Permanent tooth trauma Flashcards
Which teeth are susceptible to trauma?
Upper anteriors
What type of malocclusion is susceptible to trauma?
Proclined upper incisors - class 2 div 1
First aid advice for PERMANENT tooth trauma
- Handle the tooth by the crown only
- Wash in water if visible debris
- Try to reimplant the tooth or store in milk, saliva or in mouth
- Visit emergency dentist
Post-op instructions for the reimplanted permanent tooth
- No contact sports for 2 weeks
- OTC analgesics for pain relief
- Soft diet 2 weeks
- CHX mouthwash for 1 week
- Careful OHI
When to recall a patient after reimplanted permanent tooth
- in 24 hours to assess stability
- in 7-10 days to assess pulp vitality, radiograph and rct (mature tooth)
Emergency management of avulsed permanent tooth that is not replanted
- Rinse blood clot and any if any bony socket modifications are required
- Replant slowly with slight digital pressure
- Suture any lacerations
- Take radiograph to confirm correct position
- Splint
- Systemic antibiotics if required
- Tetanus protection
- Post op instructions and recall
What determines the prognosis of reimplanted tooth?
- Open apices have a better prognosis
- Short extra-oral time
- Transported in socket
What is a splint?
Rigid or flexible device or compound used to support, protect or immobilise a tooth that has been loosened, reimplanted, fractured or subject to endo surgical procedures.
What are the aims of splinting?
Stabilise the tooth to allow optimum healing of the PDL or repair of a root fracture
What are the two categories of splints?
Flexible / functional-physiologic
Rigid
Describe the function of flexible splints
Allows physiological mobility of the teeth to promote healing of the PDL and discourage replacement resorption
How many abutments do flexible splints require?
One tooth either side of the injured tooth
When are rigid splints indicated?
Cervical third root fracture and dentoalveolar injuries
How many abutments do rigid splints require?
Two teeth either side of the injured tooth
Ideal properties of a splint
- Stabilises tooth and maintains stabilisation throughout
- Simple to place and remove
- no additional trauma to tooth or tissues
- Allows physiologic mobility
- No occlusal interference
- Easy to clean
- Aesthetically acceptable
- Able to carry out endo/sensibility testing
List examples of flexible splints
- composite wire splint
- Ortho brackets and wire
- Fibre splint
- Titanium trauma splint
What injuries require a 4-week splinting period
- Lateral luxation
- Intrusions
- Avulsion without EOT >60 mins
- Apical or mid 1/3 root fractures
What injuries require a 2-week splinting period?
Extrusion
Avulsion with EOT <60 mins
How long does a cervical root fracture need to be splinted
4 months
Management of enamel-dentine fracture
- GIC bandage (temp) as emergency tx
- Restore
What is a GIC bandage
Temporary GIC restoration placed to prevent the ingress of bacteria through dentine tubules to the pulp
What is a complicated fracture
Fracture involving the enamel, dentine and pulp
Aims of treating a complicated fracture of a immature permanent incisor
Maintain pulp vitality so the immature tooth continues root development and maturation
Define apexogenesis
Treatment of a vital pulp via pulp capping or pulpotomy to allow continued root growth and closure of the open apex
What does the prognosis of pulp therapy depend on?
- Associated PDL injury
- Extent of exposed dentine
- Age of pt (open or closed apex)
- Time since injury
Indications fo Cvek pulpotomy
Traumatic pulp exposure of immature permanent teeth
Method of Cvek pulpotomy
- access through exposed surface
- Remove 2-3mm of pulp tissue with high speed
- Arrest haemorrhage
- Irrigate
- Dress pulp (NS CAOH or MTA)
- Restore
Define apexification
Inducing a calcified barrier in a non-vital immature tooth (open apices)
Indications for apexification
Non-vital tooth with open apices
How long can the calcific barrier take to form in apexification
up to 9 months
Management of pulp exposure of a mature permanent incisor
Direct pulp cap
Pulpotomy
Pulpectomy
Conventional RCT
Management of an avulsed mature permanent tooth
ALWAYS REQUIRES RCT as the apex is closed
Why are splints placed labially
- Prevents occlusal interference
- Allows access palatally for endo
How is an avulsed mature permanent incisor retained
Due to ankylosis
Emergency management of avulsed tooth that was replanted
- Leave in place
- Clean with water, saline or chx
- Suture gingival lacerations
- RG to confirm position
- Splint for 2 weeks
- AB + tetanus
- Post op instructions
- Recall
Management for delayed replantation
Remove attached non-viable soft tissue with gauze
RCT prior to replantation
Fluoride application on the root
Why apply fluoride to the root in delayed replantation
Can slow down osseous replacement of the tooth
What is the aim of delayed replantation
Maintain alveolar bone height
Why has delayed replantation have a poor prognosis
All PDL cells are non-viable after >60 mins dry time
Difference between replanting immature and mature permanent teeth
All mature teeth will require rct whereas immature have the ability to revascularise
What is the aim of replanting an immature permanent tooth?
Maintain pulp vitality and allow continued root development
Contraindications for replantation
- Extensive caries
- Perio disease
- Non-cooperative pt
- Severe cardiac conditions
Tx of enamel fracture
Smooth sharp corners
If extensive, composite restoration for aesthetics
Tx of ED fracture
GIC bandage
Consider indirect pulp cap
Restore definitively
Monitor pulp vitality
Signs of ED fracture
Loss of tooth structure but no pulp exposure
Pulp testing positive
Not TTP or mobile
Signs of EDP fracture
Loss of tooth structure with exposed pulp
Sensitivity to stimuli
Not TTP or mobile
Tx of EDP fracture of an immature tooth
Immature - pulp cap or pulpotomy to preserve vitality
Tx of EDP fracture of mature tooth
RCT preferred
Can do pulp cap or pulpotomy
Signs of crown-root fracture
Fracture of enamel, dentine and cementum and extends below gingival margin
- TTP
- coronal fragment mobile
- Gingival bleeding
- Vitality testing positive for apical fragment
Emergency tx of crown root fracture
Stabilise with a splint
If pulp exposure - then pulpotomy for immature and rct for mature
Signs of root fracture
Coronal segment mobile and displaced
Sucular bleeding
Vitality negative initially
Transient discolouration of the crown
Tx of root fracture
Reposition coronal fragment if displaced
Stabilise with splint (4 w or 4m depending on location)
Signs of alveolar fracture
Segment mobile and dislocated
Several teeth move together
Misaligned teeth in alveolar segment
Tx of alveolar fracture
GA, reposition segment and stabilise with splint
Monitor teeth in fragment line
Signs of subluxation
TTP
Inc mobility BUT NO DISPLACEMENT
Sucular bleeding
Vitality initially negative
Tx of subluxation
Monitor pulp vitality
Can splint to reduce discomfort
Signs of lateral luxation
Tooth displaced palatally or labially Fracture of alveolar process Immobile Metallic sound on percussion Vitality negative
Tx of lateral luxation
No occlusal interference = monitor for spontaneous repositioning
Occlusal interference - reposition and splint 4 weeks
RCT if necrosis occurs
Severe - extract
Signs of intrusion
Immobile
Metallic sound on percussion
Vitality negative
Shorter than other teeth
Radiographic signs of intrusion
CEJ located apically to other teeth
PDL space absent from all/part of the root
Radiographic signs of lateral luxation
PDL space enlarged apically
Tx of intrusion of immature teeth
Minor - monitor, if no spontaneous repositioning then carry out ortho repositioning
- >7mm intrusion - reposition surgically or w ortho with 4 week splint
Signs of extrusion
Elongated tooth
Very mobile
Bleeding
Vitality negative
Radiographic signs of extrusion
PDL widened apically
Tx of extrusion
If minor and mobile - intrude gently and splint
RCT indicated if pulpal necrosis occurs
Tx intrusion of mature teeth
Minor - allow spontaneous eruption, if nothing then reposition surgically or orthodontically
If 3-7+mm - reposition surgically or ortho and splint
RCT usually required
When is RCT carried out after repositioning of intruded teeth
2-3 weeks
