05 dentoalveolar injuries
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Transcript of 05 dentoalveolar injuries
Current Concepts in Management of Dentoalveolar Trauma
Dr. Armaghan MirzaFCPS Resident
Oral & Maxillofacial Surgeryde’Montmorency College of Dentistry
•Any injury to teeth or their supporting structures is grouped under the domain
of dentoalveolar injuries.
Dentoalveolar Injuries
Enamel Dentine Pulp Periodontal Membrane Alveolar bone
Etiology and Predisposing Factors
Predisposing factors
Male > Female Malocclusion - Class II division I Proclined teeth Contact sports Interpersonal violence Leisure activities e.g. cycling, skateboarding Handicaps Falls / Convulsive seizures e.g. epilepsy Endotracheal intubation Non Accidental Injuries ( NAI ) Child abuse
Review of Literature
Incidence of Orodental Injury 4-33% Peak age for Primary Dentition 1.5 - 3.5 yrs Peak age for Permanent Dentition 9- 10 yrs M : F ratio 2.5:1 to 3:1 Most commonly affected tooth Maxillary
central Incisor
By the age of 14 yrs, 55% have experienced trauma to dentition.
Classification Tooth fracture
1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival
--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival
--- ii) Subgingivalb) Diagonal --- i) Supragingival
--- ii) Subgingivalc) Vertical
3) Root fracture --- Apical third--- Middle third--- Coronal third
Classification Tooth fracture
1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival
--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival
--- ii) Subgingivalb) Diagonal --- i) Supragingival
--- ii) Subgingivalc) Vertical
3) Root fracture --- Apical third--- Middle third--- Coronal third
Classification Tooth fracture
1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival
--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival
--- ii) Subgingivalb) Diagonal --- i) Supragingival
--- ii) Subgingivalc) Vertical
3) Root fracture --- Apical third--- Middle third--- Coronal third
Classification Tooth fracture
1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival
--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival
--- ii) Subgingivalb) Diagonal --- i) Supragingival
--- ii) Subgingivalc) Vertical
3) Root fracture --- Apical third--- Middle third--- Coronal third
Classification Tooth fracture
1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival
--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival
--- ii) Subgingivalb) Diagonal --- i) Supragingival
--- ii) Subgingivalc) Vertical
3) Root fracture --- Apical third--- Middle third--- Coronal third
Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement
4) Avulsion Alveolar bone injuries
1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible
Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration
Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement
4) Avulsion Alveolar bone injuries
1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible
Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration
Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement
4) Avulsion Alveolar bone injuries
1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible
Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration
Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement
4) Avulsion Alveolar bone injuries
1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible
Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration
Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement
4) Avulsion Alveolar bone injuries
1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible
Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration
Management
Initial Assessment Confident and sympathetic approach by both doctor
and nurse to ensure that the parents feel the situation is under control and also helps the patient to calm down
History takinga) When did the accident occur?b) Where did the accident occur?c) How did the accident occur?d) Has the child any other symptoms?e) Have the lost teeth being accounted for?
Presenting Complaint
Tooth sensitive to hot and cold Sharp tooth Mobile tooth / teeth Oral pain Oral bleeding Malocclusion
Investigations
X-raysa) Dental ---periapicals, occlusal, Lateral Ceph.b) Jaw fractures --- Orthopantomogram, PA facec) Lips --- Periapical, Lateral Cephalogram
( foreign bodies, tooth fragment)
d) Chest X- rays--- Aspirated tooth or tooth fragment Vitality test Transillumination
Enamel fracture
With pulp vitalitySmooth fracture surfacePlace protective varnishPlace fluoride gel Without pulp vitality:Endodontic treatment
Enamel and dentin fracture
Restoration with Composite and / or GIC
Enamel and Dentine fracture with Pulpal Exposure < 2 mm Not contaminated with saliva etc. Presenting within 24 hours.
Pulp caping with calcium hydroxide plus crown restoration with composite
> 2 mm Contaminated Presenting after 24 hours
Pulpotomy with 2mm of pulp removed dressed with calcium hydroxide plus restoration.
Old exposure with pulpal necrosis Pulpectomy and endodontic therapy
Crown and root fracture
Without pulp exposure Remove the fracture segment Restoration With pulp exposure Remove the fractured segment Endodontic treatment followed by restoration
Root fracture
Primary dentition Without mobilityPreserve and should exfoliate normally
With mobility or cervical third fractureShould be removed without attempt to remove apical fragment
Root fracture
Permanent dentition Consider level of fracture
EndodonticEndodontic and apicectomyEndodontic, apicectomy and restoration (post and core, crown and implant)
Alveolar bone injuries
Reduction ---- Finger manipulation Fixation ---- Dental occlusal splints /
Direct wiring / Arch bar splinting / Plating/Acid etch composite
Immobilization --- 4 weeks
When alveolar bone component not present 2-3 weeks (Subluxation, displacement & avulsion)
Periodontal Injuries
Subluxation Displacement Avulsion
Management i) Reductionii) Immobilization --- 2-3 weeks
Gingival Injuries
Cover abrasions with antiseptic pack Suture lacerations
Acute trauma of deciduous teeth
Intrusion ----i) wait & observe if not disturbing the permanent tooth budii) extraction if possible risk of damaging the permanent tooth
bud Extrusion --- Extraction Subluxation --- Conservative ( soft diet) Avulsion --- Do not attempt to reimplant
Immobilization period for traumatized teeth Root fracture
Middle and apical third 4 weeks Cervical third 2 months
Avulsion Immature
Extra alveolar time < 60 minutes; Flexible splint 2 weeks Extra alveolar time > 60 minutes very poor prognosis
Mature Extra alveolar time < 60 minutes 2 weeks Extra alveolar time > 60 minutes 6 weeks
Luxation Concussion Splint optional (10 days) Subluxation Splint optional (10 days) Extrusion Splint for 3 weeks Lateral luxation Splint for 3-4 weeks Intrusion; Immature 3 – 4 weeks Intrusion; Mature 2 weeks
Post-operative Care
Antibiotics & Analgesics Liquids followed by soft diet – 4 weeks Nutritional supplements ( 2000 – 2200 Cal/day,
comprising proteins, fat and carbohydrates ) Maintenance of Oral hygiene
( antimicrobial mouthwashes e.g.0.2% Chlorhexidine ) Follow up every 3 months upto 1 year
Complications
Immediate ----- Bleeding (hematoma) Swelling Malocclusion
Late ---- Infection Mal union Non union Root resorption (external /
internal) Root ankylosis
Management options for traumatic intrusion of teeth
Mild < 3mm ---- Passive repositioning Moderate 3-6mm ---- Passive repositioning
---- Active repositioning (Immediate traction)
Severe > 6mm ---- Immediate repositioning ( Surgical reduction)
---- Extraction / Immediate root canal treatment ---- Extraction
Resorption
Lower prevalence when the period of dryness less than or equal to 5 mins
Prevalence of resorption with no visible contamination57.1%
Prevalence of resorption for contaminated tooth but washed clean75%
Prevalence of resorption for contaminated tooth but rubbed clean87.5%
Prevalence of resorption with visible contamination present100%
Avulsion
Recommended guidelines: Extra-alveolar time: within 30 mins Storage media: Hanks Balanced Salt solution>saline>saliva>milk Root treatment: Prereplantation treatment of root surface with
fluoride resists the resorption by forming flouroapatite.
Pre-replantation Treatment
Presenting within 2 hours: Closed Apex: HBSS for 30 minutes Open Apex: HBSS for 30 minutes , 1mg/20ml
Doxycycline soltn. for 5 minutes Presenting after 2 hours:,
Remove PDL by scraping or soaking in NaOCl for 30 minutes
Endodontic debridement, cleaning and shaping of the canal in hand
Soak in citric acid soltn for 3minutes, 1% Stannous Fluoride for 5 minutes and 1mg/20ml Doxycycline soltn. for 5 minutes
Obturate with GP
Avulsion
Injured socket Shouldn’t be debrided Clot shouldn’t be disturbed Gentle irrigation with saline Immobilization period: Splinting for 2-3 weeks Endodontic treatment: Tooth with open apex: no endodontic Rx Tooth with closed apex: within 14 days with
calcium hydroxide upto 9-12 months Periodic follow up with x rays, vitality tests and
color changes upto 2 years.
Emergency management outside surgery
Wash the tooth gently with water Avoid touching root Reimplant tooth immediately Bite on a handkerchief to hold the tooth in
place If unable to reimplant tooth, should put in the
saline / milk
Avulsion of teethIndicators of poor prognosis Extra alveolar time > 60 minutes Undesirable storage medium e.g. tap water Improper handling of root surface
Prevention of dentoalveolar injuries
Educate and empower the dental team to provide first aid care
Encourage the use of custom mouth guards during contact sports
Thank You
!for not walking out
Dentoalveolar Injury Duration of Immobilization
Mobile Tooth 7-10 Days
Tooth displacement 2-3 Weeks
Root fracture 2-4 Months
Replanted tooth(mature) 7-10 Days
Replanted tooth (immature) 3-4 Weeks