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=~ : Case Study 4 : ~=

Eliza is a new arrival from England. She doesn’t like the appearance of her upper left central incisor.


Criteria: Prepare a 10-15 PowerPoint presentation on the case study which covers the following points: Date for presentation: Tuesday 15 September at Somerton Pk at 10.30am
 * Description of patient and clinical presentation
 * Etiology of the clinical problem
 * Factors which may have contributed to the situation
 * Treatment plan which reflects a holistic approach to the care of the patient.
 * Provides an evidence base for their diagnosis and treatment planning

Sequelae: a condition following as a consequence of a disease.

= __Things to think about:__ = //Definition - //deviation or bend in the linear relationship of a crown of a tooth to its root  Dilacerated teeth generate diagnostic, management and prognostic challenges; they effect restorations, endodontic therapy, extraction and orthodontics. Consequently it is important to recognize dilacerated teeth before treatment begins.  Mechanical trauma to the primary predecessor tooth resulting in dilacerations of the permanent successor. Damage frequently occurs after avulsion or intrusion of the primary tooth. The developing permanent tooth germ is displaced and develops at an angle to the part of the tooth germ which has calcified. Idiopathic developmental disturbance – if no clear evidence of a traumatic injury Additional contribution factors may include:
 * Aesthetics
 * Occlusion
 * crowding potentially on currently errupting teeth
 * orthodontic work possibly needed.
 * teeth chipping?
 * gingivaitis -localized
 * caries potential due to plaque build up - fluoride and good OHI
 * calculus build up
 * chronic Inflammation and aggitation due to composite resin materials.
 * Sensitivity issues
 * Hypermineralisation (Hyperplasia)
 * 11 - fluorosis
 * trauma
 * tooth chipping (11)
 * to the gingiva - oral pathology?
 * Upper central incisors are the teeth which are most commonly affected by traumatic injury.
 * Majority of traumatic injuries occur between 1 and 4 years old which is during the developmental stage of the permanent crown.
 * Localised hypoplastic defect –
 * trauma in the primary dentition may cause developmental disturbances in the unerupted permanent teeth.
 * This disturbance can occur as the distance between the primary tooth and its successor is relatively close.
 * Patient age at which the trauma occurs
 * as this dictates the impact it will have on the permanent tooth in relation to the type and degree of damage.
 * At a younger age the crown of the permanent tooth is likely to be affected, however if the trauma occurs at a older age the root can also be damaged.
 * Hence, it is important to assess if the permanent root of the central incisor has been affected/damaged in a particular way.
 * Role as a therapist (scope of practice) - refer to dentist or pedodontist.
 * Dilaceration
 * Cause **
 * Scar formation
 * Developmental anomaly of the primary tooth germ
 * Facial clefting
 * Advanced root canal infections
 * Ecotpic development of the tooth germ
 * Lack of space
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Effect pf amatp,oc structure – cortical bone of the maxillary sinus, mandibular canal, nasal fossa
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Presence od – adjacent cyst, tumor or odontogenic hamartoma e.g. supernumerary tooth
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Orotacheal intubation?
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Laryngoscopy?
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Mechanical interference with eruption e.g. ankylosed primary tooth that does not resorb
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Tooth transplantation
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Extraction of primary teeth
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Hereditary factors

<span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;"> <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Depend at the stage of development of permanent successor <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Can be: <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;"> <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Less common <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Usually occure in maxillary permanent incisors due to the close proximity to the primary incisor <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Upper incisors – commonly crown dilacerations are angled palatally <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Lower incisors – commonly crown dilacerations are angled labially <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;"> <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">More common <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;"> <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Assist with detection of dilacerations, however when dilacerations are labial/buccal or palatal/lingual diagnosis is problematic. Radiographs would need to be taken from different angles to assist with diagnosis. <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;"> <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Effectiveness relies on: <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">
 * <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Location **
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Within the corwn
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Cemento-enamel junction
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Any where along the length of the root
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Root apex
 * <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Crown dilacerations **
 * <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Root dilacerations **
 * <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Radiographs **
 * <span style="color: black; font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Endodontic procedures **
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">The severity of the dilacerations
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;"> practitioner skills
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">Why the endodontic procedure was required
 * <span style="font-family: Arial; font-size: 10pt; mso-ansi-language: EN-US; mso-fareast-font-family: 'Times New Roman'; mso-fareast-language: EN-US;">How much tooth structure remains

__Patient Description (#2494d6 - colour)__
Age:
 * Approximately 9-10yrs
 * Female

__ Clinical Presentation __
Teeth Present: Soft Tissues: Hard Tissues:
 * 41
 * 31
 * 32
 * 22
 * 21
 * 11
 * Stippling
 * coral pink in most areas
 * red laceration to gingival margin of the 21
 * both interdental papillae of the 22 are red/inflamed
 * mucogingival junction of the 22 is more inflamed more than the remainder
 * Moist and shiny - good saliva
 * Bulbous, protruding gingival margins of max. incisors.
 * potential lip bite lesion on inner labial adjacent to the 31.
 * diastema approx. 2mm.
 * localised gingivitis, deep red oedma soft tissue appear very irritated
 * mamelons present on lower incisors
 * 21
 * cervical third discoloured
 * 21 incisal chip - middle - dentine exposure - potentially hypoplasia?
 * potential dilaceration - Sequelae of trauma
 * has been restored - material CR or GIC?
 * While the perm. tooth and surrounding tissues are developing - the tooth may have been restored for aesthetic purposes.
 * Once perm. tooth is completely developed perm. treatment options can be considered - endo/crown, implant
 * gingival margin has irritation - red and inflamed.
 * potentially plaque is getting stuck on the restoration's margins - causing inflamation.
 * material irritating gingiva (only if a CR)



__ Possible Contributing Factors __

 * sequelae of luxates or avulsed primary incisors - develppmental disturbances of the permanent tooth
 * damage to permanent dentition occurs more often with intrusive luxation and avultion
 * depend on:
 * direction and displacement of the primary root apex
 * potentially in this case the child fell with something in their mouth causing the crown to move labially and the roots to move palatally - therefore disrupting the development of the permanent tooth. (fig.2)
 * degree of alveolar damage
 * stage of formation of the permanent tooth

__ Treatment Plan (holistic and evidence-based) __
Further info needed: · If abscess present-pulpectomy or extraction possibly needed 4. Clinical exam – determine whether this occurred recently or previously: · Soft tissues – foreign bodies? · Hard tissues – infractions and fractures · Pulp exposures? · Mobility? · Percussion testing – damage to PDL · Cold and electric pulp test.
 * 1) Try to get case notes from Eliza’s previous dental practitioner to obtain previous treatment, or if trauma has been documented to assist with diagnosis, prognosis and appropriate treatment plan.
 * 2) Thorough dental, medical and social history - to assist with accurate diagnosis
 * 3) need radiographs - set of bitewings + PA of the 21

Diagnosis:


 * hypoplasia - masked with composite resin?
 * dilacerted tooth -Attempted to be restored?
 * Extremely difficult when defect at gingival margin.
 * Questions need to ask – how it occurred?
 * Has there been previous injury to the teeth?
 * How did the injury occur (indicates extent of injury)?
 * Where the injury occur (contamination etc)?
 * Is there a disturbance in the bite? – (difficulty to chew/talk etc)

Patient and parent options:
 * 1) If dilacerated tooth
 * 2) Explain to parent extent of damage:
 * 3) that possible previous trauma to primary tooth may have caused permanent successor to be dilacerated (bent)
 * 4) 25% of children do have developmental disturbances of permanent tooth.
 * 5) damage to permanent tooth occurs more often with intrusive luxation & avulsion in very young children
 * 6) Inform that not much can do in terms of treatment - may have to wait until Eliza is older
 * 7) Steps of treatment
 * 8) If tooth discoloured and asymptomatic
 * 9) No treatment
 * 10) Mask with composite resin (appears this is what they have attempted to do)



3. Surgical exposure and bonding of chains or brackets for orthodontic extrusion 4. Severe cases may be untreatable and may need to be removed 5. Refer to pedodontist/dentist 1. Once permanent tooth and alveolar bone is completely developed - endo/crown, or implant can be considered.

Lastly:
 * 1) Recall, monitor, review

__References:__

 * Bath-Balogh, M & Fehrenback, MJ 2006, 'Dental Embryology, Histology, and Anatomy', 2nd edn, Elsevier Saunders, St. Louis, Missouri.
 * Cameron, AC & Widmer, RP 2008, 'Handbook of Pediatric Dentistry', 3rd edn, Mosby Elsevier, China.
 * Jafarzadeh H and Abbott PV, 2007, ‘Dilaceration: Review of an Endodontic Challenge’, //The American Association of Endodontics,// No: 9, Vol: 33, pp 1025 - 1030
 * Lippincott Williams & Wilkins 2007, 'Stedman'd medical Dictionary for the Dental Professions', Wolters Kluwer Health, RR Donnelley, USA.
 * Pinkham, JR, Casamassimo, PS, Fields, HW, McTigue, DJ & Nowak, AJ 2005, 'Pediatric Dentistry - Infancy Through Adolescence', 4th edn, Elsevier Saunders, St. Louis, Missouri.