Trauma II Flashcards
What is a root fracture
a dentine and cementum fracture that involves the pulp
What is an example of a vertical root fracture
would be a fracture caused by a post crown
What is a root fracture classified by
position of fracture
displacement of fragments
stage of root development
How can you classify based on the position of the fracture
○ Apical 1/3
○ Middle 1/3
○ Coronal 1/3
How can you classify based on the displacement of the fragment
○ Displaced
○ Undisplaced
How can you classify based on the stage of root development
○ Mature (closed apex)
○ Immature (open apex)
What fracture has best prognosis
apical third
• If it heals well at the fracture line it may be undetectable in future radiographs
How can a middle third root fracture be fixed
- It is important to reduce the fracture as much as possible and to get both halves touching again like a jigsaw
- This can be done by repositioning it
- It may be useful to get different views of the same tooth as it can be useful for diagnosis in some cases
Which fracture has the worst prognosis
Coronal third
Very poor prognosis due to very little periodontal ligament support to keep the crown in position during function
It creates a very unfavourable crown:root ratio
They are very mobile
Why can the appearance of a fracture on a radiograph be fooling
• Sometimes it looks like there are multiple fracture lines when there is only one but it has occurred at an angle cutting across the beam but it is just one fracture line
What does the prognosis of a fracture depend on
○ Age of child: mature/immature tooth
○ Degree of displacement
○ Associated injuries - e.g crown fractures
○ Time between injury and treatment
○ Presence of infection
What can occur between two displaced fractured halves
there will be a blood clot between the two halves of the tooth
What does the investigation of a root fracture consist of
clinical exam
special investigations
What does the clinical exam consist of
○ Fill out a trauma stamp to help with diagnosis and allow for long term monitoring
What does the special investigation consist of
○ Sensibility tests (ethyl chloride or EPT)
○ Radiographs from at least 2 angles (e.g 2 periapicals from different angles and 1x maxillary occlusal)
○ Alternatively can use cone beam CT
How do you treat a root fracture for apical or middle third fracture
- La may not be required but may want to use if it is uncomfortable
- Clean area with water/saline/chlorhexidine
- Reposition tooth with digital pressure
- Splint for 4 weeks using flexible splint
- Review 6-8 weeks, 6 months, 1 year and 5 years with radiographs
- Soft diet for 1 week and good OH
How do you treat a coronal 1/3 fracture
• Splint for 4 months with flexible splint
What are the different healing outcomes
calcified tissue union across fracture line
connective tissue healing
calcified and connective tissue healing
bone/osseous healing
What is calcified tissue union
healed with dentine like material
What is connective tissue healing
fracture lines remain visible and the edges of the fracture show signs of eburnation where the bone cells come and remove the sharp edges
What is bone osseous healing
the 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 are non healing outcomes
• Granulation tissue (usually associated with loss of vitality)
How does granulation tissue appear
○ Radiolucency area is seen on the radiograph surrounding the fracture line
○ If you went into the root canal and hit granulation tissue with an endo file it feels spongy and bleeds darkly
What are the chances of a tooth becoming non vital
• There is 20% chance of pulp necrosis
What do you do if a tooth w/ apical / middle third fracture becomes non vital
- Extirpate to fracture line
- Dress with non setting calcium hydroxide then MTA/bio dentine just coronal to the fracture line as there is no apical stop so a barrier must be created
- Back fill with gutta percha to the fracture line
What can happen to the apical fragment of the root
- Remains in situ with its own PDL
- Resorb
- If infected then may require antibiotics/apicectomy
What are the different PDL injuries
- Concussion, subluxation
- Extrusive luxation
- Lateral luxation
- Intrusive luxation
- Avulsion
- Dentoalveolar fractures
What should you consider the impact of the injury on
- Surrounding bone (fracture?)
- Neurovascular bundle
- Root surface
What is a concussion 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
What is a subluxation injury
- Subluxation is where a traumatic injury has occurred to the periodontal tissues leading to increased mobility but no displacement
- Gingival bleeding is often detected
What is the treatment for concussion / subluxation
occlusal relief
splinting
Describe occlusal relief for concussion/subluxation
some patients have a heavy bite and the pain this causes is similar to that felt in the percussion test so sometimes we can relief it by taking a way a bit of tooth or can build up with some GI on the posterior teeth to take the pressure off the anteriors by propping the bite open
Why is a flexible splint placed for subluxation
• A flexible splint can be placed for 2 weeks if necessary to make the patient uncomfortable as they may not like the mobility
When should injuries be reviewed
Review - clinical and radiographic control at 4 weeks is required, then at 6-8 weeks and then a year
What is the advice for all lunation injuries
○ Instruct on OHI with chlorhexidine gluconate and gentle brushing
○ Soft diet
§ Not just about soft foods
§ Bite gently, eat foods that don’t take a lot of incising
○ Avoid contact sports
How should injuries be monitored
clinically
sensibility tests
radiographs
What are the sensibility tests used for monitoring
thermal + electrical
§ At time of injury
§ Transient lack of sensibility can occur (hopefully will come back)
§ This can relate to future pulp necrosis
What are radiograph testing used for monitoring
§ Root development - width of canal and length (compare with other side)
§ Comparison with other side (look to see if tooth is continuing to grow)
§ Internal and external inflammatory resorption
What does a trauma stamp look at
○ Mobility ○ Displacement ○ TTP ○ Colour ○ Sinus/tender in sulcus ○ Thermal (eth cl) ○ Electric (EPT) ○ Radiograph
What is extrusion
- Tooth injury characterized by partial or total separation of the PDL resulting in displacement of the tooth out of the socket
- The alveolar socket is intact
- This is a tearing injury within the PDL
- The tooth is expected to be seen hanging lower than it should be
What is the tx for extrusion
○ Reposition under LA (buccal and palatal)
○ Flexible splint for 2 weeks
What is lateral luxation
- Displacement of a tooth other than axially
- Displacement is accompanied by comminution or fracture of either the labial or palatal/lingual bone
- The PDL has suffered both tearing and crushing injuries
What is treatment for lateral luxation
○ Reposition under LA (buccal and palatal)
○ Flexible splint for 4 weeks
What is intrusion
- Tooth has been driven into the alveolar process due to an axially directed impact and this is the most severe form of displacement injury
- It is more likely to occur in teeth with fully developed roots
- This is a crushing injury to the PDL
What is treatment for intrusion with an open apex
□ Up to 7 mm - spontaneous repositioning
□ >7mm - then either want to rapidly but tooth back either orthodontically or surgically
What is treatment for intrusion with a closed apex
□ <3mm - spontaneous repositioning
□ 3-7mm - ortho/surgical repositioning
>7mm repositioning - surgical repositioning
What is spontaneous tooth repositioning
where the tooth has good eruptive potential and the tooth will reposition by itself
* 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
What is rapid ortho repositioning
- Use of fixed orthodontic appliance
* Use of removable orthodontic appliance
What is done for repositioning and splinting
• Flexible splint placed for 4 weeks
What is the outcome for intrusion
high risk of resorption
What is done for intrusion
• Endodontic treatment is usually necessary with a closed apex and a interim calcium hydroxide dressing is recommended but don’t want it in there for more than 4-6 weeks due to the effect on dentine
How is endo carried out for intrusion
- Endo 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
- Endo therapy within 3-4 weeks post trauma. A temp filling with calcium hydroxide is recommended
What is the 5 year pulp survival for concussion
open apex - 100%
closed apex - 95%
What is the 5 year pulp survival for subluxation
open apex - 100%
closed apex - 85%
What is the 5 year pulp survival for extrusion
open apex - 95%
closed apex - 45%
What is the 5 year pulp survival for lateral luxation
open apex - 95%
closed apex - 25%
What is the 5 year pulp survival for intrusion
open apex - 40%
closed apex - 0%
What is the 5 year root resorption for concussion
open apex - 1%
closed apex - 3%
What is the 5 year root resorption for subluxation
open apex - 1%
closed apex - 3%
What is the 5 year root resorption for extrusion
open apex - 5%
closed apex - 7%
What is the 5 year root resorption for lateral luxation
open apex - 3%
closed apex - 38%
What is the 5 year root resorption for intrusion
open apex - 67%
closed apex - 100%
What requires 2 weeks flexible splinting
○ Sub luxation
○ Extrusion
○ Avulsion (open and closed apex <60 mins EAT)
What requires flexible 4 week splinting
○ Luxation ○ Apical/middle 1/3 root fracture ○ Intrusion ○ Dento-alveolar fractures ○ Avulsion, closed apex (>60mins EAT)
What is the exception to splinting
○ Flexible - 4 months - coronal 1/3 root fracture
What are the types of splinting
- Composite with wire is best
* Can also get acrylic with wire
What is the procedure for splinting
• Cut and bend 0.3mm stainless steel wire
• Apply composite resin to traumatised tooth and those adjacent
• Sink the contoured passive wire into the composite
• Shape and cure composite
Smooth rough composite and wire ends
What is vacuum formed splints
- Gumshield splint
- Oral hygiene is often v poor
- Essix retainer also vaccum formed but much thinner and better
What type of wires are ortho wires
• Ortho wires are active and will move the teeth
For splinting they need to be passive
What are acrylic URA type splints
- First choice of splint is composite and wire
* However acrylic is useful when there is a few abutment teeth
