Trauma I Flashcards
What is the most common injury in the primary dentition
luxation
What is the most common injury in the permanent dentition
crown fracture - enamel/dentine fracture
What is the peak period for trauma
7-10 years
What teeth are most likely to experience trauma in the permanent teeth
upper incisors
more likely to be centrals than laterals
What children is trauma to front teeth more common with
large overjet
in younger age group it won’t be corrected yet
How great an overjet increases incidence of trauma
○ An overjet of greater than 9mm doubles the incidence of trauma
○ For these patients it is important they were mouthguards when playing contact sports
What are common causes of trauma
Falls
Bike, skateboard, RTA
Sport
Fights
What questions do you ask when taking a detailed history
○ How did it happen
○ Where are the lost teeth/fragments
○ When did it happen exactly
○ Any other symptoms
What are examples of aspects in medical history that may influence treatment options
○ Rheumatic fever
○ Congenital heart defects
○ Immunosuppression
These condition are not contraindications to treatment but appropriate additional treatment may need to be given such as antibiotic cover
What do we look at in an extra oral examination
○ Laceration (soft tissues) ○ Haematomas ○ Haemorrhage/CSF § Any CSF in medial stream of nose bleed, appears to be ea straw coloured liquid ○ Subconjunctival haemorrhage ○ Bony step deformities ○ Mouth opening § Does the mouth open properly
What do we look at in an intra oral examination
○ Soft tissue § Look for laceration or tears ○ Alveolar bone § Anything mobile? ○ Occlusion § Are they biting normally? § Look out for malocclusion ○ Teeth • It is important to rule out facial/jaw fractures
Where are foreign bodies most likely to be
○ Most likely to be on the floor
Could be in the soft tissues
How do we check for lacerations
Use a soft tissue radiograph
What may tooth mobility indicate
○ Displacement of tooth ○ Root fracture § Would make it more loose ○ Bone fracture § Unlikely to be just one mobile tooth, several tooth in the segment would be mobile
What does the tactile test help for
○ Fracture lines whether they maybe horizontal or vertical (transillumination can help)
Pulpal involvement
What special tests do u want to do
sensibility tests
percussion
occlusion
radiographs
What are sensibility tests
to test the nerve of the tooth. A sensibility test is based on the principle that you would not get a patent nerve without a patent supply. But the converse is not true, you can have a patent blood supply and a dead nerve.
What are the types of sensibility tests
Thermal: ethyl chloride (ECL) or warm gutta percha
Electrical: electric pulp tester (EPT)
Used on labial third of px tooth which stimulates an electrical impulse onto the tooth and the patient will tell you if they can feel it or not
What can percussion help look for
A duller note may indicate a root fracture
What can occlusion help look for
§ Traumatic occlusion demands urgent treatment
§ A traumatic occlusion is when a patient can’t get their teeth back together normally and usually the tooth that has been traumatised is propping the patient’s occlusion open or it’s the first thing they touch when they bite
What radiographs can be taken
§ Intra-oral
§ Occlusal
§ OPT
Soft tissue
What can trauma stickers be useful for
can be used in clinic to help monitor the trauma long term
How should you do the sensibility test
• Compare the injured tooth with the adjacent non-injured tooth
* Always test adjacent teeth and opposing teeth addition to those obviously injured. These teeth must have received either direct or indirect concussive injuries * Continue sensibility tests for at least 2 years after an injury * Never make clinical judgements on sensibility tests alone
What are the classification of fractures
- Enamel Fracture
- Enamel Dentine Fracture
- Enamel Dentine Pulp Fracture
- Uncomplicated* crown root fracture
- Complicated* crown root fracture
- Root Fracture
What does complicated mean
pulp involved
What does uncomplicated mean
pulp not involved
What is root fracture divided into
○ Apical third
○ Middle third
○ Coronal third
What does the prognosis depend on
○ Stage of root development § Large number of injuries occur when children's anterior teeth are at a vulnerable stage ○ Type of injury § How severe ○ If PDL is damaged too ○ Time between injury and treatment ○ Presence of infection
What are the aims of emergency treatment
○ Aim to retain vitality of any damaged or displaced tooth by displaced tooth by protecting exposed dentine by adhesive ‘dentine bandage’
○ Treat exposed pulp tissue
○ Reduction and immobilisation of displaced teeth (if the teeth have moved in the socket)
○ Tetanus prophylaxis?
§ Have they been vaccinated?
§ Where was the fall?
○ Antibiotics
What are the aims of intermediate treatment
○ Does the pulp require treatment?
○ Restoration - minimally invasive e.g acid etch restoration
What are the aims of permanent treatment
○ Apexigenesis - normal biological process of tooth maturing and dentine thickening and it getting longer
○ Apexification - when an immature tooth has been damaged and growth has discontinued and so we intervene to provide an apex, so we can pack a restorative material against that
○ Gingival and alveolar collar modification if required
Coronal restoration
How do you manage enamel fracture
- Either” bond fragment to the tooth, simply grind sharp edges or add some composite
- Take 2 periapical radiographs to rule out root fracture or luxation
- Follow up in 6-8 weeks, 6 months and 1 year
What is the prognosis of enamel fracture
• The prognosis - 0% risk of pulp necrosis
How do you manage enamel-dentine fracture
- Account for the fragment - where is the fragment? The most important one is that it isn’t in the patient’s lungs. If it is you will see wheezing and coughing trying to get rid of I t
- You can either bond the fragment to the tooth or place a composite bandage
- Take 2 periapical radiographs to rule out root fracture or luxation
- Radiograph any lip or cheek lacerations to rule out embedded fragment
- Sensibility testing and evaluate tooth maturity
- Definitive restoration
- Follow up in 6-8 weeks, 6 months and 1 year
What is the prognosis of enamel dentine fracture
The prognosis - 5% risk of pulp necrosis at 10 years
What happens in the follow up
• Review 6-8 weeks, 6 months and at one year
• Use trauma sticker for clinical review
• Check radiograph for
○ Root development - width of canal and length
§ Looking for the apex
§ Comparing it with uninjured tooth
○ Comparison with other side
○ Internal and external inflammatory resorption
○ Periapical pathology
Why is damage to an immature tooth better than a mature one
○ This is because in an immature tooth, the hole that the blood vessels enter the tooth is larger so if it is bumped the chances of the blood vessels and nerves staying alive is higher than if there is a single point of entry as with a mature tooth then if it is moved then the vessels will be ripped and torn and so the chances of the pulp surviving are much less
How do you manage a enamel dentine-pulp fracture
• Evaluate exposure:
○ Size of pulp exposure
○ Time since injury
○ Associated PDL injuries
choose from - pulp cap, partial pulpotomy, full coronal pulpotomy
What is the aim in managing dentine - pulp fracture
to preserve pulp vitality especially in an immature tooth so we radicular pulp is alive to continue tooth formation
When do we do a pulp cap
• Done for a tiny exposure (1mm) in a 24 h window
What is the procedure for a pulp cap
○ First do a trauma sticker and radiographic assessment - we should see that it is non TTP and positive to sensibility tests
○ Put LA and rubber dam
○ Clean area with water then disinfect area with sodium hypochlorite
○ Apply calcium hydroxide (dycal) or MTA White to pulp exposure
○ Restore tooth with quality composite restoration
When is a partial pulpotomy done
• For larger exposures (>1mm) or 24+ hours since trauma
What is the procedure for a partial pulpotomy
○ Trauma sticker and radiographic assessment done first
○ LA and dental dam placed
○ Clean area with saline and then disinfect area with sodium hypochlorite
○ Remove 2mm of pulp with high speed round diamond bur
○ Place saline soaked cotton wool pellet over exposure until haemostasis is achieved
§ If there is no bleeding or you can’t arrest the bleeding then proceed to a full coronal pulpotomy
Apply CaOH then GI (or white MTA) then restore with quality composite resin
What is the procedure for a full coronal pulpotomy
- Begin with a partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton wool
- If hyperaemic OR necrotic then proceed to remove ALL of the coronal pulp
- Place calcium hydroxide in pulp chamber
- Seal with GIC lining and quality coronal restoration
Compare partial and full coronal pulpotomy
• Partial is 97% success rate
• Full coronal is 75% success rate
• The aim of pulpotomy is to keep the vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in length of root and thickness of dentine
• Follow up at 6-8 weeks, 6 months and 12 months
Clinical and radiographic review required
When is a full pulpectomy required
• If the tooth is non vital then a full pulpectomy is required but the clinical problem is that there is no apical stop to allow for obturation with GP
What are options for pulpectomy
○ Placing CaOH in the canal aiming to induce a hard tissue barrier being formed in what is known as apexification
○ MTA/BioDentine placed at apex of canal to create cement barrier (immediate)
○ Regenerative Endodontic Technique to encourage hard tissue formation at apex
What is the issue with CaOH apexification
§ This used to be the traditional way
§ Issues is that the barrier is perforated (has holes)
§ Takes about 9 months to actually form and having it inside the dentine for this long will make it brittle and dry and make the tooth lose its elasticity and make it fracture
What is regenerative endo technique
§ You remove necrotic soft tissue and sterilise it by sealing in antibiotic preparations and then you go back in with a file and agitate beyond apical tissues and that allows the canal to fill up with a blood clot and hopefully stem cells come from the apical area into the blood scaffold inside the tooth and stem cells differentiate into odontoblasts and continue with root development but in some cases osteoblasts form instead and form bone instead
What is the procedure for pulpectomy for open apex
• Rubber dam
• Access
• Haemorrhage control - LA/sterile water
• Diagnostic radiograph for WL
• Diagnostic radiograph for WL
• File 2mm short of estimated WL
• Dry canal using non-setting CaOH2 (left in 4-6 weeks in the pulp chamber and no more), CW in pulp chamber
• Glass ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
• Extirpate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
MTA plug done and heated GP used as normal GP doesn’t fit in these wide canals
What is the final coronal restoration
- Once obturation is complete
- Consider bonded composite short way down canal as well as in access cavity to create a bonded core to strength the tooth around the cervical margin
- Avoid post crowns
What is crown root fracture
• This is the fracture of the crown of teeth extending beyond the gingival margin up into the root
What are the treatment options for crown root fracture
fragment removal and gingivectomy orthodontic extrusion of apical portion surgical extrusion decoronation extraction
What is fragment removal and gingivectomy
§ This is indicated in crown root fractures with palatal subgingival extension
§ You remove part of the gam so you can get in and restore the area
What is done for orthodontic extrusion of apical portion
§ 1 - endo
§ 2 - extrusion (so margin is in a better area and a restoration can be placed making the margins supragingival)
3 - post crown
What is surgical extrusion
§ Loosen off the periodontal ligament, bring it down and hold it in place
What is the point of decoronation
§ Preserve bone for future implant
