Dentoalveolar Trauma 5

Question 1

How are infractions managed?

Answer 1

Coat tooth surface with light cured unfilled resin bonding agent. This is to minimize bacterial ingress while pulp is possibly damaged or inflamed from trauma

Question 2

Is using unfilled resin to coat an infraction useful?

Answer 2

Yes, unfilled resin may help prevent infection of the pulp system. For this reason it is important to apply it as soon as possible after trauma to minimise bacterial penetration.

Question 3

Does resin last for long when used for infractions?

Answer 3

It often wears away making its protectiveness temporary. However it can be reapplied.

Question 4

How should crown fractures be managed?

Answer 4

Protect the pulp if it is exposed. Partial pulpotomy or pulpectomy can be indicated depending on stage of root development.

If pulp is not exposed; an indirect pulp cap/lining using glass ionomer is indicated.

Restore the fractured portion of the tooth using composite resin “bandage” / GIC / bond fragment if it is available.

Definitive restoration later when pulp status is clear

Question 5

How are crown:root fractures managed?

Answer 5

If uncomplicated there is minor involvement of the root so restore in the same way as a crown fracture.

If complicated there is major root involvement. Treat as a complicated crown fracture

Question 6

How can vertical crown:root fractures be treated?

Answer 6

Extraction is often best.

Question 7

How is concussion + subluxation treated?

Answer 7

PDL damage but otherwise fine. Splinting is not required unless the tooth is very loose.

Relieve the occlusion by checkiing with articulating paper.

Review after.

Question 8

What is the prognosis like for concussion and subluxation?

Answer 8

Depends on many mechanical and biological factors such as stage of root development, pulp involvement, concurrent injuries, etc

Generally very good.

Question 9

What is the probability of poor outcomes for concussion injuries?

Answer 9

Pulp necrosis = 2%

Pulp Canal Calc = 2.2%

Transient Apical Breakdown = 0.1%

Question 10

What is the probability of poor outcomes for subluxation injuries?

Answer 10

Pulp necrosis = 6 - 47% (higher if there is also a crown fracture)

Pulp Canal Calcification = 26%

Transient Apical Breakdown = 2.2%

Resorption = 4%

Question 11

How is extrusive luxation treated?

Answer 11

Reposition the tooth immediately. The longer the patient takes to come in the harder it is to reposition.

Mould the bone back to position.

Splint (Flexible for 7 - 10 days)

Suture soft tissues

Review regularly.

Question 12

What is the prognosis like in extrusive luxation?

Answer 12

Generally very good

Question 13

What is the probability of poor outcomes following extrusive luxation?

Answer 13

Pulp necrosis = 64 - 98%

PCC = 24%

TAB = 11%

Resorption = 7%

Usually no bone fracture so no bone loss.

Question 14

How is lateral luxation managed?

Answer 14

Reposition immediately. Requires 2 movements one is apical to coronally (tooth clicks into place typically) and the other is to rotate until it clicks into the socket.

Mould bone back into position.

Splint with rigid splint for 6 weeks.

Suture soft tissues.

Review regularly.

In some cases it is important to do root canal treatment especially if there is also a crown fracture.

Question 15

What is the prognosis like for lateral luxation?

Answer 15

Generally good.

Question 16

What is the probability of poor outcomes for lateral luxation?

Answer 16

Pulp necrosis = 58%

PCC = 24%

TAB = 12%

Resorption = 7%

Bone loss = 6 - 31%

Question 17

How is intrusive luxation managed?

Answer 17

Reposition immediately. Other options include using allowing to erupt or orthodontic extrusion (allowing to erupt only works for incompletely developed tooth)

Mould bone back into the position (fractured socket wall)

Rigid splint for 6 weeks

Suture soft tissues

Endodontic treatment immediately to prevent external inflammatory resorption

Antibiotics for 1 week

If immature tooth and there is no crown fracture then monitor the pulp to assess if it recovers/heals

Question 18

Which teeth require immediate RCT following trauma?

Answer 18

All mature teeth

Immature teeth with concurrent crown fractures

Question 19

Why is repositioning following intrusive luxation the best option for its treatment?

Answer 19

Repositioning is the best option. It avoids pressure necrosis of the PDL and reduces chances of external replacement resorption.

Fully developed teeth are not very likely to erupt

Allows access to the root canal.

Avoids surgery for orthodontic extrusion

Question 20

How should a tooth be repositioned following intrusive luxation?

Answer 20

Be careful not to damage the CEJ so avoid using extraction forceps in the region.

Use diamond tipped tweezers (prevents slipping of tweezers)

Acid-etch/bond a small amount of composite on the labial and palatal surfaces to give tweezers and forceps grip to move the tooth.

Often intruded teeth are also rotated meaning you may be able to hold the mesial and distal surfaces of the crown without slipping as they are almost parallel

Question 21

How is preventative management of mature and immature teeth done?

Answer 21

Systemic ABs after emergency treatment.

Start RCT and use CS-AB paste. If time is available prepare the canal.

If tooth is mature: Redress canal after 6 weeks with CS-AB. After another 6 weeks take a PA. If resorption is present, redress canal with CS-AB paste. If no resorption, place a new dressing using 50:50 CS-AB + Ca(OH)2

If immature tooth: Redress after 4 weeks with CS-AB, then after 4 weeks re-dress with CS-AB, then after another 4 weeks take PA and check resorption. If present redress canal. If not present place new 50:50 dressing. After a further 2 months take a PA. If no resorption, redress with Ca(OH)2 and change Ca(OH)2 every 2 months until apexification is evident. Then complete the RCF.

Question 22

How often should reviews be done after preventative RCT is done?

Answer 22

At 6 months after the RCF is completed and then every 3 - 4 years for as long as possible.

Question 23

What is the prognosis like for intrusive luxation?

Answer 23

Fair

Question 24

What is the probability of poor outcomes from intrusive luxation?

Answer 24

Pulp necrosis = 96%

PCC = 4%

TAB = 12%

Resorption = 52%

Bone loss = 6 - 31%

Arrested root development = 16%

Question 25

How is avulsion managed?

Answer 25

Reposition immediately.

mould bone into position

flexible splint 7 to 10 days

suture soft tissues

RCT

ABs

if immature and no crown fracture - monitor

Question 26

What is the prognosis for avulsion?

Answer 26

Fair

Question 27

What is the likelihood of outcomes following avulsion?

Answer 27

Pulp necrosis: up to 100%

PCC 4%

Resorption = 74 - 96%

Bone loss = 6 - 31%