trauma in permanent dentition Flashcards
(18 cards)
trauma in permanent dentition: short, medium and long term management principles
short:
-retain vitality of fractured or displaced tooth
-teat exposed pulp tissue
-reduction and immobilisation of displaced teeth
-antiseptic mouthwash (chlorhexidine), analgesia, antibiotics and tetanus prophylaxis
medium:
-pulp therapy if required
-minimally invasive crown restoration
long:
-apexification
-root filling
-with or without gingival collar modification
semi or permanent coronal restoration
general review schedule
1, 3 and 6 weeks then at 3, 6, 12 months with annual checks for 4-5 years
enamel infraction:
incomplete crack/fracture of enamel without the loss of tooth structure
only detected with transillumination
no TTP
positive vitality tests
one PA radiograph
no tx required just monitoring, no follow up required
permanent teeth: enamel fracture
no exposed dentine
normal mobility
positive vitality tests
one parallel PA radiograph required
missing fragments should be accounted for
bond tooth fragment back to tooth or smooth sharp edges + composite
clinical rv: 6-8wk, 1yr
favourable outcomes in enamel fractures
asymptomatic
positive response to vitality testing
good quality restoration
continued root development in immature teeth
unfavourable outcomes in enamel fracture
symptomatic
pulp necrosis and infection
apical periodontitis
loss/breakdown of restoration
lack of further root development in immature teeth
uncomplicarted crown fracture: enamel and dentine
without pulp exposure
no TTP
one PA
fragment should be soaked in saline for 20 min before bonding back to tooth
cover exposed dentine with GIC
place a CaOH pulp cap over dentine if within 0.5mm of pulp
rv: 6-8wk, 1yr
complicated crown fracrtures
pulp exposure
exposed pulp sensitivie to stimuli
PA
immature roots and open apex: preserve the pulp. cvek pulpotomy or pulp capping to promote further root development
non-setting CaOH placed as pulp cap
bond back tooth fragemenr after rehydration
or cover with GIC and composite
rv: 6-8 weeks, 3 months, 6 months, 1 year
uncomplicated crown root fractures
without pulp exposure
TTP
two radiographs at different angles
temporary stablisation
removal of coronal mobile fragment and restoration
cover exposed dentine with GIC
surgical extrusion
rv: 1wk, 6-8wk, 3 mo, 6mo, 1yr
root fracture
involves dentine pulp and cementum
coronal segment may be mobile and displaced
bleeding seen
two views for radiographs
reposition coronal part and check radiographically
stabilise the mobile coronal segment with passive and flexible splint for 4 weeks. if cervically, 4 months. no endo tx immediately, monitor the healing for 1 year. if pulpal necrosis evident, start endo treatment
rv: 4 week + removal of splint, 6-8 wk, 4 mo, 6mo, 1 year, yearly for 5 years
consider post and core or extrusion of root surgically
PDL splinting
approx 60% PDL occurs after 10 days and complete within a month
splinting should be as short as possible and splint should allow some functional movement to prevent replacement root resorption (ankylosis)
why flexible splint is needed as teeth are not completely immobilised
avulsion require 2 weeks, luxation 4 weeks
alveolar fracture
suture gingival lacerations
splint for 4 weeks
rv: 4 weeks splint removal, 6-8wks, 4mo, 6mo, 1yr
years for 5 years
concussion
no tx: anagesics, soft diet and reassurance
rv after 4 weeks, 1 year
subluxation
tooth has increased mobility but not displaced
no tx: reassurance, observation, analgesics, soft diet for 1 week, occlusal relief
chlorhexidine 0.2% mouthwash 2x daily for 1 week
if ttp significant, splint for 2 weeks or if excessive mobility.
rv: after 2 wk splint removal, 12 weeks, 6 months, 1 year
extrusion
tooth appears elongated, rupture of PDL and pulp
no response to sensibility tests
reposition tooth by gently pushing it back into socket under LA
stabilise with splint using a passive and flexible splint
if breakdown of bone, 4wks splint
if pulp becomes necrotic, endo tx appropriate to tooth’s stage of root development
rv: 2 wks after splint, 4wk, 8 wk, 12wk, 6mo, 1 year, yearly for 5 years
flexible vs rigid splint
flexible allows some mobilisation for functional movements: using 0.4mm flexible wire with composite with one abutment tooth on either side
hard splint full immobilisation of tooth: higher risk of anklyosis in this splint
lateral luxation
tooth us displaced usually in a palatal/lingual or labial direction + associated fracture of alveolar bone
tooth can be immobile as apex locked into the bone fracture
percussion will give metallic ankylotic sound
no vitality response
occlusal radiograph
tx: reposition tooth by disengaging it from its locked position under LA
stabilise for 4 weeks using a passive and flexible splint
chlorhexidine mouthwash
soft diet 2-3 weeks
2 weeks post injury: endo evaluation
if tooth has complete root formation, rct commenced with corticosteroid antibiotic medicament ledermix before to prevent inflammatory external resorption
follow up: w ek, 4wk splint removal, 8wk, 12wk, 6 mo, 1 yr, yearly for 5 years
intrusion
displacement of tooth in apial direction into alveolar bone
tooth is not mobile
percussion will give metallic ankylotic sounds
no response to vitality testing
pdl space may not be visible
tx: open apex- allow reeruption without intervention dependent on degree of intrusion
if no spontaneous re-eruption in 4wkm ortho repositioning
check pulp status
closed apex: re-eruption if less than 3mm. if no reeruption within 8wk, reposition surgically and splint for 4wk. 3-7mm: reposition surgically or ortho
beyond 7mm: reposition surgically
closed apex: rct at 2 weeks or as soon as positioning allows
rv: 2wk, 4 wk removal of splint, 8wkm 12wk, 6mo, 1 year, 1 yearly for 5 years
chlorhexidine and diet advice
incidence of ankylosis is high
2 factors affecting management: maturity of root and severity of intrusion
teeth with closed apices will undergo loss of vitality so RCT after 2 weeks
immature apex endo tx: MTA apical plug placement and obturation with thermoplastic GP technique
