Paeds Trauma- Supporting Tissue Injuries Flashcards
Give examples of supporting tissue trauma
Concussion, subluxation, lateral luxación, infusion, extrusion, avilesino, alveolar fracture
Define dental concussion
Injury to the tooth supporting structures without abnormal loosening or displacement of the tooth
Describe the clinical findings, treatment and follow up of dental concussion trauma
There is no pain on percussion
No treatment
Follow up clinically and radiographically 4 weeks later and 1 year later
Define subluxation
An injury to the tooth-supporting structures with abnormal loosening but without tooth displacement
Describe the clinical findings of subluxation trauma
Increased mobility, tender to percussion, bleeding from gingival crevice may be present
Describe the treatment and follow up of subluxation trauma
Treatment is not normally required, splint if excessive mobility or tenderness when biting
Follow up clinical and radiographic - 2 weeks later for splint removal, 12 weeks, 6 months and 1 year
How are subluxation and concussion injuries monitored at follow up?
Trauma stamp
Sensibility testes (false negative response is possible relating to future pulp necrosis)
Radiographs (looking at root development and resorption, compare with contra lateral tooth)
What is assessed in a trauma stamp
Sinus
Colour
Mobility
TTP
Percussion
Ethyl chloride
EPT
Radiograph
5 years later, what is the pulp survival in subluxation/ concussion injuries with open v closed apices?
100% survive with open apex
85 and 95% relatively with closed apices
5 years later, what is the resorption in subluxation/ concussion injuries with open v closed apices?
1% resorption in open apex
3% resorption in closed apex
Define extrusion?
An injury in which the tooth suffers axial displacement partially out of the socket
What is the clinical findings for an extrusion injury
Tooth appears elongated, usually displaced palatally, mobility present, bleeding from the gingival sulcus
Describe the treatment and follow up for extrusion trauma
Treatment- repositioning the tooth by gently pushing it back into the tooth socket under LA, splint placement
Follow up- 2 weeks later for splint removal, 4 weeks, 8 weeks, 12 weeks, 6 months and 1year.
Then annually for 5 years
5 years later, what is the pulp survival in extrusion injuries with open v closed apices?
95% in open apex
45% in closed apex
5 years later, what is the % resorption in extrusion injuries with open v closed apices?
5% in open apex
7% in closed apex
Define lateral luxación
Displacement of a tooth socket in a direction other than axial, accompanied by communication or fracture of alveolar bone plate
What are the clinical findings of a lateral luxation
Tooth appears displaced in socket, immobile, high ankylosis percussion tone
May be bleeding from gingival sulcus
Root apex may be palpable in sulcus
What is the treatment for lateral luxation
Reposition under LA, splint placement
Monitor- endodontic evaluation (2 weeks later)
What is the follow up plan for lateral luxation?
2 weeks (endo evaluation), 4 weeks (splint removal), 8 weeks, 12 weeks, 6 months, 1 year
Then annually for 5 years
At the 2 week endo evaluation for lateral luxation what are the 2 possible outcomes?
Incomplete root formation
- spontaneous revascularisation may occur
If the pulp becomes necrotic and signs of inflammatory external resorption, begin endo treatment
Complete root formation
- the pulp will likely become necrotic, begin endo treatment
- corticosteroid antibiotic/ CaOH as Intra-canal medicamento to prevent development of inflammatory external resorption
5 years later, what is the pulp survival in lateral luxation injuries with open v closed apices?
95% open apex
255 closed apex
5 years later, what is the % restoration in lateral luxation injuries with open v closed apices?
3% open apex
38% closed apex
Define intrusion
Tooth is forced into socket in axial direction and locked into bone
What are the clinical findings of intrusion
Crown appears shorter, bleeding from gingival
ankylosis high, metallic percussion tone
What are the treatment options for intrusion
Immature root formation
- spontaneous repositioning independent of the degree of intrusion
- if no re-eruption within 4 weeks- ortho repositioning
- monitor the pulp, spontaneous pulp revascularisation may occur
- if pulp becomes necrotic and infected/ signs of inflammatory external resorption- begin endo treatment ASAP when position of tooth allows.
Mature root formation
- <3mm spontaneous repositioning (if none within 8 weeks- reposition surgically and splint for 4 weeks/ orthodontically before ankylosis develops)
- 3-7 mm - surgical (preferably) or ortho repositioning
- >7mm - surgical repositioning
- pulp almost always becomes necrotic- start endo treatment 2 weeks/ as soon as positioning allows to prevent inflammatory (infection related) resorption
What is the follow up plan for intrusion
2 weeks, 4 weeks (splint removal), 8 weeks, 12 weeks, 6 months, 1 year
Then annually for 5 years
5 years later, what is the pulp survival in intrusion injuries with open v closed apices?
40% open apex
0% closed apex
5 years later, what is the % resorption in intrusion injuries with open v closed apices?
67% in open apex
100% in closed apex
Define avulsion and its clinical findings
Tooth completely displaced from socket
Socket is empty or filled with coagulum
What are the 3 critical factors in avulsion
Extra-alveolar dry time (EADT)
Extra alveolar time (EAT)
Storage medium
Provide emergency advice for a patient with an avulsed tooth
- Ensure permanent tooth
- Hold by crown
- Encourage attempt to place tooth immediately into socket (if tooth is dry, rinse gently in milk/ saline/ saliva and replant)
- Bite on gauze/ tissue etc to hold in place once replanted
- Seek immediate dental advice
What are the 5 storage mediums for an avulsed tooth
Milk
HBSS
Saliva
Saline
Water
Which 2 factors influence management of avulsion
Maturity of root
PDL cell condition
In a tooth with a closed apex, describe the overall treatment plan for avulsion
Clean injured area
Verify replanted tooth position and apical status (clinical and radiographic)
Place splint
Suture gingival lacerations if present
Consider antibiotics and check tatenus status of patient
Provide post op instructions
Follow up
In a closed apex avulsed tooth when the EADT < 60 mins, describe the management
PDL cells may be viable but compromised
Remove debris
History and exam with tooth in storage
Replant under LA
Splint
Suture gingival lacerations
Antibiotics? Tetanus status?
Post op instructions
Follow up
In an avulsed tooth with closed apex with EADT > 60 mins, describe the management
PDL cells are likely to be non-viable
Remove debris
Replant under LA
Splint
Suture gingival lacerations
Antibiotics? Tetanus status?
Post op instructions
Follow up
In an avulsed tooth with closed apex, when should endo treatment be started and which Intra canal medicament used?
Commence endo treatment within 2 weeks
Use CaOH up to 1 month or corticosteroid/ antibiotic paste for 6 weeks
What is the result of delayed replant action of an avulsed tooth with closed apex
Poor long term prognosis (ankylosis related root resorption)
Decision to replant almost always correct
Referral to paeds specialist/ inter disciplinary management
What is the follow up for avulsion with closed apex
2 weeks (splint removal)
4 weeks, 3 months, 6 months, 1 year
Then annually for 5 years
What is the management for an avulsed tooth with an open apex which has already been replanted
Clean injured area
Verify replanted tooth position and apical status (clinical and radiographic)
Place splint
Suture gingival lacerations
Antibiotics? Tetanus status?
Post op instructions
Follow up
What is the management for an avulsed tooth with open apex and EAT < 60 mins
Potential for spontaneous healing
Remove debris
History and exam with tooth in storage medium
Replant under LA
Splint
Suture gingival lacerations
Consider antibiotics, check tetanus status
Post op instructions
Follow up
What is the management of an avulsed tooth with open apex and EAT > 60 mins
PDL cells likely to be non-viable
Likely outcome is ankylosis-related (replacement) root resorption
Remove debris
Replant under LA
Splint placement
Suture gingival lacerations
Consider antibiotics, check tetanus status
Post op instructions
Follow up
What is the goal of treatment of avulsed teeth with open apices?
Revascularisation
This requires close monitoring, endo treatment if definitive signs of pulp necrosis and infection of root canal
What are the effects of delayed replant action of an open apex avulsed tooth?
Poor long term prognosis (ankylosis related (replacement) root resorption)
Decision to replant almost always correct
Refer to paeds specialist/ inter disciplinary management
What is the follow up of avulsion with open apex?
2 weeks (splint removal)
1 month, 2 months, 3 months, 6 months, 1 year
Then annually for 5 years
When should you not replant an avulsed tooth?
Medical contraindications (immunocompromised, other serious injuries requiring preferential emergency treatment)
Dental contraindications (very immature apex and extended EAT> 90 mins, very immature lower incisors in young children- may find difficult to cope)
5 years later, what is the pulp survival in avulsion injuries with open v closed apices?
30% in open apex
0% in closed apex
5 years later, what is the % resorption in avulsion injuries with open v closed apices?
Frequent.
Define dento-alveolar fracture
Fracture of alveolar bone which may or may not involve the alveolar socket
Describe the clinical findings of a dento-alveolar fracture
Complete alveolar fracture extending from the buccal to palatal bone in the maxilla and from the buccal a=to lingual bony surface in the mandible
Segment mobility and displacement with several teeth moving together
Occlusal disturbance
Gingival laceration
Outline the treatment of a dento-alveolar fracture
Reposition any displaced segment
Stabilise by splinting
Suture gingival lacerations if present
Monitor the pulp condition por all teeth involved
Outline the follow up appointments, after dento-alveolar fracture
Monitor the patient (clinical and radiograph) - looking at root development (canal width and length compared with neighbouring unaffected tooth) and resorption
4 weeks (splint removal)
6-8 weeks, 4 months, 6 months, 1 year
Annually for 5 years
In a dento-alveolar injury, what is the risk of pulpal necrosis of a tooth with closed apex?
50% risk of pulpal necrosis
provide advice for a patient with a dento-alveolar fracture
Soft diet for 7 days
Avoid contact sport whilst splint is in place
Careful oral hygiene with use of chlorohexidine mouthwash (0.12%)
How long is splint placement for a dento-alveolar fracture
4 weeks
What are the key properties of a splint?
Flexible and passive
Easy to place/ remove
Facilitate sensibility testing/ clinical monitoring
Allows oral hygiene
Aesthetic
What are the different types of splints?
Chair side
- composite and wire
- titanium trauma splint
- ortho brackets and wire
- acrylic
Lab made
- vacuum formed splint
- acrylic
What type of wire is used for composite and wire splint
And how is it placed
Stainless steel wire (up to 0.4mm in diameter)
Must be passive (ensures not placing unwanted forces on traumatised tooth) and include one tooth either side (bonded with composite, away from gingiva and proximal areas- avoids plaque retention and secondary infection, better healing)
Describe placement of titanium trauma splint
Passive splint
Rhomboid mesh structure, 0.2mm thick
Can be easily adapted to the contour of dental arch (flexible in all directions)
Secured with composite resin
When is an acrylic splint used?
When there are few abutment teeth (palatal coverage and acrylic extended over incisal edges on labial surface of anterior teeth)
What are the main complications of dental trauma
Pulp necrosis and infection
Pulp canal obliteration
Root resorption
Breakdown of marginal gingiva and bone
What is pulp canal obliteration
This is the response of a vital pulp. Common in luxation with displacement.
Progressive hard tissue formation within the pulp cavity, resulting in narrowing of pulp chamber and canal (total/ partial obliteration).
Affected tooth becomes opaque/ yellow
What is the treatment for pulp canal obliteration
Conservative management is advised
Only 1% may give rise to PAP
What are the types of root restoration
External
- surface
- external infection related (IRR)
- cervical
- ankylosis related (RRR)
Internal
- internal infection related IRR
What is external surface root resorption
Vital teeth
Superficial resorption lacunae are repaired with new cementum.
Response to localised injury
Not progressive
What is external infection related IRR
Non-vital tooth with infected pulp canals
Initiated by PDL damage (propagated by root canal toxins reaching external root surface through patent dentinas tubules)
Can be aggressive
Often a chance diagnosis from trauma review (change in the contour of the root and surrounded by bony lucency)
What is external infection related IRR
A rapid process (however, if infected canal contents are removed, the propagated stimulus is lost, lesion will arrest, endo treatment started)
Tooth dressed with CaOH for 4-6 weeks before obturación with GP.
Cervical resorption is an unusual form of external infection related IRR- initiated by damage to root surface of cervical region and propagated by infected root canal contents/ perio micro flora)
What is ankylosis related RRR
Follows severe luxation/ avulsion injuries
Initiated by severe damage to PDL and cementum
If >20% PDL is damaged/ lost bone cells can grow into contact with the root surface more quickly than remaining periodontal fibroblasts can recolonise the root surface- root now becomes involved in bony remodelling process and is replaced with bone in the folllowing years
Root will appear ragged in outline with no obvious PDL space.
What is the treatment for ankylosis related RRR
No effective treatment
Speed of progression is variable - infraoccclusion due to alveolar bone development
When discrepancy in the gingival margins of ankylosed tooth, compared with contractural tooth is more than 3mm- consider decroronation of ankylosed tooth
Plan for loss (although may be years later)
What is internal infection related IRR
This is due to progressive pulp necrosis
Infected material via non-vital coronal part of canal propagates resorption, rapid tissue destruction
Large resorptive defects affecting coronal 1/3 canal may result in pink appearance of tooth
Round, symmetrical expansion of root canal walls (ballooning of canal)
Tramlines of root canal are indistinct, root surface in tact
What is the treatment of infection related IRR
Remove stimulus
Endo treatment
- non setting CaOH for 4-6 weeks
- obturate with GP
- if progressive, plan for loss.
