Orthodontic Emergencies Flashcards
Type of problems
- Patient discomfort
- Fixed appliance problems
- Removable appliance problems
- Retainer Problems
Why might orthodontic emergencies occur?
- Patient factors
- Operator factors
What are Potential problems with irregular attendance?
- Unwanted tooth movements
- Relapse of tx changes
- Elongated treatment time
- Pain/ swelling - soft tissue injury
- Reduced complaince
- Delcalcification/ periodontal disease/ tooth wear/ root resorption.
How do we aim to limit the number of emergency visits?
- Patient factors
- Operator factors
- Practice / department factors
Management of different types of orthodontic emergencies
1- Patient discomfort
- Discomfort is expected for first 3-5 days after braces fitted
- Pain is usually worse at 24 hours after braces are fitted
- Discomfort common for first 3 days after any adjustment
- Providing reassurance helps reduce anxiety
- Analgesics advice and provision of orthodontic wax
2- Fixed appliance problems
- Soft tissue trauma
- Lost bracket / molar tube
- Archwire
- lost module or auxillary
2.1 Soft tissue why happens?
- Excess wire distally -
- Wire displaced out of molar tube
- Brace digging in cheek or lip
- dislodged auxiliary digging in cause of brushing
Wire digging in at the back ? Cause ? Treatment and prevention ?
- Due to wire sticking out of molar attachment
- Wire turn into one side
- Wire dislodged from attachment or lying over and under attachment
Treatment: - if wire has turn into one side or become dialodged - remove all o-rings place wire at correct position with Adam’s and replace o-ring
- if wire too long cut it with distal end cutter.
- Smooth the end of thick wire with green stone .
- If distal end cutter not available. Use wire cutter with cotton roll to cut wire to hold wire.
Advice - reassure patient that this is common emergency
Prevention : - careful placement of Correct archwire length
- when using self ligating bracket place o- ring to stop wire swivelling.
- Protecting light wires with Lacebacks will help to prevent these problems.
- If patient is wearing powerchain / elastics ,Long wire is good sign that spaces are closing.
- Wire
Regualr Oral ulcers
- if repeated ulcers check MH
- Advise appt with GMP if regular
- Take photos + measuring and record site of ulcers.
Debonded bracket
Cause: can be operator / patient factors dietary advise after treatment, prolong tx,
Treatment:
- Do no remove module
- Remove other modules and archwire
- Remove composite + etch + Bond + rebond bracket
- Replace wire - same size or drop down size
Loose Molar band
Cause: May be Patient factor- dietary advise - can prolonge treatment time.
Tx:
- Remove modules and archwire
- Remove loose band with band remover
- Remove residual cement with hand instrument/ slow speed with tungsten carbide bur
- Choose New band and cement with GIC
Archwire Fracture:
Cause - Patient factor , diet , habbit ( nail biting, pen chewing. Advise given to patient. Prolong treatment, inhalation, ingestion
Tx:
- Remove modules and loose fragment of af archwire
- If length of wire missing question patient
- Replace new archwire and ligate.
Loose module/ powerchain or auxiliary
Cause - auxiliary dislodged during brushing, eating or broken,
- Opertor factor- single tooth module can be composite on tie wing of bracket
Tx-
- Loose wire remove it.
- Tuck in sharp end with Mitchell’s trimmer, flatplastic, ortho tucker
- Module - replace module, ideally replace power chain if it’s possible to see where it was connected.
Prevention:
- Show pt how to tuck in similar hooks may get untucked
- Remove flesh of composite properly.
Issues of with Quadhelix or Transpalatal arch with Nance button
Cause : May dig into soft tissue
TX:
Orthodontist only
- Pt should contact orthodontist asap
- Orthodontist/ therapist can recement component.
- If cutting wire use high speed with diamond bur if digging in but hold it with Mathiau for patient safety.
- Cutting component - Extra appt and remake - last resort
- If component removed . Smooth with green stone rough edges. Orthodontist will be able to adjust and lift the component away from palate.
Prevention: Suggest to use mouthwash or super floss to clean under palate and advise to see orthodontist.
Removable appliance problems
-Loose removable appliance
- Soft tissue trauma
- Fractured acrylic
- Fractured wire
- Fracuted screw
Loose appliance no longer fits
- Cause - cribs or clasps fractured or distorted by clicking it in and out.
-Patient has not worn appliance for prolonged time. - May occur permanent tooth has erupted after appliance fitted
Tx : adjust reamaining cribs to Improve retention using Adam’s plier.
- Remove fractured cribs using heavy duty wire cutter pliers and smooth with green stone.
- remake
- discontinue require prescription
Prevention: Why wires distort and break because of clicked up and down in similar way repeatedly bending paper clip wire. Recommend keep wearing the appliance if possible.
Soft tissue trauma by removable appliance
Fracture acrylic
Cause: Excellent wear of appliance, or dropping or standing on appliance
Tx:
- Smooth acrylic with acrylic bur and trimming bur if still fits. Pt continue to wear it if possible until see orthodontist
- Repair acrylic may require in situ with their orthodontist.
- remake
Retainers problem:
Removable retainer .lost or fracture
Cause: Pt chewed it , dog chewed it
Tx: Remake new one with replacement charge.
Advise: retention of 2 nights per week indefinitely is recommended for all pt who had orthodontic treatment .
If relapse occurred explained retainer will maintain current position of teeth only not correct it.
Bonded Retainers fractured
Cause- Operator / pt not adhering to adhere to diet.
Tx:
- If wire is still in place then it may be possible to etch + bond + add composite to create smooth surface.
- If wire distorted . It will require replacement and the fractured piece can be removing wire cutter and green stone to smooth remaining composite.
- Care is needed if reattached distorted wire can move teeth into unwanted position.
Advice: Pt must wear retainer VFR every night until take new impression for bonded retainer .
, repair /replacement charges,
If Patient comes with broken elastic chain and missing close spring?
- If notes are clear , replacing it would be ideal
What if old crown will become loose/ tooth fracture/ chip when Debonding?
- Inform patient
- Call orthodontist - may need temp fit crown
- Refer to GDP for management
- Document it + photos.
Headgear issues
- Soft tissue and optical trauma
- If issue with fit - Advise pt to stop wear and book appt.
- If there is optical trauma- Attend A&e
Workplace policy and protocol for emergency appt.
- You will have system in place where you work
-Personal perspective
- Geographic considerations
- Patient co operation
Inshalation and Ingestion of Foreign Bodies.
Is the object still visible in mouth and oropharynx?
- It iş - Attempt should be made to remove it by suction ideally with patient reclined.
- Failing this- ask patient to roll side and encourage to cough up the object.
What has been inhaled or ingested?
What’smissing ? - Is it bracket, band, archwire or auxillary?
Determine ? - important to know size, shape, likely flexibllity, and radio- opacity.
- Check surrounding , floor, cloth , suction tip , distal end cutter.
Inhalation clicnical sign and symptoms of inhalation?
- Respiratory obstruction and cough
- Choking or Stridor ?
- Management: BLS- call for help
- Administer 5 back blow following 5 abdominal thrust.
- CPR
-Send hospital with information of object missing ( size, shape, flexiblity and radiopaque)
- Chest Xray Bronchoscopy)
- Inhaled - likely RHS lung
Ingestion
- Inform pt
- Ask to monitor stool.
- May be no immediate symptoms.
- possible symptoms- Vomiting , pain over 6 days.
- Chest / abdominal xray / Fibre optic endoscopy.
Ingestion object
- If object less than 5cm reach stomach 90% chance it will pass GIT in 7-10 days . Ask to monitor stool it will pass over 6 days.
- if object more than 5cm is unlikely to pass duodenum
Management : - Infrom patient
- Ask to monitor stool
- Warn vomiting and pain over 6 days.
When should be refer to hospital ?
- Object has been inhaled
- Object swallowed >5cm in length
- Patient symptoms occur.
Prevention is better than cure.
- Careful instrumentation with bracket , piece of wire, auxillaries
- Work under good lighting
- Idientify high risk patients
- Use appropriate and well maintained equipment
Example of appropriate and well maintained Instruments?
- Tweezer that meet at their tips
- Sharp distal end cutters
- Distal end cutters and cotton wool.
- Protective gauze / floss for RME (Rapid maxillary expansion) keys
- Keep nurses high speed suction available to hand
