Trauma - Crown Fractures Flashcards by Kiran Kaur

Most common injury in primary dentition

Luxation

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Most common injury in permanent dentition

Crown fractures

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Peak period for trauma to permanent teeth

7-10yrs
More common with large OJ>9mm doubles incidence

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Important MH that may influence tx

Rheumatic fever
Congenital heart defects
Immunosuppression

Not contraindications

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E/O exam of trauma

Laceration
Haematoma
Haemorrhage/CSF
Subconjunctival haemorrhage
Bony step deformities
Mouth opening

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I/O exam of trauma

Soft tissue (damage + foreign bodies)
Alveolar bone
Occlusion
Teeth

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What can tooth mobility indicate

Displacement of tooth
Root fracture
Bone fracture

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What does a dull percussion note indicate?

May indicate root fracture

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Trauma sticker components

Sinus
Colour
TTP
Mobility
EPT
ECL
Percussion note
Radiograph

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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

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Classification of fractures

E#
ED#
EDP#
Uncomplicated crown root#
Complicated crown root#
Root# (apical 3rd, middle 3rd, coronal 3rd)

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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

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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

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Follow up of enamel fracture

Clinical + radiographic
after 6-8wks
after 1yr

If associated luxation then use these follow ups

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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

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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 CaOH - 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

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