Trauma Flashcards
What guidelines should be consulted regarding trauma?
International Association of Dental Trauma
Incidence of dental trauma has three peaks, what are they?
1) 2-3 years
2) 8-10 years
3) 15 years
What injury is most common in preschool children?
luxation
What occlusal factor can be a predisposing factor for trauma?
increased overjet with protrusion of upper incisors and incompetent lips
Healing following trauma affects what tissues?
- pulp
- PDL
- apex formation
- bone
- gingivae/mucosa
What kind of injury generally occurs as a result of a hard impact e.g. pavement, road, horse kick?
e.g. lightbulb and hammer = shatter
Chipping
What kind of injury generally occurs as a result of a (relatively) soft impact e.g. fist, knee, elbow, dog?
e.g. lightbulb and boxing glove =. movement
displacement
How quickly can junctional epithelium reattach?
within 5 days
What does healing by primary intention mean?
2 sides of wound close and seal
What does healing by secondary intention mean?
wider, scabbing and can scar
What is anachoresis?
The transportation of foreign bodies via blood or lymph and subsequent collection at a site of inflammation
Revascularisation of an apex is likely if the apex is of what diameter?
> _1mm
Revascularisation of an apex is rare if the apex is of what diameter?
<_0.5mm
What classification of dental injuries is used?
WHO 1995 classification
Name the 7 types of dental injury in the WHO 1995 classification
1) enamel infraction
2) enamel fracture
3) enamel dentine fracture
4) enamel dentine pulp fracture
5) crown root fracture without pulp involvement
6) crown root fracture with pulp involvement
7) root fracture
What is an enamel infraction?
incomplete crack of enamel without loss of tooth structure
- no tenderness or radiographic abnormalities
Where is a fracture considered to be a root fracture?
cervical or mid 1/3
What is an enamel fracture?
a complete fracture of the enamel, loss of enamel.
No visible signs of exposed dentine
What are the signs of an enamel fracture?
- loss of enamel but no signs of exposed dentine
- not tender
- normal mobility
- radiographically enamel loss visible
- positive test to EPT
What is an enamel dentine fracture (uncomplicated)?
confined to enamel and dentine with loss of tooth structure, but not exposing the pulp
What are the signs of an enamel dentine fracture (uncomplicated)?
- confined to enamel and dentine, loss of structure but no pulpal exposure
- not TTP
- normal mobility
- sensibility test normally positive
- radiographically, loss of enamel and dentine
If a tooth is tender, what should you evaluate the tooth for?
possible luxation or root fracture injury
What is an enamel dentine pulp fracture (complicated)?
involving enamel and dentine with loss of tooth structure and exposure of the pulp
What are the signs of an enamel dentine pulp fracture?
not TTP
Exposed pulp sensitive to stimuli
radiographically, enamel-dentine loss visible
What is a crown root fracture without pulp involvement?
involving enamel, dentine and cementum with loss of tooth structure, but not exposing the pulp
crown fracture extending below the gingival margin
What are the signs of a crown root fracture without pulp involvement?
- crown fracture extending below gingival margin
- TTP
- coronal fragment mobile
- sensibility test normally positive for apical fragment
- radiographically, apical extension of fracture usually not visible
What is a crown root fracture with pulp involvement?
- involving enamel, dentine and cementum exposing the pulp
What are the signs of a crown root fracture with pulp involvement?
TTP
coronal fragment mobile
radiographically, apical extension of fracture usually not visible
What is a root fracture?
fracture in cervical or mid 1/3 of tooth
What are the signs of a root fracture?
- coronal fragment may be mobile or displaced
- tooth may be TTP
- bleeding from gingival sulcus may be noted
- sensibility test may give negative results initially, indicating transient or permanent neural damage
- transient crown discolouration
- fracture in horizontal or oblique plane
A root fracture that is in the horizontal can usually be detected in what kind of radiograph?
regular periapical 90 degree angle film with central beam through tooth
horizontal plane common in cervical 1/3 of root
A root fracture in an oblique plane can usually be detected by what kind of radiograph?
oblique plane common in apical 1/3 fractures
- occlusal view or radiographs with varying horizontal angles more likely to demonstrate the fracture
What is an oblique plane?
any plane that is not in any of the coronal, sagittal, median or horizontal planes
What are the four main types of periodontal injury?
1) concussion
2) subluxation
3) luxation
4) avulsion
What is a concussion periodontal injury and what are the symptoms?
bruised
- no displacement
- TTP but no increased mobility
- no radiographic abnormalities
What is a subluxation periodontal injury and what are the symptoms?
loosened
- no displacement
- TTP and has increased mobility
- bleeding from gingival crevice may be noted
- sensibility testing may be negative initially due to transient pulpal damage
- no radiographic abnormalities
What is a luxation (extrusive) periodontal injury and what are the symptoms?
extrusive
- tooth appears elongated and excessively mobile
- sensibility tests likely negative
- radiographically, increased PDL space apically
What is a luxation (intrusive) periodontal injury and what are the symptoms?
intrusive
- displaced axially into the alveolar bone
- immobile and percussion may give high, metallic (ankylotic) sound
- sensibility tests likely negative
- radiographically, PDL space may be absent from all or part of root, CEJ located more apically in intruded tooth than adjacent non-injured tooth
What significance does the intrusion of a primary tooth have?
potential damage to developing tooth germ
What should be done if a primary tooth has been intruded but displaced labially?
displaced away from the tooth germ
monitor, measure and document amount of intrusion using fixed reference points to serve as baseline
What should be done if a primary tooth has been intruded palatally?
towards the permanent successor
extract
and explain possibility of damage to permanent successor to patient/parent
What is a lateral luxation injury?
tooth displaced in a palatal/lingual or labial direction
What are the signs of a lateral luxation?
tooth will be immobile and percussion usually gives high, metallic (ankylotic) sound
fracture of alveolus present
sensibilty tests negative
radiographically, widened PDL space seen on eccentric or occlusal exposures
How is the lateral luxation of a primary tooth managed?
- if no occlusal interference, tooth should be allowed to reposition spontaneously
- any doubt that root may be displaced toward (crown displaced labially) permanent tooth, then extract
- if root moves away from perm tooth, discuss with parents and consider monitoring/repositioning
- interference with occlusion - may be necessary to selectively grind tooth
What is an avulsion injury?
tooth knocked out
What is a degloving injury?
top layers of skin and tissue being torn away from the underlying muscle, connective tissue or bone
What kind of intra oral soft tissue injuries can occur?
- grazes/lacerations
- degloving injuries
- contusions (bruises)
What kind of extra oral soft tissue injuries can occur?
- grazes/lacerations
- contusions (bruises)
- inclusion of foreign bodies e.g. gravel, tooth fragments
What are four types of skeletal injury?
- alveolus - 2 or more teeth moving as a block
- mandible
- maxilla
- cranial injuries
What is an alveolar fracture?
- 2 or more teeth moving as a block
- fracture involves alveolar bone and may extend to adjacent bone
What are the signs of an alveolar fracture?
- segment mobility and dislocation with several teeth moving together
- occlusal change due to malalignment of fractured alveolar segment
- sensibility may or may not be positive
- radiographically, fracture lines at any level, from marginal bone to root apex and above apex.
What radiographs are commonly used to investigate alveolar fracture?
- in addition to the 3 angulations and occlusal film, additional views such as DPT can be helpful in determining course and position of fracture lines
What kind of preventions can be put in place for dental trauma?
difficult
- child with double digit overjet in mixed dentition consider early OJ reduction
- provide mouthguards/facemasks for children in contact sports
What is two phase over-jet reduction?
-first stage started age 7-11 years with functional appliance then second phase in adolescence, shows reduction in incisal trauma compared to one phase
What are the three types of gumshields?
1) stock (Type 1)
2) Boil and bite (Type II)
3) Custom-made (Type III)
What is a type I gumshield?
stock
bulky material/plastic
contact biting force to retain
What is a type II gumshield?
boil and bite
- thermoplastic moulded within mouth
- deform over time
What is a type III gumshield?
custom made
- ethylene vinyl acetate
- vacuum formed over stone cast
- 5mm thick and extend to distal 6s or further
- can be built in multiple layers (laminations)
- may also protect condylar head fracture
What is the most important rule when assessing a patient following trauma?
assess for signs of head trauma or other more urgent non-dental injuries first
assess for possible aspiration
If there is doubt of possible aspiration of tooth fragments what should be done?
contact local A&E/Hospital for further advice
What are battle signs?
bruising over mastoid process
What can mandibular deviation on opening be a possible sign of?
condylar fracture
What are the typical sites of accidental injury?
- head injuries tend to involve parietal bone, occiput or forehead
- nose, chin
- palm of hand
- elbows, knees, shins
Typical sites of non-accidental injury include what?
- ears - esp pinch marks
- “triangle of safety”
- inner aspect of arms
- back and side of trunk
- black eyes esp if bilateral
- soft tissues of cheeks
- IO injuries
- forearms when raised to protect
- chest and abdomen
- groin or genital injury
- inner aspect of thighs
- soles of feet
What is the “triangle of safety”?
- ear, side of face and neck, top of shoulders
accidental injuries in these areas are unusual
Concerns of non-accidental injury should be prompted by what?
- injuries on both sides of body
- injuries to soft tissues
- injuries with particular patterns
- any injury that does not fit explanation
- delays in presentation
- untreated injuries
If you have discussed a non-accidental injury concern with a manager, how quickly should you refer to social services by writing?
within 48 hours
What kind of complications do we review trauma patients for (primary teeth)?
- pulpal necrosis (most common)
- pulpal obliteration
- root resorption
- damage to successors
What should you look for when assessing for primary tooth pulpal necrosis?
- persistent grey colour that does not fade
- no reduction in size of pulp cavity
- radiographic signs of periapical inflammation
- clinical signs of infection - TTP, sinus, suppuration, swelling, symptoms, spacing around root
What are the 5 S’s of pulpal necrosis?
Sinus
Suppuration
Swelling
Symptoms
Spacing around root
What should you do if there are signs of primary tooth pulpal necrosis?
extract if radiographic signs of inflammation or clinical signs of infection
What should you look for when assessing a tooth for signs of primary tooth pulpal obliteration?
clinically, tooth may become yellow/opaque colour
radiographically, chamber will shrink
What should you do is a tooth has signs of primary tooth pulpal obliteration?
nothing if asymptomatic
extract if radiographic signs and/or clinical signs of infection/inflammation
What should you look for when assessing a tooth for primary tooth root resorption?
- radiographic signs of root resorption
- possible clinical mobility
What should you do when a primary tooth has signs of root resorption?
extract if signs of infection
At what age does the maximum damage to successor teeth occur following trauma?
before 3 years of age because the tooth germ is still in developmental stage
What kind of injury carries the highest risk of damaging successor teeth?
Intrusive luxation
What kind of damage can occur to successor teeth following trauma and at what stage?
- white/yellow-brown enamel hypomineralisation; 2-7yrs
- white/yellow-brown enamel hypomineralisation and circular enamel hypoplasia; 2-7yrs
- crown dilaceration; approx 2yrs
- odontoma-like malformation; 1-3yrs
- sequestration of permanent tooth germs
Damage to the root of successor teeth can cause what presentations and at what age can this sort of damage occur?
- root duplication; 2-5yrs
- root dilaceration; 2-5yrs
- arrest of root formation - partial/complete; 5-7yrs
What is root dilaceration?
- deviation of root shape from the normal long axis formation
- has the potential to inhibit eruption
What should you look for when assessing a successor tooth for signs of root dilaceration?
- radiographic signs of root malformation/change in angulation
- delayed eruption/failure of eruption
How do you treat root dilaceration?
- depends on severity
- treatment planning may involve orthodontic and oral surgery input
- e.g. ortho realignment or possibly extraction
What kind of complications can we see in successor teeth following trauma?
- pulp necrosis
- resorption
- ankylosis (replacement resorption)
- external resorption
- internal resorption
- discolouration
What should you look for when assessing a permanent tooth for signs of pulpal necrosis?
- no response to sensibility testing
- greyish discolouration
- symptoms and history
- radiographic/clinical signs of periradicular inflammation/infection. In cases of immature teeth, no further signs of root development
What is transient apical breakdown?
sequelae of certain dental traumatic injuries where the injured tissues undergo a spontaneous process of repair (revascularisation) with no permanent damage to the pulp.
Increased cellular activity around apex can result in small radiolucent “cap” appearing on the 1/12 and 2/12 periapical views.
If radiolucency is only sign of non-vitality it may be prudent to wait and watch
If starting RCT within 2 weeks of reimplanting an avulsed tooth, what should you NOT use as the dressing and why?
CaOH as it can contribute to replacement resorption
How do you treat a permanent tooth with signs of pulpal necrosis when the tooth has a closed apex?
same as for adult tooth, begin endodontic treatment
How do you treat a permanent tooth with signs of pulpal necrosis with an open apex?
- we have no further root formation so no apical stop
- need to create apical stop/barrier or find way of encouraging root development (e.g. regenerative endo technique?)
- MTA apical barrier formation or CaOH apical barrier formation (MTA better)
Why is MTA considered better than CaOH as an apical barrier?
CaOH found to have drying effect on dentine, can cause fracture
What is the regenerative endodontic technique?
- works on principle of activating stem cells to recreate dental pulp
- intention is to allow continued root growth
What are the disadvantages of using CaOH as an apical barrier?
- time consuming to get a result
- incomplete apical barrier formation with vascular inclusions may lead to bacterial invasions
- changes in composition/structure of dentine; higher incidence of cervical root fractures as a result
Why is MTA the preferred treatment of choice for apical barrier formation?
- reliable
- considered gold standard for apexification
- shorter time
- confirmed hard barrier
How do you endodontically treat a tooth with a root fracture in the apical or mid 1/3/
root apical to fracture usually retains vitality
- apical 1/3 and mid 1/3 root fractures = treat up to point of fracture, DO NOT extend beyond fracture into apical portion
- MTA apical stop may be required at fracture line
- if apical portion becomes non-vital, may require surgical removal
How do you endodontically treat a tooth with a coronal 1/3 root fracture?
treatment options complicated due to unfavourable crown root ratio.
Options; splinting the coronal segment, extracting the coronal and apical portion, extracting the coronal portion
What does permanent tooth pulp canal obliteration occur due to?
arises from reactionary dentine formation in root canal and pulp chamber, causing space to narrow
What is the radiographic appearance of pulpal obliteration?
pulp chamber and root canal shrinking
What are the clinical signs of pulpal obliteration?
tooth may darken (yellowing) and will have a reduced response to sensibility tests
How do you treat a permanent tooth with pulpal canal obliteration?
monitor, can be difficult to access/find canal
- only treat if radiographic/clinical signs of periapical inflammation/infection
How can pulp canal obliteration cause pulpal necrosis?
reactionary dentine encroaches over time, narrowing canal
blood supply can become insufficient, causing pulpal necrosis
What are the four types of resorption seen in permanent teeth?
- external inflammatory resorption
- cervical resorption
- internal resorption
- replacement resorption
What is inflammatory resorption?
- caused by multi-nuclear giant cells
- these are stimulated as part of the inflammatory response. Sustained stimulation causes these cells to resorb tooth structure
What is external inflammatory resorption?
- occurs with teeth that have necrotic pulps and associated infection
- in external resorption, giant cells are activated in PDL and stimulus is the infected canal
- resorption can be rapid
How is external inflammatory resorption diagnosed?
radiographic - change in external contour of root
clinically - if excessive resorption, may have mobility
If a tooth with external inflammatory resorption is deemed restorable, how is it treated?
- commence RCT, dress with CaOH and monitor
review radiographically
What is cervical resorption?
- caused by damage to cervical region, inflammation caused by PDL microflora or infected root canal
- rare
- diagnosed in early stages radiographically
How is cervical resorption treated?
- for necrotic pulps, RCT
- for both necrotic and vital teeth, treatment may involve curettage of apical region and resorption defect
What is internal inflammatory resorption and how does it present?
- infected necrotic pulp may activate underlying vital tissue, resulting in resorption process
- can be seen as ‘pink spot’ discolouration if resorption affects coronal 1/3 of canal
- radiographically, can present as round, symmetrical radiolucency usually centred on canal
How is internal inflammatory resorption treated?
RCT, often tooth may be very vascular, dress with CaOH
When can replacement resorption (ankylosis) often occur?
- following large luxation or avulsion injury
What happens in replacement resorption (ankylosis)?
when more than 20% of the PDL is damaged before replanting or repositioning of tooth, bone cells are able to colonise the surface of the root faster than the PDL. Tooth becomes integrated in the bone and subsequently remodelled in the normal bone remodelling process
What happens to the mobility of a tooth following replacement resorption (ankylosis)?
as root unifies with surrounding bone, it will no longer have biological mobility and will appear solid
What is the radiographic appearance of a tooth with replacement resorption (ankylosis)?
no distinct demarcation between bone and tooth radiographically (absence of PDL)
In what age of the population does replacement resorption (ankylosis) occur quickest?
younger individuals where remodelling occurs more rapidly
What can a brownish colouring of the dentine following a trauma be a result of?
products of pulpal necrosis may permeate tubules and stain surrounding dentine. Initially pinkish, this may turn brownish due to haemosiderin from oxidising haemoglobin (rust)
Does discolouration indicate necrosis?
discolouration does not mean that the pulp is irreversibly necrotic, the tooth may revascularise and the colour improve
Comment on the mobility of recently erupted teeth
recently erupted teeth are normally more mobile than teeth in adult dentitions
What are the three classifications of mobility?
Class I - <1mm horizontal
Class II - >1mm horizontal
Class III - >1mm horizontal and vertical mobility
How should you review a previously traumatised tooth radiographically?
- reproduce same views as initial assessment
- radiograph the unaffected contralateral tooth of the same type to compare
- look for continued root development (narrowing of pulp space, continued root growth in an apical direction)
- signs of ankylosis, resorption, root fracture
