TRAUMA permanent Flashcards
concussion
injury to the tooth supporting structures without increased mobility or displacement of the tooth, but with pain to percussion
dx concussion
permanent
Not displaced.
Tender to touch or tapping.
No increased mobility
Sensibility
* Usually a positive result.
* important in assessing future risk of healing complications. A lack of response to the test indicates an increased risk of later pulp necrosis.
One periapical radiograph is recommended. Additional radiographs are indicated if signs or symptoms of other potential injuries are present
* No radiographic abnormalities, the tooth is in-situ in its socket
tx concussion
permanent
No need for tx
Monitor pulpal condition for at least 1 year
Pt instructions
* Soft food for 1 week.
* Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.
Clinical and radiographic follow up at 4 weeks and 1 year
subluxation
injury to the tooth supporting structures resulting in increased mobility but without displacement of the tooth
bleeding from the gingival sulcus confirms the dx
dx subluxation
permanent
Not displaced
TTP
Inc mobility
Sensibility testing may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made.
* There will be a positive sensibility test result in about half the cases.
* The test is important in assessing future risk of healing complications.
* A lack of response at the initial test indicates an increased risk of later pulp necrosis.
Occlusal, PA and 2 eccentric exposure from diff horizontal angulations
* Usually no radiographic abnormalities
tx subluxation
Clean the area with water spray, saline or chlorhexidine
Suture gingival lacerations if present
A flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks (0.4mm wire and composite)
Pt instructions
* Soft food for 1 week.
* Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris
Follow up
* Splint removal and radiographic follow up at 2 weeks
* Clinical review: 2 weeks; 12 weeks; 6 months and 1 year
extrusion
partial displacement of the tooth out of the socket
an injury to the tooth characterised by partial or total serparation of the PDL resulting in loosening and displacement of the tooth
the alveolar socket bone is in tact (unlike lat lux)
in addition to axial displacement the tooth will have an element of protrusion or retrusion ususally
dx extrusion
Appears elongated
Excessively mobile
Usually lack of response except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive result to the initial test indicates a reduced risk of later pulp necrosis.
* In immature, not fully developed teeth, pulpal revascularization usually occurs. In mature teeth pulp revascularization sometimes occurs.
Occlusal, PA and 2 eccentric exposures from different horizontal angulations
Inc PA ligament space
tx extrusion
Apply local anesthesia
The exposed root surface of the displaced tooth is cleansed with saline before repositioning
Reposition the tooth by gently re-inserting it into the tooth socket with axial digital pressure
Stabilize the tooth for 2 weeks using a flexible
If there is breakdown/fracture of the marginal bone, splint the tooth for an additional 4 weeks.
Pt instructions
* Soft food for 1 week.
* Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris
Clinical and radiographic follow up
* 2 weeks – splint removal and radiographs
* Then radiographic again – 4 weeks, 8weeks, 12weeks, 6months, 1 year and yearly for at least 5 years
* Monitoring the pulpal condition is essential to diagnose associated root resorption.
* If the pulp becomes necrotic and infected, endodontic treatment appropriate to the tooth’s stage of root development is indicated.
extrusion follow up
- 2 weeks – splint removal and radiographs
- Then radiographic again – 4 weeks, 8weeks, 12weeks, 6months, 1 year and yearly for at least 5 years
- Monitoring the pulpal condition is essential to diagnose associated root resorption.
- If the pulp becomes necrotic and infected, endodontic treatment appropriate to the tooth’s stage of root development is indicated.
lateral luxation
displacment of the tooth other than axially
accompanied by communication fracture of either the labial or palatal/lingual alveolar bone
partial or total separation PDL
dx lateral luxation
Displaced usually in palatal/lingual or labial direction
High metallic/ankylotic sound
Usually mobile
Sensibility tests will likely give a lack of response except for teeth with minor displacements.
* The test is important in assessing risk of healing complications. A positive result at the initial examination indicates a reduced risk of future pulp necrosis.
Occlusal, PA and 2 eccentric exposures from diff horizontal angulations
* Widened PA ligament space
tx lateral luxation
permanent
Aim: To reposition and splint a displaced tooth to facilitate pulp and periodontal ligament healing.
Rinse the exposed part of the root surface with saline before repositioning.
Apply a local anesthesia.
Reposition the tooth with forceps or with digital pressure to disengage it from its bony lock and gently reposition it into its original location. In case of manual repositioning, palpate the gingiva to feel the apex of the tooth. Use one finger to push downwards over the apical end of the tooth, then use another finger or thumb to push the tooth back into its socket.
Stabilize the tooth for 4 weeks using a flexible splint
* If there is breakdown/fracture of the marginal bone or alveolar socket wall, splint for an additional 4 weeks.
Teeth with incomplete root formation
* Spontaneous revascularization may occur.
* If the pulp becomes necrotic and there are signs of infection related external resorption (inflammatory resorption), root canal treatment should be initiated as soon as possible.
Teeth with complete root formation
* The pulp will likely become necrotic.
* Root canal treatment should be initiated in order to prevent infection related resorption.
lateral luxation prognosis
permanent teeth with incomplete root formation
- Spontaneous revascularization may occur.
- If the pulp becomes necrotic and there are signs of infection related external resorption (inflammatory resorption), root canal treatment should be initiated as soon as possible.
lateral luxation progonsis
permanent teeth with complete root formation
- The pulp will likely become necrotic.
- Root canal treatment should be initiated in order to prevent infection related resorption.
follow up permanent teeth lateral luxation
- Clinical and radiographic follow-up after 2 weeks.
- Clinical and radiographic follow-up and splint removal after 4 weeks.
- Clinical and radiographic follow-up after 8 weeks, 12 weeks, 6 months, 1 year and yearly for 5 years.
intrusion
Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.
dx intrusion
Tooth displaced axially into alveolar bone
High metallic/ankylotic sound
Mobile
Negative sensibility tests
Occlusal, PA and 2 eccentric horizontal angulations
* PDL space may be absent from all or part of the root
* ACJ located more apically in the intruded tooth than in adjacent non-injured teeth, at times even apical to marginal bone level
tx intrusion dependent on
risk
root development - immature or mature
tooth intrusion is associated with a potential risk of tooth loss due to progressive root resorption (ankylosis or infection related resorption).
teeth with immature development
intrusion tx
Allow re-eruption without intervention (spontaneous repositioning) for all intruded teeth independant of the degree of intrusion.
If no re-eruption within 4 weeks, initiate orthodontic repositioning.
Monitor pulp condition.
* Spontaneous pulp revascularization may occur. However, if there are signs of infectious pulp necrosis or infection related resorption, root canal treatment is indicated and should be initiated as soon as possible.
teeth with mature root development
intrusion tx
Allow re-eruption without intervention if the tooth is intruded <3 mm.
If no re-eruption within 4 weeks, reposition surgically and splint for 2 weeks or reposition the tooth orthodontically.
If the tooth is intruded 3-7 mm, reposition surgically or orthodontically.
If the tooth is intruded beyond 7 mm, reposition surgically.
Root canal treatment should be initiated within 2 weeks or as soon as the position of the tooth allows in order to prevent infection related resorption.
avulsion
tooth is completely displaced out of its socket. Clinically the socket is found empty or filled with a coagulum.
dx avulsion
Tooth removed from socket
Account for all tooth pieces
If the visual appearance of the injury raises suspicion of a possible intrusion, root fracture, alveolar fracture or jaw fracture an occlusal radiograph should be taken to confirm the diagnosis.
first aid for avulsed permanent tooth
An avulsed permanent tooth is one of the few real emergency situations in dentistry
If a tooth is avulsed, make sure it is a permanent tooth
* primary teeth should not be replanted
Keep the patient calm.
Find the tooth and pick it up by the crown (the white part). Avoid touching the root.
- If the tooth is dirty, rinse it gently in milk, saline or in the patient’s saliva and encourage the patient/parent to replant the tooth in the original position in the jaw.
Bite on a handkerchief to hold the replanted tooth in position.
If immediate replantation is not possible, place the tooth in a suitable storage medium available at the emergency site. This should be done quickly to avoid dehydration of the root surface.
* E.g. milk, Hank’s balanced salt solution, saliva (after spitting into a glass for instance) or saline.
* water is a poor medium, it is better than leaving the tooth to air-dry.
Seek emergency dental treatment immediately.
On arrival ask time out of socket – imp for tx
important considerations for avulsion of permanent teeth management
open V closed apex
Extra Alveolar Dry Time (time out of socket)
avulsed permanent tooth with open apex
replanted prior to pt arrived at dentist
tx
leave the tooth in place
Apply local anesthesia, if necessary, preferably with no vasoconstrictor.
* Clean the area with water spray, saline or chlorhexidine.
* Suture gingival laceration, if present.
Verify normal position of the replanted tooth both clinically and radiographically.
Apply a flexible splint for 2 weeks
Administer systemic antibiotics (if tooth avulsed in environment could be contaminated e.g. soil)
* Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
* If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, apexification, pulp revitalization/revascularization is recommended.
follow up for immature permanent tooth avulsion
For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis and infection
* potential for spontaneous healing to occur in the form of new connective tissue with a vascular supply - allowing continued root development and maturation
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly for at least 5 years.
tx for avulsed immature permanent tooth that has been kept in storage medium for less than 60mins (EADT<60)
Clean the root surface and apical foramen with a stream of saline.
Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
Administer local anesthesia, prefereably without vasoconstrictor.
Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
Irrigate the socket with saline.
Replant the tooth slowly with slight digital pressure.
Suture gingival lacerations, especially in the cervical area.
Verify normal position of the replanted tooth clinically and radiographically.
Apply a flexible splint for up to 2 weeks
Administer systemic antibiotics.
* Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
* If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
PDL viable but compromised
what is the goal in replanting a permanent immature tooth
possible revascularization of the tooth pulp. If that does not occur, apexification, pulp revitalization/revascularization is recommended.
* risk of infection-related root resorption should be weighed up against the chances of revascularization.
* Such resorption is very rapid in children. If revascularization does not occur, root canal treatment may be recommended.
tx for permanent avulsed tooth with EADT >60mins
Clean the root surface and apical foramen with a stream of saline.
* Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
Administer local anesthesia, prefereably without vasoconstrictor.
* Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
* Irrigate the socket with saline.
Replant the tooth slowly with slight digital pressure.
Suture gingival lacerations, especially in the cervical area.
Verify normal position of the replanted tooth clinically and radiographically.
Apply a flexible splint for up to 2 weeks
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
* If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
EADT>60 likely non viable PDL cells
concern is permanent tooth EADT>60
Delayed replantation has a poor long-term prognosis.
* PDL will be necrotic and cannot be expected to heal.
The goal in delayed replantation is to restore the tooth to the dentition for esthetic, functional and psychological reasons and to maintain alveolar contour.
The possible outcome will be ankylosis related resorption
why is replantation always advised for permanent avulsed teeth
keeps other tx options open future - restores aesthetics, function temporarily whilst maintaining alevolar bone contour, width and height
advise pt poor long term prognosis
* infraoccluded - may need decoronated or XLA
varies with pt age, growth etc - unpredictable
apical barrier formation in open apex permanent tooth which has pulpal necrosis
Mineral trioxide aggregate
5mm of MTA should be placed at the apical end of the root.
* Placement can be aided by use of a microscope.
* Placement is carried out using obtura probes, disposable MTA carriers or experimentally using a venflon.
Wait at least 24 hours for MTA to harden then obturate with a heated GP system
tx mature permanent tooth avulsion replanted prior to attending
Leave the tooth in place.
Clean the area with water spray, saline or chlorhexidine.
* Administer local anethesia if necessary, preferably with no vasoconstrictor.
* If the tooth were replanted in the wrong socket or rotated, reposition the tooth into the proper location up to 48 hours after the traumatic incident.
* Suture gingival lacerations, if present.
Verify normal position of the replanted tooth both clinically and radiographically.
Apply a flexible splint for 2 weeks
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
* If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
Initiate root canal treatment within 2 weeks after replantation and before splint removal
follow up for closed apex avulsed tooth
Root canal treatment within 2 weeks after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly after replantation and left for at least 2 weeks.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly for at least 5 years
infarction
An incomplete fracture (crack) of the enamel without loss of tooth structure.
E#
fracture confined to the enamel with loss of tooth structure
dx e#
Visible loss of enamel, no visible exposed dentine
Not TTP
Normal mobility
Usually positive. The test may be negative, initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made.
* The test is important in assessing risk of future healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.
A periapical radiograph is recommended.
* Enamel loss visible
* Additional radiographs are indicated if signs or symptoms of other potential injuries are present. - Angulations for root fractures (PA and occlusal) – luxation or root #
ED#
A fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp
ED# dx
Visible loss of enamel and dentine, no visible sign of exposed pulp tissue
Not TTP
Normal mobility
- Usually positive. The test may be negative, initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made.
- The test is important in assessing future risk of healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.
A periapical radiograph is recommended.
* Enamel-dentine loss visible
* Additional radiographs are indicated if signs or symptoms of other potential injuries are present.
If the fragment is missing and there are soft tissue injuries, radiographs of the lip and/or cheek are indicated to search for tooth fragments and/or foreign materials.
EDP#
A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.
dx EDP#
Visible loss of enamel and dentine with exposed pulp tissue
Not TTP
Normal mobility
Usually positive. The test is important in assessing risk of future healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.
A periapical radiograph is recommended.
* Loss of tooth substance visible
* Additional radiographs are indicated if signs or symptoms of other potential injuries are present.
* PA and occlusal - parallax
If the fragment is missing and there are soft tissue injuries, radiographs of the lip and/or cheek are indicated to search for tooth fragments and/or foreign materials.
crown root # without pulp involvement
fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp.
dx crown root # without pulp involvement
Crown fracture extending below gingival margin
TTP
Mobile coronal fragment
Positive apical fragment to sensibility testing
PA radiograph, an occlusal radiograph and two additional radiographs taken with different vertical and/or horizontal angulations.
* Apical extension of # not visible
* CBCT considered for better visualisation of fracture path, its extent and relationship to marginal bone
crown root fracture with pulp involvement
fracture involving enamel, dentin, and cementum with loss of tooth structure, and exposure of the pulp
dx crown root fracture with pulp involvement
Crown fracture extending below gingival margin
TTP
Coronal fragment mobile
Sensibility testing positive for apical fragment
PA radiograph, an occlusal radiograph and two additional radiographs taken with different vertical and/or horizontal angulations.
* Apical extension of # not visible
* CBCT considered for better visualisation of fracture path, its extent and relationship to marginal bone
root fracture
fracture confined to the root of the tooth involving cementum, dentin and the pulp. Root fractures can be further classified by whether the coronal fragment is displaced (see luxation injuries).
root fracture dx
coronal segment may be mobile and in some cases displaced.
Transient crown discoloration (red or grey) may occur.
Bleeding from the gingival sulcus may be noted.
May be TTP
May be mobile
Sensibility testing may give negative results initially, indicating transient or permanent neural damage. Monitoring the status of the pulp is recommended.
* The pulp sensibility test is usually negative for root fractures except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive sensibility test at the initial examination indicates a significantly reduced risk of later pulp necrosis.
Periapical, occlusal and 2 eccentric exposures.
* An occlusal exposure is optimal for locating root fractures in the apical and middle third. Bisecting angle exposure or 90 degree angulation exposure is needed to locate the fractures in the cervical third of the root.
* In cases where the above radiographs provide insufficient information for treatment planning, CBCT can be considered to determine the location, extent and direction of the fracture.
root fracture line is usually visible. The fracture involves the root of the tooth and is in a horizontal or diagonal plane
alveolar fracture
A fracture of the alveolar process; may or may not involve the alveolar socket.
Teeth associated with alveolar fractures are characterized by mobility of the alveolar process; several teeth typically will move as a unit when mobility is checked. Occlusal interference is often present.
dx alveolar fracture
Displacement of an alveolar segment.
An occlusal change due to misalignment of the fractured alveolar segment is often noted.
TTP
Entire segment mobile and moves as unit
Negative to sensibility tests
Occlusal, periapical and eccentric exposure.
* In cases where the above radiographs provide insufficient information for treatment planning, a panoramic radiograph and/or CBCT can be considered to determine the location, extent and direction of the fracture.
* vertical line of the fracture may run along the PDL or in the septum. The horizontal line may be located at any level from the marginal bone to the basal bone. An associated root fracture may be present.
