Trauma - Crown Fractures Flashcards
Most common injury in primary dentition
Luxation
Most common injury in permanent dentition
Crown fractures
Peak period for trauma to permanent teeth
7-10yrs
More common with large OJ>9mm doubles incidence
Important MH that may influence tx
Rheumatic fever
Congenital heart defects
Immunosuppression
Not contraindications
E/O exam of trauma
Laceration
Haematoma
Haemorrhage/CSF
Subconjunctival haemorrhage
Bony step deformities
Mouth opening
I/O exam of trauma
Soft tissue (damage + foreign bodies)
Alveolar bone
Occlusion
Teeth
What can tooth mobility indicate
- Displacement of tooth
- Root fracture
- Bone fracture
What does a dull percussion note indicate?
May indicate root fracture
Trauma sticker components
- Sinus
- Colour
- TTP
- Mobility
- EPT
- ECL
- Percussion note
- Radiograph
What teeth should you sensibility test?
Injured with adjacent non-injured (may have received direct or indirect concussive teeth injuries)
This applies to sensibility and when viewing root surfaces on radiographs
Classification of fractures
- E#
- ED#
- EDP#
- Uncomplicated crown root#
- Complicated crown root#
- Root# (apical 3rd, middle 3rd, coronal 3rd)
What does prognosis of trauma depend on?
- Stage of root development
- Presence of infection
- Time between injury + tx
- Type of injury
- If PDL is damaged
General aims + principles of emergency treatment
- Retain vitality
- Tx exposed pulp tissue
- Reduction and immobilisation of displaced teeth
- Tetanus prophylaxis
- Antibiotics
Permanent aims + principles of emergency treatment
- Apexigenesis
- Apexification
- Root filling +/- root extrusion
- Coronal restoration
Managing an enamel fracture
Xray
- 1 parallel PA
- Additional if injuries (lip + cheek to search for fragments/foreign bodies)
TX
- Bond fragment if available
OR
- Smooth edges
OR
- Restore with composite
Follow up of enamel fracture
Clinical + radiographic
after 6-8wks
after 1yr
If associated luxation then use these follow ups
Managing an ED fracture
Xray
- 1 parallel PA
- Additional if injuries/missing
Sensibility testing
TX
- Bond if fragment available
- Fragment should be rehydrated by soaking in water/saline for 20mins before bonding
- Cover exposed dentine with GI or use bonding agent + composite
- If exposed dentine within 0.5mm of pulp (pink but no bleeding) place CaOH lining and cover with GI
Follow up for ED fracture
Clinical + radiographic
after 6-8wks
after 1yr
When do we use a trauma sticker?
Clinical review
What to monitor radiographs for
Root development - width of canal + length
Comparison with other side
Internal + external inflammatory resorption
PA pathology
Prognosis of pulp necrosis after ED fracture
5% risk at 10yrs
Managing an EDP fracture
Xray
- 1 parallel PA
TX
1. Pulp cap
2. Partial pulpotomy
3. Full coronal pulpotomy
Indication for pulp cap
Exposure 1mm
24hr window
Not TTP + sensibility
Why do we avoid full extirpation?
Avoid unless clearly non vital
Aim of pulpotomy to keep vital pulp tissue within the canal to allow normal root growth (apex-genesis) both in length of root and thickness of dentine
Follow up for EDP fracture
6-8wks
3mths
6mths
1yr
Steps of direct pulp cap
- Tooth should be not TPP + sensibility
- LA + dam
- Clean area with water then disinfect with Sodium Hypochlorite
- Apply CaOH or MTA white to pulp exposure
- Restore with composite
Indication for partial pulpotomy
Larger exposure >1mm or 24+ hrs since trauma
Steps of partial pulpotomy
- LA + dam
- Remove 2mm radius pulp with hi-speed round diamond bur
- Assess bleeding, if no bleeding remove more tissue
- Place saline soaked CW pellet over exposure until haemostasis achieved
- Assess bleeding if hyperaemic remove more tissue
- Apply nsCaOH
- Seal in with GI
- Restore with acid etched composite tip
Steps for full coronal pulpotomy
- Begin with partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton wool
- If hyperaemic or necrotic proceed to remove all of the coronal pulp
- Place CaOH in pulp chamber
- Seal with GIC lining and coronal restoration
Success rate of partial pulpotomy
97% success
Success rate of full coronal pulpotomy
75% success
Indication for full pulpectomy
Non vital tooth
Clinical issue with root tx for immature incisors
No apical stop to allow obturation with GP
Tx options for root tx of immature incisors
Apexification - CaOH placed in canal aiming to induce hard tissue calcified barrier
OR
MTA at apex of canal to create cement barrier
Steps for pulpectomy (open apex)
- Diagnostic PA for WL
- LA+rubber dam
- Access
- File 2mm short of EWL
- Dry canal
- NsCAOH placed
- Cotton wool in pulp chamber
- GI temp cement in access cavity and evaluate CAOH fill level with radiograph
- MTA plug and heated GP obturation (5-6mm)
Management of crown root fracture with no pulp exposure
Xray
- 1 parallel PA
- 2 additional radiographs taken with diff vertical and/or horizontal angulations
- Occlusal radiograph
- CBCT considered
TX
-Temporise and plan for future
Future
- Ortho extrusion
- Surgical extrusion
- RCT - if necrotic/infected
- XLA
- Autotransplantation
Management of crown root fracture with pulp exposure
Xray
- 1 parallel PA
- 2 additional taken with diff vertical and/or horizontal angulations
- Occlusal
- CBCT can be considered
TX
- Temp stabilisation
- Partial pulpotomy (immature) nsCAOH
- Extirpation (mature)
Future:
- Complete RCT + restore
- Ortho extrusion
- Surgical extrusion
- Root submergence
- XLA
- Autotransplantation
When do we proceed to a full coronectomy (started a partial pulpotomy)
- If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy
Define apexigenesis
Vital pulp therapy procedure to encourage development and formation of root
Define apexification
Method of inducing a calcified barrier at the apex of a non vital tooth with incomplete root formation
