Trauma 1 Flashcards
Accidental damage to permanent teeth are more common in individuals with a large ________.
overject
OJ >9mm doubles incidence
What is the most common injury to permanent teeth?
enamel dentine fractures (uncomplicated- no pulpal involvment)
List some causes of accidental damage to permanent teeth
- falls (most common)
- bike, skateboard, RTA
- sport
- fights
Road Traffic accidents
What history should you take for the injury?
- when
- where
- how
- any other symptoms
- lost teeth or fragments
Why is the “when” an vital part of the history?
- success of the intervention is time sensitive
- assessment of PDL cell survival
What must you look out for if laceration injuries are also present?
- look for missing fragments
- other objects may be found in lacerations, look carefully
What are the key pieces of MH that should be taken in a trauma appointment?
- congenital and acquired heart abnormalities
- immunosuppression
- vaccination status - tetanus
What are the components of a DH in a trauma case?
- previous dental trauma
- treatment experience
- parent or child attitude
What may warrant the prescription of antibiotics in trauma injuries?
- soft tissue injuries
- medical history
(limited evidence for Abs in emergency luxation injuries)
What must you identify in an E/O examination for a trauma case?
- lacerations
- haematoma (bleeding outside BV)
- haemorrhage/CSF
- subjunctival haemorrhage- bleeding under eyes
- bony step deformities
- mouth opening
It is unusual for children to get bony step injuries unless it is a high impact injury. True or false. Why is this?
True
bone is more elastic
What should constitute your I/O examination for a trauma case?
- soft tissue- penetrating wounds
- alveolar bone
- occlusion- traumatic occlusion demands urgent treatment!
- teeth- mobility, displacement, root fracture, bone fracture
When completing an I/O examination, what is the benefit of using transillumination?
- caries
- pulpal involvement
- fracture lines on teeth
What information can you gather from a tactile test on teeth using a probe?
- horizontal fractures
- vertical fractures
What special investigations should you carry out in a trauma case?
- sensibility test (endofrost, ethylchloride, warm GP), EPT
- percussion
- radiographs (I/O, occlusal, OPT, soft tissue radiograph, additional angulations, CBCT)
- photographs
- compare with contralateral uninjured tooth- perform sensibility tests on contralateral tooth to see if you are getting the same response
What is the advantage of using endofrost over ethyl chloride?
- reaches lower temperatures and therefore more accurate
A duller note on a percussion test may be an indication of…
a root fracture
What is included in the trauma stamp/chart?
- mobility
- displacement
- TTP
- colour
- sinus/tender in sulcus
- thermal (ethyl chloride)
- EPT
- radiograph
Why may sensibility tests be unreliable?
this is because there may be transient loss of neuronal response
undifferentiated A-delta fibres in young teeth
What is the difference between A delta and A beta fibres?
A delta fibres- temperature and pain
A beta fibres- information related to touch
Temporary loss of sensibility is a frequent finding during post traumatic healing, especially post luxations. True or false
True
A lack of pulpal response for several months is definitively conclusive of pulpal necrosis. True or false
False
How long should you continue sensibility tests ? What is the basis of this
should continue to review for 5 years after injury
this is because a lack of response is not indicative of pulpal necrosis
What is a good predictor of long term prognosis of a tooth ?
baseline sensibility testing
In the first month/so of an injury, what can be observed in the periapical area? Is this a cause for concern?
transient apical breakdown
this is a normal sign
Arrested root development always indicated a loss of vitality. True or false
false
arrested root development does not necessarily mean loss of vitality
What is a sign of continued vitality of a traumatised tooth?
root canal obliteration
What is root canal obliteration?
- pulpal response to trauma
- characterised by rapid deposition of mineralised tissue in the root canal space
- this is an indication of vitality and blood continues to carry minerals to the pulpal space
What are some indications of a loss of vitality to a tooth?
- PDL widening
- arrested root development (not always)
- TTP
- slight tenderness in buccal sulcus
- poor response to sensibility testing- nerves dying off due to damaged blood supply?
- discolouration- yellow, pink, dark/grey
What signs show an OBVIOUS loss of vitality?
- periapical radiolucency
- infection
- pain
- inflammatory resorption
What are the classifications of crown and root fractures
- enamel fracture
- uncomplicated enamel-dentine fracture
- complicated enamel-dentine fracture
- uncomplicated crown-root fracture
- complicated crown-root fracture
- root fracture (apical 1/3, mid 1/3, coronal/gingival 1/3)
What does the prognosis of crown and root fractures depend on?
- age of child, mature/immature tooth (open or closed apex)
- type of injur
- combination of two types of injury on same tooth- negative synergistic effect
- time between treatment and injury
- presence of infection
What are the aims and principles of treatment in emergency management?
- try and retain vitality by protecting exposed dentine
- treat exposed pulp tissue
- reduction in mobilisation of displaced teeth
- tetanus prophylaxis
What are the aims and principles of treatment in intermediate management?
- pulp treatment (if indicated)
- restoration- minimally invasive e.g. acid etch restoration
What are the aims and principles of treatment in permanent management?
- apexification
- root filling +/- root extrusion
- gingival and alveolar collar modification if required
- coronal restoration
What is apexification?
- apexification is for non-vital teeth (no blood supply)
- induction of the development of a root apex in immature tooth by the formation of osseo-cementum (bone like tissue)
When would gingival/alveolar collar modification be required?
- this is soft tissue surgery
- soft tissue surgery around the tooth to allow a restoration to be placed
What is an infraction?
this is an incomplete enamel fracture with no tissue loss
What is an enamel fracture?
fracture of tooth confined to enamel wit loss of tooth structure
What is an enamel dentine fracture?
fracture confined to enamel and dentine with tooth loss, without pulpal involvement
What is a complicated fracture?
a fracture with pulpal involvement
What investigations are required for an enamel- dentine fracture?
- PA radiograph
- evaluate pulp size and stage of development
- sensibility test
What is the treatment for an enamel dentine fracture?
- CaOH base if fracture is within 0.5mm of pulp
- restore with either: rebonding of fragment/composite dressing
When rebonding a tooth fragment, what must you do?
rehydrate the fragment in water or saline for 20 minutes before rebonding the tooth fragment
How would you go about monitoring an enamel dentine fracture?
- clinical test- trauma stamp
- sensibility test (thermal and electrical)
- radiographs
When should you perform sensibility tests for enamel dentine fractures?
- at time of injury
- 1 month
- 3 months
- 6 months
- 1 year
- yearly for 5 years
Radiographic assessment following an enamel denting fracture involves…
- assessing root development- width and length of canal
- comparison to contralateral side
- internal and external inflammatory resorption
What is the treatment of a complicated enamel dentine fracture dependent on?
- size of exposure
- time since exposure
The prognosis of a complicated enamel dentine fracutre is also dependent on …
any associated luxation injuries (negative synergistic effect)
What is the treatment of a complicated enamel dentine fracture with a small exposure within 24 hours of the trauma?
- direct pulp cap with CaOH
- then hermetic seal with composite
MTA can be used instead of CaOH however it causes discolouration
What is the treatment option for a complicated enamel dentine fracture with a large exposure or more than 24 hours since trauma?
- pulpotomy- full or partial (cvek) pulpotomy with bioceramic (biodentine/white MTA)
- hermetic seal using composite
What is the treatment should be provided for a complicated enamel- dentine fracture where there is a larger exposure with no vital tissue in remaining portion?
- open apex tooth: pulpectomy, nonsetting CaOH first then MTA/biodentine to produce apical stop THEN obturate
- closed apex tooth: pulpectomy and conventional RCT
A pulpotomy is a treatment option for teeth that are _______ after trauma.
vital
How would you decide on where or not to perform a full or partial pulpotomy?
this is clinical decision based on the state of the pulp when once you assess the tooth
You should alwasy start with a partial pulpotomy first. True or false
true
Briefly describe the process of a cvek (partial) pulpotomy
- LA and rubber dam
- pulp tissue (2-3mm) excised with a diamond bur
- normal bleeding stops with moist cotton wool
- rinse gently with sterile saline
- apply bioceramic/calcium hydroxide to pulp
- hermetic seal with composite
When should you proceed to doing full coronal pulpotomy in a trauma case?
- no bleeding at all (necrosis)
- uncontrollable bleeding (hyperaemic)
Briefly outline the process of a full coronal pulpotomy
- excise all pulp chamber with excavator/round bur
- normal bleeding stops with moist cotton wool then you are okay to proceed
- rinse gently with sterile saline
- apply bioceramic/CaOH to dress the pulp
- hermetic seal with composite
What is the follow up for assessment following a pulpotomy (partial/full)
- 1 month
- 3 months
- 6 months
- 1 year
- then every year for 5 years
Following a pulpotomy, there are signs of non vitality, what should you do?
proceed to pulpectomy
What is the main aim of a pulpotomy following a trauma case?
keep vital pulp tissue within the canal to allow normal rooth growth (apexogenesis)
What is the success rate of partial (cvek) pulpotomies?
97%
What is the success rates for full coronal pulpotomies?
*75% success
Outline the process of a pulpectomy
- rubber dam (clamp free in children); LA not usually needed
- access
- irrigate with hypochlorite
- diagnostic radiograph for WL
- file 2mm short of estimated working length
- dry canal, non setting CaOH, cotton wool, GIC
- MTA/ biodentine for apical barrier
- obturate (GP backfill)
What are the advantages of using MTA?
- sets in a wet environment
- good sealing properties
- easy to visualise radiographically
- not soluble
- inert- does not react with other materials
- some antibacterial properties (pH- 12)
remember CaOH remains soluble in wet environment
What are options for definitive coronal restorations following an enamel dentine fracture?
- composite dowel core- bonded composite short way down canal as well as in access cavity
- bonded core
- crown
- try to avoid post crown
- go from most conservartive to least concservative
How are root fracture classified ?
- apical, mid or coronal third fracture
- displaced or undisplaced
- mature or immature (closed or open apex)
The prognosis of a root fracture depends on…
- age of child- open or closed apex
- degree of displacement
- combination of two different types of injuries on same tooth (negative synergistic effect)
- time between injury and treatment
- presence of infection
What should the clinical examination of a root fracture include?
- trauma stamp - mobility, displacement, TTP, colour, radiograph, thermal, EPT, sinus/tender in sulcus
Occlusion must also be checked in a root fracture; traumatic occlusion must be resolved!
What investigations should be carried out for root fractures?
- sensibility tests- ethylchloride, EPT
- radiographs - periapical, upper standard occlusal
Why must radiographs for root fractures be from at least two angles?
- this is because you may not necessarily see a fracture in one plane, they may become more evident in another plane
What treatment should be provided for an undisplaced, non- mobile root fracture?
- soft diet
- monitor vitality
What treatment should be provided for displaced, mobile root fracture ?
- reposition
- flexible splint
What is the splinting time for apical/mid third root fractures?
splint for 4 weeks
What is the splinting time for coronal third root fractures? Why is this?
splint for 4 months
this is because coronal 1/3 fractures require longer for stability
What are the outcomes of root fracture injuries?
- healing injury
- non-healing injury
What are the different types of evidence of healing in a healing injury?
- calcified union across the fracture line
- connective tissue
- calcified and connective tissue
What is the evidence of a non-healing tissue?
granulation tissue
associated with loss of vitality
not laying down new calfied /connective tissue a sign of loss of vitality
Pulpal prognosis of root fracture is affected by…
other injuries e.g. crown dentine fracture
negative synergistic effect
Hard tissue union in a root fracture is affected by…
- non vitality
- original displacement of the coronal part (how far is the crown moved)
How would you treat root fractures with pulpal necrosis?
- extirpate pulp to fracture line
- dress with non setting CaOH then MTA/biodentine just coronal to fracture line
- obturate to fracture line
((((((IF MTA/ BIODENTINE IS PRESENT to the fracture line HOWWW do you then obturate to the fracture line as well????????)))
- the distal fragment often requires no treatment
- remains in PDL resorbs
- risk of infection
What are the treatment option for the distal fragment of root if an infection is present?
antibiotics
apicetomy
What is the splinting time for a subluxation injury passive-flexible splint?
2 weeks
What is the splinting time for an extrusion injury passive-flexible splint?
2 weeks
What is the splinting time for a luxation injury passive-flexible splint?
4 weeks
What is the splinting time for an avulsion injury passive-flexible splint?
2 weeks
What is the splinting time for a dento-alveolar injury with a passive-flexible splint?
4 weeks
What is the thickness of the wire required for a passive flexible splint?
0.4mm
A passive flexible splint should be placed…
labially
What type of splint is useful when there are feew abutment teeth present?
Acrylic URA splint
Upper removable appliance
What is a crown-root fracture?
fracture involving enamel, dentine and cementum, loss of tooth strucuture
What is a complicated crown-root fracture?
fracture involving enamel, dentine, cementum with loss of tooth struture and exposure of pulp
What are the treatment options for a crown-root fracture
- extract coronal portion
- extract whole tooth and restore space (denture, bridge)
Following the extraction of the coronal portion of the tooth in a crown-root fracture, what are the options for treatment?
- root-fill, extrude then restore (extrusion)
- root fill if possible then cover tooth wirh mucoperiostial flap and retain. This maintains height and width of alveolus- child may become candidate for implant
Why are you not able to place implants in children?
- bone is still elastic, continued bone development
What are the requirements of an extrusion following a crown-root fracture?
- good OH, low caries rate
- sufficient adjacent teeth
- eventual position of the extruded tooth; crown to root ratio should not be <50:50
- some gingival and bone contouring (removal) is often needed after extrusion
will 4-6mm of rapid extrusion over 4-6 weeks bring the fractured surface coronal to the biological width?
