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,
