dental trauma Flashcards
gender ratio
M:F 3:1
Guideline
IADT
international association of dental traumatology
what % aren’t treated and why?
70%
lots minor
commonest type in primary dentition
luxation (soft bone)
commonest type in permanent dentition
ED fracture
peak age
7-10yrs
what OJ doubles risk of trauma?
> 9mm
HPC
other symptoms - A and E, head injury/LOC
when
how
where are lost teeth/fragments
MH
rheumatic fever - IE risk
congenital heart defects - IE risk
immunosuppression - infection risk
may need additional tx
EO exam
laceration haematomas haemorrhage/CSF - straw coloured coming out of nostril medially/ear subconjunctival haemorrhage bony step deformities - mandible and zygomatic arch mouth opening
rule out facial or jaw #s
IO exam
ST
alveolar bone
occlusion
teeth
foreign bodies
account for
check for ST damage
ST radiograph to check lacerations (puncture wounds)
trauma stamp components - longitudinal monitoring
8
sinus
colour
TTP
mobility
sensibility tests - ECL, EPT
p note
radiograph
occlusion
what does TTP indicate?
PDL injury
what can mobility indicate?
tooth displacement
bone #
root #
tactile test with probe - what to look for
# lines pulpal involvement
what do sensibility tests test?
nerve
where should Ethyl Chloride be placed?
incisal 1/3 unless Rx
what should sensibility tests be compared with?
adjacent and opposing teeth (may be injured)
contralateral
continue for at least 2yrs
dull p note
root #
traumatic occlusion
demands urgent tx
what do you need for a real vitality test?
laser doppler flowmetry
LDF
measure the blood flow within the dental pulp
classification of C and R #s
- E#
- ED#
- EDP#
- CR#
- root #
- apical 1/3 - best
- middle 1/3
- coronal 1/3
complicated - pulp involved
which type of root # is the best and why?
apical 1/3 - heal better, calcified tissue
prognosis of a traumatised tooth depends on
5
type of injury
if PDL is damaged too
time between injury and tx
infection
stage of root development
emergency tx aims
- retain vitality ‘dentine bandage’
-composite/ (GI) - tx exposed pulp
- reduction and immobilisation of displaced teeth
-
tetanus prophylaxis
- check up to date, if injury particularly dirty
(ABs? - immunocompromised)
intermediate tx
+/- pulp tx
Rx - min invasive
permanent tx
apexigenesis apexification root filling +/- root extrusion gingival and alveolar collar modification if required coronal Rx
how to manage E#
- bond fragment OR
- grind sharp edges
/
take 2 PAs to rule out root # or luxation
/
follow up 6-8wks, 6mo and 1yr
E# risk of pulpal necrosis
0%
ED# management
- account for fragment
- bond fragment or
- composite ‘bandage’ - line if close to pulp
/
- 2 PAs to rule out root # or luxation
- radiograph any lip/cheek lacerations to rule out embedded fragment
- sensibility testing and evaluate tooth maturity
- definitive Rx
/
follow up 6-8wks , 6mo and 1yr
ED# risk of pulpal necrosis
5% at 10yrs
ED# accounting for fragment
- ground
- ST - radiograph any lip/cheek lacerations to rule out embedded fragment
- swallowed
- inhalation
- R bronchus - straighter
- coughing/wheezing - send for chest xray
clinical review
trauma stamp
radiographic review
- root development - width of canal and length
- comparison with other side
- internal and external inflammatory resorption
- PAP
effect of associated injuries on pulpal survival - ED# - concussion
open - 95%
closed - 85%
effect of associated injuries on pulpal survival - ED# - subluxation
open - 80%
closed - 50%
effect of associated injuries on pulpal survival - ED# - extrusion
open - 60%
closed - 20%
effect of associated injuries on pulpal survival - ED# - lat luxation
open - 65%
closed - 15%
effect of associated injuries on pulpal survival - ED# - intrusion
0% for open and closed
aim of EDP# tx
preserve pulp vitality
EDP# evaluating exposure
size
time since injury
associated PDL injury
EDP# tx options
- pulp cap
- partial pulpotomy (Cvek)
- full coronal pulpotomy
avoid full extirpation unless tooth clearly non-vital
what is a full coronal pulpotomy?
remove all pulp in pulp chamber
when is a direct pulp cap indicated for an EDP#?
- tiny exposure 1mm
- < 24hrs
- non-TTP and positive to sensibility tests
stages of a direct pulp cap
LA and dam
clean area with water then disinfect with NaOCl
apply sCaOH (Dycal) / MTA white
composite Rx
direct pulp cap for EDP# review
6-8wks, 6mo, 1 year
when is a partial (Cvek) pulpotomy indicated for an EDP#?
- larger exposure >1mm
or
- 24 + hours since trauma
stages of a partial (Cvek) pulpotomy?
- LA and dam
- clean area with saline then disinfect with NaOCl
- remove 2mm pulp with HS round diamond bur (SS pulls out too much)
- place saline soaked CW pellet over exposure until haemostasis
- if no bleeding/can’t arrest proceed to full coronal pulpotomy
- ns CaOH then Vitrebond (or white MTA)
- composite
full coronal pulpotomy
- start with partial pulpotomy
- assess for haemostasis after application of saline-soaked CW
- if hyperaemic or necrotic - remove all coronal pulp
- nsCaOH in pulp chamber, GIC lining, Rx
- reactive tertiary dentine barrier should form
success of pulpotomies
partial (Cvek) - 97%
vs
Full coronal - 75%
aim of pulpotomies
- keep vital pulp within canal to
- allow normal root growth (apexogenesis) both in length of root and D thickness
follow up of pulpotomies
6-8wks, 6 mo, 1 year
EDP# non-vital - open apex
full pulpectomy
need apical stop to allow obturation with GP
apical stop to allow obturation with GP
- CaOH to induce apexification
- MTA/Biodentine at apex to create cement barrier
- Regenerative endodontic technique
open apex pulpectomy
- dam and access
- haemorrhage control: LA/sterile water
- diagnostic radiograph for WL
- file 2mm short of EWL
- dry canal, nsCaOH, CW in pulp chamber
- GI temp in access cavity and evaluate CaOH fill level with radiograph
what’s cons of CaOH apexification
- increase risk of root #
- increase brittleness of root
apexificaiton vs apexogeneis
apexification:
- non vital tooth therapy
- open apex
- use MTA/ Biodentine/ (sCaOH) as apical plug for obturation
apexogenesis:
- vital tooth therapy
- open apex
- use MTA/ sCaOH in chamber to encourage further root developemnt / apex closure
pulpectomy final coronal Rx
- once obturation complete
- consider bonded composite short way down canal as well as in access cavity
- bonded core
- try to avoid post-crown
how long do you place the nsCaOH in canal?
- no longer than 4-6 weeks
- it’ll increase brittleness of root
best practice of pulpectomy open apex
- MTA plug (instead of CaOH)
- heated GP obturation (instead of cold lateral compaction)
tx options for uncomplicated CR# - no pulp exposure
Initial
- removal mobile fragment + RX
- Cover the exposed dentin with GI
or DBA + comp
Future Treatment Options:
- Orthodontic extrusion +RX
- Surgical extrusion
- Extraction
- Autotransplantation
tx options for complicated CR# - pulp exposure
Initial tx
- Until a treatment plan is finalized,
temporary stabilization of the loose
fragment to the adjacent tooth/teeth
or to the non-mobile fragment should
be attempted - Immature: partial pulpotomy with ns CaOH - preserve pulp
- Mature: pulp extirpation +cover exposed dentine with GI/ DBA + comp
Future Treatment Options:
- Completion RCT + Rx
- Ortho extrusion
- Surgical extrusion
- Root submergence
- Extraction
- Autotransplantation
classifying root #s
position
- apical/middle/coronal 1/3
displaced/undisplaced
stage of root development
- mature/immature
prognosis of a injured tooth depends on
5
root development
type of injury
is PDL injured
time between injury and tx
infection
what can happen in a displaced root # over a few hours?
can get a blood clot
may need pt to bite on gauze for 20mins to squeeze clot out
features of a root #
mobile
TTP
transient grey colour
root # special investigations
sensibility tests
radiographs from at least 2 angles
- often see 2 lines in a root # - 2D image
tx root #
- clean area - water, saline, CHX
- reposition tooth with digital pressure
- splint - 2 normal teeth either side
- LA usually not required
- soft diet 1wk, good OH
- check reposition radiographically
follow-up review of a root #
- 4Weeks (splint removal)
- 6-8 Weeks
- 4 Months
- 6 Months
- 1 Year
- 5 Years
splinting for a root #
2 normal teeth either side
apical/middle 1/3 - flexible 4wks
coronal 1/3 - flexible 4m (hardly any PDL holding tooth in)
“soft diet”
don’t need to change diet e.g. chop apple up
want to stimulate PDL cells e.g. soft sandwich
inactivity means bone cells more likely to take over
root # favourable outcomes
● Positive response pulp test( false negative possible up to 3 months).
● Signs of repair between fractured segments
● Continue to next evaluation.
if tooth becomes non-vital in a root # what is the chance of pulp necrosis?
20%
tx- if coronal tooth becomes non-vital for root # in apical and middle 1/3
extirpate to # line
dress nsCaOH then MTA/Biodentine (make barrier to compact GP against) just coronal to # line
GP - root fill to # line
apical fragment of root
- remain in situ with own PDL (keeps the bone)
- resorb
- if infected - ABs/apicectomy
why are splints flexible?
allow some movement to allow PDL cells to regenerate
splinting times
ideal splint properties
- flexible
- passive
- ease of placement/ removal
- facilitate sensibility test/ monitoring
- allow OH
- aesthetic
1st choice of splint
composite and wire
Ti trauma splint
types of splint
chairside
- composite & wire
- titanium trauma splint
- composite
- ortho bracket and wire
- acrylic
lab-made
- vacuum-formed splint
- acrylic
Composite and wire
- SS wire up 0.4mm in diameter
- Flexible: included 1 tooth either side of trauma tooth
- Passive
bond and comp away from gingivae
Titanium trauma splint
rhomboid mesh structure
0.2mm thick
1.secured with comp resin
when is an acrylic URA type splint useful?
when few abutment teeth
- full palatal coverage
- extended to incisal edge and labial surface of ant teeth
PDL injuries
concussion subluxation extrusion lateral luxation intrusion avulsion dento-alveolar #s
2 nature of trauma
- separation injury - heal faster - extrusive
- crushing injury - heal slower - intrusive
concussion and symtoms
- injury to the supporting structures of a tooth without displacement or mobility of the tooth
TTP
subluxation
injury to the supporting structures of a tooth
increased mobility but no displacement
extrusion
axial displacment partially out of socket
extrusion clinical findings
- tooth appears elongated
- usually displaced palatally
- tooth mobile
- radiographically increased PDL space apically
- likely negative sensibility test
lateral luxation
- displacement of tooth other than axially,
- usually with fracture of alveolar process
clinical findings of lat luxation
- tooth appears displaced in socket
- tooth immobile
- high metallic percussion tone (ankylotic)
- root apex may be palpable in sulcus
- likely negative sensibility test
- radiographically widened PDL space
intrusion
displacement of tooth axially and lcoked into bone
clinical finding of intrusion
- crown appear shortened
- (bleedign from gingivae)
- tooth is immobile
- high ankylotic, metallic percussion tone
- likely negative sensibility test
- x-ray: absence of PDL space
avulsion
complete displacement of tooth out of socket
5yr pulpal survival - concussion
open - 100%
closed - 95%
5yr pulpal survival - subluxation
open - 100%
closed - 85%
5yr pulpal survival - extrusion
open - 95%
closed - 45%
5yr pulpal survival - lateral luxation
open - 95%
closed - 25%
5yr pulpal survival - intrusion
open - 40%
closed - 0%
5yr pulpal survival - avulsion/replantation
open - 30%
closed - 0%
5yr resorption - concussion
open - 1%
closed - 3%
5yr resorption - subluxation
open - 1%
closed - 3%
5yr resorption - extrusion
open - 5%
closed - 7%
5yr resorption - lateral luxation
open - 3%
closed - 38%
5yr resorption - intrusion
open - 67%
closed - 100%
5yr resorption - avulsion/replantation
frequent for both open and closed apex
symptoms of concussion
not mobile
ttp
symptoms of subluxation
- increased mobility
- TTP
- bleeding from gingival crevice
tx of concussion and follow up
- no tx
- 4 weeks, 6-8w, 1 year (clinic + radiograph)
tx of subluxation + follow up
- no tx
- flexible splint 2wks if excessive mobility
- 2 weeks (splint removal) , 4w, 6-8w, 6 mo, 1 year
advice
OHI with CHX and gentle brushing
soft diet
avoid contact sports
radiographic follow up of concussion and subluxation
continued root development
compare with other side
check no RR
follow-up components of concussion and subuxation
radiographic
sensibility tests
trauma stamp
what to do in cases of late presentation displaced teeth where the teeth are firm?
use URA splint to slowly move them back
extrusion tx + follow up
reposition under LA - fingers
splint 2wks
follow up:
- 2 weeks (splint removal), 4w,8w,12w,6mo,1 year
- anually for 5 years
tx of lateral luxation and follow up
reposition under LA - fingers
passive flexible splint 4wks
if becomes necrotic extirpate to prevent RR
follow-up
- 2 weeks (endo evaluation) ,4w (splint removal) ,8w,12w,6mo,1 year,
- annually for 5 years
lat luxation - 2 weeks endo evaluation options
incomplete root formation
- spontaneous revascularisation may occur
- if necrotic pulp/ signs of EIR, commence endo asap
complete root formation
- pulp likely become becrotic
- commence endo
- corticosteorid-antibiotic / CaOH to prevent EIR
treatment options for intrusion- immature root formation
- allow spontaneous repositioning
- if no re-eruption in 4 weeks, orthodontic repositioning
- monitor pulp condisiotn
- spontaneous pulp revascularization may occur
- if pulp necrotic/ infected/ signs of EIR, commence endo tx asap/ when position allow
treatment options for intrusion- mature root formation
< 3mm
- spontaneous repositioning
- if no re-eruption within 8w, reposition surgically and splint for 4 weeks OR
- reposition orthodontically before ankylosis develops
3-7mm
- reposition surgically or orthodontically
>7mm
- reposition surgically
tx at 2 weeks review - intrusion with mature root formation
- pulp almost always become necrotic
- start endo tx at 2 weeks / asap as tooth position allow
intrusion follow up
2weeks, 4w (splint) ,8w,12w,6mo,1 year
annually for at least 5 years
monitoring spontaneous eruption
- measure distance of incisal edge of intruded tooth to adjacent tooth
mixed dentition
- study model/ clincial photograph
- no constant landmark (exfoliation/ eruption)
gingival margin will change after trauma, dont use
what reduces the prognosis in intrusion?
concurrent crown #
what can endo prevent?
necrotic pulp from initiating external inflammatory root resorption
when should endo be considered?
all cases with completed root formation where chance of pulp revascularisation is unlikely
when should endo be carried out?
within 3-4wks
temp CaOH filling recommended
critical factors avulsion
EADT
EAT
storage mediums
avulsion clinical findings
socket empty or filled with coagulum
avulsion storage mediums
best - replant immediately
milk
HBSS (Hanks balanced salt solution)
saliva
saline
water (poor)
pt attends with tooth replanted - inital tx
- don’t remove - unless malpositioned
- clean injured area
- splint (2 weeks)
- radiograph - root development
- suture gingival laceration
- consider ABX/ check tetanus status
- post - op instructions
- follow up
avulsion public advice
- hold by crown only
- wash in cold running water/ saliva/ milk
- don’t rub/ scrub
- replace in socket and child bites on gauze
- seek immediate dental advice
*
PDL decision making avulsion
PDL mostly viable
- replanted immediately/very shortly after
PDL viable but compromised
- saline/milk
- EADT <60mins
PDL non-viable
- EADT >60mins - all PDL cells non-viable
aim if EAT <60mins
PDL healing
closed apex follow- up- avulsion
- 2 weeks (splint removal +endo)
- 4weeks
- 3 months
- 6 moths
- 1 year
- annually for at least 5 years
trauma stamp
avulsion not yet reimplanted initial tx
- remove debris
- history & exam
- replant under LA
- flexible splint 2wks
- suture ging laceration
- consider ABs/tetanus status
- pot-op ins
- follow up
open apex further tx
- close monitoring (hish risk of external IRR)
- endo tx if definite signs of pulp necrosis/ infected root canal
open apex tx aim and risk
- revascularisation and further development
risk
- External inflammatory root resorption
- external replacement root resorption (ankylosis)
closed apex further tx after replantation
- pulp extirpation within 2 weeks (ASAP)
- Intra-canal medicament
- CaOH up to 1 month OR
- corticosteorid/ ABX paste for 6 weeks
- follow-up
- (delayed replant refer to paeds specialist)
avoid medicament placement on crown - discoloration
> 60mins EAT closed apex high risk of, and tx aim
- Ankylosis
- Replacement Root Resorption
tx aim
- restore aesthetic
- function temporarily
- maintain alveolar bone contour width/ height
PDL likely necrotic
when not to replant?
almost never (temp space maintainer)
but
- immunocompromised
- other serious injuries: A+E
- very immature apex + extended EAT
- very immature lower incisor in young child ( diff to cope)
open apex requiring endo - technique
- MTA - mineral trioxide aggregate as apical plug
- heated GP obturation
follow-up period for open apex - avulsio
- 2 weeks (splint removal)
- 4 weeks
- 2 months
- 3 months
- 6 months
- 1 year
- anually for at least 5 years
frequent!! risk of IRR
IRR +RRR (external) signs
IRR:
- root/ bone resorption
RRR:
- absence of PDL space
- replacement of root structure by bone
- metallic percussion note
dento-alveolar #s tx
- LA
- reposition
- flexible splint 4wks
- suture gingival laceration
- monitor pulp condition of all teeth involved (sensibility test)
dento-alveolar # clinical findings
- segment mobility and displacement ( sev teeth moving tgt)
- occlusal disturbance
- gingival laceration
dento-alveolar #s monitoring aspect
- Root development - canal width and length, compare
- Resorption
dento-alveolar #s risk of pulpal necrosis closed apex
50% at 5 years
advice for all dental injuries
- soft diet 7days
- avoid contact sports whilst splint
- careful OH, CHX MW 0.12%
follow up for dento-alveolar #
- 4 weeks (spint removal)
- 6-8weeks
- 4 months
- 6 months
- 1 year
- anually at least 5 years
main post-trauma complication
- pulp necrosis & infection
- pulp canal obliteration
- root resorption
- breakdown of marginal gingivae and bone
pulp canal obliteration
- response of vital pulp
- progressive hard tissue formation within pulp cavity
- total/ partial obliteration
- yellow/ opaque color on crown
- narrowing of canal/ chamber (x-ray)
pulp canal obliteration tx
conservative - only 1% may give rise to PAP
