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CONS > Traumatised teeth > Flashcards

Traumatised teeth Flashcards

1
Q

List the different types of dental injuries that an adult permanent tooth may sustain

A

Crown fracture
Crown-root fracture
Root Fracture
Concussion and subluxation
Extrusion and lateral luxation
Intrusion
Avulsion
Soft tissue injuries

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2
Q

Obtain, record, and interpret a comprehensive contemporaneous patient history (following trauma)

A

When, where, how? Any other injuries? Initial treatment? Lost teeth/fragments recovered? (Assault? Medicolegal responsibilties? Careful notes / Photographs?)

Loss of consciousness? , amnesia, headache, nausea, vomiting

Disturbance to the occlusion

Reaction to hot or cold

PDH: ? Previous dental injury

PMH: Allergies or illnesses, Tetanus status-do they need a booster?
The medical history should reveal possible allergies, blood disorders and other information that may influence treatment. The dental history should indicate previous dental traumas, information which may explain radiographic findings such as pulp canal obliteration or apical pathology

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3
Q

Undertake relevant special investigations and diagnostic procedures, including radiography (following trauma)

A

Examination

“Vitality” Sensibility Testing (ept endo frost)

Radiographs

Photographs (need written consent from patient)

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4
Q

Examination

A

Examination- Clean the face and the oral cavity with water or saline. If there are soft tissue wounds, a mild detergent should be used. This cleaning will make the patient feel more comfortable and facilitate extra oral and intra oral examination

Clinical examination

Extra oral: soft tissues-abrasions/lacerations, obvious abnormalities, palpate facial skeleton if concerned(stand behind pt)/you are 1st to treat/see pt following trauma
Soft tissues-look and palpate if necessary-?tooth fragment in lip or soft tissues, ?lacerations to gingiva/abrasions
Hard tissues-?tooth #, ?displacement, mobility, Tender to percussion, ankylosis tone
Occlusion-normal/abnormal, if unsure ask patient does their bite feel different

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5
Q

Radiographic examination

A

Soft tissues (if indicated) e.g. Suspect presence of tooth fragment/foreign body such as glass

Anterior Occlusal

Intra-oral periapical – parallax if suspect root #

OPG if indicated e.g. Suspicious of # mandible etc

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6
Q

What are the aims of emergency attendance?

A

Relieve pain
Dress # teeth, treat pulp exposure
Reduction and immobilisation of displaced teeth
Antiseptic mouthwash +/- antibiotics

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7
Q

How to arrive at a treatment plan?

A

History
Examination
SI
Diagosis
Treatment plan

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8
Q

Types of crown fracture and describe each

A

Crown infractions-incomplete fracture of enamel without loss of tooth structure
vitality test and IOPA, if ok then monitor no treatment needed

Uncomplicated/Simple crown fracture –enamel # or enamel/dentine # pulp not exposed.

Complicated fracture – enamel & dentine # and pulp is exposed

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9
Q

Types of dental fracture

A

Crown fracture
Enamel fracture

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10
Q

Uncomplicated/ simple crown fracture

A

enamel # or enamel/dentine # pulp not exposed.
A fracture confined to enamel and dentine with loss of tooth structure, but not involving the pulp.

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11
Q

Describe the management of each type of crown fracture- simple/ uncomplicated crown fracture

A

Always Vitality test, percussion test, IOPA (baseline information)

If small enamel fracture:
Smooth if very minimal or etch bond and composite

If larger enamel/dentine with no exposure and pulp pathology-free prior to injury:
Etch bond and composite/bond tooth fragment
(consider use celluloid crown former-odus pella)

If very close to pulp but no exposure
consider indirect pulp cap with calcium hydroxide (e.g. dycal) before restoring with composite or bonded tooth fragment

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12
Q

Clinical procedure of dealing with uncomplicated/ simple crown fracture

A

Clinical procedure:

Bevel fractured incisor
Etch enamel and dentine

Re-bond tooth fragment- (Make sure # portion is clean!
Bevel fragment and tooth, then etch bond and use composite(match shade) to bond fragment to tooth and light cure
If obvious # line can drill a gutter and re-bevel and then add in composite)

Restore with composite resin
Shape and polish

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13
Q

How to deal with a complicated fracture

A

If larger enamel/dentine fracture and pulp pathology-free prior to injury:
with small exposure (<2mm)
AND
< 24 hours since injury

Dycal pulp cap and restore with composite resin or rebond tooth fragment

Consider newer materials for pulp capping: MTA or Biodentine

If pulp pathology-free prior to injury, + good blood supply to pulp(i.e young pt, immature tooth)
AND
Big exposure
But < 24 hours since injury
Rx: Partial pulpotomy (2mm) cover with Dycal and restore with composite resin (rubber dam mandatory)

Consider newer materials for pulp capping/pulpotomy-Biodentine?

If fully developed root (adult patient) and large exposure or >24hours since injury extirpate pulp and carry out 1st stage RCT.

Interim GIC/composite dressing

Final Coronal Restoration will be required after RCT completed

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14
Q

(doesn’t say to explain it on LO)
Explain process of carrying out partial pulpotomy

A

Remove 2mm of coronal pulp under rubber dam, moisten cotton pellet with saline then apply to area until haemostasis achieved. Apply dycal, vitrebond and then composite restoration

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15
Q

Emergency treatment of a crown root fracture?

A

Splint fractured tooth to adjacent teeth to relieve pain on biting (functional splint), (One tooth either side of affected tooth)

Ideal splint is twist flex wire and composite (Trim wire to size, spot etch, bond and attach with composite)

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16
Q

Post-Immediate Treatment

A

Remove coronal fragment and assess restorability

+ gingivectomy
+ osteotomy

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17
Q

Overview of how to deal with a crown root fracture

A

Coronal fragment is removed
Subgingival fracture line

Fabricate post and core with diaphragm

Final post-retained

If unrestorable by these means:

Remove fractured coronal fragment and extrude root surgically or by orthodontic extrusion

Consider extraction in cases of extensive crown-root fractures which extend very subgingivally

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18
Q

Management of a root fracture and healing?

A

Reposition coronal fragment and splint non-rigidly for 10 days to stabilise position-can leave splint on up to 4 weeks
Vitality testing and review at
3 weeks
6 weeks
3 months
6 months

Healing
May occur by internal root resorption at site of root fracture
No treatment required, but regular monitoring to determine if coronal pulp has become non-vital
60% of teeth undergo pulp canal obliteration of coronal and apical root canals - monitor

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19
Q

Management of root fracture and pulpal necrosis

A

Pulpal Necrosis
Can present with pain and swelling
Resorption of bone at level of root fracture
Will require RCT of coronal fragment only
Dress with non-setting calcium hydroxide
Calcific barrier will form after 6-12 months
Then obturate with Gutta Percha
Do not instrument apical root fragment

19
Q

Management of root fracture and pulpal necrosis

A

Pulpal Necrosis
Can present with pain and swelling
Resorption of bone at level of root fracture
Will require RCT of coronal fragment only
Dress with non-setting calcium hydroxide
Calcific barrier will form after 6-12 months
Then obturate with Gutta Percha
Do not instrument apical root fragment

20
Q

Management of concussion and subluxation

A

Remove occlusal interferences
Soft diet
If tooth uncomfortable to bite on splint non-rigidly for < 2 weeks (usually 10-14 days)
Vitality tests:
At time of injury
1 month
2 months
Good Prognosis

21
Q

not in LO Prognosis of a root fracture

A

Root fractures in cervical third have poorer prognosis and may require permanent splinting.
More likely to become infected via gingival sulcus
25% of teeth with root fractures will become necrotic

22
Q

not in LO
Concussion - what are they, what to they cause and presentation?

A

These are minor traumatic injuries to the teeth
Concussion:-An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion.
Impact causes haemorrhage and oedema of periodontal ligament
Tooth TTP and on biting

23
Q

not in LO subluxation- what is it, what does it cause

A

Minor traumatic injuries to the teeth
Caused by greater impact
Some periodontal ligament fibres are ruptured, tooth loosened – but not displaced, slight bleeding from gingival crevice.

24
Q

What is extrusion not in LO

A

An acute impact forces tooth partially out of socket
Periodontal ligament and pulp ruptured
Tooth displaced from socket-usually very loose

25
Q

Management

A

Radiographs -Anterior occlusal and IOPA’s
Repositioning under LA
Stand behind patient, free apical lock, finger in buccal sulcus, feel click as apex released, reposition apically back into socket

Splint non-rigidly for 3 weeks
Clinical and radiographic review at 3 weeks
If signs of external root resorption, carry out RCT and dress canal with non-setting calcium hydroxide

26
Q

Intrusion

A

This injury indicates maximum damage to the pulp and supporting tissues
Tooth driven up into alveolar process

27
Q

Intrusion diagnosis

A

Difference in incisal heights between intruded and non-intruded teeth
Check buccal sulcus above tooth-might see/feel bulbosity
Percussion – high metallic tone of ankylosis as apex impacted into bone

28
Q

Healing

A

This injury causes extensive damage to the periodontal ligament leading to progressive external root resorption
Damage to the pulp leads to internal root resorption
Management aims to limit this damage

29
Q

Intrusion if immature root formation

A

Spontaneous re-eruption may be anticipated over several months

If after 10 days, no sign of movement, give LA and release tooth with forceps

Monitor pulpal healing with radiographs 3,4,6 weeks post-injury

30
Q

Pulpal necrosis with intrusion

A

If symptoms, periapical radiolucency or inflammatory root resorption, carry out RCT and dress with non-setting calcium hydroxide.
Pulp necrosis is very common

31
Q

Intrusion If mature root development

A

Spontaneous re-eruption is unpredictable/unlikely
Carry out immediate orthodontic extrusion over 2-3 weeks.
Carry out RCT as 100% of teeth become non-vital, dress with CaOH2

32
Q

Prognosis

A

58-70% of teeth will exhibit root resorption
Ankylosis can occur 5-10 years following injury
Long review period required

33
Q

What is avulsion

A

Total dislocation of tooth from socket
Most common injury in young dentition as root development incomplete and periodontium is very resilient

34
Q

Avulsion - healing depends on

A

Length of extra-alveolar period
Storage of the tooth out of the socket

35
Q

Avulsion- replantation

A

Do not attempt if

Gross caries of tooth
Major loss of periodontal support
Other life-threatening injuries prevent treatment
Contraindicated by PMH

36
Q

Management of avulsion

A

If out of mouth < 1 hour and stored in suitable medium (saliva, milk, saline) replant and splint
Replant tooth with gentle finger pressure (May need LA for this)
Splint non-rigidly for 1 week

Antibiotic therapy
Check tetanus status, may need to refer to GP for booster

37
Q

If root formation incomplete (apical foramen > 1 mm)

A

Pulp revascularisation is a possibility

38
Q

If root formation complete (apical foramen < 1 mm)

A

Mature teeth with a dry storage time > 1 hour will have a non-vital PDL

Remove necrotic PDL, Extirpate the pulp at chairside and obturate with GP, rinse root with saline and replant, splint for 4 weeks

Aiming for ankylosis

39
Q

Complications which might follow trauma to teeth and types

A

Root resorption

There are 2 types of resorption
Inflammatory
(i)internal (ii) external
Replacement [ankylosis]

40
Q

(inflammatory) External root resorption- diagnosis is by

A

asymmetrical radiolucent shape of surface of root with intact root canal walls

41
Q

Internal root resorption

A

diagnosis is as a ballooning of root canal with intact root surface

42
Q

Treatment of both types of inflammtory resorption:

A

thorough mechanical and chemical debridement, dress with non-setting calcium hydroxide paste(hypocal) in order to halt the process

If cessation of resorption then obturate but if continues then extract tooth

43
Q

Ankylosis what is it and how to check for it

A

also known as “replacement resorption”

progressive resorption of tooth structure and its replacement with bone as part of continued bone remodelling

Check for it clinically- dull sound to percussion

Check on radiograph- loss of lamina dura

44
Q

Management

A

It CANNOT be treated, tooth should be kept in mouth for as long as possible if it has to be extracted make plans for permanent prosthetic replacement

45
Q

Long term management of traumatised teeth

A

Monitor teeth after RCT check for problems clinically and radiographically
Resorption- remember types
Inflammatory-external and internal root resorption
Replacement-ankylosis

46
Q

Long term treatment planning

A

Remember that replacement of the damaged tooth by a dental implant may be a possibility in the future
‘Tooth Years’
Aim to maintain bone quantity – height and width for any potential implant placement

CONS (10 decks)

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