Trauma II Flashcards
root fractire
dentine and cementum fracture involving the pulp
classifications of root fractures (3)
position of fracture
displacement of fragments
stage of root development
position of root fracture classes (3)
apical 1/3
middle 1/3
coronal 1/3
displacement of fragments of root fracture classes (2)
displaced
undisplaced
- edges of tooth still in tact
stage of root development root fracture classes (2)
mature (closed apex)
immature (open apex)
apical 3rd root fractures
Best prognosis, especially if no displacement has occurred.
If heals well the fracture line may be undetectable in future radiographs.
middle 3rd root fractures
Important to reduce fracture as much as possible
- i.e. get both halves touching again like a jigsaw
Different views of the same tooth can be important for diagnosis in some cases
coronal 3rd root fractures
Very poor prognosis as very little PDL support to keep the crown in position during function.
Creation of an extremely unfavourable crown:root ratio.
radiographic appearance of root fractures - imp to remember
Remember a radiograph is a 2 dimensional picture.
Occasionally it looks like there are multiple fracture lines when the break has occurred at an angle cutting across the beam
prognosis of root fracture depends on (5)
Age of child; mature / immature tooth
Degree of displacement
Associated injuries – e.g. crown fractures
Time between injury and treatment
Presence of infection
clinical exam for root fracture do
trauma stamp
special investigations for root fracture (2)
Sensibility tests
Radiographs from at least 2 angles
- E.g. 2 periapical from different angles and 1 Maxillary occlusal
Alternatively a cone beam CT
how to treat a root fracture
apical or middle third fracture (if displaced)
Clean area with water/saline/chlorohexidine
Reposition tooth with digital pressure
(LA not usually needed)
Splint: flexible splint for 4 weeks
(Soft diet for 1 week and Good OH)
Review: 6-8weeks, 6 months, 1 year and 5 year with radiographs
how to treat a root fracture
coronal third
Clean area with water/saline/chlorohexidine
Reposition tooth with digital pressure
(LA not usually needed)
Splint: flexible splint for 4 months
(Soft diet for 1 week and Good OH)
Review: 6-8weeks, 6 months, 1 year and 5 year with radiographs
what to attempt when repositioning fragments
attempt to completely approximate edges - like a jigsaw
- smooth outline on radiograph
healing outcomes of root fracture (4)
Calcified tissue union across fracture line
Connective tissue
Calcified + connective tissue
Bone/osseous
non-healing outcome of root fracture
Granulation tissue (usually associated with loss of vitality). - Radiolucent area seen on radiograph surrounding fracture line
calcified tissue healing of root fracture
Healed with dentine-like material,
- almost indistinguishable on second radiograph
connective tissue healing of root fracture
Fracture lines remain visible.
- Edges of fracture show signs of eburnation
- Smoothed out – not jagged
osseous healing of root fracture
Separate parts of the root become discrete entities with no connection
- each part has its own distinct PDL space and bone is clearly seen between the fragments
what happens if root fractured tooth becomes non-vital
20% chance of pulp necrosis
Apical and Middle Third Fractures
- extirpate to fracture line
- dress CaOH then MTA / Biodentine just coronal to # line (as no apical stop)
- GP - root fill to # line
Coronal fragment of root
- Remain in situ with own PDL
- Resorb
- If infected - antibiotics/apicectomy
root fracture -> pulp necrosis of
coronal fragment of root
- Remain in situ with own PDL
- Resorb
- If infected - antibiotics/apicectomy
root fracture -> pulp necrosis of
apical and middle third fractures
- extirpate to fracture line
- dress CaOH then MTA / Biodentine just coronal to # line (as no apical stop)
- GP - root fill to # line
classification of PDL injuries (6)
Concussion, subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation
Avulsion
Dentoalveolar fractures
what should be considered when assessing PDL injuries
impact on:
- Surrounding bone (fracture?)
- Neurovascular Bundle
- Root surface
concussion PDL injury
Concussion injury to the tooth supporting structures without increased mobility, displacement of the tooth or gingival bleeding.
There is pain on percussion and sensibility tests may be negative on initial assessment.
subluxation PDL injury
traumatic injury has occurred to the periodontal tissues leading to increased mobility but no displacement.
Gingival bleeding is often detected.
concussion/subluxation injury Tx
Occlusal relief – build up with GI on posterior
Flexible splint 2 weeks if necessary, to make patient feel more comfortable
Review
- Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year
Can have false positive for up to 3 months
Would like to see intact lamina dura and continued root level
increased mobility in
concussion?
no
increased mobility in
subluxation?
yes
TTP in
concussion?
Yes
TTP in
subluxation?
yes
follow up clinical and radiographs in
concussion?
4 weeks, 6-8 weeks, 1 year
follow up clinical and radiographs in
subluxation?
2 weeks, 4 weeks, 6-8 weeks, 1 year
splint in
concussion?
no
splint in
subluxation?
2 weeks flexible (sometimes if needed)
advice for all luxation injuries (3)
Instruct on OHI with chlorhexidine gluconate and gentle brushing
Soft Diet – soft bread, foods that don’t need a lot of incising
Avoid Contact Sports
how to monitor concussion subluxation (3)
Clinical tests - Trauma Sticker
Sensibility tests: thermal + electrical
- at time of injury
- Transient lack of sensibility can occur
- This can relate to future pulp necrosis
Radiographs:
- root development - width of canal and length
- comparison with other side
- internal + external inflammatory resorption
what is included on a trauma sticker/stamp? (8)
Mobility
Displacement
TTP
Colour
Sinus/tender in sulcus
Thermal (Eth Cl)
Electric (EPT)
Radiograph
% pulpal survival for concussion injuries
open apex 100%
closed apex 95%
% pulpal survival for subluxation injuries
open apex 100%
closed apex 85%
5 years resorption for concussion injuries
open apex 1%
closed apex 3%
5 years resorption for subluxation injuries
open apex 1%
closed apex 3%
pulpal survival closed Vs open apex
More frequently in teeth with OPEN apices after severe LUXATION
- Usually indicates ongoing pulpal vitality
PCO high rates with luxation, extrusion, intrusion, root fractures
- Less frequent in subluxed and crown fractured teeth
extrusion injury
Tooth injury characterized by partial or total separation of the periodontal ligament resulting in displacement of the tooth out of the socket.
The alveolar socket is intact.
This is a tearing injury within the PDL (wide)
treatment of extruded permanent teeth
Reposition under LA (buccal and palatal)
Flexible splint
- 2 weeks
review of extruded teeth
Clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months, and yearly for 5 years.
% pulpal survival of extrusion
open apex 95%
closed apex 45%
5 years resorption for extrusion injuries
open apex 5%
closed apex 7%
lateral luxation injury
Displacement of a tooth other than axially.
- usually palatally or lingually or labially
- IMMOBILE
Displacement is accompanied by comminution or fracture of either the labial or palatal/lingual bone.
- fracture alveolus
The PDL has suffered both tearing and crushing injuries
special investigation results for lat luxation injury
TTP
- gives a high metallic (ankylotic) sound
Sensibility tests
- likely negative
Xray
- widened PDL space
- take 2 X rays
Tx lateral luxation
Reposition under LA (buccal and palatal)
- disengage from bony lock forceps or digitally
Flexible splint
- 4 weeks
what to do if pulp becomes necrotic post lateral luxation
If becomes necrotic – extirpate to prevent root resorption
See signs of success for extrusion
May have replacement resorption or EIR
review for lateral luxation
clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months, and yearly for 5 years.
% year pulpal survival for lateral luxation
open apex 95%
closed apex 25%
5 year resorption for lateral luxation
open apex 3%
closed apex 38%
intrusion injury
Tooth has been driven into the alveolar process due to an axially directed impact.
most severe form of displacement injury.
more likely to occur in teeth with fully developed roots.
crushing injury to the PDL
most severe form of displacement injury.
intrusion
high metallic note on TTP ->
intrusion or luxation
need 2 xrays
Tx for intrusion options (3)
based on assessment
allow for spontaneous reposition
Fixate orthodontic elastic around the arch wire and bracket for traction
Reposition tooth with forceps
spontaneous tooth repositioning for intrusion
Advice re diet and oral hygiene
Review patient monthly to observe re-eruption
Measure progress against fixed point
- E.g. Incisal edge of fully erupted non-displaced adjacent incisor
Draw in notes
orthodontic repositioning for intrusion
Use of fixed orthodontic appliance
- Not relying on pt to reposition
Use of removable orthodontic appliance
e.g. Orthodontic Extrusion after tooth given opportunity to re-erupt
reposition tooth with forceps Tx for intrusion
Reposition with forceps
Flexible splint for 4 weeks
what is there a high risk of in intrusion injuries
High risk of resorption
Endodontic treatment usually necessary with closed apex. (almost always)
- Interim calcium hydroxide dressing recommended
review of intrusion injuries
Control after 2 weeks.
Splint removal and control after 4 weeks,
6-8 weeks,
6 months,
1 year
yearly for 5 year
% year pulpal survival for intrusion
open apex 45%
closed apex 0%
- take pulp out as soon as for closed apex intruded teeth
5 year resorption for intrusion injuries
open apex 67%
closed apex 100%
affect on the prognosis for PDL injury if the crown is fractured too
prognosis is reduced
follow up for intrusion
Endodontic treatment can prevent the necrotic pulp from initiating infection-related root resorption.
Consider in all cases with completed root formation where the chance of pulp revascularization is unlikely.
Endodontic therapy within 3-4 weeks post-trauma. A temporary filling with calcium hydroxide is recommended.
Review after 2 weeks. Splint removal and review after 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years
