Quartz 4

W2 Case 3

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Case 3: Dental Trauma

Patient Profile1

  • Age: 3 years old
  • Gender: Male
  • Chief Complaint: Oral bleeding

Clinical Overview

  • Initial discussion and history taking
  • Clinical and radiographic investigations
  • Diagnosis based on clinical presentation and imaging
  • Comprehensive management plan

Trauma History and Clinical Assessment

Injury History2

  • Mechanism of Injury: Fell forwards onto the edge of play equipment
  • Timing: 2 hours ago
  • Location: At the park
  • Witnesses: Grandma and older brother

Medical and Trauma Screening

  • Loss of Consciousness: No
  • Previous Dental Trauma: No
  • Medical History: Fit and healthy; fully immunized
  • Non-dental Injuries: None reported

Clinical Examination Findings3

  • Tooth Displacement:
    • Tooth 61 is palatally luxated
  • Mobility:
    • Tooth 51: Grade I mobility
    • Teeth 61 and 62: No mobility
  • Tenderness to Percussion/Palpation:
    • Teeth 51 and 61 are tender
  • Gingival Assessment:
    • Bleeding at the gingival crevice of 51 and 61
    • Soft tissue injuries: Mild gingival bruising only

Radiographic Diagnosis

Radiographic Imaging4

  • Views Obtained: Maxillary occlusal and 3 Periapical (PA) radiographs

Radiographic Findings

  • Tooth 51:
    • Normal Periodontal Ligament (PDL) space
  • Tooth 61:
    • Root appears foreshortened
    • Tooth is displaced
    • Widened PDL space

Clinical Diagnosis5

  • Tooth 61: Lateral luxation in a palatal direction
  • Tooth 51: Subluxation

Trauma Management Plan

Treatment Plan by Tooth6

Tooth 61

  • If there is occlusal interference: Extraction (Exo)
  • If there is no occlusal interference: Conservative management

Tooth 51

  • Conservative management

General Post-Trauma Instructions

  • Soft diet
  • Analgesia as required
  • Ongoing review and clinical monitoring

Footnotes

  1. Original PDF page 26: W2 Case Based Discussion 2, p.26 ↩

  2. Original PDF page 27: W2 Case Based Discussion 2, p.27 ↩

  3. Original PDF page 28: W2 Case Based Discussion 2, p.28 ↩

  4. Original PDF page 29: W2 Case Based Discussion 2, p.29 ↩

  5. Original PDF page 30: W2 Case Based Discussion 2, p.30 ↩

  6. Original PDF page 31: W2 Case Based Discussion 2, p.31 ↩

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