Dental Trauma Flashcards
dental trauma in kids is mainly in what teeth
maxillary primary incisor teeth
concussion
tooth tender to touch but not displaced. PDL tissue affected, normal mobility but no bleeding into gingival sulcus
subluxation
tender to touch, mobility increased but not displaced, bleeding from gingival crevice noticed
3 types of luxation injuries
- lateral luxation
- intrusion
- extrusion
lateral luxation
tooth displaced in a palatal / lingual / labial direction i.e. any direction other than axial along with comminution or fracture of alveolar bone
intrusion
tooth displaced through labial bone plate into alveolar bone with comminution or fracture to alveolar bone, can impinge on permanent tooth bud
extrusion
partial displacement of tooth out of it’s socket
avulsion
tooth is completely out of the socket, can be found imbedded in lips, cheeks, tongue, ingested or inhaled
what should happen if an avulsed tooth is not found
child should be sent for a medical assessment in the emergency department
7 steps when managing a patient who comes in with trauma
- reassurance
- history
- exam
- diagnosis
- emergency treatment
- important information
- further treatment & review
what to look for in extraoral trauma exam
- lacerations
- haematoma
- haemorrhage / CSF
- subconjunctival haemorrhage
- bony step deformities
- mouth opening
what to look for in intraoral trauma exam
- soft tissues
- alveolar bone
- occlusion
- teeth
what is contained within a trauma stamp
mobility // colour // TTP // sinus // percussion note // radiograph
aftercare advice to give to parents
- analgesia - ibuprofen and/or paracetamol
- soft diet for 10-14 days
- brush with soft toothbrush after every meal
- topical chlorhexidine gluconate 0.12% mouth rinse applied topically 2x daily for 1 week
- warn re signs of infection
for an uncomplicated enamel dentine fracture
cover all exposed dentine with GI / composite, lost tooth structure can be restored immediately with composite or at a later visit
for a complicated crown fracture i.e. enamel, dentine, pulp
partial pulpotomy / extract
coronal / cervical pulpotomy = larger removal of pulp before CaOH, GIC and composite placement
action if crown root fracture but crown can be restored
- no pulp exposed - cover exposed dentine with GI
- pulp exposed - pulpotomy or endo
action if crown root fracture but crown is unrestorable
- extract loose fragments
- do not dig !
treatment for concussion
no treatment / observation
treatment for subluxation
no treatment / observation
may place passive flexible splint for 2wks if necessary
treatment for lateral luxation
- minimal / no occlusal interference = allow to reposition spontaneously
- severe displacement = extract OR reposition +/- splint but if splinting for 4wks caution should be taken to avoid damage to permanent successor
treatment for intrusion
allow to spontaneously reposition irrespective of direction of displacement
what radiographs should be used and why in an intrusion
use either periapical or lateral premaxilla (extra-oral film) to assess danger to permanent successor
treatment for extrusion
- not interfering with occlusion - allow for spontaneous repositioning
- excessive mobility or extruded >3mm then extract
treatment for avulsion of primary tooth
take radiograph to confirm avulsion but DO NOT REPLANT
treatment for alveolar fracture
reposition segment and stabilise with flexible splint for 4wks, teeth may need extracted after this
sequelae of trauma to primary tooth
- discolouration
- discolouration & infection
- delayed exfoliation
asymptomatic discolouration ( tooth can be vital / non vital )
mild grey - immediate discolouration may maintain vitality
opaque / yellow - pulp obliteration
no signs of pulp necrosis or infection
no treatment - review
symptomatic discolouration (non vital )
sinus, gingival swelling, abscess
increased mobility
radiographic evidence of periapical pathology
extract or endodontic treatment
what is enamel hypomineralisation
qualitative defect of enamel i.e. normal thickness but poorly mineralised, white / yellow defect
treatment of enamel hypomineralisation
no treatment
composite masking +/- localised removal
tooth whitening
what is enamel hypoplasia
quantitative defect of enamel i.e. reduced thickness but normal mineralisation, yellow / brown defect
treatment of enamel hypoplasia
no treatment
composite masking
what is dilaceration
abrupt deviation of the long axis of the crown or root portion of the tooth
crown dilaceration management options
surgical exposure & orthodontic realignment, improve aesthetics restoratively
root dilaceration / angulation / duplication management options
combined surgical and orthodontic approach
premature loss of a primary tooth can result in
delayed eruption of up to 1yr due to thickened mucosa
when would you take a radiograph to investigate delayed eruption
if > 6 month delay compared to contralateral tooth
management options of ectopic tooth
surgical exposure, orthodontic realignment, extraction
management options for arrested development of root
- endo - if favourable root length
- extraction
what is an odontoma
a slow growing, asymptomatic neoplasm found in the jaw usually associated with unerupted or impacted teeth
management of odontome formation
surgical removal
what is the most common injury in primary dentition
luxation injury
3 key aspects of MH that may influence treatment options
- rheumatic fever
- congenital heart defects
- immunosuppression
when carrying out tactile test with probe look for (2)
- fracture lines; horizontal / vertical, transillumination can help
- pulpal involvement
what is traumatic occlusion
can only bite on one displaced tooth - requires urgent treatment
how does percussion indicate root fracture
duller note may = root #
key feature when sensibility testing & viewing root surfaces on radiographs
always compare injured tooth with the adjacent non injured tooth and opposing teeth
5 things the prognosis depends on
- type of injury
- if PDL is also damaged
- time between injury & treatment
- presence of infection
- stage of root development
how to manage enamel fracture
- either bond fragment to tooth or grind sharp edges
- take 2 periapicals to rule out root fracture or luxation
- follow up 6/8wks, 6mths, 1yr
- prognosis = 0% risk of pulp necrosis
(no exposed tubules)
how to manage enamel dentine fracture
- account for fragment
- bond fragment to tooth or place composite bandage
- line restoration if fracture is close to pulp
- take 2 periapicals to rule out root fracture / luxation
- radiograph any lip / cheek lacerations to rule out embedded fragment
- sensibility testing & evaluate tooth maturity
- definitive restoration
- follow up 6/8wks, 6mths, 1yr
- prognosis = 5% risk of pulp necrosis at 10yrs
when following up trauma case you are checking radiographs for
- root development - width & length of canal
- comparison with other side
- internal + external inflammatory response
- periapical pathology
how to manage EDP fractures
- evaluate size of exposure, time since and associated PDL injuries
- choose between pulp cap / partial (Cvek) pulpotomy / full coronal pulpotomy
aim is to preserve pulp vitality and aim to avoid full extirpation unless tooth is clearly non vital
when would you carry out a direct pulp cap
if small exposure (1mm) and within 24hr window
how to carry out direct pulp cap
- trauma sticker & radiographic assessment
- should be non TTP and +ve to sensibility tests
- clean area with water, disinfect with sodium hypochlorite
- apply CaOH (Dycal) or MTA white to pulp exposure or biodentine (a bioceramic)
- restore
- review 6/8wks, 6mths, 1yr
when to carry out partial (Cvek) pulpotomy
larger exposure > 1mm, or 24+ hrs since trauma
how to carry out partial (Cvek) pulpotomy
- trauma sticker & radiographic assessment
- clean area with saline, disinfect with sodium hypochlorite
- remove 2mm of pulp using high speed round diamond bur
- place saline soaked CW pellet over exposure until haemostasis achieved
- if not achieved proceed to full coronal pulpotomy
- apply CaOH then GI or white MTA then restore
- review as with pulp cap
how to carry out full coronal pulpotomy
- begin with partial
- assess for haemostasis after application of saline soaked cotton wool
- if hyperaemic OR necrotic - proceed to remove all of coronal pulp
- place CaOH in pulp chamber
- seal with GIC lining and quality coronal restoration
issue with root treatment in immature incisors
if tooth non vital , full pulpectomy required but there is no apical stop to allow obturation with GP
options for full pulpectomy
- CaOH to induce apexification but no longer used as more likely to cause root fracture can place non setting CaOH but only for 4-6 wks after being identified as non vital
- MTA / BioDentine placed at apex of canal to create cement barrier
- regenerative endo technique to encourage hard tissue formation at apex
MTA plug and heated GP obturation
- need working length radiograph of open apex
- 3-4mm radiopaque material (likely MTA) placed in canal and condensed using pluggers / paper points
- thermal obturation - cut short around ACJ to prevent shine through of orange / pink to cervical aspect of tooth
- seal off with vitrebond / RMGI
why do thermal obturation
open apices = wide canals so cold lateral compaction is very time consuming
crown root fracture with no pulp exposure treatment options
- fragment removal only & restore
- fragment removal & gingivectomy - indicated in c-r fractures with palatal subgingival extension
- orthodontic extrusion of apical portion (endo, extrusion, post-crown)
- surgical extrusion
- decoronation - preserve bone for future implant
- extraction
crown root fracture with pulp exposure
- can be temporised with composite for up to 2wks
- fragment removal & gingivectomy - indicated in c-r fractures with palatal subgingival extension
- orthodontic extrusion of apical portion (endo, extrusion, post-crown)
- surgical extrusion
- decoronation - preserve bone for future implant
- extraction
in supporting tissues have to consider impact of injury on (3)
- surrounding bone
- neurovascular bundle
- root surface
separation injury
extrusive luxation where major part of injury consists of cleavage of cellular components e.g. collagen
crushing injury
intrusive luxation where extensive damage to cellular and intercellular systems
in lateral luxation if incomplete root formation
spontaneous revascularisation may occur
if pulp becomes necrotic & signs of inflammatory infection related external resorption then start endo treatment
in lateral luxation if complete root formation
pulp will likely become necrotic
start endo
corticosteroid antibiotic or CaOH as intra canal medicament to prevent development of inflammatory infection related external resorption
lateral luxation and intrusion both have what kind of percussion sound
high ankylotic percussion tone
treatment of intrusion in immature root
allow spontaneous repositioning
if no re eruption in 4wks - ortho repositioning
monitor pulp
spontaneous pulp revascularisation may occur
if it becomes necrotic / infected start endo
treatment of intrusion in mature root
<3mm - spontaneous repositioning, if no re eruption in 8wks reposition surgically and splint for 4wks or reposition orthodontically before ankylosis develops
3-7mm - reposition surgically or ortho
>7mm - reposition surgically
what often happens pulp in teeth with complete root formation after intrusion
pulp almost always becomes necrotic so start endo treatment at 2wks or as soon as tooth position allows to prevent development of inflammatory infection related external resorption
what shouldn’t you measure during intrusion and why
don’t measure from gingival margin to incisal edge as gingival margin is subject to change upon healing
follow up following intrusion
2/4/8/12 wks, 6mths, 1yr, annually for 5yrs
what constitutes complete healing
revascularisation and can only be expected in teeth with open apices when a luxation injury has occurred
what is a common complication following intrusion injury to teeth with closed apices
root resorption which may occur up to 5-10yrs after
what is EADT
extra alveolar dry time i.e. time the avulsed tooth is out of the mouth
what is EAT
extra alveolar time i.e. total time an avulsed tooth is out of the mouth either dry or in a storage medium
what 3 PDL factors must be taken into consideration following an avulsed tooth
- if PDL is mostly viable - replanted immediately or v shortly after
- if PDL viable but compromised - kept in saline / milk, total dry time <60mins
- PDL non viable - dry time > 60mins regardless of what happened after this time all PDL cells are non viable
what emergency advice to give when tooth avulsion
- ensure it is a permanent tooth
- hold by crown
- encourage attempt to place tooth immediately into socket - rinse gently in milk/saline/person’s saliva and replant
- bite on gauze to hold in place
- seek immediate dental advice
appropriate storage mediums in order of decreasing suitability
- milk
- HBSS
- saliva
- saline
- water
2 main factors to consider with an avulsed tooth
- maturity of the root
- PDL cell condition - depends on time spent out of the mouth and medium in which avulsed tooth is kept
management for avulsed tooth with closed apex already replanted
- clean injured area using chlorhexidine
- verify replanted tooth position & apical status clinically & radiographically
- leave in place unless malpositioned and if incorrect using digitation can reposition for up to 48hrs post avulsion
- place passive flexible splint
- suture gingival lacerations if present
- consider antibiotics & check tetanus status
- provide post op instruction
- follow up
management of avulsed tooth with closed apex & EADT <60mins
PDL cells may be viable but compromised
- remove debris using saline
- history & exam with tooth in storage medium
- correct position to be verified clinically & radiographically
- replant tooth under LA
- splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instructions
- follow up
management of avulsed tooth with closed apex & EADT >60mins
PDL cells likely to be non-viable
- remove debris & irrigate socket with sterile saline
- history & exam with tooth in storage medium
- correct position to be verified clinically & radiographically
- replant tooth under LA
- splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instructions
- follow up
endo treatment for avulsed permanent tooth with closed apex
- should begin within 2wks
- CaOH recommended as intracanal medicament for up to 1 mth
- if corticosteroid / antibiotic corticosteroid mix is used as anti-inflam an anti-resorptive intracanal medicament should be placed immediately after and left in situ for at least 6wks
- should be applied carefully to root canal itself and not crown as this can cause discolouration
management of avulsed tooth with delayed replantation
- poor long term prognosis; pdl becomes necrotic and not expected to regenerate so ankylosis-related root resorption
- decision to replant almost always correct
- refer to specialist / inter-disciplinary management
what is the aim of replantation
to restore aesthetic and function temporarily while maintaining alveolar bone contour, width & height
ultimate goal is revascularisation
management of avulsed tooth with open apex if tooth already replanted
- clean using saline or chlorhexidine
- verify replanted tooth position & apical status clinically + radiographically
- correct malposition using digital pressure if necessary
- place splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instruction
- follow up
management of open apex tooth with EAT > 60mins
PDL cells likely to be non-viable, likely outcome is ankylosis related root resorption
- remove debris and clean using saline or chlorhexidine
- replant under LA
- correct malposition using digital pressure if necessary
- place splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instruction
- follow up
is replanting the correct decision
even as a temporary space maintainer the right choice is usually to replant
when should you not replant
- child = immunosuppressed
- other serious injuries requiring preferential emergency treatment
- very immature apex and extended EAT >90mins
- very immature lower incisors in young child finding it difficult to cope
what is a dento-alveolar fracture
fracture of the alveolar bone which may or may not involve the alveolar socket
clinical findings of a dento-alveolar fracture
- complete alveolar fracture extending from the buccal to palatal bone in the maxilla and from the buccal to lingual bony surface in the mandible
- segment mobility and displacement with several teeth moving together
- occlusal disturbance
- gingival laceration
treatment for dento-alveolar fracture
reposition any displaced segment
stabilise with passive flexible splint for 4wks
suture gingival lacerations if present
monitor pulp condition & root development of all teeth involved
advice to give following treatment for dento-alveolar fracture
- soft diet for 7 days
- avoid contact sport whilst splint is in place
- careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12%
what injuries would you splint for 2/52
subluxation
extrusive luxation
avulsion
what injuries would you splint for 4/52
intrusive luxation
lateral luxation
root # - mid root & apical 1/3
dento-alveolar #
what injuries would you splint for 4/12
root # - cervical 1/3
why choose a splint
- flexible and passive
- ease of placement / removal
- facilitate sensibility testing / clinical monitoring
- allows oral hygiene
- aesthetic
2 main categories of splint
- chair-side
- lab-made
types of chair-side splint
composite & wire
titanium trauma splint
composite
orthodontic brackets & wire
acrylic
types of lab-made splint
vacuum formed splint
acrylic
composite & wire splint
stainless steel wire up to 0.4mm diameter
ensure passive
flexible = includes one tooth either side of traumatised tooth/teeth
titanium trauma splint
rhomboid mesh structure
0.2mm thick
secured to teeth with composite resin
4 main post trauma complications
- pulp necrosis & infection
- pulp canal obliteration
- root resorption
- breakdown of marginal gingiva & bone
pulp canal obliteration
- response of vital pulp
- progressive hard tissue formation within pulp cavity
- gradual narrowing of pulp chamber & canal; total or partial obliteration
- commonly seen in luxation
- affected tooth can take on opaque / yellow tinge
treatment = conservative
2 main types of root resorption
- external
- internal
types of external root resorption
- surface
- external infection related IRR
- cervical
- ankylosis related RRR
types of internal root resorption
- internal infection related IRR
external surface resorption
superficial resorption lacunae repaired with new cementum
response to localised injury
not progressive
external infection related IRR
non vital tooth
initiated by PDL damage; propagated by root canal toxins reaching external root surface via dentinal tubules
diagnosis - indistinct root surface; root canal tramlines intact
external infection related IRR
rapid
remove stimulus & endo treatment; non setting CaOH for 4-6wks obturate with GP
cervical resorption
ankylosis related RRR
initiated by severe damage to PDL & cementum; normal repair does not occur, bone cells than PDL fibroblasts
severe luxation or avulsion
root involved in remodelling - radiograph has ‘ragged’ root outline, no obvious PDL space
speed variable - infraocclusion due to alveolar bone development
treatment = plan loss
decoronation & ankylosis related RRR
alveolar bone of affected region will move further in apical direction. once gingival margin of ankylosed tooth is >3mm compared to contralateral unaffected tooth, should consider decoronation of ankylosed tooth
internal infection related IRR
due to progressive pulp necrosis - infected material via non-vital coronal part of canal propagates resorption
radiograph - symmetrical expansion of root canal walls, tramlines of root canal are indistinct, root surface intact
treatment = remove stimulus & endodontic treatment
