Trauma to the permanent dentition part 2 Flashcards
Explain the management of a root fracture, and explain the steps you would take when doing this clinically
· Immediate repositioning of coronal fragment and stabilization with a flexible splint
· Fixation is necessary even if there is no dislocation - as close contact between the fragments is considered essential during the period of initial repair
Steps to performing
· LA, reposition the coronal fragment gently with digital pressure. Take a control radiograph to ensure repositioning is optimal
· Stabilize with a splint
· With middle or apical 1/3 fractures, a splinting period of 4 weeks appears to be sufficient
· Fractures in the cervical 1/3 may require longer periods (up to 4 months)
For concussion and subluxation injuries, define each one and state their management
Concussion
· Injury to tooth-supporting tissues, without displacement or mobility
· Management - No immediate treatment is required, but follow up appointments are important to verify that no associated pulp injury has occurred (Take PA radiograph)
Subluxation
· Injury to tooth-supporting tissues, causing increased mobility but no displacement or mobility. Bleeding from sulcus confirms diagnosis
· Management - No treatment required, however, if mobility detected in both horizontal and vertical direction the tooth may be splinted for 1-2 weeks for the comfort of the patient. (Take PA radiograph)
Explain the treatment for extrusive luxation
· Immediate reposition
· Fixation (1-2 weeks flexible splint)
· Optimal repositioning is essential to healing of periodontal ligament, optimal revascularization and continued root development of immature teeth
· Chlorhexidine, tetanus, antibiotics(?)
For lateral luxation, state the most common type and its management (all steps clinically) BEYOND SCOPE
· Most often a palatal luxation occurs. The apex is displaced buccally and usually forced through the buccal bone
· Apply LA
· Palpate the vestibular sulcus and localize the displaced root apex
· Apply firm, digital pressure in an incisal direction and move the tooth back through the fenestration into the socket (bc may need to ‘jump’ the bony ledge)
· Reposition the tooth back into its original position by axial pressure
· Reposition fractured bone with finger pressure
· Take a radiograph to verify correct position
· Stabilize the tooth with a splint
· Maintain the splint for a minimum of 4 weeks
· Take a radiograph after 4 weeks. If there is signs of marginal bone breakdown the splint is maintained for another 3-4 wks
· Chlorhexidine, tetanus, antibiotics (?)
Intrusive luxations have the most poorest prognosis due to damage to neurovascular supply. State its management for immature and mature teeth
Immature teeth:
· Leave the tooth to re-erupt if less than 7mm. If no movement in 3 weeks use light orthodontic forces to reposition
· Reposition by orthodontic forces or surgical forces more than 7mm
Mature teeth:
· Leave the tooth to re-erupt if less than 3mm
· If no movement in 2 weeks use orthodontic forces or surgical repositioning
· Reposition by surgical forces more than 3mm
· Address the pulpal issue (most likely RCT) within 3 weeks. The chances for pulp necrosis and inflammatory resorption are high
List and explain the 4 main complications that occur after luxation injuries
· Pulp Canal Obliteration: crown will become more yellow. This is more common in primary teeth
· Pulp Necrosis: happens less frequently in immature teeth because they have big apical opening, allowing for slight movements of the apex without disrupting blood vessels. Obtain radiographic evidence 2-3 weeks after trauma.
· Cervical root fractures: occurs due to thin dentinal walls and long time use of calcium hydroxide. Prevalence decreases as age increases
· Root resorption: can be repair related and the tooth has a periodontal ligament space of normal width. Inflammatory resorption is seen most often after re-implantation, and occurs due to cell damage to the PDL and cementum. Here, RCT will arrest the resorption. Next, replacement resorption can occur
Explain why replacement resorption is more problematic for the primary dentition than the permanent
· Treatment: no effective treatment presently
· The progression rate for replacement resorption is slow for patients who have completed adolescent growth
· Prognosis poor for replanted immature tooth compare to mature tooth- ankylosis will disturb growth of the alveolar process in young patients due to infra-position of the tooth- therefore a decoronation/root burial is recommended
Identify what each tooth colour means following a luxation injury
· An immediate pinkish discolouration indicates intrapulpal bleeding and not necrosis
· If discolouration slowly disappears – then the pulp will retain its vita
· If the crown turns progressively gray – necrosis should be expected (the grey colour usually signifies decomposition of pulp)
State the treatment for avulsion (tooth out of socket), including:
- How the public should deal with it
- How clinicians should deal with it
- Post operative care
- Follow up
- General prognosis
How public should deal with it
· The most critical factor related to periodontal healing is the extraoral time. A Danish study reported that replanted teeth within 5 minutes has the best prognosis
· 15-20 minutes seems to be the limit of drying of an avulsed tooth to avoid root resorption
· An avulsed tooth should be stored in a physiologic storage medium until it can be replanted–Eg. Milk, physiologic saline, tissue culture media, organ transplant medium, coconut water
· Pick up the tooth by the crown
· Avoid touching the root (does not contaminate period ligament with foreign cells)
· Push the tooth back in place as quickly as possible
· OR if impossible, place the tooth in a glass of milk (or other storage medium) and get dental help immediately
For clinician
· Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline thereby removing contamination and dead cells from the root surface.
· Administer local anaesthesia
· Irrigate the socket with saline
· Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument
· Replant the tooth slowly with slight digital pressure. Do not use force
· Suture gingival lacerations if present
· Verify normal position of the replanted tooth both, clinically and radiographically
· Apply a flexible splint for up to 2 weeks, keep away from the gingiva
· Administer systemic antibiotics. If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster
· The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the pulp space
· For adult teeth, RCT needs to take place 7-10 days after treatment and before splint removal
Patient instructions
· Soft food for up to 2 weeks
· Brush teeth with a soft toothbrush after each meal
· Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week
Follow up
· For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis
· Splint removal and clinical and radiographic control after 2 weeks
· Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter
Prognosis
· The long term prognosis is POOR
· Ankylosis with subsequent resorption is the expected outcome
· However, fluoride treatment of the root surface will delay progress of the resorption
Explain the management of an avulsed tooth with incomplete root formation
· A replanted tooth with incomplete root formation should be radio-graphed every 2 weeks until necrosis is confirmed or until root formation is evident
· With signs of necrosis (e.g. Inflammatory root resorption) endodontic treatment should be started immediately for immature tooth
· Pulp revascularization is not likely to happen in teeth with a closed apex
· RCT must be started within 1-2 weeks after replantation to prevent onset of inflammatory root resorption
· Replacement resorption (ankylosis) HIGHLY likely and increased chance with longer extra-oral dry time
· Progressive infraocclusion in growing child
Explain how fractures to the alveolar process is ascertained
· To differentiate from a root fracture: change the angulation of the central beam
· In a root fracture the fracture position on the root surface will not change
· In case of an alveolar fracture the line will more up or down
· A bone fracture may disrupt the vascular supply to the teeth, which can result in pulp necrosis
List the 6 treatment options for children who lose their permanent incisors
· Removable prosthesis: plastic denture with Adams clasps for younger children or cast metal partial denture (issue is dento-alveolar bone loss with loss of tooth root)
· Conventional Fixed Prosthodontics: usually have to wait until adult age
· Resin-retained Fixed Prosthodontics: Maryland Bridges can be inserted in growing individuals if a tooth extracted
· Auto-transplantation of premolars e.g. to upper incisor position
· Single implant: must have completed jaw growth and no periodontal ligament means won’t continue to erupt like surrounding teeth
· Decoronation or root burial to preserve bone for future implant (use of removable prosthesis in the interim)
Explain the treatment for alveolar process fractures BEYOND SCOPE
· Repositioning and immobilization of bone-tooth fragment and monitoring of pulp vitality
· LA
· Repositioning of teeth and bone
· Flexible spint for 4 weeks
· Soft diet
· Maxillary and mandibular fractures are reduced and fixed by maxillo-facial surgeons
Explain the process of splinting for dental trauma
· A flexible orthodontic wire (0.032 or 0.016) or fishing line is bent to conform with the buccal surfaces (middle 1/3) of the injured teeth and also to one or two uninjured teeth on either side of the teeth to be stabilized
· Apply phosphoric acid gel for 15-20 sec to the buccal surfaces of the selected teeth
· Rinse with water
· Apply a thin layer of light curing composite
· Attach the wire/fishing line to the uninjured teeth first and thereafter to the injured teeth. Ensure they are in proper position
· Chlorhexidine mouth rinse twice daily for a week
List the 5 things that are conducted during a follow up exam and state how often follow up appointments occur
· Testing of pulp sensitivity · Percussion · Mobility · Tooth colour · Radiographs – peri-radicular condition and changes within the pulp cavity
How often follow up appointments occur
· 1 week, 4 weeks, 3 months, 6 months and 1 year
· Thereafter once a year for 5 years
