Management of dental trauma (IADT) Flashcards
First things to ask relating to the trauma
When was the injury? - exposure to infection of pulp
Where did it happen? - is there a chance for soil contamination
How did it happen? direction of the fall, bruises and grazes elsewhere on the body? Head injuries or loss of conciousness? - NAI
Where has the tooth/fragment gone? - inhaled? embedded in the lip? must be documented.
Any associated injuries? lacerated lip?
Important signs in history for trauma
Is child conscious
Have there been previous injuries?
disturbance in bite?
Hot/cold sensitivity - dont do ethyl chloride on exposed pulp as pt will dislike
medical history - allergies, MIH, prolonged bleeding
tetanus status?
Dental compliance
Is family known to social services?
Follow up for dental trauma injuries - IADT
2 weeks, 4 weeks, 6-8 weeks
6 months
1 year
Yearly for 5 years
Follow up for monitoring vitality (lecture)
Review vitality:
1 week (periodontium starts to heal), 3 weeks (more vigorous inflammatory response), 6 weeks
2 and 6 months
1 year
Follow up periods for teeth where they risk loss of vitality (crown/root fracture) - IADT
Clinical and radiographic evaluations are necessary after
6-8 weeks
1 year
Root fracture 4 weeks, 6-8 weeks, 6 months, 1 year, yearly for 5 years
-follow luxation follow up regime if there is a luxation injury also
Sequelae for dental trauma
Pulp survival
Pulp canal obliteration
Pulp necrosis
Resorption
Management of enamel infractions in permanent teeth
Incomplete crack of the enamel with no loss of tooth structure (transillumination and mirror to identify, no need for RGs unless symptoms) can be managed by:
-Either no treatment
-Severe cracks may be etched and sealed with bonding resin to prevent discolouration and bacterial ingress.
No follow up unless there is associated luxation injury
Management of enamel fractures
Clinically and radiographically (PA and occlusal views) rule out luxation or root fracture
Check soft tissues for fragment
If the fragment is still available - can be bonded back onto tooth (dry and discoloured)
Otherwise remove sharp edges and place an etch retained composite restoration (incremental or crown former templates)
Bevel to avoid leakage and remove unsupported enamel and bond to enamel and improve aesthetics
Management of enamel- dentine fracture (most important consideration/difference with enamel fractures)
Clinical and radiographic exam (PA and occlusal) - rule out root fracture or luxation
a) Tooth fragment available and intact - rehydrated in water or saline/milk for 20 min, clean both surfaces with pumice and v notch into fragment for composite fill before etching and bonding back onto tooth
b) Cover exposed dentin (prevent pulp inflammation) with glass-ionomer or any restorative option - bonding agent and composite resin (more permanent)
c) If exposed dentin is within 0.5 mm of the pulp (pink but no bleeding), can place a CaOH lining and cover with glass-ionomer/perm restoration
Review for loss of vitality
Management of complicated crown fracture (enamel- dentine- pulp) - IMMATURE TEETH - vital
What factors influence pulp vitality?
MAINTAIN VITALITY - apexogenesis
Immature root with open apices :
Cvek partial pulpotomy or pulp capping
Partial pulpotomy also favoured as a conservative solution for closed apices.
Can bond back tooth fragment if available otherwise GIC or bonded composite restoration
Clinical and Rx at - 6-8 weeks, 1 year intervals - assess need for RCT
If fails/HSTS not achieved - conventional pulpotomy BUT weakens pulp and obliteration may occur
Factors:
Pulp status before injury
Time from injury
Apex development
Injury to periodontal tissues (PDL and blood supply) - luxation injuries
Cvek’s pulpotomy technique
LA
Rubber dam
Remove 1-2mm of exposed pulp
Saline wash to remove extravascular blood clot (lead to internal resorption)
press with cotton wool (+- CHX) until haemostasis is achieved
Dress with CaOH2 cement
composite restoration
APEXOGENESIS
Cveck Pulpotomy vs direct pulp cap
Significance of the bleeding in these procedures
Essentially same thing
Pulpotomy removes pulp tissue due to bacteria/inflammation
Direct pulp cap may involve removal if the pulp exposure is a result of caries etc rather than mechanical or trauma
XS bleeding - XS pulp inflammation and moisture issues for adequate restorative seal after
Management of complicated crown fracture (enamel-dentine-pulp) - immature teeth NON VITAL
Apexification - calcified apical barrier induced for apex formation and effectively close it –> endodontic obturation
NOT a mechanical barrier - repeated replacement of CaOH in canals after 1 month and then every 3 months for 2 years OR MTA that then induces apex closure
Pulp and root canals cleaned out, MTA used for apex barrier, CaOH dressing and GIC/intracanal CaOH or MTA
Final obturation only when absence of symptoms, sinus, mobility and radiographic evidence of firm stop at apex
Apexogenesis vs apexification
Apexogenesis - vital pulp therapy to encourage physiological development and formation of root apex
Apexification - induction of a calcified apex barrier of non vital immature tooth to facilitate endodontic treatment
Management of uncomplicated crown root fractures - enamel-dentine-cementum
Clinical and radiographic exam (ttp and extent of fracture subgingivally - PA and Occ)
initially stabilise the loose fragment to the adjacent teeth/tooth
Consider restorability
Unrestorable (vertical fracture, sig apical extension) - extract
Restorable - consider restoration after removing mobile fragment (gingivectomies, osteotomies)
More retention needed:
Post crown RCT option –> fracture may extend subgingivally - surgical or orthodontic extrusion may be later necessary for 2mm crown ferrule
RCT if restoration becomes infected
Autotransplantation
Review:
6-8 week, 1 yr,
Management of complicated root-crown fractures - immature teeth
SAME AS UNCOMPLICATED BUT pulp vitality preserved
Temporary stabilisation of the loose fragment to adjacent teeth or non mobile fragment of tooth
Immature teeth - partial pulpotomy (non-setting CaOH2 or non staining calcium silicate cement may be used on the pulp)
Management of complicated root-crown fractures - mature teeth
Temporary stabilisation of the loose fragment to adjacent teeth or non mobile fragment of tooth
RCT then post crown
Surgical or orthodontic extrusion followed by gingival recontouring - ferrule for post crown
autotransplantation
Intentional reimplantation +- rotation of the root
Management of permanent teeth with root fractures
Mobile, displaced, tender to touch and gingival bleeding
Horizontal or oblique (PAs and Occlusals)/which third of root
If displaced, reposition the coronal segment ASAP and confirm position radiographically
Stabilise the coronal segment with a passive and flexible splint for 4 weeks - more cervically placed fractures may need upto 4 mth stabilisation
monitor healing and pulp status for at least one year using trauma grid
No endo tx started at emergency appt as it has the potential to heal
If non-vital (or becomes):
- RCT up to fracture line
Apical segment rarely undergoes pathological changes, the coronal part only is more likely to require endo tx in event of pulpal necrosis
false negative vitality testing may occur for many months - don’t commence endo tx based solely on this!
Alveolar fracture definition and management, review
Alveolar bone and may extend
to adjacent bone.
● Segment mobility and
dislocation with several teeth
moving together
● An occlusal change due to
misalignment
● Sensibility testing may or
may not be positive.
PA, Occ, Panoramic
MGMT:
Reposition the displaced segment
stabilise the teeth with passive and flexible splint for 4 weeks
suture gingival tears
no RCT at emergency visit, monitor pulpal conditions at follow ups as well as bone and soft tissue healing
4, 6-8 weeks, 4 , 6 months, 1 year, yearly 5 years
Management of concussion injuries and review times (IADT)
Bleeding and oedema, TTT, no RG signs
No tx
monitor pulpal condition for 4 weeks, 6-8 weeks and 1 year
may have false negative pulpal testing
Management of subluxation injuries and review times (IADT)
PDL damage, TTT, bleeding from gingival crevice due to PDL severance, no RG signs, mobile
normally no tx required
Passive and flexible splint for upto 2 wks if there is excessive mobility and tenderness on biting
monitor pulpal condition for 2, 4, 6-8 weeks, 6 months 1 year
Management of extrusive luxation injuries
PDL severance, XS ttt and mobility, -ve vitality response
Maturity of tooth is important for revascularisation - determines need for RCT (closed vs open apex)
Reposition tooth back into socket under LA (wash and debride exposed root surface) - check position and occlusion RG
Stabilise for 2 weeks with flexible and passive splint
splint for further 4 weeks if there is breakdown of the marginal bone
Monitor pulp - endo tx/RCT according to level of tooth development/lack of pulp response/discolouration in mature teeth may be required
Management of intrusive luxation injuries - immature teeth
No mobility or vitality test response, ankylosis may occur –> loss of PDL space
IMMATURE teeth:
allow re-eruption to occur on it’s own - no matter how bad it is - amount of intrusion does not matter here
if it doesn’t happen spontaneously within 4 weeks - start orthodontic or surgical repositioning to prevent ankylosis
Ortho (slow, delayed presentation and repair of marginal bone)
Surgical (major intrusion and immed after injury)
SPLINT to stabilise
Monitor pulp - spontaneous revascularisation may occur.
Signs of infection, necrosis or inflammatory external resorption endo tx RCT is indicated (once tooth is in correct position)
ALL mature teeth consider RCT and commence 7-10 days after injury in mature teeth (chances of revascularisation low)
Management of intrusive luxation injuries - mature teeth
What are you trying to prevent?
MATURE teeth
Allow re-eruption if it is less than 3mm intruded
If fails/ or 3mm-7mm intruded, reposition surgically and splint for 4 wks or orthodontically to prevent ankylosis
In closed apices, tooth almost always becomes necrotic. Start RCT after 2 weeks/7-10 days or ASAP once the tooth position allows. Antibiotic or CaOH2 should be used as intra-canal medicament to prevent infection related external resorption.
Types of storage media for avulsed teeth
Physiologic storage media - tissue culture media and cell transport media
Osmolality balanced media - milk and Hanks balanced salt solution
Saliva, Saline (antibiotics may increase chances of revascularisation etc in immature teeth
First aid for avulsed teeth at the place of the accident
1- keep patient calm
2- pick up tooth by crown and attempt to place back into jaw
3- if dirty, rinse with milk, pt saliva or saline and reimplant
4- once reimplanted, pt bites on gauze/ napkin to keep position
5- If not possible to implant (unconscious patient) place in storage or transport medium (milk, HBSS, patients saliva, saline)
6- bring pt to emergency clinic
Classifying the condition of avulsed teeth based on PDL viability
1 - Tooth reimplanted immediately = PDL cells are most likely viable
2- Tooth kept in storage medium and total extra oral dry time is up to 60 mins = PDL cells may be compromised
3- extra oral dry time is over 60 mins (whether in medium or not) = PDL cells are likely non-viable
Considerations if the tooth has been reimplanted at site of injury …
Clean injured area with saline, CHX or water
Extra oral dry time and storage, maturity
Check tooth is in correct place (clinically and radiographically)
Leave if correct, or correct malpositioning with slight digital pressure - consider splinting
LA if necessary with no vasoconstrictor
If tooth put in wrong socket or rotated, may reposition upto 48 hours after the injury
Considerations if the tooth is kept in storage medium with EO dry time under 60 mins
Rinse away visible contamination with saline or osmolality balanced media
- Leave tooth in storage medium when taking history, examining clinically and Rx, and preparing pt for reimplantation
-LA without vasoconstrictor
- Irrigate socket with saline
- Examine socket for fracture and reposition fragment if necessary
-Remove coagulum with saline stream if needed to aid repositioning
-Re-implant with slight digital pressure and verify position clinically and Rx
-Splint 2 weeks
For avulsed closed apex teeth - E/O dry time <60 mins
Re implant using digital pressure and check position clinically and radiographically
Stabilise the tooth for 2 weeks with a passive flexible splint
keep composite bonding agents away from gingival tissues
nylon fishing line can create flexible splint where there are enough permanent teeth present for stabilisation
with associated alveolar bone fracture - a more rigid splint is used for 4 weeks
-suture gingival lacerations
-initiate RCT tx after 2 weeks from reimplantation
-administer systemic antibiotics
Check tetanus status
Post op and follow up
For avulsed open apex teeth
Stabilise the tooth for 2 weeks with a passive flexible splint
keep composite bonding agents away from gingival tissues
nylon fishing line can create flexible splint where there are enough permanent teeth present for stabilisation
with associated alveolar bone fracture - a more rigid splint is used for 4 weeks
-suture gingival lacerations
-pulp revascularisation and further root development is the goal - external resorption occurs very fast in children so risk must be weighed. In pulpal necrosis and infection, apexification and RCT is indicated.
-Administer systemic antibiotics
-Check tetanus status
-Post op and follow up
Why are teeth with EO time over 60 mins still reimplanted?
Despite the poor prognosis due to necrotic PDL - reimplantation allows us to restore aesthetics, function,(temporarily) alveolar bone contour, width and height - implants
Tooth is likely to have ankylosis-related (replacement) root resorption.
It can later be extracted after inter-disciplinary assessment is carried out.
Parents should be warned that the tooth decoronation or autotransplantation may be later required if tooth is ankylosed or infra-positioned depending on child’s growth rate.
Which antibiotics can be administered for patients following tooth avulsion reimplantation?
Under 12 - penicillin, amoxicillin (according to weight and age)
Over 12 - Doxycycline 2x a day for 7 days (anti-inflammatory, anti-resorptive effects)
The use of splinting for stabilisation of teeth
Studies show that pulpal and periodontal healing are promoted when the tooth is subjected to slight movement and function - hence the use of flexible, passive splints.
Stainless steel wire or nylon fishing line used
Likelihood of periodontal healing is not likely affected by duration - studies show 2 weeks.
Composite stabilisation of the wire should be on labial surfaces to allow palatal/ lingual entry for endo tx.
Keep bonding agents and composite away from gingival margin to prevent plaque traps and limit 2o infection.
Tooth may be slightly mobile after removing splint and further splinting may be necessary if opposing arch further traumatises tooth and it can’t maintain it’s position.
Patient instructions following reimplanted avulsed tooth
Avoid contact sports
Soft diet for 2 weeks
Brush with soft brush after each meal
CHX (0.12%) mw daily for 2 weeks
