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BDS3 Paeds > Dental Trauma Permanent teeth > Flashcards

Dental Trauma Permanent teeth Flashcards

1
Q

epidemiology of permanent dentition trauma

A
  • boy: girl ~ 3:1
  • 25% all skl children
  • 33% adults
  • peak 7-10yo
  • 70% not treated
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2
Q

what is the most common cause of permanent teeth trauma

A

fall

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3
Q

what increases risk of trauma to permanent teeth

A
  • overjet
  • absence of competent lips
  • OJ >9mm doubles the incidence
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4
Q

what condition in MH may influence tx option?

A
  • Rheumatic fever
  • congenital heart defects
  • immunosuppression

(not contraindications but additional tx may require)

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5
Q

what is the most common injury in permanent dentition?
(and in primary dentition)

A

crown fracture (enamel-dentine #)

(luxation in primary dentition)

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6
Q

E/O of permanent teeth trauma

A
  • laceration
  • haematomas
  • haemorrhage/ CSF (yellow fluid from nose and ears)
  • subconjunctival haemorrhage
  • bony step deformaties
  • mouth opening
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7
Q

I/O of permanent teeth trauma

A
  • soft tissue
  • alveolar bone
  • occlusion
  • teeth
  • facial/jaw #
  • take radiogrpahs if suspicious of foreign objects
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8
Q

what could tooth mobility in trauma suggest

A
  • displacment of tooth (PDL damage)
  • root #
  • Bone #
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9
Q

what speical test you can do if suspect of fracture

A
  • tactile test with probe (# line)
  • transillumination (curing light at palatal aspect)
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10
Q

What sensibility tests can you do on detailed intro-oral exam of trauma?

A

Thermal - Ethyl chloride (ECL) or warm Gutta-Percha
Electrical - Electric pulp tester (EPT)

  • Compare to adjacent non-injured tooth
  • Test on adjacent and opposing teeth as they can receive direct or indirect concussive injuries
  • Continue sensibility tests at least 2years after
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11
Q

trauma sticker for permanent teeth

A
  • sinus
  • colour
  • TTP
  • mobility
  • EPT
  • ECL
  • P. note
  • Radiograph
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12
Q

What does prognosis of the tooth depend on?

A
  • Presence of infection
  • Time between injury and treatment
  • If PDL is also damaged
  • Type of injury
  • Stage of root development
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13
Q

General aim of emergency treatment?

A
  • Retain vitality of tooth by protecting exposed dentine by an adhesive ‘dentine bandage’
  • Treat exposed pulp tissue
  • Reduction and immobilisation of displaced teeth
  • Tetanus prophylaxis
  • Antibiotics?
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14
Q

General aim of intermediate treatment?

A
  • +/- Pulp treatment
  • Restoration (Minimally invasive e.g. acid etch restoration)
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15
Q

General aim of permanent treatment following trauma?

A
  • Apexigenesis
  • Apexification
  • Root filling +/- root extrusion
  • Gingival and alveolar collar modification if required
  • Coronal restoration
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16
Q

what is apexigenesis

A

vital pulp therapy procedure performed to encourage phsysiological development and formation of root

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17
Q

what is apexification

A

induce a calcific barrier in root with incomplete formation or open apex of tooth with necrotic pulp

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18
Q

How to manage enamel fracture?

A

either
- bond fragments to tooth or
- simply grind sharp edges with sof lex polishing bur
and
- take 2 PA radiographs to rule out root # or luxation

follow up
- 6-8 weeks/ 6mo/ 1 year

prognosis
- 0% risk of pulp necrosis

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19
Q

How to manage enamel-dentine fracture?

A
  • Account for fragment

Either
- bond fragment to tooth or
- place comp bandage
and
- Take 2 periapical radiographs to rule out root fracture or luxation
- Radiograph any lip or cheek lacerations to rule out embedded fragment
- Sensibility testing and evaluate tooth maturity
- Definitive restoration

Follow up
- 6-8weeks/6months/1year

Prognosis
- 5% risk of pulp necrosis at 10years

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20
Q

what do you do at trauma review appt?

A

trauma stamp and
radiograph to check:
- root development - width of canal and length
- comparison with contralateral side
- internal/ external inflammatory resorption
- periapical pathology

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21
Q

what is pulpal survival of ED fracture assoc. with intrusion

A

0% with open or closed apex

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22
Q

How to manage enamel-dentine-pulp fractures?

A

Evaluate exposure
- Size of pulp exposure
- Time since injury
- Associated PDL injuries

Choose either
- Pulp cap
- Partial pulpotomy (Cvek Pulpotomy)
- Full coronal pulpotomy

Avoid full extirpation unless tooth clearly non-vital

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23
Q

When and how to perform a direct pulp cap?

A
  • If tiny exposure 1mm within 24hour period
  • Trauma sticker and radiographic assessment
  • Should be non-TTP and positive to sensibility tests
  • LA and rubber dam
  • Clean area with water then disinfect with sodium hypochlorite
  • Apply CaOH (Dycal) or MTA white to pulp exposure
  • Restore tooth with quality composite restoration
  • Review 6-8weeks/6months/1 year
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24
Q

When and how to perform partial pulpotomy (Cvek Pulpotomy)?

A
  • Larger exposure >1mm or 24hrs+since trauma
  • Trauma sticker and radiographic assessment
  • LA and dental dam
  • Clean area with saline then disinfect with sodium hypochlorite
  • Remove 2mm of pulp with hi-speed round diamond bur
  • Place saline soaked CW pellet over exposure until haemostasis acheived
  • If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy
  • Apply CaOH then GI then restore with quality composite
  • Follow up 6-8weeks/6months/1year
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25
Q

When and how to perform full coronal pulpotomy?

A
  • Begin with partial pulpotomy
  • Assess for haemostasis after application of saline soaked cotton wool
  • If hyperaemic or necrotic proceed to remove all coronal pulp
  • Place CaOH in pulp chamber
  • Seal with GIC lining and quality coronal restoration
    Follow up - 6-8weeks/6months/1year
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26
Q

what are the option for intra-canal medicament for trauma?

A
  • CaOH (dycal)
  • MTA white
  • bio dentine
  • bio ceramic (total fill)
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27
Q

What is the aim of pulpotomy?

A
  • To keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine
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28
Q

success rate of partial and full coronal pulpotomy?

A

Partial - 97%
full coronal - 75%

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29
Q

How to manage root treatment for immature incisors?

A
  • If tooth non-vital then full pulpectomy required
    Clinical problem - no apical stop to allow obturation with GP

Options
- CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification) - not ideal, increased root brittleness and risk of root #
- MTA/BioDentine placed at apex of canal to create cemenet barrier (apical plug)
- Regenerative Endodontic technique to encourage hard tissue formation at apex

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30
Q

What is the technique for Pulpectomy in open apex ?

A
  • Rubber dam
  • Gain access
  • Haemorrhage control (LA/sterile water)
  • Diagnostic radiographic for WL
  • File 2mm short of estimated WL
  • Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
  • Glass ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph

Place CaOH no longer than 4-6weeks after identified as non vital as problems with CaOH apexification - risk of root #

  • MTA plug and heated GP obturation

Final coronal restoration

  • Once obturation complete
  • Consider bonded composite short way down canal as well as in access cavity
  • Bonded core
  • Try to avoid post crown (invasive, root #)
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31
Q

What are the treatment options for crown-root fracture no pulp exposure?

A
  • Fragment removal only and restore
  • Fragment removal and gingivectomy (indicated in # with palatal subgingival extension)
  • Decoronation (Preserve bone for future implant)
  • Surgical extrusion
  • Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
  • Extraction (last choice)
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32
Q

What are the treatment options for crown-root fracture with pulp exposure?

A
  • Can be temporised with composite for up to 2weeks
  • Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
  • Decoronation (Preserve bone for future implant)
  • Surgical extrusion
  • Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
  • Extraction (last choice)
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33
Q

How can the nature of the trauma be described?

A
  • Separation injury (extrusion)
  • Crushing injury (intrusion)
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34
Q

Management of permanent tooth concussion

A

no tx
follow up: clinical and radiograph 1 month, 1 year

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35
Q

Management of permanent tooth subluxation

A
  • no tx required
  • splint if excessive mobility/ tender to bite
  • follow up: clinical and radiograph 2 weeks (spint removal), 3 mo, 6 mo, 1 year
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36
Q

What are the critical factors related to an avulsion injury?

A
  • Extra-alveolar dry time (EADT)
  • Extra-alveolar time (EAT)
  • Storage medium
37
Q

In avulsion, when is PDL viable and non-viable ?

A
  • PDL viable mostly (replanted immediately or v shortly after)
  • PDL viable but compromised (kept in saline/milk, total dry time <60 mins)
  • PDL non-viable (dry time >60 mins regardless of what happened after this time)
  • After dry time of 60 mins or more, ALL PDL cells are NON VIABLE
38
Q

What is the emergency advice for an avulsed tooth?

A
  • Ensure permanent tooth
  • Hold by crown
  • Encourage attempt to place tooth immediately into socket
  • If the tooth dirty, rinse it gently in milk, saline or in the patient’s saliva and replant
  • Bite on gauze/handkerchief to hold in place once replanted
  • Seek immediate dental advice
39
Q

What are the only storage medium you should place an avulsed tooth into?

A
  • Milk (Most preferred)
  • HBSS (Hanks balanced salt solution)
  • Saliva
  • Saline
  • Water (poor medium and least preferred)
    Avoid dehydration of tooth tissue
40
Q

How to manage an avulsed tooth with a closed apex that has already been replanted?

A
  • Clean the injured area
  • Verify replanted tooth position and apical status
  • Clinical & radiographic
  • Place passive flexible splint (2 weeks)
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-op instructions
  • Follow up 2weeks splint removal/4weeks/3months/6months/1year/annually for 5years

Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks

41
Q

How to manage an avulsed tooth with EADT<60mins?

A
  • PDL cells may be viable but compromised
  • Remove debris
  • History & examination with tooth in storage medium
  • Replant tooth under LA
  • Splint 2 weeks
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks/4weeks/3months/6months/1year/annually for 5years

Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks

42
Q

How to manage an avulsed tooth with closed apex with EADT > 60mins?

A
  • PDL cells likely to be non-viable
  • Remove debris
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks/4weeks/3months/6months/1year/annually for 5years

Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks

43
Q

How does delayed replantation affect prognosis on permanent tooth with closed apex?

A
  • Poor long term prognosis (ankylosis-related root resorption)
  • Decision to replant almost always correct
  • Referral to Paediatric Specialist/ Inter-disciplinary management
44
Q

How to manage an avulsed permanent tooth with an open apex that has already been replanted?

A
  • Clean the injured area
  • Verify replanted tooth position and apical status
  • Clinical & radiographic
  • Place splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks splint removal/1month/2month/3month/6month/1year/annually for 5years
45
Q

How to manage an avulsed tooth with open apex that has EAT < 60mins?

A
  • Has potential for spontaneous healing
  • Remove debris
  • History & examination with tooth in storage medium
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks splint removal/1month/3month/6month/1year/annually for 5years
46
Q

How to manage an avulsed tooth with open apex with EAT >60mins?

A
  • PDL cells likely to be non-viable
  • Likely outcome is ankylosis-related (replacement) root resorption
  • Remove debris
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks splint removal/1month/3month/6month/1year/annually for 5years
47
Q

What is the aim of an avulsed tooth with open apex?

A

Revascularisation!
- Further development vs risk of external infection-related (inflammatory) root resorption
- Close monitoring
- Endodontic treatment if definite signs of pulp necrosis and infection of root canal system

48
Q

what is MTA

A

Mineral trioxide aggregate

49
Q

When do you not replant an avulsed permanent tooth?

A

Even as a temporary space maintainer - the right choice is usually to replant

Medical contraindications?

  • Child immunocompromised
  • Other serious injuries requiring preferential emergency treatment

Dental contraindications?

  • Very immature apex and extended EAT (>90mins)?
  • Very immature lower incisors in young child finding it difficult to cope?
50
Q

What is the 5year pulp survival rate of avulsion for open apex and closed apex?

A

Open - 30%
Closed - 0%

51
Q

what is the 5 year reosption rate of avulsed/ replanted tooth

A

frequent

52
Q

What are the clinical findings of a dento-alveolar fracture of permanent tooth?

A
  • Fracture of alveolar bone which may or may not involve the alveolar socket
  • Complete alveolar fracture extending from the buccal to the palatal bone in the maxilla and from the buccal to the lingual bony surface in the mandible
  • Segment mobility and displacement with several teeth moving together
  • Occlusal disturbance
  • Gingival laceration
53
Q

How to manage a dento-alveolar fracture?

A
  • Reposition any displaced segment
  • Stabilise by splinting 4 weeks
  • Suture gingival lacerations if present
  • Monitor the pulp condition of all teeth involved

Monitor clinically and radiographically for
- Root development
- Resorption

Follow up 4weeks inc splint removal/6-8weeks/4months/6months/1year/annually for 5years

Risk of pulpal necrosis if closed apex is 50% at 5 years

54
Q

Post-op advice for dento-alevolar fracture?

A
  • Soft diet for 7 days
  • Avoid contact sport whilst splint in place
  • Careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12% at separate time of brushing
55
Q

What are the splinting times for each injury to permanent teeth?

A
56
Q

What are the splint properties?

A
  • Flexible and passive
  • Ease of placement/ removal
  • Facilitate sensibility testing/ clinical monitoring
  • Allow oral hygiene
  • Aesthetic
57
Q

fucntion of splint

A
  • maintian reposition in correct position
  • favour initial healing and
  • providing comfort and controlled fx
58
Q

What are the types of splint?

A

Chair side
- Composite & wire gold standard
- Titanium trauma splint gold standar
- Composite
- Orthodontic brackets & wire (must be passive to avoid extra trauma to teeth)
- Acrylic

Lab-made
- Vacuum-formed splint
- Acrylic (useful when few abutment teeth)

59
Q

What is a composite and wire splint?

A
  • Stainless steel wire up to 0.4mm in diameter
  • Quick and easy
  • Ensure placed passively
  • Flexible (include one tooth either side of traumatised tooth/teeth)
  • Don’t place near gingival margin as this can be plaque retentive factor
60
Q

What is a titanium trauma splint (TTS)?

A
  • Rhomboid mesh structure
  • Passive and flexible
  • 0.2mm thick
  • Easily adaptable with fingers
  • Secured with composite resin
61
Q

when is acrylic splint used?

A
  • only few abutment teeth
  • gives full palatal coverage
  • acrylic extended to incisal and labial of ant teeth
62
Q

What are the main post-trauma complications?

A
  • Pulp Necrosis & Infection
  • Pulp Canal Obliteration
  • Root Resorption
  • Breakdown of Marginal Gingiva and Bone
63
Q

What is pulp canal obliteration (PCO)?

A
  • Response of a vital pulp to traumatic injury
  • Progressive hard tissue formation within pulp cavity
  • Gradual narrowing of pulp chamber and pulp canal - Result in total or partial obliteration
  • Can become opaque or slightly yellow
    Treatment:
  • Conservative management, only 1% may give rise to PAP
64
Q

What are the types of root resorption?

A

External
- Surface
- External infection related IRR (inflam root resorption)
- Prev known as external inflammatory resorption
- Cervical
- Ankylosis related RRR (replacement root resorption)

Internal
- Internal infection related IRR (inflam root resorption)
- Prev known as internal inflammatory resorption

65
Q

What is external surface resorption?

A
  • Superficial resorption lacunae are repaired with new cementum
  • Response to localised injury in vital teeth
  • Not progressive
  • occurs in vital tooth
66
Q

What is external infection related Inflammatory root resorption (IRR)?

A
  • Occurs in Non-vital tooth with infected pulp canals

Initiated by PDL damage following trauma
- But Propagated by root canal toxins reaching external root surface through patent dentinal tubules

  • Rapid
  • Can cause cervical resoprtion
    Diagnosis:
  • Indistinct root surface; root canal tramlines intact
  • External contour of root, surrounded by bony lucency
67
Q

How to manage external infection related IRR?

A
  • Remove stimulus by removing infected canal content
    Endodontic treatment
  • Non-setting CaOH for 4-6 weeks
  • Obturate with GP
68
Q

What is ankylosis related RRR?

A

Initiated by severe damage to PDL and cementum.
- Normal repair does not occur
- Bone cells faster than PDL fibroblasts

Root involved in remodelling
- Radiograph: ‘Ragged’ root outline; no obvious PDL space

Speed of progression is variable and infraocclusion due to alveolar bone development

69
Q

tx for ankylosis related RRR

A

Treatment - No effective treatment and plan for loss once discrepancies in gingival margins of affected tooth compared to contralateral tooth is lower than 3mm then plan loss - assessed by multidisciplinary team
consider decoronation

70
Q

what type of injury would mostly likely lead to ankylosis related RRR

A
  • luxation
  • avulsion
71
Q

What is internal infection related IRR?

A
  • Due to progressive pulp necrosis
  • Infected material via non-vital coronal part of canal propagates resorption by underlying tissue and rapid tissue destruction follows

Radiographic
-Symmetrical expansion of root canal walls (‘ballooning’ of canal)
- Tramlines of root canal are indistinct; root surface intact

72
Q

How to manage internal infection related IRR?

A
  • Remove stimulus of infected canal
  • Endodontic treatment prompt after diagnosis
  • Non-setting CaOH for 4-6 weeks
  • Obturate with GP
  • If progressive, plan for loss
73
Q

What is the 5year pulp survival rate of concussion injury?

A

Open apex - 100%
Closed apex - 95%

74
Q

What is the 5year pulp survival rate of subluxation injury?

A

Open apex - 100%
Closed apex - 85%

75
Q

What is the 5year resorption rate of concussion and subluxation injury?

A

Open apex - 1%
Closed apex - 3%

76
Q

How to manage an extrusion injury?

A
  • Reposition the tooth by gently pushing It back into the tooth socket under local anaesthesia
  • Flexible Splint 2 weeks

Follow up 2weeks inc splint removal /4weeks/2months/3months/6months/1year/annually for 5years

77
Q

What is the 5year pulp survival rate of extrusion injury?

A

Open apex - 95%
Closed apex - 45%

78
Q

What is the 5year resorption rate of extrusion injury?

A

Open apex - 5%
Closed apex - 7%

79
Q

How to manage permanent tooth lateral luxation injury?

A
  • Reposition under LA
  • passive flexible Splint 4 weeks
  • Monitor pulp with sensibility test
  • Endodontic evaluation (approx. 2/52 post-injury)

Follow up 2weeks/4weeks splint removal/2months/3months/6months/1year/annually 5years

80
Q

What happen when tooth with lateral luxation injury has incomplete root formation?

A
  • Spontaneous revascularisation may occur
  • If the pulp becomes necrotic and signs of inflammatory (infection-related) external resorption commence endodontic treatment
81
Q

What happens when tooth with lateral luxation injury has complete root formation?

A
  • The pulp will likely become necrotic
  • Commence endodontic treatment
  • Corticosteroid-antibiotic or CaOH as intra-canal medicament to prevent the development of inflammatory (infection-related) external resorption
82
Q

What is the 5year pulp survival rate of lateral luxation injury?

A

Open apex - 95%
Closed apex - 25%

83
Q

What is the 5year resorption rate of lateral luxation injury?

A

Open apex - 3%
Closed apex - 38%

84
Q

How to manage a permanent tooth intrusion injury with immature root formation?

A
  • Spontaneous repositioning independent of the degree of intrusion
  • If no re-eruption within 4 weeks: orthodontic repositioning
  • Monitor the pulp condition
  • Spontaneous pulp revascularisation may occur
  • If pulp becomes necrotic and infected or signs of inflammatory (infection-related) external resorption: endodontic treatment, as soon as possible when the position of the tooth allows

Follow up 2weeks/4weeks inc splint removal/2months/3months/6months/1year/annually 5years

85
Q

How to manage intrusion injury with mature root formation?

A

<3mm:
- Spontaneous repositioning
- If no re- eruption within 8 weeks: reposition surgically and splint for 4 weeks OR reposition orthodontically before ankylosis develops

3 -7mm:
- Reposition surgically (preferably) or orthodontically

> 7mm:
- Reposition surgically

Pulp almost always becomes necrotic so start Endodontic treatment at 2weeks or as soon as tooth position allows and aim to prevent development of inflammatory (infection-related) external resorption

Follow up 2weeks/4weeks inc splint removal/2months/3months/6months/1year/annually 5years

86
Q

how to monitor if spontaneous eruption is happening

A
  • measure distance of incisal edge to adj tooth
    for mixed dentition
  • study model
  • ## clinical radiograph
87
Q

What is the 5year pulp survival rate of intrusion injury?

A

Open apex - 40%
Closed apex - 0%

88
Q

What is 5year resorption rate of intrusion injury?

A

Open apex - 67%
Closed apex - 100%

89
Q
A

BDS3 Paeds (13 decks)

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