Paul Friel Accidental damage to permanent teeth 6 of 8year olds 19 of 13year olds Boysgirls 31 70 not treated Peak period 710 years Commonest injury is EnamelDentine Fracture More common with large overjet gt4mm ID: 929861
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Slide1
Dental Trauma
Glasgow MJDF/MFDS Study Group
Paul Friel
Slide2Accidental damage to permanent teeth
6% of 8-year olds
19% of 13-year olds
Boys:girls 3:1
70% not treated
Peak period 7-10 years
Commonest injury is Enamel-Dentine Fracture
More common with large overjet (>4mm)
Causes- falls/trips most common, then activities/sports
Slide3Displacement/Luxation Injuries
Concussion
Definition - Mild stretching or crushing of the tooth supporting structures
Clinically – TTP, no change in position, no mobility
Radiographically – No changes
Treatment – Reassurance, Standard Trauma Advice, Monitoring, No SplintRadiograph of initial injury and then only if subsequent changes
Slide4Displacement/Luxation Injuries
Subluxation
Definition – Moderate stretching or crushing of the tooth supporting structures, NO DISPLACEMENT
Clinically – TTP, mobility, no change in position
Bleeding from gingival crevice
due to tearing of PDLRadiographically – No changesTreatment – Reassurance, Standard Trauma Advice, Monitoring, No Splint routinely (sometimes if excessively tender, also in adult?)
Slide5Displacement/Luxation Injuries
Extrusion (Extrusive Luxation)
Definition – Partial displacement of a tooth
out
of the socket in an axial direction
Clinically – Appears longer than contralateral, occlusal interference, mobility (usually), TTP (usually)Radiographically – Depends on severity. If mild – widening of PDL space. If severe – outline of socket visible.
Treatment – Standard Trauma Advice, Digital Repositioning (watch-winding), Reposition with check radiograph
Check occlusion, Radiograph following repositioning to assess success, Splint 2 weeks
Monitoring
Slide6Displacement/Luxation
Lateral Luxation
Definition – Displacement of a tooth either buccally or palatally/lingually that is often associated with a dento-alveolar fracture
Clinically – Tooth buccally or palatally/lingually inclined compared to contralateral, Occlusal Interference
Percussion note can sound metallic if apex locked against alveolus fracture, TTP, can be mobile or solid
Radiographically – Displacement of tooth compared with adjacent, widening of PDL space in parts & narrowing of others
Treatment – Standard Trauma Advice, Repositioning under LA (Buccal and Palatal injections)- NB APICAL LOCK, Reposition with CWR
Radiograph following repositioning, Splint 4 weeks, Monitoring
Slide7Displacement/Luxation Injuries
Intrusion (Intrusive Luxation)
Definition – Displacement of the tooth into the socket in an axial direction, often associated with dentoalveolar fracture and wedging of the socket
Clinically – Incisal edge more apical than that of the contralateral tooth, TTP, often not mobile, metallic percussion note
Radiographically – Loss of PDL Space, ACJ more apical compared with adjacent teeth
Slide8Displacement/Luxation Injuries
Treatment –
If mild (<3mm) and tooth is
immature
(
open apex)Monitor for 2-4 weeks for spontaneous re-eruption due to continued root developmentIf no change – digital repositioning prior to ankylosis
If mild (<3mm) and tooth is
mature
(closed apex)
Reposition under LA
Splint 4 weeks
If severe
, (>3mm for mature, >7mm for immature)
Reposition under LA
Splint 4 weeks
Slide9Displacement/Luxation Injuries
Avulsion
Definition – Displacement of the tooth completely out of the socket
Clinically – No tooth present in socket
Radiographically – Empty socket observed or commonly a retained apical third of a root following root fracture
Slide10Displacement/Luxation Injuries (Cont’d)
Treatment-
Slide11Displacement/Luxation Injuries (Cont’d)
Closed apex – regardless of EADT, begin RCT in 7-10 days intra-orally
Open apex – if EADT < 60 mins, reimplant and monitor (hope for revascularisation)
If EADT >60 mins – remove necrotic PDL cells (sodium hypochlorite 5% for 5 mins, sodium fluoride 2% for 20 mins, initiate RCT prior to reimplantation
Storage Medium
‘Save a Tooth’ (HBSS) – designated tooth storage medium: excellent
Milk: very good for up to 6hrs
Saliva of patient – extra-orally or within buccal sulcus (not as good as milk)
Saliva of mother/father (?)
Water- poor
Slide12Splinting
0.018” stainless steel orthodontic wire
(best)
1 tooth either side of traumatised tooth/teeth for flexible splint (e.g. 1 traumatised tooth= 3
teth
splinted together)Etch, bond, place large balls of composite (4mm) & wire, quick-curePlace small (2mm) balls of composite, and cure. NB ensure all of wire is encased in composite
Slide13Remembering Splinting Times:
“2 weeks by the SEA”
Slide14Fracture Injuries
Slide15Fracture Injuries
Infraction
Definition – Incomplete fracture line of enamel without loss of tooth structure
Clinically – Small fracture line detectable (can use curing light), mild TTP, slightly sensitive to cold
Radiographically – All appears healthy
Treatment – Monitor for propagationSeal with bond if very sensitive
Slide16Fracture Injuries
Enamel Fracture
Definition – Loss of enamel with no evidence of exposure of dentine
Clinically – Enamel fracture. Try and account for fragment – soft tissues
Radiographically – All appears healthy
Treatment – Monitor & SmoothOr, rebond fragment
Or, restore with Composite
Enamel-Dentine Fracture
Definition – Loss of enamel and dentine with no evidence of pulpal exposure
Clinically – Sensitive to cold. Try and account for fragment – soft tissues
Treatment- As above
Slide17Enamel-Dentine & Pulp Fracture
Definition – Loss of enamel and dentine with exposure of the pulpal tissue
Clinically – Tender to touch, sensitive to hot & cold, pulpal bleeding
Radiographically – Enamel and dentine loss with pulpal involvement
Treatment- Cvek pulpotomy: 96% success rate (remove 2-3mm of pulp tissue). If still bleeding, remove a further 1-2mm (success rate drops to 75% for a coronal pulpotomy). If still bleeding down to CEJ, proceed to full pulpal extirpation.
Slide18Fracture Injuries
Root Fractures
Classified into Coronal, Middle, Apical thirds
Can be horizontal (most common) or oblique
Treatment – Reposition (watch-winding), splint (see below)
Coronal – 4 months RIGID splinting (very poor prognosis)Middle & Apical Thirds – 4 weeks flexible splinting
Slide19Fracture Injuries
Crown Root Fractures
Definition – loss of enamel and dentine of the coronal aspects and root aspects of a tooth, with or without
involvement of the pulp
Clinically – fragment loss, loose or fracture lines and some mobility, very TTP, very tender to mobilisation of fragments (if pulpal involvement)
Radiographically – evidence of fracture linesTreatment – Without Pulpal Involvement: stabilise fragment and monitor
With Pulpal Involvement: please see Dental Update Paper 2 (S. Djemal) for management
Slide20Long-term complications
Discolouration
Loss of vitality
Resorption (
inflammatory
[external/internal] or replacement resorption) Ankylosis (due to external replacement resorption)Unfavourable tooth positionHard/soft tissue defects
Slide21Pulp Survival after Trauma
Injury type
Open Closed
Concussion 100% 96%
Subluxation 100% 85%
Extrusion 95% 45%Lateral Luxation 95% 25%Intrusion 40% 0%
Avulsion/Replantation 30% 0%