Dental Trauma Permanent teeth Flashcards
What is avulsion?
- Tooth totally displaced from socket
Clinical findings;
- Socket empty or filled with coagulum
One of only few real emergency situations in dentistry as successful healing can occur if only minimal damage to pulp and PDL
What are the critical factors related to an avulsion injury?
- Extra-alveolar dry time (EADT)
- Extra-alveolar time (EAT)
- Storage medium
Decide if;
- 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
What is the emergency advice for an avulsed tooth?
- 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
What are the only storage medium you should place an avulsed tooth into?
- Milk (Most preferred)
- HBSS (Hanks balanced salt solution)
- Saliva
- Saline
- Water (poor medium and least preferred)
Avoid dehydration of tooth tissue
How to manage an avulsed tooth with a closed apex that has already been replanted?
- 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/4weeks splint removal/3months/6months/1year/annually for 5years
Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks
How to manage an avulsed tooth with EADT<60mins?
- PDL cells may be viable but compromised
- 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/4weeks splint removal/3months/6months/1year/annually for 5years
Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks
How to manage an avulsed tooth with closed apex with EADT > 60mins?
- 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 splint removal/3months/6months/1year/annually for 5years
Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks
How does delayed replantation affect prognosis on permanent tooth with closed apex?
- Poor long term prognosis (ankylosis-related root resorption)
- Decision to replant almost always correct
- Referral to Paediatric Specialist/ Inter-disciplinary management
How to manage an avulsed permanent tooth with an open apex that has already been replanted?
- 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
How to manage an avulsed tooth with open apex that has EAT < 60mins?
- 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
How to manage an avulsed tooth with open apex with EAT >60mins?
- 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
What is the aim of an avulsed tooth with open apex?
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
How does delayed replantation affect prognosis of avulsed tooth with open apex?
- Poor long-term prognosis: ankylosis-related (replacement) root resorption
- Decision to replant almost always correct
- Referral to Paediatric Specialist/ Inter-disciplinary management
When do you not replant an avulsed permanent tooth?
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?
What is the 5year pulp survival rate of avulsion for open apex and closed apex?
Open - 30%
Closed - 0%
What are the clinical findings of a dento-alveolar fracture of permanent tooth?
- 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
How to manage a dento-alveolar fracture?
- Reposition any displaced segment
- Stabilise by splinting
- Suture gingival lacerations if present
- Monitor the pulp condition of all teeth involved
Monitor clinically and radiographically
- Root development including canal width and length, compare with neighbouring unaffected tooth
- 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
Post-op advice for dento-alevolar fracture?
- Soft diet for 7 days
- Avoid contact sport whilst splint in place
- Careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12%
What are the splinting times for each injury to permanent teeth?
Subluxation - 2weeks
Extrusive luxation - 2 weeks
Intrusive luxation - 4weeks
Avulsion - 2weeks
Lateral luxation - 4weeks
Root fracture (mid root and apical third) - 4weeks
Root fracture (cervical third) - 4months
Dento-alevolar fracture - 4weeks
What are the splint properties?
- Flexible and passive
- Ease of placement/ removal
- Facilitate sensibility testing/ clinical monitoring
- Allow oral hygiene
- Aesthetic
What are the types of splint?
Chair side
- Composite & wire
- Titanium trauma splint
- 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)
What is a composite and wire splint?
- 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
What is a titanium trauma splint (TTS)?
- Rhomboid mesh structure
- Passive and flexible
- 0.2mm thick
- Easily adaptable with fingers
- Secured with composite resin
What are the main post-trauma complications?
- Pulp Necrosis & Infection
- Pulp Canal Obliteration
- Root Resorption
- Breakdown of Marginal Gingiva and Bone
What is pulp canal obliteration (PCO)?
- 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
What are the types of root resorption?
External
- Surface
- External infection related IRR (inflam root resorption)
- Prev known as external inflammatory resorption
- Cervical
- Ankylosis related RRR (root related resorption)
Internal
- Internal infection related IRR (inflam root resorption)
- Prev known as internal inflammatory resorption
What is external surface resorption?
- Superficial resorption lacunae are repaired with new cementum
- Response to localised injury in vital teeth
- Not progressive
What is external infection related Inflammatory root resorption (IRR)?
- 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
How to manage external infection related IRR?
- Remove stimulus by removing infected canal and lesion will arrest
Endodontic treatment - Non-setting CaOH for 4-6 weeks
- Obturate with GP
What is ankylosis related RRR?
Initiated by severe damage to PDL and cementum.
- Normal repair does not occur
- Bone cells faster than PDL fibroblasts
Severe luxation or avulsion
Root involved in remodelling
- Radiograph: ‘Ragged’ root outline; no obvious PDL space
Speed of progression is variable and infraocclusion due to alveolar bone development
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
What is internal infection related IRR?
- 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
How to manage internal infection related IRR?
- 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
How to manage a concussion injury for permanent teeth?
- Injury to tooth supporting structures without abnormal loosening or displacement of tooth
Clinical findings;
- Pain on percussion
No treatment
Follow up - Clinical and radiographic, 1month/1year
What are the clinical findings of subluxation injury to permanent teeth?
- An injury to the tooth-supporting structures with abnormal loosening, but without tooth displacement
Clinical findings
- Increased mobility
- Tender to percussion
- Bleeding from the gingival crevice may be present
How to manage a subluxation injury?
- Normally not required
- Splint if excessive mobility or tenderness when biting
Follow up
- Clinical and radiographic
- 2weeks inc splint removal/ 3months/6months/1year
How to monitor a concussion/subluxation injury?
Trauma Stamp
Sensibility tests:
- Thermal and electrical (At time of injury)
- False negative response is possible (Can relate to future pulp necrosis)
Radiographs:
- Root development
- Comparison with contralateral tooth
- Resorption
What is included in a trauma stamp?
- Sinus
- Colour
-Mobility - TTP
- Percussion
- Ethyl chloride
- EPT (Electric pulp test)
- Radiograph
What is the 5year pulp survival rate of concussion injury?
Open apex - 100%
Closed apex - 95%
What is the 5year pulp survival rate of subluxation injury?
Open apex - 100%
Closed apex - 85%
What is the 5year resorption rate of concussion injury?
Open apex - 1%
Closed apex - 3%
What is the 5year resorption rate of subluxation injury?
Open apex - 1%
Closed apex - 3%
What are the clinical findings of extrusion injury?
- An injury in which the tooth suffers axial displacement partially out of the socket
Clinical findings:
- Tooth appears elongated
- Usually displaced palatally
- Tooth mobile
- Bleeding from gingival sulcus
How to manage an extrusion injury?
- Reposition the tooth by gently pushing It back into the tooth socket under local anaesthesia
- Splint
Follow up 2weeks inc splint removal/4weeks/2months/3months/6months/1year/annually for 5years
What is the 5year pulp survival rate of extrusion injury?
Open apex - 95%
Closed apex - 45%
What is the 5year resorption rate of extrusion injury?
Open apex - 5%
Closed apex - 7%
What are the clinical findings of lateral luxation?
- Displacement of a tooth in socket in a direction other than axially; accompanied by comminution or fracture of alveolar bone plate
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
How to manage lateral luxation injury?
- Reposition under local anaesthesia
- Splint
- Monitor
- Endodontic evaluation (approx. 2/52 post-injury)
Follow up 2weeks/4weeks splint removal/2months/3months/6months/1year/annually 5years
What happen when tooth with lateral luxation injury has incomplete root formation?
- Spontaneous revascularisation may occur
- If the pulp becomes necrotic and signs of inflammatory (infection-related) external resorption commence endodontic treatment
What happens when tooth with lateral luxation injury has complete root formation?
- The pulp will likely become necrotic
- Commence endodontic treatment
- Corticosteroid-antibiotic or calcium hydroxide as intra-canal medicament to prevent the development of inflammatory (infection-related) external resorption
What is the 5year pulp survival rate of lateral luxation injury?
Open apex - 95%
Closed apex - 25%
What is the 5year resorption rate of lateral luxation injury?
Open apex - 3%
Closed apex - 38%
What are the clinical findings of an intrusion injury?
- Tooth forced into socket in axial direction and locked into bone
Clinical findings:
- Crown appears shortened
- Bleeding from gingivae
- Ankylotic high, metallic percussion tone
How to manage an intrusion injury with immature root formation?
- 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
How to manage intrusion injury with mature root formation?
<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
What is the 5year pulp survival rate of intrusion injury?
Open apex - 40%
Closed apex - 0%
What is 5year resorption rate of intrusion injury?
Open apex - 67%
Closed apex - 100%