Paeds-trauma Flashcards
What is a laceration?
A soft tissue tear.
Why do you check if a pateint can open their mouth?
As if the patient had any jaw fractures, opening their mouth would be difficult.
How does trauma affect the patient’s occlusion?
It could prevent the teeth occluding together by propping them open or being the first thing that touches them when they touch.
Where do you check for foreign bodies after trauma?
Lodged in soft tissues
Penetrating wounds.
What does tooth mobility indicate?
Tooth displacement
Root fracture
Bone fracture (if several teeth on a segment are mobile)
How long does trauma review continue for after injury?
Sensibility tests are continued for at least 2 years after injury.
Name this fracture?
Enamel fracture
Name this fracture?
Enamel dentinal fracture.
Name this fracture
Enamel dentine pulp fracture.
Name this fracture & explain how you would further describe this?
This is a root fracture. It is further described by the 1/3 of the root that has fractured:
apical 1/3
middle 1/3
coronal 1/3
Compare these two fractures
On the left- UNcomplicated crown root fracture- the fracture is affecting enamel, dentine and into the root but is not affecting the pulp.
R- complicated crown root fracture- The pulp is also affected by the fracture.
Why would a tetanus prophyaxis be used as an emergency treatment for trauma?
In case bacteria would get into the wound.
Compare apexigensis with apexification?
Apexigenesis- when the tooth growth naturally continues after damages.
Apexification- when an intervention is needed to to provide an apex for the tooth.
When should you follow up fractures?
For enamel or enamel dentine
6-8 weeks and 1 year.
Enamel dentine pulp
6-8 weeks. 3 months. 6 months. 1 year.
Crown root fractures
1 week. 6-8 weeks. 3 months. 6 months. 1 year. yearly for 5 years
In what ways can we manage an enamel fracture?
Bond the fragment back to the tooth
Grind the sharp edges
Replace the fracture with a little bit of composite.
How do we manage an enamel dentine fracture?
We bond the fragment to the tooth.
Place a composite bandage.
Where would you look for a lost fragment?
On the ground
In soft tissues
In the lungs (Especially if patient is coughing or wheezing)
It may have been swallowed.
How do we check for root development in a radiograph?
We check for:
- width of the canal
- Length of the canal (if the root continues to grow it is still alive)
- Internal or external resorption.
- periapical pathologies.
Why is there more chance of damage with trauma of a mature tooth than an immature tooth?
A mature tooth has a small apex. The smaller apex means it is more likely for the nerves to be ripped and torn causing pulp death.
This is in contrast to a wider apex (immature tooth)
In an enamel dentine pulp fracture-
The pulp exposure is <1mm and <24 hours old.
How would you treat this?
Direct pulp cap.
- LA
- Isolate tooth with rubber dam
- Clean exposed area with saline
- Disinfect with sodium hypochlorite
- Place calcium hydroxide over the exposed site
- Seal the exposed resin with GIC or composite resin
- Restore tooth with composite.
In an enamel dentine pulp fracture-
The pulp exposure is bigger than 1mm. How do you treat this?
Partial pulpotomy.
- LA
- Isolate with rubber dam
- Clean exposed area with saline
- Disinfect with sodium hypochlorite
- Remove pulp to a depth and width of 1-2mm using a round diamond bur
- Place a saline moistened cotton pellet on the pulp & check haemostasis
- Apply calcium hydroxide
- Seal exposed dentine with GIC or composite.
- Restore with composite.
In an enamel dentine pulp fracture-
The pulp exposure is more than 24 hours old. How do you treat this?
Partial pulpotomy.
- LA
- Isolate with rubber dam
- Clean exposed area with saline
- Disinfect with sodium hypochlorite
- Remove pulp to a depth and width of 1-2mm using a round diamond bur
- Place a saline moistened cotton pellet on the pulp & check haemostasis
- Apply calcium hydroxide
- Seal exposed dentine with GIC or composite.
- Restore with composite.
In an enamel dentine pulp fracture-
You have started treating the pulp, but cannot arrest the bleeding. How do you manage this?
A full coronal pulpotomy.
- Remove all of the coronal pulp
- Place calcium hydroxide in the pulp chamber. (Thin layer so we have space for the vitrebond- prevents the dycal washing out)
- Seal with GIC lining & a quality coronal restoration.
Compare a concussion injury to a subluxation injury.
including review and treatment.
concussion- injury without increased mobility.
Subluxation- injury with increased mobility
Concussion review- 4 week,1y
Subluxation review- 2w,12w,6m,1y
Treatment for concussion- occlusal relief
Treatment for subluxation- a 2 week flexible splint
What is occlusal relief?
This is the use of RMGI to build up on the posterior teeth and prop open the bite. This takes the pressure off the tooth.
Discuss the sensibility test monitoring for concussion and subluxation injuries.
The thermal and electrical tests should be done at the time of injury.
There can be a short term lack of sensibility that returns
Poor sensibility at the start increases the chance of pulp necrosis.
What are we looking for in the radiographic monitoring of subluxation and concussion injuries.
We are looking for:
- Root development (how long and wide is the canal?)
(compairing the injured root to the root on the oposing side)
- The presence of internal and external inflammatory resorption.
What is an extrusion injury?
Tooth injury where there is partial or total seperation of the PDL which causes displacement out of the socket.
What do we see clinically and radiographically for an extrusion injury.
Clinically- We see the tooth incisal edge lower than the other teeth
Radiographically- We see a widened PDL space.
How do we treat an extrusion injury and when do we review?
Reposition under LA.
Patient wears a flexible splint for 2 weeks.
Review:
2 weeks
4weeks
8weeks
12 weeks
6 months
yearly for 5 years.
What is a lateral luxation injury?
Displacement of the tooth to the side (Not up or down)
The PDL is torn on one side and crushed on the other.
How do we treat a lateral luxation injury?
& when do we review it.
If presents early- Reposition under LA
If it presents late- Use orthodontic forces.
The patient should wear a flexible splint for 4 weeks.
It is reviewed at:
2 weeks
4 weeks
8 weeks
12 weeks
6 months
Yearly for 5 years.
What is an intrusion injury?
When the tooth is pushed back up into the alveolar process.
All the PDL around the tooth has been crushed against the alveolar bone (crushing injury)
What do we need to consider before treating an intrusion injury?
- is the apex open or closed?
- how retruded is the tooth (i.e. measure how far has the tooth been pushed up)
Compare the three treatment options for intrusion?
Spontaneous- leave the tooth to move on its own due to forces from the tongue and lips.
Orthodontic- use an orthodontic appliance to move the teeth back into position.
Surgical- use surgery to pull the tooth back down.
We then hold the tooth in place using a flexible splint for 4 weeks.
How do you treat an open apex tooth with up to 7mm intrusion?
Spontaneous
How do you treat an open apex tooth with more than 7mm intrusion?
Orthodontic or surgical.
How do you treat a closed apex tooth with up to 3mm intrusion?
spontaneous
How do you treat a closed apex tooth with 3-7mm intrusion?
orthodontic or surgical
How do you treat a closed apex tooth with more than 7mm intrusion?
surgical.
What is a high risk result of intrusion of a tooth with a closed apex?
There is a high risk of root resorption.
When do we review a patient with an intrusion injury?
2 weeks (checking splint)
4 weeks (removing the splint)
8 weeks
12 weeks
6 months
1 year
yearly for 5 years.
What is avulsion?
The tooth being completely knocked out.
What are the critical factors for successful healing from an avulsion injury?
EADT- extra-alveolar dry time
Type of storage medium (e.g. milk)
extra alveolar time (the total time outside of the mouth )
What do you do if a patient arrives with the tooth already implanted after an avulsion injury?
Leave it in &splint (unless the tooth is extremely dirty)
Use radiographs (to establish how much root there is and if the apex is open or closed)
What is the public advice regarding knocking out teeth?
Hold the tooth by the crown
Put the tooth back in the mouth (and get the child to bite down on some tissue)
Or store in cold fresh milk or saliva.
Seek dental advice
When should you not re-implant an avulsed tooth?
If the child is immunosuppressed or it is a primary tooth (it could damage the developing tooth germ)
Compare treatment of an open and closed apex avulsed teeth after <60 minutes EAT.
- Re-inplant the tooth under LA
- Flexible splint for 2 weeks.
- Antibiotics? and check tetanus status
Open apex:
closely monitor for success (continued root growth)
Closed apex:
Remove pulp as soon as possible. Leave antibiotic steroid paste first for 2 weeks before CaOH (which interfeers with PDL healing
Obturate at 4-6 weeks.
Why do we use antibiotic paste first before CaOH when treating Aluvsion injuries?
CaOH interferes with PDL healing.
compare the review time for avulsion injuries with EAT <60 minutes for open and closed apexs.
Open apex:
2w, 4w, 2m,3m,6m, yearly.
Closed apex:
3m,6m,12m, yearly.
Compare the treatment for an avulsed tooth when the EAT >60 for an open apex and a closed apex.
Open apex:
- Re-implant the tooth under LA
- 2 week flexible splint
- Monitor for signs of necrois v continued root development.
Closed apex:
- Remove any Damaged PDL
- Re-implant the tooth
- Extirpate
- Intracanal medicament
- (Replace using NS CAOH for 4 weeks or corticosteroid/AB paste for 6 weeks)
- 2 week flexible splint.
What is a root fracture?
This is a dentine and cementum fracture involving the pulp
Classify this root fracture
This is an apical 1/3 root fracture.
It has the best prognosis.
Classify this root fracture
This is a middle 1/3 root fracture.
It is vital we reduce these types of fracture (get the halves touching again)
Classify this root fracture
This is a coronal 1/ 3 fracture.
This has a very poor prognosisis as there is little PDL support to keep the crown in position during function (an unfavourable crown/root ratio)
Compare a displaced and undisplaced root fracture?
Displaced- bones burst apart
Undisplaced- the bone is still fitted together.
What is the prognosis of a root fractured tooth dependant on?
Age of the child (mature/ immature)
The degree of displacement
The associated injuries e.g. a crown fracture)
The time between injury and treatment
Presence of infection.
How do you treat a root fracture?
What treatment outcome of a root fracture is shown in this radiograph?
Calcified tissue healing.
This is the ideal treatment outcome as it is very similar to dentine.
What type of healing is shown on this radiograph
This is connective tissue healing-
We can see that the fracture lines remain visible.
The edges of the fracture show Eburnation- where the corners of the fracture are rounded off)
What type of tissue healing is shown on this radiograph.
This is bony healing.
The two parts of bone become unique entities that don’t connect.
There is a clear layer of bone that has formed between the two fragments.
What does granulation tissue look like on a radiograph?
A radiolucent area surrounding the fracture line.
What do you do if the fractured part of the root becomes non-vital
- you remove the root up to the fracture line
- Create an apical barrier using CaOH then MTA or biodentine.
- Backfill from the fracture line using GP.
- The apical part of the root can be left unless infected
- If infected- antibiotics and apicectomy
What is a Dento-alveolar fracture?
Where there has been damage to the alveolar bone. The teeth are secure in the socket but the bone holding them in has fractured.
How do we treat a dento-alveolar fracture?
- LA
- Move the bone into the correct place
- 4 week flexible splint
- Cover with antibotics.
When do you review a dento-alveolar fracture?
At 2w, 4w, 8w, 4 months, 6months, 1 year, yearly for 5 years.
What do we treat with 2 week flexible splints?
Subluxation.
Extrusion
Avulsion
What do we treat with a 4 week flexible splint?
Lateral Luxation
Apical and middle 1/3 root fracture.
Intrusion
Dento-alveolar fractures
What do we treat with a 4 month flexible splint?
Coronal 1/3 root fracture.
What is the most common type of injury in young children and why?
Luxation- becuase the bone takes the injury and absorbs the force rather than the tooth.
Why do we look for soft tissue damage in our intra-oral examination?
to find penetrating wounds or foreign bodies.
Why do we test tooth mobility after dental trauma ?
In case of displacement, tooth or bone fracture.
Why do we transluminate the tooth after trauma?
To show fracture lines, pulpal degeneration and caries.
What is the purpose of the tactile test?
Using a probe we feel for fractures horizontally, vertically and involving the pulp.
Why do we check the percussion of teeth?
Root fractures have a duller note.
How do we treat a child with a small enamel fracture?
Smooth the sharp edges.
How do we treat a child with a larger enamel fracture or enamel dentine fracture.
Cover exposed dentine and restore with composite or compomer
How do we treat a child with an enamel dentine pulp fracture?
Consider how long till exfoliation then either:
Extraction
Endodontic therapy using calcium hydroxide paste.
How do we treat a child with a crown and root fracture?
Extract coronal fragment & leave any obvious root fragments to resorb
You don’t want to risk damaging the developing tooth follicle.
How do we treat a child with an alveolar bone fracture.
Reposition segment and splint to adjacent teeth for 4 weeks.
Why do we not use GP for endodontic therapy in primary teeth?
Because the primary teeth have to resorb in order to make space for the secondary teeth.
How do you treat a primary tooth concussion or subluxation?
You observe it.
How do you treat lateral luxation in a primary tooth?
If there is no occlusal obstruction allow the tooth to spontaneously reposition.
If there is occlusal obstruction- extract.
How do you treat intrusion in a primary tooth
You monitor the re-eruption of the tooth.
If the tooth does not erupt within 6 months then extract to avoid any problems with the permanent tooth erupting.
how do you treat an extrusion injury in a primary tooth?
Extract the tooth- we do not want to risk damage to the developing tooth germ
How do you treat an avulsion injury in a primary tooth?
Radiograph to check the tooth is fully avulsed, and do not replant.
What information does this radiograph give us regarding the injury?
The root of the tooth is longer than the contralateral tooth.
This shows that the apex is displaced towards the permanent tooth germ.
What does this radiograph tell us about the injury?
If the apical tip appears shorter than the contralateral tooth it has been displaced towards the buccal plate (away from the tooth germ)
The primary tooth is discolored but vital, how do we treat it?
No treatment- but the tooth will remain discoloured.
A primary tooth is non-vital and on the radiograph we see a sinus or PAP.
How do we treat this?
RCT or extraction.
A primary tooth is non-vital and we don’t see a sinus or PAP on the radiograph
How do we treat this?
Leave it.
What causes an opaque primary tooth and how do we treat it?
Scerlosis of the canal causes an opaque tooth.
We leave the tooth as this is like natures own root canal treatment.
You see this clinical presentation, what do you think ?
The pinkish colour- there is a burst blood vessel in the tooth and nowhere for the blood to go.
The immediate discoloration is a good indication that the tooth may maintain vitality.
You see this clinical presentation, what do you think?
Red/brown/ black tooth colour is caused by the necrotic pulp products.
This is a non-vital tooth.
The colour change over a few weeks indicates death.
What is this and how do we treat it?
There are yellow or white marks on the teeth = hypomineralisation.
There is normal enamel thickness, it just hasn’t been fully mineralised.
Treatment:
Leave
Mask with a layer of compsoite
External bleaching
Localised removal and restoration with composite.
What is this and how would you treat it?
Hypoplasia.
Reduced enamel tissue thickness
Treatment:
Porcelain veneers after 16 (once the gingival level has stabilised)
Composite restoration
What is a crown dilaceration?
When there is a bend in the linear relationship between the crown and the root.
What are some long term complications of trauma on primary teeth?
- Discoloration
- Loss of vitality
- delayed exfoliation
- May need extracted.
WHat are some long term complications of trauma on permanent teeth?
- Delayed eruption.
- Ectopic eruption
- Damage to crown development (dilacerated crown/ hypomineralisation/hypoplasia)
- Damage to root development (Arrested root development/root dilaceration)
- Odontome
- Undeveloped tooth germ.
What does this radiograph show?
An odontome
A benign tumour assoicated with tooth develoment (Looks like a bag of teeth)
Why does trauma cause delayed tooth eruption?
Premature primary tooth loss causes thickened mucosa delaying eruption by about a year.
What is the prognosis for immature teeth and why?
It is better, as the apex is open allowing more space for blood vessels and nerves to enter the tooth.
Explain what is going on in this radiograph
And how do we treat it.
A common seqaule of all luxation injuries that include displacement.
It is a condition where hard tissue is formed within the pulp cavity and deposited. This causes gradual narrowing of the pulp chamber and pulp canal (total or partial obliteration)
Treatment- conservative (only 1% of cases give rise to periapical pathology).
How do we deal with an an avulsed tooth with visible dirt on it?
Agitate it in storage solution or a stream of saline.
If an avulsed tooth has been reimplanted in the wrong position- discuss treatment options.
If within first 48 hours- reposition it.
After this time- Restore with composite to improve aesthetics.
Why do we use a flexible splint for reimplanting a tooth?
The flexible splint recreates the physiological movement of the tooth to stimulate PDL regeneration.
Discuss antibiotic use in the treatment of dental trauma.
If root or soft tissue injuries are contaminated.
First line- Amoxicillin
Doxycycline (if allergic or aged <12)
What are we looking for when reviewing a trauma case?
Continuation of the root formation
Loss of pulp vitality
PDL breakdown
Resorption (Types and process)
Types of root fracture healing
Name and discuss this type of resorption.
External surface resorption-
Response to localised injury
e. g. get damage to the PDL which subsequently heals
e. g.
Maxillary canines/ Maxillary laterals/ Excessive orthodontic forces.
Name and discuss this type of resorption.
& why do you know.
External inflammatory resorption-
There is damage to the PDL this is maintained and proagated by the necrotic pulp tissue via the dentinal tubules.
Diagnosis- root surfaces indistinct/ tramlines of the root canal are intact.
Name and discuss this type of resorption.
& how do we know?
Internal inflammatory resorption.
This is a progressive resorption initiated by non vitality.
The root surface is intact but the tramlines of the root canal are indistinct (internal ballooning of the canal)
How do we treat teeth with Infection related inflammatory root resorption?
Pulp extirpation
Mechanical debridement
Chemical irirgation.
NS CaOH 4-6 weeks then obturate.
What is this?
Ankylsosis related replacement root resorption. The bone is fused directly to dentine (no normal repair). The tooth is gradually resroebd as it becomes part of the bone remodelling.
This is initated by severe damage to the PDL.
Diagnosis- loss of PDL (no PDL space) and loss of lamina dura.
Treatment- NIL.
List the main complications after trauma?
Tooth loss
Pulp necrosis and infection
Pulp obliteration
Root resorption
Breakdown of marginal gingivae and bone.
List some predictors of bone loss
Avulsion
Intrusion
crown/root fracture
Cervical root fracture.
List some traumatic predictors for necrosis and infection of the tooth
Crushing injuries
Closed apex
Joint-crown fracture and luxation.
List some traumatic predictors for pulp canal obliteration
Open apex.
Root fracture
Severe luxation injuries (Intrusion/extrusion/lateral luxation)
List some traumatic predictors for root resorption
Early root development
Compression of the PDL
Avulsion- if PDL is left to dry (Outwith appropriate storage medium)
List some traumatic predictors for breakdown of the marginal bone or gingivae.
Marginal bone crushing injuries (intrusion/avulsion)
Alveolus or jaw fractures.
Your patient has attended with a pulpal exposure >1mm. You have started treatment and are checking the haemostasis. What are the posibilities you could face?
Bright red blood & good haemostasis- normal bleeding- Stumps you have left are healthy/vital and uninflamed.
Deep crimson colour and continued bleeding after pressure- Abnormal bleeding- The pulp stumps you have left are inflamed and unhealthy (try pressure again)
No bleeding- Abnormal- That part of the pulp is infected and non vital so should be removed
Compare a primary pulpectomy to a pulpectomy in an immature permanent tooth?
Primary pulpectomy- Calcium hydroxide paste is used to fill the canal as the tooth has to resorb.
Immature permanent pulpectomy- We need to induce an apical stop (using MTA or Calcium hydroxide) prior to obturation with heated GP
What patient instructions should be given to the parent after treatment of the child’s Pulpal exposure
Be careful when eating not to further traumatise the injured tooth (eat soft food) before returning to normal function as soon as possible.
(For young children) Parents should clean the affected area with a soft brush or cotton wab & alcohol free 0.1% chlorohexidine gluconate mouthrinse Twice a day for 1 week.
Parents should be advised abut possible complications to watch out for (swelling/discoloration/ increased mobility/ fistula)
What is the problem faced when completing. a pulpectomy on an immature permanent tooth?
It is still forming so has an open apex. This means there is no apical stop to allow obturation with GP.
Why do we want apexification and how do we achieve it?
We want a calcific barrier to condense the root canal filling against.
Using MTA or CaOH.
Compare the use of MTA or CaOH for apexification
**Mineral Trioxide Aggregate: **
1. Place 5mm at the apical end of the root
2. Wait 15 minutes for it to harden.
3. Obturate with Heated GP (Immature canal is too large to fit GP cones in)
CaOH
1. Placed in the tooth for 4-6 weeks until a barrier is formed. Then we remove CaOH & Obturate.
DISADV- Any longer reduces dentine mineral content making the tooth brittle and more susceptible to root fracture. The barrier created also contains holes (risk for bacteria)
