Trauma Flashcards
What is the most common injury in primary dentition
luxation
What are the most common injury in permanent dentition
crown fractures, particularly enamel-dentine fractures
What age is the peak period of damage to permanent dentition and why is this significant
between ages 7 and 10
significant because the teeth are immature
What can cause dental trauma
- large overjet
- falls
- bike, skateboard,
- sport
- fights
what four things are important when taking a detailed history on dental trauma
- how did it happen?
- when exactly did it happen?
- where are the lost teeth/ fragments?
- are there any other symptoms?
what aspects of medical history may influence treatment options
- rheumatic fever
- congenital heart defects
- immunosuppression
(not contradictions, but need to be given additional support/treatment)
What do you look for when doing an extra-oral examination after dental trauma
- lacerations
- haematomas
- haemorrhage/ CSF
- Subconjunctival haemorrhage - common in trauma (blood vessel of eye)
- bony step deformities
- mouth opening (rule out facial and jaw fractures)
what do you look for when doing an intra-oral examination after dental trauma
- soft tissues injury
- look for alveolar bone displacement
- occlusion
- teeth
- foreign bodies (soft tissue radiograph)
What could tooth mobility indicate?
- root fracture
- bone fracture
- displacement of the tooth within the socket
What would you use for a sensibility test and how would you
- Thermal: ethyl chloride or warm gutta-percha
- Electrical: electric pulp tester (EPT)
- compare injured tooth with adjacent non injured tooth
- test adjacent teeth and opposing teeth (would have received direct or indirect concussive injuries)
- conduct sensibility tests for 2 years post injury
How can percussion tests help diagnose trauma
- a duller note may indicate a root fracture
What is traumatic occlusion
- when patients cant get teeth back together normally
what is an uncomplicated fracture
- enamel fracture
- not involving pulp
what is a complicated fracture
- one involving the pulp
- enamel-dentine fracture
- enamel-dentine-pulp fracture
what does the prognosis of a tooth depend on after dental trauma
- presence of infection (infection present, prognosis is not great)
- stage of root development
- type of injury
- if the PDL is also damaged
- time between injury and treatment
Describe the initial emergency treatment outline
- aim to retain vitality of any damaged or displaced tooth by protecting esposed dentine by an adhesive ‘dentine bandage’
- treat exposed pulp tissue
- reduction and immobilisation of displaced teeth
- tetanus prophylaxis
- antibiotics
describe the intermediate treatment outline
- does the pulp require treatment
- is a minimally invasive restoration an option, e.g. acid etch restoration
describe long term treatment considerations
- will the tooth achieve apexigenesis (normal biological process of tooth maturation)
- Do we need to do apexification? provide an apex to the tooth
- root filling
- coronal restoration
- gingival and alveolar collar
how do you manage an enamel fracture?
- either bond fragment to tooth or simply grind sharp edges or put some composite on it
- Take 2 periodical radiographs to rule out root fracture or lunation
- Follow up 6-8 weeks, 6 months and 1 year
What is the prognosis of an enamel fracture
- 0% risk of pulp
how do you manage an enamel-dentine fracture?
- Account for the fragment
- Either - bond fragment to tooth or place composite bandage. Line the restoration if the fracture is close to pulp
- Take 2 periodical radiographs to rule out root fracture of luxation
- radiograph any lip or cheek lacerations to rule out embedded fragment
- Sensibility testing and evaluate tooth maturity
- Definitive restoration
- Follow up 6-8 weeks, 6 months and 1 year
what is the prognosis of an enamel-dentine fracture
5% risk of pulp necrosis at ten years
At follow ups of an enamel-dentine fracture, what should you check radiographs for ?
- root development > check width of the canal and length
- comparison with other side
- internal and external inflammatory resorption
- periapical pathology
how do you manage Enamel-dentine-pulp fractures
- Evaluate exposure
- size of pulp exposure
- time since injury
- associated PDL injuries - Choose from following options
- direct pulp cap
- partial pulpotomy
- full coronal pulpotomy
When would you use a direct pulp cap
- an enamel dentine pulp fracture
- a pulp exposure of <1mm in size AND <24 hours old
How would you carry out a direct pulp cap?
- Trauma sticker and radiographic assessment (should be non-TTP and positive to sensibility tests)
- use LA and rubber dam
- Clean area with water and then disinfect with sodium hypochlorite
- Apply calcium hydroxide (dycal) or MTA white to pulp exposure
- restore tooth
- review 6-8 weeks, 6 months and 1 year
when do you carry out a Cvek pulpotomy (partial pulpotomy)?
pulp exposure of >1 mm or 24 hours + since trauma occurred
How do you carry out a Partial pulpotomy (Cvek pulpotomy)
- Trauma sticker and radiographic assessment
- Use LA and rubber dam
- Clean area with saline then disinfect area with sodium hypochlorite
- Remove 2-3mm of pulp with hi-speed, round diamond bur
- Place saline soaked cotton wool pellet over exposure until haemostasis is achieved (if no bleeding or cant arrest bleeding proceed to full coronal pulpotomy)
- Apply CaOH and then GI (or white MTA) then restore with composite)
How do you carry out a full coronal pulpotomy
- begin with partial pulpotomy
- assess for haemostats after application of saline soaked cotton wool
- if hyperaemic or necrotic proceed to remove all coronal pulp
- place calcium hydroxide in the pulp chamber
- seal with GIC lining and coronal restoration
What is the aim of a pulpotomy ?
- to keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of root and thickness of dentine
What do you do if a tooth is non-vital
a full pulpectomy
What is the clinical problem with root canal treatment in paediatrics
there is no apical stop to allow obturation with gutta percha
What are the options for a pulpectomy in paediatrics?
- CaOH place in canal aiming to induce hard tissue barrier to form apexification (not great)
- MTA/BioDentine placed at the apex of the canal to create a cement barrier (best option, allows a barrier to be created straight away)
- Regenerative endodontic technique to encourage hard tissue formation at the apex (still experimental)
how do you carry out a pulpectomy
- rubber dam
- access
- Diagnostic radiograph for working length
- file 2mm short of estimated WL
- Dry canal, non setting CaOH and CW in pulp chamber
- Glass ionomer temporary cement in access cavity and evaluate CaOH fill level with a radiograph
- Extirpate pulp and place CaOH for no longer than 4-6 weeks after tooth identified as non vital
- fill apical area with MTA plug and fill rest of canal with heated GP
what are the treatment options for a crown-root fracture with no pulp exposure
- fragment removal only and restore
- fragment removal and gingivectomy - indicated in crown-root fractures with palatal subgingival extension
- orthodontic extrusion to gain access to supragingival margins
- surgical extrusion - if affected tooth position, loosening off PDL moving tooth down and holding in place
- decoronation preserve bone for future implant
- extraction
what are the treatment options for a crown-root fracture with pulp exposure
- can be temporised with composite for up to 2 weeks
- fragment removal and gingivectomy - indicated in crown-root fractures with palatal subgingival extension
- orthodontic extrusion to gain access to supragingival margins (may require endodontic treatment after orthodontic extrusion and consideration of a post retained crown)
- surgical extrusion
- decoronation to preserve bone
- extractio
what is a root fracture
a root fracture is a dentine and cementum fracture involving the pulp
what root fracture has the best prognosis
apical root fracture
- best prognosis if no displacement has occurred
- if heals well, fracture line may become undetectable in future radiographs
what is important when treating a middle root fracture
important to reduce fracture as much as possible (get both halves touching)
What is the prognosis of a coronal fracture
very poor prognosis as very little PDL support to keep the crown in position during function
What does the prognosis of a root-fracture depend on
- age of child; mature or immature tooth
- degree of displacement
- associated injuries e.g. crown fractures
- time between injury and treatment
- presence of infection
How do you investigate a root fracture
clinical exam - use trauma stamp
special investigations
- sensibility tests
- radiographs from at least two angles (e.g. 2 x periodicals from different angles and 1 x maxillary occlusal)
How do you treat an apical or middle root fracture
- clean area with saline/ water/ chlorhexidine
- Reposition tooth with digital pressure
- Splint: flexible splint for 4 weeks
- Review 6-8 weeks, 6 months, 1 year and 5 years with radiographs
- Soft diet for 1 week and good oral hygiene
How do you treat a coronal root fracture
Same as apical and middle except splint for 4 MONTHS instead of 4 weeks
What are the possible healing outcomes after root fracture treatment
- calcified tissue union across the fracture line
- connective tissue
- calcified and connective tissue
- bone/osseous
what are the possible non-healing outcomes following root fracture treatment
- granulation tissue (usually associated with los of vitality)
- radiolucent area seen on radiograph surrounding the fracture line
What does calcified tissue healing in root fracture treatment look like
hard tissue healing, healed with a dentine-like material
What does connective tissue healing in root fracture treatment look like
fracture lines will remain visible but the edges of the fracture show signs of eburnation (rounding off of sharp edges)
what does osseous (bony) healing in root fracture treatment look like
separate parts of the root become discrete entities with no connection and each part has its own distinct PDL sa
what are the chances of pulp necrosis if a tooth has a root fracture
20%
How do you treat non vital apical and middle root fractures
- extirpate to the fracture line
- Dress ns CaOH then MTA just coronal to fracture line
GP root fill
what happens to the apical fragment of the root after root canal treatment of a root fractured tooth
- remain in situ with its own PDL
- resorb
- if infected, give antibiotics or an apicectomy
What is a concussion injury
a concussion injury is injury to the tooth supporting structures without increased mobility, displacement of the tooth or gingival bleeding but with pain on percussion
what is a subluxation injury
a traumatic injury to the periodontal tissues leading to increased mobility but no displacement. Gingival bleeding is often detected
how do you treat a concussion injury
- do nothing
- follow up 4 weeks, 6-8 weeks and 1 year post trauma
how do you treat a subluxation injury
- 2 weeks flexible splint if needed
- follow up at 2 weeks, 4 weeks, 6-8 weeks and 1 year post trauma
What advice do you give patients with a luxation injury
- OHI
- with chlorhexidine gluconate and brush gently
- avoid all contact sport
How do you monitor concussion and subluxation injuries
- clinical tests: trauma sticker
- sensibility tests: thermal and electrical (do at time of injury and on checkups as transient lack of sensibility can occur)
- radiographs - look at root development (width and length of canal), comparison to other side and check for internal and external inflammatory resorption
what are the 5 year pulpal survival figures for a concussion injury with an open apex and a closed apex
open apex: 100%
closed apex: 95%
what are the 5 year plural survival figures for a subluxation injury with an open apex and a closed apex
open apex: 100%
closed apex: 85%
what are the 5 year chances of resorption for a concussion injury with an open apex and a closed apex?
open apex: 1%
closed apex: 3%
what are the 5 year chances of resorption for a subluxation injury with an open apex and a closed apex?
open apex: 1%
closed apex: 3%
what is an extrusion injury?
tooth injury characterised by partial or total separation of the periodontal ligament resulting in displacement of the tooth out of the socket
The alveolar socket is in tact but there is a tearing injury within the PDL
How do you treat an extruded permanent tooth
- reposition under LA
- flexible splint for 2 weeks
- review clinically and radiographically at 4 weeks, 6-8 weeks, 6 months and yearly for 5 years
what are the 5 year chances of pulp survival with an extrusion injury on an open and closed apex permanent tooth?
open apex - 95%
closed apex - 45%
What are the 5 year chances of root resorption with an extrusion injury on an open and closed apex permanent tooth
open apex - 5%
closed apex - 7%
what is a lateral luxation injury?
displacement of a tooth other than axially (not up or down). Displacement is accompanied by communication or fracture of either the labial or palatal/lingual bone
The PDL has suffered both tearing and crushing injuries
What is the treatment of lateral luxation injuries
- reposition under LA (buccal and palatal)
- Flexible splint for 4 weeks
- review at 4 weeks, 6-8 weeks, 6 month and yearly for 5 years
what are the 5 year chances of pulpal survival after a lateral luxation injury on a tooth with an open apex and a closed apex
open apex - 95%
closed apex - 25%
what are the 5 year chances of root resorption after a lateral luxation injury on a tooth with an open apex and a closed apex
open apex - 3%
closed apex - 37%
what is an intrusion injury
The tooth has been driven into the alveolar process due to an axially directed impact.
This is the most severe form of displacement injury
It is most likely to occur in teeth with fully developed roots
This is a crushing injury to the PDL
In a tooth with an open apex what are the treatment options following an intrusion injury
intrusion severity up to 7mm is spontaneous repositioning
intrusion severity of over 7mm either orthodontic or surgical repositioning
In a tooth with a closed apex what are the treatment options following an intrusion injury
up to 3mm, spontaneous repositioning
3-7mm, surgical or orthodontic repositioning
more than 7mm surgical repositioning
how do you treat an intrusion injury with spontaneous tooth repositioning
give diet advice and oral hygiene
review patient monthly to observe re-eruption
measure progress against a fixed point, e.g. incised edge of fully erupted non displaced adjacent incisor
how do you treat an intrusion injury surgically
reposition with forceps and flexible splint for 4 weeks
Endodontic treatment is usually necessary in a tooth with a closed apex
control after two weeks, remove the splint and control after 4 weeks, 6-8 weeks and 1 year and yearly for 5 years
what is the 5 year chances of pulpal survival after an intrusion injury on an open apex and closed apex tooth
open apex - 40%
closed apex - 0%
what is the 5 year chances of root resorption after an intrusion injury on an open apex and closed apex tooth
open apex - 67%
closed apex - 100%
What is the follow up treatment for an intrusion injury
- endodontic treatment can prevent the necrotic pulp from initiating infection-related tooth resorption
- carry out endodontic therapy within 3-4 weeks post trauma
- temporary filling of calcium hydroxide is recommended
- review after 2 weeks, splint removal and review after 4 weeks, 6-8 weeks 6 months and 1 year, then yearly for 5 years
what is an avulsion injury
when the tooth comes completely out of the socket and there is separation of the PDL
What is the critical factors
- extra-alveolar dry times (EADT) (the time the tooth is out of mouth in air, not in a storage medium or in mouth or in socket)
- extra-alveolar time (EAT) total time out of mouth, including being in a medium and not in a medium
- type of storage medium
If a patient attends with a replanted tooth which was previously avulsed, what do you do?
- do not remove
- leave as is and follow instructions regarding splinting depending on circumstances
- radiograph to establish status of root development
A teacher phones and says an 8 year old child has fallen in the playground and avulsed their 21, what instructions do you give
- hold tooth by the crown only
- wash in cold running water
- replace in socket and child bites on tissue
- or store in milk, saliva or normal saline
- seek immediate dental advice
what are the possible periodontal healing outcomes after an avulsion injury
- regeneration (likely if it was put straight back into the socket)
- PDL/cemental healing
- bony healing
- uncontrolled infection
what are the possible plural outcomes after an avulsion injury
- regeneration
- controlled necrosis (elective disinfection)
- uncontrolled infection
if the EAT is <60 minutes and stored in a suitable medium after avulsion, what is the aim and treatment plan
aim is for periodontal ligament healing
Replant the tooth under LA
Flexible splint for 14 days
Consider antibiotics and check tetanus status
Carry out pulp extirpation at 0-10 days UNLESS apex is open
what do you do if the EAT is less than 60 minutes and it is an immature tooth (open apex)
- if decision is made not to root treat the tooth, it must be closely monitored clinical and radiographically for signs of continued growth vs loss of vitality
- Review at 2 weeks (remove splint), 4 weeks, 2 months, 3 months, 6 months and then yearly
- If tooth is found to be non vital extirpate the pulp and refer to a paediatric specialist
what do you do if the EAT is less than 60 minutes and it is a mature tooth (closed apex)
- after replantation and splinting, remove pulp as soon as possible
- follow extirpation and disinfection, place antibiotic steroid paste as intra canal medicament - leave in place for 2 weeks
- remove splint at 14 days
- clean and replace intracranial medicament with NSCaOH
- obturation with GP should take place within 4-6 weeks
what do you do if the EAT is over 60 minutes and the apex is closed
- unlikely to get PDL healing, aim for bony healing
- scrub root clean of dead PDL cells
- extra-oral endodontics can be carried out prior to replantation
- replant tooth under LA
- 4 weeks flexible splint
- consider antibiotic prescription
- if extra-oral endodontics not carried out, extirpate at 7-10days and use NSCaOH as initial intra-canal medicament for 4 weeks prior to obturation with GP
what do you do if the EAT is over 60 minutes and the apex is open
- very small chance that pulp may still re-vascularise, do not root treat unless there are signs of loss of vitality on follow up
- replant tooth under LA
- flexible splint for 4 weeks
- consider antibiotic prescription
- check tetanus status
- monitor closely for signs of necrosis vs continued root development
- review 2 weeks, 4 weeks, 2 month, 3 month, 6 month and then yearly
when, following avulsion, should you not replant a tooth
- almost never
- if child is immunocompromised
- the child has other serious injuries and warrant preferential emergency treatment/ intensive care
- even as a temporary space maintainer, the right choice is usually to replant especially when guiding position of adjacent erupting tooth
when monitoring avulsion/replantation what should you look for on follow up radiographs
- root development (width of canal and length)
- comparison with other side
- internal and external inflammatory resorption
what are the chances of 5 year pulpal survival following an avulsion injury on an open and closed apex
open - 30%
closed - 0%
what are the chances of 5 year root resorption following an avulsion injury on an open and closed apex tooth
frequent
what injuries require a 2 week flexible splint
- subluxation
- extrusion
- avulsion (open and closed apex of <60 minutes EADT)
what injuries require a 4 week flexible splint
- luxation
- apical/middle root fractures
- intrusion
- dento-alveolar fractures
- avulsion of closed apex >60 mins EADT
What injury requires a 4 month flexible splint
- coronal root fracture
How do you make a flexible splint
- use composite and stainless steel wire
- cut and bend 0.3mm of stainless steel wire
- apply composite resin to traumatised tooth and those adjacent
- sink the contoured passive wire into the composite
- shape and cure composite
- smooth rough edges
what is the downside of a vacuum splint
- oral hygiene is often very poor
what is the difficulty with using orthodontic brackets and wire to splint
- difficult to ensure it is passive
what is a dent-alevolar fracture
- damage to the alveolar bone, but no displacement of the teeth
- never happens to a single tooth, it is in blocks or three or four
how do you treat a dento-alevolar fracture
- Give LA
- reposition
- flexible splint 4 weeks
- antibiotic
what is the immediate home management advice to give for primary tooth trauma
- soft diet for 10-14 days
- brush teeth with soft toothbrush after each meal
- topical chlorhexidine by parent twice daily for one week
what are the potential long term complications following primary tooth trauma
- discolouration
- discolouration and infection
- delayed exfoliation
what is the treatment for a discoloured or discoloured with infection infection tooth
if tooth is vital, no treatment and stays discoloured
if tooth is non vital, take radiograph and if there is a sinus or PAP then consider root canal or extraction. If no sinus or PAP then leave and review
what is treatment option of a delayed exfoliation of a primary tooth
- extraction is necessary or permanent successor will erupt ectopically
what injuries have worst prognosis
- the worst injuries and the younger age
what are the possible defects that can occur due to trauma to primary teeth
- enamel defects 44%
- abnormal tooth/root morphology
- delayed eruption
- ectopic tooth position
- arrest in tooth formation
- complete failure of tooth to form
- odontome formation
what are the potential enamel defects to permanent teeth following trauma of primary teeth
hypo mineralisation or hypoplasia
what is hypo mineralisation and what are the treatment options
- yellow/white spots
- normal thickness of enamel
treatment
- mask with composite
- localised removal and restore with composite
- external bleaching
what is hypoplasia and what are the treatment options
- yellow and brown areas
- less than normal thickness of enamel
treatment
- restore with composite
- porcelain veneer when gingival level is stabilised (at least age 16 but preferably early 20s)
why can premature loss of a primary tooth cause delayed eruption of the permanent successor
due to a thickened mucosa, and it can be up to 1 year delay
