dental trauma Flashcards
1
Q
dental hard tissue and pulp injuries
A
- enamel fracture
-enamel/dentine fracture
-enamel dentine and pulp fracture
-crown-root fracture
-root fracture
2
Q
what are supporting tissue injuries
A
- concussion
-subluxation
-lat luxation - intrusion
-extrusion
-avulsion
-alveolar fracture
3
Q
what is concussion
A
tooth tender to touch but not displaced
4
Q
what is subluxation
A
- tender to touch, mobility but not displaced
5
Q
what is lateral laxation
A
- tooth displaced in palatal/lingual or labial direction
6
Q
what is intrusion
A
- tooth displaced through labial bone plate or it can impinge on permanent tooth bud
7
Q
what is extrusion
A
partial displacement of tooth out of socket
8
Q
what is avulsion
A
tooth completely out of socket
9
Q
what is alveolar fracture
A
involves alveolar bone (labial and palatal/lingual) may extend to adjacent bone
10
Q
what to look for intraorally on examination (trauma)
A
- soft tissue damage - lost tooth fragment
- tooth mobility
-transillumination - fracture lines or caries - tactile test with probe - fractures
-percussion- dull note = fracture
-traumatic occlusion
11
Q
what is special test for trauma
A
trauma stamp
12
Q
what is included in trauma stamp
A
- mobility
-colour
-TTP
-sinus
-percussion note
-radiograph
13
Q
homecare for managing trauma
A
- analgesia
-soft diet
-soft toothbrush
-topical chlorhexidine
14
Q
management of enamel fracture
(primary)
A
- smooth sharp edges
15
Q
management of enamel dentine fracture (primary)
A
- cover exposed dentine
16
Q
management of enamel dentine pulp trauma(primary)
A
partial pulpectomy
extract
17
Q
management of crown root fracture(primary)
A
- remove loose fragment and determine restorability
if restorable
- pulp exposed ; pulpotomy, endo
-no pulp : cover exposed dentine
if unrestoable
-extract loose fragment
18
Q
treatment of root fracture(primary)
A
coronal fragment not displaced
- no treatment
coronal fragment displaced but not excessively mobile
- leave coronal fragment to spontaneously reposition even if some occlusal interference
coronal fragment displaced, excessively mobile and interfering with occlusion
- option A: extract only the loose coronal fragment
- option B: reposition the loose coronal fragment +/- splint
19
Q
treatment of concussion (primary)
A
no treatment
20
Q
treatment of subluxation (primary)
A
no treatment
21
Q
treatment of lat laxation (primary)
A
if no occlusal interference - allow spontaneous reposition
if severe displacement - extraction, reposition
22
Q
intrusion injury management (primary)
A
allow to spontaneously reposition irrespective of direction of displacement
23
Q
how to determine direction of displacement in intrusion
A
not parallax as only one radiograph is used
- use either
- peri-apical
- lateral premaxilla (extra-oral film)
being able to assess the danger to permanent tooth allows better counselling re prognosis
24
Q
extrusion management (primary)
A
- not interfering with occlusion - spontaneous reposition
- excessive mobility or extruded >3mm
then extract
25
allusion management (primary)
- dont replant
26
alveolar fracture management (primary)
- reposition segment
- stabilise with a flexible splint to the adjacent uninjured teeth for 4 weeks
- teeth may need to be extracted after alveolar stability has been achieved
27
what guidelines exist for trauma
IADT
28
sequelae of primary tooth trauma
- discolouration
- discolouration and infection
- delayed exfoliation
29
how may discolouration in primary teeth present
asymptomatic (vital or non-vital)
- mild grey : immediate discolouration may maintain vitality
- opaque/yellow: pulp obliteration
- no sign of pulp necrosis or infection
- no treatment; review
symptomatic (non-vital)
- sinus, gingival swelling, abscess
- increased mobility
- radiographic evidence of peri-apical pathology
- extract or endodontic treatment
30
which injury causes most disturbance
intrusion
31
what effects on permanent successor after trauma
- enamel defects
- abnormal crown/root morphology
-delayed eruption
-ectopic tooth position
-arrested development
-failure of tooth to form
-odontome formation
32
enamel defects that can happen to permanent successor after trauma
enamel hypominerallisation
enamel hypoplasia
33
what is enamel hypoplasia
- quantitative defect of enamel
- i.e. reduced thickness but normal mineralisation
- yellow/brown defects
treatment
- no treatment
- composite masking
34
what is enamel hypomineralisation
- qualitative defect of enamel
- i.e. normal thickness but poorly mineralised
- white yellow defect
treatment
- no treatment
- composite masking +/- localised removal
- tooth whitening
35
what abnormal morphology can occur after trauma to permanent successor
dilaceration
- deviation of long axis of the crown or root portion of tooth
management of crown dilcaeration
-surgical exposure and realign
management or root dilaceration
-surgical and orthodontic approach
36
primary tooth trauma effect on eruption
- delayed eruption
- 1 year
- need radiograph if >6 month delay
37
which injury most common in permanent dentition
crown fractures
38
what malocclusion makes trauma more likely
OJ
39
what aspects of MH may influence trauma Tx options
- congenital heart defects
- immunosuppression - children with cancers
- rheumatic fever
40
what does high note percussion indicate
ankylosis
41
prognosis of trauma is dependant on
- stage of root development
- presence of infection
- type of injury
- time between injury and treatment
- if PDL is damaged too
42
managing enamel fracture (permanent)
- bond fragment to tooth or polish
- 2 PAs to rule out root fracture or laxation
- follow up : 6-8, 6 months, 1 year
43
managing a enamel dentine fracture (permanent)
- account fragment
- bond fragment or place comp bandage
- 2 PAs
- look for lacerations
-sensibilty testing
44
follow up for enamel dentine fracture
6-8 weeks, 6 months, 1 year
45
what should you look for in enamel dentine PA
- rule out root fracture or luxation
-root development
-comparison with other side
-PAP
- internal and external inflammatory resorption
46
how to evaluate enamel dentine pulp exposure
- size of pulp exposure
- time since injury
- associated PDL injuries
47
3 types of management for EDP fracture (permanent)
pulp cap - cover CaOH
partial pulpotomy - remove small amount of inflamed nerve tissue
full coronal pulpotomy - remove all inflamed nerve tissue of coronal aspect, leave vital radicular tissue
48
what is direct pulp cap
<24hrs
1mm exposure
non-stop and positive to sensibility
- CaOH then restore
review :6-8 wks, 6 months , 1 year
49
When to do partial pulpotomy
Larger exposure
>1mm or 24hrs
-remove 2mm of pulp
If bleeding is arrested then stop here
50
When to do full coronal pulpotomy
If haemostasis cannot be achieved after partial pulpotomy
51
What is aim of pulpotomy
pulpotomy is to keep vital pulp tissue within canal to allow normal root growth (apexogeneis) both in the length of root and thickness of dentine
52
What is problem with full pulpectomy in immature teeth
No apical stop
53
What are TX options for immature incisors (RCT)
- CaOH in canal to induce hard tissue barrier apexification
- or MTA/biodentine placed at apex of canal to create cement barrier - apical plug - placed with very small pluggers
- or regenerative endodontic technique to encourage hard tissue formation
54
How often should CaOH be changed
4-6 weeks due to increasing brittleness
55
What are TX options for crown root fracture with no pulp exposure (permanent)
- remove fragment and restore
-extraction
-decoronation
-surgical extrusion
-gingivectomy
56
What is a separation injury
Extrusive luxation
Cleavage of intracellular structures
Limited damage to cells in areas of trauma
57
What is crushing injury
Intrusive luxation
injury extensive damage to cellular and intracellular systems - damage tissue must be removed by macrophages and or osteoclasts before it can be restored - adds weeks to healing
58
Treatment for concussion in permanent teeth
NIL
Follow up 4 weeks and 1 year
59
Clinical findings in subluxation
- increased mobility
- tender to percussion
- bleeding from gingival crevice may be present
- looks normal on radiograph
60
Treatment for subluxation (permanent)
None
Or splint if mobile or sore on biting
2 week splint
Review
- 12 weeks
- 6 months
-1 year
61
How to monitor concussion and subluxation
Trauma stamp
Sensibility test - false negative possible
Radiographs - root development, comparison, resorption
62
Clinical findings In extrusion
- tooth looks elongated
- usually displaced palatally
- tooth mobile
- bleeding from gingival sulcus
- radiograph increased PDL space apically and laterally
- tooth not seated in socket
63
Treatment for extrusion (permanent)
- reposition by gently pushing back to socket
- 2 week splint
- 4 weeks if fractured
Follow up
- 2 weeks splint removal
-4,8,12 weeks
- 6 months, 1 year
64
What is outcome after extrusion (permanent)
Open apex - necrosis rare, obliteration common
Closed apex - opposite
65
Clinical findings in lateral luxation
clinical findings
- tooth appears displaced in socket
- tooth immobile
- high ankylotic percussion tone
- may be bleeding from gingival sulcus
- root apex may be palpable in sulcus
- widened PDL space on radiograph
66
Treatment of lat luxation (permanent)
- reposition LA - disengage from locked and move
- 4 week splint
- endo monitor - 2/52
If incomplete root
- may revascularise
-if necrotic then commence endo
If complete
- commence endo
67
Follow up for lat luxation permanent
2 weeks
4 weeks
8 weeks
12 weeks
6 months
1year
68
Complications following lat luxation (permanent)
- open apex - low resorption and necrosis
-closed apex- high resorption and necrosis
69
Clinical findings in intrusion
- crown shortened
- immobile
- bleeding from gingivae
- ankylotic high, metallic percussion tone
- PDL space not always visible especially apically
-CEJ more apical in intruded tooth
70
Treatment of intrusion (permanent) immature root
- spontaneous reposition
- if no re-eruption within 4 weeks : orthodontic reposition
- monitor pulp condition - high chance of losing vitality
- 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 position of tooth allows
71
Treatment of intrusion mature root (permanent)
<3mm
- spontaneous reposition
- if no re-eruption 8 weeks - surgically reposition and splint 4 weeks or reposition orthodontically before ankylosis
3-7mm
- reposition surgically - under LA or orthodontically
>7mm
- surgically
After 2 weeks monitor endo status - do ASAP to prevent resorption
72
Follow up for intrusion
- 2 weeks
-4 weeks
- 8, 12 weeks
-6 months
- 1 year
-annually for 5 years
73
Sequelae for intrusion (permanent)
- complete healing only in open apex teeth
-root resorption common
74
What are critical factors in avulsion
EADT- out of mouth and dry
EAT - out of mouth
Storage medium
75
When is PDL likely to be non viable
After 60 mins
76
Emergency advice for avulsion
- hold by crown
- place tooth back into socket if clean
-if dirty- milk or saline then replace
-bite on gauze to hold in place
77
Types of storage medium for avulsion
- milk
-HBSS
- saliva
-saline
-water
78
Management of avulsion if tooth replanted (closed apex)
-clean
-check position and apical status
- correct with digital pressure
- can reposition up to 48 hours after
-splint - 2 weeks
79
Management of avulsion EADT<60 mins closed apex
- remove debris
- wash socket
-replant under LA
- splint 2 weeks
80
TX of avulsion if EADT>60 mins closed apex
Same as previous
But comment ends 2/52 weeks later
81
Issues with delayed replantation in avulsion
- PDL necrotic
-ankylosis resorption
-decoronation and autotransplantation likely needed in future
82
Follow up for avulsion (permanent)closed apex teeth
2/52,4/52
3 months , 6 months
1 year
Annually
83
How is endo completed in avulsion of open apex teeth
- MTA apical plug
84
Follow up of avulsion in open apex teeth
2/52 - splint
1 , 2, 3, 6 months
1 year
85
When not to replant
- if immunocompromised
- immature apex and EAT over 90 mins
86
clinical findings in dento-alveolar fractures
- complete alveolar fracture extending from the buccal to the palatal bone in the maxilla and from the buccal to the lingual bony surface in mandible
- segment mobility and displacement with several teeth moving together
- occlusal disturbance - due to displacement and misalignment of alveolar segment
- gingival laceration
87
TX for dento-alveolar fracture (permanent)
- fracture lines may be at any level from marginal bone to root of apex
- reposition displaced segment
- stabilise by splinting - 4 weeks passive
- suture gingival lacerations
- monitor pulp condition of all teeth involved - sensibility testing
88
Follow up for Dento-alveolar fracture permanent
4, 6 week
4 months
6 months
1 year
Annually
89
Advice following dento-alveolar fracture
- soft diet
-avoid contact sport
-careful OH
90
How should a splint be in trauma
- passive and flexible
91
Types of splint
- vacuum formed splint
-composite and wire
-titanium trauma splint
92
Main post op trauma complications
Necrosis and infection
Obliteration
Root resorption
Breakdown of marginal gingiva and bone
93
What is pulp canal obliteration
- response of vital pulp
- common in luxation with displacement
- progressive hard tissue formation within pulp cavity
- gradual narrowing of pulp chamber and pulp canal - total or partial obliteration
- looks opaque or yellow
treatment
- conservative, only 1% may give rise to PAP
94
Types of root resorption
external
- surface
- external infection related IRR
- previously known as external inflammatory resorption
- cervical
- ankylosis related RRR
internal
- internal infection related IRR
- previously known as internal inflammatory resorption
95
What is external surface resorption
- in vital teeth
- superficial resorption lacunae are repaired with new cementum
- occurs in response to localised injury
- this is not progressive
96
What is external infection related IRR
Non vital tooth with infected pulp canals
PDL damage following trauma
Rapid
Diagnosis
- indistinct root surface; root canal tramlines intact
- trans-radiographic finding
- change external contour of root , boney lucency
97
Management of external infection related IRR
-remove stimulus
-endo
98
What is Ankylosis related RR
-severe damage to PDL and cementum
-follows severe luxation or avulsion
-root gradually replaced by bone
-Plan loss
99
What is internal infection related IRR
Progressive pulp necrosis
Pink discolouration
infected material via non-vital coronal part of canal propagates resorption by underlying vital tissue
100
Treatment of internal infection related IRR
- remove stimulus
-commence Endo
101
What to look for in trauma review
Root development
Pulp vitality
Resorption
