Trauma to the permanent dentition: luxation injuries

Question 1

Define concussion (3)

Answer 1

Injury to supporting tissues
No loosening or displacement of tooth
TTP

Question 2

Define subluxation (3)

Answer 2

Injury to tooth supporting tissues WITH abnormal loosening of tooth
No displacement

Question 3

What should you look for as evidence of a concussion or subluxation injury?

Answer 3

Bleeding at the gingival margin

Question 4

What is lateral luxation? (4)

Answer 4

Bodily movement of tooth within socket
Not usually mobile
Rupture of neurovascular bundle
Crushing of PDL cells in palatal cervical region

Question 5

What is extrusion? (3)

Answer 5

Axial displacement partially out of socket
Mobile
Appears elongated

Question 6

What is intrusion? (3)

Answer 6

Tooth forced upwards into socket (in developing dentition - may be difficult to tell if teeth were partially erupting anyway)
Complex and severe injury
Crushing of PDL cells and neurovascular bundle

Question 7

What is avulsion? (3)

Answer 7

Tooth completely lost from socket
Ischaemic injury to pulp
PDL cell death

Question 8

Prognosis of pulp in luxation injuries dependent on (3)

Answer 8

Type of injury
Age of pt (ie stage of apical development)
Concomitant injury (fracture)

Question 9

Types of pulpal healing (3)

Answer 9

Complete healing
Pulp canal obliteration
Pulp necrosis - inflammatory resorption

Question 10

Sequelae of pulp canal obliteration (2)

Answer 10

Necrotic pulp –> inflammatory resorption/????

Question 11

Types of resorption (3)

Answer 11

Inflammatory
Replacement
Internal

Question 12

What is inflammatory (external resorption) (3)

Answer 12

Continuation of surface resorption due to toxins from necrotic pulp
Progressive until bacteria removed (i.e. pulp extirpation)
Will be filled in with cementum or bone on healing

Question 13

Inflammatory (internal) resorption treatment (1)

Answer 13

Extirpation and dressing with calcium hydroxide

Question 14

Features of inflammatory (internal) resorption (4)

Answer 14

Infrequent complication
Necrotic pulp
Ballooning of canal
Rapid progression

Question 15

What is replacement resorption? (3)

Answer 15

Extensive PDL damage
Osteoclasts are in direct contact with dentine
Normal bone turnover leads to progressive replacement resorption - progressive

Question 16

General advice for management of luxation injuries (5)

Answer 16

Soft diet for 7 days
Analgesics as necessary
Good oral hygiene
Chlorhexidine mouthwash or gel
Review splint at 48 hours

Question 17

Concussion treatment (2)

Answer 17

No treatment required

Monitor at 4 weeks, 6-8 weeks, 1 year

Question 18

Subluxation treatment (2)

Answer 18

A flexible splint can be placed for up to 2 weeks (if necessary)
Monitor for 4 weeks, 6-8 weeks, 1 year

Question 19

Extrusion treatment (4)

Answer 19

Reposition by gently repositioning with or without LA
Avoid high speed suction
Flexible splint for 2 weeks
Monitor a 2, 4, 6-8 weeks, 6 months, 1 year, yearly for 5 years

Question 20

Treatment of lateral luxation (3)

Answer 20

Reposition, disengaging tooth from any bony lock (usually with LA)
Flexible splint for 4 weeks
Monitor at 2, 4, 6-8 weeks, 6 months, 1 year, yearly for 5 years

Question 21

Treatment options for intrusion (3)

Answer 21

Leave - may spontaneously erupt
Orthodontically extrude
Surgically extrude

Question 22

Treatment for intrusion for teeth with immature apex (2)

Answer 22

Allow spontaneous repositioning to take place
-if no movement noted within a few weeks, recommend rapid ortho repositioning
If intruded >7mm reposition surgically or orthodontically

Question 23

Treatment for intrusion for teeth with mature apex (5)

Answer 23

Allow re-eruption if tooth intruded <3mm, if no movement after 2-4 weeks reposition surgically or orthodontically
If intruded 3-7mm surgical or ortho repositioning
If intruded >7mm, reposition surgically
Splint for 4-8 weeks once surgically repositioned
Commence RCT within 3-4 weeks

Question 24

Telephone advice for avulsion (4)

Answer 24

Find tooth
Hold tooth by crown (white part) NOT root (yellow, pointy part)
If dirty, rinse with cold water (10s - care not to drop down plughole)
Put in milk/ saliva
OR
Place tooth back in socket
Get child to bite on rolled up tissue to hold in place

Question 25

Unfavourable healing for avulsion (3)

Answer 25

Extra aveolar time >90mins Extra alveolar dry time >30 mins 90% chance of ankylosis if replanted after these times - in reality, anything more than 5 mins will result in PDL cell death

Question 26

Replacement resorption pathway - avulsion (3)

Answer 26

Death PDL Bone in direct contact with tooth Ankylosis and replacement resorption -leading to infraocclusion

Question 27

Replant or not? Consider... (5)

Answer 27

``` Prognosis Medical status Behavioural aspects Burden of care Child/ parent wishes ```

Question 28

Advantages of replanting avulsed teeth (5)

Answer 28

``` Aesthetics Space maintenance (avoidance of denture) Maintain options (bone preservation, transplants) Prevent restorative treatment Psychological benefit ```

Question 29

Disadvantages of replanting avulsed teeth (4)

Answer 29

Infra-occlusion Loss of gingival contour and bone Multiple visits (burden to family and child) Tooth will be lost eventually

Question 30

Key findings of socio-economic burden of permanent incisor replantation on children and parents (6)

Answer 30

9.1 treatment visits in 1st year post injury (1.2 emergencies) 7.2 hrs direct tx time Direct tx cost £900 Loss of work time for 86% parents School missed for 1-2 weeks after injury 18% replanted teeth were extracted within 1st year

Question 31

Stat: if you knew what you know now, would prefer to have incisor replanted or left out? (2)

Answer 31

Parents: 19% would not Children: 33% would not

Question 32

Potential contraindications of avusion (5)

Answer 32

Immunosuppression Severe cardiac disease Caries/ perio disease Children with severe learning difficulties who would not be able to manage ongoing tx Severe incisor crowding, supplemental incisor

Question 33

Management of avulsions: before replanting (7)

Answer 33

-store tooth in saline/ milk -LA if required -gently irrigate socket to remove clot -handle tooth by crown not root -if contaminated remove debris with saline -if stubborn debris, gently dab with saline soaked gauze Tip> measure tooth length prior to replanting to conform WL for future RCT

Question 34

Management of avulsions: replanting (6)

Answer 34

Replant with gentle p If won't replant fully, STOP Reposition any bony fractures with blunt instrument (flat plastic) if required Flexible splint for 7-14 days Systemic Abx Extirpate pulp in mature tooth between 0-10 days

Question 35

Systemic Abx avulsions (3)

Answer 35

Recommended where contamination, multiple injured teeth, med conditions rendering child susceptible to infection >12yrs: doxycycline 2x for 1 day, then 100mg 2x/ day for 10 days <12yrs: amoxicillin 500mg 3x/ day for 5-7 days

Question 36

Endo for avulsed teeth (6)

Answer 36

RCT is mandatory for teeth with mature apex Ideal time 0-10 days (before splint removal, so tooth stable during tx) If extirpated prior to 7 days, use odontopaste instead of CaOH Dress with non setting CaOH for 1 month Definitive obturation at 1 month In teeth with open apices, RCT can be avoided unless clinical and rad evidence of pulpal necrosis

Question 37

Extra oral endo (4)

Answer 37

Only usually in older pts, where growth complete and excessive extra-oral dry time - ankylosis expected - with conventional access cavity - replant - flexible splint for 7-10 days

Question 38

Follow up regime after avulsion (10)

Answer 38

``` Frequent clinical and rad examination 1/2 days (splint check) 0-10 days (RCT if required) 2 weeks (splint removal) 4 weeks (definitive RCT if required) 6-8 weeks 3 months 6 months 1 year Yearly ```

Question 39

Duration of splinting: what is splinted for 2 weeks? (3)

Answer 39

Subluxation Extrusion Avulsion

Question 40

Duration of splinting: what is splinted for 4 weeks? (3)

Answer 40

Lateral luxation Dento-alveolar fracture Middle/ apical third root fracture

Question 41

Duration of splinting: what is splinted for 4 months? (1)

Answer 41

Cervical third root fracture (poor prognosis)

Question 42

Types of splint (2)

Answer 42

Direct (physiological better as encourages healing and reduces risk of ankylosis) Indirect

Question 43

Direct splints (4)

Answer 43

Physiological -titanium splint (best but spenny) -flexible ortho brackets and flexible wire Composite/ GIC 'bandage' (only in emergency) Surgical wiring (only by max fax)

Question 44

Indirect splints and disadvantages (6)

Answer 44

``` Essix type retainer, use of temp cement -only if unable to get moisture control for direct splint or insufficient teeth to splint to > costs (lab costs) Teeth may come out in impression Not good for OH Can't access for RCT ```