Trauma 1 (Crown #) Flashcards
How do we take a detailed trauma history?
Ask the pt:
- how?
- when?
- where are the lost teeth/fragments?
- any other symptoms
What must we be aware of in trauma MH?
Rheumatic fever
Congenital heart defects
immunosuppression
In the trauma exam what do we look for extra orally?
Any:
- lacerations
- haemotomas
- haemorrhage or CSF from pts nose
- subconjunctival haemorrhage
- bony step deformities
- mouth opening - can they open?
What do we look for in the trauma exam intra orally?
soft tissue lacs or scars
alveolar bone
occlusion - pts can have maloclussions
teeth
What must we rule out in trauma exam?
Facial and jaw fractures
What must we always check for in trauma exam?
Soft tissue damage
Penetrating wounds, foreign bodies
How do we check lacerations?
Take soft tissue radiograph - can show foreign bodies
What can tooth mobility indicate? 3
Displacement of tooth in socket
root fracture causing tooth looseness
Bone fracture - in this case there would be several loose teeth on a segment of bone
Why do we do a tactile test?
We do this with a probe to look for fracture lines and plural involvement
How do we look for fracture lines?
Tactile probing and transillumination to help - use curing light
What detailed intra oral exam do we carry out in trauma?
sensibility testing to check nerve supply
- thermal - ethyl chloride
- electric - EPT
PERCUSSION - dull sound can indicate root fracture
OCCLUSION - traumatic occlusion needs urgent tx
RADIOGRAPHS
CLASSIFY TRAUMA
What will a root fracture sound like on percussion?
Dull
What is a traumatic occlusion?
Traumatic occlusion is when the pt can’t get teeth back together normally due to displaced tooth or damage which causes mouth to be propped open
What radiographs can we take when trauma has occurred?
Intra oral
occlusal
OPT
Soft tissue
What is on a trauma sticker?
Sinus - any infection? Colour - describe the colour - yellow/dark? TTP - pos or neg? Mobility - grade 1 2 3 EPT - value ECL - post/neg P.Note - root fracture indication Radiograph
When carrying out a sensibility test what must we do?
Compare injured tooth with adjacent non injured tooth (can also test opposing teeth)
How long should we do sensibility tests post trauma?
2 years at least
What are the types of fracture?
Enamel # Enamel dentine # Enamel dentine pulp # Uncomplicated crown root # Complicated crown root # Root fracture #
Where can root fractures occur?
Apical third
middle third
coronal third
What is a complicated crown root #?
this is when the pulp is involved
What is an uncomplicated crown root #?
when the pulp isn’t involved
What does the prognosis depend on?
Type of injury PDL involvement Stage of root development Presence of infection time between injury and tx
What are emergency tx for any type of fractures?
we want to RETAIN VITALITY of any displaced and damaged teeth by protecting any exposed dentine with ADHESIVE DENTINE BANDAGE
Treat EXPOSED PULP TISSUE
Reduce and immobilise displaced teeth
consider tetanus prophylaxis
antibiotics?
How do we protect exposed dentine?
Adhesive dentine bandage
Why might we consider tetanus prophylaxis?
If injury occurred in dirty area or if pt isn’t up to date with tetanus immunisations
What are the intermediate trauma treatment?
Pulp treatment
Restoration - acid etch restoration
What is the permanent tx for trauma?
Apexigenesis Apexification Root filling and or root extrusion gingival and alveolar collar modification if req coronal restoration
What is apexification?
Apexification is a procedure that closes the end of an open tooth root. It’s often required for treating permanent teeth with incompletely formed roots that require root canal therapy.
clean out the root of the tooth and seal the root canal’s end with a chemical material. Two common sealing materials are mineral trioxide aggregate and calcium hydroxide. Both substances form a hardened layer over the apex, called a calcific barrier. While some teeth might require further treatments, most easily create a calcified apex. This hardened plug is visible on X-rays after the apexification occurs.
What is apexigenesis?
The goal of apexogenesis is the preservation of vital pulp tissue so that continued root development with apical closure may occur. Most or all of the coronal pulp is removed, often to the level of the canal orifices, and calcium hydroxide paste is placed as a wound dressing.4-8 An aseptic technic combining the use of the rubber dam and sterile burs is strongly recommended. According to Granath et al,5 the instrument of choice for tissue removal is an abrasive diamond bur at high speed with adequate water-cooling. The goal is to minimize any further damage to the underlying pulpal tissue. Following coronal pulp amputation, the pulp chamber is rinsed with sterile saline or sterile water to remove all debris. The excess liquid should then be carefully removed via vacuum or sterile cotton pellets. Air should not be blown on the exposed pulp, as this may cause desiccation and additional tissue damage. Once the pulpal bleeding is controlled, calcium hydroxide paste is placed over the amputation site. Care must be taken to avoid placing the calcium hydroxide on a blood clot6 and the entire pulp surface must be covered. Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely. A coronal restoration should then be placed that will ensure the maximum long-term seal. The patient should be re-evaluated every three months for the first year, and then every 6 months for 2 to 4 years to determine if successful root formation is taking place and that there are no signs of pulp necrosis, root resorption or periradicular pathosis.
How do we manage an enamel fracture?
there are several options:
1. bond fragment of tooth - hard as small
- grind sharp edges
- composite filling
- PA radiographs
Why do we take PAs with enamel fractures?
To rule out root fractures or lunation injuries
What is the follow up for enamel #?
follow up 6-8 weeks later
6 months
1 years
What is the prognosis for enamel #?
Great prognosis
0% necrosis of pulp as no plural involvement - just replace missing enamel with comp resto
How do we manage enamel dentine #?
- account for missing fragment - need to ensure pt hasn’t swallowed it
- we have several options:
- bond fragment to tooth if big enough
- place comp bandage
- place proper comp
- if fracture close to pulp then line restoration - take 2 PAs to rule out any root fractures or lunation and also soft tissue radiographs to check for lacs or embedded ligaments - esp if we can’t account for fragment
- sensibility testing and evaluate tooth maturity
- definitive resto
- follow up 6-8 weeks–> 1 year
What if we can’t account for a missing fragment of tooth?
take radiograph - soft tissues to check for any lodgement of hard tissue
also as if pt thinks they have swallowed it - if in lungs pt will cough, wheeze and show symptoms that require CXR
What is follow up like for enamel dentine #
6-8 weeks
6 months
1 year
What do we check the radiographs for following an enamel dentine fracture at the initial appt and review appts?
we look at root development - width of canal and length
we compare the tooth with other non injured contralateral tooth
internal and external inflammatory resorption
periodical pathology
What is prognosis for enamel dentine #?
5% risk of pulp necrosis at 10 years - warn pt of this but high chance it will be fine
In a follow up appt of a enamel dentine # with a large open apex what would we be expecting?
If all is good and tooth is alive and growing we would expect a longer root, narrower apex, thicker dentine
Why is damage to an immature pulp better in terms of tooth prognosis?
Changes of pulp survival better in immature tooth comp to mature tooth - this is because in an immature tooth the apex is wide and open with lots of nerves and BVs entering so if the tooth is displaced there is a higher chance of nerves and BVs staying alive and regenerating
How do we deal with enamel dentine pulp #?
First we must evaluate the exposure:
- what size is the pulp exposure?
- how long has it been since injury?
- are there any associated PDL injuries
What are the 3 options for enamel dentine pulp #?
pulp cap
partial pulpotomy - removal of 2mm of pulp - this is done if more than 24 hrs or if bigger than 1mm
full coronal pulpotomy - depends on damage or how long since injury
How can we preserve pulp vitality?
By pulp capping or carrying our partial pulpotomy to secure further root development (also done in pts with closed apices)
What materials can we use for pulp capping?
Calcium hydroxide compounds
MTA
When would we do a direct pulp cap?
If exposure is 1mm and within 24 hr window
Describe the direct pulp cap procedure
Trauma sticker and radiographs - non TTP and pos to sensibility tests
- LA and dam
- clean area with water then disinfect with sodium hypochlorite
- apply setting calcium hydroxide (DYCAL) or MTA white to pulp exposure
- restore tooth
- review (6-8wks, 6 myths, year)
What is decal?
setting calcium hydroxide whiich we can use for pulp capping (or MTA)
what is a partial pulptomy?
This is done if 24hrs after injury or if bigger than 1mm exposure
How do we do a partial pulpotomy?
Following local anesthesia, the teeth are isolated with a rub- ber dam.
After smoothing sharp fracture edges or removing remaining carious dentin, the exposed pulp and surround- ing dentin are flushed clean with isotonic saline solution.
The superficial layer of the exposed pulp and the surround- ing dentin are excised to a depth of about 2 mm using a
high-speed diamond bur with light touch under waterspray cooling.
The surface of the remaining pulp is irrigated gen- tly with isotonic saline until bleeding has ceased.
After hemostasis, a pulpal medicament containing biologically available calcium hydroxide is applied to the wound surface
Care should be taken to avoid a significant blood clot developing between the wound surface and the dressing medicament.
Dry, sterile cotton pellets are used carefully with modest pressure to adapt the medicament to the pre- pared cavity and to remove excess water from the paste.
The remaining coronal cavity is then restored with a material that provides a long-term hermetic seal. It is critical to avoid bacterial contamination to the pulp tissue during the pro- cedures and to avoid any subsequent leakage following restoration.
Describe the steps in partial pulpotomy
- Trauma sticker and radiographic assessment – this is when we have larger exposure >1mm or 24+ hrs since trauma
- LA and dam
- Clean Area with saline then disinfects area with sodium hypochlorite
- Remove 2mm of pulp with hi-speed, round diamond bur
- Place saline soaked CW pellet over exposure until haemostasis achieved
- Apply CaOH then GI (or white MTA) then restore with quality composite resin
- If no bleeding or can’t arrest bleeding proceed to a full coronal pulpotomy – still got infected tissue there
What happens if during partial pulptomy we can’t stop bleeding or there is no bleeding at all?
We must proceed to full coronal pulpotomy - still infection or necrotic tooth
What is a full coronal pulptotomy?
This is where we remove all the coronal pulp if the tooth is hyperaemic or necrotic and not bleeding at all
How do we check if we need to carry out full coronal pulpotomy?
we assess for haemostats - after applying saline soaked cotton wool and pressure if won’t stop bleeding or if no bleeding then proceed
What are the steps of a full coronal pulpotomy
- Assess for haemostasis after application of saline soaked cotton-wool and bit of pressure
- If hyperaemic OR necrotic (no blood at all) proceed to remove ALL of the coronal pulp
- Place calcium hydroxide in pulp chamber
- Seal with GIC lining and quality coronal restoration
What is the success rate of cvek?
97%
What is the success rate of full coronal pulpotomy?
75%
What is the aim of a pulpotomy?
This is to keep vital pulp tissue in the canal to allow the root to grow normally in length of root and thickness of dentine
In immature incisors if the tooth is non vital what are our tx options?
Full pulpectomy
In immature incisors if the tooth is vital what are our tx options?
pulpotomy
What is the clinical problem with immature teeth and RCT?
no apical stop - the apex is wide and open so there is no apical stop for obturation of GP - gp can spill out to other tissues
What are our options for root canal tx of immature teeth?
We can place calcium hydroxide in the canal to aim to induce hard tissue barrier formation (apexification)
MTA/Biodentine placed at apex of canal to create cement barrier
regen endo technique
What happens when we place CaOH into immature root canal
We get hard tissue barrier forming however the barrier has many holes and is easily penetrated
also takes 9 months to form - this is an issue as non setting CaOH will denature dentine which makes tooth very brittle and prone to fracture
What is the issue with non setting CaOH?
will denature dentine
tooth becomes v brittle
prone to fracture
What is the regenerative end technique?
this is where we seal in antibiotics prep then with a file we agitate beyond the apical tissues so the canal can fill up with a blood clot - stem cells come from apical area and attach to clot and we want them to diff into odontoblasts
How do we carry out a pulpectomy of open apex?
- Rubber dam
- Access
- Haemorrhage control - LA / sterile water
- Diagnostic radiograph for WL
- File 2mm short of estimated WL – to avoid gp in different tissus
- Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
- Glass-ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
- Extipate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
- (Problems with CaOH apexification)
a. Immature teeth have large canals so we use a GP cylinder and heated gp is placed into canal via this system - MTA plug and heated GP obturation
How do we get MTA to apex?
Using disposable carriers to get MTA in 2mm of apex
How much MTA do we want?
5-6mm
What is MTA angelus?
This is a new form of MTA that sets in 15 mins - this means we could fill with GP that day (after radiograph to check position it should have hardened)
How long does traditional MTA take to set?
24 hrs - needs two visits to obturate canal
When do we do the final restoration of RCT?
After obturation is complete - we can use bonded composite short way down canal as well as in access cavity
What are our tx options in a crown root fracture that is uncomplicated?
- fragment removal and restore
- fragment removal and gingivectomy
- ortho extrusion
- surgical extrusion
- decoronation
- extraction
Why might we do fragment removal + gingivectomy?
To remove part of the gum to get into the area and restore - indicted in crown root fractures with palatal sub gingival extension
Why might we consider ortho extrusion?
To gain access to supra gingival margins - we extrude down until margin is in better place for restoration
Why might we consider surgical extrusion?
is there is serve trauma - we can loosen PDL and move tooth down
Why would we decoronate?
to preserve bone for future implant - we keep roots
What are out tx options for root fracture with pulp exposure?
- temporise with composite for up to 2 weeks
- fragment removal and gingivectomy
- ortho extrusion
- surgical extrusion - then crown (post crown)
- decoronation
- extraction
