Trauma Flashcards
Which type of injury has the worst prognosis for pulpal healing?
intrusion and avulsion
in what type of tooth can apexogenesis occur?
An immature VITAL tooth
What is the most common type of injury in the primary dentition?
luxations
What types of injuries to the periodontal tissues can occur?
Concussion
subluxation
intrisive luxation
lateral luxation
extrusive luxation
avulsion
What types of injury can you get to the gingivae or oral mucosa?
laceration
contusion
abrasion
degloving
What different treatments can be performed to allow apexogenesis?
Cvek pulpotomy
Cervical pulpotomy - remove the coronal pulp
What questions would you ask about a child that has suffered from dental trauma?
Do a brief accurate medical history (allergies, bleeding disorders, immunisation status)
What, where, when, how, who
LOC?
Signs of head injuries or other body injuries?
How would you treat this type of fracture?
Radiographic assessment of tooth - PA if possible, if not an alternative
If there is no pulp involvement you would do the following:
- Remove the mobile fragment and clean the area both with the triple spray and a little sodium hypocholorite
- suture any lacerations if present
- Apply GIC or composite over the exposed dentine.
- Either temporise with GIC, monitor and then build with composite or straight to composite
What treatment would you do for a tooth with a root fracture?
1. Rinse exposed root surface with saline before repositioning.
If displaced, reposition the coronal segment of the tooth as soon as possible.
Check that correct position has been reached radiographically.
- Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth stabilization is benificial for a longer period of time (up to 4 months).
3. Monitor healing for at least 1 year to determine pulpal status.If pulp necrosis develops, then root canal treatment of the coronal tooth segment to the fracture line is indicated.
What is this?
Intrusion/intrusive luxation
Displacement of the tooth into the alveolar bone, accompanied by fracture of the alveolar socket
What is contusion?
**Bruise - **there is no break in the mucosa, usually from a blunt object
What types of injury can you get to the supporting bone?
Communation of the socket wall
fracture of the socket wall
fracture of the alveolar process
fracture of the maxilla/mandible
What type of injury is this and what structures are involved?
Complicated crown fracture - enamel, dentine and pulp involved
What is the treatment for this type of injury?
No treatment is necessary
Adivce a soft diet and good OH. Can topically apply 01% chlorhexidine to the area. Follow up after a week and then 2 months
What is this type of injury?
Lateral luxation. The tooth is displaced other than axially.
There is associated fracture of the palatal/lingual alveolar bone
What are the treatment options for this type of trauma, if the tooth had a closed apex and the tooth was re-implanted by the patient?
if the tooth was re-implanted prior to arrival for treatment - leave the tooth in place and clean around the tooth (0.1% chlorhexidine, saline) and suture any lacerations. Verify the normal position of the tooth both clincally and radiographically.
Splint for 1-2 weeks and prescribe systemic antibiotics (tetracycline for adults and penicillin v for children)
Begin RCT after 7-10 days following reimplantation and before splint removal
What type of Injury is this?
Complicated crown-root fracture with pulp involement
What is enamel hypomineralisation?
Disturbance of the maturation phase of amelogenesis. White/cream/brown reas of the tooth which are softer then enamel. You are likely to get post eruptive breakdown and is a process that occures after eruption
What treatment options are there for an enamel-dentine fracture?
If you can take a PA radiograph/alternative to rule out a root fracture
if fragment is available, it can be bonded onto the tooth
provisional treatment - GIC
permanent treatment - composite
Define apexogenesis
The stimulation of the formation of a closed apex of a tooth following trauma. The pulp is healthy.
How would you treat a complicated crown fracture?
If there is no displacement of the tooth, direct pulp capping or a pulpotomy.
Partial pulpotomy are usually preferred due to a better prognosis
Older patients with closed apicies and an associated luxation injury - RCT is the treatment of choice
At what age will damage to the primary tooth cause **HYPOMINERALISATION **of the secondary tooth?
After the age of 4
What are the classifications of dento-alveolar injuries?
Dental hard tissues and the pulp
periodontal tissues
supporting bone
gingiva or oral mucosa
What type of injury is this?
Enamel fracture - fracture is confined to the enamel only
What would you do it a patient presented with an avulsed tooth with an open apex?
**REIMPLANTED BEFORE ATTENDANCE - **Clean area, suture any lacerations, prescribe systemic antibiotics and apply flexible splint. Monitor the tooth and hope for revascularisation
Clean the socket and tooth with saline. Topical antibiotics is thought to help with the revascularisation process. Then do as above
**>60mins outside the mouth - **poor prognosis. can perform rct before reimplantation or after
Define apexification
induced rppt development or apical closure by hard tissue deposition
Apexification establishes a calcific barrier to facilitate endodontic obturation
How could you treat an ankylosed tooth?
Decoronation of the residual root to minimise futher bone loss and allow for aesthetic replacement - either removable or fixed
What complications can arise due to delayed reimplantation?
Ankylosis
What are the treatment options for an avulsed tooth with a closed apex that has not been re-implanted prior to the appointment?
- LA, clean the socket and tooth with saline, reimplant the tooth, clean the area again (0.1% chlorhexidine), suture any lacerations, splint the tooth for 2 weeks and prescribe systemic antibiotics (tetracylcine or penicillin if
**>60 mins - **delayed reimplantation has a poor prognosis. You can rct the tooth before reimplantation. Re-implant the tooth and do as above but splint for 4 weeks
What are the treatment options for extrusion?
minor extrusion (- either wait for spontaneous alignement or reposition tooth
severe extrusion - extract
Advise a soft diet for 1 week and good OH. chlorhexidine 0.1% can be applied to the area.
Follow up
Advise parents to look out for changes in the tooth e.g colour, sinus formation etc.
What is a degloving injury?
It is a type of avulsion. An extensive section of skin is completely torn off the underlying tissue, severing its blood supply.
What type of diplacement leads to greater risk of damage to the permanent successor?
Palatal displacement of the tooth apex
What is meant by laceration?
A shallow or deep wound in the mucosa, resulting from a tear, usually from a sharp object
What is pulp canal obliteration?
The loss of the pulpal canal due to intense dentine deposisition as a response to severe injury of the neurovascular supply of the tooth
PARTIAL - mainly affects the pulp chamber
**TOTAL - ** affecting the pulp chamber and root canal
What occurs in lateral luxation?
Displacement of the tooth other than axailly
fracture of the labial or the palatal/lingual alveolar bone
if the apex of the displaced tooth is inclined palatally or lingually there can be damage to the permanent successor
Partial/ total separtation of the PDL ligaments
Non mobile with a high metallic or ankylotic sound on percussion
What is meant an abrasion injury to the mucosa?
Superficial wound produced by rubbing/scraping. Raw
How would you perform non-vital bleaching?
The tooth if non vital will be discoloured grey
you would access the pulp chamber, etch the pulp chamber and add sodium perborate. You would do this on multiple visits.
Which factors could predispose a child to dental trauma?
- Class 2 div 1 malocclusion - the greater the overjet, the greater the frequency of trauma (3-6mm x2, >6mm x3)
- Mental and physical impairments - epilepsry, autism
- lots of contact sports
- accident prone children
What is the incidence of trauma to the permanent maxiallry incisors at 8 and 15 years?
8 years - 5%
15 year - 13%
Which types of root fracture have the worst prognosis?
coronal 1/3 root fractures
What is subluxation?
Injury to the tooth supporting structure with increased mobility but no displacement.
There is bleeding at the gingival sulcus shortly after the incident and the tooth is TTP
Initial sensibility testing may be negative showing transient pulpal damage - monitor
What type of fracture is this?
Root fracture
Which type of injuries are associated with developmental disturbances of the dentition?
**Avulsions - **delayed eruption of permanent successors
Intrusuions
What are the treatment options of avulsion of a primary tooth?
**DO NOT REPLANT AN AVULSED PRIMARY TOOTH **
advise a soft diet and good oral hygiene
What is this?
Extrusion injury
Which types of injury are likely to lead to pulpal necrosis?
avulsions
intrusions
lateral luxations
extrusions
due to severe damage of the neurovascular bundle of the injured tooth
What treatment options are there for an enamel fracture?
Take a PA to rule out any root fracture
tx - composite resin, or if the enamel fragment has been retained, stick that on
What are the treatment options for this type of injury?
- Spontaneous repositioning if the apex is displaced towards the labial bone plate
- If the apex is displaced towards the developing tooth germ - extract
soft diet for a couple of weeks with good OH, use of 0.1% chlorhexidine
What would you advise a patient who has avulsed their tooth to do?
- Pick up the tooth by the crown and avoid touching the root
- If the tooth is dirty, briefly wash under cold water for 10 secs, and try to get the patient to re-implant the tooth
- If the patient doesnt want to reimplant the tooth, keep in a suitable storage medium like cold milk/saline. If the patient is able to, they could also keep the tooth in the mouth in the sulcus adjacent to the molars
What types of injuries can occur to the dental hard tissues and the pulp?
Infraction
uncomplicated enamel fracture (enamel fracture/enamel dentine fracture)
complicated enamel fracture
crown-root fracture (complicated and uncomplicated)
root fracture
What is enamel hypoplasia?
Disturbance in the secretion phase of amelogenesis. Defects in the form of the tooth, not the quility. presents as pits and grooves. severe- considerable portion of the enamel may be missing
Can present as a neonatal line/ring
What type of fracture is this?
crown-root fracture without pulp involvement
Which gender are more likely to suffer from dental trauma?
Males
Which factors influence pulpal healing?
- Initial pulp status
- status of the apex - open/closed (open more likely to lead to survival/obliteration)
- time since injury. longer –> NECROSIS
- Concurrent injuries (PDL damage –> necrosis)
What injury is this?
Alveolar fracture
A fracture of the alveolar process may or may not involve the alveolar socket
There is severance of the neurovascular supply, and PDL ligament
There is mobility of the alveolar process and several teeth with often move as a unit. Occlusion is usually affected
What extra-oral features would you look for?
Trauma to other body sights
facial assymetry
palpitation of facial skeleton
facial injuries
What is the treament for this type of injury?
Need radiographic assessment
Fragment removal and gingivectomy (sometimes ostectomy)
Removal of coronal fragment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy and sometimes ostectomy with osteoplasty. This treatment option is only indicated in crown-root fractures with palatal subgingival extension.
Orthodontic extrusion of apical fragment
Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown.
Surgical extrusion
Removal of the mobile fractured fragment with subsequent repositioning of the root in a more coronal position. A rotation of the root (90 or 180) may offter a better position for periodontal ligament healing. Because the fracture site becomes exposed labially and thereby more periodontal ligament can be saved
Decoronation (Root submergence)
An implant solution is planned, the root fragment may be left in situ after decoronation in order to avoid alveolar resorption maintaining the volume of the alveolar process for later optimal implant installation
.
Extraction
Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable in very deep crown-root fractures, the extreme being a vertical fracture.
What is the most common type of injury to permanent teeth?
Enamel Fractures
What type of injury is this?
Enamel-dentine fracture
What special investigtions would you carry out?
Colour
Mobility
Percussion
Sensibility testing
radiograph
What are the clinical features of intrusion of a primary tooth?
The tooth is non mobile and there is a high metallic ankylotic sound on percussion
How would you treat an alveolar fracture?
- LA
- Manual repositioning using finger pressure labially and lingually to reposition the displaced segment
- clean the area with saline/chlorhexidine. Suture any lacerations if present
- splint stabilisation for 4 weeks
- Follow up after 4 weeks with splint removal and radiograph
What are the different types of peridontal healing by external resorption?
**surface - ** repair related
**inflammatory - **closed apex, necrotic pulp due to significant injury. Rx extirpirate the pulp
**replacement - **ankylosis due to PDL cell death. Progressive. no treatment is really successful
On what type of tooth can apexification be carried out?
An immature **non-vital **tooth
What are the potential indicators of non-accidental injury?
bruising to soft tissues not overlying boney prominances
delayed presentation
stories dont add up
injuries at different ages
injuries take a shape of a recognisable object
injuries at infancy/neonate
What are the different suitable storage mediums for an avlused tooth?
cold fresh milk
normal saline
saliva
How could you record your findings?
Trauma grid
radiographic report
clinical photographs
draw diagrams
What intra-oral features would you look for?
soft tissues - bruising, laceration, bleedin, degloving
teeth - missing? trauma? mobility?
occlusion
What is concussion?
An injury to the tooth supporting structures, without increasing mobility or displacement - the tooth is often TTP
Normal PDL space and no abnormal radiographic changes
NO TREATMENT REQUIRED
Below what age can damage to the primary dentition, cause **HYPOPLASIA **of the secondary teeth?
Below the age of 4, as the permanent tooth will be in the early stage of development
What would you use to perform vital bleaching?
10% carbamide peroxide (7% urea and 3% hydrogen peroxide)
eg Opalesence
White and Bright
Rembrandt
What is the definition of extrusion?
Partial displacement of the tooth out of its socket due to partial or total separation of the PDL
There is increased mobility and the occlusion is altered
Radiographically there is an increase in PDL space apically
What are the treatment options for this type of injury?
Extraction if severe displacement or interference with the permanent successor
spontaneous repositioning if no occlusal interference and not affecting the permanent successor
soft diet, advise parents to look out for changes in colour, sinus formation etc.
follow up 1 week, 2 weeks, 2 months, 1 year
