Trauma Guidelines Permanent Dentition - International Association of Dental Traumatology 2020 Flashcards
What is enamel infarction
- incomplete enamel fracture
- no loss of tooth fractures
What would a trauma stamp for enamel infarction show
no TTP
no mobility
EPT/ECL = positive (however it is possible for it to be negative - transient pulp damage)
no radiographic abnormalities
What x-ray should we take for enamel infarction
PA
What tx can we do for enamel infarction
no tx
if severe or unaesthetic, can seal with composite to prevent bacterial ingress and prevent discolouration
What is the follow up for enamel infarction
none required
What are the favourable outcomes of enamel infarction
- asymptomatic
- positive pulp testing
- continued root development in immature teeth
What are the unfavourable outcomes of enamel infarction
- symptomatic
- pulp necrosis
- infection
- apical periodontitis
- lack of further root development
What would the trauma stamp for enamel fracture show
- no ttp
- normal mobility
- ept/ecl usually positive response
clinically - loss of enamel. remember to ask about where the fragment is
What x-rays for enamel fracture
- PA
- additional views only indicated if considering other potential injuries or trying to locate missing fragment
- will see enamel loss on x-ray
What is the tx for enamel fracture
- can bond fragment back on
- smooth broken edge and leave
- place composite
What is the follow up for enamel fracture
6-8wks
1 yr
What are the favourable outcomes for enamel fracture
- asymptomatic
- positive pulp testing
- good quality restoration
- continued root development
What are the unfavourable outcomes of enamel fracture
- symptomatic
- pulp necrosis
- apical periodontitis
- loss of restoration
- breakdown of restoration
- lack of further development in immature teeth
What would the trauma stamp for uncomplicated enamel dentine fracture show
- TTP - nil
- mobility - nil
- EPT/ECL - positive usually
What radiographs for uncomplicated enamel dentine fracture
PA unless others indicated
enamel and dentine loss visible
What is the tx for uncomplicated crown (enamel dentine) fracture
- bond fragment back on
- rehydrate the fragment first for 20 mins
or - cover exposed dentine - gi or comp
*if close to pulp (0.5mm) then caoh liner and cover
What is the follow up for uncomplicated crown fracture
6-8wks
1 yr
What are the favourable outcomes of uncomplicated fracture
- asymptomatic
- +ve pulp testing
- good quality restoration
- continued root development
What are the unfavourable outcomes of uncomplicated enamel dentine fracture
- symptomatic
- pulp necrosis and infection
- apical periodontitis
- loss of restoration
- breakdown of restoration
- lack of further development in immature teeth
What would the trauma stamp for complicated crown fracture show
- TTP - nil
- mobility - nil
- EPT/ECL - usually +ve
- exposed pulp sensitive to stimuli
What are the radiographs for complicated crown fracture
PA
other views only taken if indicated
enamel dentine loss visible
What is the tx for complicated crown fracture if the tooth is immature i.e open apex
- aim to preserve pulp via pulp cap, partial pulpotomy
When is pulp cap indicated
<24h and <1mm exposure
When is partial pulpotomy indicated
> 24h
1mm exposure
When should you do a coronal pulpotomy rather than partial pulpotomy
necrosis/hyperaemia
- What is the tx for complicated crown fracture with a closed apice
- conservative options still preferred e.g partial pulpotomy
- may need to consider RCT
What is the follow up for complicated enamel dentine fracture
- 6-8wks
- 3 months
- 6 months
- 1 year
What do we want to see on a radiograph to assess continuing development of an immature tooth
- lengthening of root - mirroring adjacent undamaged teeth
- thicker dentine walls
- no PAP
- no root resorption
What are favourable outcomes of complicated enamel dentine fracture
- aymptomatic
- positive pulp test response
- good quality restoration
- continued root development
What are unfavourable outcomes for complicated crown fracture
- symptomatic
- pulp necrosis
- apical periodontitis
- loss/breakdown of restoration
- lack of further development of immature tooth
- discolouration
What is the procedure for a pulp cap
- trauma stamp - need no TTP and positive pulp test
- LA & dam
- clean area with water and disinfect with hypochlorite
- NS-CaOh placed on pulp wound.
- Seal with GI/Comp restoration
Can also bond fragment back on
What can be used instead of NSCaOH for dressing pulp wounds
- non staining calcium disilicate
What are the clinical findings/trauma stamp for uncomplicated root fracture
- crown fracture extends below GM
- TTP - yes
- mobiility - coronal fragment mobile
- EPT/ECL - usually positive for apical fragment
What xrays do we want for uncomplicated crown root fracture
- PA + occlusal
- 2 additional xrays (parallax)
- apical extension of fracture not usually visible. may require CBCT for whole apical extension of fracture
What is the emergency tx for uncomplicated crown root fracture
stabilise loose fragment temporarily
What are the long term tx options for uncomplicated crown root fracture
- fragment removal only + restoration (has to be subcrestal fracture)
- fragment removal + gingivectomy
- orthodontic extrusion of apical fragment
- surgical extrusion
- coronectomy
- XLA
*note that RCT is indicated for many of these tx options
RCT must be done for teeth which require post-crowns due to lack of tooth tissue
coronectomy aims to preserve bone until age for implant
What is the follow up regimen for uncomplicated crown root fracture
- 1wk
- 6-8wk
- 3 mo
- 6mo
- 1yr
- every year for 5 years minimum
What are the favourable outcomes for uncomplicated crown root fracture
- asymptomatic
- +ve pulp test
- continued root development
- good quality rest
What are unfavourable outcomes for uncomplicated crown root fracture
- symptomatic
- discolouration
- pulp necrosis and infection
- apical periodontitis
- lack of further root development
- loss/breakdown of restoration
- marginal bone loss and periodontal inflammation
What are the clinical findings/trauma stamp findigns of complicated crown root fractures
- crown fracture extends below GM
- TTP - yes
- mobile - yes coronal fragment only
- EPT/ECL - usually positive for apical fragment
What is emergency tx for complicated crown root fracture
*stabilise loose fragment
What is the tx options in the mid to longer term for complicated root fracture
- open apice - partial pulpotomy
- closed apice - pulpectomy
- cover exposed dentine
- long term - tx options same as uncomplicated
What is the follow up regimen for complicated crown root fracture
- 1wk
- 6-8 wks
- 3 mo
- 6 mo
- 1 yr
- yearly for at least 5 y
What are favourable outcomes for complicated crown root fracture
- asymptomatic
- continued root development
- good quality restoration
What are the unfavourable outcomes for complicated crown root fracture
- symptomatic
- pulp necrsos and infection
- apical periodontitis
- lack of further root development
- loss or breakdown of restoration
- marginal bone loss and peridontal inflammation
What is the procedure for partial pulpotomy
- trauma stamp first
- LA and dam
- clean area with saline and disinfect with hypochlorite
- remove 2mm of pulp with high speed round bur
- place saline soaked cotton wool over exposure until haemostasis achieved
- apply NSCaOH or non-staining calcium silicate
- seal exposed dentine
- restore
What are the clinical findings/trauma stamp findings for root fracture
- coronal segment may be mobile and displaced
- ttp - yes
- bleeding from gingival sulcus
- EPT/ECl - may be negative initially
What x-rays do we want for root fracture
- PA and Occlusal
- 2 additional x-rays - parallax
- root fractures may be undetected on imaging - may require CBCT for tx plan
- occlusal view optimal for locating root fractures in apical mid 1/3
- bisecting angle or 90 degree exposure may be required for cervical 1/3
What are the tx options for root fracture
Displaced
* reposition, splint 4wks for apical and mid third fractures, 4mo for cervical 1/3
No emergency endodontic tx
If pulp becomes necrotic then RCT to fracture line
apexification may be required
in more mature teeth with coronal 1/3 fracture, you may opt to remove the fragment, RCT and do a post retained crown
can also offer ortho extrusion, crown lengthening, surgical extursion, XLA
What is the follow up regimen for root fracture
- 4 wk (splint removal)
- 6-8 wks
- 4 mo (splint removal)
- 6 mo
- 1y
- yearly for at least 5 years
What are the favourable outcomes for root fracture
- positive pulp response. may take a while to come back. dont rct based on negative response alone
- signs of repair between segments
- normal/slight mobility of coronal segment
What are unfavourable outcomes for root fracture
- symptomatic
- extrusion and/or excessive mobility of coronal fragment
- radiolucency at fracture line
- pulp necrosis and infection w/ inflammation at fracture line
What are the healing outcomes for root fractures
- calcified tissue healing
- connective tissue healing
- calcified & CT tissue healing
- bone/osseus healing
What are the non healing outcomes for root fractures
- granulation tissue
- radiolucency surrounding fracture line
- feels spongy and bleeds darkly when accessed
What are the clinical findings/trauma stamp for alveolar fracture
- segment mobility
- displacement of several teeth moving together
- occlusal disturbance
- ttp - yes
- ept/ecl - negative
What x-rays do we need for alveolar fracture
- pa and occlusal
- 2 additional parallax views
- may also require OPT or CBCT
What is the tx for alveolar fracture
- reposition displaced segment and splitn for 4 weeks (flexible and passive splint)
- suture gingival lacerations
- RCT contra-indicated at emergency visit
- monitor pulp condition and RCT as requried
What is the follow up regimen for alveolar fractures
- clinical and radiographic exam
- 4 wk - splint removal
- 6-8wk
- 4 months
- 6 months
- 1 year
- yearly for at least 5y
bone and soft tissue healing should be monitored
What are favourable outcomes for alveolar fracture
- positive response to pulp test - may be negative for months
- no signs of pulp necrosis/infection
- ST healing
- radiographic signs of bone repair
- slight tenderness to palpation/masitcation may remain for several months
What are unfavourable outcomes for alveolar fracture
- symptomatic
- pulp necrosis and infection
- apical periodontitis
- inadequate ST healing
- non-healing of bone fracture
- external inflammatory resorption
What are the clinical findings/trauma stamp for concussion
- TTP - yes
- mobility - no
- EPT/ECL - positive
What xray should we get for concussion
PA
no radiographic abnormalities
What tx for concussion injury
none
observe pulp condition for at least 1yr
What is the follow up regimen for concussion
- clinical and radiographic evaluation at 4wk and 1yr
What are the favourable outcomes for concussion
- asymptomatic
- +ve pulp response - false negatives are possible however for several months
- continued root development in immature teeth
- intact lamina dura
What are unfavourable outcomes in concussion injuries
- symptomatic
- pulp necrosis/infection
- apical periodontits
- no further root development in immature teeth
What are the clininal findings/trauma stamp for subluxation
- no displacement
- ttp - yes
- mobile - yes
- bleeding from gingival crevice
- ept/ecl - may be negative initally (50% have negative EPT). Indicates transient pulp damage. Monitor pulp response until definitive diagnosis can be made regarding pulp
What is the radiographs for subluxation
PA and occlusal
2 parallax xrays also
normal xray appearance
What is the tx for subluxation
- normally no tx
- passisve and flexible splint for 2wks only if excessive mobility or pain on biting
What is the follow up regimen of subluxation
- 2 week, 12 weeks, 6 months, 1 year
What are the favourable subluxation outcomes
- asymptomatic
- positive pulp test
- continued root development in immature teeth
- intact lamina dura
What are unfavourable outcomes subluxation injuries
- symptomatic
- pulp necrosis and infection
- apical periodontitis
- no further root development
- external inflammatory resorption
If you see external inflammatory resorption, what should you do
RCT immediately
use CaOh as intracanal medicament for 3 weeks and contiously replace until resorptive lesions disappear
What are the clinical findings/trauma stamp for extrusive luxation
- displacement of tooth out of socket in incisal/axial direction
- tooth appears elongated
- mobility - yes
- EPT/ECL negative
- TTP - yes
What radiographs for extrusive luxation
- PA + occlusal
- and 2 additional xrays (parallax)
- radiographic appearance - increased pdl space apically and laterally and tooth not seated in socket, appears elongated
What is the tx of extrusive luxation
- reposition under la
- 2 wk splint - if fracture to marginal bone then 4 wk splint
- if pulp necrosis develops –> pulpectomy
What is the follow up for extrusive luxation
- 2 wk
- 4 wk
- 8 wk
- 12 wk
- 6 mo
- 1 yr
- yearly for at least 5 years
What are the favourable outcomes for extrusive luxation
- asymptomatic
- pdl healing
- positive pulp response
- no marginal bone loss
- continued root development
What are unfavourable outcomes of extrusive luxation
- symptomatic
- pulp nercosis/inection
- apical periodontitis
- breakdown of marginal bone
- external inflammatory resorption
What is the procedure for pulpectomy in open apce
- la and dam
- remove pulp contents
- apical barrier formation - mta
- wait 24h to set - heated gp in
What is extrusive luxation characterized by
- partial/total seperation of PDL resulting in loosening
- socket intact
What are the clinical findings/trauma stamp of lateral luxation
- displacement other than axially
- accompanied by damage to alveolar bone
- partial/total seperation of PDL
- gives high metallic sound when percussed
- immobile
- ept/ecl negative
Why are lateral luxation injuries immobile
they become locked in by the bone fracture
What radiographs do we want for lateral luxation
pa + occlusal
2 additional x-rays (parallax)
radiographic apeparance
increased PDL space
* best seen on horizontal angle shift or on occlusal
What treatment would we do for lateral luxation
Reposition and splint 4 wks
Evaluate pulp status at 2wk
* open apex - may spontaneously revascularise so dont RCT unless signs of nercosis or EIR
* closed apex - high necrosis risk, start RCT and use CaOh or corticosteroid/AB mix to prevent EIR
What is the follow up regimen for lateral luxation
2wk, 4 wk (splint removed), 8 wk, 12wk, 6mo, 1yr
What are unfavourable outcomes of lateral luxation
- symptomatic
- breakdown of marginal bone
- pulp nercosis and infection
- apical periodontits
- ankylosis
- ERR
- EIR
What are the clinical findings of intrusion
- displaement apically
- immobile
- percussion - high metallic sound
- ept/ecl - no response
What x-rays do we want for intrusion and what do we expect to see
- PA + occlusal
- 2 additional xrays (parallax)
Radiographic appearance - pdl space may not be visible for all/part of the root esp apically
- CEJ located more apical
What is the tx for an intrusion injury with open apice
- allow for spontaneous reeruption
- if none in 4 wks, intiate ortho extrusion
- monitor pulp - spontaneous revascularisation may occur
What is the tx for a intrusion injury for a closed apice tooth
<3mm intrusion
* allow for spontaneous reeruption
* if none in 8 wks, surgical/ortho resposition + 4wk splint
3-7mm intrusion
* surgical or orthodontic repositioning
>7mm intrusion
* reposition surgically
start endo within 2 wks
What is the follow up regimen for intrusion
- clinical and radiographic
- 2 wk
- 4 wk
- 8 wk
- 12wk
- 6 mo
- 1 yr
- then yearly for 5 yr
What are the unfavourable outcomes of intrusion
- symptomatic
- tooth locked in place/ankylotic tone to percussion
- pulp nercosis/infection
- apical periodontitis
- ankylosis
- ERR
- EIR
What are favourable outcomes of intrusion
- asymptomatic
- tooth in place/re-erupting
- intact lamina dura
- +ve response to pulp tests
- no signs of resorption
- continued root development
What is the first aid advise for avulsion
- stay calm
- pick tooth up by crown
- rinse in milk/saline/saliva if dirty. if not possible, gently rinse under tap no longer than 10 secs
- replant
- get px to bite on smth to hold in place
- if cant replant, store in milk, HBSS (special salt solution), saliva, saline
- bring tooth to dentist
What is the tx for open apex avulsion that has been immediately reimplanted
- it is likely that the damage to the PDL cells are minimal so high chance of PDL healing
- in open apex teeth, also chance of pulp revascularisation so no endo tx unless signs of necrosis
1. leave tooth in situ
2. apply LA, clean area and suture any lacerations
3. verify position w xray
4. apply flexible splint 2wks
5. consider AB and tetanus risk
What is the tx for open apex with EOT <60 minutes
- aiming for pulp revascularisation and pdl healing
What is the tx for open apex EOT <60 minutes
- clean root surface - saline
- LA without adrenaline and irrigate socket with saline
- replant tooth and confirm position with xray
- 2 week splint
aiming for pulp revascularisation and pdl healing
dont do endo tx unless signs of pulp necrosis/infection
What is the tx for open apex tooth avulsion EOT >60 minutes
- clean root surface with saline, want to get rid of any dead PDL cells prior to implanation
- LA and irrigate socket
- replant
- verify position w/ xray
- 2 week flexible splint
- consider AB and tetanus shot
Aim: pulp revascularisation. PDL healing unlikely expecting ankylosis / possibly root resorption
What is the tx for a closed apex avulsion with immediate implanation
- leave tooth in place
- LA as required
- clean area, suture any gingival lacerations
- check implatation position - if required, reposition within 48h. verify position on xray
- flexible splint 2wk
- initiate RCT within 2wks, before splint removal (do it asap)
Aiming for PDL healing
What is the tx for avulsion of closed apex tooth EADT <60 minutes
- clean tooth
- LA, irrigate socket, replant
- 2 week splint
- initiate RCT within 2 wks prior to splint removal
Aiming for PDL healing
What is the tx for closed apex avulsion EADT >60 minutes
- clean root surface and apice to remove dead PDL cells
- replant and verify position
- 2wk flexible splint
- initiate rct within 2wks prior to splint removal
- expecting ankylosis
What is the intercanal medicament for endo tx post avulsion
caoh
place for one month
followed by placement of gp
What is the tx protocol for endo tx for avulsed tooth
start endo tx asap
caoh is intracanal medicament
should be placed for 1 month, to prevent RR
then fill with GP
What is the favourable outcomes for closed apex avulsion
- asymptomatic
- functional
- normal mobility
- no TTP
- normal percussion sound
- no RR
- no radiolucencies
- normal lamina dura
What are the unfavourable outcomes for closed apex avulsion
- symptoms
- swelling
- sinus tract
- excessive mobility/no mobility
- high pitched metallic sound
- EIR,ERR
- infraocclusion in growing px
What are favourable outcomes for the open apex avulsion
- asymptomatic
- functional
- normal mobility
- normal percussion sound
- continuing development
- may see pulp canal obliteration in first year - this is how the pulp immature tooth avulsion heals
What are unfavourable outcomes in open apex avulsion
- symptoms
- swelling
- sinus tract
- excessive mobility/no mobility
- high pitched metallic sound
- EIR, ERR
- infra occlusion in growing px
- no further root development
What is the follow up regimen for closed apex avulsion
- 2wks
- 4wks
- 3 month
- 6 month
- 1 yr
- every year for at least 5 yr
WHat is the follow up regimen for open apex avulsion
- 2 wks
- 1 mo
- 2 mo
- 3 mo
- 6 mo
- 1 yr
- every year for at least 5 years
What is the aftercare for avulsion
- avoid participation in contact spots
- soft food 2 wks
- brush teeth with soft brush
- 0.1% CHX for cleaning
What are the favourable outcomes of lateral luxation
- asympatomic
- +ve pulp response
- marginal bone height corresponds to that seen on x-ray after repositioning
- continued root development
