traumatic injuries and avulsions specifically, initial emergency instructions could be delivered on phones till obtaining emergency healthcare services is possible. This helps in calming patients or patients' guardians and maintains the first actions of replanting teeth or storing it in proper storage medium according to the recommendations. Teledentistry is also used at times of follow-up to report symptoms or other complications. It is mainly essential when specialty dentist is not available, yet their consultation, supervision, and valuable support could be used by the dental team in managing such cases [73]. A report showed that around 60% of patients contacted the telemedical center during the so-called "out of office hours" for dental

trauma injuries. This percentage signifies the importance of having proper teledental channels addressing these incidents.

#### **8. Discussion**

Tooth avulsion is the complete displacement of the tooth from its socket in the dental arch.

In this chapter, we tried to gather the scattered information about tooth avulsion. Despite the rich published literature, but still a lot of researches are needed to reach evidence-based conclusions.

Although the tooth avulsion is the topic of concern in general dentistry, we tried to write this perceived paper in the specialist's manner to reflect more light on many related details.

Causes of tooth avulsion are divided into those for deciduous dentition and other for permanent dentition which are differ from each in their pattern and severity of the trauma [11–17].

Epidemiology has shown a reduction of cases during COVID-19 era. This was explained by patients' perceived fear of acquiring viral infections and thus hesitancy to reach out to emergency centers [8–10].

Avulsion treatment outcomes are very dependent on the first-aid measure as well as the agility to seek dental treatment.

For the management, put it as two phases may let the whole picture organized and well determined by specific time (at the time of trauma) the first phase and the other which are at the clinic.

The storage media (milk, HBSS, saliva, or saline) are discussed in detail regarding the characteristic of each. Nevertheless, researches are still looking for an ideal medium; some materials such as propolis and egg white are very promising. However, the quality of evidence is considered low [74]; on the other hand, teeth splinting is discussed generally as well as specifically for the avulsed teeth (with and without alveolar bone fracture) [20].

The literature regarding the adjunctive therapies for the teeth avulsion showed the role of these therapies; in this chapter, we considered them concisely with stress upon the indications for each [19, 20, 48, 60].

Criteria of successful treatment is widely discussed which is depending on both clinical and radiographic features.

Alternative treatments for the avulsed tooth in cases of the failure of aforementioned treatment are decoronation, autotransplantation, partial prosthesis, and dental implant [61–65].

The key of optimum outcomes in avulsions cases rely on both radiographical and clinical follow-ups. This signifies the importance of teledentistry and its role in addressing such incidents [72].

The main adverse outcome of tooth replantation is replacement root resorption (ankylosis). It implies possible risks of infraocclusion, impairment of alveolar bone growth, and tooth loss. The risk increases dramatically with delayed replantation [20].

#### **9. Conclusion**

Tooth avulsion is one of few emergencies in dentistry; prevalence differs from area to area according to the cause and gender. Replantation, immediate or delayed is the

treatment of choice for the avulsed permanent tooth still immediate and proper replantation is important for long term good prognosis. Many factors may determine the outcome and use of antibiotic; although it is questionable, it is indicated in certain conditions. Although there is no strong evidence for their effect on healing, storage media is one of the factors for the preservation of the vitality of the tooth. It is used according to its availability at the trauma site. There are two stages in the treatment: emergency treatment and definitive treatment; even so, there is no grantee for the success of the treatment. Any avulsed tooth may be followed by complications, either immediately or lately. Despite the recommendation for the manager of the avulsed teeth, still not all recommendation can be applied for every avulsed tooth. Accordingly, any tooth has got special related factors which would determine the treatment plan after studying them carefully.

As a result, immediate and proper replantation is important for long-term good prognosis.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Acronyms and abbreviations**


*Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

#### **Author details**

Manal Abdalla Eltahir<sup>1</sup> \*, Randa Fath Elrahman Ibrahim<sup>2</sup> and Hanan Alharbi<sup>3</sup>

1 Oral and Maxillofacial Surgery and Diagnostic Science, College of Dentistry, Qassim University, Qassim, Saudi Arabia

2 College of Dentistry, Qassim University, Qassim, Saudi Arabia

3 Department of Conservative Sciences, Division of Endodontics, College of Dentistry, Qassim University, Qassim, Saudi Arabia

\*Address all correspondence to: manltahir@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### *Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

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#### **Chapter 5**

## Perspective Chapter: Splinting of Traumatized Teeth

*Eswari Ramassamy*

#### **Abstract**

Repositioning or replantation followed by stabilization with splint is the standard management of traumatized teeth. Numerous types of splints are being used and each type has its own advantages and disadvantages. Knowledge on the different types of splints and its effect on dental tissues so as to aid in the clinical decision on the type of splint to be used for managing a particular type of traumatic dental injury and its fixation period are important. Therefore, this chapter aims in explaining the different methods of splinting along with its advantages and disadvantages of each type along with the standard recommendation for duration of splinting.

**Keywords:** splinting, flexible splints, rigid splints, traumatized teeth, wire composite splints

#### **1. Introduction**

Splinting is recommended in the management of traumatic dental injuries which requires repositioning and stabilization of the luxated teeth. Earlier, the management of luxated teeth was similar to the management of fractures of Jaws, which are arch bars with wires and cap splints. But due to their negative effect on periodontal structures along with the advent of adhesive materials, a wide range of splints are being developed [1, 2]. A splint is "An apparatus used to support, protect or immobilize teeth that have been loosened, replanted, fractured or subjected to certain endodontic surgical procedures" [3]. The aim of this chapter is to enumerate the ideal requirements of splints, types and description of each types of splints and International Association of Dental Traumatology (IADT) recommendations of splinting duration and types.

#### **2. Ideal requirements of splints**


But, all the splinting techniques do not satisfy all the requirements mentioned above [1, 4, 5].

#### **3. Classification of splints**

Splints can be classified as Rigid splints Semi-rigid splints/Flexible splints

#### **3.1 Rigid splints**

Rigid splints are those splints which does not allow physiologic movement of the repositioned teeth [2].

Eg: Erich arch bars, Acrylic cap splint, Schuchardt splint, Interdental wiring methods like figure-eight wiring & loop wiring.

In case of arch bar splints (**Figure 1**) and the interdental wiring methods, the ligature wires used in these splints tend to become loose with time and come to rest on the marginal gingiva. This could cause gingival irritation and inflammation as it becomes the site for plaque deposition. The patient's inability to maintain good oral hygiene around the wires could worsen the condition [4, 6]. These splints also cause physical damage to gingiva and cementum surface when removed after the splinting period [7]. If these ligature wires, when positioned apical to the cervical prominence while splinting especially in a mobile tooth, they tend to elevate the tooth slowly making the cemento-enamel junction lose its integrity [4, 6].

Schuchardt splint was initially designed for splinting of luxation injuries. But its extreme rigidity and difficulty in adapting to the arch form accounts for its high thickness of 2 mm diameter bar made of aluminum-brass alloy. Acrylic cap splint is cemented on uninjured teeth when used for luxation injuries provides too much rigidity [6].

*Perspective Chapter: Splinting of Traumatized Teeth DOI: http://dx.doi.org/10.5772/intechopen.108908*

**Figure 1.** *Arch bar splint.*

In addition to these disadvantages, there is high incidence of pulp necrosis, external root resorption and ankylosis of the repositioned teeth when rigid splints are applied [2, 8].

For the above reasons, the usage of rigid splints is restricted only for stabilizing jaw fractures.

#### **3.2 Semi-rigid/flexible splints**

Flexible splints are those splints which allow functional movement of the stabilized teeth [4]. Studies conducted on animals had shown that normal masticatory stimulation can lower the incidence of ankylosis which led to the development of flexible splints so as to allow the functional movement of the traumatized and stabilized teeth [9].

Many varieties of flexible splints are being introduced. Most of these splints make use of the acid etch technique.

#### *3.2.1 Composite and wire splints*

Flexible wire composite splint (**Figure 2**) uses a wire of 0.3–0.4 mm in diameter bonded onto the labial surface of the teeth with composite [4]. Rigidity of the splint increases with increase in the thickness of wire or by adding composite in the interdental space [1]. Rigidity also increases with increase in the length of the wire splint [10].

The main advantage of this splint is that the materials used for the construction of this splint are routinely available in all dental clinics. Other advantages are it is well accepted by the patients, does not cause any injuries to the supporting structures and easy maintenance of oral hygiene. But a major disadvantage is that it can cause potential damage to enamel while removing [1].

#### *3.2.2 Other alternatives*

Many splints are being constructed using other materials as an alternative to wire.

a.Nylon/Fishing Line splint (**Figure 3**) – In this splint a thin nylon/Fishing line is used instead of wire. The advantages of this splint is that it is atraumatic to

**Figure 2.** *Wire composite splint.*

```
Figure 3.
Nylon line splint.
```
supporting structures, relatively esthetic, easy to maintain oral hygiene, inexpensive and comfortable for patient [11]. The main disadvantage is that it is slightly difficult to position the nylon line as it is thin. This problem can be overcome by fixing the nylon line and light curing the composite one tooth at a time and thus it is slightly time consuming [12].


*Perspective Chapter: Splinting of Traumatized Teeth DOI: http://dx.doi.org/10.5772/intechopen.108908*

**Figure 4.** *Power chain splint.*

#### *3.2.3 Suture splint*

It is the simplest form used as temporary splinting of traumatized deciduous teeth or partially erupted permanent teeth in a situation where the child is difficult to manage. It is a temporary splint because it is retained only for 3 to 4 days until the child becomes more receptive to a definitive treatment. A suture is placed over the incisal edge from palatal gingiva to the labial gingiva. (**Figure 5**) It prevents the tooth from extruding. But the biggest disadvantage of this splint is that sometimes the incisal edge has to be grooved to hold the suture material in position [1, 5].

#### *3.2.4 Orthodontic splint*

It requires the orthodontic materials like brackets and wires (**Figure 6**). The brackets are bonded to the teeth and are connected by 0.014 NiTi flexible wire [4].

It is indicated in a few clinical conditions like:

**Figure 5.** *Suture splint.*

**Figure 6.** *Orthodontic wire splint.*

i. severely malpositioned teeth which makes the placement of wire-composite splint difficult.

ii.In case of intrusive luxation, where repositioning of the tooth is to done [14].

The main advantage of this splint is that it is the least traumatic technique for repositioning tooth with intrusive luxation injury [14]. However, when used in other situations except intrusive luxation, care must be taken to reduce orthodontic forces that disturbs the healing of the luxated tooth [15].

It is known through studies that splints constructed with orthodontic materials always generate some amount of force over the teeth, but these forces could be reduced with certain conditions like the form of arch wire, type of cross section of the wire and the type of ligature used [16]. Hence, it is recommended that only trained clinician in handling orthodontic materials can utilize this splint properly. This becomes a major disadvantage of this splint [17]. Other disadvantages are the requirement of materials which are not commonly available in clinics and irritation to the lips and buccal mucosa and discomfort to the patient especially at the beginning of the treatment, which can be reduced by lubricating the lips [18].

#### *3.2.5 Fiber-reinforced composite splints*

These splints use fibers which are attached to the teeth either by unfilled resin or with composite [4].

The commercially available fibers are:


*Perspective Chapter: Splinting of Traumatized Teeth DOI: http://dx.doi.org/10.5772/intechopen.108908*

**Figure 7.** *Ribbond splint.*

Fiber splints are esthetically acceptable and it is easy to apply and remove. It does not cause any trauma to surrounding structures and maintenance of oral hygiene is easy. Fiber splints are associated with highest frequency of healing outcomes [19].

#### *3.2.6 Titanium trauma splint (TTS)*

This splint was developed by von Arx in collaboration with Medartis AG, Basel, Switzerland. The objective behind developing this splint was to optimize the splinting techniques, (i.e) ease of application and removal from the dental surgeon's aspect and increase in comfort and easy maintenance of oral hygiene from the patient's aspect.

It is a pre-fabricated splint made of titanium of 0.2 mm thickness and 2.8 mm width. Due to its least thickness, it is operator friendly, it does not require any special pliers or other instruments to manipulate; it can be easily adapted onto the arch by fingers. It is available in two different lengths 52 mm and 100 mm and it could be cut to the desired length.

Its unique design with a rhomboid mesh structure makes the splint more flexible without subjecting the splinted teeth to any orthodontic forces. Yet another advantage is that it could be easily secured to the teeth. The rhomboid openings are in the size of 1.8x2.8 mm and hence only a small area of bonding is needed with the tooth. It does not require a bulk composite around the splint; only a thin layer of flowable composite is required.

While removing the splint, the composite can be ground down to the level of TTS and the splint can be "peeled-off" easily from the tooth with a hemostat. Any remnant composite can be removed with easily with a curett and tooth surface can be polished [20]. The only disadvantage of this splint is its high cost [4].

#### *3.2.7 Resin splint*

This splint is applied with resin materials like Protemp and Luxatemp, which are used in temprorary prosthetic restorations and for lining prefabricated crowns. Luxatemp is dual cured; by both chemical and light cured, while Protemp is chemically cured material [1]. The resin materials are available in syringe forms and can be directly applied to the labial aspects of the crowns of the teeth to be splinted. Once the material is set/cured, any sharp edges can be removed to prevent irritation to the surrounding soft tissues [21].

The advantages are these materials do not exert any force on tooth during application and are acceptable esthetically and hygienically. They are not indicated when

the adjacent are not fully erupted and difficult in case of any edentulous area. The main disadvantage is that they tend to fracture easily and care must be taken during removal. [1].

### **4. Splinting type and duration**

#### **4.1 For permanent dentition**

Experiments and studies demonstrated that rigid immobilization for longer duration of time increased the risk of pulp necrosis, external root resorption and ankylosis. The International Association of Dental Traumatology (IADT) has formulated guidelines for the management of traumatic dental injuries. Based on current evidences, short-term, passive and flexible splints are recommended for splinting luxated, avulsed and root-fractured teeth. For alveolar bone fractures, splinting of teeth may be used for bone segment immobilization. Splinting duration depends on the type of dental injury. The duration of splinting for Permanent Dentition as given by IADT 2020 is given in **Table 1** [22].


#### **Table 1.**

*IADT guidelines for splinting duration of permanent dentition.*


#### **Table 2.**

*IADT guidelines for splinting duration of primary dentition.*

#### **4.2 For primary dentition**

According to IADT guidelines, splinting of primary dentition is recommended only in case of alveolar bone fractures. Root fractures and lateral luxations may occasionally require splinting. Only flexible splints are used including alveolar fracture where the splint is stabilized on adjacent uninjured teeth for 4 weeks. (IADT guidelines) The duration of splinting for Permanent Dentition as given by IADT 2020 is given in **Table 2** [22].

#### **5. Removal of splint**

One of the important requirement of a splint is that it should be applied and removed easily without causing any damage to the enamel surface. The resin-based materials cause iatrogenic enamel damage while removing them is a major concern. Various techniques are employed for removing the remnant composite material used for retaining the splints from the enamel surface. They are hand instruments like scalers and pliers, burs, abrasive discs, rubber wheels and cups. In an experimental study conducted to assess the surface roughness of enamel after employing various methods to remove the material, it was noted that Soflex discs and 16-blade tungsten carbide bur cause least damage to the enamel [17, 23].

#### **6. Emergency splinting**

Patients with multiple injuries as in road traffic accidents, often sustain dental injuries. Traumatic dental injuries not being life-threatening, emergency rooms not being equipped to manage traumatic dental injuries, inadequacy of knowledge and skill of medical personal handling the patients are the reasons for either delaying/ignoring the management of traumatic dental injuries [24, 25]. In such emergency situations, an easy to perform splinting technique is "criss-cross" pattern suture splints which can be rapidly placed by any medical personal. This splint can be placed with 2/0 silk suture material with a horizontal locking mattress design to keep the reimplanted tooth in position until the patient could be mobilized to Dental Department for more definitive management. The advantage of this technique is that it is a quick method which could be performed by any medical personal when the patient is treated under General Anesthesia for other injuries and does not delay the general treatment procedures.

The criss-cross pattern splint is given by the following steps:

Step 1 – the first bite (point 1 in **Figure 8**) is taken at the base of the distal interdental papilla on the labial side of the tooth to be repositioned and crossed over the incisal edge towards the mesial-palatal aspect.

Step 2 – suture then penetrates the base of the mesial interdental papilla (point 2 in **Figure 8**) on the palatal side and emerges out at the base of the distal interdental papilla on the palatal aspect (point 3 in **Figure 8**).

Step 3 – the suture then crosses over the incisal edge to pierce the base of the mesial interdental papilla on the labial aspect (point 4 in **Figure 8**).

Step 4 – from point 4, the suture retraces the path underneath the previous suture upto the criss-cross point (point 5 in **Figure 9**) on the labial aspect and winds around the point 5 to pierce at mid buccal region (point 6 in **Figure 9**) on the labial aspect.

Step 5 – knot is placed between point 1 and 6 (**Figure 9**) [24].

**Figure 8.** *Criss-cross splint.*

**Figure 9.** *Criss-cross splint.*

#### **7. Home-care instructions to parents**

Post-treatment maintenance of good oral hygiene is the key to uneventful healing of the injured tissues. Therefore, parents/caregivers must be sensitized about the importance of maintaining good oral hygiene and also taught the methods to maintain it. Most important instructions to be given are:


#### **8. Conclusion**

To summarize, splinting is important for stabilizing the luxated teeth; use of semirigid/flexible splints is mandatory as it allows functional movements of the tooth and short-term immobilization is recommended as longer period of splinting is associated with complications.

### **Author details**

Eswari Ramassamy

Department of Pediatric and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India

\*Address all correspondence to: eswari80ashok@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 6**

## Perspective Chapter: Orbital Reconstruction and Orbital Volume

*Yousry Eldek, Heba Sleem, Mohamad Katamesh and Fahmy Hasanin*

#### **Abstract**

Orbital fractures are common presentation in the head and neck trauma centers. They can result in functional and esthetic problems. The primary goal in the repair of the orbital fractures is to restore the orbital shape and volume, free the incarcerated or prolapsed orbital tissue from the fracture defect, and span the bony defect with reconstructive implant material. Titanium mesh was very appropriate reconstructive material for anatomic reconstruction. The orbit has a special complex geometry which makes perfect anatomic reconstruction very difficult. The manual process of fitting and adapting the implant within the orbit is time consuming and operator dependent. The advanced techniques in maxillofacial imaging and computer assisted techniques resulted in improvement in the implant design for management of orbital fractures. The current study was made to review the accuracy of adapting the titanium mesh using STL model versus conventional technique for restoring the orbital volume in management of orbital floor fracture.

**Keywords:** orbital reconstruction, orbital volume, titanium mesh, STL model, computer assisted surgery

#### **1. Introduction**

Orbital fractures are one of the most common fractures of the midface and result in significant complications such as enopthalmos, diplopia, restriction of gaze, and dystopia [1]. Orbital reconstruction aims to restore the normal orbital volume and architecture and reduce the herniated orbital tissues to prevent the compications [2]. The choice of the implant material depends on many factors such as: size of the defect, involvement of many walls, adaptation to internal contours, restoration of accurate volume, presence of adjacent sinus cavity, prevention of displacement, restriction of ocular motility, risk of further trauma, and early versus late repair [3].

**Avashia et al.** reviewed the materials used for orbital reconstruction and classified it into biological materials and manufactured materials. Biologic materials include autografts, allogarfts, xenografts. Manufactured materials include resorbable materials as polymers and nonresorbable materials as porous polyethylene, bioactive glass, silastic rubber, titanium, teflon, nylon, and other materials. Avashia et al. reported no consensus for any material as the optimal choice for orbital floor reconstruction [4].

Many surgical techniques have been adopted and evaluated for correction of orbital volume. Topography of the orbital floor (S shape in sagittal plane) is one of the difficult factors during insertion and manipulation of reconstructive material. However there is a continuous search and study for the best method to achieve accuracy, feasibility, and reliability for restoration of the orbit [5].

#### **2. Titanium implant**

Literature review revealed the use of many surgical approaches and many implant materials for orbital reconstruction. Titanium mesh was very appropriate reconstructive material for anatomic reconstruction [6]. Titanium implants are considered as an established implant material to reconstruct the orbital and craniofacial skeleton. There are many forms and shapes of titanium mesh and different thickness and sizes [7].

Titanium mesh is the most commonly used reconstructive material for orbital reconstruction [8]. Intra-operative manual bending and adaptation to the titanium mesh after exposure and reduction of fractured segments is a traditional or conventional technique. However, this leads to more dissection, multiple trials, and longer operative time especially in comminuted fractures. This technique makes the reconstruction process a subject of interpersonal variation because the manipulation and bending of the implant material depends on the operator experience [9].

Titanium meshes have high biocompatible properties. They are easily molded to fit simple and complex orbital defects. They can provide a strong support without change in the shapes or locations over time. They can be fixed to adjacent bone. They have many good characters such as: availability, easy sterilization, and a wellrecognized osseointegration. Titanium has a high corrosion resistance because of the spontaneously forming thin oxide layers on the surface. This guarantees its passive behavior to avoid toxic or allergic reactions [4].

In 2009**, Lee and Nunery** revealed that the use of titanium mesh in the orbital floor can lead to fibrous adhesion around the implant resulting in diplopia or restricted eye movement after orbital floor repair by 2 months. It is a rare complication which requires replacing the titanium mesh with another implant. They considered the titanium itself caused fibrous adhesion and named it "orbital adherence syndrome" [10]. However, in 2013, **Kersey et al.** revealed in their study that the fracture can result in rupture or splitting through the periorbita, causing fibrous adhesion due to inadequate separation between the orbital contents and the bone or the implant and this complication can ocuur occur with or without the titanium implant [11].

#### **3. Computer assisted surgery**

The orbit has a special complex geometry, so the perfect anatomic reconstruction is very difficult. The process of fitting and adapting the implant in the orbit is time consuming and operator dependent. The narrow field in addition to the complex anatomy of the orbit make the orbital reconstruction difficult and almost impossible to achieve "true-to-original" 3D shape [12].

The management of the orbital fractures has changed over the years. The advanced techniques for maxillofacial imaging and computer assisted techniques lead to an improvement in the implant design for orbital reconstruction [13].

#### *Perspective Chapter: Orbital Reconstruction and Orbital Volume DOI: http://dx.doi.org/10.5772/intechopen.106369*

Over the last 2 decades, there was great and rapid improvement in the computed tomography which has added a third dimension to the imaging of complex craniomaxillofacial deformity. This development has significantly decreased the degree of inaccuracy that is inherent in any clinical assessment. Three dimensional (3D) reconstruction from volume data collected from helical CT is now an established technique in craniomaxillofacial surgery to provide animated screen images and accurate reproduction of the hard and/or soft tissues with models [14].

The development of computer assisted surgeries represents a new technology and a turn point in the field of craniofacial reconstruction. Some of the computer assisted techniques are used for virtual reconstruction of the fractured orbit and rapid prototyping. STL model was used for adapting and contouring the orbital mesh to allow accurate orbital volume, decrease operative time, decrease hospital costs, strengthen the surgical skills, and improve patient outcomes [15–17].

**Lim et al.** found that the direct intraoperative trimming and adaptation may take long operative time depending on the extension of the defect and experience of the surgeon when compared with STL models [18]. On the other hand, preoperative rapid prototyping reduces the intraoperative time, risk of orbital mesh malposition, poor anatomical contour, and trauma to soft tissue because of multiple insertions during trimming and adaptation of the titanium mesh [19].

Rapid prototyping is a new technique characterized by rapidly and accurately preparing solid bodies with complex shapes, so it has a promising and extensive application in the medical fields [20]. Since its introduction into craniomaxillofacial surgery in the 1990s, it has been used for the treatment of various medical problems, such as orbital hypertelorism, craniosynostosis, facial asymmetry, craniomaxillofacial defects, maxillofacial implants, orthognathic surgery, tumor surgery [21].

Rapid prototyping is a three dimensional (3D) printing process which involves an additive manufacturing technology which offers an expedient and accurate reproduction of an osseous anatomy. The intact orbit was mirrored onto the fractured one to create virtual model. The virtual model data were converted to STL (Standard Triangulation Language or Standard Tessellation Language) format to form a solid physical orbital model using a 3D printer and computer-aided manufacturing machines. STL model was used to adapt and contour the orbital mesh to allow accurate orbital volume, decrease risks and time consuming, and help improve postoperative results [18, 21].

In 1986, **Hull** introduced the stereolithography apparatus (SLA) technique to create an accurate, hardened, three dimensiona; acrylic models from CT data [22, 23]. In 1990, the first stereolithographic patient model was built. It represented an actual three- dimensional model to reproduce the anatomy of a patient based on CT images taken during that patient's examination [24].

In 1998, **Perry et al.** reported that 3D models of the facial skeleton differ in their accuracy, reproducibility and cost. The early attempts to build and form models from CT scans were stacked polystyrene slices where each of which represented a corresponding slice from an axial scan. Since then model building has developed into 2 distinct processes: computer aided manufacture (CAM) and stereolithography. In the computer aided manufacture (CAM) technique, the models are milled by computer guidance from different materials as soft expanded polyurethane and titanium alloy. It is considered as a removal process by an expensive milling machine. Stereolithography is a computer controlled construction process including 0.25 mm layer by layer polymerization of LASER curable liquid resin which are built on top of each other. It is accurate, slow and expensive technique [14]**.**

In 1999, **Holck et al.** described the benefits of the sterolithography (SLA) modeling system for planning the surgery for bony orbital pathology. They reported that the SLA models were beneficial preoperatively for evaluating the dimensions of the bony defects and surgical planning. Intraoperatively, SLA models facilitated the surgical rehabilitation of the orbit leading to postoperative satisfactory results [24]**.**

In 2006, **Metzger et al**. measured the accuracy of a technique for making individual preformed titanium meshes for orbital fractures. The study included 5 patients with unilateral orbital fractures and the patients underwent preoperative CT scans of 1 mm thickness followed by surgical planning using surgical planning software, then stereolithographic models were built after using the mirroring tool from unaffected side on affected side. Titanium meshes were then adapted manually on the STL models and sterilized. Intra-operatively, the meshes were positioned with the aid of navigation tools to ensure correct placement of the mesh as on the template by using reference points. Postoperative CT scans were obtained to compare the actual position of the titanium mesh implant to the planned position of the orbital floor. They reported accurate reproduction of the planned surgery [25].

In 2006, **Schon et al.** used individually preformed implants to reconstruct an extensive orbital floor fractures in 19 patients. The orbital floor and walls were studied by preoperative diagnostic CT scan data. The form of the virtual reconstructed orbit was printed into a model for the orbital cavity by a template machine. They reported that the orbital reconstruction using a preformed implants is less time consuming, more accurate, and less invasive in comparison to free hand efforts for the restoration of the orbital fractures using titanium mesh and calvarial grafts [26]**.**

In 2010, **Zhang et al.** studied 21 patients with delayed treatment of unilateral impure fracture of the orbit and post-traumatic enophthalmos. They used anatomically adaptive titanium mesh depending on computer-aided design and computeraided manufacturing techniques (CAD/CAM). After exposure to orbital floor defect and reduction to the herniated soft tissue, the titanium mesh was placed to restore the internal orbit. Measurements were taken to evaluate the change in the degree of enophthalmos and orbital volume before and after surgery. They found that this method was useful to some degree to decrease the expanded orbital volume and correct post-traumatic enophthalmos [27].

In 2012, **He et al.** made a retrospective review of a consecutive clinical case series. 64 patients from 2008 to 2010 were diagnosed with delayed orbitozygomatic fractures with enophthalmos. Traditional surgery and computer-assisted treatment (navigation and 3D models) were used for zygoma reduction. They found that computer-assisted surgery can improve the treatment results [28].

In 2016, **Oh et al.** made a study to use individualized prebent titanium-Medpor mesh implants and stereolithographic modeling in a series of patients who underwent orbital wall reconstruction. They obtained good results and concluded that orbital reconstruction can be optimized by using individually manufactured rapid prototype skull model and premolded synthetic scaffold by computer-aid of mirroring-reconstruction of 3-dimensional images and 3-dimensional printing techniques [29].

**In 2020, Sigron et al.** made a study to compare the efficacy of the intraoperative bending of titanium mesh with the efficacy of pre-contoured "hybrid" patientspecific titanium mesh using 3D-printed anatomical models as bending guides for the surgical repair of isolated orbital floor fractures. They concluded that t the use of 3D-printed orbital models leads to a more accurate reconstruction and a time reduction during surgery [30].

#### **4. Orbital volume measurement**

Orbital volume measurement after maxillofacial trauma reveals a significant data for evaluating the severity of the injury and prevention of possible complications caused by enophthalmos [31]. The Volume of the orbit is the space formed by the size and position of the orbital walls [32].

In 1873 in France, **Gayat** may have been the first to publish orbital volume data [33]. He used lead pellets to fill the orbital cavity of 11 skulls and poured them into a graduated cylinder to determine the orbital volume. He found the average of the orbital volume approximately equal to 29 cm3 . After **Gayat**, some authors used alternative methods for measurement on corpses using silicone, water, glass beads or sand were used [34].

During the 20th century, OVM for living patients became possible with the development of medical imaging techniques. The first OVM for a living patient was performed in the 1960's with manual evaluation of roentgenographic images [33].

With the advent of tomodensitometry, volume measurement of irregular objects became possible. In 1985, **Forbes et al.** transferred the data from CT scan images to special program to calculate the volume of the orbital structures. The software counted the number of pixels to calculate the volume according to the number of slices and special formulas [35].

Manual segmentation for OVM (planimetry methods) is considered to be the most common method for this purpose. It depends on the summation of the manually delineated areas obtained from a CT images [36]. The operator manually delineates the boundaries of the orbital bone cavity on a series of CT slices. The boundaries are defined by the operator and not by standard charts. This can represent a source of errors with low reproducibility. Planimetry method is extremely time-consuming to be accurate but its advantage lies in its availability on all standard medical imaging softwares [37].

Automatic methods for OVM contains automatic segmentation of the orbital cavity which can be undertaken using a function integrated within software. This method relies on atlas segmentation [38]. Semi-automatic method for OVM is defined as a method using volumetric built-in functionality in software, combined with manual adjustments. Various semi-automatic methods are available, depending on the software used. The are some softwares which are considered as different methods described in the literature for OVM [37]**.**

Several studies have shown a correlation between an increased OV and enophthalmos. Using planimetry, **Whitehouse et al**. showed that enophthalmos increased by 0.8 mm per 1 cm3 of OV expansion [39]. In 1993, **Charteris et al**. proposed that the amount of increase in the orbital volume may determine the need for surgical intervention [40].

Some authors consider the OV as a predictive of long-term symptoms, while other authors did not find a significant correlation between an increased OV and enophthalmos [41]. Choi et al. showed that the OV cannot be considered as a reliable measure to estimate the size of enophthalmos because of inter-individual variations in the OV [42].

The use of intraoperative navigation during the orbital surgery according to data from CT scans or MRI assisted in implementation of preoperative plan, volume measurement, and protecting the vital structures [38]. In the recently published studies, administration of CT images was recommended as the standard method to determine the volume of the orbital cavity in living patients [34]. However, there is no consensus concerning the gold standard for orbital volume measurement [43].

The difference in the volume of bony orbit can reach 0–8% between the right and left orbit when measured in the same person [35, 44], and up to 22% between subjects [32]. This normal difference can be considered as a protective factor for the surgeon, allowing him some malleability in the work for not insisting to achieve the ideal OV and reflecting the great tolerance in orbital volumetric restoration. A perfect symmetry between the 2 orbits is not necessary, and a variation of around 10–20% of the volume between the 2 orbits may involve no or only minor imperceptible facial irregularity. This minor difference may lead to a satisfactory result for the patient and the surgeon [44].

Stereolithography (SLA) technology developed into many types such as powder bed fusion, fused deposition modeling (FDM), selective laser sintering (SLS) for 3D printing which is known as additive manufacturing or desktop fabrication. Some metals as titanium, silver, gold, steel, and stainless steel can be used as raw materials for 3D printing. However, the plastics are most commonly used such as: acrylonitrile butadiene styrene (ABS) or "Lego" plastic material, polylactic acid (PLA) which is readily available in soft and hard grades, polyvinyl alcohol (PVA), and polycarbonate (PC). ABS materials are sturdy, strong, and providing more structural integrity than PLA which is less expensive, more biocompatible, and providing more precise prints [45–48].

#### **5. Conclusion**

Both techniques conventional technique and STL model for titanium mesh adaptation lead to significant correction of the orbital volume. Conventional technique is still a valid and cheap method among the attractive new techniques. STL technique is helpful in the cases presented with massive orbital disruption and/or malunion. It offers less operative time and less tissue manipulation.

*Perspective Chapter: Orbital Reconstruction and Orbital Volume DOI: http://dx.doi.org/10.5772/intechopen.106369*

#### **Author details**

Yousry Eldek1 \*, Heba Sleem<sup>2</sup> , Mohamad Katamesh2 and Fahmy Hasanin3

1 Oral and Maxillofacial Specialist, Nasser Institute Hospital, Cairo, Egypt

2 Faculty of Dentistry, Professor of Oral and Maxillofacial Surgery, Ain Shams University, Cairo, Egypt

3 Faculty of Dentisry, Professor of Oral and Maxillofacial Surgery, Cairo University, Cairo, Egypt

\*Address all correspondence to: usridk@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*Perspective Chapter: Orbital Reconstruction and Orbital Volume DOI: http://dx.doi.org/10.5772/intechopen.106369*

prefabricated mesh. Journal of Oral and Maxillofacial Surgery. 2009;**67**(11):2404-2411

[45] Ngo TD, Kashani A, Imbalzano G, Nguyen KTQ, Hui D. Additive manufacturing (3D printing): A review of materials, methods, applications and challenges. Composites. Part B, Engineering. 2018;**143**:172-196

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#### **Chapter 7**

## Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines

*Prashanth Shetty, Shweta Hegde, Shubham Chelkar, Rahul Chaturvedi, Shruti Pochhi, Aakanksha Shrivastava, Dudala Lakshmi, Shreya Mukherjee, Pankaj Bajaj and Shahzada Asif Raza*

#### **Abstract**

Occlusal trauma is trauma to the periodontium from functional or parafunctional force's causing damage to the teeth and its attachment apparatus by exceeding its adaptive and reparative capacities. Occlusal instability is a common cause for trauma from occlusion, resulting in numerous complications. It often leads to interference which reflexively shifts or slides the jaw forward on one or both the side to find a spot where most teeth come together. This action protects the teeth from injury caused by chewing on just one tooth. Overtime, this shift can cause a whole host of problems from TMJ pain, post restorative complications, headache, tooth sensitivity, recession, broken and loss of teeth and orofacial pain. These occlusal interferences and bite discrepancies are treatable with minimally invasive dentistry. Occlusal equilibration is a therapy that is used when the cause of trauma is due to occlusal instability. This involves the reshaping of the teeth where the improper biting surfaces are located. The key lies in decoding the cause, but often treatment is only directed towards the effects. Only a thorough evaluation and occlusal analysis will lead to a definitive diagnosis that will help in better anticipation of the damages.

**Keywords:** occlusal trauma, occlusal instability, occlusal interferences, occlusal analysis, biometric analysis, occlusal equilibration

#### **1. Introduction**

Ideal occlusion is characterized by simultaneous contacting of all teeth at maximum intercuspation, with an equal intensity force on right and left side of the arch. This helps to preserve all the physiological components of the stomatognathic system namely the occlusion, the attachment apparatus, TMJ and the neuromusculature in harmony as they are closely interrelated. When the functional or parafunctional occlusal forces exceeds the capacity for adaptation and repair of one tooth or group of teeth and its attachment, limited or progressive injury occurs. This is called occlusal trauma. In the presence of interference, the jaw will reflexively shift and slide forward on one or both the side to find a spot where most teeth come together. An unstable occlusion is a common cause for numerous post restoration complications. Overtime, this may cause a whole host of problems from TMJ pain, headache to sensitivity, recession, broken and lost teeth and Orofacial Pain.

Establishing a stable and harmonious occlusion goes a long way in preventing the deterioration of the dentition and its associated structures [1]. Trauma from occlusion is a clinical finding often ignored by the dentist as it is not a part of the chief complaint. The key lies in decoding the cause, but most often treatment is only directed towards the effects. Only a thorough evaluation and occlusal analysis will lead to a definite diagnosis. A good diagnosis helps in better anticipation of the direction the damages will take.

Digital occlusal analysis is a powerful tool which provides the dentists with an objective reproducible data. These occlusal technologies along with a biometric approach will allow for an accurate diagnosis treatment and reevaluation of the inter relationship between teeth, muscles & joints [2].

#### **2. Terminologies used with trauma from occlusion**

#### **2.1 Trauma from occlusion**

Occlusal trauma was defined as "An injury to the attachment apparatus as a result of excessive occlusal force" "Glossary of Periodontics terms" (American Academy of Periodontology 1986), [3].

#### **2.2 Occlusal interferences**

Any contact that inhibits the remaining occluding surfaces from achieving stable and harmonious contacts.

#### **2.3 Occlusal adjustment**

Reshaping of the occlusal surfaces of teeth by grinding to create harmonious contact relationships between the upper and lower teeth, or orthodontic movement of the teeth to create more harmonious contact relationship.

#### **2.4 Fremitus**

A palpable or visible movement of a tooth when subjected to occlusal forces (also known as functional mobility).

#### **2.5 Premature occlusal contact**

A condition of tooth contact that diverts the mandible from a normal path of closure.

*Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

#### **3. Classification**

#### **3.1 Glickman's classification (1953)**

#### *3.1.1 According to duration of cause*

#### I.Acute trauma from occlusion:

This type of trauma is caused because of abrupt occlusal impact, like due to biting on a tough object or high restorations or prosthetic appliances. The clinical signs and symptoms of the condition include tooth pain and sensitivity to percussion, fremitus, tooth mobility and once the cause is removed, symptoms subside and complete healing takes place [4–7].

#### II.Chronic trauma from occlusion:

When abnormal occlusal forces are exerted on the tooth-supporting structures for a longer duration of time, chronic trauma from occlusion occur. It is more significant than the acute condition because it results in progressive changes in occlusion clinically seen as tooth migration, tooth wear and extrusion of teeth [4–7].

#### *3.1.2 According to nature of cause*

I.Primary trauma from occlusion:

It refers to the injury resulting from excessive occlusal forces applied to a tooth or teeth with adequate support

#### II.Secondary trauma from occlusion:

It refers to the injury resulting from normal occlusal forces applied to a tooth or teeth with inadequate support.

#### **3.2 Box's classification**

#### *3.2.1 Physiologic occlusion*

Box defined it as a condition, in which the systems of forces acting upon the tooth during the occlusion are in a state of equilibrium, and they do not and cannot change the normal relationship existing between the tooth and its supporting structures [8].

#### *3.2.2 Traumatic occlusion*

The damage produced in the periodontium is due to the overstress produced by the occlusion (**Table 1**).

#### *Dental Trauma and Adverse Oral Conditions - Practice and Management Techniques*


**Table 1.** *Etiology of trauma from occlusion.*

#### **4. Pathophysiology of trauma from occlusion**

Excessive occlusal force

↓ **Soft tissue change**

Traumatic v shaped gingival crescent Stillman's cleft (indentations in the gingival margin generally on one side of tooth) McCall's festoons (Buccal Bone dehiscence)

Absence of stippling – Edema secondary to trauma

↓ Alteration in occlusal forces

↓

#### **Hard tissue change**

Occlusal wearing pattern of tooth not attributed to any abnormality in patient diet

↓

Tooth mobility, migration, shifting & tilting of tooth

↓ Discomfort on eating ↓ Sensitivity of teeth

↓ Hypertonicity of muscle

↓

Mandibular deviation

#### **5. Stages of tissue response to excessive occlusal forces**

Excessive force of occlusion causes the tissue to respond in three stages Injury, repair and adaptive remodeling of periodontium.

#### **5.1 Stage 1: injury**

Soft tissue injury is the immediate result of excessive occlusal forces. The magnitude of forces varies from slightly excessive, greater then excessive or severely high.

#### *Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

The centre of rotation of a single rooted tooth lies at the junction of middle and apical third of the tooth and is located near the furcation area of the multirooted teeth.

When excessive occlusal forces are subjected to teeth they rotate around the fulcrum of rotation. This rotation in the tooth socket creates areas of presser and tension on the opposite side of the fulcrum. When the force is unidirectional, these are created on the opposite surface, whereas in the case of jiggling forces these areas may co – exist on the same surface.

Effect of excessive occlusal forces on the periodontium.

**Slightly excessive forces**- simulates bone resorption in area of presser, causing the widening of periodontal ligament space. Elongation of PDL fibers takes place in the areas of tension.

**Greater than slightly excessive forces**- caused marked changes in the tooth supporting structures producing areas of hyalinization and necrose when excessive compressive forces are produced from trauma from occlusion.

**Severely high occlusal force**- results in thrombosis, hemorrhage, tearing & widening of pdl space and undermined bone resorption. If the forces are removed, or tooth moves away the periodontium is completely repaired.

#### **5.2 Stage 2: repair**

Takes place when the damage tissue is replaced by new connective tissue and cells. This is a well-regulated mechanism and the healing process is directly or indirectly facilitated by the extracellular matrix and certain inflammatory mediators. The activity is increased during TFO & the body tries to reinforce the trabeculae within the new bone by a process known as buttressing bone formation. When it occurs in the buccal and lingual surface of the alveolar bone it is known as peripheral buttressing and central buttressing when this process occurs within the bone this helps to bear increased occlusal load. There is a shelf-life thickening of the bone on the labial or lingual surface of the alveolar bone is referred to as lipping.

#### **5.3 Stage 3: adaptive remodeling of the periodontium**

Establishes a structural relationship in such a way that the forces of occlusion are no longer harmful to the periodontium, and the repair process can keep pace with the destructive occlusal forces.

Tooth mobility is an important clinical sign when TFO is increase it occurs in two phases the initial phase there is an increase in the width of the PDL and reduction of the number of the periodontal fibers leading to alveolar bone resorption.

The second phase results in the permanent widening of the PDL space which occurs after the repair of the traumatic lesion as an adaptation to the increased forces.

#### **6. Is traumatic occlusion reversible?**

If excessive occlusal forces are neutralized, healing takes place. The presence of plaque may however impair healing so resolution of inflammation should be first initiated. Injury caused by TFO is reversible but there may or may not be complete restoration of the supporting structures of the tooth.

#### **7. Examination, evaluation, diagnosis and prognosis of trauma from occlusion**

Clinical history of the patient and clinical examination are the cornerstones of correct diagnosis of TFO.

#### **7.1 Clinical features of occlusal trauma**


#### **7.2 Tooth mobility**

Miller's Index (1938) is most often used to classify tooth mobility. Normal physiological movement vary between 10 μm and 150 μm and is not detectable on examination.

Class 0 – Within physiologic range when force is applied.

Class I – Mobility more the physiologic range.

Class II – Tooth moves upto 1 mm or more laterally (mesiodistal/buccolingual). Inability to vertically depress the tooth (apicocoronally).

Class III – Tooth can be moved 1 mm or more laterally (labiolingually or mesiodistally). Tooth can be depressed in a vertical direction.

#### **7.3 Fremitus test**

TFO can clinically detected using this test. The movement or vibratory pattern is measured when the teeth are placed in contacting positions and during lateral and protrusive movements.

In this test the vibratory movement of the tooth/teeth is identified and graded by placing dampened index finger along the labial surfaces of maxillary teeth.

The patient is asked to tap the teeth together in MIP and then grind systematically in lateral and protrusive movements.

Classification system used:

Class I fremitus: Mild movements/vibration detected.

Class II fremitus: No visible movements/easily palpable vibration.

Class III fremitus: Movements are visible to the naked eye.

#### **7.4 Radiographic signs**


#### **Radiographical Features**

1.Hypercementosis.

2. Secondary dentin laid down in the pulp chamber.

#### **8. Occlusal trauma and implants**

Osseointegration of implants is a direct structural and functional connection between ordered living bone and the surface of a load carrying implant.

Functional load enhances the integration when the load is adequately distributed. Occlusal overload however adversely affects implant stability. Strain is the key factor in controlling bone remodeling. Strain is created when any object is subjected to external stress. Stress in the oral environment is the occlusal overload. Mechanoreceptors present in the bone play a major role in initiating bone remodeling. When implant restorations are subject to TFO, stress of a higher level are imposed at the interface. This initiates resorption of bone and may lead to failure of implants.

Crestal bone loss observed around implants occurs mainly because of the difference in modulus of elasticity of the implant and bone. As the modulus of elasticity of titanium is 5–10 times greater than that of the cortical bone. In osseointegrated implants stresses are concentrated at the crestal bone level. Thus, any sustained overload on the implant restoration may lead to implant instability.

#### **9. Our present understanding of trauma from occlusion**

Periodontal health depends on the normal occlusal forces. Any increase in the functional demand the periodontium accommodates by thickening of the lamina dura and reinforcement of bony trabeculae.

When the functional demand of the tooth cannot be met, tissue injury results. If the stimulus is chronic and noxious widening of the PDL space is seen at the expense of bone resorption. This has a cushioning effect which enables the tooth to bear the excess forces.

Many concepts still needs to be clarified about trauma from occlusion. However, the following conclusions can be drawn from the present data.

Presently there is no evidence that suggests that gingivitis or periodontitis is caused by trauma from occlusion or can accelerate the progression of gingivitis to periodontitis.

PDL is a dynamic tissue and has the ability to adapt to increased forces of occlusion by widening of the periodontal ligament & crestal bone resorption. But when the excessive forces are removed, the periodontium & the tooth comeback to their normal state of function.

Trauma from occlusion may be considered a co factor which can increase the rate of progression of an existing periodontal disease.

As a rule the first line of treatment should be to resolve inflammation by elimination of local factors by scaling & root planning.

An important component to ensure smooth function & comfort of the patient is occlusal therapy.

#### **10. Treatment of trauma from occlusion**

#### **10.1 Treatment plan: systematic approach**

I.Make the patient aware, accept and own the problem and make them partners on the road to co-discovery and co-treatment in order to achieve functional, esthetic and biological goals.


Mount cast with facebow transfer at the first point of contact, protrusive and centric records are taken to program the articulator.

Treatment Planning can be done with the help of


#### **10.2 Treatment options**

Different treatment options can be planned for the same diagnosis. The option taken will be determined by several patient related factors and occlusal analysis. The treatment of TFO involves removal of the excessive occlusal forces and bringing the tooth/teeth in a comfortable position. Many treatment modalities have been advised to treat TFO. These include,

#### I.Occlusal adjustments and occlusal equilibration


#### **10.3 Occlusal adjustments and occlusal equilibration**

#### *10.3.1 Occlusal equilibration*

"It is a controlled destruction of tooth surface aimed at reducing the biological price the dentition will eventually pay if not done. Establishing a stable and harmonious occlusion goes a long way in preventing the deterioration of the dentition and its associated structures. This can be achieved by occlusal equilibration, which is a minimally invasive therapy involving reshaping of the teeth when improper biting forces are located.

#### *10.3.2 Steps in occlusal equilibration*

#### 1.Mock Equilibration in the Articulator.

The centric and eccentric interference are marked and eliminated in a sequence. Establishing of a harmonious and optimum anterior guidance to the new envelop of function. Developing the guidance with a wax up after customizing the anterior guidance table. This establishes a tentative blue print of the procedures and amount of reduction to be carried out on the identified teeth.

2.Occlusal adjustment is done directly in the mouth with a Kois Deprogrammer (**Figure 1**) with an anterior ramp at pre-establishing vertical dimension and centric relation.

#### *10.3.3 Occlusal equilibration can be done in 4 steps*


#### **Figure 1.** *Kois deprogrammer. SOURCE- https://www.koiscenter.com/kois-center-a-new-standard/kois-center-resea rch/kois-deprogrammer/.*

	- 1.Narrow the stamp cusps before reshaping the fossa.
	- 2.Do not shorten the stamp cusp.
	- 3.Always adjust centric interferences first.
	- 4.Eliminate all posterior incline contacts & preserve only the cusp tip.

#### *10.3.5 Occlusal reduction*

	- a. Retrusive interference
	- b. Centric slide MUDL
	- a. BULL- Balancing interference
	- b. LUBL- Working interference

DUML- The patient is guided to centric and asked to slide forward and back

#### iv. PATHWAY ADJUSTMENT

Harmonization of anterior guidance to the envelop of function at an erect posture and asked to chew on 200-micron paper.


#### **10.4 Management of parafunctional habits**

Parafunctional habit is a repetitive behavior that targets oral structures occlusal wear, fractured cusps, clenching/bruxism, obstructive sleep apnea are common signs of parafunctional activity. They can occur consciously when awake or at night and have been linked to stress & anxiety.

Management begins with creating a cognitive and behavioral awareness. Use of hard acrylic splints which are correctly adjusted for occlusion, helps protect the teeth and relax the muscles.

Localized occlusal interference splint and orthotic devices help in management of dental arch malrelationship.

#### **10.5 Biometric management of trauma from occlusion**

A biometric approach includes the jaw vibrational analysis (JVA) (**Figure 3**) of the TMJ, EMG (**Figure 4**) of the muscles and digital occlusal scan (**Figure 5**) of the teeth.

**Figure 2.** *Equilibrated occlusion.*

**Figure 3.**

*Jaw vibrational analysis [JVA]. SOURCE- https://www.bioresearchinc.com/joint-vibration-analysis/.*

Harmony in the muscle, joint, teeth & restorations are closely interrelated, the biometric approach gives the critical information needed to create this harmony,

Advanced computerized systems are now able to give objective, reproducible data allowing for accurate diagnosis, treatment and re-evaluation of occlusal condition.

*Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

**Figure 4.** *Electromyograph [EMG]. SOURCE- https://www.bioresearchinc.com/emg-bioresearch/.*

**Figure 5.** *T-scan (digital occlusal analysis). SOURCE- https://www.tekscan.com/dental-scan-t-scan.*

Occlusion analysis is elevated to a true science as compared to subjective analytical methods followed when using articulating papers.

When used pro-actively clinicians can detect potential problem early thus preventing the progression of debilitating conditions.

Step 1. – Joint vibration analysis is an instrument which produces virtual image of the recordings by measuring the wavelength of different types of vibration and patterns of friction. It is shown to be 98% specific in diagnosis of joint pathology. It can be paired with other devices to synchronize the vibration analysis with jaw tracking and EMG recording.

Step 2- The Craniofacial muscle activity in both rest and function is recorded using the EMG to determine the specific activity of the muscles of mastication, timed exactly with the occlusal contact forces.

EMG studies help improve muscle coordination, and reduce incoordination and hyperactivity. Electric activity in the muscle quiets down almost immediately after a clench is released, whereas with occlusal disharmony muscle activity is prolonged even after the teeth are separated. Electromyography helps measure specific muscle activity, allowing treatment to be biologically based instead of just spatially driven.

Step 3- Digital Occlusal Scans- gives a functional picture of the mouth which helps establish the dynamic occlusion that balances both force and time. The role of occlusion is often overlooked, minimized or ignored in dental practice due to difficulty in understanding the concepts. Occlusal scans can be used along with tenets of both popular school of thoughts regarding occlusion by coordinating the timing and activity of individual muscle as well as canine protected occlusion.

When used simultaneously with a link software between EMG and occlusal scan it will help improve the patient's overall occlusion. This is because the scan software shows the exact timing and specific tooth contact and loads in conjunction with muscle activity. The use of disocclusal time reduction (DTR) therapy can reduce the time taken for disocclusion from MIP to Canine rise, and also help reduce interference that disrupt the harmony of tooth muscle joint complex.

Digital scans also help analyze and address the causes of occlusal discrepancy instead of just treating the effects. Thus, removing potential triggers from any muscle based clinical pathologies creating harmony synergy and symmetry in the stomatognathic system [2].

#### **10.6 Orthodontic tooth movement**

Tooth malposition are prime cause for Trauma from Occlusion. Orthodontic therapy (**Figure 6**) has a big role to play in prevention and treatment of malposition. The teeth should be moved to a position which will improve its stability and long-term prognosis by eliminating abnormal occlusal forces. Early detection of occlusal trauma and correction can help mitigate the harmful occlusal forces and help prevent damage to the teeth and the periodontium. Investigations that help aid this include visual inspection of occlusion with articulating paper, mobility assessment, full mouth radiographs and use of computer aided occlusal evaluation system. The assessment should be made both in static and functional excursions.

Orthodontic treatment may itself create occlusal interferences, these are temporary and do not last long. The reasons are usually related to inappropriate tooth position, occlusal morphology and overload in excursive movements. These interferences if present should be allowed to settle down over a duration of time by natural accommodation and assessed over a period of time. A through occlusal analysis should always be performed before and after completion of orthodontic treatment.

*Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

#### **Figure 6.**

*Orthotic appliances. SOURCE- https://drandrewwilloughby.com/smile-gallery/neuromuscular-orthotics-for-trea tment-of-tmj-dysfunction/.*

#### **10.7 Occlusal reconstruction**

Redesigning of the complete occlusal scheme is done when no other means of occlusal equilibration can be achieved. This is done by fabrication, crowns, fixed partial and implant supported prosthesis and requires a thorough understanding of occlusion and then extensively on an appropriate articulated cast and is then replicated in the patient's mouth.

The chewing and biting surfaces of teeth are in balance and proper alignment. Thus, the pressure on individual teeth is lessen there by making them less susceptible to trauma. Thereby improving the normal functioning of the mouth.

A thorough examination and a differential diagnosis procedure is essential to restore the health of the articulating system restore individual tooth to its best anatomic position. This requires an integrated approach including (using) all disciplines of dentistry, to support, manage, limit and lessen the wear and destruction of the element of the masticatory apparatus and restore a healthy physical support.

#### **10.8 Surgical management**

Extraction of tooth that interferes with occlusion is a rarely used option. In certain situations, extraction of the selective teeth with poor prognosis with extensive periodontal involvement is done to improve the prognosis of the remaining teeth. This helps achieve a proper true position and alignment of the remaining teeth and immediate structures and the total articulating system.

#### **11. Discussion**

Trauma from occlusion is a term often used but least understood. It refers to tooth/ tissue injury due to distorted occlusion and/or occlusal forces. The damaging forces may affect the tooth, its supporting structures and immediate structures that may extend to involve the articulating system. A lack of awareness often leads to the cascading consequences in the masticatory system.

This is mostly to do with difficulty in decoding the cause as a result management is only directed at the effects. Treatment approach needs to include through evaluation of occlusion, understanding of occlusal instability and early diagnosis of changes in the supporting structures.

#### **11.1 Periodontal management**

Any occlusal force which goes beyond the adaptive capacity of the underlying tissues leads to damage to the periodontal structures. The current understanding of the role of TFO is it can amplify not cause localized loss of attachment.

Trauma from occlusion is reversible but attachment loss may not be. The development of pockets and recession are not a direct consequence of TFO. The development of pockets and recession are not a direct consequence of TFO but due to other etiological factors & plaque and calculus. When diagnosing the periodontal condition, his/her unique susceptibility, history and site specificity, specific to the direction of the force to a particular tooth [6, 9].

Management is directed towards intercepting any pathological process or to eliminate conditions conducive to disease or injury by looking for risk factors early help manage with minimal treatment. This is done by containing inflammation and instituting proper plaque control measures including supra/sub gingival debridement. If mobility persists teeth should be stabilized with fixed splints only after the traumatic occlusal forces are eliminated. If TFO is left untreated the chances of periodontal disease increases greatly [10].

Occlusal instability is a trigger to a host of adverse consequences leading to occlusal disharmony. Failure to replace missing teeth, malocclusion and improperly aligned teeth to each other produces irregular and less repeatable chewing strokes. The chewing is shorter and slower and may also have an irregular pathway. Mandibular deviation may result in order to avoid deflective contacts. This manifests as pain in the jaw muscles, and a host of adverse consequences in the masticatory apparatus. Occlusal equilibration is the widely used option of treatment, in which the chewing and biting surfaces of the teeth is either selectively reduced or restored to achieve the ideal occlusion [11].

Analysis of the direction of the stress in the centric closure versus that of eccentric closure discloses on the important causes of pathologic wear of teeth and the resultant effect on the supporting structures. Objective treatment plan should restore a harmonious cuspal relationship within physiologic limit and harmonize the jaw in centric at peace with the neuromusculature. This allows the jaw to function where it is comfortable and not restricted [12].

The goal is to confine all excursive contacts on to the anterior teeth, removing any posterior interferences if any that trigger and activates the muscle hyperactivity that prevents the turning off of the elevator muscle activity. The role of occlusion is often overlooked minimized or ignored in general dental practice. As many dentists find it difficult to understand concepts and when, where and how to incorporate occlusal technologies in to the practice [1].

Biometric approach gives clinician a powerful objective tool for incorporating occlusal analysis leading to improved clinical results and fewer failures in prosthetic restorations and orthodontic tooth repositioning. It connects the biological markers with the patient's occlusion and gives critical information that is required to create harmony between teeth, muscles and jaw [2].

Prevention, Interception and correction are terms synonymous with orthodontic, should also be integrated into management of TFO. Malposition of teeth are prime

#### *Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

reasons for development of damaging forces, orthodontics is the ideal means of correcting these teeth irregularities. Early diagnosis and repositioning of teeth to an ideal occlusion in static and dynamic function allows for proper anatomical alignment of opposing teeth and the arches. Adapting a comprehensive individualized treatment approach after assessing the effects on each element of the masticatory apparatus will lead to a better outcome.

If parafunctional habits are involved, habit counseling, cognitive and behavioral awareness therapy needs to be instituted. The habits can lead gradually weaved off, if needed the help of permissive or stabilizing splints can be used. This may be followed by a restorative management.

#### **12. Conclusion**

The key to understand trauma from occlusion is to understand how the brain finds the teeth, it finds the teeth by the best of fit. The jaw should be allowed to close into maximum intercuspal position without any interference and not force itself in, So better the fit into MIP the healthier the occlusion. The chewing pathway is as important as the anterior guidance which does not interferes with the pathway. Occlusion is unique to each individual so is the pathway. A systemic approach in the sequence of treatment selected and planned will help in improving the long-term prognosis and rehabilitation of patients by establishing the occlusion which is in harmony with the envelope of function. An inter disciplinary treatment approach with digital occlusal analysis will go a long way in developing neuro-occluso-muscular harmony.

#### **Acknowledgements**

We would like to acknowledge and appreciate the support and facilities provided by Triveni Institute of Dental Sciences Hospital and Research Centre Bilaspur, Chhattisgarh, India and thank them sincerely for the same.

#### **Nomenclature**


#### **Author details**

Prashanth Shetty\*, Shweta Hegde, Shubham Chelkar, Rahul Chaturvedi, Shruti Pochhi, Aakanksha Shrivastava, Dudala Lakshmi, Shreya Mukherjee, Pankaj Bajaj and Shahzada Asif Raza Triveni Institute of Dental Sciences Hospital and Research Centre, Bilaspur, India

\*Address all correspondence to: dr.prashanths@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

#### **References**

[1] Dawson PE. Functional occlusion: From TMJ to smile design. Journal of Indian Prosthodont Society. 2007; **7**:49

[2] Becker RM. Biometrics role in occlusion. Compendium of Continuing Education in Dentistry. 2009;**29**(1):1-7

[3] American Academy of Periodontology. Glossary of Periodontal Terms. 4th ed. 2001. p. 35

[4] Glickman I, Smulow J. The combined effects of inflammation and trauma from occlusion in periodontics. International Dental Journal. 1969;**19**:393

[5] Glickman I, Sumlow JB. Effect of excessive occlusal forces upon the pathway of gingival inflammation in human. Journal of Periodontology. 1965; **36**:141-147

[6] Glickman I, Smulow JB. Further observations on the effects of trauma from occlusion in humans. Journal of Periodontology. 1967;**38**:280-293

[7] Glickman I, Smulow JB. Adaptive alterations in the periodontium of the rhesus monkey in chronic trauma from occlusion. Journal of Periodontology. 1968;**39**:101-105

[8] Box HK. Traumatic occlusion and traumatogenic occlusion. Oral Health. 1930;**20**:642-646

[9] Leonard HJ. The occlusal factor in periodontal disease. Journal of Periodontology. 1946;**17**:80-91

[10] Jin LJ, Cao CF. Clinical diagnosis of trauma from occlusion and its relation with severity of periodontitis. Journal of clinical periodontology. 1992;**19**(2): 92-97

[11] Shefter GJ, McFall WT Jr. Occlusal relations and periodontal status in human adults. Journal of Periodontology. 1986;**57**:1-6

[12] Singh DK, Jalaluddin M, Rajeev R. Trauma from occlusion: The overstrain of the supporting structures of the teeth. Indian Journal of Dental Sciences. 2017; **9**:126-132

#### **Chapter 8**

## Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality of Life in Children – Low- and Middle-Income Countries

*Yolanda Malele-Kolisa, Nazia Khan, Mpho Primrose Molete, Maphefo Desiree Thekiso and Mzubanzi Mabongo*

#### **Abstract**

Orofacial trauma including traumatic dental injuries is a public health problem and has the potential to adversely affect the quality of life in children. These injuries include hard and soft tissue. Quality of life is impacted when the health and oral health of the children and their parents and family are affected. Oral health includes the ability to speak, smile, smell, taste, chew, swallow, and convey emotions through facial expressions with confidence. Poor oral health conditions include dental injuries from trauma, result in pain, soreness, discomfort, and embarrassment during routine daily activities. Traumatic dental injuries contribute to the aesthetic, functional, psychological, social, and economic distress lowering self-image and negatively impacting the quality of life among children, and their families in both developed and low- and middle-income countries. It is important to appreciate the impacts of dental trauma on children and their families more so in areas of low income as these areas have a higher propensity of above average oral-related quality of life impacts. Necessary dental management and treatment should be performed as soon as possible consequent to injury to relieve pain and discomfort, restore function, uplift appearance, and self-esteem, and enhance social well-being. This holistic management approach will improve treatment outcomes and ultimately enhance the quality-of-life post-dental injury.

**Keywords:** dental trauma, pain, health-related quality of life, children, low-middle income countries

#### **1. Introduction**

Dental Trauma or Traumatic Dental Injuries (TDI) refer to injury in the oral cavity involving the hard, soft tissues and periodontium such as the gingiva, periodontal

ligament, alveolar bone, and cementum. Although there is some classification to the type of traumatic injuries, the traumas can occur in various combinations and be associated with some facial or bodily injury [1]. A severe form of trauma in children is that of orofacial fractures, these types of fractures cause significant morbidity, and mortality in children, and may have a devastating impact on their quality of life [2]. Dental trauma account for 5% of all bodily injuries in all ages and children are most affected; furthermore, 1 in 5 children have experienced an injury to their anterior teeth before leaving school [1].

#### **1.1 Epidemiology**

The global prevalence of dental trauma among children is approximately 17.5%–22.0% and is found to be higher in America as compared to the rest of the world. In South America it is 34,1%, followed by Europe, 26%, then Africa 16.7% and then Asia (8.91%) [1, 3]. Frequent causes of dental trauma is falling at home, followed by school and sports injuries. The greatest incidence of trauma in children occur in the primary teeth at the ages of 2–3 years old when toddlers are developing their motor skills as they learn to walk [4]. The incidence rate of primary teeth traumatic injuries is 2.75 and that of permanent teeth injuries is 2.72, yet often little emphasis is given to the management of primary teeth as it is assumed that the teeth will eventually exfoliate and require no care. However, we need to be mindful of the consequential effects that lead to developmental disturbances of underlying permanent teeth that result from pre-mature loss of primary teeth [1].

In primary teeth the prevalence of TDI has been found to be approximately 24.4% with boys more prone to injuries (30%) than girls (26.8%). Most occurred at home (72%) followed by at school. Children with incompetent lip closures are also found to be most vulnerable (49.4%), followed by those with increased overjet (44.1%) and increased open bite (33.3%) [3]. Globally the prevalence of primary teeth trauma in Southeast Asia is 27%, followed by America 26.5%, Eastern Mediterranean and Africa at 22.7%; then the lowest being Europe at 14.2%. Moreover, prevalence of TDI on permanent teeth of 12-year-olds, globally is 18.1%.

Severe extensive trauma as orofacial fractures not only affect the oral cavity but also the facial and head and neck regions as well. Such fractures commonly affect adults with less than 15% affecting children [5]. These traumas are a substantial public health problem as they cause significant morbidity, mortality in children, and may have a devastating impact emotionally, physically and functionally on children [2]. These trauma's result from motor vehicle accidents, falls, violence, and sports injuries. When they do affect children, they can also cause possible concussion and brain injury [6]. These consequences can have long lasting impact on the social and cognitive functioning of a child. Type of fractures that were associated with concussion reported by a USA study, included orbital fracture (54.8%); nasal fracture (28.8%); skull fracture (25.6%); maxillary fracture (23.7%).

A systematic review assessing 27 studies consisting of 403,339 patients around the world found that in terms of the pattern of aetiology in maxillofacial fractures globally, Road Traffic accidents (RTA) accounted for the highest cause (34%). This is followed by falls (31%); violence (11%) and sports injuries (4%). RTA are found to be highest (over 40%) in Africa and Asia. Falls are more prevalent in Europe especially among school children and violence is more prevalent in North America [7]. One would expect the traumatic dental impact on oral related quality of life literature to be readily available.

In South Africa, study reviewing 87 children under the age of 13 with facial fractures admitted at the Red Cross trauma unit in Cape Town between2006 and 2014 found

#### *Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

that over half of the children (n = 49) had injuries that were caused by motor vehicle accidents particularly when children were unrestrained in the car. Of the motorvehicle collision (n = 25 were passengers and (n = 24) were pedestrians. Other injuries were caused by falls (n = 20); assaults (n = 8); and (n = 7) reported as others [8]. In Johannesburg a study undertaken at the Chris Hani Baragwanath paediatric trauma unit indicated the prevalence of head injuries to be as high as 45.7%, this was followed by mouth injuries (26.6%) [7]. The dental injury experienced involved largely maxillary and mandibular incisors and canines. In addition, teeth displacement, intrusion, mobility, fracture avulsion and pulp injury were prevalent [9]. In a separate study aimed at describing the nature of injuries sustained by patients attending the trauma unit at Chris Hani Baragwanath Academic Hospital, over three months in 2017; the injuries sustained by the children less than five years were found to be 12.35% [10]. The prevalence of orofacial and dental trauma is significant in the LMIC. Moreover, the severity of trauma seems to me more than the primary anterior dentition but more severe head injuries where one study it was as high as 45,7% [7] and mouth approximately 27% [7]. The impact of these traumas on health-related quality of life warrants a more attention.

#### *1.1.1 Factors related to the occurrence of TDI and Oro-facial injuries in low- and middle-income counties*

The prevalence of orofacial trauma has increased over the years in many LMIC because of interpersonal violence, motor vehicle accidents and wars. Particularly among the adult population [11]. Having said that, most dental injuries studies in LMIC are focused on the adult population and very little studies have been undertaken on the child population.

The few studies that have been looked at show that there are similarities between LMIC and high income countries in terms of demographic characteristics of male children being more affected and the most common places of injury being the home environment [12].

A study conducted in India in 2015 looking at association between TDI, Obesity and socio-economic status among 6- and 13-year-old, found that the injuries were more prevalent among overweight and obese children. Furthermore, children from low socio-economic status had a higher likelihood of experiencing dental trauma than children from medium and upper socio-economic status [13].

Of concern is the studies of child orofacial trauma in LMIC being linked to physical child abuse and fatalities [14]. Physical Child abuse is defined by the WHO as an experience that results in actual or potential physical harm of a child from a parent or person in a position of responsibility, power and trust [15]. In South Africa two of the most recent studies on physical child abuse among children in a Cape Town children's hospital found the following; injuries to the face occurred in 59% of child abuse cases and that most of the times, the lips were traumatised (54%) [16]. The second study assessed autopsy reports of 1809 children under the age of 9 years old between (1998–2004). They found that 2.62% of the fatalities were attributed to physical child abuse among children aged 1 month and 11 years old. The main cause of the children's death being head injuries [17].

#### **2. Rationale**

The pattern of trauma in children described depict that the condition is a dental public health problem as reflected by the prevalence, the rising incidence and the

economic burden that Low-Middle Income (LMIC) countries have to bear in managing and treating such cases. These conditions have a severe impact on individual children, families, and society generally especially due to its long-term consequences. Therefore, acknowledging the public health impacts of dental trauma and, understanding the health-related quality of life impacts is necessary for holistic management of the problem. Oral-health-related quality of life is context reliant, and it is used increasingly as a person-reported outcome measure in oral health research. More so that environment, economic, society, culture and age, may influence health, illness and quality of life [18].

#### **3. Objectives**

The objectives of this chapter are to:


#### **4. Methods**

An extensive literature search was conducted on the health research databases, PubMed, CINAHL, EBSCOhost, and Google Scholar and this generated current literature for comprehensive information on the epidemiology of dental trauma, management and the oral-health-related quality of life impacts.

#### **5. Health-related quality of life and Oral-health-related quality of life**

Health related quality of life (HRQoL) evolves from the general concept of quality of life [19], which the latter implies general satisfaction with life. Gururatana and colleagues [20] have labelled HRQoL as a multi-dimensional construct comprising the physical, emotional and social aspects relating to illness and its treatment [20]. Thus HRQoL can be summarised as a functional effect of sickness, illness and the related treatment as perceived by the patient [19]. A goal for overall oral health should include measure of oral health-related-quality-of-life as oral health is a predictor of health and wellbeing [21]. Oral-health-related quality of life (OHRQoL) is thus, explained simply and loosely as the 'impact of oral conditions on daily functioning' [22].

The dental profession has for many years used clinical indices to measure oral health and disease outcomes which only provide one facet of child oral health [23, 24]. As much as clinical indices have measured oral conditions well, they do not take into account the children's and family's subjective perspective and the impact of oral problems on their day-to-day life [25]. Thus, OHRQoL is a patient reported outcome used to assess the outcome of oral diseases on patients' overall wellbeing.

*Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

#### **5.1 Conceptual framework**

The health-related quality of life relationships model by Ferrans et al. [26] in **Figure 1**; shows the relationships between the individual and environmental characteristics and an oral disease/condition (dental trauma) and how all the elements namely *biological functions, symptoms, functional status, general health perceptions* influence overall health-related quality of life [26].

#### **Figure 1.**

*A conceptual framework of health-related quality of life and its determinants. Source: Ferrans et al., 2005 (Ferrans CE, Zerwic JJ, Wilbur JE, Larson JL. Conceptual model of health-related quality of life. Journal of Nursing Scholarship. 2005;37(4):336–42.) [26].*


#### **Table 1.**

*Synopsis of Children's Oral health related quality life tools.*

#### **5.2 Measurement of oral health-related quality of life**

Dental trauma invariably has the result of extreme pain and hampers daily activities, and it negatively affects normal growth; a crooked bite causing reduced self-esteem and cognitive development, may impair speech, school performance, and is costly to manage. Objective measures of disease are important, they might give insight into the impact of oral diseases on quality of life. It is for this reason that we summarise the patient-based tools available to measure subjectively, the impacts of oral diseases on children and adolescents using objective measures in **Table 1**. The environment and the culture are aspects of the society that determines how health is perceived, experienced and conceptualised by communities according to Traebert and colleagues [38]. Thus, the conceptualisation of health-related quality of life is a social construct, additionally health related quality of life is measured objectively using the tools seeking subject inputs from subjects. These measures can be applied daily in facilities or practices to assess and report these impacts of oral diseases to evaluate dental management of oral trauma. These validated tools are often used to assess the effect or impact of any oral condition or oral disease.

#### **6. Impact of dental trauma on oral health related quality of life**

#### **6.1 Physical impact of dental trauma**

Traumatic injuries do not only affect facial aesthetics, but also normal masticatory function, making it difficult for the child to chew. Dental problems that cause chewing to be painful affect the intake of dietary fibre and some nutrient-rich foods; significantly lowering serum levels of beta carotene, folate, and vitamin C [39]. Furthermore, trauma to anterior teeth can result in difficulties experienced in the pronunciation of words or phrases. For example, if upper incisor teeth are missing, the pronunciation of the v and f becomes indistinct [40]. Further literature indicates that if the lower incisors are missing, which may be trauma related, the sounds such as 'z', 'sh', and 'ch', will become defective [40] and 's' sound more complicated. Such situations lead to serious speech problems resulting in the child becoming annoyed or feeling reluctant to verbally interact with his/her classmates. The above highlights the strong correlation between teeth and speech.

#### **6.2 Psychological impact of dental trauma**

The psychological and social sequelae of dental trauma are a common finding causing the impairment of the child's social functioning, emotional balance, and well-being [41]. The unexpected nature of the traumatic dental injury, accompanied by emotional distress, physical impairment, and accompanying pain often contribute to a lasting memory of the traumatic experience. The memory issue is significant for a paediatric patient, who will have to endure the additional stress of transportation, emergency diagnostic procedures, and treatment [41] and even be triggered by such memories.

Emotionally the child may become an introvert and he/she may be reluctant to smile and find it difficult to adapt to everyday life [40]. This hurts their self-esteem and confidence. The self-esteem associated with oral health decreases as the teeth appear less attractive [42].

*Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

Overall, dental injuries are the most serious dental condition experienced by children [40]. Therefore, it is of utmost importance that treatment is sought as soon as possible after the onset of injury, allowing for favourable treatment outcomes [43] and enhanced quality of life, to be as close to normal/pre-trauma as possible.

#### **6.3 Social impact of dental trauma: Effects on family**

Families and households in Low Middle-Income Countries (LMIC's) are subjected to poverty with published literature demonstrating that family income and deprivation level are a potential risk factor to TDI's [33]. Dental traumas impact the quality of life of not just the child, but the whole family [34]. The assessment of OHRQoL in younger children may be challenging due to children's limited understanding of what is being evaluated [35]. Thus, more often the parental or family perception is important in providing evidence of the impact of TDI's on children and family OHRQoL.

In LMIC's parents of low-income households are often required to work long hours resulting in decreased family time, thus TDI's on the teeth and mouth can result in considerable psychological stress and social costs on the OHRQoL of parents due to pain experienced by children and high absenteeism from work [36]. Furthermore, illiteracy levels among adults are high in LMIC's resulting in parents with low education lacking specific TDI's prevention skills to transfer to their children [37].

Severe dental trauma is associated with a higher impact on the OHRQoL family function, as parents expand greater attention on the injured child due to the severity of the lesion. Family daily activities can be negatively affected in severe trauma cases as the children experience more physical and psychological discomfort, limited functionality and more financial resources are required for rehabilitation of the child [44]. The severity of caries on teeth with TDI's have a higher impact on family OHRQoL more so that complicated trauma cases may involve fractured dentine or dentine/pulp [45] resulting in parents feeling more distressed immediately after the injury and after the TDI treatment [41]. TDI's on older children in LIC's has a significant lower impact on the parents/family OHRQoL because older children are more independent needing less parental intervention and supervision than younger children [42].

#### **7. Factors related to oral health-related quality of life outcomes on the child with dental trauma**

Treatment of traumatic dental injuries reduces the OHRQoL of the children and adolescents [46]. Management of dental trauma involve multiple dental specialties including pedodontics, endodontics, orthodontics, oral medicine and periodontology, and oral surgery. This integration is necessary to ensure the correct rehabilitation of the patient [40]. Dental trauma requires special comprehensive examinations and detailed history of the incident to determine the correct diagnosis and to rapidly manage the injuries [40].

As shown in the Fig 1, some factors influence the outcome and a better or worse OHRQoL on the individual and environmental level in LMIC's. At *individual level*, a Brazilian study reported that factors such as parental dental anxiety has a significant correlation with children's OHRQoL because parental dental anxiety is an indicator of the children's oral health, children's dental service utilisation and a major barrier to access dental care [47]. Children who present with dental trauma are generally trauma prone. Nearly half of the children with multiple dental traumas will re-traumatise the same tooth [41]. Also, in LMIC's individual family dynamics such as compliance and cooperation by the patient and the family, starting from the moment of injury is critical [41]. In a Brazilian study, an effective management of dental trauma was shown to require a swift multidisciplinary management with long-term follow-up care [48].

On the *environmental level*, the following health systems aspects such as the availability of the facility and increased waiting time in hospital emergency departments may be responsible for the late presentation of dental trauma patients thus contributing to unfavourable outcomes and a poor OHRQoL scores in a Turkish study [43]. Also related to *health systems* is the issue of collaboration between paediatricians in hospital emergency departments and paediatric dentists will enable urgent and best-possible care for the injured patients ultimately improving prognosis [43]. The mode of treatment such as comprehensive dental treatment on the dental chair or full mouth rehabilitation under general anaesthesia has been associated with considerable improvement in OHRQoL [49] and thus highlights the importance of multidisciplinary care, however this is a great challenge in LMIC's. The factors mentioned above are not exhaustive however is a considerable gap in the paucity of studies conducted in Africa.

In many of the developing countries, majority of households are subjected to poverty. It is thus plausible that a review by Das et al. [50] highlights that the families with a lower socioeconomic status, when the facilities are not sufficient, living conditions with unsafe environments may lead to children to be prone to traumatic injuries. The poor living surroundings, the quality of health care is questionable, therefore the children and families suffer severe impacts on their care and experience a lower OHRQoL.

The success of the dental treatment is not only based on the clinical outcome, but also the psychological impact of treatment [51]. The ability of a treatment to enable a person to improve function (eat, speak,) and socialise without pain, discomfort, or active disease have been indicators of success.

Most literature of the factors on TDIs and OHRQoL are conducted in the developed countries. In LMIC such as Brazil, the impact of restorative treatment only improved the OHRQoL impact of adolescents than the families. This may be due to economic and financial cost passed on to families [50]. Another Brazilian study reported concomitant presence of other conditions such as dental caries, pain, orofacial dysfunction, in addition to dental trauma, impact twofold to the OHRQoL [50]. There is skewness of literature in that majority of studies are conducted in Brazil and few conducted in other LMIC such as Africa when it comes to traumas and OHRQoL. This chapter highlights that more work needs to be conducted in developing countries seeing that countries' economy, environment, and societal aspects have a potential to influence the impact of traumas on the oral health quality of life in societies.

#### **8. Management of traumatic dental injures and orofacial trauma in paediatric patients**

Although the incidence of facial trauma in the paediatric population is higher than in the adult population, the incidence of facial fracture is lower in children [52]. The frontal bone is commonly involved, and the type of management is mostly conservative treatment [7] (**Box 1**).

*Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

#### **Box 1.**

*Source: Fouche and Mabongo 2019. \*permission to reproduce image was obtained from both the authors and SADJ.*

#### **8.1 Traumatic dental injuries**

#### *8.1.1 Management and treatment*

#### *8.1.1.1 Crown fracture: Uncomplicated*

The clinical and radiographic findings show a break in enamel or dentin. In this case one would need to restore normal aesthetics and function by restoring and smoothening the tooth margins [53, 54].

#### *8.1.1.2 Crown fracture: complicated*

The clinical and radiologic findings reveal a loss of tooth structure and pulp exposure. In primary teeth, management decisions are based on the vitality of the pulp and the life expectancy of the tooth, alternatives could therefore be, pulpotomy, pulpectomy, or extraction. For permanent teeth, the treatment would be, direct pulp capping, pulpotomy, or a complete root canal treatment.

#### *8.1.1.3 Crown and root fracture (uncomplicated or complicated)*

Clinical findings usually reveal a mobile coronal fragment attached to the gingiva with or without pulp exposure. In primary teeth, an extraction would be indicated. In permanent teeth, stabilisation of the coronal fragment would be necessary. If you cannot remove the fragment, complete root canal treatment with post-core and crown. If the root component is irreparable, then an extraction would be indicated.

#### *8.1.1.4 Concussion*

In this case, clinical findings would reveal a tooth that is tender to pressure and percussion without mobility. There may also be some sulcular bleeding. Management would involve optimising the healing of the periodontal ligament and maintaining the vitality of the pulp.

#### *8.1.1.5 Subluxation*

This involves injury to the tooth structures with loosening, however there is no tooth displacement. There may be sulcular bleeding. In primary teeth, the tooth should be observed over 2 weeks, if no healing occurs and the pulp is affected, then an extraction would be indicated. In permanent teeth, the tooth needs to be splinted for 2 weeks and the vitality of the pulp should be closely monitored.

#### *8.1.1.6 Lateral luxation*

The periodontal ligament is torn and there may be a fracture of the supporting alveolar bone. The tooth could be displaced palatally or lingually. Often it is locked in that position and not mobile. In primary teeth try to gently reposition the tooth. If it is not possible and the displacement is causing discomfort in the oral cavity, then an extraction would be indicated. In permanent teeth, reposition as soon as you can, and stabilise the tooth for approximately 2–4 weeks. In addition, monitor the vitality of the pulp closely.

#### *8.1.1.7 Intrusive luxation*

In this type of luxation, the tooth is driven into the socket compressing the periodontal ligament and crushing the alveolar socket, therefore it appears shortened. In addition, the tooth is not mobile or tender to touch. In primary teeth, the tooth may re-erupt spontaneously, however, if it is found to cause disruption to eruption of a permanent tooth, extraction is indicated. In permanent teeth, the tooth can be repositioned passively or surgically and then stabilised with a splint for up to 4 weeks. During treatment, monitor the vitality of the pulp closely.

#### *8.1.1.8 Extrusive luxation*

The tooth is partially displaced axially, and the tooth appears elongated and mobile. In addition, the periodontal ligament is usually torn. For primary teeth, time should be given to allow them to reposition spontaneously. Should the extrusion be severe or there is mobility, an extraction should be indicated. In permanent teeth, repositioning should occur as soon as possible, then it should be stabilised and splinted for 2 weeks.

#### *8.1.1.9 Avulsion*

When the tooth is completely displaced out of the socket, primary teeth should not be replanted. In permanent teeth, replanting should occur as soon as possible, and the tooth be splinted for 2 weeks.

#### **8.2 Orofacial trauma**

General considerations in the young trauma patient include maintenance of the airway, balance of fluid and electrolyte levels and adequate nutritional intake during treatment. As in adults, the pre-injury skeletal and dentoalveolar anatomy and function are re-established by anatomic reduction of fractures based on the occlusion [55].

#### *Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

Like in adults, paediatric fractures are managed by conservative, closed reduction and open reduction and internal fixation. Children have greater osteogenic potential and faster healing rates than adults Therefore, immobilisation times should be shorter. Surgical interventions usually require two operations under general anaesthesia. For open reduction and internal fixation, care should be taken not to traumatise both root of teeth and dental follicles [46].

#### i.Conservative Management

In this mode of treatment, the is no active surgical intervention, close observation of the patient, control of pain, and minimal movement of the fractured bone is maintained, this is by restricting the patient to a soft diet in the case of fractured jaws. Un-displaced and minimally displaced fractures of the jaws are best treated by this option in children. Most facial fractures in children are managed by this modality [47].

#### ii.Closed reduction

This mode of treatment may be compromised by fewer available teeth, lack of stability of primary teeth due to root resorption, and anatomy of the crowns of the teeth available primary teeth and partially erupted permanent teeth making arch stabilisation with Erich arch bars impossible. All these factors make intermaxillary fixation (IMF) more difficult than in adults. Secondly, IMF is not easily tolerated by children, as it restricts mandibular movements causing discomfort and increased anxiety; furthermore, it is detrimental to the child's quality of life, as a liquid diet adversely affects nutritional intake. Lastly, IMF may result in ankylosis of the temporomandibular joint in patients with condylar fractures [46].

#### iii.Open reduction and Internal fixation

In older children with displaced fractures closed or open reduction and internal fixation (ORIF) may be indicated. ORIF of mandible fractures in children is generally avoided due to the potential damage to developing tooth germs and disruption of the periosteum. The other challenges in children include the small size of the facial bones and the relatively soft bone showing good elasticity. A reduction of the mandibular immobilisation period also contributes to the recovery of joint function and early return to function [46].

The goals for management are to restore function, form, aesthetics, and most importantly in children, to preserve growth and development. Managing paediatric facial fractures is complex because of the continued growth and development of the facial skeleton, [46]. Therefore, management strategies must provide proper stabilisation of fractures to restore facial anatomy, without hindering future bone and soft tissue growth. Many paediatric facial fractures can be managed conservatively owing to the high osteogenic potential of the paediatric skeleton; however, surgical intervention may be necessary for patients with severe facial injuries [56].

#### **9. Conclusions and future directions**

Management of dental trauma in both developed and developing countries requires a life-long commitment on behalf of the patient and dentist, especially in a growing patient with a developing facial musculature, oral structures, and dentition. The traumatic injuries affect all communities regardless of countries economy status; however, literature has shown that the severity of traumas such as those leading to head injuries was reported more in the developing countries. Oral trauma among children, their experiences and the impact of the trauma must be, understood by all the multi-disciplinary team of practitioners. There was minimal literature on the impacts of traumatic injuries on OHRQoL in the LMIC areas such as Africa though plenty of Brazilian and some Indian studies were evident. The socio-dental indicators or the tools measuring the patient-based impact of dental and oral trauma, despite being developed in non-African settings, are vital in providing important feedback on how to evaluate the management of trauma and thus should be part of the general protocols for management. Dental practitioners must be cognizant of the non-clinical impacts of orofacial and dental trauma and be familiar with the socio-dental indices to measure patient-based outcomes. It is recommended that more studies are conducted in the LMIC, specifically African countries to highlight the importance of patient-based inputs and evaluation of care related to traumatic dental injuries.

### **Acknowledgements**

The authors would love to acknowledge the supportive research environment within the department of community dentistry and the broader School of Oral Health Sciences at the University of Witwatersrand and the department of maxillofacial surgery, University of Pretoria.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Yolanda Malele-Kolisa1 \*, Nazia Khan2 , Mpho Primrose Molete1 , Maphefo Desiree Thekiso1 and Mzubanzi Mabongo2

1 Department of Community Dentistry, University of Witwatersrand, South Africa

2 Department of Maxillofacial Surgery, University of Pretoria, South Africa

\*Address all correspondence to: yolanda.kolisa@wits.ac.za

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

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[28] Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Measuring parental perceptions of child oral health-related quality of life. Journal of Public Health Dentistry. 2003;**63**(2):67-72

[29] Jokovic A, Locker D, Tompson B, Guyatt G. Questionnaire for measuring oral health-related quality of life in eight-to ten-year-old children. Pediatric Dentistry. 2004;**26**(6):512-518

[30] Jokovic A, Locker D, Guyatt G. Short forms of the child perceptions questionnaire for 11-14-year-old children *Perspective Chapter: Dental and Orofacial Trauma Impacts on Oral-Health-Related—Quality... DOI: http://dx.doi.org/10.5772/intechopen.105845*

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[35] Huntington NL, Spetter D, Jones JA, Rich SE, Garcia RI, Spiro A 3rd. Development and validation of a measure of pediatric oral health-related quality of life: the POQL. Journal of Public Health Dentistry. 2011;**71**(3):185-193

[36] Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson L. Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5). Health and Quality of Life Outcomes. 2012;**10**(1):1-8

[37] Foster Page LA, Thomson WM, Marshman Z, Stevens KJ. The potential of the child health utility 9D index as an outcome measure for child dental health. BMC Oral Health. 2014;**14**(1):90

[38] Traebert J, Foster Page LA, Murray Thomson W, Locker D. Differential item functioning related to ethnicity in an oral health-related quality of life measure. International Journal of Paediatric Dentistry. 2010;**20**(6):435-441

[39] Sheiham A, Steele J. Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrient and dietary intake and nutritional status amongst older people? Public Health Nutrition. 2001;**4**(3):797-803

[40] Dascălu IT, Manolea HO, Coleş E, Dăguci C, Bătăiosu M, Andrei CM, et al. The prevalence of crown injuries to frontal teeth at schoolchildren aged 6 to 14 and their effects on the periodontal tissue. Romanian Journal of Morphology and Embryology. 2016;**57** (2 Suppl):729-735

[41] Lee JY, Divaris K. Hidden consequences of dental trauma: The social and psychological effects. Pediatric Dentistry. 2009;**31**(2):96-101

[42] Buldur B, Güvendi ON. Conceptual modelling of the factors affecting oral health-related quality of life in children: A path analysis. International Journal of Paediatric Dentistry. 2020;**30**(2):181-192

[43] Vukovic A, Vukovic R, Markovic D, Soldatovic I, Mandinic Z, Beloica M, et al. After-hours versus office-hours dental injuries in children: Does timing influence outcome? Clinical Pediatrics. 2016;**55**(1):29-35

[44] Pauli LA, Costa F, Dos S, Amaral CC, Ardenghi TM, Demarco FF, et al. Severe traumatic dental injuries and oral health related quality of life of preschool children. RGO-Revista Gaúcha de Odontología. 2020:68. DOI: 10.1590/1981- 863720200004820190044. Available from: https://www.scielo.br/j/rgo/a/

FSntRKrQtRhnJXszFVYMc8x/ abstract/?lang=en

[45] Sakaryali D, Bani M, Cinar C, Alacam A. Evaluation of the impact of early childhood caries, traumatic dental injury, and malocclusion on oral health-related quality of life for Turkish preschool children and families. Nigerian Journal of Clinical Practice. 2019;**22**(6):817-817

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[47] Goettems ML, Ardenghi TM, Romano AR, Demarco FF, Torriani DD. Influence of maternal dental anxiety on oral health-related quality of life of preschool children. Quality of Life Research. 2011;**20**(6):951-959

[48] Ode W, Lopez V, Wong ML, Schou L, Yu VSH. Understanding patients' and dentists' perspectives in dental trauma management: A mixedmethods study. Dental Traumatology. 2018;**34**(5):320-328

[49] Farsi NJ, Farsi DJ, Aldajani MB, Farsi NM, El-Housseiny AA. Sustainability of improvement in Oral health-related quality of life in children after dental treatment. Patient Preference and Adherence. 2021;**15**:271

[50] Das P, Mishra L, Jena D, Govind S, Panda S, Lapinska B. Oral health-related quality of life in children and adolescents with a traumatic injury of permanent teeth and the impact on their families: A systematic review. International Journal of Environmental Research and Public Health. 2022;**19**(5):3087

[51] Farsi DJ, Farsi NJ, El-Housseiny AA, Turkistani JM, Farsi NM. Impact of dental rehabilitation on Oral healthrelated quality-of-life in healthy children and those with special health care needs. The Journal of Contemporary Dental Practice. 2018;**19**(4):367-374

[52] Andrew TW, Morbia R, Lorenz HP. Pediatric facial trauma. Clinics in Plastic Surgery. 2019;**46**(2):239-247

[53] Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford: Blackwell Munksgaard; 2007

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#### **Chapter 9**

## The Impact of Traumatic Dental Injuries on the Mental and Social Well-Being of Children and Adolescents: Recommendations for Patient Management

*Aneesa Moolla*

#### **Abstract**

Traumatic injuries to the oral cavity are frequent during childhood, with a documented rate of more than 30% worldwide. These injuries commonly include the skull and mouth, and thus teeth are frequently impacted. Consequently, the individual ends up in pain accompanied by both esthetic and functional issues. The combination of these factors can have a detrimental impact upon normal functioning of a young individual's lives if the injury is not efficiently treated or managed. This then impacts on the individual's mental health and their quality of life. Not being able to function as part of a society that they are accustomed to, can cause people to withdraw from society and lose self-confidence. The negative psychological effect of traumatic dental injuries is specific to an individual, and as such each patient should be treated holistically with all factors taken into account. There is a dearth in literature around the full psycho-social impacts of traumatic dental injuries. Dentistry as a clinical field is advancing in treatment of such injuries, but there is still a lack of knowledge and awareness regarding the individual experience and how this could be managed going forward in terms in-chair strategies and the involvement of a multi-disciplinary team.

**Keywords:** traumatic dental injuries, patient management, dental trauma management, child health

#### **1. Introduction**

Facial esthetics play an important role in how one perceives one own self and how one is perceived by others. Any detrimental impact caused by trauma that then affects one's physical appearance can lead to distress and anxiety. This in turn can then affect the quality of life of individuals who are impacted.

Globally, the reported prevalence of traumatic dental injuries (TDI) during childhood or adolescence is a common occurrence with up to 30% [1–3] of young individuals being impacted. For those affected, these TDIs are painful experiences on a physical level, but they often also influence the emotional and psychosocial well-being of these individuals [4, 5]. Current evidence [6] supports the above notion that children and adolescents who have suffered a traumatic injury to the dentition experience significant negative impacts to their overall well-being.

The psychological, social and emotional impacts of a TDI are unique to each individual which then impacts upon their treatment preferences, coping and eventual recovery. Contemporary dentistry and medicine now recognize the critical prerequisite which is to identify and address these psychosocial aspects as part of a more holistic approach to healthcare. Furthermore, if such traumatic injuries are not effectively and holistically managed, then the affected individuals are shown to be more likely to suffer decreased self-esteem and low feelings of self-worth due to their changed appearance [4]. Quality of life is negatively impacted and often children whose appearance is affected are reluctant to laugh or smile and if there is pain or a fracture then they are also unable to enjoy their food or even brush their teeth properly. This has further consequences for them in terms of their health. This could then impact their lives negatively as they often do not have the coping mechanisms in place to help them navigate these difficult situations. Thus, childhood and adolescence are sensitive developmental periods that may pose complex challenges to the effective management of dental trauma. Dealing with the consequences of childhood trauma is a complex interplay between managing expectations with the hidden impacts of the traumatic event. This eventually influences both patient compliance and cooperation which are key to successful outcomes. Thus, full family collaboration and involvement from the starting point of injury is critical. The emphasis on a team effort being a point of note to be emphasized at all visits. There is also an urgency to engage in consistent monitoring and long-term follow up, especially in the not fully mature patient with a developing dentition. The high probability that there will be psychological impacts stemming from the traumatic event has become a frequent finding with studies [4–6] showing that effects can be seen in the overall negative well-being of the child.

In this chapter we will consider the possible social and psychological consequences of dental trauma in young individuals whilst simultaneously indicating the various management techniques for approaching these dental traumatic injuries in children and adolescents.

#### **2. Psychological impact of dental trauma on children and adolescents**

Tooth loss affects many people and can impact individuals severely in that it often leads to hidden consequences that need to be managed strategically and holistically. These hidden consequences at impact affected individuals in varying degrees include psychosocial and emotional impacts. A recent study [4] also indicated that the mental well-being of children is frequently adversely affected following dental trauma and the consequences of such injuries significantly impact the psychosocial and emotional wellbeing of the affected children. This is because whether a tooth was knocked out due to dental trauma or disease, the result is the same: negatively affected oral health and esthetics.

It is common knowledge amongst oral health professionals that not attending to tooth loss can have detrimental effects for oral health wellbeing in any individual. The long term effects include tooth migration, jawbone loss and even the eventual loss of additional remaining teeth. Thus as noted, dental trauma and the physical effects are usually given priority within the clinical context. However, a critical aspect of dental

#### *The Impact of Traumatic Dental Injuries on the Mental and Social Well-Being of Children and… DOI: http://dx.doi.org/10.5772/intechopen.109950*

trauma which is linked to the nature or circumstances of the incident itself, is the potential for affected children to consequently experience negative mental health outcomes. Whilst the physical effects of tooth loss are known and documented widely, distinguishing the deeper level emotional effects of the dental trauma can be more challenging.

Evidence also indicates that previous traumatic injuries to a child's dentition impacts negatively on their oral-health-related quality of life [7, 8]. No matter the reason, tooth loss or other types of dental trauma for any individual is almost always a negative experience. Children are particularly vulnerable in these circumstances. A child who has been impacted by dental trauma can go on to develop decreased feelings of self-worth and a lowered self-esteem due to their changed appearance. They may often also experience feelings of sadness, anger, hopelessness and loss of confidence. Affected appearances may also predispose these children to teasing, bullying [9] and torment from other children or peers they come into contact with. This is especially the case for those injuries that have not been effectively or holistically managed.

To this effect, literature around general physical injuries on any part of the body of a child indicates that approximately 50% of all injured children can show signs of post-traumatic stress disorder (PTSD) at six weeks and as late as eight months after the physical injury [10, 11]. In terms of facial esthetics, Kaur et al. found that disappointment with one's own dental esthetics is a strong predictor for negative selfesteem [12]. A myriad of dental issues that include visible tooth loss, visible untreated caries and malaligned teeth influence a person's perceptions of esthetics as well as psychosocial behavior in young people. This then impacts on self-esteem**.**

It is now almost a decade since the global medical pediatric emergency fraternity called out for improved psychological evaluations and assessments of children impacted by any type of trauma [11]. This was so that management and support guidelines could be duly effected in order to be able to emotionally support those young individuals who are vulnerable and at high risk of developing Post Traumatic Stress Disorder (PTSD). Consequently, it is crucial that oral health professionals are also conscious of the possibility that some children with a traumatic dental injury may experience negative psychological effects due to the mental trauma associated with the distressing incident. The impacts of negative mental health within the dental context may only become obvious at subsequent dental visits through displays of anxiety and disruptive behavior. These factors also need to be further explored. It should also be noted that the affected children have to deal with both the traumatic incident from their own perspective, as well as the secondary emotions and distress from their parents and/or friends.

#### **3. Impact of traumatic injury on social well-being and Oral health related quality of life (QoL) in children and adolescents**

Taking the above factors into consideration, it is indicative that a part of the reason a person loses self-confidence is related to the underlying social stigma attached to tooth loss. Evidence points to social consequences which includes shying away from relationships or socializing with peers [13, 14]. This ultimately leads to patients who had dental trauma having less meaningful social interactions that can affect their overall well-being, as compared to others with no trauma that affects their esthetics.

Evidence [15] shows that essential functional activities that are compromised in children affected by dental trauma include: chewing, speaking, showing their teeth and brushing. Peers also engage in social judgment [16, 17] and tend to judge those

with visible facial trauma more negatively than they judge others, with younger age groups being more negatively judgmental than older children. This can also be attributed to a greater degree of mental maturity in older children [18, 19]. Unfortunately, these negative social judgments can then have a lifetime of consequences, impacting career and even relationship success [16, 17].

Due to a lower self-esteem and poor confidence levels stemming from these traumatic events, affected individuals are then prone to neglect their self-care and may even start to lack in basic hygiene. This ultimately leads to poor social interactions and eventually impacts on financial status and income in later years. The lack of social interaction also impacts individuals negatively because this then impairs their ability to form close friendships or engage in romantic relationships later in life. Thus, the long term impacts of poorly managed dental trauma can significantly impact on individuals well-being and be pervasive in all areas of their lives [20].

#### **4. Management guidelines for managing dental trauma amongst children and adolescents**

Management guidelines for the holistic treatment of dental trauma amongst young individuals include the following:

#### **4.1 Treatment of immediate pain and full history of complaint**

As a first step, the oral health professional should immediately conduct all the necessary steps that entail selection of appropriate trauma treatment as needed. Pain elimination should be a high priority. The clinician should also simultaneously reassure the child and the parents/caregivers in order to alleviate their high levels of anxiety. This stage of treatment is also crucial for building rapport with the child and the parent/caregiver. The element of trust needs to be solidified early in this relationship between clinician and the affected child with parents/caregiver included.

Because there will be pain involved this first step is crucial because all individuals associate new experiences with past experiences and if the past experience was accompanied by pain, then future dental visits may be construed in the same light. Parents/caregivers may also be anxious about long term impacts on the child's esthetics as well as the added financial burden that this injury now presents with. Thus, by alleviating all these concerns, the oral health professional will help to allay long-term consequences that could significantly impact long-term treatment and care.

During this visit, a full medical, behavioral and social history of the patient should be detailed out in the patients file. All this information can be garnered from the parent who can then be distracted from their anxiety during this information session as well since they will be kept busy, even if for a short period of time. The importance of attending all follow-up visits must also be constantly reiterated with patients and if needed, a financial plan drawn up together with the patient in order to consider all factors that may impact upon long term follow-up visits.

#### **4.2 Strategies to ease anxiety in affected individuals**

The entire oral health team will need to work together to ensure that these young individuals are afforded a very low stress environment in order for treatment procedures to be meted out successfully. The following recommended treatment and

*The Impact of Traumatic Dental Injuries on the Mental and Social Well-Being of Children and… DOI: http://dx.doi.org/10.5772/intechopen.109950*

behavioral strategies can be considered when managing these individuals who will be fearful and anxious due to the uncertainties surrounding the short and long-term consequences of their injuries:

#### *4.2.1 Restoration of esthetics: after the initial clinical examination, radiographic examination and sensibility tests to determine condition of the pulp, recommended treatment strategies for dental traumatic injuries should be followed*

According to Flores et al., for an uncomplicated crown fracture the following can be done: if any portion of the broken tooth is available, this can be bonded to the affected tooth. Emergency care involves covering of the exposed dentin with either permanent restoration material or a glass ionomer using a compatible bonding agent. The use of accepted dental restorative materials is recommended in order to restore esthetics to the highest level of suitability as possible [21].

According to Flores et al., for complicated crown fractures the following can be done: for teeth that are still developing, all attempts to preserve pulp vitality by a partial pulpotomy or pulp capping. This treatment procedure can also be used in children with completely formed teeth. Esthetically pleasing materials for such procedures include calcium hydroxide and Mineral Trioxide Aggregate (white). With patients more advanced in age, root canal treatment can be the treatment of choice and factors that also further determine this would include how much time has lapsed between the incident and treatment [21].

Behavioral strategies to ease anxiety in children during their clinical examination and treatment include the following:

#### *4.2.2 Distraction*

This technique involves talking to the child in a comforting manner throughout the treatment procedure in order to veer their thoughts away from what you are doing on them currently. All words and terminology used should meet the mental maturity of the individual at all times. Distraction may also include allowing the child to watch cartoons or music videos whilst you are working on them.

#### *4.2.3 Tell-show-do*

This technique involves you showing the child the instrument you will be using on them whilst showing them the instrument itself and then only using the instrument on him/her. It thus focuses on using a step-by-step technique to draw the individual into this specific experience. For example, if you are planning on using a probe to start off with, then show the individual the probe whilst you explain the functions of the probe and what you are going to do in the mouth with it. This technique was introduced by Addelston [22] more than half a century ago and has been shown to be highly effective [22].

#### *4.2.4 Behavior shaping*

For this technique, you introduce everything that you are doing in small steps and praise the child after each accomplishment. Example, sitting on chair follows with praise, then opening mouth wide follows with praise then allowing you to treat them

is followed by praise or even a reward, like a sticker. Ensure that you are always using basic language and terminologies that the individual will easily understand.

#### *4.2.5 Modeling*

In the modeling technique, one would show the affected child video clips of other children having dental procedures being done on them. This will hopefully prompt the child to feel that they are also capable of being like the children in the video clips.

#### *4.2.6 Right of choice*

In order for the individual to feel a sense of involvement in the procedure, it is important to involve them in some aspects of decision-making around their treatment which are non-impactful. An example of this would be what flavor of topical anesthetic to use or even which glove to put on which of the clinician's hands [22, 23].

#### *4.2.7 Non-verbal communication*

Patients can be informed that they can communicate at any time during the treatment by lifting their hand up or if questioned, they can use a thumbs up for affirmative and thumbs down for negative. The clinician will always stop for the hand up signal or thumbs down signal. This will help in reassuring the patient that they are still able to communicate with the clinician during the procedure and may reduce feelings of powerlessness that young individuals may feel when being treated in a clinical environment.

#### *4.2.8 Management of psychological impacts*

Children who experience dental trauma often develop anxiety and fear due to pain associated with the traumatic injury itself. Experiencing pain during such an episode can have lifelong consequences on future and long-term dental treatment. Because research [8] strongly indicates a negative impact on oral health quality of life and levels of anxiety in children, dentists are advised [23] to manage patients whilst taking into consideration the following factors: (a) Removing or minimizing of predisposing factors (example, do not keep extraction forceps within sight or do not have pictures/artwork of individuals in dental chairs having extractions done) in order to create a safe and comfortable environment within the dental setting to avoid further negative experiences; (b) educating children and their caregivers on how to avoid situations leading to dental trauma (example, having seatbelts on at all times or using mouthguards during extreme sports); (c) encouraging use of and providing protective devices for children who are susceptible to dental traumatic injuries (example, mouthguards and head/face protective helmets for those children engaging frequently in high impact and/or contact sports); and (d) immediately treat any signs of traumatic dental injury. Since the occlusion is a predisposing factor for traumatic dental injuries, early orthodontic treatment for such children may be a factor worth considering as a long term preventive strategy. Subjective and objective evaluations of anxious, fearful and phobic patients who display negative psychological behavior in the dental setting are suggested in order to enhance the diagnosis for comfortable and successful patient management.

*The Impact of Traumatic Dental Injuries on the Mental and Social Well-Being of Children and… DOI: http://dx.doi.org/10.5772/intechopen.109950*

Psychophysiological patient responses can include the following:


Subsequent behavioral and emotional responses can include the following:


Based on the dentist's experience and expertise, anxiety and phobias can be managed by psychotherapeutic interventions, pharmacologic interventions, or a combination of both.

According to Appukuttan [24], psychotherapeutic interventions can include the following [24]:


*The Impact of Traumatic Dental Injuries on the Mental and Social Well-Being of Children and… DOI: http://dx.doi.org/10.5772/intechopen.109950*

#### **4.3 Multi-disciplinary team approach**

Oral health professionals should have a comprehensive referral list on hand where patients can be referred and duly accommodated at the practice being referred to. At one of the initial dental visits, families should be comprehensively informed about all the possible consequences of traumatic dental injuries and who they could see if any issues arise post-treatment if the issue does not have a dental focus. The referral list should then be shared with all families of young individuals experiencing dental trauma—whether they ask to be referred to other healthcare professionals or not. This list should include amongst others: social workers, psychologists, trauma counselors, play therapists, pediatric specialists and maxillofacial surgeons who specialize in treating children. There should also be regular communication amongst these professionals as this is imperative to long-term treatment success for any of these professionals.

#### **5. Conclusion**

Traumatic dental injuries that are not effectively and holistically managed are significant in that they have been shown to impact on an individual's quality of life. In most societies, esthetics is held in high regard, specifically facial esthetics. Trauma to the outer and inner oral structures can leave an individual with dental anomalies or deformities. This can then cause body dysmorphic issues in that a person battles to accept their changed appearance leaving them stressed and anxious. The traumatic event itself can have lasting negative repercussions which when combined with a changed appearance, can cause long term psychological effects for the patient. These negative impacts can be negated by means of a comprehensive emergency care strategy that is accompanied by a comprehensive referral system and multidisciplinary team approach.

#### **Conflict of interest**

The author confirms that there are no conflicts of interest related to this piece of work.

#### **Author details**

Aneesa Moolla Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa

\*Address all correspondence to: aneesa.moolla@wits.ac.za

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 2
