Trauma III Flashcards
avulsion replantation
Successful healing can occur if there is only minimal damage to the pulp and the PDL
3 critical factors for successful healing after avulsion replantation
Extra-alveolar dry time - EADT
Extra-alveolar time - EAT
Type of storage medium
EADT
Extra-alveolar dry time
EAT
Extra-alveolar time
what to do if pt attends with tooth already replanted after avulsion
Do not remove. Leave as is and follow instructions regarding splinting etc dependent on circumstance
Radiograph important to establish status of root development
3 options for tooth life post avulsion
PDL viable mostly (replanted immediately or v shortly after)
PDL viable but compromised (kept in saline/milk, total dry time <60 mins)
PDL non-viable (dry time >60 mins regardless of what happened after this time)
- After dry time of 60 mins or more, ALL PDL cells are NON VIABLE
if tooth replanted immediately/v shortly after avulsion
PDL viable mostly
if tooth kept in saline/milk, and total dry time is <60 mins
PDL viable but compromised
if tooth dry time >60mins, regardless of what has happened in that time
PDL non-viable
After dry time of 60 mins or more, ALL PDL cells are NON VIABLE
public advice for avulsed tooth
Essential for parents/sports coaches/teachers
Hold by crown only
Wash in cold running water
Replace in socket and child bites on tissue
Or Store in milk/saliva/normal physiological saline (not contact lenses)
Seek immediate dental advice
replantation initial decision making based on
Extra alveolar dry time EADT
2 main time categories to consider when replanting
EADT < 30 mins
EADT > 30 mins
healing outcomes after avulsion
periodontal (4)
Regeneration
PDL/cemental healing
Bony Healing
Uncontrolled infection
healing outcomes after avulsion
pulpal (3)
Regeneration
Controlled necrosis (elective disinfection)
Uncontrolled infection
EAT < 60 mins and stored in an appropriate storage medium (e.g. milk, physiological saline or saliva)
Tx
then there is a chance of cemental/PDL healing.
- AIM: PDL healing
Replant tooth under LA
Flexible splint 14 days
Consider antibiotics and check tetanus status e.g. occurred in muddy environment
Carry out pulp extirpation at 0-10 days UNLESS apex is open (immature root)
Teeth with an open apex may revascularize
EAT < 60 mins immature teeth
Tx after replantation
If the decision is made not to root treat the tooth it must be closely monitored clinically and radiographically for signs of continued growth vs loss of vitality
Review Interval: 2wks (splint removal), 4wks, 2mths, 3mths, 6mths then yearly.
If the tooth is found to be non vital extipate pulp and refer to paediatric specialist. Inter-disciplinary management is recommended
EAT < 60 mins closed apex (mature teeth)
Tx after replantation
After replantation and splinting, remove pulp as soon as possible. (Ideally day 0)
Following extirpation and disinfection, place antibiotic-steroid paste as intra-canal medicament- leave in place for 2 weeks
Remove splint after 14 days
At 2 weeks- clean and replace intracanal medicament with NSCaOH
- Don’t want CaOH in tooth more than 4-6 weeks and cause dentine necrosis
Obturation with GP should take place within 4-6 weeks
Refer to a specialist paediatric dental team for interdisciplinary management
Review 3, 6, 12 monthly then yearly
teeth > 60 mins EAT and closed apex
Tx
Unlikely to get PDL healing
The aim is for bony healing (by ankylosis)
- so scrub root clean of dead PDL cells
Extra-oral endodontics can be carried out prior to replantation
- Harder but possible
Replant tooth under LA
Splint: 4 weeks flexible splint
Consider antibiotic prescription
If extra-oral endodontics not carried out- extirpate at 7-10 days and use NSCaOH as initial intra-canal medicament for 4wks prior to obturation with GP
- Review 3, 6, 12 monthly and then yearly
teeth > 60 mins EAT and closed apex
Tx
If extra-oral endodontics not carried out
extirpate at 7-10 days and use NSCaOH as initial intra-canal medicament for 4wks prior to obturation with GP
- Review 3, 6, 12 monthly and then yearly
teeth > 60 mins EAT and open apex
Tx
Unlikely to get PDL healing
Very small chance that pulp may still revascularize
Do not root treat unless signs of loss of vitality on follow-up
Replant tooth under LA
Splint: 4 weeks flexible splint
Consider antibiotic prescription
Check tetanus status
Monitor closely for signs of necrosis vs continued root development
Review 2 weeks, 4 weeks (splint removal), 2 months, 3 months, 6 months then yearly
When not to replant tooth
Almost never
If very immature apex and EAT> 90mins (may still be best to replant)
Child is immunocompromised
- Cancer etc
The child has other serious injuries and warrant preferential emergency treatment and / or intensive care being dealt with.
? Very immature lower incisors in young child finding it difficult to cope?
- May only last 6 months, space can close easy
Even as a temporary space maintainer- the right choice is usually to replant esp when guiding position of adjacent erupting tooth
- Prevent drifting that child is too young for orthodontic Tx
monitoring of avulsion/replantation
Open Apex Teeth require close monitoring
If pulpal necrosis detected- pulp extirpation must be carried out as soon as possible to avoid inflammatory resorption
Clinical tests - Trauma Stamp
Sensibility tests: thermal + electrical
- at time of injury
- 1 month, 2months, 3 months, then 6-monthly for an average of 2 years
Radiographs:
- root development - width of canal and length
- comparison with other side
- internal + external inflammatory resorption
what to look for on radiographs of avulsed replanted teeth
- root development - width of canal and length
- comparison with other side
- internal + external inflammatory resorption
when to carry out sensibility tests (thermal and EPT) for avulsed replanted teeth
- at time of injury
- 1 month, 2months, 3 months, then 6-monthly for an average of 2 years
pulpectomy
open apex, best practice
Extipate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
- (Problems with CaOH apexification)
MTA plug and heated GP obturation (MTA sets in 15mins - check; then GP will take 24hrs)
5 year pupal survival rate for avulsion/replantation
open apex 30%
closed apex 0%
5 year resorption for avulsion/replantation
frequent for both open and closed apex
flexible 2 week splinting for (3)
Subluxation
Extrusion
Avulsion – open and closed apex <60 mins EADT
flexible 4 week splinting for (5)
Luxation
Apical/middle 1/3 root #
Intrusion
Dento-alveolar fractures
Avulsion- closed apex >60mins EADT
flexible 4 month splints for (1)
coronal 1/3 root fractures
types of splint
composite wire (best)
acrylic wire - also option
titanium helix - very good but expensive
how to splint a re-implanted tooth
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.
vacuum formed splints
Gumshield’ splint.
Oral hygiene is often very poor.
Essix retainer also vacuum formed but much thinner and better.
ortho brackets and wire
wire must be
PASSIVE
if wire ‘active’ then teeth will be moved
first choice splint
composite wire
acrylic useful when few abutment teeth
dento alveolar fractures
Don’t have displacement of teeth in sockets
Mobility yes but not teeth in sockets been damaged to alveolar bone
Happens in segmented
- Teeth secure in their socket but it is the bone that is fracture
dento alveolar fractures Tx
LA
Reposition - ‘apical lock; may be present
- Moved a bit of bone so unable to get back in place
- Numb, lift over back into right place
Flexible splint 4 weeks
Antibiotics
follow up dento alveolar fractures
Monitor Clinically and Radiographically
- Checking for root development-canal width and length, compare with neighbouring unaffected tooth
- Check for signs of inflammatory resorption
- Follow up: 2wk,4wk, 8 weeks, 4 months, 6 months, 1 year and yearly for 5 years
- Risk of pulpal necrosis where closed apex is 50% at 5 years.
advice for all dental injuries
Soft diet for 7 days
Avoid contact sport whilst splint in place
Careful OH with use of chlorhexidine gluconate mouthwash 0.1%
follow up times for dento alveolar fractures
Follow up: 2wk,4wk, 8 weeks, 4 months, 6 months, 1 year and yearly for 5 years
