Trauma 2 - (Root #) Flashcards
what is a root fracture?
This is where there is involvement of dentine, cementum and pulp involvement
What are traumatic root fractures?
Horizontal - most at an angle
What fractures can post crowns and restorative materials cause?
Vertical root fractures
How do we classify root fractures? 3
POSITION
DISPLACEMENT OF FRAGMENTS
STAGE OF ROOT DEVELOPMENT
What are the positions of root fragment?
apical 1/3
middle 1/3
coronal 1/3
What does displaced mean?
This means the fragments have been pushed apart
What does undisplayed mean?
Edges of fractured fragments are still together
What are the two stages of root development?
Mature - closed
Immature - open
What are apical root fractures?
fractures in apical 1/3 of tooth that can be difficult to see -
Prognosis of apical root fractures?
very good - especially if no displacement has occurred
if healing Is well then often fracture line can be undetecable
What is important with middle 3rd root fractures?
we must reduce the fracture as much as possible - GET BOTH HALVES TOUCHING AGAIN LIKE A JIGSAW
What is reduction?
when we get fragments to touch again or as close as
What is the prognosis of coronal 3rd root fractures?
Poor - very little PDL support to keep crown in position during function - eating etc
What is the issue with coronal 3rd root fractures?
Unfavourable crown:root ratio - crown is barely being held in - very mobile and will all out
How will teeth look with coronal 3rd root fractures?
They may look great but radiographs show the extend of how bad it is
What can fracture line look like on a radiograph sometimes?
occasionally looks like several fracture lines when break has occurred at an angle cutting across the beam - in reality only one fracture line
What does prognosis of fractured tooth depend on?
Age of child - immature or mature?
Degree of displacement - how well can we reduce teeth?
associated injuries? - has crown fractures too?
time between injury and tx - if we don’t reduce quickly then clot forms between two fragments making reduction v hard
What happens if we don’t do tooth fragment reduction quickly?
blood clot forms between two bits and reduction is much harder
What is the root fracture exam and investigations involve?
Clinical exam - trauma stamp
SIs:
- sensibility testing
- radiographs from two angles (2x pas from diff angles and maxillary occlusal)
What is the tx plan for a apical or middle third fracture which has displaced?
- clean area with water, saline or CHX
- Reposition tooth with digital pressure
- splint - flexible for 4 weeks
- review - 6-8wks, 6mths, 1 year, 5years
What does coronal third root fracture always need?
Flexible splint for 4 months
Do we require LA for reduction and splinting?N
Not always - depends on pt if in pain YES!
What advice do we give post reduction and splinting?
Soft diet for 1 week
no contact sports
good OH
How long is a splint placed for in middle and apical third fractures?
FLEXIBILE SPLINT 4 WEEKS
What are the healing outcomes following reduction?
- calcified tissue union across fracture line
- connective tissue healing
- calcified and ct healing
- bone and osseous healing
What is Calcified tissue union across fracture line
this is where the fracture is healing with dentine like material - will be v hard to see previous fracture line on second radiograph
What is connective tissue healing?
This is when the fracture line will always be obvious in radiographs
there is rounding off of edges as bone cells nibble away at edge of corners as they are sharp
What is eburnation?
o Rounding off edges – bone cells nibble away at edge of corners as they are sharp
What is bone and osseous healing?
This is when bony healing occurs - two diff segments become unique entities that aren’t associated with each other - we can trace the PDL between both parts
How do we tell how the fracture has repaired?
calcified tissue union - no fracture line
CT - eburnation (rounding off off of edges and fracture line still present)
bone and osseous healing - two separate entities
what are the chances of tooth becoming non vital?
20%
What do we do for a NV tooth with apical and middle third fracture lines?
we would extirpate pulp to fracture line
dress with non setting cash then MTA/biodetine to coronal fracture line
then GP fill to fracture line
What are the types of PDL injuries?
Concussion
Subluxation
Extrusion
Lateral Luxation
Intrusion
Avulsion
Dentoalveolar fractures
What is a concussion injury?
This is where there is an injury to tooth supporting structures WITHOUT inc mobility or displacement of the tooth
Pain to percussion
no gingival bleeding
No need to splint
What is a subluxation injury?
this is an injury to tooth supporting structures resulting in inc mobility and pain to percussion but NO displacement of tooth
Bleeding from gingival sulcus may be present
- inc mob, bleeding from gums
What can we provide for subluxation injury?
splint for 2 weeks but not needed - flexible splint (helps put pt at ease esp if in pain or if teeth move)
occlusal relief - if pt has a heavy bite we can remove part of tooth tissue or build up posterior teeth to take pressure off occlusion - prop dentition open with GI
When might we do occlusal relief?
If pt has heavy bite - can help relieve pain
What is the review process fro subluxation?
4 weeks
6-8 weeks
1 year
Compare concussion and subluxation
Concussion - no displacement, no bleeding, no inc mobility but TTP, no need to splint, subluxation is where there is no displacement, inc mobility, gingival bleeding, ttp and requires 2-4 week flexible splint (2 weeks, 4 weeks, 6-8 weeks, 1 year review period)
What is advice for any lunation injuries?
Soft diet for a week
OHI, gentle brushing
How do we monitor concussion subluxations?
Clinical test - trauma sticker
Sensibility testing - at time of injury and at reviews
radiographs - look at root development - width and length of canal, compare with other side, can compare to see if continued growth
What is 5 year pulp; survival in concussion? subluxation?
open - 100%
closed - 95%
open - 100%
closed - 85%
What is 5 year resorption in concussion? subluxation?
open - 1%
closed - 3%
open - 1%
closed - 3%
What is extrusion?
This is an injury to the tooth with partial or total separation of the PDL resulting in loosening and displacement of the tooth
alveolar socket remains in tact
axial displacement and some protrusive or recursive orientation
pdl torn so tooth hangs lower
wide pal space in radiograph- tooth isn’t where it should be
What do we see on radiographs for extrusion?
We see a wide PDL space as the tooth isn’t where it should be
How do we tx an extruded perm tooth?
reposition it under LA which has ben given buccal and palatally
flexible splint for 2 weeks
How often do we review extrusion injuries?
4 weeks, 6-8wks, 6 months, yearly for 5 years
What is the 5 year plural survival for extrusion?
Open - 95%
closed - 45%
What is 5 yr resorption rates for extrusion?
open - 5%
closed - 7%
What is a lateral lunation injury?
This is displacement of tooth other than up or down - its accompanied by communication or fracture of either labial or palatal/lingual bone
pal suffers both tear and crush injuries
What happens to PDL in lateral luxation injury?
it is CRUSHED AND TORN!!
The pal is torn where tooth moves away and crushed on other side of alveolar plate
How do we tx lateral lunation?
Reposition under LA admin buccally and palatally
flexible splint for 4 week
How often do we review lateral lunation?
clinical and radiographic review at 4, 6-8 weeks, 6 months, and yearly for 5 years
What is an intrusion injury?
This is when tooth is driven into alveolar process due to axially directed impact - most severe displacement injury
crush injury to pal - all pdl crushed into bone as tooth is forced straight up
When are intrusion injuries more likely?
teeth with fully developed roots
What is there a high risk of in intrusion injuries?
Resorption - end tx often needed with closed apex teeth - use an interim calcium hydroxide dressing
How do we tx intrusion?
Radiograph then must identify if open or closed apex and then we decide how severely intruded the tooth is - measure incised edge of undamaged tooth to compare (can draw and put picture in notes for memory)
How do we manage an intrusion of up to 7mm in open apex teeth?
monitor tooth to see what happens but if more than 7m then rapid ortho or surgical tx
When would we monitor for spontaneous eruption in closed apex intruded teeth?
up to 3mm, after 3mm-7mm we look at ortho extrusion and more than 7mm we do a surgical
If closed apex tooth is intruded 3-7mm what do we do?
ortho extrusion
If closed apex tooth is intruded more than 7mm what do we do?
surgical
How does ortho tx of intrusion work?
we place ortho bracket on tooth and fix ortho elastic around the arch wire and bracket for traction to extrude
How does surgical tx of intrusion work?
Take forceps and reposition tooth gently
then apply flexible splint for 4 weeks and begin review process
When do we allow spontaneous repositioning to occur?
Open apex up to 7mm
closed apex up to 3mm
What do we do for spontaneous repositioning?
We give pt diet and OH advice
Review monthly to observe re-eruption and ensure progress against fixed point (adjacent tooth) - draw picture
When do we use ortho for tx of intrusion?
+7mm for open apex or 3-7mm for closed apex
When do we use surgical tx for intrusion?
> 7mm for open apex or >7mm for closed apex
What are the review procedures for intruded teeth?
2 weeks, 4 weeks splint removal, 6-8 weeks, 6 months, 1 year then yearly for 5 years
What is 5 year pulp survival for intrusion injuries?
Open - 40%
closed - 0%
What are the 5 year resorption rates for intrusion injuries?
Open - 67%
closed -100%
What are the follow ups for intrusion?
Endo tx wil be needed in closed apex teeth to prevent necrotic pulp from initiating infection related root resorption
When should we consider end for intrusion injuries?
in all cases with completed root formation where chance of pulp revascularising is low
