Trauma 1 Flashcards
Whats the most common injury in primary dentition?
Luxation injury
Whats the most common injury in permanent dentition?
Crown fractures
- Enamel dentine fracture
What malocclusion increases the risk of trauma?
Large OJ
OJ > 9mm doubles the incidence
Questions to ask in the trauma hx (4)
- How did it happen?
- When did it happen exactly?
- Where are the lost teeth/fragments?
- Any other symptoms
What conditions may require additional tx for dental trauma tx?
- Rheumatic fever
- Congenital heart defects
- Immunosuppression
Extraoral checks for a trauma patient (6)
- Laceration
- Haematomas
- Haemorrhage/CSF
- Subconjunctival haemorrhage
- Bony step deformities
- Mouth opening
Intraoral checks for a trauma patient (4)
- Soft tissue
- Alveolar bone
- Occlusion
- Teeth
What 3 things can tooth mobility indicate?
- Displacement of tooth within socket
- Root fracture
- Bone fracture
When you’re doing a tactile test for trauma, what do you look for?
- Fracture lines
- Horizontal or vertical - Pulpal involvement
List examples of tests to undertake for a detailed intraoral exam (4)
- Sensibility tests
Thermal: ECL or warm GP
Electrical: EPT - Percussion
- Duller note may indicate root fracture - Occlusion
- Traumatic occlusion demands urgent tx - Radiographs
- Intraoral, occlusal, periapicals, OPT, soft tissue
CLASSIFY THE TRAUMA
What does sensibility testing check?
Nerve supply
If you have a + nerve supply then must have blood supply too
Sensibility testing confirms vitality too
What does vitality testing check?
Blood supply
Laser dopler
How does an ECL work?
Ethyl chloride placed on a cotton wool pellet and placed on the labial 3rd of the patients tooth
They then say whether they feel cold or hot
> Can do ECL with warm GP to see if they feel heat
How does an EPT work?
Electric machine you use on the labial 1/3rd of the patients tooth to stimulate an electrical impulse into the tooth
Patient lets you know when they can feel it, patient creates an electrical circuit by holding on to an EPT
What radiographs are used for detecting any bony fractures?
Occipital mental radiographs
PA mandibles
What teeth should be tested for sensibility + looked at in radiographs when examining an injured tooth?
Test adjacent and opposing teeth in adjacent to those injured
Why do we need to test adjacent teeth for trauma too?
They may have received either direct or indirect concussive injuries
How long should sensibility testing be continued for after injury?
Continue for at least 2 years after an injury
What does a complicated root fracture mean?
Pulp is involved
What does a non-complicated root fracture mean?
Pulp is not involved
List the different types of uncomplicated root fracture (3)
- Enamel fracture
- Enamel dentine fracture
- Crown root fracture (can be complicated/uncomplicated)
List the different types of complicated root fracture
- Crown root fracture
- Root fracture
- Apical 3rd
- Middle 3rd
- Coronal 3rd
What does the prognosis depend on? (5)
- Stage of root development
- Type of injury
- If PDL is damaged too
- Time between injury and tx
- Presence of infection
Emergency tx protocol for trauma (5)
- Retain vitality of any damaged/displaced tooth by protecting exposed dentine with an adhesive dentine bandage
- Treat exposed pulp tissue
- Reduction and immobilisation of displaced teeth
- Tetanus prophylaxis
- Antibiotics
When would you need tetanus prophylaxis?
Tooth dropped in mud
Intermediate tx protocol for trauma (2)
- Consider if pulp needs tx
- Restoration
- Minimally invasive
- E.g. acid etch restoration
Permanent tx protocol for trauma (5)
- Apexigenesis
- Apexification
- Root filling +/- root extrusion
- Gingival + alveolar collar modification if required
- Coronal restoration
Compare apexogenesis + apexification
APEXOGENESIS
> Tx of vital pulp to allow continued growth of root + closure of open apex
> Thickening of RC walls
> RCT may be needed
APEXIFICATION
> Tx of necrotic pulp to allow closure of the apex to do an RCT later with obturation
> No thickening of RC walls
> RCT always needed
How do we manage an enamel fracture? (3)
- Bond fragment to tooth or simply grind sharp edges
- Take 2 periodical radiographs to rule out root fracture or luxation
- Follow up:
- 6-8wks
- 6 months
- 1 year
Whats the prognosis for an enamel fracture?
0% risk
How do we manage an enamel-dentine fracture? (6)
- Bond fragment to tooth or place composite manage
- Take 2 periodical radiographs to rule out root fracture or lunation
- Radiograph any lip or cheek lacerations to rule out embedded fragment
- Sensibility testing + evaluate tooth maturity
- Definitive restoration
- Follow up:
- 6-8wks
- 6 months
- 1 year
Whats the prognosis for an enamel dentine fracture?
5% risk of pulp necrosis at 10yrs
What should we check the follow up radiographs for? (4)
- Root development
- Width of canal + length - Comparison with other side
- Internal + external inflammatory resorption
- Periapical pathology
What associated injury with an ED fracture has the best pulp survival prognosis?
Concussion + subluxation
What associated injury with an ED fracture has the worst pulp survival prognosis?
Intrusion
Why do immature teeth have a higher chance of survival post trauma?
- Mature tooth with a complete apex + BV going into one narrow hole
- Immature tooth with a wide apex with more nerves, bvs going in
> If displaced in any way the chances of the pulp, nerves + bfs staying alive + regenerating is much higher than if theres a single point of entry
How do we manage ED pulp fractures?
Evaluate exposure
- Size of pulp exposure
- Time since injury
- Associated PDL injuries
CHOOSE from
- Pulp cap
- Partial pulpotomy
- Full coronal pulpotomy
When do we do a partial pulpotomy?
Pulp exposure >1mm
OR
24+ hrs since trauma
How do we carry out a direct pulp cap? (4)
- LA + rubber dam
- Clean area with water then disinfect area with sodium hypochlorite
- Apply CaOH or MTA white to pulp exposure
- Restore tooth with quality composite restoration
REVIEW:
6-8wks
6 months
1 year
When do we do a pulp cap?
When pulp exposure <1mm
24 hr window
How do we carry out a partial pulpotomy?
- LA + dental dam
- Clean area with saline then disinfect area with Sodium hypochlorite
- Remove 2mm of pulp with hi-speed round diamond bur
- Place saline soaked CW pellet over exposure until haemostasis achieved
- If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy - Apply CaOH then GI (or white MTA) then restore with quality composite resin
How do we carry out a full coronal pulpotomy?
- Begin with partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton wool
- If hyperaemic remove all the coronal pulp - Place CaOH in pulp chamber
- Seal with GIC lining and quality coronal restoration
How do we carry out a full coronal pulpotomy? (4)
- Begin with partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton wool
- If hyperaemic remove all the coronal pulp - Place CaOH in pulp chamber
- Seal with GIC lining and quality coronal restoration
Success rate for partial pulpotomy
97%
Success rate for coronal pulpotomy
75%
Root tx for immature incisors
If tooth is non vital –> then full pulpectomy is required
- CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification)
- MTA/BioDentine placed at apex of canal to create cement barrier
- Regenerative Endodontic Technique to encourage hard tissue formation at apex
Why would we not use setting CaOH in root canal for 4-6wks?
We will denature all of the dentine in the tooth and make it dry and brittle and snap off
It loses its elasticity so we prefer to place cement to create a barrier (MTA/BioDentine placed at the apex of the canal
Pulpectomy open apex tx
- Rubber dam
- Access
- Diagnostic radiograph for WL
- File 2mm short of estimated WL
- Dry canal with paper points, non setting CaOH, cotton wool in pulp chamber
- GI temporary cement in access cavity and evaluate CaOH fill level with radiograph
Crown root fracture with no PULP exposure tx
- Fragment removal only + restore
- Fragment removal + gingivectomy
- Orthodontic extrusion to gain access to supragingival margins
- Surgical extrusion
- Decoronation
- Extraction
Crown root fracture with pulp exposure tx
Exact same as without pulp exposure EXCEPT
Can be temporised with composite for up to 2wks
