trauma and management - dental care pakistan

Report
TRAUMA
DR.BILAL ARJUMAND
MIHS
Diagnostic steps dental trauma
• Medical and health history
• History of the dental injury and immediate care
provided
• Neurologic evaluation
• Clinical examination of the head and neck
• Oral examination of soft and hard tissues
• Radiographic examination
• Photographic documentation
HISTORY
• When
• How
• Where
With time blood clots begin to form, periodontal
ligaments of teeth dry out, and saliva contaminates
the wound
Locating specific injuries, and cause will give info
about severity
Prophylactic tetanus toxoid, insurance and litigation
Clinical Examination
Chief Complaint
• Pain and bleeding
• Don't fit together now
• Pain on closure
Possible displacements or a bone fracture
Crown, root, or bone fractures
Neurologic Examination
• Head and neck injuries?
• Patient is communicating?
• Ringing in the ears?
• Paresthesia of the lips or Tongue?
• Referred immediately for appropriate medical treatment.
External Examination
• External signs of injury
• Lacerations of the head and neck
• (TMJ) should be palpated externally while the patient opens and closes.
• Zygomatic arch, angle, and lower border of the mandible palpated and note made of any
areas of tenderness, swelling, or bruising of the face, cheek, neck, or lips for possible bone
fractures.
Clinical Examination Cont….
Hard-Tissue Examination
• After visual examination and abnormal findings are noted, radiographs of the
injured areas should be taken
Thermal and Electric Tests
• Traumatized tooth vulnerable to false negative readings from these test
• Conduction capability of the nerve endings or sensory receptors or both is
sufficiently deranged to inhibit the nerve impulse from an electric/thermal stimulus
• Teeth that yield a negative response (or no response) cannot be assumed to have
necrotic pulps, because they may give a positive response later
• Transition from a negative to a positive response at a subsequent test may be
considered a sign of a healthy pulp
• The persistence of a negative response would suggest that the pulp has been
irreversibly damaged
• Tests should be repeated at 3 weeks; 3, 6, and 12 months; and at yearly intervals
after the accident
Radiographic Examinations
• Root fractures, subgingival crown fractures, tooth displacements, bone fractures, or
foreign objects
• Soft-tissue laceration it is advisable to radiograph the injured area before suturing to
be sure that no foreign objects have been embedded
PREVENTION OF DENTAL INJURIES
Face Guards
• Cage-type guards attached to helmet
• Face guards of clear polycarbonate plastic
Mouth Guards
• Stock mouth guard
• Boil-and bite mouth guard
• Custom-made mouth guard
CLASSIFICATION OF INJURY TO DENTAL TISSUE
• Enamel Infraction
Uncomplicated Crown Fracture
• Enamel Fracture
• Enamel Dentine Fracture
•
•
•
•
Complicated Crown Fracture
Uncomplicated Crown Root Fracture
Complicated Crown Root Fracture
Root Fracture
The Ellis Classification
1. Enamel Fracture
2. Dentin Fracture without Pulp Exposure
3. Crown fracture with Pulp Exposure
4. Root Fracture
5. Tooth Luxation
6. Tooth Intrusion
INJURIES TO PERIODONTAL TISSUE
• Concussion
No loosening but pain on percussion
• Subluxation
Abnormal loosening but no displacement
• Extrusive Luxation
Partial displacement from socket
• Lateral Luxation
Displacement other than axially with
communication or fracture of alveolar socket
• Intrusive Luxation
Displacement into alveolar bone with
communication or fracture of alveolar socket
• Avulsion
Complete displacement of tooth from socket
Injuries to Gingiva or Oral Mucosa
• Laceration
Wound in mucosa resulting from Tear
• Contusion
Bruise not accompanied by break, causing sub mucosal haemorrhage
• Abrasion
Superficial wound results from rub or scrap
CROWN INFRACTION
• A crown infraction is an incomplete fracture of
enamel without loss of tooth structure.
Biologic Consequences:
• "weak points" through which bacteria and their byproducts can travel
Diagnosis and Clinical Presentation:
• Indirect light or transillumination
• Routine examination
Treatment
• involves establishing a baseline pulp status with routine
sensitivity testing.
Follow-Up
• The clinician should schedule follow-up examinations at
3,6, and 12 months and annually thereafter.
Photograph of traumatized
tooth illuminated with a resin
curinglight.
Enamel craze lines are clearly
visible
UNCOMPLICATED CROWN
FRACTURE
• An uncomplicated crown fracture is a fracture of the
enamel or the enamel and dentin without pulp
exposure.
• If the fracture involves the enamel only, the
consequences are minimal
• If dentin is exposed a direct pathway exists for noxious
stimuli to pass through the dentinal tubules to the pulp
• The reaction of the pulp depends on a number of
factors, including time of treatment, distance of the
fracture from the pulp, and size of the dentinal tubules
A, Uncomplicated crown fracture
of the maxillary central
i ncisor.
B, The fractured segment is
bonded to tooth after placement of
a calcium hydroxide base
Maxillary right central incisor with an
UNCOMPLICATED CROWN FRACTURE involving
the enamel and dentin
Diagnosis and Clinical Presentation
• Enamel fracture includes a superficial, rough edge that
may cause irritation to the tongue or lip. Sensitivity to
air or liquids (hot or cold) is not a complaint
• Enamel and dentin fracture also includes a rough edge
on the tooth , sensitivity to air and hot and cold liquids
may be a chief complaint.
• Commonly a lip bruise or laceration is present
Treatment
• Smooth the sharp edges and leave, if esthetically
acceptable. Placing bonded composite resins may be
necessary for esthetics.
Enamel and Dentin Fracture
• Rx as soon as possible
• A hard-setting calcium hydroxide base is placed over
exposed dentinal tubules to disinfect the fractured
dentinal surface and stimulate closure of the tubules,
making them less permeable to noxious stimuli
followed by restoration with a bonded resin technique
• Fractured tooth fragment if located can be bonded to
get esthetic results
• If the tooth fragment is not located, a lip radiograph
should be taken to ensure the fragment has not lodged
in the lip
Follow-Up:The clinician should schedule follow-up
examinations at 3,6, and 12 months and annually
thereafter. Prognosis is good.
COMPLICATED CROWN FRACTURE
• A complicated crown fracture involves the enamel,
dentin,and pulp.
• A crown fracture involving the pulp, if left untreated,
will always result in pulp necrosis
• The manner and time sequence in which the pulp
becomes necrotic allows a great deal of potential for
successful intervention to maintain pulp vitality
Cervical pulpotomy of an immature maxillary incisor tooth followed by pulpectomy after
root formation. A, Pulpotomy is initiated. B, Six months later a hard-tissue barrier has
formed and the root continues to develop. C, One year later root development is
complete. D, A pulpectomy followed by a permanent root canal therapy is performed.
TREATMENT
There are two treatment options
(1) Vital pulp therapy comprising pulp capping,
partial pulpotomy, and cervical pulpotomy
(2) Pulpectomy.
Choice of treatment depends on the stage of
development of the tooth, time between the
accident and treatment, concomitant periodontal
injury, and restorative treatment plan.
CROWN AND ROOT FRACTURE
• A crown and root fracture is a fracture involving
enamel,dentin, and cementum. The pulp may or
may not be involved
• Biologic consequences of a crown root fracture
are identical to an uncomplicated (if the pulp is
not exposed) or complicated (if the crown is
exposed) crown fracture.
• Periodontal complications are also present
because the fracture may encroach on the
attachment apparatus
Diagnosis and Clinical Presentation
• Crown root fractures are result of direct trauma that
produces a chisel type of fracture
• Fragments may be firm, loose
• The periodontal injury causes pain on pressure and
biting, and exposed dentin or pulp causes pain to air
and hot or cold liquids.
• Indirect light and transillumination is an effective way
of diagnosing these fractures.
• The "cracked tooth syndrome" in a posterior tooth is
also an example of a crown root fracture
Crown and root fracture of maxillary left central incisor. A, Chisel type of fracture has
resulted in multiple fragments, one of which extends below the attachment level.
B, Radiograph of the same tooth.
Treatment
• Injuries are treated in the same manner as
uncomplicated or complicated crown fractures,
with additional treatment for any attachment injury
• All loose fragments are removed.
• A periodontal assessment is made as to whether the
tooth can be treated periodontally to allow it to be
adequately restored.
• Surgical access or orthodontic extrusion to the site
for proper restoration of defect
• Extraction if not managable
ROOT FRACTURE
• A root fracture is a fracture of the cementum and
dentin involving the pulp
• When a root fractures horizontally, the coronal
segment is displaced to a varying degree; generally the
apical segment is not displaced
• Pulpal circulation intact in apical segment and pulp
necrosis in coronal segment
• Rigid stabilization of the segments (for 2 to 4 months)
will allow healing and "reattachment" of the fractured
segments
Diagnosis and Clinical Presentation
• Clinical presentation is similar to that of luxation
injuries
• Imperative to take at least three angled radiographs so
that at least at one angulation the x-ray beam will pass
directly through the fracture line
Treatment
• Repositioning of the segments in as close proximity as
possible and rigidly splinting to adjacent teeth for 2 to
4 months
• If a long period has elapsed between the injury and
treatment, it will likely not be possible to reposition
the segments
A, At this angle, no "fracture" is seen.
B, The "fracture" appears complicated in nature.
C, Only at this angle, the true nature of the fracture can be seen
Healing Patterns
• Healing with calcified tissue-Radiographically, the
fracture line is visible, but the fragments are in close
contact.
• Healing with interproximal connective tissue.
Radiographically,the fragments appear separated by a
narrow radiolucent line, and the fractured edges
appear rounded.
• Healing with interproximal bone and connective
tissue-Radiographically, a distinct bony ridge
separates the fragments
• Interproximal inflammatory tissue without healingRadiographically, a widening of the fracture line, a
developing radiolucency
Healing patterns after horizontal root
fractures.
A, Healing with calcified tissue.
B, Healing with interproximal
connective tissue.
C, Healing with bone and connective
tissue.
D, Interproximal connective tissue
without healing.
Treatment of Complications
1. Coronal Root Fractures
• Fractures in the coronal segment had a poor prognosis
• If Reattachment of the fractured segments is not
possible, extraction of the coronal segment is
indicated.
• The level of fracture and length of the remaining root
are evaluated for restorability
• If the apical root segment is long enough, forced
eruption of this segment can be carried out to enable
a restoration to be fabricated
2. Mid 3rd Fracture
• In almost all cases the necrosis occurs in the coronal
segment with apical segment remaining vital
• Endodontic treatment is indicated in the coronal root
segment only unless periapical pathology
• The coronal segment is obturated after a hard-tissue
barrier has formed apically in the coronal segment
and periradicular healing has taken place.
• When both the coronal and apical pulp are necrotic,
treatment is more complicated. Treatment
through the fracture is extremely difficult
• If healing of the fracture is completed, followed by
necrosis of apical end, prognosis is much improved.
Conservative root canal treatment of the
coronal and apical segments.
Note the filling material in the fracture
line that compromises
the healing response
3. Apical root fractures
• Necrotic apical segments can be surgically
removed
• Removal of the apical segment in midroot
fractures leaves the coronal segment with a
compromised attachment
• Endodontic implants are used to provide
additional support to the tooth
Orthodontic forced eruption of
a tooth that has undergone a
root fracture at the
cervical bone level
INJURIES TO PERIODONTAL TISSUE
• Concussion
No loosening but pain on percussion
• Subluxation
Abnormal loosening but no displacement
• Extrusive Luxation
Partial displacement from socket
• Lateral Luxation
Displacement other than axially with
communication or fracture of alveolar socket
• Intrusive Luxation
Displacement into alveolar bone with
communication or fracture of alveolar socket
• Avulsion
Complete displacement of tooth from socket
Concussion
• Not brought to dentist until tooth discolors
• Impact force causes edema and haemorrhage in PDL
• Tooth is tender to percussion (t.t.p.)
• No rupture of PDL , tooth firm in socket
Subluxation
• In addition to previous findings there is rupture
of some PDL fibres
• Tooth is mobile in socket but not displaced
Treatment of Concussion & Subluxation
• Occlusal relief
• Soft diet for 7 days
• Immobilisation with splint if t.t.p
• CHX 0.2% mouthwash, twice daily
Little risk of pulp necrosis or resorption
Extrusive & Lateral Luxation
Extrusive Luxation
• Rupture of PDL and Pulp
Lateral Luxation
• Rupture of PDL and Pulp
• Compression injury of alveolar plate
Rx
• LA buccal and palatal
• Atraumatic repositioning of tooth with firm pressure
• Functional splint 2-3 weeks
• Antibiotics age related dose of amoxicillin
• CHX mouth wash
• Soft diet 2-3 weeks
Treatment
• LA buccal and palatal
• Atraumatic repositioning of tooth with firm
pressure
• Functional splint 2-3 weeks
• Antibiotics age related dose of amoxicillin
• CHX mouth wash
• Soft diet 2-3 weeks
• Endodontic Rx on subsequent visit depending
on clinical and radio graphical examination
• With severe damage more chances of resorption
Intrusive Luxation
• Result of apical impact
• Extensive damage to PDL and Alveolar plate
• Risk of Pulp necrosis, resorption & ankylosis high
2 distinct situation exist
Open Apex:
Two treatment courses for open apex intrusive luxation
• Disimpact with forceps if necessary and allowed to
erupt spontaniously for 2-3 months, if no movement
then start orthodontic extrusion
• Disimpact and surgically reposition using functional
splint for 7-10 days , monitor pulpal status clinically
and radiographically and start endo if necessary
• Non setting CAOH in root canal in advocated
• Once apexification is achieved obturation is done.
Closed Apex
• Elective orthodontic/surgical extrusion immediately
• Functional splint for 7-10 days after extrusion
• Elective RCT at 10th day
• Maintenance of CaOH in RC during ortho Rx
• Finally obturate with GP

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