Trauma to the permanent dentition part 1 Flashcards
What are the things you would look out for in the medical history of a child who has gone through trauma?
Determine tetanus protection status – has the child had this immunisation? (esp with dirty wounds eg; soil in deep laceration of intrusion)
What are the types of things you would ask the patient who has been through trauma?
- Where – place event occurred, type of surface
- When – time/date – affects tx options
- How – e.g. a blow to the chin – the mandible will be forced backwards with jaw fracture, crown root fracture in the premolar or molar region as possible injuries
- Was there a period of unconsciousness?
- Headache, amnesia, vomiting, excitation or difficulties focusing the eyes?. These are all signs of brain concussion and require medical attention
- Could there be other issues to look for e.g. skull fracture, concussion etc., could it be abuse?
State what you would be looking out for in the extra oral exam
- Swelling, laceration, bruises and haemorrhage on the skin or face.
- Chin-point ecchymosis often associated with gingival degloving, laceration and /or a mandibular fracture, as blood collects to the most dependent poin
- Battle sign, or bruising of the mastoid region, is associated with a base of skull fracture
- Submucosal hematomas in the vestibular region or the floor of the mouth may indicate jaw fracture and careful radiographic exam is indicated
- Assessment of facial skeleton
- Stiffness or pain in the neck, immediate referral to physician to rule out cervical spine injury
- Abnormalities in opening and closing - may imply luxation injury, alveolar fracture, jaw fracture, or luxation/ fracture of the TMJ
State what you would be looking out for in the intra oral exam
- Numbness/pins and needles
- Soft Tissues: swelling, laceration and haemorrhage of the oral mucosa and gingiva, foreign bodies in lacerations of lips and cheeks
- Occlusion
- Hard tissues: missing, displaced or loosened teeth, fractured crowns, or cracks in the enamel
State the 5 types of examinations conducted on traumatised teeth
- Displacement (record direction and the extent)-e.g. “luxated palatally”
- Mobility (both horizontal and vertical) document severity/grade. Also, when several teeth move together in a block, a fracture of the alveolar process is suspected
- Percussion (mirror handle gently in horizontal and vertical direction)tenderness indicates damage to the periodontal ligament/inflammation. A high metal tone implies that the injured tooth is locked in bone
- Color of the tooth: discoloration may appear almost immediately after the injury. Special attention – the palatal surface in the gingival 1/3 of the crown
- Reaction to sensibility tests: usually not possible to obtain reliable information from a young, frightened child
List some reasons why a radiographic examination is important following trauma
- Extent of root development, helps with deciding prognosis
- Position of unerupted teeth
- Size of pulp chamber
- Periapical radiolucencies
- Root fractures and root resorption
- Extent and type of root fractures
- Jaw fractures
- Presence of tooth fragments and other foreign bodies. For soft tissue xray, use ¼ the normal exposure time
List and define the 3 types of soft tissue injuries
- Laceration - usually from a sharp object producing a puncture or tear in the tissue
- Contusion - a bruise from a blunt object causing subsurface bleeding
- Abrasion - a raw bleeding surface from rubbing or scraping
For the 3 types of soft tissue injuries, state their treatment
Contusion
• Usually no treatment necessary
• Radiographs to rule out any fractures
• Soft diet for 3-4 days
Abrasion
• Thorough debridement of the area to remove any impacted foreign bodies
• Chlorhexidine / warm saline mouth rinses
• Analgesics
Laceration
• Thorough debridement of area
• Small shallow lacerations left to heal
• Long and deep lacerations approximated and sutured
• If contaminated by soil–prophylactic vaccination against tetanus (booster)
• Chlorhexidine / warm saline mouth rinses
Define “degloving injury”, state its common causes, its management and complications (3) associated with delayed treatment
Definition
• The stripping of soft tissues down to the bone, including the neurovascular bundles and muscle attachment either by trauma or by surgery
Causes
• Due to an angular impact of jaws during a fall (from bikes, horses, sports activities
Management • Thorough debridement of all foreign matter • Reposition hard and soft tissues • Suture in place • Appropriate tetanus prophylaxis • Make review appointment
Complications
• Delayed or lack of repair causing painful healing and bunching of tissues
• Exposure of, or damage to mental nerve
• Infection due to lack of early diagnosis and repair.
For cracked enamel, state how it is best diagnosed and its treatment
- Incomplete fractures without loss of tooth substance. The fracture line usually stops at the DEJ
- Infraction lines are best seen when the light beam is directed parallel to the long axis of the tooth “Craze lines”
- No active treatment is required
- However, the energy of the impact may be transmitted to the periodontal tissues and the neurovascular supply at the apical foramen.
For an enamel infraction (fracture), state its treatment and management
- Need for restoration depends on extent and needs, except for slight contouring to reduce sharpness and/or improve aesthetics
- Radiograph to assess the extent of fracture
- Pulp sensibility tests after 6 - 8 weeks
For uncomplicated crown fractures (enamel - dentine), state its risks, 3 options for management (4)
Risks
• Exposure of dentinal tubules to the oral environment
• If left unprotected – bacteria or bacterial toxins may penetrate the tubules, resulting in pulpal inflammation
• May be reversible but pulp necrosis is a possible outcome
Management
• Radiographs and pulp sensibility tests after 6 - 8 weeks
• Temporary Coverage: Cover the whole fracture surface with a glass ionomer (e.g. vitrebond- luting GIC)
• Reattachment of a crown fragment: Avoid dehydration of the fragment. Place in water/milk and seek dental treatment immediately. If the tooth cannot be restored immediately the fragment should be stored in physiologic saline in the interim period
• Composite crown build-up: Could bevel the edges for more bonding surface area
For a complicated crown fracture (enamel, dentine and pulp) state treatment
- Overall aim is preservation of a vital non-inflamed pulp
- The pulp must be sealed from bacteria so that it is not infected during the period of repair
- In most cases can this be achieved by performing a partial (Cvek) pulpotomy (beyond scope in adults) some specific cases would be appropriate with only Ca OH pulp capping
For pulp capping, state:
- Its 4 indications
- Technique
- 4 reasons for failures
Its 4 indications
· Pulp status normal prior to trauma
· No associated luxation injury with damage to the apical supply
· Pulp exposure less than 1 mm
· Interval between pulp exposure and treatment less than 24 hours
Technique
· Rubber-dam isolation
· Clean fracture surface with sterile cotton pellets and chlorhexidine (without alcohol)
· Dry the exposure site with sterile pellets
· Cover perforation with calcium hydroxide or MTA and apply the protective restoration (temporary restoration, fragment reattachment or composite build up). A bacteria tight seal is essential for success.
4 reasons for failures
· Attempting to treat an inflamed pulp
· Lack of space for a bacterial tight seal
· Breakdown of CaOH, loss of antibacterial properties
· Hard tissue barrier has ‘tunnels’ with vascular inclusions
Explain the management of a crown - root fracture as well as 5 other types of treatments
· In most crown-root fractures, the treatment is to remove the loose fragment
· If the pulp is exposed, RCT must be performed
If the root portion is of sufficient length, one of the following procedures is suggested:
· Removal of coronal fragment and supragingival restoration
· Surgical exposure of the fractured site
· Orthodontic extrusion
· Root burial (when root is left behind, helping preserve alveolar bone)
· Extraction
