Trauma Flashcards
1
Q
What are the most likely circumstances (e.g. age, gender, teeth) to experience trauma to primary teeth?
A
- more common in males
- maxillary primary incisors most commonly affected
- peak incidence between 2-4 years old
2
Q
What are the most common reasons for traumatic dental injuries in the primary dentition?
A
- falls
- bumping into objects
- non-accidental
3
Q
What injuries can occur to the dental hard tissues and pulp?
A
- enamel fracture
- enamel and dentine fracture
- enamel, dentine and pulp fracture
- crown-root fracture
- root fracture
4
Q
What injuries can occur to the supporting tissues (periodontium, bone)?
A
- concussion
- subluxation
- lateral luxation
- intrusion
- extrusion
- avulsion
- alveolar fracture
5
Q
Which fractures are considered complicated?
A
- any fracture involving the pulp
- enamel, dentine and pulp fracture
6
Q
What is a crown-root fracture
A
- fracture involving enamel, dentine and root
- may or may not have pulpal involvement
- determines whether complicated or uncomplicated
7
Q
What is concussion?
A
- PDL injury
- tooth tender to touch
- has not been displaced from line of arch
- normal mobility
- no bleeding into gingival sulcus
8
Q
What is subluxation
A
- PDL injury
- tooth tender to touch
- increased mobility
- not displaced from line of arch
- bleeding into gingival sulcus
9
Q
What is lateral luxation?
A
- tooth displaced in a palatal/lingual or labial direction
- any direction other than axial
- comminuted or fractured alveolar socket
10
Q
What is intrusion?
A
- tooth usually displaced through the labial bone plate
- can impinge on permanent tooth bud
- comminuted or fractured alveolar socket
11
Q
What is extrusion?
A
- partial displacement of the tooth out of its socket
12
Q
What is avulsion?
A
- tooth is completely displaced out of its socket
- must determine location of tooth
- most commonly lost out of the mouth
- can be ingested or inhaled
- can be embedded in surrounding soft tissues
- must determine location of tooth
13
Q
What is alveolar fracture?
A
- fracture involving the alveolar bone
- labial and palatal/lingual
- may extend to adjacent bone
- mobility and dislocation of segment common
- occlusal interference usually present
14
Q
What is the most common type of injury in the primary dentition?
A
- luxation injuries
15
Q
What does a trauma examination involve?
A
- reassurance
- history
- examination
- diagnosis
- emergency treatment
- important information
- further treatment and review
16
Q
How can a patient be reassured after a traumatic dental injury?
A
- distressing for parent and child
- often also first visit to dentist
- not planned
- adds to anxiety
17
Q
How do you take a trauma history?
A
- injury
- when did it happen?
- time interval determines prognosis - where did it happen?
- tentanus prophylaxis
- further investigation - how did it happen?
- nature of accident
- indicates type of injury to expect
- discrepancy can indicate abuse - any other symptoms or injuries?
- concussion
- headache
- vomiting
- amnesia
- brain injury must be excluded
- if suspicious refer to hospital - lost teeth/fragments?
- if lost but not accounted for chest radiograph required
- need to determine where
- when did it happen?
- medical history
- congenital heart disease
- history of rheumatic fever or immunosuppression
- bleeding disorders
- haematological team must be contacted - allergies
- short course of antibiotics may be required - tetanus immunisation status
- no vaccine or booster required
- dental history
- previous trauma
- can explain baseline clinical and radiographic findings
- repeated injury can indicate neglect or abuse - treatment experience
- ability to cope in past - legal guardian and child attitude
- how easy is it attending for the family?
- previous trauma
18
Q
What does an extra oral examination for dental trauma involve?
A
- swellings
- bruising
- lacerations
- may require debridement and suturing
- haematoma
- haemorrhage
- subconjunctival haemorrhage
- bony step deformities
- mouth opening
- limited mandibular movement/mandibular deviation
- can indicate jaw fracture or dislocation
19
Q
What does an intra oral examination for dental trauma involve?
A
- soft tissue
- lacerations
- haematomas
- penetrating wounds
- suspicion of foreign bodies
- alveolar bone
- evidence of fracture
- occlusion
- teeth well interdigitated
- does bite feel normal to patient?
- teeth
- charted
- injuries recorded
- mobile
- tooth displacement
- root or bone fracture - transillumination
- fracture lines (crazing)
- pulpal degeneration (particularly palatally)
- caries identification - tactile test with probe
- detect horizontal and vertical fractures
- detect pulpal involvement - percussion
- dull sound in case of root fracture - occlusion
- if traumatic requires urgent treatment - sensibility tests
- thermal (ethyl chloride, warm gutta-percha)
- electrical (electric pulp tester)
20
Q
What is a trauma stamp?
A
- measure of all of the factors requiring monitoring
- mobility
- colour
- TTP
- sensibility tests
- presence of a sinus
- percussion note
- radiograph obtained at visit
21
Q
What radiographs may be used to assess dental trauma?
A
- periodical
- anterior occlusal
- lateral pre-maxilla
- extraoral
- panoramic
- soft tissue view
22
Q
What is often the most appropriate option for emergency treatment in the primary dentition? When is this option not appropriate?
A
- observation
- not appropriate
- risk of aspiration or ingestion
- occlusal interference
23
Q
What advice should be given on home care?
A
- analgesia
- ibuprofen and/or paracetamol
- soft diet
- 10-14 days
- normal diet but cut everything small
- chew with molars
- brush teeth with soft toothbrush
- after every meal
- topical chlorhexidine gluconate 0.12% mouthrinse
- topically twice daily
- one week
- separately to toothbrushing
- applied with gauze or cotton bud
- advise on signs of infection
24
Q
How are enamel fractures managed?
A
- smooth sharp edges
- soflex disc
- bond fragment to tooth
25
How are enamel-dentine fractures managed?
- cover exposed dentine
- glass ionomer or composite
- restore lost tooth structure
- composite
- immediate or subsequent visit
- bond fragment to tooth
- radiograph lacerations if fragment has not been located
- evaluate tooth maturity
- sensibility test
26
How are enamel-dentine-pulp fractures managed in primary teeth?
- partial pulpotomy
- some of the coronal pulp is removed
- non setting calcium hydroxide paste over pulp
- thin layer of glass ionomer cement
- restored with composite
- cervical pulpotomy if larger exposure
- extraction
- LA required for both
- both invasive
- risk of long term dental anxiety
- dependent on maturity level of child
27
How are crown-root fractures managed?
- removal of loose fragment
- determine whether crown can be restored
- restorable
- no pulp exposed
- cover exposed dentine with glass ionomer
- pulp exposed
- pulpotomy
- endodontic treatment (level of fracture/root development)
- unrestorable
- extract loose fragments
- don't dig
- do not damage permanent successor
- firm fragments left in situ
28
How are root fractures managed?
- if coronal fragment is not displaced
- no treatment
- if coronal fragment displaced but not excessively mobile
- leave coronal fragment to spontaneously reposition
- even if interfering with occlusion
- if coronal fragment displaces, excessively mobile and interfering with occlusion
- extract only the loose coronal fragment
- often the favoured option
- reposition the loose coronal fragment
- can splint to secure fragment
29
How is concussion managed?
- no treatment
- in permanent teeth splint
- excessive mobility or tenderness on biting
- passive and flexible
- 2 weeks
- observation
30
How is subluxation
- no treatment
- observation
31
How is lateral luxation managed?
- if minimal or no occlusal interference
- allow to reposition spontaneously
- if severe displacement
- extract
- favoured option
- reposition
- can splint for around 4 weeks
- extreme caution to avoid damage to permanent successor
- in permanent teeth reposition under local anaesthetic
- splint for 4 weeks
- incomplete root formation
- spontaneous revascularisation may occur
- endodontic treatment may be indicated
- necrotic pulp
- signs of inflammatory external resorption
- complete root formation
- pulp likely to become necrotic
- commence endodontic treatment
- corticosteroid-antibiotic or CaOh as intracranial medicament
- prevent development of inflammatory external resorption
32
How is intrusion managed?
- allow spontaneous reposition
- irrespective of direction of displacement
- usually within 6 months but can take up to a year
- determine direction of displacement
- only one radiographic image used (not parallax)
- periodical or lateral premaxilla
- assesses danger to permanent tooth
- two possible scenarios for primary teeth
- one
- tip of apex can be seen
- tooth appears shortened compared to contralateral
- apex displaced towards or through labial bone plate
- displaced away from developing permanent successor
- two
- apex cannot be visualised on radiograph
- tooth appears elongated compared to contralateral
- apex has been displaced towards permanent tooth germ
- increased risk of damage to the permanent successor
- two possible treatment options for permanent teeth
- immature root formation
- spontaneous repositioning
- no re-eruption indicates orthodontic treatment
- monitor pulp condition
- spontaneous pulp revascularisation may occur
- endo if necrotic pulp or signs of inflammatory external resorption
- mature root formation (<3mm)
- spontaneous repositioning
- surgical reposition after 8 weeks (4 weeks splint)
- orthodontic repositioning
- endodontic treatment if indicated
- mature root formation (3-7mm)
- reposition surgically or orthodontically
- endodontic treatment if indicated
- mature root formation (>7mm)
- reposition surgically
- endodontic treatment if indicated
33
How is extrusion managed?
- if not interfering with occlusion
- spontaneous repositioning
- excessively mobile or extruded >3mm
- extraction
- in permanent teeth reposition the tooth
- gently push back into socket
- under local anaesthetic
- splint
34
How is avulsion managed?
- radiograph to confirm avulsion
- do not replant
- never for primary teeth
35
How is alveolar fracture managed?
- repositioning of segment
- if mobile or causing occlusal interference
- stabilise with flexible splint
- adjacent uninjured teeth
- 4 weeks
- suture gingival lacerations if present
- teeth may need extracted after alveolar stability is achieved
- monitor pulp condition of all teeth involved
- monitor root development
- canal width
- canal length
- resorption
- risk of pulpal necrosis in closed apex teeth at 5 years
- advice to patent and carer
- soft diet for 7 days
- avoid contact sport while splint is in place
- careful oral hygiene
- chlorhexidine gluconate mouthwash 0.12%
36
What are the possible long term complications of trauma to primary teeth regarding the primary tooth?
- discolouration
- discolouration and infection
- delayed exfoliation
37
Describe discolouration of primary teeth
- asymptomatic
- vital or non-vital
- mild grey
- immediate discolouration
- intrapulpal bleeding
- may maintain vitality
- discolouration may recede
- opaque yellow
- pulp obliteration
- response of pulp to dental injury
- pulp responding by laying down dentine for protection
- no signs of pulp necrosis or infection
- no treatment
- review
38
Describe discolouration and infection of primary teeth
- symptomatic
- non-vital
- sinus
- gingival swelling
- abscess
- increased mobility
- TTP
- radiographic evidence of periodical pathology
- extract
- often favoured
- endodontic treatment
- caution not to damage permanent predecessor
- consider root length and time to exfoliation
- requires some level of cooperation
39
Describe delayed exfoliation of primary teeth
- primary tooth retained too long
- consequences for developing occlusion
- ectopic eruption of permanent successor
- delayed eruption of permanent successor
- no eruption of permanent successor
- may affect aesthetics and therefore confidence
40
How does trauma to the primary teeth impact on the permanent teeth?
- injuries to permanent teeth related to age of trauma to primary teeth
- decreases with age
- intrusion causes the most disturbance
- due to contact with developing tooth germ
41
What are the possible long term complications of trauma to primary teeth regarding the permanent teeth?
- enamel defects
- most common
- abnormal crown/root morphology
- crown duplication or dilaceration
- root duplication or dilaceration
- delayed eruption
- ectopic tooth position
- arrested development
- complete failure of tooth to form
- odontome formation
- benign tumour composed of tooth tissue
42
What enamel defects may be seen in permanent teeth after trauma to primary teeth?
- enamel hypomineralisation
- qualitative defect
- normal thickness but poorly mineralised
- white/yellow defect
- treatment options
- no treatment
- composite masking (+/- localised removal)
- tooth whitening
- enamel hypoplasia
- quantitative defect
- reduced thickness but normal mineralisation
- yellow/brown defects
- treatment options
- no treatment
- composite masking
- veneers
43
What is dilaceration and how can it be managed?
- abrupt deviation of the long axis of the crown or root
- crown dilaceration
- surgical exposure and orthodontic realignment
- restorative work to improve aesthetics
- root dilaceration/angulation/duplication
- combined surgical and orthodontic approach
- more complex than crown management
44
Describe the management of delayed eruption of permanent teeth after trauma to primary teeth
- premature loss of primary tooth can result in delayed eruption of 1 year
- due to thickened mucosa in area
- radiograph taken if 6 month delay to contralateral tooth
- surgical exposure and orthodontic alignment may be required
45
Describe management of ectopic tooth positioning of a permanent tooth after trauma to primary teeth
- due to primary tooth injury displacing permanent tooth
- due to retention of primary tooth
- treatment options
- surgical exposure and orthodontic realignment
- extraction
- if not possible to move to appropriate position
46
Describe arrested development as a complication to permanent teeth as a result of trauma to primary teeth
- permanent tooth developing at time of trauma
- development stopped
- treatment options
- endodontic treatment
- required favourable root length
- extraction
47
Describe complete failure of a tooth to form as a complication to permanent teeth as a result of trauma to primary teeth
- trauma to primary tooth causes complete failure of permanent tooth formation
- tooth germ may sequestrate spontaneously
- may require removal
48
Describe odontome formation as a complication to permanent teeth as a result of trauma to primary teeth
- permanent tooth is severely disrupted due to primary dental trauma
- surgical removal required
49
What is the most common injury in permanent teeth?
- crown fractures
- enamel-dentine fracture
50
What are the most likely circumstances (e.g. age, gender, anatomy) to experience trauma to permanent teeth?
- mostly before 19 years old
- peaks between 7-10 years
- more common in boys
- large overjet
- >9mm doubled incidence of trauma
- teeth further forward and incompetent lips
51
What are the causes of trauma to permanent teeth?
- falls
- bike/skateboard/RTA
- sport
- fights
52
How long should sensibility testing be carried out after an injury?
- 2 years
53
What does the prognosis of a tooth involved in trauma depend on?
- stage of root development
- type of injury
- PDL damage
- time between injury and treatment
- presence of infection
54
What are the general aims and principles of treatment for trauma to permanent teeth?
- emergency
- retain vitality of and damaged or displaced tooth
- protect exposed dentine (adhesive dentine bandage)
- prevents ingress via tubules
- treat exposed pulp tissue
- reduce and immobilise displaced teeth
- tetanus prophylaxis
- antibiotic delivery variable
- intermediate
- possibly pulp treatment
- pulp capping
- pulpotomy
- pulpectomy
- extrication of pulp
- restoration
- minimally invasive
- permanent
- apexigenesis
- maintain vitality of radicular pulp
- encouraging increased length and thickness of roots
- apexification
- removal of pulp
- formation of barrier at apex
- root filling +/- root extrusion
- gingival and alveolar collar modification if required
- coronal restoration
55
What is the prognosis of enamel fracture?
- 0% risk of pulp necrosis
- must take 2 periodical radiographs to rule out fracture and luxation
56
When should follow up appointments be made for review of enamel and enamel-dentine fractures?
- 6-8 weeks
- 6 months
- 1 year
57
What is the prognosis of enamel-dentine fracture?
- 5% risk of pulp necrosis at 10 years
58
How does open vs closed apex affect pulpal survival after injury to supporting tissues?
- an open apex increases the rate of pulpal survival after injury to supporting tissues (e.g. luxation, extrusion, concussion, etc.)
59
How are enamel-dentine-pulp fractures managed in permanent teeth?
- evaluate exposure
- size of pulp exposure
- time since injury
- associated PDL injuries
- pulp cap
- covering pulp exposure with medicament
- setting calcium hydroxide
- glass ionomer
- bioceramic materials
- partial pulpotomy
- removal of small amount of inflamed tissue
- arrest bleeding
- place medicament
- full coronal pulpotomy
- all pulp in coronal aspect removed
- radicular pulp left
- maintain pulp vitality
- increases root thickness and root dentinal walls
- reduce fracture risk
- avoid full extrication
- unless non vital
- especially in teeth with open apices
60
What is a direct pulp cap?
- small exposure
- around 1mm
- within 24 hours
- no TTP
- positive to sensibility tests
- LA and rubber dam
- clean with water
- disinfect with sodium hypochlorite
- apply calcium hydroxide (Dycal) or MTA white
- biodentine and total fill can also be used
- bioceramic materials
- less staining
- restore with composite
- review
- assess symptoms
- radiographic assessment of root development and pulpal vitality
61
What is a direct pulp cap?
- small exposure
- around 1mm
- within 24 hours
- no TTP
- positive to sensibility tests
- LA and rubber dam
- clean with water
- disinfect with sodium hypochlorite
- apply calcium hydroxide (Dycal) or MTA white
- biodentine and total fill can also be used
- bioceramic materials
- less staining
- restore with composite
- review
- assess symptoms
- radiographic assessment of root development and pulpal vitality
62
What is a partial pulpotomy?
- larger exposure
- >1mm
- over 24 hours after exposure
- LA and rubber dam
- clean with water
- disinfect with sodium hypochlorite
- remove 2mm of pulp with high speed round diamond bur
- can use sharp sterile excavator
- place saline soaked cotton wool pellet over exposure
- until haemostasis achieved
- if no haemostasis proceed to full pulpotomy
- apply calcium hydroxide then glass ionomer (or white MTA)
- restore with composite
- 97% success rate
63
What is a full coronal pulpotomy?
- begins as partial pulpotomy
- assess for haemostasis after application saline soaked cotton wool
- if hyperaemic or necrotic remove all of the coronal pulp
- place calcium hydroxide, bioceramic or MTA in pulp chamber
- seal with glass ionomer cement
- restore with composite
- 75% success rate
64
How is root treatment for immature incisors carried out?
- full pulpectomy if non-vital
- no apical stop in immature teeth
- calcium hydroxide place in canal
- induce hard tissue barrier to form
- apexification
- not routine, CaOH increases brittleness of roots
- MTA/BioDentine placed at apex of canal
- creation of a cement barrier
- apical plug to obturate against
- regenerative endodontic technique
- encourage hard tissue formation at apex
- stimulation of bleeding periodically
- new and not routine, very short roots
65
What does a pulpectomy of a tooth with an open tooth involve?
- rubber dam
- access
- haemorrhage control
- local anaesthetic
- sterile water
- diagnostic radiograph
- working length
- important for placement for apical plug
- file 2mm short of estimated working length
- dry canal
- place non setting calcium hydroxide
- place cotton wool pellet in pulp chamber
- glass ionomer as temporary cement
- radiograph
- evaluate placement if calcium hydroxide placement
- no extrusion of calcium hydroxide into periapical tissues
- irritation
- post op pain
- no voids
- calcific barrier formation
- placement of calcium hydroxide for no longer than 4-6 weeks
- increased brittleness of root tissues
- increased risk of fracture
- placement of apical plug
- MTA
- BioDentine
- total fill material
- heated GP obturation
- thermal obturation
- cold lateral condensation time consuming in wide canals
66
What does a pulpectomy of a tooth with an open tooth involve?
- rubber dam
- access
- haemorrhage control
- local anaesthetic
- sterile water
- diagnostic radiograph
- working length
- important for placement for apical plug
- file 2mm short of estimated working length
- dry canal
- place non setting calcium hydroxide
- place cotton wool pellet in pulp chamber
- glass ionomer as temporary cement
- radiograph
- evaluate placement if calcium hydroxide placement
- no extrusion of calcium hydroxide into periapical tissues
- irritation
- post op pain
- no voids
- calcific barrier formation
- placement of calcium hydroxide for no longer than 4-6 weeks
- increased brittleness of root tissues
- increased risk of fracture
- placement of apical plug
- MTA
- BioDentine
- total fill material
- heated GP obturation
- thermal obturation
- cold lateral condensation time consuming in wide canals
- restoration of tooth
- bonded composite into canal and access cavity
- bonded core
- avoid post crown
- invasive
- increased risk of root fracture
- aesthetically sub optimal with ageing
67
How are crown-root fractures managed in permanent teeth?
- no pulpal exposure
- fragment removal only and restore
- fragment removal and gingivectomy
- indicated by palatal subgingival extension
- orthodontic extrusion of apical portion
- surgical extrusion
- manual repositioning under local anaesthetic
- decoronation
- preserve bone for future implant
- easier to provide prosthesis (e.g. bridge)
- extraction
- pulpal exposure
- temporised with composite for up to 2 weeks
- fragment removal and gingivectomy
- indicated by palatal subgingival extension
- orthodontic extrusion of apical portion
- surgical extrusion
- manual repositioning under local anaesthetic
- decoronation
- preserve bone for future implant
- extraction
68
What must be considered when looking at injury to supporting tissue?
- surrounding bone
- neuromuscular bundle
- root surface
69
What are the two categories of the nature of injury to soft tissues?
- separation injury
- major part of injury is cleavage of intracellular structures
- collagen
- limited damage to cells in area of trauma
- wound healing can arise from existing cellular systems
- minimal delay
- crushing injury
- injuries with extensive damage to cellular and intercellular
- must be removed by macrophages/osteoclasts
- traumatised tissue then restores
- longer healing time
70
What are the critical factors in avulsion of a permanent tooth?
- extra-alveolar dry time (EADT)
- extra-alveolar time (EAT)
- storage medium
71
What advice should be given in the emergency situation of avulsion of a permanent tooth?
- ensure it is a permanent tooth that has been lost
- primary teeth should not be avulsed
- hold by the crown
- encourage attempt to place tooth immediately into socket
- if dirty rinse with milk, saline or patient's saliva
- do not rub/scrub root
- bite on gauze/hankerchief
- holds in place once replanted
- seek immediate dental advice
72
How should an avulsed permanent tooth be stored?
- only if replantation is not possible
- patient unconscious
- must be stored in medium as soon as possible
- prevents root surface drying out
- starts within minutes of avulsion
- storage media
- milk
- best option
- HBSS
- Hank's balances dalt solution
- saliva
- patient's own
- spit into tub
- saline
- water
- poor but better than air drying
73
What factors affect the way in which permanent tooth avulsion is treated?
- maturity of root
- open or closed apex
- PDL cell condition
- dependent on time out of mouth and storage medium
74
How is avulsion of a permanent tooth with a closed apex managed?
- if tooth already replanted
- clean injured area
- verify replanted tooth position and apical status
- clinically and radiographically
- leave in place
- unless malpositioned
- correct with digital pressure
- if in wrong socket or rotated, replace up to 48 hours
- stabilise with splint
- passive, flexible splint
- two weeks
- suture any gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instructions
- arrange follow up
- if extra-alveolar dry time over 60 minutes
- PDL cells may be viable but compromised
- remove debris
- history and examination with tooth in storage medium
- clinical and radiographic examination
- replant tooth under local anaesthetic
- gently irrigate socket with saline
- examine socket prior to replantation
- fracture of socket wall should first be repositioned
- slowly with slight pressure
- splint
- after verification of correct tooth position
- passive, flexible splint for two weeks
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- arrange follow up
- if extra-alveolar dry time over 60
- PDL cells likely to be non-viable
- remove debris
- history and examination with tooth in storage medium
- clinical and radiographic examination
- replant tooth under local anaesthetic
- gently irrigate socket with saline
- examine socket prior to replantation
- fracture of socket wall should first be repositioned
- slowly with slight pressure
- splint
- after verification of correct tooth position
- passive, flexible splint for two weeks
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- arrange follow up
- commence endodontic treatment within 2 weeks
- calcium hydroxide as intracanal medicament
- up to 1 month
- corticosteroid/antibiotic paste for 6 weeks
- complete with conventional endodontic treatment
- if delayed replantation
- poor long term prognosis
- necrotic PDL, little regeneration
- ankylosis-related root resorption
- restore aesthetics and function (temporarily)
- maintains alveolar bone contour, width and height
- decoronation may be required
- depends on growth rate
- risk of ankylosis and infra occlusion
- referral to paediatric specialist
- inter-disceplinary management
75
How is avulsion of a permanent tooth with an open apex managed?
- tooth already replanted
- clean injured area
- verify replanted tooth position and apical status
- clinically and radiographically
- leave in place
- unless malpositioned
- correct with digital pressure
- if in wrong socket or rotated, replace up to 48 hours
- stabilise with splint
- passive, flexible splint
- two weeks
- suture any gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instructions
- arrange follow up
- if extra-alveolar time less than 60 minutes
- potential for spontaneous healing
- correct storage medium vital
- remove debris
- history and examination with tooth in storage medium
- clinical and radiographic examination
- replant tooth under local anaesthetic
- gently irrigate socket with saline
- examine socket prior to replantation
- fracture of socket wall should first be repositioned
- slowly with slight pressure
- splint
- after verification of correct tooth position
- passive, flexible splint for two weeks
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- arrange follow up
- monitor for revascularisation
- endodontic treatment if pulp necrosis, etc.
- if extra-alveolar time more than 60 minutes
- PDL cells likely to be non-viable
- remove debris
- history and examination with tooth in storage medium
- clinical and radiographic examination
- replant tooth under local anaesthetic
- gently irrigate socket with saline
- examine socket prior to replantation
- fracture of socket wall should first be repositioned
- slowly with slight pressure
- splint
- after verification of correct tooth position
- passive, flexible splint for two weeks
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- arrange follow up
- likely ankylosis-related root resorption
- delayed replantation
- poor long term prognosis
- necrotic PDL, little regeneration
- ankylosis-related root resorption
- restore aesthetics and function (temporarily)
- maintains alveolar bone contour, width and height
- decoronation may be required
- depends on growth rate
- risk of ankylosis and infra occlusion
- referral to paediatric specialist
- inter-disceplinary management
76
When is it indicated to not replant a tooth?
- usually is right decision to replant
- temporary space maintainer
- medical contraindication
- immunocompromised child
- other serious injuries
- requiring preferential emergency treatment
- dental contraindications
- very immature apex
- extra-alveolar time over 90 minutes
- very immature lower incisors
- young children finding it difficult to cope
77
What injuries to supporting tissues are splinted for 2 weeks?
- subluxation
- extrusion
- avulsion
78
What injuries to supporting tissues are splinted for 4 weeks?
- intrusion
- lateral luxation
- root fracture
- mid third
- apical third
- dento-alveolar fracture
79
What injuries to supporting tissues are splinted for 4 months?
- root fracture
- cervical third
80
What are the desirable properties of splints?
- flexible and passive
- ease of placement/removal
- facilitate sensibility testing and clinical monitoring
- allow oral hygiene
- aesthetic
- acceptable to patient
81
What are the desirable properties of splints?
- flexible and passive
- ease of placement/removal
- facilitate sensibility testing and clinical monitoring
- allow oral hygiene
- aesthetic
- acceptable to patient
82
Provide examples of splints from both categories of splint type
- chair-side
- composite and wire
- titanium trauma splint
- composite
- orthodontic brackets and wire
- acrylic
- lab-made
- vacuum-formed splint
- acrylic
83
What are the gold standard splints?
- composite and wire
- titanium trauma splint
84
Describe the qualities of a composite and wire splint
- stainless steel wire
- up to 0.4mm in diameter
- must be passive
- no unwanted forces on traumatised tooth
- flexible
- including one uninjured tooth on either side
- secured in composite resin
- quick and easy to place
- composite and bonding agents
- kept away from gingiva and proximal areas
- plaque retention and secondary infection
- bacterial wicking
- better healing of the marginal gingiva and bone
85
Describe the qualities of a titanium trauma splint (TTS)
- rhomboid mesh structure
- 0.2mm thickness
- passive and flexible
- quick and easy to place
- easily adapted with fingers to dental arch
- flexible in all dimensions
- allows physiologic tooth mobility
- no forces applied to splinted teeth
- secured to teeth with composite resin
86
What are the four main post-trauma complications after traumatic dental injury?
- pulp necrosis and infection
- pulp canal obliteration
- root resorption
- breakdown of marginal gingivae and bone
87
What is pulp canal obliteration?
- response of a vital pulp to trauma
- most commonly luxation with displacement
- progressive hard tissue formation within the pulp cavity
- gradual narrowing of pulp chamber and canal
- total or partial obliteration
- tooth becomes opaque/yellow
- treatment
- conservative management
88
What are the two different types of root resorption
- external
- surface
- external infection related inflammatory root resorption
- cervical
- ankylosis related replacement root resorption
- internal
- internal infection related inflammatory root resorption
89
What is external surface root resorption?
- superficial resorption lacunae
- repaired with new cementum
- response to localised injury
in vital teeth
- not progressive
90
What is external infection related inflammatory root resorption?
- occurs in non vital teeth
- infected pulp canals
- initiated by PDL damage
- following trauma
- propagated by root canal toxins reaching external root surface through patent dentinal tubules
- rapid progression
- diagnosis
- chance radiographic finding
- change to external contour of root
- surrounded by bony lucency
- root canal tram lines remain in tact
- management
- removal of stimulus
- infected root canal contents
- endodontic treatment
- non-setting CaOh for 4-6 weeks
- obturate with GP
- cervical resorption
- unusual form
- damage to root in cervical area
- propagated by infected canal contents or periodontal microflora
- small entry point propagates widely before entering pulp chamber
91
What is ankylosis related replacement root resorption
- following severe luxation or avulsion
- severe damage to PDL and cementum
- normal repair does not occur
- bone cells faster than PDL fibroblasts
- if more than 20% of PDL damaged
- root involved in bone remodelling
- radiographically appears ragged root outline
- no obvious PDL space
- speed variable
- tooth become infraoccluded
- alveolar bone does not develop
- gingival margins move apically
- decoronation once over 3mm
- treatment
- no treatment
- plan for loss of tooth
- may not be for a number of years
92
what is internal infection related inflammatory root resorption?
- due to progressive pulp necrosis
- infected material propagated resorption
- though non-vital coronal part of canal
- radiographically
- symmetrical expansion of root canal walls
- tramlines of root canal indistinct
- root surface in tact
- treatment
- removal of stimulus
- endodontic treatment
- non-setting CaOh for 4-6 weeks
- obturate with GP
- if progressive plan for loss
