Paeds Trauma- Assessment, Classification And Management Of Crown Fractures Flashcards
What type of trauma injuries are most common in the primary dentition?
Luxation
What is the most common type of trauma injury in the permanent dentition?
Enamel-dentina fracture
What size of overjet doubles the incidence of trauma to permanent teeth?
9mm overjet doubles trauma incidence
Which 3 conditions should you be aware of when taking a medical history of trauma patient?
Rheumatic fever
Congenital heart defects
Immunisuppression
Describe things to look for when carrying out extra oral exam?
Any other injuries (non dental)
Lacerations
Haematomas
Haemorrhage / CSF
Subconjunctival haemorrhage
Bony step deformities
Mouth opening (jaw fracture possible if limited)
What should you look for when carrying out Intra oral exam of trauma patient?
Soft tissue
Alveolar bone
Occlusion
Teeth
Penetrating wounds/foreign bodies
What may be indicated by tooth mobility?
Displacement of tooth
Root fracture (tooth will be shorter, more mobile)
Bone fracture (often multiple mobile teeth and overlying soft tissue moving with it)
What is included in a trauma stamp?
Sinus (draining/ non-draining)
Colour
TTP
Mobility (give a grade)
EPT
ECL
Percussion note
Radiograph
What does the colour of the tooth indicate?
Dark grey/ brown- non vital
Pink- internal resorption/ pulpal bleeding (this can turn to purple as blood products are broken down)
Yellow- pulp canal obliteration (reparatory deposition of dentine)
How long should you continue to carry out sensibility testing after trauma?
At least 2 years
Outline the classification of fractures
Enamel
Enamel- dentine
Enamel- dentine- pulp
Uncomplicated crown root fracture
Root fracture (apical/ middle/ coronal third)
Complicated crown root fracture
What 5 factors does prognosis of fractured tooth depend on?
- stage of root development
- type of injury
- if PDL is damaged
- time between injury and treatment
- presence of infection
Why is there a higher chance of maintaining vitality in open apex tooth?
Larger neurovascular bundle at the apex, more able to revascularize.
What are the 5 main principles of emergency treatment
Aim to retain vitality of any damaged tooth by protecting exposed dentine by an adhesive definite bandage
Treat exposed pulp tissue
Reduction and immobilisation of displaced teeth
Tetanus prophylaxis
Antibiotics?
What are the intermediate principles of treatment
- ongoing management of splinting, loss of vitality, restorations
- pulp treatment (direct/ indirect pulp cap, pulpotomy, pulpectomy)
- restoration (minimally invasive eg. Acid etch)
What are the principles of permanent treatment
Apexigenesis (maintain vitality of radicular pulp for root development - thickening of root dentinas walls)
Apexification
Root filling (+/- root extrusion)
Gingival and alveolar colla modification if required
Coronal restoration
What is and how is an enamel fracture managed?
Confined to enamel, no dentine tubules exposed, lack of sensitivity
- Bond fragment to tooth OR grind sharp edges
- take 2 periapical radiographs to rule out luxation/ root fracture
- follow up 6-8 weeks, 6 months and 1 year
What is the prognosis of pulpal necrosis in an enamel fracture?
0% risk pulpal necrosis
How is an enamel-dentine fracture managed?
- account for fragment
- either bond fragment to tooth OR place composite bandage (line restoration if close to the pulp)
- take 2 periapical radiographs to rule out luxation/ root fracture
- radiograph any lip/ cheek lacerations to rule out embedded fragment
- sensibility testing and evaluate tooth maturity (ethyl chloride and EPT)
- definitive restoration
- follow up 6-8 weeks, 6 months and 1 year
What is a composite bandage?
Small, easily applied composite restoration to seal dentinal tubules
What is an adhesive dentine bandage?
Anything which will close dentinal tubules so no fluid movement which would irritate the pulpal tissues/ ingress bacteria.
What is the prognosis of the pulp in ED fracture
5% risk of pulpal necrosis at 10 years
At follow up appointments, what should be reviewed
Trauma sticker
Radiographs- look at root development (width/ length of canal) compared to contra lateral tooth, internal and external inflammatory resorption (change to outline of external root surface/ internal canal surface), periapical pathology (darkening around apex)
How are enamel-dentine-pulp fractures managed?
Evaluate exposure (size of pulp exposure, time since injury, associated PDL injuries)
Choose from following options:
- pulp cap (setting CaOH or GI-not ideal)
- partial pulpotomy (Cvek pulpotomy)
- full coronal pulpotomy
Avoid full extirpation unless the tooth is clearly non-vital
What is the main aim in hound patients with open apices in EDP fracture
it is very important to preserve the pulp vitality by pulp capping or partial pulpotomy in order to secure further root development.
setting CaOH and MTA are suitable materials for this procedure.
For EDP fracture, when would a direct pulp cap be placed?
A small exposure (1mm), within 24 hour window.
Outline the procedure of direct pulp cap
- trauma sticker and radiographic assessment - should be non-TTP and + to sensibility testing
- LA and rubber dam
- clean area with water then disinfect area with sodium hypochlorite
- apply CaOH (Dycal) or MTA (white) to pulp exposure
- restore tooth with quality composite restoration
- review at 6-8 weeks, 6 months, 1 year (reassess trauma stamp and radiographs)
In EDP fracture, when is partial pulpotomy carried out
Larger exposure (>1mm), 24+ hours since trauma
Outline the procedure for partial pulpotomy (Cvek pulpotomy)
- trauma stamp and radiographic assessment
- LA and dental dam
- clean area with saline then disinfect area with sodium hypochlorite
- remove 2,, of pulp with high speed, round diamond bur
- place saline stacked CW pellet over exposure until haemostasis is achieved
- (if no bleeding, or can’t be arrested, proceed to full coronal pulpotomy as nerve is inflamed and unlikely to maintain vitality- irreversible pulpitis)
- otherwise, apply CaOH then GI (or white MTA) then restore with quality composite resin.
- review in 6-8 weeks, 6 months, 1 year (clinical and radiographic review)
In EDP fracture, when is a full coronal pulpotomy carried out?
Being with partial pulpotomy, assess for haemostasis after application of saline soaked cotton wool,
If hyperaemic OR necrotic, proceed to remove all of coronal pulp
Outline the procedure of full coronal pulpotomy
Remove all of coronal pulp
Place setting CaOH in pulp chamber
Seal with GIC lining and quality coronal restoration
What is the aim of pulpotomy
Aim is to keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of dentine
If the tooth is non-vital (EDP fracture) what is the last resort of treatment?
Full pulpectomy is required.
What is the issue with carrying out a full pulpectomy on an immature tooth?
There is no apical stop to allow obturación with GP
What are the 3 options of material to use for immature tooth full pulpectomy?
CaOH in canal (monthly basis) aiming to induce hard tissue barrier to form (apexification)
MTA/ BioDentine placed at apex of canal to create cement barrier (apical pulp)
Regenerative endodontic technique to encourage hard tissue formation at apex (stimulating of periapical bleeding to encourage hard tissue formation- only done in very young patients)
What is a disadvantage of using CaOH
Increases chance of root fracture as CaOH increases brittleness of root
Outline the procedure of a pulpectomy on an open apex
- rubber dam
- access
- haemorrhage control (LA/ sterile water)
- diagnostic radiograph for WL (especially important for apical plug placement- radiograph + apexificator)
- file 2mm short of estimated WL
- dry canal, non-setting CaOH, CW in pulp chamber
- glass ionomer temporary cement in access cavity and evaluate CaOH fill level with radiograph (ensure to appropriate length, minimise extrusion of material into periapical tissue (post op pain), ensure no clear voids (results in calcific barrier formation- hard tissue)
- exptipate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital (due to increased brittleness)
- MTA plug and heated GP obturation
- usually wide canals - lateral compression is very time consuming
- consider coronal restoration as bonded composite a short way down the canal to increase SA
What are the treatment options for a crown- root fracture with pulp exposure?
- can be temporised with composite for up to 2 weeks
- fragment removal and gingivectomy (indicated in crown- root fractures with palatal subgingival extension)
- ortho extrusion of apical portion (ends, extrusion, post crown)
- surgical extrusion
- decoronation (preserve bone for future implants)
- extraction
What are the treatment options for a crown- root fracture without pulp exposure?
- fragment removal only and restore
- fragment removal and gingivectomy
- ortho extrusion of apical portion
- surgical extrusion- reposition tooth manually
- decoronation
- extraction
