Trauma II Flashcards
(72 cards)
1
Q
What is a root fracture?
A
- A dentine and cementum fracture involving the pulp
- Can be perfectly horizontal but most of them are at an angle (due to trauma)
2
Q
How can we classify root fractures? (3)
A
- Position of fracture
- Displacement of fragments
- Stage of root development
3
Q
How can we classify a root fracture in relation to the position of the fracture? (3)
A
- Apical 1/3
- Middle 1/3
- Coronal 1/3
4
Q
How can we classify a root fracture in relation to displacement of fragments? (2)
A
- Displaced
- Undisplaced
5
Q
How can we classify a root fracture in relation to the stage of root development? (2)
A
- Mature (closed apex)
- Immature (open apex)
6
Q
Which position of root fracture has the best prognosis?
A
- Apical 3rd root fracture
- Best prognosis, especially if no displacement has occurred
- If heals well the fracture line may be undetectable in future radiographs
7
Q
What is it important to do with middle 1/3 root fractures?
A
- Important to reduce fracture as much as possible i.e. get both halves touching again like a jigsaw
8
Q
Different views of the same tooth can be important for diagnosis in some cases. When is this especially important?
A
- Especially if the fracture isn’t displaced because it can be difficult to detect
9
Q
What is the prognosis for a coronal 1/3 root fracture?
A
- Very poor prognosis as very little PDL support to keep the crown in position during function. Creation of an extremely unfavourable crown:root ratio
10
Q
Why might it sometimes look like there is more than one fracture line in a radiograph?
A
- Remember that a radiograph is a 2 dimensional picture. Occasionally it looks like there are multiple fracture lines when the break has occurred at an angle cutting across the beam
11
Q
What factors does the prognosis of a root fractured tooth depend on? (5)
A
- Age of child: mature/immature tooth
- Degree of displacement
- Associated injuries e.g. crown fractures
- Time between injury and treatment
- Presence of infection
12
Q
Why is time between the injury and treatment important in relation to a displaced fracture?
A
- If you have a displaced fracture that you have not reduced, quickly you will get a blood clot between the 2 halves of the tooth and then that makes it difficult to get those 2 bits sitting together like a jigsaw
13
Q
What do we use in a clinical exam to help with diagnosis an prognosis and long term monitoring?
A
- Use a trauma stamp
14
Q
What special investigations would we take for a root fracture exam and investigations? (3)
A
- Sensibility tests
- Radiographs from at least 2 angles e.g. 2x periapicals from different angles and 1x maxillary occlusal
- Alternatively cone beam CT
15
Q
How would we treat an apical or middle third root fracture?
A
- If displaced:
- Clean area with water/saline/chlorhexidine
- Reposition tooth with digital pressure
- Splint with a flexible splint for 4 weeks
- Review: 6-8 weeks, 6 months, 1 year and 5 years with radiographs
- Soft diet for 1 week and good OH
16
Q
How would we treat a coronal third root fracture?
A
- These require splinting for 4 months with a flexible splint
- Soft diet for 1 week and good OH
17
Q
What are the possible healing outcomes of a root fracture? (4)
A
- Calcified tissue union across fracture line
- Connective tissue
- Calcified + connective tissue
- Bone/osseous
18
Q
What is the non-healing outcome of a root fracture?
A
- Granulation tissue (usually associated with loss of vitality). Radiolucent area seen on radiograph surrounding fracture line
19
Q
Which type of healing outcome do we ideally want for a root fracture?
A
- Calcified tissue healing
- Healed with dentine like material, almost indistinguishable on second radiograph
20
Q
What happens with connective tissue healing?
A
- Fracture lines remain visible
- Edges of fracture show signs of eburnation (rounding off of sharp edges)
21
Q
What is osseous healing?
A
- Separate parts of the root become discrete entities with no connection, each part has its own distinct PDL space and bone is clearly seen between the fragments
22
Q
If a tooth becomes non-vital due to a root fracture what is the % chance of pulp necrosis?
A
20%
23
Q
How do we treat a non-vital apical or middle third fracture? (3)
A
- Extirpate to fracture line
- Dress ns CaOH then MTA/Biodentine just coronal to the fracture line (to create an apical stop)
- GP - root fill to fracture line
24
Q
How do we treat a non-vital apical fragment of root?
A
- Remain in situ with own PDL
- Resorb
- In infected - antibiotics/apicectomy
25
Why do we need to classify PDL injuries?
Because that is going to help us decide how we are going to treat it
26
What are the possible classifications of PDL injuries? (6)
- Concussion, subluxation
- Extrusive luxation
- Lateral luxation
- Intrusive luxation
- Avulsion
- Dentoalveolar fractures
27
When there is a PDL injury we have to consider its impact on what other structures? (3)
- Surrounding bone
- Neurovascular bundle
- Root surface
28
What is a concussion injury?
- Concussion injury to the tooth supporting structures without increased mobility, displacement of the tooth of gingival bleeding. There is pain on percussion and sensibility tests may be negative on initial assessment
29
What is a subluxation injury?
Subluxation is where a traumatic injury has occurred to the periodontal tissues leading to increased mobility but no displacement. Gingival bleeding is often detected
30
What do we do for a subluxation/concussion injury?
- Occlusal relief
- If patient has a heavy bite it is like doing the TTP test every time you put teeth together - can take a bit of pressure off the occlusion by either taking away a bit of tooth (which seems very extreme) or you can build up with a little bit of GI on posterior teeth to relieve anterior teeth a bit
- Flexible splint 2 weeks if necessary to make patient feel more comfortable
- Review - clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year
31
What should we do with all luxation injuries?
| 3
- Instruct on OHI with chlorhexidine gluconate and gentle brushing
- Soft diet
- Avoid contact sports
32
Is there increase mobility with a concussion injury?
No
33
Is there increase mobility with a subluxation injury?
Yes
34
Is there TTP with a concussion injury?
Yes
35
IS there TTP with a subluxation injury?
Yes
36
When should we do follow up clinical and radiographs with a concussion injury?
4 weeks, 6-8 weeks and 1 year
37
When should we do follow up clinical and radiographs with a subluxation injury?
2 weeks, 4 weeks, 6-8 weeks and 1 year
38
Should we splint a concussion injury?
No
39
Should we splint a subluxation injury?
2 week flexible splint
40
Why do we encourage a patient to gently bite a soft diet when they have a luxation injury?
Bite gently with your splinted teeth after a few days on very soft things - to get proper healing of the PDL it needs to do its job so need to stimulate it so the bone cells don't get carried away and stop the PDL from generating
41
What can we do to monitor a concussion or subluxation injury? (3)
- Clinical tests - trauma sticker
- Sensibility tests: thermal and electrical
- Radiographs
42
Why do we take thermal and electrical sensibility tests when monitoring concussion and subluxation injuries? (3)
- Do at time of injury
- Transient lack of sensibility can occur (which will hopefully come back)
- This can lead to future pulp necrosis
43
Why do we use radiographs to monitor concussion and subluxation injuries? (3)
- Root development - width of canal and length
- Comparison with other side
- Internal and external inflammatory resorption
44
What is included in a trauma sticker/stamp? (8)
- Mobility
- Displacement
- TTP
- Colour
- Sinus/tender in sulcus
- Thermal
- Electric
- Radiograph
45
Look at pulpal survival table
Notes
46
What is an extrusion injury?
- Tooth injury characterised by partial or total separation of the periodontal ligament resulting in displacement of the tooth out of the socket. The alveolar socket is intact. This is a tearing injury within the PDL
- So not been crushed - it has been torn apart
- So expecting to see a tooth that is hanging lower down that it should be
- When take a radiograph will see a wide PDL space because tooth is not where it should be
47
What should the treatment be of an extruded permanent tooth?
- Reposition under LA (buccal and palatal)
- Flexible splint - 2 weeks
Review:
- Clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months and yearly for 5 years
48
What is a lateral luxation injury?
- Displacement of a tooth other then axially. Displacement is accompanied by communication or fracture of either the labial or palatal/lingual bone. The PDL has suffered both tearing and crushing injuries
49
What is the treatment for a lateral luxation injury?
- Reposition under LA (buccal and palatal)
- Flexible splint - 4 weeks (longer because it is a much more serious injury)
Review:
- Clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months and yearly for 5 years
50
Look at clinical photos in notes
Notes
51
What is an intrusion injury?
Tooth has been driven into the alveolar process sue to an axillary directed impact. This is the most severe form of displacement injury after avulsion. It is more likely to occur in teeth with gully developed roots. This is a crushing injury to the PDL
52
What repositioning would we do if we had an open apex tooth with an intrusion severity of up to 7mm?
- Spontaneous repositioning
53
What repositioning would we do if we had an open apex tooth with an intrusion severity of more than 7mm?
- Orthodontic
| - Surgical
54
What repositioning would we do if we had a closed apex tooth with an intrusion severity of up to 3mm?
- Spontaneous
55
What repositioning would we do if we had a closed apex tooth with an intrusion severity of between 3-7mm?
- Orthodontic
| - Surgical
56
What repositioning would we do if we had a closed apex tooth with an intrusion severity of more than 7mm?
- Surgical
57
What is spontaneous repositioning?
- Allowing for spontaneous repositioning
| - Measuring its incisal edge against the adjacent teeth and checking that it comes down into the position you want it to
58
What is orthodontic repositioning?
- Fixate orthodontic elastic around the arch wire and bracket for traction
- This can be fixed or removable
59
What is surgical repositioning?
- Reposition the tooth with forceps
- Gently putting some extraction forceps on the tooth - loosening it and bringing it into the position that it is supposed to be and then holding it there with a splint
60
What should we do if we are decide to allow spontaneous tooth repositioning? (3)
- Give advice re diet and oral hygiene
- Review patient monthly to observe re-eruption
- Measure progress against fixed point e.g. incisal edge of fully erupted non-displaced adjacent incisor
61
If doing surgical repositioning we then have to splint. How long should we splint for?
- Flexible splint for 4 weeks
62
With an intrusion injury there is a high risk of resorption. What do we usually need to do?
- Endodontic treatment usually necessary with closed apex. Interim calcium hydroxide dressing recommended.
- We do not want the calcium hydroxide in there for more than 4-6 weeks because of tis effects on dentine
Review:
- Control after 2 weeks. Splint removal and control after 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years
63
For a closed apex tooth with an intrusion injury there is a 0% chance of pulpal survival so we are going to take the pulp out as soon as possible. When do we want to do this?
- Want to do this in 7-10 days
64
What follow up do we need to do for an intrusion injury?
- Endodontic treatment can prevent the necrotic pulp form initiating infection-related root resorption
- Consider in all cases with completed root formation where the chance of pulp revascularisation is unlikely
- Endodontic therapy within 3-4 weeks post-trauma. A temporary filling with calcium hydroxide is recommended
- Review after 2 weeks. Splint removal and review after 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years
65
When would we provide a flexible 2 week splint? (3)
- Subluxation
- Extrusion
- Avulsion - open and closed apex <60 mins EADT
66
When would we provide a flexible 4 week splint? (5)
- Luxation
- Apical/middle 1/3 root fracture
- Intrusion
- Dento-alveolar fractures
- Avulsion - closed apex >60 mins EADT
67
When would we give a flexible 4 month splint?
- For a coronal 1/3 root fracture
68
What is the best form of splint?
- Composite with wire
- There is also titanium helix which is really good
- Also have acrylic with wire
69
How would we apply a splint? (5)
- Cut and bend 0.3mm stainless steel wire
- Apply composite resin to traumatised tooth and those adjacent
- Sink the contoured, passive wire into the composite
- Shape and cure composite
- Smooth rough composite and wire ends
70
What is a vaccum formed splint?
- 'gumshield' splint
- Oral hygiene is often very poor
- Essix retainer also vaccum formed but much thinner and better
71
Are ortho bracket and wire acceptable to use as a splint?
- Yes but the wire MUST be passive
| - If the wire is active the teeth will be moved
72
When would we use an acrylic URA type splint?
- First choice of splint is composite and wire. However, acrylic is useful when there are few abutment teeth
