Paediatric Trauma III - LUXATION INJURIES Flashcards
Define concussion
Injury to supporting tissues
No loosening or displacement of tooth
TTP
Define subluxation
Injury to tooth supporting tissues WITH abnormal loosening
No displacement
What to look for as evidence of a concussion/subluxation injury?
Bleeding at the gingival margin
Lateral luxation?
Bodily movement of the tooth within the socket
Not usually mobile
Rupture of neurovascular bundle
Crushing of PDL cells in the palatal cervical region
Extrusion?
Axial displacement partially out of the socket
Mobile
Appears elongated
Intrusion?
Tooth forces upwards into the socket (in developing dentition - may be difficult to tell if teeth were partially erupting anyway)
Complex and severe injury
Crushing of PDL cells and neurovascular bundle
Avulsion?
Tooth lost from socket
Ischaemic injury to the pulp
PDL cell death
Structures involved in luxation injuries?
Pulp - severing of apical blood supply (if closed apex cannot resolve this damage)
PDL - rupture and/or crushing of tissue (can regenerate if not crushed)
Prognosis of the pulp depends on?
Type of injury
Age of pt (stage of clinical dev - open/closed apex)
Concomitant injury (fracture)
Types of pulpal healing?
Complete healing
Pulp canal obliteration = pulp tries to heal itself = more 2ndry dentine formed (no RCT done as still vital, monitor tooth, tooth can go yellower)
Pulp necrosis = inflammatory resorption = non-vital = treat with caoh asap to stop inflammatory resorption
Pulpal survival rates following luxation injuries - greatest survival rate to lowest survival rate)
Concussion - highest survival rate Subluxation Extrusion Lateral luxation Intrusion - lowest
Types of resorption?
Inflammatory
Replacement
Internal
What is external inflammatory resorption?
Continuation of surface resorption due to toxins from the necrotic pulp
Progressive until bac removed (e.g. pulp extirpation)
Will be filled in with cementum or bone healing
Internal resorption?
Necrotic pulp
Ballooning of the canal
Rapid progression
Extirpation and dressing with caoh required
Replacement resorption?
Extensive PDL damage
Osteoclasts are in direct contact with dentine
Normal bone turnover process leads to progressive replacement resorption - progressive (quicker in growing children)
General advice to manage luxation injuries?
Soft diet 7 days
Analgesics as necessary
Good OH
Chlorhexidine MW or gel - rub on affected area to avoid brushing area if painful
Review splint at 48hrs to ensure it’s still stuck down
How to treat concussion injuries?
No tx
Monitor 4 weeks, 6-8 weeks, 1yr
Subluxation management?
A flexible splint can be placed for up to 2 weeks if pt finding it uncomfortable
Monitoring - 4 weeks, 6-8 weeks, 1 yr
Extrusion management?
Reposition by gently repositioning (with/wo LA)
Avoid high speed suction
Flexible splint for 2 weeks
Monitoring 2w, 4w, 6-8w, 6m, 1yr, yearly for 5 yrs
Lateral luxation management?
Reposition, disengaging tooth from any bony lock (push apex past bony lock) (usually with LA)
Flexible splint for 4 weeks
Monitor 2 w, 4w, 6-8w, 6m, 1yr, yrly for 5 yrs
Likely pulp will become non-vital
Intrusion management?
Leave - may spontaneously erupt
Ortho extrude
Surgically extrude
= Specialist management
Management of intrusion of a tooth with an immature apex?
Allow spontaneous repositioning to occur - if no movement in a few weeks, recommend rapid ortho repositioning
If intruded more than 7mm reposition surgically or orthodontically
Management of intrusion of a tooth with mature apex?
Teeth with complete root formation:
- Allow re-eruption if tooth intruded over 3mm, if no movement after 2-4 weeks reposition surgically or orthodontically
If intruded more than 7mm reposition surgically
Splint for 4-8weeks once surgically repositioned
Commence with RCT within 3-4 weeks
Telephone advice for avulsion
Find tooth
Hold tooth by the crown, not root
If dirty, rinse with cold water - 10 secs, plug in sink
Put in milk/pts own saliva
Put tooth back in socket
Get child to bite on rolled up tissue to hold it in place
What can luxation injuries lead to?
Death PDL - Bone in direct contact with tooth - ankylosis and replacement resorption - if growig pt = infraocclusion (ankylosis) and vertical bone loss
Benefits of replanting teeth?
Aesthetics Space maintenance (avoid denture) Maintain options (bone preservation, transplants) Prevent restorative tx Psychological benefit
Disadvantages of replanting teeth?
Intra-occlusion
Loss of gingival contour and bone
Multiple visits
Tooth will be lost eventually
Potential contraindications of replanting teeth?
Immunosuppression
Severe cardiac disease
Caries/PD
Children with severe learning disabilities who would not be able to manage ongoing tx
Severe incisor crowding, supplemental incisor
Management of avulsions?
- Replant ASAP:
Store tooth in saline/milk
LA
Gently irrigate socket to remove clot
Handle tooth by the crown NOT the root
If contaminated, remove debris with saline
If stubborn debris, dab with saline soaked gauze
(Measure tooth length prior to replanting = confirms WL for future RCT)
If wont replant - stop
Reposition bony fractures with blunt instrument if required
Flexible splint for 7-14 days
Systemic antibiotics
Extirpate pulp in mature tooth between 0-10 days
When to provide systemic antibiotics after luxation? What antibiotics?
Contam, multiple injured teeth, med conditions rendering child susceptible to infec
Over 12 yrs: doxycycline 200mg twice daily for 1st day, then 100mg 2x daily for 10 days
Under 12 yrs: amoxicillin 250mg 3x daily for 5-7 days
When to do endo tx after injury for teeth with a mature apex?
RCT - mandatory for teeth with mature apex
Done 0-10 days (before splint removal, so tooth is stable during tx)
If extirpated prior to 7 days, use odontopaste instead of caoh
Dress with non setting caoh for 1 month
Definitive obturation at 1 month
In teeth with open apices, RCT can be avoided unless clinical and rad evidence of pulpal necrosis
When to do extraoral endodontics?
Only in older pts, where growth complete and excessive extra-oral dry time - ankylosis is expected
Replant tooth
Flexible splint 7-10 days
Follow up regimen?
Rad and clinical exam 1/2 days (splint check) 0-10 days - RCT if needed 2w (splint removal) 4w definitive RCT needed 6-8w 3m 6m 1yr Yearly
Subluxation, extrusion and avulsion splint time?
2 weeks
Lat luxation, dento-alveolar fracture and middle/apical 3rd root fracture splint time?
4 weeks
Cervical 3rd root fracture (poor prog) splint time?
4 months
Types of splint?
Direct
Indirect
What do direct splints aim for?
Physiological splint to encourage healing and reduce risk of ankylosis
Types of direct splints?
Titanium splint (gold wire but expensive)
Flexible ortho wire and composite
Ortho bracket and flexible wire
Composite/glass ionomer bandage (emergency)
Surgical wiring (max fax)
When to use an indirect splint?
Essix type retainer, use of temp cement
Only if unable to get moisture control for direct splint or insufficient teeth to splint to
Negatives of indirect splints?
Expensive as lab made splint
Teeth may come out in alginate impression
Not good for OH
Cannot access RCT with splint on
How to fit a splint?
Reposition tooth (LA)
Control bleeding
Bend wire into passive arch, extend to one stable tooth either side of mobile tooth and cut to correct size
Spot etch teeth mid-crown and apply composite button using dark shade
Place arch wire on uncured composite wire, towards the incisal third of the tooth - light cure
Check no rough composite and no sharp wire
