avulsion and luxation injuries Flashcards
what is concussion to primary and permanent teeth?
> No abnormal loosening, bleeding or displacement but TTP
> oedema and haemorrhage in the PDL
> Quite often Primary tooth concussion injuries will not attend dentist
what is the management for concussion in primary and perm teeth?
> Check sensibility (unreliable in primary)
> IOPA
> Reassure, educate and analgesia advice
> soft diet for 1 week
> Good OH ( +0.2%Chlorhex swab/mw bd for 1 week)
> Monitor
what is subluxation in the primary/ perm dentition?
> Abnormal loosening, but no displacement
> Mobile, TTP, +/ - bleeding
> No abnormal radiological findings
what is the management of subluxation in a primary tooth ?
> Reassure and analgesia advice
> 1-2/52 soft diet
> Good OH
> Monitor
*Good OH consider Chlohexidene MW/swab
what is the management of subluxation in a perm tooth?
> Check sensibility (informs prognosis)
> Reassure and analgesia advice
> 1-2/52 soft diet
> Good OH
> Consider flexible splint (2/52) if very mobile/ tender or closed apex
> Monitor
when would you use a flexible/ physiological splint?
> if there is 1 tooth either side
when would you use a rigid splint?
> when there is over 1 tooth either side
what are example of direct splints?
> Composite and wire
> Composite and titanium trauma splint
> Orthodontic bracket and wire
> Foil -cement
> Composite/ acrylic
what are examples of indirect splints?
> Acrylic
> Thermoplastic
what is lateral luxation?
> displacement of the tooth in any lateral direction
what is the management of lateral luxation in primary teeth?
> No/minimal occlusal interference
- Spontaneous repositioning
> Severe
- Extraction
- Reposition and splint
- Risk (high)/benefit discussion pre treatment
- Consider stability/ splint placement / R/O etc
> 10-14/7 soft diet
> Good OH
> Monitor
what is extrusion in a primary tooth?
> partial displacement of tooth out of socket
what is treatment of exclusion based off?
> Degree of displacement
> Mobility
> Interference with occlusion
> Root formation
> Splint options (co-op)
what is the management of extrusion?
> If no occlusal interference conservative
> excess mobility or >3mm extract under LA
> 1-2/52 soft diet
> Good OH
> reassurance and analgesia advice
> Monitor
what is extrusive luxation?
> Lateral luxation-displacement other than axially, with comminution or fracture of alveolar plate
what is the treatment for extrusion and lateral luxation in a permeant tooth?
> Reposition (after cleansing of tooth surface)
- +/- LA
- Digital
- Orthodontic appliances (if digital fails)
> Splint
- Flexible
- Lateral 4/52
- Extrusive 2/52
> Pt instructions
+/- antibiotics
Monitor
when a tooth has intruded what is important to assess?
> Important to assess degree of intrusion as informs treatment
> Age of patient
> History of previous position
> Other teeth
> Radiograph
- Compare cej, apices
> Previous dental treatment
> A large force is required to severely intrude teeth so be aware of the possibility of other injuries – adjacent teeth, head injury
what is the treatment of an intruded primary tooth?
> Monitor for reeruption
- Usually within 6 months-1year
> 10-14/7 soft diet
Reassurance and analgesia advice
Good OH
Monitor
what are the treatment aims and options for intrusion of a permanent tooth?
> Aims to maintain the tooth if possible
> Treatment options
- Monitor only +/- orthodontics later
- Monitor for up to 4 weeks if no movement -» Ortho
- Immediate orthodontic extrusion
- Surgical repositioning
> Consider pulp therapy and timing
what are the 2 repositioning techniques?
> orthodontic
> surgical
what is orthodontic repositioning?
> A removable appliance with a self-supporting spring or elastic module to apply vertical extrusive force through a bracket bonded onto the labial or incisal surface.
> UFA (sectional)
what is surgical repositioning?
> LA (Sedation or GA may be required)
> Gentle movements with a flat plastic instrument/forceps
> If resistant, consider if a bony impaction is present and release this before repositioning the labial plate of bone and soft tissue closure and suturing.
> Splint 4/52
> benefits? = reduced number of visits, rapid access for RCT
what is the IADT - dental traumaa guide guidelines for open and closed apex intrusions?
> open apex =
- monitor up to 4/52
- then orthodontic
> closed apex
- up to 3mm = monitor +/- ortho/ surgery
- 3-7mm = ortho/ surgery
- over 7mm = surgery
what is the follow up management of intrusion in permanent teeth?
> Incomplete Apex
- Monitor
- If signs or symptoms of pulp death start RCT with apexification
> Closed Apex
- Elective pulp extirpation will be necessary for all intrusive luxation injuries on closed apex teeth
- Within 2 weeks of the injury
- Keep dressed with calcium hydroxide paste until any inflammatory resorption has stopped
what are the indication to use antibiotics during trauma?
> Contamination
> Additional injury to soft tissues or other injuries
> Significant surgical intervention
> Medical condition rendering more prone to infections
> Always for reimplantation in permanent teeth
what type of antibiotics are used for trauma injuries?
> First line amoxicillin or penicillin based unless CI/ allergy
- > 12 yrs doxycycline based as alternative
what is the management of avulsion at the site of injury?
> offer advice over the telephone
> Plan A =
- Re-implant immediately
- Contaminated -rinse in milk or saline or saliva
- Avoiding handling of the root surface
- Hold tooth in place by biting on folded handkerchief or napkin
- Attend dental surgeon immediately
> Plan B =
- If re-implantation not possible store in suitable storage medium - in order of preference:
- Cold fresh milk
- Hank’s Balanced Salt Solution
- Saliva (buccal sulcus or spit in a cup)
ATTEND DENTIST IMMEDIATELY
what history would you need to take for avulsion?
> Avoid unnecessary delay before re-implantation
> During examination place in suitable storage medium if not currently in one
> Thorough medical, dental and accident history
what are the treatment options for a patient who’s experienced avulsion if not already reimplanted?
> LA if patient co-operation allows
> Reimplant ASAP!
- Keep pt calm
- Prepare socket
- No unnecessary manipulation
- If clot present gently irrigate with saline in syringe and use suction to remove clot
- Avoid curettage
- Reposition any bone fragments
> Handling Tooth
- Don’t touch root
- If contaminated wash in normal saline
> Push tooth gently into socket
> If obstructed by alveolar bone fragments gently use blunt instrument to reposition bone
> Check position
> Splint (if already reimplanted start here (after History and Exam)
- Flexible splint for 2 weeks
- Check occlusion
- +/- sutures
> Advise soft diet, good oral hygiene (soft tooth brush and chlorhexidine mouth rinse), avoid contact sports
> Follow-up
what does the IADT advise for avulsion in open apex teeth?
> Reimplanted prior to Clinic attendance
- Antibiotics +/ - tetanus
- Splint 2 wks
- Flexible
- Avoid contact sports
- Avoid RCT unless signs
> EODT <60 mins
- Reimplant
- Antibiotics +/ - tetanus
- Splint 2 wks
- Flexible
- Avoid contact sports
- Avoid RCT unless signs
> EODT >60 mins (or non-physiologic media)
- Reimplant
- Antibiotics +/- tetanus
- Splint 2 wks
- Flexible
- Avoid contact sports
- Avoid RCT unless signs
what does the IADT advise for avulsion in closed apex teeth?
> Reimplanted prior to Clinic attendance
- Antibiotics +/ - tetanus
- Splint 2 wks
- Flexible
- Avoid contact sports
- RCT within 2 wks
Calcium Hydroxide 1mth
> EODT <60 mins
- Reimplant
- Antibiotics +/ - tetanus
- Splint 2 wks
- Flexible
- Avoid contact sports
- RCT within 2 wks
Calcium Hydroxide 1mth
> EODT >60 mins (or non-physiologic media)
- Reimplant
- Antibiotics +/- tetanus
- Splint 2 wks
- Flexible
- Avoid contact sports
- RCT within 2 wks
Calcium Hydroxide 1mth
when do you not reimplant a tooth?
> Primary teeth
> Other injuries
- Where other injures are severe and require preferential emergency treatment
> Medical history
- Depressed immunity eg. Acute lymphoblastic anaemia
- If in doubt liaise with physician
> Immature permanent tooth with short wide open apex and prolonged extra-oral time
- Replacement resorption is inevitable
> Gross contamination/ long time out
> Grossly carious tooth
> Severe periodontal disease
> Patient choice
what is the follow up management for avulsion?
> Ideally review within 48 hrs
- Check splint and modify if necessary
- Reinforce OH and soft diet
> Review 2 weeks
- Radiograph prior to splint removal
- Commence RCT if indicated
- Remove splint
what is a critical survival factor for avulsion trauma?
> Periodontal ligament survival is critical factor
> Dry storage time is most important factor
Wet time less critical
Contamination of root adverse effect
Handling root adverse effect
what decreases inflammatory resorptions in avulsion?
Prompt RCT decreases inflammatory resorption
what are examples of injuries to supporting bone?
> Comminution of alveolar socket wall
> Fracture of alveolar socket wall
> Fracture of mandibular or maxillary alveolar process
> Fracture of mandible or maxilla
what is a clinical appearance of an alveolar fracture?
> Mobility of several teeth ‘en bloc’
> Displacement, Occlusal interference, TTP
> take radiographs
what is the treatment for an alveolar fracture?
> Debridement
> LA/GA Reposition
> Soft tissue repair
> Flexible Splint 4/52
> Soft diet
> Antibiotics
> Good OH
> Monitor
