1. Dental Trauma Flashcards
\_\_\_\_ >/= female 25% of the population 6 to 50 years of age anterior teeth \_\_\_\_ year \_\_\_\_ children - no seasonal variation \_\_\_\_ children - injuries during summer \_\_\_\_ highest frequency of emergencies
males 8 to 12 young older fridays
• Equal among females now, bc of increase in sport participation
• 25% will have some sort of trauma on their ____
○ Most common age trauma = 8 to 12 y/o
§ The patient is growing and developing at this age - the roots are still open and they’re clsing, and even more importatntly -> the jaws are growing
§ If patients lose a tooth heree -> the ridge will resorb, and rest of jaw grows -> defect, difficult to place implants
□ For the ridge to grow and for bone to remain, the tooth must be present while the growth spurts happen
• Seasonal variation -> young children in the spring
○ Older children -> summer -> sports camps
○ Friday is the most common day
§ Why important: the weekend is starting
□ Private practice that you’re closing, and a pt walks up as you’re closing and in pain -> pulpitis
® Prescribe pain meds if you close the office and check at 8 to see them
® However, cannot do it with trauma injuries -> ____, legal issues and the consequences of waiting a few hours in traumatic injury is WORSE
◊ A TRUE EMERGENCY - must see the patient!
} Decides the fate of the teeth
NO
• ____ most common site
○ Centrals and laterals
• ____ are least common
○ Protected by max anterior, and when you fall you clench
max anteriors
man anteriors
Classification
Dentofacial injuries
• Under the big group of dentofacial injuries ○ \_\_\_\_ came up with the classification ○ \_\_\_\_ changed the classification
WHO
andreason
Dentofacial injuries
• Group I ○ \_\_\_\_ injuries § Nothing to d with boens or teeth • Group IV ○ \_\_\_\_ injuries § Not the \_\_\_\_, bu the jaw and facial bones
soft tissue
skeletal
teeth
• Group I injury
○ Patient falls, and breaks off an anterior -> ____ on lip
○ Responsibility when soft tissue injury:
§ Larg gash and bleeding -> numb, and ____ if need be
§ More important: when there is break in the tissue, need to take an ____ of the soft tissue
□ Foreign body (tooth, or gravel, etc.)
□ Make sure nothing is in the laceration!
® If you find soemthing -> remove the object
laceration
suture
x-ray
Group IV injury
• Difference bt R and L eyes
○ R eye cannot open, red inside and outside
○ Scan -> facial bone is broken
§ Walks into office like this -> four teeth are in the patient’s hands (avulsed them)
□ What’s important: the patient!
□ Cannot place the teeth back in, you’re not liable?
□ Any facial injury -> ____
® Involvement of the brain, head, etc.
911 call
Group 2 injury TOOTH \_\_\_\_ - enamel infraction - enamel fracture - crown fractures (uncomplicated/no pulp exposure) - crown fractures (complicated w/ pulp exposure) - crown-root fractures - root fractures
Group 3 injury \_\_\_\_ INJURIES - tooth concussion - subluxation - extrusive luxation - lateral luxation - intrusive luxation - avulsion
fractures
luxation
• This what we will attempt to treat • Group 2 ○ Fractures § At various levels on tooth AND \_\_\_\_ § Tooth breaks at various levels along the length of the tooth • Group 3 ○ Luxation § Movement of the tooth in the socket (or out of the socket) § Tooth is \_\_\_\_, but it's not in \_\_\_\_
root
intact
place
Abuse
• First thing in diagnosis -> \_\_\_\_ ○ Required when you get your license to go through child abuse education online, must renew the CE every time you get the license renewed (every 2 years) • If you see an injury, and it doesn't fit with what the parent/child is saying ○ Suspect child abuse -> you have to report it • 260 records of child abuse in 70-75 ○ Out of those records -> 50% will have a \_\_\_\_ injury, and 20% will have \_\_\_\_ ○ The history could be 30% child abuse???
child abuse
facial
dental trauma
Abuse
____ in seeking treatment ____ for injury differs from person to
person
____ for injury does not fit the clinical findings
____ to other people ____ b/w family members
• Suspect abuse? • Kid fell a month ago -> now bringing the child ○ Not how parent responds to normal injury • If explanation differs ○ Child and parent don't agree ○ \_\_\_\_ between the patient and parent
delay explanation explanation reaction relationship tension
Abuse
Primary aim - the ____ of the patient
Secondary aim - provide ____ - counseling for the family so that the abuse stops
• Reason you have to call it in -> primary concern is the safety of the child ○ Not worried about the teeth, etc
safety
treatment
Treatment
____ concrete systems for treating traumatized teeth
Purpose is to provide a ____ for treatment
• Trauma is not studied by study designs -> cannot execute them! ○ Must be go by data that is collected from trauma hospitals • Provide a guideline, no concrete treatment plan ○ You as a clinicain decide the final tx
no
guideline
To prevent ____ clinical signs or symptoms
To ____ as close to original location as possible
To achieve evidence of continued ____
• Three aims of treatment: ○ Get ht epatinet out of pain ○ If the tooth has been dislocated/luxated -> want the tooth back in the oriignal position ○ MOST \_\_\_\_: patient/jaw continues to \_\_\_\_ § Alveolar growth continues
adverse
reposition
alveolar growth
important
grow
TREATMENT
Objective
Maintain esthetics & function Pulp - continued root & alveolar Tooth - continued alveolar
Follow up
• ??? • Very important set of words ○ \_\_\_\_ § What happens w trauma injuries? □ Some of the repercussions of injuries -> pulp necrosis, etc. ® Can happen as late as \_\_\_\_ years after the injury ® Follow on a yearly basis ® Some specific scheudles for specific injuries
follow-up
30-40
• Specific things when you diagnose
○ CC
○ Dentla history
○ Med hisotry
○ Look inside the ____ before looking at tooth you think is ht eproblem
• Face is bloodied -> do not jump inot the mouth that’s causing the bleeding
○ Go trhough the process of dx
○ Aska bout the CC, history and then at the soft tissue, extraoral and intraoral
○ Must follow the sequence
mouth
History of Present Illness (injury)
• In a traumatic injury, some questions: ○ Where § Why important: \_\_\_\_, or tetanus ○ How ○ When § If a tooth was knocked out of place \_\_\_\_ -> will be much harder to put back in plcae bc the area starts to heal § Important in avulsion -> how \_\_\_\_ was it outside? Where was it outside? ○ Unconscious? § Yes -> call \_\_\_\_ ○ Bite disturbance § \_\_\_\_ injury or tooth is out of place ○ Hot and cold? § Pulp is exposed ○ Treated elsewhere? § Placement of splint? Pulp cap? ○ Hx of previous injuries
infection yesterday long 911 skeletal
Clinical Examination
• Minor luxation ○ Tooth is slightly out of arch ○ Check if tooth is in right position by checking for § \_\_\_\_ □ Using instruemnts § \_\_\_\_ § \_\_\_\_ § \_\_\_\_ tests
mobility
percussion
palpation
vitality
Clinical examination
Mobility/displacement
• Tooth is slightly out of the arch
○ Who is the best to answer whether normal or not -> the ____!
§ Age group -> ____ y/o
patient
8-12
Clinical examination
Percussion/palpation
• \_\_\_\_ AND \_\_\_\_ percussion ○ Test the entiere periradicular tissue • Looking for soft tissue and skeletal injury ○ May find \_\_\_\_ ○ Buccal and the palatal
vertical
lateral
tenderness
Clinical examination
• Vitality tests ○ Cold ○ Hot ○ EPT • For trauma: \_\_\_\_ • Where do you get false positive and false negative? ○ \_\_\_\_ teeth § Plexus is immature and not formed § Add injury to the tooth -> will you get accurate results? □ NO! □ Why do it -> bc this is the \_\_\_\_ ® On the day of injury -> this is what I got ® Do testing from \_\_\_\_ on the top and bottom ◊ Irrespective of how many teeth are involved in injury } EACH TOOTH IS TESTED FOR COLD AND EPT ◊ If PM involved -> go \_\_\_\_ back • Follow up patients ○ Test the same teeth, and compare the results with those you got last time
cold and EPT immature baseline canine to canine further
Clinical examination
Immature teeth/trauma
• Immature and traumatic teeth ○ \_\_\_\_ and \_\_\_\_ reactions, but will still go through the tests
false positive
false negative
Vitality test
- Trauma
• Discoloration of the tooth ○ Injured, BV broke -> \_\_\_\_ (iron -> deposits in the tubules) -> gets browner w light and oxygen -> tooth gets darker and darker ○ Can happen in the first week § In concussion injuries -> some teeth will discolor \_\_\_\_ years down the line, adns ome immediately § Some discolorations can \_\_\_\_ without treatment • Intact tooth on the R with a small lesion ○ Pt got hurt two hours ago § Will a PA lesion form in two hours? □ Why is there a lesion there? -> \_\_\_\_ standing traumatic injury □ Lesion on recent trauma? ® \_\_\_\_ -> not in original position -> x-ray -> \_\_\_\_, and they can come across as a lesion on an x-ray
RBCs 30 reverse long luxated gaps
Vitality test
- trauma
• Wuold you look at this lesion and immediately do an endo? ○ Other than luxation -> possible breakdown of the apical area § This isn't two days after, a few months after the injury -> looks like a lesion -> no response to heat/cold/EPT -> tooth was injured 6 mo to 10 yrs ago -> no cold or EPT or heat response -> see a lesion -> expect to be \_\_\_\_ □ Quite often -> 20 cases in 73 -> went into pulp chamber -> saw \_\_\_\_! ® Termed it as \_\_\_\_ (anderson) ◊ As a clinicain when do you decide to treat? These cases were still vital!! Are you wrong in accessing tooth and doing an endo?? } If you find vital pulp when you go in -> it can happen!!
necrotic
bleeding
transient apical breakdown
Vitality test
- immature teeth
False negative:
1. Myelinated nerve fibers-maximum ____ years after tooth eruption
- Lack of development of the ____ plexus in the Pulp-dentin border-final stages of root formation
5
raschkow
Clinical examination
- no probing• Only thing you will not do -> ____!
○ In traumatic injuries
○ Why?
§ Can introduce ____ and bacteria upon making the lesion worse
§ Tendency to push bacteria from sulcus into the PDL -> make the PDL sterile so healing can happen!
probing
infection
Radiographic examination
• FOA ○ Large or small • CB scans are helpful, but worry about radiation ○ Take 4 x-rays to figure out whether there is an injury or not ○ Radiation in a CBCT scan -> 6-8 x-rays § What is being said -> trauamtic injury if the child is young, rather take a \_\_\_\_ scan than avoid the x-ray □ Gives \_\_\_\_ information from a CBCT than an x-ray • Check if apex is open or closed ○ Treatment depends on this!
CBCT
more
Radiographic examination
- previous Hx
• X ray on child who fell yesterday ○ Resorption on the left • External/internal \_\_\_\_ happens after trauma ○ The presentation of this resoprtion can happen as early as 2 weeks, to as late as 2 years ○ See somethignlike this -> \_\_\_\_ injury (on a recently traumatized kid) • R side ○ Ankylosis of the tooth § Tooth has been resorbed, and replaced by bone § Did an endo -> GP remains in the bone § Sequale of dnetal trauma -> \_\_\_\_ traumatic injury □ Did dyou get hurt before? Dental trauma before? ® Yes 2 years ago fell down -> fits the. Bill!
resorption
old
old
Radiographic examination
- displacement
• L: PAP ○ It's the \_\_\_\_ of the tooth, which presents as a PA lesion § 50% (???)
displacement
Radiographic examination
- fractures
• Horizontal fracture on the R ○ In order to be able to see -> befor eth CBCT -> take multiple \_\_\_\_ (per WHO) that are angulated in order for it show up § Only shows when -> when the beam travels right through the \_\_\_\_ □ Vertical angulation must be going directly thorugh the crack
x-rays
crack
Radiographic examination
- multiple x-rays
• The horizontal fractures are usually \_\_\_\_ in nature, not 90 degrees ○ Doesn't snap 90 to the long axis, usually oblique in th ebody of the tooth
oblique
Radiographic examination
- multiple x-rays
• For the fracture to show -> only when the beam travels thorugh the cracked line at one point it will show up ○ Misleading: looks like apex is fracture, but it's running \_\_\_\_ § This is why \_\_\_\_ is a better idea than x-ray □ X ray doesn't give adaequeate amount
oblique
CBCT
Radiographic examination
- CBCT
• R: waved line -> tooth fracture • \_\_\_\_ -> see an obvious fracture (on the L) ○ Buccal and lingual extent of the crack • Don't see much on. The x-ray ○ When take the scan -> alveolar bone on the lingual (BR) has fractured (white arrow) § MORE info and MORE valuable than an x-ray
CBCT
Examination & Diagnosis
Follow-up schedule \_\_\_\_ weeks \_\_\_\_ weeks \_\_\_\_ months \_\_\_\_ months \_\_\_\_yrs
• General follow up schedule that you need to follow for the injury ○ Might see changes in the schuelde based on the injury that occurs
4 6-8 6 12 1 year - yearly for 5
Layers of tissue from pulp proper to the outside: • \_\_\_\_ inside the tooth • \_\_\_\_ • \_\_\_\_ • \_\_\_\_ • \_\_\_\_ • \_\_\_\_ (attaches ot the bone)
• Precementum and predentin are important ○ Cementum and dentin are calcified tissues ○ Precementum and predentin -> not as \_\_\_\_ § A thin layer on the \_\_\_\_ of the dentin, or \_\_\_\_ of cementum which covers the hard tissues § Acts as protective layer -> scratch it off or cause an injury (inside PD or outside PC) -> stimulates \_\_\_\_ -> resorbs and attaches to the hard tissues and starts to resorb § When an injury happens -> significant defect as a result of injury on PC or PD -> resorption, but still don't know how much injury must happen □ Theory: accidentally walk into door and cause some injury, but doesn't lead to resorption □ Doesn't know what surface area must be occurring!
pulp predentin dentin cementum precementum PDL
calcified
inside
outside
osteoclasts
Classification
- crown fractures
• Enamel infraction ○ \_\_\_\_ lines that you see on every tooth ○ Are they caused by trauma? We don't know § Always there? possibly • Do a backlight ○ Enamel infractions • Do we treat? ○ \_\_\_\_!
craze
no
Enamel infraction
Objective
Maintain ____ & function
Pulp - continued ____ & alveolar
Treatment
____
Follow up - ____ weeks - ____ year
• Test the teeth again (canine to canine) in 6-8 weeks - 1year ○ Not just the teeth with enamel infractions
esthetics root none 6-8 1
Enamel fracture
• Happens within the body of the enamel
○ ____ is NOT exposed
○ Can reattach on the tooth again, or do ____ (take a bur and round off the edges), or do a composite restoration and give the hspae of the tooth back
• WILL NOT DO:
○ Compposite restoration and build the tooth back -> in t he rporcude of placing the compositei ->
§ YOU CAN ____
§ MAKE SURE THE TOOTH IS NOT IN ____
§ After placing and shaping -> POLISH, and grind away so it shines
□ What has jus thappened ot the pulp -> under trauma -> when you polish, you create HEAT -> will cook the pulp further
□ DON’T ____ THE TEETH
® Do it ____ weeks later and then polish it
dentin enameloplasty etch traumatic occlusion polish
Enamel fracture
• Charts with injuries ○ X = number o fyears after injury ○ Y = pulp necrosis that has happened § Portion of enamel fallen off -> risk of necrosis is very \_\_\_\_ § Happened in the first year, after -> no \_\_\_\_ of these injuries
low
repercussions
Enamel fracture
Enamel Fracture
Objective
Maintain ____ & function Pulp - continued root & alveolar
Treatment
____
____
Follow up - ____
• Bring esthetcis back by enamelplasty or bonded restoration ○ Polish it later (\_\_\_\_ weeks later)
esthetics
enameloplasty
bond
6-8 weeks - year
6-8
• Crown fractures ○ Two types: § Uncomplicated □ No \_\_\_\_ § Complicated □ \_\_\_\_ exposure
complications
pulp
Uncomplicated fracture
• What is exposed instead in uncomplicated? ○ \_\_\_\_ - tubular in nature, direct highway to the pulp § Leave exposed for long periods -> \_\_\_\_ rinjure the pulp by toxins, bacteria traveling into the pulp § Have tubules exposed -> restorative procedure that will \_\_\_\_ the tubules
dentin
further
block
Uncomplicated fracture
• Can do a composite, or if the piece is still available can attach the piece back ○ Closing the dnetinal tubules ○ Close w \_\_\_\_ composite, and can do it at a later time if you want ○ WANT TO \_\_\_\_ THE TUBULES the \_\_\_\_ of the visit
flowable
seal
day
Uncomplicated fracture
• Dentin is exposed • \_\_\_\_ is not formed yet • How to know if tx is working? ○ When patient comes backa dn the \_\_\_\_ contineus to form -> pulp is still vital § Cold and EPT should be \_\_\_\_ □ But if false neg -> as longa s apex \_\_\_\_ -> can be certain the pulp inside is vital and viable
apex
apex
vital
closes
Uncomplicated fracture
• Almost exactly the same as enamel infraction ○ Pulp doesn't not get \_\_\_\_ ○ Less than 5% of the time and within the first year ○ Not a big deal as long as you close th \_\_\_\_ and don't cause further injury to the pulp
necrotic
tubules
Uncomplicated fracture
Enamel Fracture
Objective
Maintain ____ & function Pulp - continued root & alveolar
Treatment
____
____
Follow up - ____
esthetics
bond
restore
6-8 weeks - 1 year
Complicated fracture
• \_\_\_\_ is exposed • Sometimes is horizontal, someitmes its oblique ○ Important to figure out wehre the \_\_\_\_ and \_\_\_\_ extens are
pulp
buccal
lingual
Complicated fracture
• Key: \_\_\_\_ IS EXPOSED ○ Dnetinal tubules covering th epulp, but very \_\_\_\_ ○ \_\_\_\_ is happening
pulp
thin
bleeding
Complicated fracture
Cvek
• Remmeber Cvek ○ Dentist who looked into traumatic injruies with complicated fractures ○ Took rats -> through steel balls on their teeth -> exposed the pulps -> left exposed for as long as \_\_\_\_ hours -> found that when he sacrified the rats and made histology slides -> inlfam in exposed trauam was only \_\_\_\_ mm off the exposed pulp § Eveyrhting below that was histoloigcally normal; restricted ot the superficial region of the pulp □ Why? ® Difference bt caries on molar vs fractured pulp on the anterior: ◊ \_\_\_\_ can't seat ◊ Fracture in the front -> lip, tongue is rubbinga gainst, etc. -> constantly \_\_\_\_ it } Molar w deep groove -> bacteria is seated } "\_\_\_\_" injury -> most of the time inflammation is limited ot the coornal protion of the pulp
1200
2-4
bacteria
cleaning
Complicated fracture
Treatment modalities
____
Cvek or partial pulpotomy ____
Pulpectomy with RCT Or ____
Pulp revasularization
• DPC ○ Pulp is exposed ○ Wash the pulp w saline, and plcae restoration on top of that expowed pulp ○ What are you capping § \_\_\_\_ § 2-4mm of inalmmation is capped with material -> chances of that workign \_\_\_\_ -> capping an inflamed pulp
direct pulp capping
full pulpotomy
apexification
inflammation
Cvek pulpotomy
• Cvek partial pulpotomy • When have pulp exposure (2-4mm) -> opne expoesed pulp \_\_\_\_ -> round bur (HS) -> take the pulp down (excise) 2-4mm down ○ In vital pulp therapy, vs cvek in truama § 1: in VPT -> partial pulp on a carious lesion, the pulp has been chroncially exposed to trauma § Here, this is acute traum -> for sure we know it's \_\_\_\_mm of the pulp □ In carious, we don't know where the lesion stops □ WE ARE GUESSING THAT WE ARE IN GOOD PULP ® In cvek -> MORE \_\_\_\_ -> histologically he proved that the inflammation is within the top 2-4mm of the pulp ○ Calcium hydroxide, or bio ceramic material to cap the pulp directly -> build I tup and etch bound with composite § YOU WILL NOT \_\_\_\_!!
further
2-4
reliable
polish
Cvek pulpotomy
• Take the pulp down -> \_\_\_\_ on it -> what happens to the pulp if you leave it alone -> forms pulpdentin junction again -> forms a \_\_\_\_ layer under the material Pulp chamber is reformed -> \_\_\_\_, but it's healthy! That is reformed
bioceramic
dentin
smaller
Cvek Pulpotomy
- preservation of the pulp• ____ of the pulp is KEY for cvek
○ Becomes important in injuries with apices that are open
○ Apices need to ____ by you doing cvek pulpotmy
○ If apex comes closed, and then pulp is exposed -> if resotre tooth with a c omposite -> don’t need a crown, cvek is still a better option
§ What’s best to fill tooth -> ____ pulp
§ If you can rpeserve, it’s the best thing to do!
• If placing a crown, need a post -> ____ is th eright treamtnet
preservation
close
vital
endo
Cvek pulpotomy
• How often will the pulp necrose under cvek ○ 3% of the time ○ \_\_\_\_% of the time the pulp will REMAIN VITAL • First line tx: \_\_\_\_ PULP for a complicated crown fracture
97
cvek
Complicated fracture
• Comes 1000 hours later, pulp is necoritc and forming a lesion and open apex ○ Apexification and revascularization ○ Pulp became necrotic while apex wasn't \_\_\_\_ § One tx option: apexification □ Put a \_\_\_\_ of bioceramic material (bc it's hard to obturaete that's open at apex) -> fill the rest w \_\_\_\_ or composite
closed
plug
GP
Pulp revascularization
* Another option: revascularization * Tooht necortic with open apex -> invovles creating a \_\_\_\_ in the apical 2/3 of the tooth and putting a plup here (\_\_\_\_ up) and lallowing the blood clot to become \_\_\_\_ tissue * Roots continue to \_\_\_\_ and there is tissue within the tooth * \_\_\_\_ tooth this way rather than apexificiation bc the walls have thickened
blood clot farther live grow strong
Objective
Maintain ____ & function Pulp - continued root & alveolar
Treatment
Immature (vital) (____) (Nonvital) ____
Mature
(vital) (____) (Nonvital) ____
Follow up - ____
esthetics
apexogenesis
revascularization, apexification
cvek, RCT
RCT
6-8 weeks - 1 year
• Immature tooth
○ Vital = ____
§ Formation of the apex that the body does
§ Allows for apexogeneis by doing a cvek/full pulpotomy or a DPC
□ Best choice: ____
○ Nonvital (far after truama occurs) § \_\_\_\_ § \_\_\_\_
• Mature tooth ○ Complicatied § Vital = \_\_\_\_ § IF need a restoration -> \_\_\_\_ § Nonvital => \_\_\_\_ • Get patient back in 6-8 weeks to do the diagnostic tests
apexogenesis
cvek
revascularization
apexification
cvek
root canal treatment
root canal treatment
Treatment Choice
____ of Development of the root / age
____ between accident and when u see the patient ____ treatment
____ Injury
stage
time
restorative
periodontal
Crown-root fracture
Chisel type: extrusion
* \_\_\_\_ -> starts in crown, ends up in the root * \_\_\_\_ apex, and child -> preserve what is remaining in the mouth * Ortho \_\_\_\_ is an option, or a \_\_\_\_ and build with the composite * Keep the \_\_\_\_ in the mouth
oblique
open
extrusion
tooth
Crown-root fracture
Objective
Maintain esthetics & function Pulp - continued root & alveolar
Treatment
Immature - save pulp for ____ growth.
Mature - ____ - ____, maintain until alveolar growth - OR - ____
Follow up for ____ restoration
• Crown root fracture ○ Immature -> save pulp bc you wanna save the bone ○ Mature -> RCT, extrude, extract/implant
alveolar
RCT
extrusion
implant
perm
