Trauma Flashcards
What are some injuries to the hard tissues and pulp?
- Infraction
- Enamel
- Enamel-dentine
- Enamel-dentine-pulp
- Root
What is infraction?
An incomplete fracture (crack) of the enamel without loss of tooth substance.
What is an enamel fracture?
A fracture with loss of tooth substance confined to the enamel
What is an enamel-dentine fracture and what is it also called?
A fracture with loss of tooth substance confined to enamel and dentine but not involving the pulp.
Also called an uncomplicated crown fracture
What is an enamel-dentine-pulp fracture?
A fracture involving enamel and dentine and exposing the pulp.
AKA as a complicated crown fracture
What is a crown root fracture?
A fracture involving enamel, dentine and cementum
The pulp may or may not be involved
No pulp involvement - uncomplicated crown root fracture
Pulp exposed - complicated crown root fracture
What is a root fracture?
A fracture involving dentine, cementum and the pulp
How can root fractures be further classified?
Location - horizontal/vertical
Displacement of the coronal fragment - displaced or non-displaced
What are some injuries to the periodontal tissues?
Concussion
Subluxation
Extrusion
Lateral luxation
Avulsion
Intrusion
Alveolar fracture
What is concussion?
An injury to the tooth supporting structures without abnormal loosening or displacement of the tooth, but with marked reaction to percussion.
What is subluxation?
An injury to the tooth supporting structures with abnormal loosening, but without displacement of the tooth
What is extrusive luxation?
Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.
As the apex has been pushed into the socket the neurovascular bundle has been crushed and the PDL cells have also been crushed
What is avulsion?
Complete displacement of the tooth out of its socket
What clinical special investigations can you use in trauma?
Mobility - grade I/II/III
Transillumination - curing light from palatal aspect to see infraction lines
Percussion - is the tooth tender on percussion (TTP?)
What does it sound like when percussed? - normal/high
Colour - Normal? Blue/grey? Pinkish?
Sensibility tests - only in traumatised permanent teeth
What radiographs do you take at the initial trauma visit?
PA + USO
2 x PA
OPT only if possible bony fractures
Assess root development stage
Assess presence/absence of root fracture
Why don’t we do sensibility tests on deciduous teeth?
Unreliable because the child may be anxious or in pain and there are poorly myelinated nerve fibres in an immature tooth.
What are the root development stages?
1 = <2/3
2 = >2/3
3 = complete (apex open)
4 = complete (apex closed)
What factors do you take into account for prognosis of a traumatised tooth?
Root development stage
Combination injuries
Previous TDI
Severity of injury (response to sensibility test)
What are some of the responses of the PDL to injury?
Surface resorption
Infection related (inflammatory) resorption
Replacement resorption
What are the main prognostic factors of PDL resorption?
Maturity of tooth (open apex and closed apex)
Type of injury
What is surface resorption?
Physiological and can be pathological
Arrests quickly as stimulus is removed so is not transient and can see post orthodontic treatment
May see in relation to very minor trauma
What happens in crushing injuries?
Normal circumstances are Bone-PDL-Cementum
Fibroblasts stop osteoblasts from coming into the tooth
Cementoblasts help maintain integrity of the PDL
In injury destruction of PDL and fibroblasts and cementoblasts
These cells will mediate regeneration of the PDL
(most vulnerable to crushing injuries = intrusion in comparison to extrusion - tearing injury with intact cells around)
What is replacement resorption?
Death of PDL so bone is in direct contact with the tooth and you get ankylosis (osteoclasts being able to get to tooth) and tooth is involved in the remodelling process and tooth is resorbed and replaced by bone. = ankylosis
How do you identify ankylosis?
No mobility - no PDL
Ankylotic sound (cracked teacup)
Infraocclusion - tooth stuck and left behind, alveolar bone grows around it and carries the teeth around it.
What is inflammatory related resorption?
Toxins diffuse through dentinal tubules which compromises the PDL causing inflammatory resorption of bone and PDL around the tooth.
Associated radiolucency
Not progressive if RCT eliminates source of infection
What are factors affecting periodontal healing?
Type of injury - crushing of PDL is worst
Maturity - blood supply to periodontal ligament
What are factors affecting pulpal healing?
Type of injury - worst crushing (of apical foramen)
Maturity - blood supply to pulp
Concomitant fracture - fracture as well as a luxation injury etc
What are the differences between replacement and inflammatory resorption?
Replacement - death of PDL, no radiolucency and progressive
Inflammatory - death of pulp, radiolucency and able to arrest
What is the most common primary tooth injury?
Luxation - displacement and damage to PDL
What are aims of treatment when treating trauma?
Prevent further damage to permanent successor, treat pain, restore function and aesthetics.
What does treatment depend on?
Behaviour, parental choice, MH, type of injury
Does the early loss of a primary incisor have an effect on speech or occlusion?
No
How do you manage subluxation/concussion?
Soft diet, analgesics, monitor
How do you manage lateral luxations in primary teeth?
Leave if they are stable, no interference with occlusion and can undergo spontaneous repositioning.
Or extract is significantly extruded/interfere with occlusion
How do you manage extrusions in primary teeth?
Usually interfere with occlusion and become non-vital so extract
How do you manage intrusions in primary teeth?
Lateral radiograph - see relationship of primary tooth to permanent successor
Leave unless:
Clear interference with permanent successor
Infection
Failure to re-erupt (within 3-6 months)
How do you manage avulsion in primary teeth?
DO NOT reimplant
How do you manage an uncomplicated crown fracture in primary teeth?
Leave, smooth, composite
How do you manage a complicated root fracture?
Extraction
Pulpotomy
Pulpectomy
How do you manage a root fracture in a primary tooth?
If stable - leave and monitor
If unstable - extract coronal segment and leave apical segment
How do we extract injured primary teeth?
LA, sedation, GA
What is the sequelae of dental trauma?
Discolouration, loss of vitality and damage to permanent successor
What does a grey colour of tooth usually mean?
Probably haemorrhage of tooth, usually happens quickly with subsequent gradual resolution, not a sign of loss of vitality.
What are signs of loss of vitality in primary teeth?
Chronic abscess, periapical pathology, other signs - pain, mobility, discolouration
What are some signs of damage to permanent successor?
White or brown discolouration with/without hypoplasia
Dilaceration of crown
Dilaceration of root
Odontome like formation
Root duplication
Partial or total failure of root development
Failure of tooth development
What is a dilaceration?
Displacement of formed hard tissue in relation to developing root, abrupt change in direction of root.
Results in delayed or non eruption
What are treatment options for uncomplicated fractures?
Composite crown or reattach fragment
What are general considerations for complicated enamel dentine fractures?
Time since fracture occurred
Degree of contamination
Degree of damage
Other injury (luxation)
Stage of root development
Treatment options for immature teeth with complicated fractures?
Pulp capping - small exposure that was recent and kept clean
Partial pulpotomy
Pulpectomy
What is the technique for a Cvek pulpotomy?
LA and isolation
Remove 2mm pulpal tissue
Haemostasis
Apply non setting CaOH
Apply hard setting lining
Restore
What do you do for complicated fractures in terms of the tooth’s apex?
Closed - pulpectomy
Open - apexification
What is apexification?
Method of inducing apical closure through the formation of mineralised tissue in the apical pulp region of a non vital tooth with an open apex.
What are some problems with apexification?
No increase in root dimensions
Final root filling is difficult
Root is predisposed to fracture
How do we do apexification?
When the apex is open and pulp necrotic
Establish working length (1-2mm short of the apex)
Chemo mechanical preparation
Clean walls gently with large files
Sodium hypochlorite
Dress with CaOH
Reassess and redress 3 monthly
Obturate definitively when hard apical barrier formed (usually 9-12 months)
What is the prognosis of apexification?
75-96% forms a hard tissue apical barrier
High risk of cervical root fracture
Apex open <2/3 of root complete - 75%
Apex open >1mm root length complete 25%
What are potential problems with crown root fractures?
Isolation for endodontics, impressions, crowns
Crown root fracture treatment options
Supragingival restoration
Surgical exposure of fracture site
Surgical extrusion
Orthodontic extrusion
REFER these cases
Treatment options for root fractures
Undisplaced/stable fracture - no splint
Displaced/unstable fracture - flexible splint - 4 weeks
How do we diagnose root fractures?
Clinically - mobility increased, extrusion/lateral luxation of crown
Radiographic - radiographs from two angles in vertical plane eg parallelling technique and anterior occlusal
Why reposition teeth?
Occlusion - protect from occlusal interference
Aesthetics
Patient comfort
How do we reposition?
LA
Manual and gentle
Or manipulate position by biting
How do we splint?
Give LA
Choose light orthodontic wire and cut to correct length - should extend from midline of teeth adjacent to luxated tooth
Bend wire so it sits passively on teeth
Cement to support teeth
Place composite on luxated tooth
Reposition
Cement into position
Treatment of extrusion and lateral luxation
Reposition tooth
Physiological splint for 3-4 weeks
Antibiotics, chlorhexidine
What time and extra oral medium guarantees unfavourable healing in avulsion?
Extra alveolar time - 60 mins
Extra alveolar medium - 60 mins
Extra alveolar dry time - 30 minutes
What are disadvantages of reimplanting after avulsion?
Infraocclusion
Gingival contour
Multiple visits
Tooth will be lost
