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BDS3 Paediatrics > Trauma > Flashcards

Trauma Flashcards

1
Q

What are the most likely circumstances (e.g. age, gender, teeth) to experience trauma to primary teeth?

A
  • more common in males
  • maxillary primary incisors most commonly affected
  • peak incidence between 2-4 years old
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2
Q

What are the most common reasons for traumatic dental injuries in the primary dentition?

A
  • falls
  • bumping into objects
  • non-accidental
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3
Q

What injuries can occur to the dental hard tissues and pulp?

A
  • enamel fracture
  • enamel and dentine fracture
  • enamel, dentine and pulp fracture
  • crown-root fracture
  • root fracture
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4
Q

What injuries can occur to the supporting tissues (periodontium, bone)?

A
  • concussion
  • subluxation
  • lateral luxation
  • intrusion
  • extrusion
  • avulsion
  • alveolar fracture
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5
Q

Which fractures are considered complicated?

A
  • any fracture involving the pulp
    • enamel, dentine and pulp fracture
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6
Q

What is a crown-root fracture

A
  • fracture involving enamel, dentine and root
    • may or may not have pulpal involvement
    • determines whether complicated or uncomplicated
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7
Q

What is concussion?

A
  • PDL injury
    • tooth tender to touch
    • has not been displaced from line of arch
    • normal mobility
    • no bleeding into gingival sulcus
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8
Q

What is subluxation

A
  • PDL injury
    • tooth tender to touch
    • increased mobility
    • not displaced from line of arch
    • bleeding into gingival sulcus
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9
Q

What is lateral luxation?

A
  • tooth displaced in a palatal/lingual or labial direction
    • any direction other than axial
    • comminuted or fractured alveolar socket
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10
Q

What is intrusion?

A
  • tooth usually displaced through the labial bone plate
    • can impinge on permanent tooth bud
    • comminuted or fractured alveolar socket
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11
Q

What is extrusion?

A
  • partial displacement of the tooth out of its socket
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12
Q

What is avulsion?

A
  • tooth is completely displaced out of its socket
    • must determine location of tooth
      - most commonly lost out of the mouth
      - can be ingested or inhaled
      - can be embedded in surrounding soft tissues
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13
Q

What is alveolar fracture?

A
  • fracture involving the alveolar bone
    • labial and palatal/lingual
    • may extend to adjacent bone
    • mobility and dislocation of segment common
    • occlusal interference usually present
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14
Q

What is the most common type of injury in the primary dentition?

A
  • luxation injuries
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15
Q

What does a trauma examination involve?

A
  • reassurance
  • history
  • examination
  • diagnosis
  • emergency treatment
  • important information
  • further treatment and review
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16
Q

How can a patient be reassured after a traumatic dental injury?

A
  • distressing for parent and child
  • often also first visit to dentist
    • not planned
    • adds to anxiety
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17
Q

How do you take a trauma history?

A
  • injury
    • when did it happen?
      - time interval determines prognosis
    • where did it happen?
      - tentanus prophylaxis
      - further investigation
    • how did it happen?
      - nature of accident
      - indicates type of injury to expect
      - discrepancy can indicate abuse
    • any other symptoms or injuries?
      - concussion
      - headache
      - vomiting
      - amnesia
      - brain injury must be excluded
      - if suspicious refer to hospital
    • lost teeth/fragments?
      - if lost but not accounted for chest radiograph required
      - need to determine where
  • medical history
    • congenital heart disease
    • history of rheumatic fever or immunosuppression
    • bleeding disorders
      - haematological team must be contacted
    • allergies
      - short course of antibiotics may be required
    • tetanus immunisation status
      - no vaccine or booster required
  • dental history
    • previous trauma
      - can explain baseline clinical and radiographic findings
      - repeated injury can indicate neglect or abuse
    • treatment experience
      - ability to cope in past
    • legal guardian and child attitude
      - how easy is it attending for the family?
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18
Q

What does an extra oral examination for dental trauma involve?

A
  • swellings
  • bruising
  • lacerations
    • may require debridement and suturing
  • haematoma
  • haemorrhage
  • subconjunctival haemorrhage
  • bony step deformities
  • mouth opening
    • limited mandibular movement/mandibular deviation
    • can indicate jaw fracture or dislocation
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19
Q

What does an intra oral examination for dental trauma involve?

A
  • soft tissue
    • lacerations
    • haematomas
    • penetrating wounds
      - suspicion of foreign bodies
  • alveolar bone
    • evidence of fracture
  • occlusion
    • teeth well interdigitated
    • does bite feel normal to patient?
  • teeth
    • charted
    • injuries recorded
    • mobile
      - tooth displacement
      - root or bone fracture
    • transillumination
      - fracture lines (crazing)
      - pulpal degeneration (particularly palatally)
      - caries identification
    • tactile test with probe
      - detect horizontal and vertical fractures
      - detect pulpal involvement
    • percussion
      - dull sound in case of root fracture
    • occlusion
      - if traumatic requires urgent treatment
    • sensibility tests
      - thermal (ethyl chloride, warm gutta-percha)
      - electrical (electric pulp tester)
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20
Q

What is a trauma stamp?

A
  • measure of all of the factors requiring monitoring
    • mobility
    • colour
    • TTP
    • sensibility tests
    • presence of a sinus
    • percussion note
    • radiograph obtained at visit
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21
Q

What radiographs may be used to assess dental trauma?

A
  • periodical
  • anterior occlusal
  • lateral pre-maxilla
    • extraoral
  • panoramic
  • soft tissue view
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22
Q

What is often the most appropriate option for emergency treatment in the primary dentition? When is this option not appropriate?

A
  • observation
  • not appropriate
    • risk of aspiration or ingestion
    • occlusal interference
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23
Q

What advice should be given on home care?

A
  • analgesia
    • ibuprofen and/or paracetamol
  • soft diet
    • 10-14 days
    • normal diet but cut everything small
    • chew with molars
  • brush teeth with soft toothbrush
    • after every meal
  • topical chlorhexidine gluconate 0.12% mouthrinse
    • topically twice daily
    • one week
    • separately to toothbrushing
    • applied with gauze or cotton bud
  • advise on signs of infection
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24
Q

How are enamel fractures managed?

A
  • smooth sharp edges
    • soflex disc
  • bond fragment to tooth
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25
Q

How are enamel-dentine fractures managed?

A
  • cover exposed dentine
    • glass ionomer or composite
  • restore lost tooth structure
    • composite
    • immediate or subsequent visit
  • bond fragment to tooth
  • radiograph lacerations if fragment has not been located
  • evaluate tooth maturity
    • sensibility test
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26
Q

How are enamel-dentine-pulp fractures managed in primary teeth?

A
  • partial pulpotomy
    • some of the coronal pulp is removed
    • non setting calcium hydroxide paste over pulp
    • thin layer of glass ionomer cement
    • restored with composite
  • cervical pulpotomy if larger exposure
  • extraction
  • LA required for both
  • both invasive
  • risk of long term dental anxiety
  • dependent on maturity level of child
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27
Q

How are crown-root fractures managed?

A
  • removal of loose fragment
  • determine whether crown can be restored
  • restorable
    • no pulp exposed
      - cover exposed dentine with glass ionomer
    • pulp exposed
      - pulpotomy
      - endodontic treatment (level of fracture/root development)
  • unrestorable
    • extract loose fragments
    • don’t dig
      - do not damage permanent successor
      - firm fragments left in situ
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28
Q

How are root fractures managed?

A
  • if coronal fragment is not displaced
    • no treatment
  • if coronal fragment displaced but not excessively mobile
    • leave coronal fragment to spontaneously reposition
    • even if interfering with occlusion
  • if coronal fragment displaces, excessively mobile and interfering with occlusion
    • extract only the loose coronal fragment
      - often the favoured option
    • reposition the loose coronal fragment
      - can splint to secure fragment
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29
Q

How is concussion managed?

A
  • no treatment
  • in permanent teeth splint
    • excessive mobility or tenderness on biting
    • passive and flexible
    • 2 weeks
  • observation
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30
Q

How is subluxation

A
  • no treatment
  • observation
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31
Q

How is lateral luxation managed?

A
  • if minimal or no occlusal interference
    • allow to reposition spontaneously
  • if severe displacement
    • extract
      - favoured option
    • reposition
      - can splint for around 4 weeks
      - extreme caution to avoid damage to permanent successor
  • in permanent teeth reposition under local anaesthetic
    • splint for 4 weeks
  • incomplete root formation
    • spontaneous revascularisation may occur
    • endodontic treatment may be indicated
      - necrotic pulp
      - signs of inflammatory external resorption
  • complete root formation
    • pulp likely to become necrotic
    • commence endodontic treatment
      - corticosteroid-antibiotic or CaOh as intracranial medicament
      - prevent development of inflammatory external resorption
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32
Q

How is intrusion managed?

A
  • allow spontaneous reposition
    • irrespective of direction of displacement
    • usually within 6 months but can take up to a year
  • determine direction of displacement
    • only one radiographic image used (not parallax)
    • periodical or lateral premaxilla
    • assesses danger to permanent tooth
  • two possible scenarios for primary teeth
    • one
      - tip of apex can be seen
      - tooth appears shortened compared to contralateral
      - apex displaced towards or through labial bone plate
      - displaced away from developing permanent successor
    • two
      - apex cannot be visualised on radiograph
      - tooth appears elongated compared to contralateral
      - apex has been displaced towards permanent tooth germ
      - increased risk of damage to the permanent successor
  • two possible treatment options for permanent teeth
    • immature root formation
      - spontaneous repositioning
      - no re-eruption indicates orthodontic treatment
      - monitor pulp condition
      - spontaneous pulp revascularisation may occur
      - endo if necrotic pulp or signs of inflammatory external resorption
    • mature root formation (<3mm)
      - spontaneous repositioning
      - surgical reposition after 8 weeks (4 weeks splint)
      - orthodontic repositioning
      - endodontic treatment if indicated
    • mature root formation (3-7mm)
      - reposition surgically or orthodontically
      - endodontic treatment if indicated
    • mature root formation (>7mm)
      - reposition surgically
      - endodontic treatment if indicated
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33
Q

How is extrusion managed?

A
  • if not interfering with occlusion
    • spontaneous repositioning
  • excessively mobile or extruded >3mm
    • extraction
  • in permanent teeth reposition the tooth
    • gently push back into socket
    • under local anaesthetic
    • splint
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34
Q

How is avulsion managed?

A
  • radiograph to confirm avulsion
  • do not replant
    • never for primary teeth
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35
Q

How is alveolar fracture managed?

A
  • repositioning of segment
    • if mobile or causing occlusal interference
  • stabilise with flexible splint
    • adjacent uninjured teeth
    • 4 weeks
  • suture gingival lacerations if present
  • teeth may need extracted after alveolar stability is achieved
    • monitor pulp condition of all teeth involved
    • monitor root development
      - canal width
      - canal length
      - resorption
    • risk of pulpal necrosis in closed apex teeth at 5 years
  • advice to patent and carer
    • soft diet for 7 days
    • avoid contact sport while splint is in place
    • careful oral hygiene
      - chlorhexidine gluconate mouthwash 0.12%
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36
Q

What are the possible long term complications of trauma to primary teeth regarding the primary tooth?

A
  • discolouration
  • discolouration and infection
  • delayed exfoliation
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37
Q

Describe discolouration of primary teeth

A
  • asymptomatic
  • vital or non-vital
  • mild grey
    • immediate discolouration
    • intrapulpal bleeding
    • may maintain vitality
    • discolouration may recede
  • opaque yellow
    • pulp obliteration
    • response of pulp to dental injury
    • pulp responding by laying down dentine for protection
  • no signs of pulp necrosis or infection
    • no treatment
    • review
38
Q

Describe discolouration and infection of primary teeth

A
  • symptomatic
  • non-vital
  • sinus
  • gingival swelling
  • abscess
  • increased mobility
  • TTP
  • radiographic evidence of periodical pathology
  • extract
    • often favoured
  • endodontic treatment
    • caution not to damage permanent predecessor
    • consider root length and time to exfoliation
    • requires some level of cooperation
39
Q

Describe delayed exfoliation of primary teeth

A
  • primary tooth retained too long
  • consequences for developing occlusion
    • ectopic eruption of permanent successor
    • delayed eruption of permanent successor
    • no eruption of permanent successor
  • may affect aesthetics and therefore confidence
40
Q

How does trauma to the primary teeth impact on the permanent teeth?

A
  • injuries to permanent teeth related to age of trauma to primary teeth
    • decreases with age
  • intrusion causes the most disturbance
    • due to contact with developing tooth germ
41
Q

What are the possible long term complications of trauma to primary teeth regarding the permanent teeth?

A
  • enamel defects
    • most common
  • abnormal crown/root morphology
    • crown duplication or dilaceration
    • root duplication or dilaceration
  • delayed eruption
  • ectopic tooth position
  • arrested development
  • complete failure of tooth to form
  • odontome formation
    • benign tumour composed of tooth tissue
42
Q

What enamel defects may be seen in permanent teeth after trauma to primary teeth?

A
  • enamel hypomineralisation
    • qualitative defect
      - normal thickness but poorly mineralised
    • white/yellow defect
    • treatment options
      - no treatment
      - composite masking (+/- localised removal)
      - tooth whitening
  • enamel hypoplasia
    • quantitative defect
      - reduced thickness but normal mineralisation
    • yellow/brown defects
    • treatment options
      - no treatment
      - composite masking
      - veneers
43
Q

What is dilaceration and how can it be managed?

A
  • abrupt deviation of the long axis of the crown or root
  • crown dilaceration
    • surgical exposure and orthodontic realignment
    • restorative work to improve aesthetics
  • root dilaceration/angulation/duplication
    • combined surgical and orthodontic approach
    • more complex than crown management
44
Q

Describe the management of delayed eruption of permanent teeth after trauma to primary teeth

A
  • premature loss of primary tooth can result in delayed eruption of 1 year
    • due to thickened mucosa in area
  • radiograph taken if 6 month delay to contralateral tooth
  • surgical exposure and orthodontic alignment may be required
45
Q

Describe management of ectopic tooth positioning of a permanent tooth after trauma to primary teeth

A
  • due to primary tooth injury displacing permanent tooth
  • due to retention of primary tooth
  • treatment options
    • surgical exposure and orthodontic realignment
    • extraction
      - if not possible to move to appropriate position
46
Q

Describe arrested development as a complication to permanent teeth as a result of trauma to primary teeth

A
  • permanent tooth developing at time of trauma
    • development stopped
  • treatment options
    • endodontic treatment
      - required favourable root length
    • extraction
47
Q

Describe complete failure of a tooth to form as a complication to permanent teeth as a result of trauma to primary teeth

A
  • trauma to primary tooth causes complete failure of permanent tooth formation
  • tooth germ may sequestrate spontaneously
  • may require removal
48
Q

Describe odontome formation as a complication to permanent teeth as a result of trauma to primary teeth

A
  • permanent tooth is severely disrupted due to primary dental trauma
  • surgical removal required
49
Q

What is the most common injury in permanent teeth?

A
  • crown fractures
  • enamel-dentine fracture
50
Q

What are the most likely circumstances (e.g. age, gender, anatomy) to experience trauma to permanent teeth?

A
  • mostly before 19 years old
    • peaks between 7-10 years
  • more common in boys
  • large overjet
    • > 9mm doubled incidence of trauma
    • teeth further forward and incompetent lips
51
Q

What are the causes of trauma to permanent teeth?

A
  • falls
  • bike/skateboard/RTA
  • sport
  • fights
52
Q

How long should sensibility testing be carried out after an injury?

53
Q

What does the prognosis of a tooth involved in trauma depend on?

A
  • stage of root development
  • type of injury
  • PDL damage
  • time between injury and treatment
  • presence of infection
54
Q

What are the general aims and principles of treatment for trauma to permanent teeth?

A
  • emergency
    • retain vitality of and damaged or displaced tooth
      - protect exposed dentine (adhesive dentine bandage)
      - prevents ingress via tubules
    • treat exposed pulp tissue
    • reduce and immobilise displaced teeth
    • tetanus prophylaxis
      - antibiotic delivery variable
  • intermediate
    • possibly pulp treatment
      - pulp capping
      - pulpotomy
      - pulpectomy
      - extrication of pulp
    • restoration
      - minimally invasive
  • permanent
    • apexigenesis
      - maintain vitality of radicular pulp
      - encouraging increased length and thickness of roots
    • apexification
      - removal of pulp
      - formation of barrier at apex
    • root filling +/- root extrusion
    • gingival and alveolar collar modification if required
    • coronal restoration
55
Q

What is the prognosis of enamel fracture?

A
  • 0% risk of pulp necrosis
  • must take 2 periodical radiographs to rule out fracture and luxation
56
Q

When should follow up appointments be made for review of enamel and enamel-dentine fractures?

A
  • 6-8 weeks
  • 6 months
  • 1 year
57
Q

What is the prognosis of enamel-dentine fracture?

A
  • 5% risk of pulp necrosis at 10 years
58
Q

How does open vs closed apex affect pulpal survival after injury to supporting tissues?

A
  • an open apex increases the rate of pulpal survival after injury to supporting tissues (e.g. luxation, extrusion, concussion, etc.)
59
Q

How are enamel-dentine-pulp fractures managed in permanent teeth?

A
  • evaluate exposure
    • size of pulp exposure
    • time since injury
    • associated PDL injuries
  • pulp cap
    • covering pulp exposure with medicament
      - setting calcium hydroxide
      - glass ionomer
      - bioceramic materials
  • partial pulpotomy
    • removal of small amount of inflamed tissue
      - arrest bleeding
      - place medicament
  • full coronal pulpotomy
    • all pulp in coronal aspect removed
    • radicular pulp left
  • maintain pulp vitality
    • increases root thickness and root dentinal walls
      - reduce fracture risk
  • avoid full extrication
    • unless non vital
    • especially in teeth with open apices
60
Q

What is a direct pulp cap?

A
  • small exposure
    • around 1mm
    • within 24 hours
  • no TTP
  • positive to sensibility tests
  • LA and rubber dam
  • clean with water
  • disinfect with sodium hypochlorite
  • apply calcium hydroxide (Dycal) or MTA white
    • biodentine and total fill can also be used
      - bioceramic materials
      - less staining
  • restore with composite
  • review
    • assess symptoms
    • radiographic assessment of root development and pulpal vitality
61
Q

What is a direct pulp cap?

A
  • small exposure
    • around 1mm
    • within 24 hours
  • no TTP
  • positive to sensibility tests
  • LA and rubber dam
  • clean with water
  • disinfect with sodium hypochlorite
  • apply calcium hydroxide (Dycal) or MTA white
    • biodentine and total fill can also be used
      - bioceramic materials
      - less staining
  • restore with composite
  • review
    • assess symptoms
    • radiographic assessment of root development and pulpal vitality
62
Q

What is a partial pulpotomy?

A
  • larger exposure
    • > 1mm
    • over 24 hours after exposure
  • LA and rubber dam
  • clean with water
  • disinfect with sodium hypochlorite
  • remove 2mm of pulp with high speed round diamond bur
    • can use sharp sterile excavator
  • place saline soaked cotton wool pellet over exposure
    • until haemostasis achieved
    • if no haemostasis proceed to full pulpotomy
  • apply calcium hydroxide then glass ionomer (or white MTA)
  • restore with composite
  • 97% success rate
63
Q

What is a full coronal pulpotomy?

A
  • begins as partial pulpotomy
  • assess for haemostasis after application saline soaked cotton wool
  • if hyperaemic or necrotic remove all of the coronal pulp
  • place calcium hydroxide, bioceramic or MTA in pulp chamber
  • seal with glass ionomer cement
  • restore with composite
  • 75% success rate
64
Q

How is root treatment for immature incisors carried out?

A
  • full pulpectomy if non-vital
  • no apical stop in immature teeth
    • calcium hydroxide place in canal
      - induce hard tissue barrier to form
      - apexification
      - not routine, CaOH increases brittleness of roots
    • MTA/BioDentine placed at apex of canal
      - creation of a cement barrier
      - apical plug to obturate against
    • regenerative endodontic technique
      - encourage hard tissue formation at apex
      - stimulation of bleeding periodically
      - new and not routine, very short roots
65
Q

What does a pulpectomy of a tooth with an open tooth involve?

A
  • rubber dam
  • access
  • haemorrhage control
    • local anaesthetic
    • sterile water
  • diagnostic radiograph
    • working length
    • important for placement for apical plug
  • file 2mm short of estimated working length
  • dry canal
    • place non setting calcium hydroxide
    • place cotton wool pellet in pulp chamber
  • glass ionomer as temporary cement
  • radiograph
    • evaluate placement if calcium hydroxide placement
    • no extrusion of calcium hydroxide into periapical tissues
      - irritation
      - post op pain
    • no voids
      - calcific barrier formation
  • placement of calcium hydroxide for no longer than 4-6 weeks
    • increased brittleness of root tissues
    • increased risk of fracture
  • placement of apical plug
    • MTA
    • BioDentine
    • total fill material
  • heated GP obturation
    • thermal obturation
    • cold lateral condensation time consuming in wide canals
66
Q

What does a pulpectomy of a tooth with an open tooth involve?

A
  • rubber dam
  • access
  • haemorrhage control
    • local anaesthetic
    • sterile water
  • diagnostic radiograph
    • working length
    • important for placement for apical plug
  • file 2mm short of estimated working length
  • dry canal
    • place non setting calcium hydroxide
    • place cotton wool pellet in pulp chamber
  • glass ionomer as temporary cement
  • radiograph
    • evaluate placement if calcium hydroxide placement
    • no extrusion of calcium hydroxide into periapical tissues
      - irritation
      - post op pain
    • no voids
      - calcific barrier formation
  • placement of calcium hydroxide for no longer than 4-6 weeks
    • increased brittleness of root tissues
    • increased risk of fracture
  • placement of apical plug
    • MTA
    • BioDentine
    • total fill material
  • heated GP obturation
    • thermal obturation
    • cold lateral condensation time consuming in wide canals
  • restoration of tooth
    • bonded composite into canal and access cavity
    • bonded core
    • avoid post crown
      - invasive
      - increased risk of root fracture
      - aesthetically sub optimal with ageing
67
Q

How are crown-root fractures managed in permanent teeth?

A
  • no pulpal exposure
    • fragment removal only and restore
    • fragment removal and gingivectomy
      - indicated by palatal subgingival extension
    • orthodontic extrusion of apical portion
    • surgical extrusion
      - manual repositioning under local anaesthetic
    • decoronation
      - preserve bone for future implant
      - easier to provide prosthesis (e.g. bridge)
    • extraction
  • pulpal exposure
    • temporised with composite for up to 2 weeks
    • fragment removal and gingivectomy
      - indicated by palatal subgingival extension
    • orthodontic extrusion of apical portion
    • surgical extrusion
      - manual repositioning under local anaesthetic
    • decoronation
      - preserve bone for future implant
    • extraction
68
Q

What must be considered when looking at injury to supporting tissue?

A
  • surrounding bone
  • neuromuscular bundle
  • root surface
69
Q

What are the two categories of the nature of injury to soft tissues?

A
  • separation injury
    • major part of injury is cleavage of intracellular structures
      - collagen
      - limited damage to cells in area of trauma
    • wound healing can arise from existing cellular systems
      - minimal delay
  • crushing injury
    • injuries with extensive damage to cellular and intercellular
      - must be removed by macrophages/osteoclasts
      - traumatised tissue then restores
      - longer healing time
70
Q

What are the critical factors in avulsion of a permanent tooth?

A
  • extra-alveolar dry time (EADT)
  • extra-alveolar time (EAT)
  • storage medium
71
Q

What advice should be given in the emergency situation of avulsion of a permanent tooth?

A
  • ensure it is a permanent tooth that has been lost
    • primary teeth should not be avulsed
  • hold by the crown
  • encourage attempt to place tooth immediately into socket
    • if dirty rinse with milk, saline or patient’s saliva
    • do not rub/scrub root
  • bite on gauze/hankerchief
    • holds in place once replanted
  • seek immediate dental advice
72
Q

How should an avulsed permanent tooth be stored?

A
  • only if replantation is not possible
    • patient unconscious
  • must be stored in medium as soon as possible
    • prevents root surface drying out
    • starts within minutes of avulsion
  • storage media
    • milk
      - best option
    • HBSS
      - Hank’s balances dalt solution
    • saliva
      - patient’s own
      - spit into tub
    • saline
    • water
      - poor but better than air drying
73
Q

What factors affect the way in which permanent tooth avulsion is treated?

A
  • maturity of root
    • open or closed apex
  • PDL cell condition
    • dependent on time out of mouth and storage medium
74
Q

How is avulsion of a permanent tooth with a closed apex managed?

A
  • if tooth already replanted
    • clean injured area
    • verify replanted tooth position and apical status
      - clinically and radiographically
    • leave in place
      - unless malpositioned
      - correct with digital pressure
      - if in wrong socket or rotated, replace up to 48 hours
    • stabilise with splint
      - passive, flexible splint
      - two weeks
    • suture any gingival lacerations if present
    • consider antibiotics and check tetanus status
    • provide post op instructions
    • arrange follow up
  • if extra-alveolar dry time over 60 minutes
    • PDL cells may be viable but compromised
    • remove debris
    • history and examination with tooth in storage medium
      - clinical and radiographic examination
    • replant tooth under local anaesthetic
      - gently irrigate socket with saline
      - examine socket prior to replantation
      - fracture of socket wall should first be repositioned
      - slowly with slight pressure
    • splint
      - after verification of correct tooth position
      - passive, flexible splint for two weeks
    • suture gingival lacerations if present
    • consider antibiotics and check tetanus status
    • arrange follow up
  • if extra-alveolar dry time over 60
    • PDL cells likely to be non-viable
    • remove debris
    • history and examination with tooth in storage medium
      - clinical and radiographic examination
  • replant tooth under local anaesthetic
    - gently irrigate socket with saline
    - examine socket prior to replantation
    - fracture of socket wall should first be repositioned
    - slowly with slight pressure
    • splint
      - after verification of correct tooth position
      - passive, flexible splint for two weeks
    • suture gingival lacerations if present
    • consider antibiotics and check tetanus status
    • arrange follow up
    • commence endodontic treatment within 2 weeks
      - calcium hydroxide as intracanal medicament
      - up to 1 month
      - corticosteroid/antibiotic paste for 6 weeks
      - complete with conventional endodontic treatment
  • if delayed replantation
    • poor long term prognosis
      - necrotic PDL, little regeneration
    • ankylosis-related root resorption
    • restore aesthetics and function (temporarily)
    • maintains alveolar bone contour, width and height
    • decoronation may be required
      - depends on growth rate
      - risk of ankylosis and infra occlusion
    • referral to paediatric specialist
      - inter-disceplinary management
75
Q

How is avulsion of a permanent tooth with an open apex managed?

A
  • tooth already replanted
    • clean injured area
    • verify replanted tooth position and apical status
      - clinically and radiographically
    • leave in place
      - unless malpositioned
      - correct with digital pressure
      - if in wrong socket or rotated, replace up to 48 hours
    • stabilise with splint
      - passive, flexible splint
      - two weeks
    • suture any gingival lacerations if present
    • consider antibiotics and check tetanus status
    • provide post op instructions
    • arrange follow up
  • if extra-alveolar time less than 60 minutes
    • potential for spontaneous healing
      - correct storage medium vital
  • remove debris
    • history and examination with tooth in storage medium
      - clinical and radiographic examination
    • replant tooth under local anaesthetic
      - gently irrigate socket with saline
      - examine socket prior to replantation
      - fracture of socket wall should first be repositioned
      - slowly with slight pressure
    • splint
      - after verification of correct tooth position
      - passive, flexible splint for two weeks
    • suture gingival lacerations if present
    • consider antibiotics and check tetanus status
    • arrange follow up
      - monitor for revascularisation
      - endodontic treatment if pulp necrosis, etc.
  • if extra-alveolar time more than 60 minutes
    • PDL cells likely to be non-viable
  • remove debris
    • history and examination with tooth in storage medium
      - clinical and radiographic examination
    • replant tooth under local anaesthetic
      - gently irrigate socket with saline
      - examine socket prior to replantation
      - fracture of socket wall should first be repositioned
      - slowly with slight pressure
    • splint
      - after verification of correct tooth position
      - passive, flexible splint for two weeks
    • suture gingival lacerations if present
    • consider antibiotics and check tetanus status
    • arrange follow up
      - likely ankylosis-related root resorption
  • delayed replantation
    • poor long term prognosis
      - necrotic PDL, little regeneration
    • ankylosis-related root resorption
    • restore aesthetics and function (temporarily)
    • maintains alveolar bone contour, width and height
    • decoronation may be required
      - depends on growth rate
      - risk of ankylosis and infra occlusion
    • referral to paediatric specialist
      - inter-disceplinary management
76
Q

When is it indicated to not replant a tooth?

A
  • usually is right decision to replant
    • temporary space maintainer
  • medical contraindication
    • immunocompromised child
    • other serious injuries
      - requiring preferential emergency treatment
  • dental contraindications
    • very immature apex
      - extra-alveolar time over 90 minutes
    • very immature lower incisors
      - young children finding it difficult to cope
77
Q

What injuries to supporting tissues are splinted for 2 weeks?

A
  • subluxation
  • extrusion
  • avulsion
78
Q

What injuries to supporting tissues are splinted for 4 weeks?

A
  • intrusion
  • lateral luxation
  • root fracture
    • mid third
    • apical third
  • dento-alveolar fracture
79
Q

What injuries to supporting tissues are splinted for 4 months?

A
  • root fracture
    • cervical third
80
Q

What are the desirable properties of splints?

A
  • flexible and passive
  • ease of placement/removal
  • facilitate sensibility testing and clinical monitoring
  • allow oral hygiene
  • aesthetic
    • acceptable to patient
81
Q

What are the desirable properties of splints?

A
  • flexible and passive
  • ease of placement/removal
  • facilitate sensibility testing and clinical monitoring
  • allow oral hygiene
  • aesthetic
    • acceptable to patient
82
Q

Provide examples of splints from both categories of splint type

A
  • chair-side
    • composite and wire
    • titanium trauma splint
    • composite
    • orthodontic brackets and wire
    • acrylic
  • lab-made
    • vacuum-formed splint
    • acrylic
83
Q

What are the gold standard splints?

A
  • composite and wire
  • titanium trauma splint
84
Q

Describe the qualities of a composite and wire splint

A
  • stainless steel wire
    • up to 0.4mm in diameter
  • must be passive
    • no unwanted forces on traumatised tooth
  • flexible
    • including one uninjured tooth on either side
    • secured in composite resin
  • quick and easy to place
  • composite and bonding agents
    • kept away from gingiva and proximal areas
    • plaque retention and secondary infection
      - bacterial wicking
    • better healing of the marginal gingiva and bone
85
Q

Describe the qualities of a titanium trauma splint (TTS)

A
  • rhomboid mesh structure
    • 0.2mm thickness
  • passive and flexible
    • quick and easy to place
    • easily adapted with fingers to dental arch
    • flexible in all dimensions
    • allows physiologic tooth mobility
    • no forces applied to splinted teeth
  • secured to teeth with composite resin
86
Q

What are the four main post-trauma complications after traumatic dental injury?

A
  • pulp necrosis and infection
  • pulp canal obliteration
  • root resorption
  • breakdown of marginal gingivae and bone
87
Q

What is pulp canal obliteration?

A
  • response of a vital pulp to trauma
    • most commonly luxation with displacement
  • progressive hard tissue formation within the pulp cavity
    • gradual narrowing of pulp chamber and canal
    • total or partial obliteration
  • tooth becomes opaque/yellow
  • treatment
    • conservative management
88
Q

What are the two different types of root resorption

A
  • external
    • surface
    • external infection related inflammatory root resorption
    • cervical
    • ankylosis related replacement root resorption
  • internal
    • internal infection related inflammatory root resorption
89
Q

What is external surface root resorption?

A
  • superficial resorption lacunae
    • repaired with new cementum
  • response to localised injury
    in vital teeth
  • not progressive
90
Q

What is external infection related inflammatory root resorption?

A
  • occurs in non vital teeth
    • infected pulp canals
  • initiated by PDL damage
    • following trauma
    • propagated by root canal toxins reaching external root surface through patent dentinal tubules
    • rapid progression
  • diagnosis
    • chance radiographic finding
    • change to external contour of root
    • surrounded by bony lucency
    • root canal tram lines remain in tact
  • management
    • removal of stimulus
      - infected root canal contents
    • endodontic treatment
      - non-setting CaOh for 4-6 weeks
      - obturate with GP
  • cervical resorption
    • unusual form
    • damage to root in cervical area
    • propagated by infected canal contents or periodontal microflora
    • small entry point propagates widely before entering pulp chamber
91
Q

What is ankylosis related replacement root resorption

A
  • following severe luxation or avulsion
  • severe damage to PDL and cementum
    • normal repair does not occur
    • bone cells faster than PDL fibroblasts
    • if more than 20% of PDL damaged
  • root involved in bone remodelling
    • radiographically appears ragged root outline
    • no obvious PDL space
  • speed variable
    • tooth become infraoccluded
    • alveolar bone does not develop
    • gingival margins move apically
    • decoronation once over 3mm
  • treatment
    • no treatment
    • plan for loss of tooth
      - may not be for a number of years
92
Q

what is internal infection related inflammatory root resorption?

A
  • due to progressive pulp necrosis
    • infected material propagated resorption
    • though non-vital coronal part of canal
  • radiographically
    • symmetrical expansion of root canal walls
    • tramlines of root canal indistinct
    • root surface in tact
  • treatment
    • removal of stimulus
    • endodontic treatment
      • non-setting CaOh for 4-6 weeks
      • obturate with GP
      • if progressive plan for loss

BDS3 Paediatrics (6 decks)

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