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TRAUMATIC INJURIES
CONTENTS
1. Introduction
2. Definitions and Anatomical considerations.
3. Classification, Etiology, Epidemoilogy.
4. Trauma to primary dentition
5. Examination, diagnosis and management of dental injuries
6. Crown Fracture
7. Crown Root Fracture
8. Root Fracture
9. Concussion and Subluxation
10. Extrusive and Lateral luxation
11.Intrusive luxation .
12. Avulsion
13. Trauma to supporting structures.
14. Prevention of dental injuries.
INTRODUCTION
Traumatic dental injuries can be rated as second occurance compared to
limbs and other part of body. Considering all the injuries special attention
is given to traumatic dental injuries because of esthetics and the patients
phycologic factors involvement. In most of the traumatic dental injuries
treatment concerned is not only to the injury but also in bringing back the
lost laugh.
Traumatic dental injuries are always caused by sudden impact force.
This impact force varies depending on the object and force.
Traumatic dental injuries are common in children and adults (F.K.K.
kahabuka et al)
Trauma to teeth is a common occurrence that every dental surgeon must
be prepared to asses, evaluate and treat when necessary. (Satish
chandra)
Trauma to the oral cavity may involve soft tissues such as lips, cheeks,
tongue and floor of the mouth and hard tissues such as teeth, jaws and
Definitions
A fracture is understood to be the cracking or breaking of a tooth that has
been subjected to a force or impact greater than its resistance (Enrique
basrani)
One important factor responsible for the loss of sound tooth structure that
is not directly associated with disease is DENTAL TRAUMA (Esthetics)
Anatomical Considerations
Dentoalveolar trauma involves many tissues and structures. Recognizing the
normal configuration of teeth and their supporting tissues will be helpful when
assessing the effects of trauma, planning corrective treatment and evaluating
the outcome.
A tooth consists of three hard tissues: enamel, dentin and cementum. Dentin
is formed by pulp cells and cementum is formed by periodontal ligament cells.
Embryologically, the alveolar bone is composed of the alveolar one proper and
the alveolar process. The alveolar bone proper is the compact bone within
alveolar and is formed by periotonal ligament cells.
The periodontal membrane lies between the alveolar bone and the cementum.
It is connected to the tooth and alveolar bone.
This connective tissue attachment on the alveolar bone margin is usually
about 1mmm wide and the epithelial attachment is approximately 1mm
coronally. This 2mm width is called the biologic width.
A tooth with an immature root has hertwigs epithelial root sheath in the apical
region (Mitsuhiero Tscikibashi)
Hertwigs epithelial root sheath in the apical region. Hertwigs epithelial sheath
was originally the reduced enamel epithelium separated from the enamel. The
reduced enamel is the tissue where inner and outer enamel epithelium
combine. Hertwigs epithelial sheath plays an important role in root formation.
On the pulpal side of the Hertwigs epithelial sheath pulpcells are induced and
differentiated to become odentoblasts, on the periodontal membrane side,
cells of the dental follicles are induced and differentiated to become
periodontal membrane cells (cementablasts, fibroblasts and osteoblasts)
CLASSIFICATION
Ellis Classification (Louis I. Grossman)
It consist of 6 groups
a. Enamel fracture
b. Dentin fracture without pulp exposure.
c. Crown fracture with pulp exposure
d. Root fracture
e. Tooth luxation
f.
Tooth intrusion
Class 1.
Class 2
Class 3
Class 4
Fracture line within the coronal third of the root, but below
the level of the alveolar crest.
Enamel fracture
873.61
873.62
873.63
Root fracture
873.64
873.66
Tooth luxation
873.67
873.68
Avulsion of tooth
873.69
802.20
802.40
802.21
802.41
873.60
Crown infraction
873.61
873.62
873.63
Root fracture
873.64
873.64
873.66
Concussion
873.66
Sub luxation
873.66
Lateral luxation
873.67
Intrusive luxation
873.67
Extrusive luxation
873.68
2. The absolute conviction that is impossible to view the dentin and the pulp
as separate organs and that they constitute one organ.
3. Determination of treatment.
Classification of Basrani (Enrique Basrani)
A. Crown fractures
1. Fractures of the enamel
2. Fractures of the enamel and dentin
a.Without pulp exposure
b.With pulp exposure
B. Root fractures
C. Crown root fractures
Subclass C
When a pulp exposition exists
Class D Compromises :
All the enamel dentin lesions, which involve a mesial or distal coronal angle
and the incisal or palaal surface, with root involvement.
Sub Class D
When a pulp exposition exists.
Predisposing factors to traumatic injuries :
Increased overget with protrusion of upper incisors
Insufficient lip closure (J.O. Andreasen)
Mouth breathing.
Etiology:
There are innumerable causes of tooth trauma and each causative factor
presents with unique circumstances.
Epileptic fits and cerebral palsy (Satish Chandra)
Child battered syndrome/physical abuse (Satish chandra)
Accidents caused by falls
Accidents caused by stones
Traffic accidents
Opening bottles with teeth
Injuries in flights
Sports
Playground (Blows from head)
Biting thread with the teeth
Injuries in amusement parks (Bumper cars)
Any injury to children on the face affecting the appearance, speech and
functions causes much concern physically, physiologically and psychologically.
More traumatized will be the parents, which at times requires more attention
than the child.
History taking, examinations, diagnosis and treatment should be done
carefully. All things should be properly documented with proper procedures
and skill.
There are 3 treatment goals for traumatic injuries to the primary
dentions.
1. To protect the patients health
2. To protect the developing tooth bud
3. To maintain the integrity of the injured tooth.
Epidemiology:
4 to 33% of all children
Maxillary central incisors are involved.
Causes- Falls, bike accidents, sports play auto accidents, child
abuse and iatrogenic injuries.
Classification:
Injuries to primary teeth only are classified as
Crown infraction
Crown fracture
Crown and root fracture
Root fracture
Injuries to the periodontal attachment are classified as
Concussion
10
Subluxation
Extrusion
Lateral luxation
Intrusion
Avulsion
Treatment:
Treatment of primary tooth trauma crown infraction and crown fractures that
do not involve the pulp
Smoothing rough edges
Placement of bonded resin restorations
Crown fractures involving the pulp
Pulp therapy and resin restorations or full coverage, stainless steel or tooth
coloured crowns.
Crown and root fractures:
These teeth usually extracted, but pulp therapy and full coverage is an option
in some instances.
Root fractures:
Splinting mobile teeth or extraction.
Luxation and Exarticulation injuries:
Alveolarbone surrounding the primary teeth is very vesilent which yields
during the injury causing luxations & avulsions.
Another cause is resorbed roots. Most affected are the maxillary centrals.
Displacement like intrusions at times neglected as pain or injury or bleeding is
minimum. While examining the intruded teeth certain factors should be
considered as:
Root fractures
11
12
13
The extent of damage depends on the age of the patient, at the time of trauma
and the nature of the traumatic injury.
The most damage to permanent tooth bud follows Intrusive luxation of primary incisors:
The younger the child the greater the extent of damage to the permanent
tooth bud.
Speculative effects of trauma to the primary teeth on permanent tooth
budsBuccal intrusion of the primary tooth damages the enamel organ formation
resulting in hypoplasia and pigmentation. Malformation of the crown and
hypoplasia of the enamel are due to vertical force. Bending and deformity of
the crown is caused by the tooth germ being bent due to the root of the
primary tooth being pushed against the tooth germ palatally. Bending of the
root, lack of root development is caused by damage of Hertwigs epthelial root
sheath when the entire tooth germ is pushed apically.
Examination and diagnosis of dental injuries:
As discussed any injury may not be confirming to only dental or oral tissues.
Face injuries, head injuries and vital organs should be recognized and proper
reference should be made if necessary.
Each patient should be carefully examined and evaluated for providing
treatment.
Dental injuries should always be considered as an emergency condition and
treated immediately to relieve pain, facilitate the reduction of displaced teeth
and improve the prognosis. (J.O Andreasen)
Complete examination
[Satish chandra]
14
Good and
Relevant
history
Clinical
examination
Sensitivity
tests
Radiographic
examination
15
Thermal tests
16
Detection of discoloration
Root fractures
Jaw fractures
The size of the pulp chamber and root canal, the apical root
development, the appearance of the periodontal ligament space.
5. Resorption and calcifications.
Record of traumatired teeth:
Date of birth
Age
Patients Name
Male
(Mitsuhiero tscikiboshi)
Female
Date
Present trauma
Teeth involved
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Date :
Cause
:
Place :
General findings:
Headache
consciousness
Clear
Primary
Permanent
Spontaneous pain :
Yes
No
Pain to ice
Yes
No
Percussion pain
Yes
No
Pulp exposure
Yes
No
Yes
No
No
Nausea
Yes
Yes
No
Not clear
No
Discoloration
Tooth mobility
Yes
Damage
Oralmucosa
Laceration of lips
Other
Radiographic findings:
Completion of root formation
Complete
Incomplete
Root fracture
Yes
No
Apical lesion
Yes
No
Yes
No
Yes
No
Yes
No
Root resorption
:
:
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Yes
No
__________________ (Minutes)
dry
Tap water
Saliva
Milk
Diagnosis:
Crown Fracture
Root fracture
Concussion
Extrusive luxation
Intrusive luxation
Subluxation
Avulsion
873:60
Enamel fracture
Treatment :
a. Sealing the exposed dentin tubules.
b. Stimulating the pulp to form a layer of reparative dentin
The remaining pulpal dentin thickness over the pulp is important in managing
this type of fracture.
Stanley observed that remaining pulpal dentin more than 2mm is sufficient for
shielding the pulp from most forms of irritation.
Ca (OH)2 is applied for the following reasons : (Sathish chandra)
19
Immediate treatment increases the chances for the preservation of pulp vitality
and normal health of pulp.
Treatment planning basically depends on the following three factors.
1. The extent of fracture
2. The length of time between injury & treatment.
3. The stage of root development.
There are two treatment options:
1. Vital pulp therapy comprising pulp capping, partial pulpotomy and cervical
pulpotomy.
2. Pulpectomy.
Pulp Capping: (MC Donald)
20
Indications:
a.
b.
c.
Pinpoint exposure (when the diameter of exposure is less than 1.5 mm)
d.
No haemorrage is seen from the exposure site but pink healthy pulp is
visible.
e.
Technique:
The exposed dentin and the exposed pulp are covered with a ca (OH)
paste such as dycal.
The lost tooth structure is restored with acid etch composite resin.
Follow up:
Electrical pulp testing, thermal testing, palpation tests and percussion tests
should be carried out at 3 weeks, 3,6, and 12 months. A hard tissue barrier
can be visualized as early as 6 weeks post treatment.
Partial pulpotomy : (Ingle)
Removal of coronal pulp tissue to the level of healthy pulp.
Indications:
The zone of inflammation in the pulp has extended more than 2mm in an
apical direction.
Procedure:
21
1. After anesthesia and rubber dam isolation, remove granulation tissue from
the exposure site using spoon excavator. This evaluates the size of
exposure.
2. Remove pulp tissue into the pulp proper to a depth of 1 or 2mm with a
water cooled round diamond stone.
3. Allow plenty of coolant water spray to irrigate and prevent heat damage to
pulp tissue.
4. After preparing pulp tissue, rinse the wound with saline and allow the
bleeding to stop then wash the wound gently with saline.
5. Apply a Ca (OH) 2 liner over the wound.
6. An intermediate base of hard setting Znpo4 or GIC may be used before
restoration with bonded composite resins.
7. The lost tooth structure is replaced with acid-etched composite resin.
Follow up and Prognosis:
The teeth need periodic evaluation, radio graphically and clinically to
determine the status of the pulp. Prognosis 94 to 96%.
(Teeth with incomplete apical formation: Partial Bipulpectomy: Enrique
Basrani)
Extirpation of a part of the vital pulp under anesthesia. The pulp remanent is
protected with a dressing. It is important to maintain the vitality of the healthy
pulp until apical development is complete. In this way, the normal
development of the entire length of the root will be obtained.
Indications:
1. When there is doubt that direct pulp protection will succeed.
2. When the patient comes to dental office more than 24 hrs after the injury.
3. In teeth with under developed apices that have pulp polyps.
4. In extensive pulp exposures.
Contra indications:
22
continued by filling the rest of the cavity with ZnoE followed by Zn Po4.
h. Amalgam in posterior tooth or composite in anterior tooth.
i. Post operative radiograph.
j. Clincoradiographic recall examinations. This will serve to verify the
formation of a calcific barrier and degree of apical development.
FULL CERRICAL PULPOTOMY (cohen)
Pulpotomy involves removal of the entire coronal pulp to the level of the root
orifices.
23
INDICATIONS:
The pulp is inflamed to the deeper levels of coronal pulp.
Traumatic exposure [after 72 hours]
TECHNIQUE:
1. After anesthesia, rubber dam is placed and superficial disinfections are
instituted.
2. The coronal pulp is removed but only to the level of the root orifices.
3. Ca (OH)2 dressing and coronal restoration carried out.
Prognosis: 75%
Pulpectomy:
Removal of entire pulp upto the level of apical foramen. (Cohen)
Indications:
Complicated crown fracture of matured teeth.
Technique:
1. Rubber dam is applied and roof of the pulp chamber should be removed to
gain access to the root canals.
2. The contents of the pulp chamber and all debris from the occlusal third of
the canals should be removed.
3. A moistened pellet of camphorated monochlorophenol, with excess
moisture blotted, should be in pulp chamber. The chamber may be sealed
with ZnoE.
Prognosis : 90%
Partial pulpectomy:
24
b. Immature tooth :
RCT
Apexification
Indications:
Teeth with open apices in which instrumentation techniques cannot create an
apical stop to facilitate effective obturation of the canal.
Technique:
Disinfection of the canal:
1. Access to canals is achieved.
2. Working length has been confirmed radiographically, light filing is
performed with copious irrigation with 0.5% sodium hypochlorite. This is
useful in disinfecting the canals of these immature teeth.
3. The canal is dried with paper points and a soft mix of Ca (OH) 2 spun into
the canal with a lentulo spiral instrument.
Stimulation of a hard tissue barrier:
4. Pure Ca (OH)2 is mixed with sterile solution to a thick consistency.
5. The Ca (OH)2 is packed against the apical soft tissue with a plugger.
6. Ca (OH)2 meticulously removed from the access cavity and well setting
temporary filling is placed in access cavity.
7. A radiograph is taken at 3 months intervals to evaluate whether a hard
tissue barrier has formed.
25
2. Oblique
26
3. Vertical
Location of fracture:
1. The cervical third:
Horizontal fracture:
a. Patient experiences discomfort over the buccal portion of the affected tooth.
b. Tooth is sensitive to vertical and horizontal percussion.
c. Spontaneous pain present.
d. Slight or moderate mobility.
e. Patient feel that tooth may elongated.
f. Color change in crown.
g. Palpation provide information about the degree of tooth malposition
Radiographic examination:
Fracture is seen in radiographs as a dark line that extend across the root.
Treatment:
Immediate treatment: (Emergency Treatment)
The type of emergency Treatment depends on whether the pulp remains vital.
With pulp vitality:
a.
Anesthesia.
b.
c.
27
d.
e.
f.
g.
Orthodontic wire
2.
Acrylic splint
3.
4.
Orthodontic Wire:
Stainless steel wire 0.8 to 1 mm is recommended extending at least to
adjacent tooth on each side of the fractured tooth. The wire is passed from
the buccal to the palatal area of the ends are loosely adjusted on the distal of
the last tooth on the splint. To complete the fixation, small V-shaped wires is
placed from the palatal side to buccal side of each interdental space,
engaging the palatal and buccal portion of the principle arch wire.
Once this step has been done, the free ends of V shaped wires are twisted
with a haemostat. The excessive wire is removed, leaving about 2mm of
twisted ends which are bent into each interdental space.
Acrylic Splint:
a. Direct :
1. without a brush
2. Brush on technique
b. Indirect
Direct:
This is done in mouth with self-curing acrylic. The acrylic mass is placed on
the labial aspect of the teeth and removed before it polymerizes to avoid its
retention. Check occlusion, polish and cement with ZnoE or poly carboxylate
cement. The affected tooth and at least adjacent tooth on either side of
28
fractured tooth is isolated and dried. Acrylic powder and liquid are applied with
a brush to labial and lingual surfaces in middle third and in inter-dental
spaces. After the material sets, it is polished with sandpaper disc. Occlusion is
checked.
Indirect:
a. An impression is taken.
b. The area on the model is covered with wax to eliminate undercut
c. A splint is made of self-curing acrylic.
d. After polishing, the splint is cemented.
3. Orthodontic bands and brackets cemented and connected by wires, make a
successful splint.
4. Composite with acid etch:
The Composite and acid etch is utilized, covering of affected teeth and
adjacent teeth to the level of the contact point.
5. Intra radicular splint (Endodontic splint)
Both the segments are treated endodontically, post space is made in both
segments in which rigid [vitallium or chrom cobal ] post splint is fixed
Follow-up
With vitality: Periodic clinico radiographic examination.
Immediate and follow-up:
A. With and without vitality:
Fractures in the cervical third without coronal segments:
1. Endodontic and periodontal (Gingivoplasty and alveoloplasty)
Disadvantage: Decrease the esthetics.
29
Endodontic
Total without mobility
Coronal With mobility
2.
3.
30
31
segment to continue its euption and the apical segment remains included in
the bone.
2. Bone and connective tissue are seen separating both segments. These
segments are surrounded by periodontal ligament.
3. The tooth is firm and maintains its vitality.
d. Interposition of granulation tissue between the segments:
1. When the pulp tissue in the coronal fragment becomes necrotic or when
the line of fracture is close to the gingival sulcus, it causes contamination
and proliferation of chronic inflammatory tissue.
32
33
First, remove any pulp tissue from the pulp horn of the tooth fragment and
bevel the entire pheriphery of the fracture line of the both fragment.
Next, bevel the entire pheriphery of the fractured surface of the remaining
tooth. Fit the matrix band lightly to isolate the adhesive surface from the
exudates, then apply the etchant and bonding agent to the remaining tooth
and the tooth fragment. Apply light-curing resin to the remaining tooth and
the tooth fragment and adapt the fractured surfaces closely.Tightening the
matrix band during curing allows the tooth fragment to return to its orignal
position buccolingually & mesiodistally.
7. Reshaping and polishing
8. Followup
Complicated crown-root fracture management.
1. Examination and diagnosis
2. Removal of loose tooth fragment
3. Root canal treatment
4. Re-establishing the biologic width
5. Confirmation of healing
6. Root canal filling
7. Crown restoration : post and core
8. Follow up
873.66 Tooth luxation: (Grossman)
WHO has classified tooth luxation (WHO classification 873.66) into:
Concussion - tooth is sensitive to percussion, but is not displaced.
Subluxation - tooth has abnormal mobility, but is not displaced.
Luxation- tooth is loose and displaced.
34
Lateral luxation -Teeth usually have their crown displaced lingually and are
often associated with fractures of the vestibalar part of the socket wall.
Management:
Concussion and subluxation, the treatment may be confined to occlusal
grinding of the opposing teeth, supplemental by repeated vitality tests during
the follow up period, minimum 1 year.
Incase of lateral luxation, repositioning is often complicated by the
associated alveolar bone fracture. Usually the apex of the displaced tooth has
been forced through the facial bone plate, thus locking the tooth in its new
position. In these cases, it is essential to disengage the apex first by pressing
over the apical area and on the lingual aspect of crown.
Displaced bone fragments can be repositioned by means of digital pressure.
Lacerated gingiva should be readapted to the neck of the tooth and sutured.
Finally, radiographs should be taken in order to verify adequate repositioning.
Immobilize the tooth with splints.
Splinting: (Andreasen)
The object of splinting is stabilization of injured tooth and prevention of further
damage to the pulp and periodontal structures during the healing period.
35
36
Interdental fixation:
Thin, soft stainless wires (0.2mm, 32 gauge) are used for this type of fixation.
It is important that the ligatures are applied to several adjacent teeth on both
sides of traumtized area.
Archbar:
Metal bars fitted to the dental arch and ligated to the individual teeth are
commonly used. Semicircular soft metal bar is manually shaped to fit the
dental arch.
Resin full arch splint:
Cold-curing resin was popular as a splinting material.
Cast silver cap splint:
Used extensively in the past
Time consuming
Requires impression of a traumatized teeth.
Splinting period:
Injury to periodontal ligament 2-3 weeks
Injury to bone & periodontal ligament 3-4 weeks
Injury to lateral luxation 6-8 weeks.
Topical use of chlorhexidine twice a day for one week follow up.
37
Pathology:
1. Pulp necrosis.
a. Replacement resorption
b. Inflammatory resorption
2. Pulp canal obliteraton.
3. Root resorption, external
4. Root resorption, internal
a. Internal replacement resorption
b. Internal inflammatory resorption
Pulp necrosis:
Most commonly occur in intrusion
Another important factor is the stage of root development at the time of
injury.
An age factor also seems to operate these. Increasing age seems to
favour pulp necrosis after luxation when root development is complete.
When a tooth is forcefully displaced in the alveolus, vessels at the apical
foramen are compressed, injured or severed and circulation in the pulp
disturbed. Subsequent reactions in the pulp depend on the degree,
duration of nutritional disturbance, the stage of root development the
presence of bacterial contamination.
A sudden complete break in circulation causes inflammation of the entire
pulp, lack of oxygen which leads to denaturation of proteins and
coagulation necrosis.
2. Pulpcanal obliteration:
Pulpcanal obliteration can be regarded as a response to moderate injury
consisting of an accelerated dentin deposition & is frequently encountered
after luxation injuries of permanent teeth.
Common in severely mobile or dislocated teeth.
38
Inflammatory resorption:
39
Radiographic
findings:
Root
resorption
with
an
adjacent
rediolucency.
Internal root resorption:
Internal replacement resorption:
Radiographically characterized by an irregular enlargement of the pulp
chamber.
The continuous rebuilding of bone at the expense of dentin is responsible
for the gradual enlargement of the pulp chamber.
Internal inflammatory resorption:
Radiographically characterized by an oval shape increase in the size of
pulp chamber.
Progression of internal resorption depends upon the interaction of necrotic
and vital pulp tissue at their interface.
Treatment: Root canal Treatment
873.67 Intrusion or Extrusion
Intrusion: (Cohen)
Displacement of the tooth deeper into the alveolar bone.
The tooth may be pushed into socket sometimes giving the appearance that
has been avulsed.
The tooth presents with the clinical presentation of ankylosis because the
tooth is firm in the socket, gives a metallic sound to the percussion test and
after the injury is in infra occlusion.
The obvious difference is the recent traumatic injury. Radiographic evaluation
is essential to evaluate the extent and the position of the intruded tooth.
Palpation of the alveolar process often reveals the position of the displaced
tooth. (Andreasen)
40
41
h. Splinting period.
1. Extrusion
2. Intrusion
:
:
i. Follow up period
2-3 weeks
6-8 weeks
:
Minimum 1 year
a. Pulp necrosis
15-59%
6-35%
c. External resorption
1-11%
d. Internal resorption
2%
10%
Prognosis:
873.68 Avulsion:
Tooth has been totally displaced out of its socket (Grossman)
The avulsed tooth is both a dental and an emotional problem. It is usually the
trauma to an anterior tooth of a child.
The shock and pain of the injury, the loss of a tooth needed for eating,
speaking and smiling often lead to emotional upheaval in-patient as well as
parent.
The situation is compounded by the need for emergency treatment, to
enhance the prognosis.
The longer the luxated tooth is out of its socket, the less likely it will remain in
a healthily functional state after replantation.
The following instructions should be given to the parent as soon as the dentist
has been informed of the accident and in preparation for a imminent visit.
1. Wash the tooth in running water without brushing or cleaning it.
42
2. Have the patient rinse mouth. Replace tooth in its socket using gentle,
steady finger pressure. If the patient is cooperative and able, have the
patient gently close the teeth together to force the tooth back into its
original position.
3. Take the patient to the dentist immediately.
If the patient or parent cannot replace the tooth in its socket then care in
transporting that tooth to the dentist becomes essential.
The tooth must be carried in a moist vehicle to maintain the viability of the torn
periodontal ligament. The most readily available vehicle is the patient mouth,
in which the tooth is bathed in saliva at body temperature.
If this cannot be done safely such as if the patient is too young then one
should place the tooth in a container of milk.
The tooth should not be wrapped in dry handkerchief or tissue because the
periodontal ligament will become dehydrated.
Several studies have shown that extra oral time for an avulsed tooth optimally
should not exceed 30 min and the patient must be taken to the dentist
immediately.
The sooner the replantation, the better the prognosis.
Factors affecting the success of replantation (Jacob G.Daniel)
Extraoral time:
Shorter the extraoral time, the better the prognosis for the replanted tooth.
Both the pulp and the periodontal ligament suffer extensive damage during an
extra-alveolar period and healing is almost entirely dependent upon the time
of an handling during the extra alveolar period (Andreasen)
43
44
It has been used as a tissue culture and has demonstrated the ability to
preserve and reconstitute the cells of the periodontal ligament.
Hanks balanced salt solution to be superior to milk and comparable to
viaspan, a tissue medium for transplant. It maintains the osmolarity of
periodontal ligament cells.
Saliva:
Saliva is the best transport medium for an avulsed tooth.
Disadvantage:
If child is too young, is unreliable, there is too great a chance for swallowing
the tooth on the trip to the dentists office
Advantage:
Tooth is bathed in saliva at body temperature.
A commercially available storage and transport system, Save-A-Tooth, has
been developed. These containers may be purchased and kept available in
areas where accident are more likely to happen.
Diagnosis and History:
The importance of the medical history should not be compromised and must
be completed before local anesthetic is administered.
The aim of the emergency treatment is preservation of as many viable
periodontal ligament cells as possible.
The case history is taken with emphasis on the time interval and condition
under which the tooth has been stored.
Determination of other injuries and the extent of bony involvement may give
the clinician as how the avulsion have occurred.
45
When the trauma occurred, whether the tooth was dry or wet and the storage
condition are critical in formulating a treatment plan. The place of the accident
may dramatically influence the prognosis contact with foreign material and
may alter the treatment.
Treatment:
Main aim is to replant the tooth with the maximum number of periodontal
ligament cells that has potentially to regenerate. If this is not possible steps
are taken to prepare the root to slowdown the inevitable resorption.
Endodontics is not initiated at the emergency replantation- not performed
extra orally if any hope exists or vital periodontal ligament cells.
In Clinics:
Tooth should initially be placed in storage media (Hanks Balanced salt
solution).
The socket is cleaned with saline. Thorough examination of other teeth
performed may make the clinician to note any alveolar bone fracture or soft
tissues injury.
Preparation of the root:
Extra oral dry time less than 20 minutes:
Closed apex:
Revitalization not possible, because less than 20 minutes chances of
periodontal ligament cells healing is excellent.
Extra oral dry time less than 20 minutes:
Open apex:
46
Rinsing and replanting at the earliest. The tooth is socked in storage media to
reduce ankylosis by socking debris and bacteria are reduced which reduces
inflammation. The doxycyline may help better.
The tooth has already The tooth has been Extra oral drytime
been replanted
kept in special more than 60 min
storage media the
extraoral dry time
in less than 60 min
47
Treatment
Suture gingival laceration, especially in the cerrical area. Verify normal position of
the replanted tooth radiographically. Apply a flexible splint for 1 week
Administer systemic antibiotics:
Doxy cycline 2 x per day for 7 days at appropriate dose for at patient age & weight.
Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come
to contact with soil or tetanus coverage is uncertain.
Initiate endodontic treatment after 7-10 days. Place ca(OH) 2 as an intracanal
medicament.
Patient instructions:
a. Soft diet for 2 weeks
b. Brush teeth with a soft brush after each meal.
c. Use chlorhexidine mouth rinse (0.1%) twice a day for 1 week
d. Follow-up
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Treatment
Replantation is not
indicated
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Splinting:
Semi-rigid splinting for 7 to 10 days is recommended with bony fracture,
longer splinting times may be necessary.
The acid-etch composite & arch-wire splint is the most commonly used splint
for traumatic injuries.
Many splints satisfy the requirements of an acceptable splint, with a new
(Titanium Trauma Splint) recently been shown to be particularly effective and
easy to use. (Matin trope)
Periodontal Healing and Resorption:
Andreasen has identified four distinct types of healing in the periodontal
ligaments.
1. Healing with a normal periodontal ligament
2. Healing with surface resorption
3. Healing with ankylosis
4. Healing with inflammatory resorption.
Prognosis:
External progressive root resorption 74 to 96%
1. Surface resorption
2. Replacement resorption
3. Inflammatory resorption.
Pulp Necrosis:
TRAUMA TO SUPPORTING STRUCTURES:
Injuries to teeth may be combined with fractures of the alveolar bone soft
tissues and mandible as well as soft tissues trauma to the gingiva and oral
musoca.
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and
radiographs
made
to
examine
the
entire
jaw
pantomography.
2. Repositioning, Suturing and Splinting:
After the administration of anesthetic, reposition the teeth and alveolar
bone. Attend to any other problems related to the trauma and suture the
soft tissues and splint the teeth.
3. Endodontic treatment:
Traumatic teeth associated with alveolar bone fracture usually have apical
vascular disruption of the pulps. Perform endodontic treatment for pulp
necrosis so that it does not hinder fracture healing.
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52
MOUTH GUARDS:
Mouth guard is very effective in decreasing the severity and number of dental
injuries. There a 3 types of mouthguard in the market.
i.
ii.
mouth guard
iii.
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and
polyethylene. These are heated and then either vacuumed down on the
cast or pressed down with positive pressure.