Trauma I Flashcards
accidental damage to permanent teeth occurence
25% all school children experience dental trauma
33% adults - permanent dentition mostly before 19yrs
Boys:girls approximately 3:1
70% not treated
what is the most common injury in primary dentition
luxation
what is the most common injury in permanent dentition
crown fractures
- enamel dentine fracture
peak period for trauma to permanent teeth
7-10 years
what makes trauma to permanent teeth more likely
large overjet (likely not fixed by ortho yet)
OJ > 9mm doubles the incidence of trauma
causes of trauma (4)
Falls
- 50%
Bike, skateboard, RTA.
- 17-35%
Sport
- 14 – 25%
Fights
- 3%
what should you take in dental history of trauma child
How did it happen
When did it happen exactly
Where are the lost teeth/fragments
Any other symptoms
Take a dental and medical history
- Important to identify if any aspects of MH may influence treatment options
Be aware if : - Rheumatic Fever - Congenital heart defects - Immunosuppression These conditions are not contraindications to treatment but appropriate additional treatment may need to be given.
what types of MH may influence dental Tx for trauma child pt
Be aware if : - Rheumatic Fever - Congenital heart defects - Immunosuppression These conditions are not contraindications to treatment but appropriate additional treatment may need to be given.
order of EO and IO examination for child trauma pt
rule out facial/jaw fracture
Extra oral
- Laceration
- Haematomas
- Haemorrhage / CSF
- Subconjunctival haemorrhage
- Bony step deformities
- Mouth opening
Intraoral
- Soft tissue
- Alveolar bone
- Occlusion
- Teeth
what may be in the wound of child dental trauma
foreign bodies
Check for soft tissue damage
- Penetrating wounds, foreign bodies
- Soft tissue radiograph to check lacerations
tooth mobility tested with
probe
tooth mobility may indicate (2)
- displacement of tooth
- root or bone fracture (horizontal or vertical - transillumination can help)
potential pulpal involvement
5 stages in detailed intra oral exam of child pt with trauma
Sensibility tests
- Thermal: ethyl chloride (ECL) or warm Gutta-Percha
- Electrical: electric pulp tester (EPT).
Percussion
- duller note may indicate root#
Occlusion
- traumatic occlusion demands urgent treatment
Radiographs
- intra-oral, occlusal, OPT, soft tissue.
Classify the trauma
percussion of traumatised tooth
duller note = indicate root fracture
sensibility tests assess
nerve response
vitality – blood – Laser Dopler
types of sensibility tests (2)
- Thermal: ethyl chloride (ECL) or warm Gutta-Percha
- Electrical: electric pulp tester (EPT).
what type of occlusion needs urgent treatment
traumatic occlusion
trauma sticker
Label FDI notation at top
+/- for:
- sinus,
- TTP,
- ECL,
- P.NOTE,
- radiograph (see below)
Color describe
Mobility grade
EPT score after test
how to carry out a sensibility test
Compare injured tooth with the adjacent non-injured tooth.
- Always test adjacent teeth and opposing teeth in addition to those obviously injured. These teeth must have received either direct or indirect concussive injuries.
This applies to both sensibility tests AND when viewing root surfaces on radiographs
Continue sensibility tests for at least 2 years after an injury
Never make clinical judgements on sensibility tests alone
classification of crown and root fracture
enamel fracture
enamel dentine fracture
enamel dentine pulp fracture
uncomplicated crown root fracture
root fracture (apical, middle or cervical third)
complicated crown root fracture
uncomplicated fracture means
the pulp is not involved
complicated fracture means
pulp is the involved
prognosis of traumatised tooth depends on (5)
Stage of root development - positive and negative impacts
Type of injury
If PDL is damaged to
Time between injury and treatment
Presence of infection
general aims and principles of treatment
emergency Tx
5
Aim to retain vitality of any damaged or displaced tooth by protecting exposed dentine by an adhesive ‘dentine bandage’
Treat exposed pulp tissue
Reduction and immobilisation of displaced teeth
Tetanus prophylaxis
Antibiotics - Depends on location trauma
general aims and principles of treatment
immediate Tx
2
+/- Pulp treatment
Restoration
- Minimally invasive e.g. acid etch restoration
general aims and principles of treatment
permanent Tx
5
Apexigenesis
- normal biological process of apex growing and closing - worked
Apexification
- intervene to provide an apex as developmental process halter
Root filling +/- root extrusion
Gingival and alveolar collar modification if required
Coronal restoration
apexigenesis
normal biological process of apex growing and closing - worked
apexification
intervene to provide an apex as developmental process halter
how to manage an enamel fracture (2 options)
Either
- Bond fragment to tooth or
- Simply grind sharp edges
Take 2 periapical radiographs to rule out root fracture or luxation
Follow up
- 6-8weeks and at 1 year
Prognosis – 0% risk of pulp necrosis
follow up for enamel fracture
6-8weeks and at 1 year
prognosis of enamel fracture
0% risk of pulp necrosis
how to manage an enamel dentine fracture
2 options
Either
- Bond fragment to tooth or
- Place composite bandage
Line the restoration if the fracture is close to the pulp
then definitive restoration
how to manage an enamel dentine fracture
first step
Account for fragment – know where it is, bond on/composite bandage/ composite
Special tests for enamel dentine fracture
Take 2 periapical
radiographs to rule our root fracture or luxation
Radiograph any lip or cheek lacerations to rule out embedded fragment
Sensibility testing and evaluate tooth maturity
when is follow up for enamel dentine fracture
Follow up – 6-8 weeks and at 1 year
prognosis of restored crown after ED fracture
5% chance pulp necrosis at 10 years
what to check on radiographs for in follow up fo ED fracture
root development - width of canal and length
comparison with other side
internal + external inflammatory resorption
periapical pathology
effect on concussion on pulpal survival in ED fracture
open apex
95%
effect on concussion on pulpal survival in ED fracture
closed apex
85%
effect on subluxation on pulpal survival in ED fracture
open apex
80%
effect on subluxation on pulpal survival in ED fracture
closed apex
50%
effect on extrusion on pulpal survival in ED fracture
open apex
60%
effect on extrusion on pulpal survival in ED fracture
closed apex
20%
effect on lateral luxation on pulpal survival in ED fracture
open apex
65%
effect on lateral luxation on pulpal survival in ED fracture
closed apex
15%
effect on intrusion on pulpal survival in ED fracture
open apex
0%
effect on intrusion on pulpal survival in ED fracture
closed apex
0%
mature Vs immature tooth chance of pulpal survival after trauma
Chances of pulp survival better in immature tooth – open, lots of access to nerves and blood vessels compared to single point entry for closed apex
3 things to evaluate after enamel-dentine-pulp exposure
size of pulp exposure
time since injury
associated PDL injuries
treatment options for enamel-dentine-pulp exposure (3)
pulp cap
- less than 24hr
partial pulpotomy (Cvek Pulpotomy) - more than 24hr old
full coronal pulpotomy
- damage to pulp is and length exposed
- last resort
what is the aim of treatment for enamel-dentine-pulp exposure
to preserve pulp vitality
treatment of choice in open and closed apices with EDP exposure
preserve pulp vitality by pulp capping or partial pulpotomy
- in order to secure further root development.
This treatment is also the treatment of choice in patients with closed apices.
Calcium hydroxide compounds and MTA (white) are suitable materials for such procedures.
direct pup cap when
tiny exposure (1mm)
24hr window
direct pulp cap procedure
Trauma sticker and radiographic assessment
- Should be non-TTP and positive to sensibility tests
LA and rubber dam
Clean area with water then disinfect area with sodium hypochlorite
Apply calcium hydroxide (Dycal) or MTA White to pulp exposre
Restore tooth with quality composite restoration
Review 6-8 weeks then 1 year
partial pulpotomy (Cvek pulpotomy) when
larger exposure (>1mm)
24+ hours since trauma
partial pulpotomy (Cvek pulpotomy) procedure
Trauma sticker and radiographic assessment
LA and rubber dam
Clean area with water then disinfect area with sodium hypochlorite
Remove 2mm of pulp with high speed round diamond bur
Place saline soaked CW pellet over exposure until haemostasis achieved
- If no bleeding or can’t arrest bleeding (hyperaemic) proceed to full coronal pulpotomy
Apply CaOH then vitrebond (or white MTA) then restore with quality composure resin
should get continued root development from wide open apex
full coronal pulpotomy procedure
Begin with partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton-wool
(Last resort)
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
when do you resort full coronal pulpotomy
when assessing haemostasis at partial
- saline soaked cotton wool
hyperaemic or necrotic (no bleeding), then proceed to remove ALL of the coronal pulp
partial (Cvek) Vs full coronal pulpotomy
partial - 97% success
full coronal - 75% success
aim of pulpotomy
to keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine.
follow up for pulpotomy
6-8 weeks and 12 months
clinical and radiographic review
root treatment for immature incisors
tooth non-vital then
full pulpectomy needed
root treatment for immature incisors
tooth non-vital but
apex of tooth is open
clinical problem is the need to have an apical stop to allow obturation with GP
how to achieve apical stop in open apex tooth needing pulpectomy (3 options)
CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification)
- Not great, takes 9 months to form properly but CaOH denatures dentine after 4 weeks
or MTA/BioDentine/bioceramic placed at apex of canal to create cement barrier
Or Regenerative Endodontic Technique to encourage hard tissue formation at apex
- Stem cells activate and differentiate into odontoblasts, then make dentine (sometimes bone so still in early stage)
best material for achieve apical stop in open apex tooth
MTA/BioDentine/bioceramic placed at apex of canal to create cement barrie
pulpectomy - open apex
- Rubber dam
- Access
- Haemorrhage control - LA / sterile water
- Diagnostic radiograph for WL
- File 2mm short of estimated WL
- Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
Extirpate pulp and place MTA plug and heated GP obturation (5-6mm of MTA)
- cylinder of GP to fill wide canal
Glass-ionomer temporary cement in access cavity and evaluate MTA fill level with radiograph
how is MTA placed
use carriers
final coronal restoration of pulpectomy
Once obturation complete
Consider bonded composite short way down canal as well as in access cavity
Bonded core
Try to avoid post crown
crown-root fracture with no pulp exposure
extends beyond gum – past gingival level and crestal bone
treatment options (7)
fragment removal only and restore
Fragment removal and gingivectomy
- Indicated in crown-root fractures with palatal
subgingival extension
Orthodontic extrusion of apical portion
- Extrusion
- Endodontic
- Post crown
Surgical extrusion
- Removing all PDL and lowering tooth into place – severe. If pulp alive unlike
Orthodontic extrusion of apical portion
Decoronation
- Preserve bone for future implant
Extraction
May need to do temporary treatment as need more information before can proceed
when is fragment removal and ginivectomy indicated in crown-root fractures
Indicated in crown-root fractures with palatal
subgingival extension
purpose of decoronation
perserve boen for future implant
post crown
not wanted in crown-root fracture Tx but sometimes needed
