Glasgow eprints Service

Cameron, J. S. and Threlfall, A. R. (2006) A retrospective analysis of

dentoalveolar trauma at Brisbane’s Royal Children’s Hospital. BDS

Elective Report

Glasgow ePrints Service http://eprints.gla.ac.uk

Student Elective 2006:

A Retrospective Analysis of

Dentoalveolar Trauma at

Brisbane Royal Children’s

Hospital

Students:

0206275

0206579

Abstract

Over the summer we visited Brisbane Royal Children’s Hospital to undergo a retrospective study of the mechanisms of dentoalveolar trauma. The purpose of this study was to review the injuries recorded in the Hospital and then compare these to existing results in Glasgow, at the same time gaining an insight into the way the Hospital operates. A sample of 100 children was taken from the records in the hospital and details entered in a reproducible format.

The main categories assessed were: type of injury, mechanism of injury. The various types of injury were split into three categories: those of a hard tissue nature, those affecting the PDL and those relating to the supporting bone. The mechanisms being assessed were Fall, Bicycle, Sport, RTA, Assault, Not recorded or Other. The majority of injuries were recorded as being caused by falls reported in 64% of cases compared with a figure of 49% recorded in Glasgow. The most common types of injuries were enamel fractures to both primary and secondary teeth and lateral luxation and intrusion to deciduous teeth. (See Figure 4+5)

Two distinct peaks in the incidence of injuries occurred between the ages of 2-3 years and 8-11 years. The study shows that there is a difference in patterns recorded between Brisbane and Glasgow and this may be due to various factors such as patients treated, note taking and location of the dental service.

Epidemiology

Dental trauma is very common and boys are twice as likely to experience it, than girls.1+3 Studies have provided epidemiological statistics for the prevalence of paediatric dental trauma, and in the UK 31-40% of boys and 16-30% have had some dental trauma by the age of 5. By age 12 this has changed to 12-33% and 4-19% respectively.1

The majority of trauma to the primary dentition occurs between the ages of 2 and 4 years of age from falls around the home when children are learning to walk and explore their surroundings1+3. The permanent dentition sustains the majority of it’s trauma in a second peak incidence between the ages of 7 and 101+3 , however in Glasgow this was actually found to be between 8 and 112. In older children falls are still implicated but these are often associated with bicycles, running, sports (in the teenage years), road traffic accidents and assault.

A large number of dentoalveolar trauma cases tend to be seen during the summer months.2

Unfortunately orofacial trauma can be associated with up to 50% of cases where non-accidental injury (NAI) is involved.1

Mechanisms of Dental Treatment (Aetiology)

Even though a variety of mechanisms exist to cause dental trauma, they can be

generalised into either direct or indirect trauma. Direct trauma is when the energy from the impact is delivered directly through the tooth in contact, resulting in the trauma. Indirect trauma is when the mandible is forced to occlude against the maxillary dentition resulting in trauma. Direct trauma is mainly indicated in to trauma to the anterior teeth, whereas indirect trauma, like a blow to the chin most often leads to injuries to the premolar and molar teeth. The type of dental trauma sustained is influenced by several factors including the direction of force, the force of impact and the resilience of the impacting object.

A clinical audit carried out between 2002 and 2004 at the Glasgow Dental School and Hospital, looked at 398 case records of children that had attended the trauma clinic. Of these 398 cases falls accounted for 49% of all injuries, sports accidents 18%, bicycles 13%, assault 7% and road traffic accidents 1.5%.2

A similar pattern of injury has been demonstrated in a 9-year study carried out by RK Hall at the Melbourne Royal Children’s Hospital in the 70’s looking at the aetiology of maxillofacial injuries.3

Percentage of injuries occurring at each age

group

Percentage of

total injuries

0-5yrs

5-10yrs

10-15yrs

Falls 50.1 32.8 17.1 43.2

Play accidents 39.5

43.5

17

17.7

MVA’s 31.9

44.1

24

17.4

Sporting 9

29.5

61.5

8.3

Dog Bite’s

63.3

29.6

7.1

6.4

Fights and

assaults

- 21.9

78.1

1.4

Child abuse

80

20

-

1

Others

4.6

A dental student colleague carrying out the same elective research project in 2004 in Sydney, Australia, found that falls accounted for 50% of traumatic injuries to the dentition and bicycles 19%.4

Types of Dental Trauma

The World Health Organisation (WHO) has four categories for the classification and nature of dentoalveolar injuries. These four categories can be loosely grouped into injuries to the dental hard tissue and pulp, injuries to the periodontal tissues, injuries to the supporting bone and injuries to the oral mucosa or gingivae. Even though distinct categories are given a single tooth may have a range of traumatic injuries.

Injuries to the dental hard tissues can range from the minor enamel infraction, where an incomplete fracture of enamel occurs without loss of tooth substance, to the more severe complicated crown-root fracture. Other injuries include enamel fractures, enamel-dentine fractures, complicated crown fractures, uncomplicated and complicated crown root fractures and root fracture. An enamel fracture is when tooth substance is lost due to trauma but is confined to enamel and an enamel-dentine fracture when the tooth

substance lost contains both enamel and dentine but the pulp is not involved. If the pulp was involved this would become a complicated crown fracture. If the cementum of the root is also fractured along with the coronal tissues this is a crown-root fracture and the classification of complicated or uncomplicated again refers to the involvement of pulpal tissues. A root fracture involves the cementum, dentine and pulp and the fracture itself can be further classified by its position in the root. The length of the root is divided into thirds and hence the fracture could be classified as being apical, middle or coronal.

Injuries to the periodontal tissues can lead to displacement of the tooth, discolouration of the tooth or may lead to eventual death of the pulpal tissues due to changes in the blood flow through the apex. The periodontal tissue injuries include concussion, subluxation, luxation and avulsion. Concussion is when trauma has resulted in no abnormal mobility or displacement but the tooth is more sensitive to percussion. A child may only present after discolouration of the tooth has occurred. Subluxation is when the tooth becomes more mobile but there is no displacement of the tooth, whereas luxation is where there is displacement of the tooth. The direction in which the tooth has been displaced by the

force of the impact helps to classify the injury. An intrusive luxation is when the trauma results in displacement of the tooth into the alveolus with possible comminution or fracture of the alveolar socket. The opposite of this axial movement is extrusive luxation or partial avulsion from the socket. Finally the tooth may be displaced in a non-axial direction and this is lateral luxation and again may occur with or without comminution or fracture of the socket wall. If the tooth is completely displaced from the socket this is known as avulsion.

A comminution is when there is crushing and compression of the alveolar socket wall and is one of the injuries to the supporting bone in the WHO classification along with fracture of the alveolar socket wall, fracture of the alveolar process, which may or may not

involve tooth sockets and fracture of the mandible or maxilla.

Injuries to the gingivae or oral mucosa include lacerations, contusions and abrasions.

Sequelae

Certain types of dentoalveolar trauma in the primary dentition may have a subsequent impact on the development of the permanent successor. Injury to the successor may be present in 12-69% of primary tooth trauma cases and in 19-68% of cases of jaw

fractures1. Since the permanent central incisors develop palatally and in close proximity to the apex of the primary incisor, damage to the successor may occur through lateral and intrusive luxation of the primary. If the crown is displaced buccally the apex of the primary tooth will move palatally into the path of the developing tooth. Intrusive luxation may result in impeded or ectopic eruption of the permanent successor if the deciduous tooth becomes ankylosed. Delayed eruption of the successor may be a possibility after the avulsion of the deciduous tooth due to the increased amount of abnormal connective tissue.

Treatment of traumatized teeth may range from a simple composite restoration, to pulpectomies and subsequent restoration or even extraction. It is vital therefore that a substantial history is taken when a trauma case presents, and traumatized teeth should be regularly checked for developing signs and symptoms such as inflammatory root

resorption and pulpal pathology. Extraction and avulsion of teeth can lead to problems with space maintenance so proper consideration should be given to this when a treatment plan is constructed for the patient.

Details of the most common injuries and the causes may allow for better planning of the treatment of dentoalveolar trauma.

Aims of Study

The aim of this study is to ascertain the mechanism of dentoalveolar trauma and the extent of the trauma experienced by children in Brisbane, Australia compared to that of Glasgow, Scotland. The age of the child at the time of trauma will also be investigated and parallels drawn to other studies.

Also whilst in Brisbane we took the opportunity to observe clinical practice in another country and see how dental practice differs in the absence of a National Health Service. We were also able to learn more about the treatment of patients with cleft lip and palate and other craniofacial abnormalities, and also the oral management of patients

Dentistry in Australia

The day-to-day running of the dental department in the Brisbane Royal Children’s hospital is very much different to that of GDSH in several ways. The clinic is a free clinic however you must hold a Medicare card to be treated there. This card is available to the child if they have a congenital disorder or other extenuating circumstances.

Therefore the patients attending the Child Oral Health Department (COH) quite often have craniofacial abnormalities, cleft lip and palate and other conditions such as epilepsy or long term illness. The RCH is the main treatment area for all cleft lip and palate cases in Queensland and also for north New South Wales, it therefore sees a large number of these patients, whom we had the opportunity to meet whilst attending the clinic. They also have a large number of orthodontists working in the department and therefore most of the treatment that we saw in the department was orthodontic in nature. This is due to

the fact that the children with cleft lip and palate quite often had associated hypodontia, spacing or crowding problems and poor dental aesthetics. Craniofacial abnormalities also led to a higher need for orthodontic and orthognathic treatment. The general atmosphere of the hospital seemed relaxed and the staff was very friendly, which aided in behavior management of the majority of children.

During our time at the hospital we also attended a ward round in the cancer patient unit. This started with a multidisciplinary team meeting headed by medical staff discussing individual patients and their needs, followed by a walk around the various wards observing Dr Hallett carrying out simple check ups on patients with a tongue depressor and penlight. He would give them OH advice and also prescribe a series of mouthwashes (fluoride, anti fungal, anti bacterial) to prevent any infections while undergoing

chemotherapy or radiotherapy. Any patients requiring dental treatment before their cancer treatment started were to be scheduled later that day or when they were next in a stable condition.

The department also made considerable use of the dental therapist in the department as he saw almost every child that attended the department for orthodontic treatment. He would give advice on oral hygiene and diet, and general information about wearing a new orthodontic appliance. When a patient first has a fixed appliance placed they see the therapist and he gives out a pack including brushes, toothpaste and information on oral hygiene with orthodontic appliances. Like PCD’s in Britain we learnt that a dental therapist in Australia can do a range of treatment as long as they are trained to do so, which enabled Steven to debond ortho brackets, place an arch wire and place modules as long as the wire was pre-selected by a qualified orthodontist and no alterations were made to shape or size. There was also great interest rising in the nursing staff, as changes to legislation in Queensland would allow them to take alginate impressions providing they had been trained to do so.

We also witnessed during our time at the hospital numerous procedures carried out under GA some on children with conditions like cerebral palsy but many on normal children.

They seem to have a more relaxed attitude towards GA than in the UK carrying out procedures that would possibly be done under sedation in the UK. The children were treated upon a standard operating table and drug induction agents were used rather than volatile gasses like sevofluorane to achieve anaesthesia. This requires the child to be intubated during the procedure and obviously has consequences on operator technique and vision. Some children were just undergoing simple extractions that only took 4 seconds and had to go through all of this first.

Also they have a different attitude towards post treatment analgesia. For example after an 11-month-old baby had a primary anterior tooth extracted following partial extrusion as a result of trauma and one of the options for postoperative analgesia was pethidine.

We were fortunate enough to be given a private lecture by Dr Steve Atkin the head of the Child Oral Health Department on the management of cleft lip and palate and the role of the multidisciplinary team in achieving this. We were both quite surprised to see that the primary objective in dealing with any cleft palate patient in Australia is making sure the child’s hearing is not affected. This they deemed necessary for the development of speech and learning. Speaking to some students who had been working closely with Cleft lip and palate teams in Britain for their elective where not aware of this necessity. The senior members of staff have set out a guideline for the treatment of patients with cleft lip/palate that they teach to their trainee postgraduates and this can be found in the appendix.

Method

A clinical audit was carried out on pre-exisisting case records from the Child Oral Health Department in the Brisbane Royal Children’s Hospital, Brisbane, Queensland, Australia. 100 case files were retrieved by carrying out a computer search listing any patients with a history of dental trauma and these were subjected to a retrospective analysis by

completing the same questionnaire used by Professor Richard Welbury and colleagues in a Glasgow study carried out in 2004. The same questionnaire was used in a number of dental elective projects in Sydney, Melbourne and Auckland New Zealand.

The questionnaire contained sections on the mechanism of dental trauma, the nature of the trauma itself, and the age of the patient and the time of trauma. A copy of the questionnaire can be found in Appendix 1.

Whilst in Brisbane a decision was made to extend the age range of the children

investigated from the original study up until the age of 16 to allow for a greater number of cases. This was necessary due to the nature of the patients treated in the Child Oral Health Department in Brisbane, as is discussed elsewhere in this report.

Results

Out of the 100 cases investigated 57 of them where male and 43 female, with peak incidences of trauma found at ages 2-3 and 8-11 (fig. 1). 64% of all trauma cases had a fall recorded as the cause of injury (fig. 2), and 62% of the cases had trauma to multiple teeth. Unfortunately the location of the accident was not recorded in 45% of the cases but of the remaining 55 cases, 38 of the accidents happened outdoors and 17 indoors following the general trends in the literature.

Percentage of Children By Age Group 0 5 10 15 20 25 30

0-11 months 12-23 months 2-3 yrs 4-7 yrs 8-11 yrs 12-15 yrs 16+

Figure 1

Mechanism of Dental Trauma

Fall 64% Sport injury 4%Assault 0%

RTA 8% Not Recorded 9%

Bicycle 8%Other 7%

Figure 2

Figure 3 below shows the number of cases experiencing the different mechanisms of trauma within each age group. The graph clearly shows a marked increase in the number of falls resulting in dental trauma between 11months and 3 years and a subsequent decline afterwards. This coincides with the child learning to walk whilst still not having the same level of self-control as older children. Bicycle accidents increase with age, as do the number of road traffic accidents and this may relate to decreasing parental

Some examples of the ‘Other’ cases include: an enamel fracture due to an accident whilst a child was undergoing surgery, trauma sustained during an epileptic fit, and knocks to the dentition either by collision with other people or objects like slides and beds.

Incidence of Trauma by Mechanisms and

Age Group

Figure 3

Injuries to the periodontal tissues where the most common occurring in 65% of the cases, whereas injuries to the dental hard tissues and pulp occurred in 56% and to the supporting bone in 12 cases. Of these twelve cases 9 where alveolar fractures and 3 dentoalveolar fractures. A separate case involved a condylar head fracture after being involved in a road traffic accident.

Dental Hard Tissue and Pulp Injuries 16 18 0 1 7 8 4 2 5 _{1 1 1} 0 5 10 15 20 Ena mel # 1 Ena mel # 2 Ena mel De ntine # 1 Ena mel De ntine # 2 Comp crow n # 1 Comp crow n # 2 Crow n ro ot # 1 Crow n ro ot # 2 Comp crow n root # 1 Comp crow n root # 2 Root # m iddle 2 Root # c orona l 2 Figure 4

Enamel fractures of both the primary and secondary dentition were the most common dental hard tissue injury, accounting for 53% of all the dental hard tissue injuries. The management of these is often quite simple, as any sharp edges just need to be smoothed. At a later date if the child is more cooperative and wishes so, the enamel can be restored using composite. Complicated crown fractures were the second most common dental hard tissue injury, and their management depends upon the size of the pulpal exposure, the time since exposure occurred, whether the tooth is restorable or whether it is soon to exfoliate. In some cases if the exposure is small and less than 24 hours old it may be possible to save the vitality of the tooth by carrying out a Cvenk pulpotomy.

Periodontal Tissue Injuries

7 11 17 5 12 4 8 1 11 9 0 5 10 15 20 concu ssion 1 concu ssion 2 Lat Lux ation 1 Lat Lux ation 2 intrusive lux 1 Intrusive lux 2 Ext rus ive lux 1 Ext rus ive lux 2 Avu lsion 1 Avu lsion 2 Figure 5

Periodontal tissue injuries occurred in 65% of the cases investigated, and figure 5 shows that many of these happened in the primary dentition (65% of the PDL injuries). The softer, more pliable bone of the younger child may explain this. A reduction in

periodontal tissue injuries from 78% of all recorded injuries to 43% was found between the 4-7 year old age group and the 8-11 year old age group.

Dental Hard Tissue Injuries Occurring In Each Age Group

0-11 months

12-23 months

2-3 yrs 4-7 yrs 8-11 yrs 12-15 yrs 16 yrs

Enamel # 1 9 4 2 1 Enamel # 2 9 7 1 Enamel dentine #1 Enamel dentine #2 1 Complicated crown #1 2 5 Complicated crown #2 4 3 1 Crown root #1 1 3 Crown root #2 3 Complicated crown root #1 2 2 1 Complicated crown root #2 1 Root # middle 2 1 Root # coronal 2 1 Figure 6

Periodontal Tissue Injuries Occurring In Each Age Group

0-11 months

12-23 months

2-3 yrs 4-7 yrs 8-11 yrs 12-15 yrs 16 yrs

Concussion/ Subluxation 1 1 1 2 Concussion/ Subluxation 2 4 5 2 Lateral Luxation 1 3 8 5 Lateral Luxation 2 2 1 2 Intrusive Luxation 1 1 2 6 3 1 Intrusive Luxation 2 1 2 1 Extrusive Luxation 1 2 1 5 Extrusive Luxation 2 1 Avulsion 1 1 2 3 4 1 Avulsion 2 6 3 Figure 7

Falls were by far the most common mechanism of dentoalveolar trauma and the most common consequences were enamel fractures of deciduous teeth, lateral luxation of deciduous teeth, and intrusive luxation of deciduous teeth, each accounting for 13% of all injuries sustained from falls. If the secondary dentition is taken into account for the same injuries the result would be 17.5%, 16% and 14% respectively.

Percentage of Injury Type vs. Mechanism of Injury

Sport Fall Assault Bicycle Not

Recorded RTA Other E # 1 0 13 0 0 9 0 11 E # 2 0 4.5 0 29 9 18.75 11 ED # 1 0 0 0 0 0 0 0 ED # 2 0 1 0 0 0 0 0 Complicated Crown # 1 0 4.5 0 0 9 6.25 5.5 Complicated Crown # 2 0 2 0 18 0 12.5 5.5 Crown Root # 1 12.5 0 0 0 9 0 0 Crown Root # 2 0 2 0 0 0 0 0 Complicated crown root #1 0 4.5 0 0 0 6.25 5.5 Complicated crown root #2 0 2 0 0 0 0 0 Root # Apical 2 0 0 0 0 0 0 0 Root # middle 2 0 0 0 0 0 0 5.5 Root # coronal 2 0 0 0 0 9 0 0 Concussion 1 12.5 6.5 0 0 0 0 0 Concussion 2 12.5 5.5 0 12 9 12.5 5.5 Lateral Luxation 1 0 13 0 0 0 6.25 11 Lateral luxation 2 12.5 3 0 6 0 0 0 Intrusive luxation 1 12.5 13 0 0 9 0 11 Intrusive luxation 2 0 1 0 6 9 6.25 0 Extrusive luxation 1 12.5 6.5 0 0 9 0 5.5 Extrusive luxation 2 0 1 0 0 0 0 0 Avulsion 1 9 0 0 9 6.25 11 Avulsion 2 12.5 1 0 23 9 0 5.5 Alveolar # 12.5 5.5 0 6 0 12.5 5.5 Dentoalveolar # 0 1 0 0 0 12.5 0 Figure 8

Discussion

In our research falls accounted for 64% of the dentoalveolar trauma sustained. This was much higher than that recorded in the literature (49% in Glasgow2). This discrepancy may be attributable to a number of factors. Firstly the accuracy of the trauma

documentation may be taken into account. When reading some of the case files an extensive history was not always present and the single word ‘fall’ may have just been recorded. Due to this injuries such as falls from bikes or falls whilst playing sports may not have been accounted for hence increasing the percentage of falls and decreasing the percentage of injuries from other mechanisms. This highlights the need for a universal procedure for taking a child’s history when dental trauma occurs so fairer comparisons can be made. Secondly a consideration must be given to the different types of patients treated in the Royal Children’s Hospital Oral Health Department. Many of the children attending the clinic have underlying mental and physical disabilities that may make them more prone to falling, and less likely to partake in sport or ride bicycles if they are wheelchair bound for instance. The results may also have been skewed due to the fact that the majority of dental trauma would be treated elsewhere, either by private

practitioners or the School Dental Service.

Road traffic accidents occurred in 1.5% of the cases in the Glasgow study2 but 8% of the cases in Brisbane. This we believe to be a result of the fact that the Oral Health

Department is attached to a much larger children’s hospital, so any children that have been admitted as a result of an RTA would automatically be referred to the Child Oral Health Department if any dental trauma has been experienced. This would not

necessarily be the case in the Glasgow Dental Hospital and School.

Sports related injuries were far less common than quoted in the literature and this can be explained in the same manor as for falls. In this study though 87.5% of the injuries received due to sports accidents were to the periodontal tissues, so it would be prudent for all dentists to recommend the use of mouth guards in all contact sports, and sports where injury is more likely to occur (e.g. skateboarding).

Injuries to the periodontal tissues occurred in 65% of the cases so any primary care giver should be proficient in dealing with these injuries. Splinting may often be necessary and early referral to a paediatric specialist should be made if there are concerns to the

developing dentition or any orthodontic implications. Of injuries to the hard tissues this study shows that enamel fractures are the most common type of injury sustained so again dentists should be aware of the management of these, but may have to refer the child for more substantial injuries if cooperation is poor.

Personally we felt that the use of general anaesthesia was quite excessive in Brisbane but understand the difficulties that they encounter with some of the patients they treat. We never saw any inhalational sedation and we feel that we would rather try this first due to the inherent risks of GA, especially if the patient is only having a scale and polish and a fissure sealant.

Appendix 1

Example of the questionnaire

Retrospective Analysis of Mechanisms

Of Dentoalveolar Trauma

Data recorder A.B. G.MC Prof. R.W.

Unit Number:- Sex:- Male

Female

Age at Trauma:- year(s) month(s)

Age Group:- 0-11 months 4 – 7 years

12–23 months 8-11 years

2-3 years 12-15 years

Date of Trauma:- / /

Location:- Inside Outside

Mechanism:- Sporting Assault

RTA Not Specified

Fall Other (please state)

___________________

Bicycle/Scooter

Injuries to Dental Hard Tissues and the Pulp

(Please specify the tooth/teeth injured as primary, secondary dentition or both)

Primary Secondary

Both

Enamel/Enamel-dentine fracture

Enamel-dentine-pulp fracture

Crown-root fracture not involving pulp

Crown-root fracture involving pulp

Root Fracture -Apical Third

-Middle Third

-Coronal/gingival Third

None recorded

Injuries to the Periodontal Tissues

Primary Secondary Both Concussion/subluxation Extrusive luxation Intrusive luxation Lateral luxation Avulsion None recorded

Injuries to the Supporting Bone

Dentoalveolar fracture

Alveolar fracture only

None recorded

Appendix 2

Extract from postgraduate teaching document, Child Oral Health Department Brisbane Australia.

1. Infancy

Pre-lip repair

-Early referrel

-Minor surgery if required

-Extraction of malposiutioned 52, 62 or neonatal teeth -Release of Simonart’s band

-Pre surgical orthodontics, mainly infants with bilateral cleft lip and palate

Lip repair

-Age 3-6 months (range)

Palate repair

-Age 9-12 months

2. Deciduous dentition

+/- Grommets

+/- Lip revision

+/- Pharyngoplasty

+/- Extract 52, 62

3. Early mixed dentition

-Pre-alveolar/nostril base bone graft

-Maxillary expansion realignment of upper incisors -+/- Extraction of retained deciduous anterior teeth -+/- Frenectomies/ +/-Gingivoplasty

- 4. Late mixed dentition (9-10yrs)

-Alveolar/nostril base bone graft

-+/- Extractions adjacent to the cleft -+/- Other extractions -+/- Gingivoplasty

-+/- Maxillary surgical splint and Coe-Pak dressing

-Post-alveolar/nostril base bone graft

-Two weeks post-op- clean splint

Irrigate area

-Appointments for new maxillary retainer -Retention of expanded maxilla (critical)

5. Early Permanent Dentition

-Fixed appliance orthodontic treatment

-+/- Extraction of retained posterior deciduous teeth

-Decision required: Orthodontics only OR Orthognathic surgery later to advance the maxilla

-Lip and nose revisions may be considered

6. The Young Adult (16+ female and 17-18+ males) -Find out what the young adult really wants.

-+/- Maxillary advancement osteotomy- removal of 8’s -pre-surgical orthodontics

-post-surgical orthodontics -retention

-Rhinoplasty

-+/- Genioplasty

-+/- Post-osteotomy pharyngoplasty

7. The Mature Adult (Age20-65+ years)

-Soft palate lengthening and pharyngoplasty

-Comprehensive conservative/prosthodontic dentistry -Prosthetics-New well-designed denture

-Nasal tip rhinoplasty/ lip-nose revision -Clear nasal passage

-Reduction/augmentation rhinoplasty -Reduction/augmentation genioplasty -Osteotomies

Acknowledgements

Glasgow- Professor Richard R Welbury, Glasgow Dental School and

Hospital, Sauchiehall St, Glasgow, Scotland

[email protected]

Brisbane- Dr Kerrod Hallett, Brisbane Dental Hospital, Turbot St, Brisbane

[email protected]

Brisbane- Dr Steve Atkin, Royal Children’s Hospital, Oral Health

Department, Herston Road, Brisbane.

We would also like to thank all the other staff at Brisbane RCH for their

kind hospitality and assistance with location of case notes. Their help was

indispensable.

Bibliography

R. R. Welbury; Paediatric Dentistry; Oxford Press; 3rd Edition1 Wright G, Bell A, McGlashan G, Vincent C, Welbury RR. Dentoalveolar trauma in Glasgow: an audit of mechanism and injury. Dental Traumatology 20062