Paeds Trauma- Assessment, Classification And Management Of Crown Fractures

Question 1

What type of trauma injuries are most common in the primary dentition?

Answer 1

Luxation

Question 2

What is the most common type of trauma injury in the permanent dentition?

Answer 2

Enamel-dentina fracture

Question 3

What size of overjet doubles the incidence of trauma to permanent teeth?

Answer 3

9mm overjet doubles trauma incidence

Question 4

Which 3 conditions should you be aware of when taking a medical history of trauma patient?

Answer 4

Rheumatic fever
Congenital heart defects
Immunisuppression

Question 5

Describe things to look for when carrying out extra oral exam?

Answer 5

Any other injuries (non dental)

Lacerations
Haematomas
Haemorrhage / CSF
Subconjunctival haemorrhage
Bony step deformities
Mouth opening (jaw fracture possible if limited)

Question 6

What should you look for when carrying out Intra oral exam of trauma patient?

Answer 6

Soft tissue
Alveolar bone
Occlusion
Teeth
Penetrating wounds/foreign bodies

Question 7

What may be indicated by tooth mobility?

Answer 7

Displacement of tooth
Root fracture (tooth will be shorter, more mobile)
Bone fracture (often multiple mobile teeth and overlying soft tissue moving with it)

Question 8

What is included in a trauma stamp?

Answer 8

Sinus (draining/ non-draining)
Colour
TTP
Mobility (give a grade)
EPT
ECL
Percussion note
Radiograph

Question 9

What does the colour of the tooth indicate?

Answer 9

Dark grey/ brown- non vital
Pink- internal resorption/ pulpal bleeding (this can turn to purple as blood products are broken down)
Yellow- pulp canal obliteration (reparatory deposition of dentine)

Question 10

How long should you continue to carry out sensibility testing after trauma?

Answer 10

At least 2 years

Question 11

Outline the classification of fractures

Answer 11

Enamel
Enamel- dentine
Enamel- dentine- pulp
Uncomplicated crown root fracture
Root fracture (apical/ middle/ coronal third)
Complicated crown root fracture

Question 12

What 5 factors does prognosis of fractured tooth depend on?

Answer 12

• stage of root development
• type of injury
• if PDL is damaged
• time between injury and treatment
• presence of infection

Question 13

Why is there a higher chance of maintaining vitality in open apex tooth?

Answer 13

Larger neurovascular bundle at the apex, more able to revascularize.

Question 14

What are the 5 main principles of emergency treatment

Answer 14

Aim to retain vitality of any damaged tooth by protecting exposed dentine by an adhesive definite bandage

Treat exposed pulp tissue

Reduction and immobilisation of displaced teeth

Tetanus prophylaxis

Antibiotics?

Question 15

What are the intermediate principles of treatment

Answer 15

• ongoing management of splinting, loss of vitality, restorations
• pulp treatment (direct/ indirect pulp cap, pulpotomy, pulpectomy)
• restoration (minimally invasive eg. Acid etch)

Question 16

What are the principles of permanent treatment

Answer 16

Apexigenesis (maintain vitality of radicular pulp for root development - thickening of root dentinas walls)
Apexification
Root filling (+/- root extrusion)
Gingival and alveolar colla modification if required
Coronal restoration

Question 17

What is and how is an enamel fracture managed?

Answer 17

Confined to enamel, no dentine tubules exposed, lack of sensitivity

• Bond fragment to tooth OR grind sharp edges
• take 2 periapical radiographs to rule out luxation/ root fracture
• follow up 6-8 weeks, 6 months and 1 year

Question 18

What is the prognosis of pulpal necrosis in an enamel fracture?

Answer 18

0% risk pulpal necrosis

Question 19

How is an enamel-dentine fracture managed?

Answer 19

• account for fragment
• either bond fragment to tooth OR place composite bandage (line restoration if close to the pulp)
• take 2 periapical radiographs to rule out luxation/ root fracture
• radiograph any lip/ cheek lacerations to rule out embedded fragment
• sensibility testing and evaluate tooth maturity (ethyl chloride and EPT)
• definitive restoration
• follow up 6-8 weeks, 6 months and 1 year

Question 20

What is a composite bandage?

Answer 20

Small, easily applied composite restoration to seal dentinal tubules

Question 21

What is an adhesive dentine bandage?

Answer 21

Anything which will close dentinal tubules so no fluid movement which would irritate the pulpal tissues/ ingress bacteria.

Question 22

What is the prognosis of the pulp in ED fracture

Answer 22

5% risk of pulpal necrosis at 10 years

Question 23

At follow up appointments, what should be reviewed

Answer 23

Trauma sticker

Radiographs- look at root development (width/ length of canal) compared to contra lateral tooth, internal and external inflammatory resorption (change to outline of external root surface/ internal canal surface), periapical pathology (darkening around apex)

Question 24

How are enamel-dentine-pulp fractures managed?

Answer 24

Evaluate exposure (size of pulp exposure, time since injury, associated PDL injuries)
Choose from following options:
- pulp cap (setting CaOH or GI-not ideal)
- partial pulpotomy (Cvek pulpotomy)
- full coronal pulpotomy

Avoid full extirpation unless the tooth is clearly non-vital

Question 25

What is the main aim in hound patients with open apices in EDP fracture

Answer 25

it is very important to preserve the pulp vitality by pulp capping or partial pulpotomy in order to secure further root development. setting CaOH and MTA are suitable materials for this procedure.

Question 26

For EDP fracture, when would a direct pulp cap be placed?

Answer 26

A small exposure (1mm), within 24 hour window.

Question 27

Outline the procedure of direct pulp cap

Answer 27

- trauma sticker and radiographic assessment - should be non-TTP and + to sensibility testing - LA and rubber dam - clean area with water then disinfect area with sodium hypochlorite - apply CaOH (Dycal) or MTA (white) to pulp exposure - restore tooth with quality composite restoration - review at 6-8 weeks, 6 months, 1 year (reassess trauma stamp and radiographs)

Question 28

In EDP fracture, when is partial pulpotomy carried out

Answer 28

Larger exposure (>1mm), 24+ hours since trauma

Question 29

Outline the procedure for partial pulpotomy (Cvek pulpotomy)

Answer 29

- trauma stamp and radiographic assessment - LA and dental dam - clean area with saline then disinfect area with sodium hypochlorite - remove 2,, of pulp with high speed, round diamond bur - place saline stacked CW pellet over exposure until haemostasis is achieved - (if no bleeding, or can't be arrested, proceed to full coronal pulpotomy as nerve is inflamed and unlikely to maintain vitality- irreversible pulpitis) - otherwise, apply CaOH then GI (or white MTA) then restore with quality composite resin. - review in 6-8 weeks, 6 months, 1 year (clinical and radiographic review)

Question 30

In EDP fracture, when is a full coronal pulpotomy carried out?

Answer 30

Being with partial pulpotomy, assess for haemostasis after application of saline soaked cotton wool, If hyperaemic OR necrotic, proceed to remove all of coronal pulp

Question 31

Outline the procedure of full coronal pulpotomy

Answer 31

Remove all of coronal pulp Place setting CaOH in pulp chamber Seal with GIC lining and quality coronal restoration

Question 32

What is the aim of pulpotomy

Answer 32

Aim is to keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of dentine

Question 33

If the tooth is non-vital (EDP fracture) what is the last resort of treatment?

Answer 33

Full pulpectomy is required.

Question 34

What is the issue with carrying out a full pulpectomy on an immature tooth?

Answer 34

There is no apical stop to allow obturación with GP

Question 35

What are the 3 options of material to use for immature tooth full pulpectomy?

Answer 35

CaOH in canal (monthly basis) aiming to induce hard tissue barrier to form (apexification) MTA/ BioDentine placed at apex of canal to create cement barrier (apical pulp) Regenerative endodontic technique to encourage hard tissue formation at apex (stimulating of periapical bleeding to encourage hard tissue formation- only done in very young patients)

Question 36

What is a disadvantage of using CaOH

Answer 36

Increases chance of root fracture as CaOH increases brittleness of root

Question 37

Outline the procedure of a pulpectomy on an open apex

Answer 37

- rubber dam - access - haemorrhage control (LA/ sterile water) - diagnostic radiograph for WL (especially important for apical plug placement- radiograph + apexificator) - file 2mm short of estimated WL - dry canal, non-setting CaOH, CW in pulp chamber - glass ionomer temporary cement in access cavity and evaluate CaOH fill level with radiograph (ensure to appropriate length, minimise extrusion of material into periapical tissue (post op pain), ensure no clear voids (results in calcific barrier formation- hard tissue) - exptipate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital (due to increased brittleness) - MTA plug and heated GP obturation - usually wide canals - lateral compression is very time consuming - consider coronal restoration as bonded composite a short way down the canal to increase SA

Question 38

What are the treatment options for a crown- root fracture with pulp exposure?

Answer 38

- can be temporised with composite for up to 2 weeks - fragment removal and gingivectomy (indicated in crown- root fractures with palatal subgingival extension) - ortho extrusion of apical portion (ends, extrusion, post crown) - surgical extrusion - decoronation (preserve bone for future implants) - extraction

Question 39

What are the treatment options for a crown- root fracture without pulp exposure?

Answer 39

- fragment removal only and restore - fragment removal and gingivectomy - ortho extrusion of apical portion - surgical extrusion- reposition tooth manually - decoronation - extraction