Trauma 3 (Avulsions) Flashcards
What is avulsion?
tooth comes out socket
separation of pdl
exposure of root surface
What is the most important thing with avulsion?
Reimplantation into socket asap
When can successful healing occur in avulsion injuries?
If there is minimal damage to pulp and PDL
What are 3 critical factors in avulsion?
Extra-alveolar dry time (EADT)
Extra alveolar time (EAT)
type of storage medium
What is EADT?
Extra-alveolar dry time (EADT)
this is how long tooth is out mouth in air (on ground, on table, in hands etc)
What is EAT?
Extra alveolar time
this is how long tooth is out the mouth dry and then placed into storage medium
What is the type of storage medium?
This is what is used to transfer tooth to us - affects prognosis
What do we do if pt attends with tooth reimplanted?
leave it as is!! however if lots of debris then we may need to remove and clean any big parts of debris
take radiographs to establish open or closed apex
What advice to we give to emergency phone calls?
Find out what tooth has avulsed and if pt has any med conditions
HOLD TOOTH BY CROWN NOT ROOT (PART YOU NORMALLY SEE NOT BIT INSIDE THE GUMS)
IF ANY OBVIOUS DEBRIS THEN TURN UR COLD TAP ON FOR A FEW SECONDS THEN RUN TOOTH ROOT UNDER IT FOR MAXIMUM OF 10 SECONDS TO REMOVE ANY BIG DEBRIS
PLACE TOOTH BACK INTO SOCKET AND BITE ON TISSUE
IF ABOVE CANT BE DONE THEN PUT INTO STORAGE MEDIUM - MILK, SALIVA, BLOOD, SALINE
THEN GET TO US ASAP
What is the initial reimplantation decision based on?
we want to know if eadt is < or > than 30 mins
we have diff tx depending on how long its out mouth for
What are the healing outcomes periodontally for avulsion?
regeneration
PDL/Cemental healing
bony healing
uncontrolled healing
What is periodontal regeneration?
This occurs if tooth is put back in socket
When does cement/pdl healing occur?
This occurs if tooth isn’t put back in asap
What is bony healing?
This is when bone is fused right up to the tooth and resorption starts
What is uncontrolled healing?
this is when there is no healing, granulation tissue, infection and abscesses
What are some plural healing outcomes following avulsion?
Regeneration
Controlled necrosis - elective disinfection
Uncontrolled infection
What is the best plural outcome in avulsion injuries?
Regeneration
occurs more in open apex teeth - wider, lots of nerves and bvs compared to closed apex with less nerves and bvs
What is controlled necrosis?
This is when we know from studies that tooth will become nerrotic so we elect for end tx before death of tooth and initiation of infection
What is uncontrolled infection?
Pulp goes necrotic and will need end or xla
What if the EAT < 60 mins?
Then there is a chance of cement/pdl healing
we would reimplant tooth under la
flexible splint for 2 weeks
consider antibiotics and tetanus
When would we extirpate pulp when eat<60 mins
Day 0-10 unless open apex which has chance to revascularise so we can monitor for this
What is the eat <60 mins in immature teeth with open apex?
We can decide to not root treat and instead monitor tooth clinically and radiographically for signs of continued growth or signs of loss of vitality
we can tell fast if revascularisation has occurred - radiographs to compare with adjacent tooth for root dev signs
How often do we review avulsed teeth where eat<60 mins and immature teeth?
2 weeks, to remove splint, 4 weeks, 2 months, 6 months, yearly
if nv pulp then extirpate pulp and refer
What if EAT<60 mins in mature teeth
Replant tooth into socket and splint for two weeks
we want to remove pulp- (day 0-10 if needed)
extirpate pulp and disinfect then place antibiotic steroid past as intra canal medicament - leave in for 2 weeks
then clean and replace with non setting calcium hydroxide
obturate gp with 4-6 weeks (max time for calcium hydroxide)
refer
What is EAT>60 mins and closed apex?
PDL healing unlikely - we aim for bony healing by ankylosis so need to ensure we scrub out clean of dead pdl cells
When we do end tx in closed apex tooth with eat>60 mins what can we do?
can do out the mouth extra oral ends prior to reimplantation
then we splint for 4 weeks with flexible splint
antibiotics and tetanus consideration
if we don’t do extra oral ends then extirpate at 7-10 days and use non setting calcium hydroxide as intra canal medicament for 4 weeks before gp obturation
What do we do when eat>60 mins and open apex?
We won’t likely get pdl healing - only tiny chance of revascularation
BUT DONT ROOT TREAT UNLESS SIGNS OF LOSS OF VITALITY ON FOLLOW UP APPT
Splint flexible.4 weeks
review - 2 weeks, 4 weeks for splint removal, 8 weeks, 3mths, 6 months, yearly to monitor closely for necrosis signs v continued root development
When do we not reimplant a tooth?
Almost never however if very immature apex and EAT>90mins then we are starting to reach borderline limits
if pt is immunocompromised - cancer, cardiac problems
if child has other serious injuries that require preferential tx or icu admittance
Why may we not reimplant immature lower incisors?
they tend to only last 6 months - people won’t notice and the space will close however reimplant upper teeth to act as a space maintainer to guide position of adjacent erupting tooth
How do we monitor avulsion injuries?
OPEN APEX - CLOSE MONITORING FOR SIGNS OF LOSS OF VITALITY
if plural necrosis occur then we must extirpate pulp to avoid inflammation response
clinical tests - trauma stamp
sensibility tests - thermal and electric (1 math, 2mnth, 3 math, 6mth, yearly)
radiographs - compare root canal with and length
How do we do pulpetctomy on open apexed teeth?
extirpate pulp
place caoh for 4-6 weeks maximum
mta plug - 2mm from apex, 5-6mm
then heated gp backfilled because cones won’t fit wide canal
What do we use a 2 week flexible splint for?
Subluxation
Avulsion - open and closed apex with EAT <60 mins
Extrusion
What do we use a 4 week flexible splint for?
Luxation
Avulsion - open and closed apex >60 mins EAT >60
Apical, middle and 1/3 root fractures
Intrusion
Dento-alveolar fractures
What gauge of SS do we use for flexible splint?
0.3mm SS adapted and moulded to shape
Where does flexible splint lie?
It is placed on one abutment tooth either side of the trauma tooth for 2 weeks (or 4 in certain cases)
What else can we use as a splint?
Vacuum formed splint - gum shield splint but OH is poor (can also use Essex retainer) - pts also don’t like taking it in and out as they worry about tooth movement
Ortho brackets and wire - must be PASSIVE because if active then teeth will move
Acrylic URA type splint - useful when few abutment teeth but not first choice as composite is
Foil temporary splint cemented with kalzinol - old fashioned
Describe the splinting procedure
- cut 0.3mm SS round wire and bend around counter of teeth to ensure passive when in place
- cut wire to size
- acid etch teeth for 10 seconds then apply bond
- dry teeth - enamel will appear forsted
- apply bond and light cure
- apply comp resin to labial surfaces and position the wire then cure trauma tooth and adjacent teeth
- keep away from gingival margin and take flat plastic and mould comp around the wire and cure
- polish down any sharp wire edges and rough composite - keep wire away from gingivae to ensure good OH
- Leave splint for 2-4 weeks depending on injury
What is a dento-alveolar fracture?
Displacement of teeth in socket - mobility but not individual teeth
damage to alveolar bone which holds teeth in
happens in blocks of 3-4 teeth or more
What do dento-alveolar fractures happen in?
Blocks of 3-4 teeth
How do we treat dent-alveaolr fractures?
We need to put fracture back into place and then splint for 4 weeks
How do we treat dentoalvelar fractures? - procedure
LA
Reduce fracture to correct position (sometimes bone can get wedged and affect reduction so LA allows us to lift up over bit of bone and put the fracture back into place
splint for 4 weeks
How do we monitor dentoalveolar fractures?
clinically and radiographically
check for root development - canal width and length comp to unaffected tooth
check for signs of inflammatory response
follow up - 2wks, 4 weeks, 7-8weeks, 4 myths, 6 myths, yearly for 5 years
What is the follow up review procedure for dentoalveolar fractures?
2 weeks 4 weeks 7-8 weeks 4 months 6 months yearly for 5 years
What is the risk of pulpal necrosis?
50% at 5 years
What is the advice for pts with dental injuries?
Soft diet for 7 days
avoid contact sports whilst splint in place
careful ahi
use of chlorohexidine gluconate mouthwash 0.1%
