Traumatic Injuries Flashcards
Incidence of trauma
- male > female
- maxilla more than mandible
- anterior more than posterior
- falls or accidents near home or school
most common tooth with trauma
max central incisor
crown fractures is a ? types
trauma
- complicated
- INVOLVES PULP - uncomplicated
- no pulp
- fracture of dentin or enamel
- very frequent
if percussion + symptoms are within?
the PDL
clinical examination of non complicated fracture
vital test is +
mobility seems normal
percussion is (-)
radiographic examination for uncomplicated fracture
1 occlusal , 1 mesial, and 1 distal to rule out luxation or root fracture
1 soft tissue laceration - rule ut foreign body
treatment for uncomplicated
SEAL EXPOSED DENTIN ASAP
- minimize bacterail ingress
- reduce patients discomfort
remaining dentin thickness in terms of treatment with uncomplicated fracture
greater than 0.5 mm - normal restorative treatment
less tha 0.5 indirect pulp capping with hard setting calcium hydroxide like dycal
recall for uncomplicated fracture
6-8 weeks, 1 year
complicated crown fracture definition
fracture that includes enamel, dentin, and pulp
*so there is pulp exposure
clinical examination with complicated crown fracture
vital test (+)
mobility - normal
Percussion (-- or percussion (+) -- rule out other types of injuries (luxation or root fracture)
treatment of compicated crown fracture in terms of superficial infection?
time importance?
YES - time is important
first 24 hours bacteria can get into first 2 mm of pulp
after 48 hours – ??
immature vs mature tx for complicated crown fracture
immature
- vital pulp therapy (apexogenesis)
regenerative procedure
NSRCT with apexification (last resort)
CANNOT OBTURATE ON IMMATURE ROOT)
MATURE
- vital pulp theray
- NSRCT
describe vital pulp therapy
removal of inflammed tissue and preserve unaffected tisssue to allow continuous root formation to prevent NSRCT
- disinfect and isolation
- using high speed diamond bur
depth of vital pulp therapy
2mm ( if less than 48 hours) or the level of controllable hemmorrhage
pulp dressing used in vital pulp therapy
MTA
- mineral trioxide aggregate
Pure Ca(OH)2 power mixed with sterile water
- dycal CaOH2
- but not really doing that anymmore – stick with MTA
add bacterial tight seal over pulp dressing
regenerative procedure done when?
on immature root when vital pulp therapy not applicable
following appropriate disinfection, a blood clot matrix was established in the root canal space to encourage residual apical stem cell to migrate and regeneratte ulp tissue and therefore apexogenesis
aexification done when?
on immature root when vital therapy is not applicable or regenerative is not
using MTA
- need to basically form a plug that you can the pack gutta percha against
recalls with complicated root fracture?
6-8 weeks, 1 year
what is involved in a crown - root fracture
enamel, dentin, cementum
may or may not involve the pulp
clinical exam of crown- root fracture will likely include ? why?
Vital (+)
mobility (+, coronal fragment)
Percussion (+) – because of root involvement
radiographic examination of crown root fracture
1 occlusal, 1 meial , 1 distal
CBCT considered
Treatment to crown root fracture
similar to crown fracture of complicated / uncomplicated – if pulp exposure apexogensis on immature and RCT on mature
deeply positioned root fracture?
concerns about restorability
- may need gingivectomy, crown lengthenin procedure, orthodontic or surgical extrution to expose the subgingival fracture site
recalls for crown and root fracture
6-8 weeks, 1 year
root fractures rare on?
deciduous or immature teeth
describe root fracture
coronal fragment is usually mobile and sometimes displaced, similar to luxation injuries
apical segment is usually NOT displaced - the apical part usually survives due to the minimally affected blood circulation and well protected environment
necrosis in root fractures?
usualy only 25 % of the coronal fragment turns nectroic because of the collateral blood supply in the area
vitality in root fractuer?
may be (-) because of the transient pulp damage
GIVE IT TIME TO HEAL BEFORE YOU ASSUME NECROTIC
radiogrpahic exam for root fracture
1 occlusal, 2 PA with varying horizontal angles
CBCT considered helpful with fracture at middle 1/3 with an oblique of fracture involving the cervical third in the labiolingual dimension
treatment for root fracture
splint for 4 weeks or longer with FLEXIBLE SPLINT
- if symptomatic – treat top part
recalls for root fracture
4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, yearly for 5 years
4 major types of root healing ***
- healing with calcified tissue
- healing with interproximal connective tissue
- healing with interproximal bone and connective tissue
- interproximal inflammatory tissue WITHOUT healing
splinting time with root fracture AND WHY
flexible splint for 4 weeks or longer
- not Ni
- BUT STAINLESS STEEL WORKS
- do not want to cause resorption
root fracture what is important?
GIVE IT TIME IF NO SYMPTOMS – let it heal – can stay vital
- but if symptomatic –> treat the coronal aspect
root fracture what is important?
GIVE IT TIME IF NO SYMPTOMS – let it heal – can stay vital
- but if symptomatic –> treat the coronal aspect
breakdown of luxation injuries
- concussion
- subluxation
- extrusion
- lateral luxation
- intrusion
concussion vs subluxation
subluxation will present with GINGIVAL BLEEDING AROUND THE SULCUS
- all other clinical test of vitality (+), tender to percusssion and biting with no mobility will be the same
Imaging for concussion and subluxation
2 PA’s aat different angulations
treatment for concussion?
time and diet (soft foods) and good oral hygeine
treatment for subluxation
relief occlusion and splinting is not necessary unless patient is not cofortable – but no more than 2 weeks!!
recalls for concussion and subluxation
2 weeks, 4 weeks, 6-8 weeks, 6 months, 1 year, yearly for 5 years
extrusion definition
out of socket
clincial tests in extrusion likely will be
vitality (-)
percussion (+)
elongated tooth
excessively mobile
radiographs all reveal widened PDL space
general rule for splinting
2 weeks!!
treatment for extrusion
rinse area
reposition and take x-ray
splinting but no more than 2 weeks!! – flexible splint
monitor pulp status – if necrois and immature - try apexification or regeneration if mature – RCT
RECALL IS IMP.
lateral luxation clinical distinguishing feature?
Percussion – will sound metallic – ankylotic tone
lateral luxation displaced?
into bone usually - laterally (M-D or B-L)
- sometimes with alveolar bone fracture
treatment for lateral luxation
rinse area – reposition and unlock from bone – take an x ray and splint for two weeks with flexible
- 4 if extensive
- watch for necrosis!
- monitor pulp status – if necrois and immature - try apexification or regeneration if mature – RCT
what type has worst prognosis?
intrusive luxation
intrusive luxation
the tooth is displaced apically and us usually locked into bone
- usually alveolar bone fracture
high metallic sound – ankylotic tone on percussion
poorest pulpal and periradicular prognosis
which may have an ankylotic tone on percussion?
intrusive luxation
lateral luxation
which could show no PDL space anymore
intrusive luxation
intrusive luxation clinical features
vital (-)
percussion (+)
locked into bone - no mobility
infra-occluded
fracture of the alveolar bone may be palpable
treatment for immature intrusive luxation
important number??
if LESS THAN 7MM – allow for passive erruption
- if no movement initiate endo treatment within 3 weeks
if GREATER THAN 7 –> reposition surgically or initiate ortho treatment within 3 weeks, flexible splint for 2 weeks (up to 4 if needed/ extensive)
monitor pulp – if necrotic – apexificatino or revascularization
treatment for MATURE intrusive luxation
important numbers?
if less than 3 mm and patient is under 17 years old - allow for passive eruption if no movement within 2-3 weeks – reposition surgically or orthodontically before ankylosis occurs
if 3-7 mm - reposition surgically or initiate ortho with flexible splint for 2 weeks (up to 4 if needed)
greater than 7 mm initiate surgical repositioning and sploint for 2 weeks
necrosis most likely to occur with what injury?
intrusive luxation in a mature tooth – so pulpectomy 2 weeks after injury and leave Ca(OH) 2 in for 4 weeks, then finish RCT
what do you need to be careful of in repositioning a deciduous tooth that intrusive occured on?
the dental follicle of the perment tooth
what could also look like avulsion?
intrusion – tooth maybe all the way in the socket
when is avulsion usually occuring?
youonger because not completely formed – immature root development
trauma includes what in avulsion?
PDL teat, residual PDL on root surface, cemental damage and pulpal necrosis
prognosis depends on what in avulsion
extra-oral period and handeling which determine the extend of peri-radicualr inflammation
tx considerations based on
- extra oral time
2. the stages of root development
if decidous tooth what is tx for avulsion
NONE - because of high risk of demaging the underlying permanen dentitino
- if already back in - leave it
place tooth in what? best to worst?
- hank’s balanced salt solution
- physiologic slaine
- milk
- saliva
- water
to promote the survival of PDL
time to consider in treatment of mature alvused teeth
60 minutes!
treatment for mature avulsion if under 60 or over 60
under 60
- examine
-rinse with saline
reposition and take x-ray and have splint for 2 weeks
start root canal therapy within 7-10 days
CaOH 2 for 4 weeks and corticosteroids for 2
if over 60 - everything is the same except rinse with 2.4% Na Fluoride for 20 minutes before repositioning!!!
treatment for immmature avulsion if under 60 or over 60
under 60
- examine
- SOAK IN DOXYCYCLINE OR MINOCYCLINE
- reposition and take x-ray
- flexible splint for 2 weeks
- moitor – if necrosis - apexification or revascularization
over 60 - examine - rinse with SALINE - reposition and take an x-ray - FLEXIBLE SPLINT FOR 4 WEEKS -
why put fluoride on mature tooth if out for more than 60 minutes
decrease chance of anklylosis
cases we can splint for 4 weeks ***
- root fracture
- extensive intrusion
- immature avulsioned tooth that has been out for over 60 minutes
anklyosis in immatuer tooth what should you do
decoronatino so we keep something in the bone socket until we can place an implant later on
avulsion, extensive intrusion, and root fracture and alveolar fracture all have what in common
can splint for 4 weeks
systemic antibiotics in?
avulsion
if over 12 - doxycycline for 7 days
if under 12 amoxiciilin for 7 days
.12% CHX rinse BID for 2 weeks
recall is 2 weeks, 4w, 3m, 6m, 1 year, yearly for 5 years
alveolar fracture details
usually more than 2 teeth are involved and more likely the mandibular anterior region
partial fracture or communication of labial or lingual plates is common to lateral luxation
clinical exam in alveolar fracture
could be at any level - more than one tooth involved
could see mobility with teeth involved
could have occlusal interferences
displacement of alveolar segment
get PA’s of different angulations and CBCT for extension and direction of fractue
splinting time for root fracture
4 weeks up to 4 months
tx plan for alveolar fracture
reposition fragment ASAP and stabalize with a flexible splint for 4 weeks
chances of necoriss in alveolar fracture
if fracture line involves root apices – higher chance of necrosis
Types of Periodintal healing
- SURFACE RESOPRTION– if limited to PDL and cementum lie in concussion or subluxation – followed by new repair cementum and PDL is resulted (no treatment)
- INFLAMMAOTRY RESORPTION - moderate injury to PDL and cementum is accompanied by pulpal infection through dentinal tubules
- new repair expected once infection is removed - ## REPLACEMENT RESORPTION — DENTOALVEOLAR AKLYOSIS – if extensive injury to PDL and cementum (over 20% of root surface) like intrusion or alvulsion
types of pulpal response
- pulp necrosis
- internal resorption – but could have necrosis above or below that
- PULP CANAL OBLITERATION – one year after traums - more common in open apices
- PULPAL REVASCULARIZATION
- PULPAL REVASCULARIZATION
