Management of Traumatized Teeth

8/3/2019 Management of Traumatized Teeth

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Introduction to Managementof traumatized teeth

Diagnosis

Classification

management



Examination and Diagnosis

Examination of a patient with dental injuriesshould include the following :

•

chief complaint

• history of present illness

• medical history

• clinical examination.

• Radiographic examination



Chief Complaint

I broke my tooth , my tooth feels looseOr sometimes the injury is obvious 1. When and how did the injury occur?

The date and

time of the accidenthow it took place2.Have you had any other injuries to your mouth or

teeth in the past? Crown or root fractures may have occurred

as a result of an earlier injury but are observed

at a later time.3.What problems are you now having with your tooth

or teeth? Pain, mobility, and occlusal interference

History of Present Injury

Few questions must be asked



1. Soft tissueThe purpose of the soft tissue evaluation is todetermine the extent of tissue damage and toidentify and remove foreign objects from

wounds.

2.Facial Skeleton The facial skeleton is evaluated for possiblefractures of the jaw or alveolar process

Medical historyClinical

examination

the patient’s medical condition

affects the treatment

3.Teeth and Supporting Tissues: Mobility, displacement,periradicular damage, pulp status and Crown color change



1. Mobility. Teeth are examined (gently) for mobility,

examining adjacent teeth also for movement which if present indicatesalveolar fracture

If there is no mobility, the teeth arepercussed for sounds of ankylosis (metallic sound). Absence of mobility mayindicate normal status or "locking" of the tooth in bone, such as in intrusion

2. Displacement.

3.Periradicular damage. Injury to the

supporting structures of teeth may result inswelling and bleeding involving theperiodontal ligament , such teeth aresensitive to percussion even light tapping

4.Pulpal status may be determined by symptoms,history, and clinical tests aselectrical pulp test (EPT) and carbondioxide ice. These tests are generally reliable in evaluatingand monitoring pulpal status except in teeth with incomplete

root development



A. Pulp testing. Carbon dioxide ice or the EPT is used to test teeth that have

been injured; several adjacent and opposing teeth are included in the test.

An initial lack of response or a high reading on the pulp tester is normal

Retesting is done in 4 to 6 weeks; the results are recorded and compared with

the initial responses.

If the pulp responds in both instances, the prognosis is good.

A pulp response that is absent initially and present at the second

visit indicates recovery of vitality

If the pulp fails to respond both times,

the tooth is retested in 3 to 4 months.

Continued lack of response may indicate pulp

necrosis



Radiographs are examined for fractures of bone or teethand stage of developmentConventional angulations may miss any irregularities

therefore multiple exposures are taken to ensure completediagnosis

Radiographic examination.



Radiographic evaluation. The initial radiograph made after the injurywill not show the pulp condition but it is useful in making a generalevaluation and for comparison with following radiographs

Another radiograph is taken after 4-6 weeks

Resorptive changes, particularly external changes, mayoccur soon after injury

Inflammatory resorption canbe intercepted by endodontic intervention

Pulp space calcification or obliteration is acommon finding after luxation injuries."

canal obliteration may be partial or nearlycomplete (after several years) and doesnot require root canal treatment

Crown color changes: Pulp injury may cause discoloration, evenafter only a few days. Initial changes tend to be pink. Subsequently,if the pulp does not recover and becomes necrotic, there may be agrayish darkening of the crown



classification1.Enamel fracture

2.Crown fractures without pulp involvement:

3. Crown fractures with pulp involvement

4. Crown – root fracture

5. Root fracture

6. Luxation

7.Avulsion8.Fracture of alveolar process





CROWN FRACTURES WITHOUTPULP EXPOSURE

prognosis is good

1. Restoring fractured part by composite resin

2. reattachment of dentin-enamelcrown fragments

Advantage : Dental

anatomy is restored perfectly with normaltoothstructure

In primary teeth

Such fractures are not important torestore thus the fracturesite may be smoothed without restoring.



CROWN FRACTURESWITH PULP EXPOSURE3 factors are very important

1.The extent of fracture:a small fracture may undergo vital pulp therapyand can be restored by an acid-etchedcomposite restoration.

An extensive fracture may require root canaltreatmentwith a post and core-supported crown2. the stage of root development:The stage of root maturation is an importantfactor in choosing between pulpotomy and

pulpectomy.3.the length of time since injury:the sooner a tooth is treated, the betterthe prognosis for preserving the pulp.



In immature teeth : a shallow pulpotomy is much preferred than anormal pulpotomyIt allows completion of root development

Cvek technique or shallow pulpotomy

pulp tissue is removed to a depth of about 2 mmbelow the exposure.

After the bleeding stops hard-setting calcium hydroxide liner and then fill the

cavity with hard setting cement such as IRM, or glass ionomer. When the

cement has set, the tooth may be restored with acid-etched , Composite is used

to restore the tooth

If MTA is used in place of calcium hydroxide, it is not necessary towait for bleeding to stop completely.

Treatment is evaluated after 6 months and then yearly.

In teeth with complete roots root canal therapy is the treatment



In case of primary teeth treatment includes pulpotomy, rootcanal therapy, or extraction, depending on patient

age and cooperation.

Primary teeth

Cvek technique



CROWN-ROOT FRACTURES

These fractures are usually oblique and involveboth crown and root. it may or may not involve pulpexposure



Teeth with crown-root fractures are often painfulsuch injuries often require urgent care. Thismay consist only of removing loose tooth fragments

but often also includes pulp therapyIf the root is immature, pulpotomy and also "Vital Pulp Therapy" is preferable topulpectomy, whereas pulpectomy is the treatment of choice in patientswith fully developed teeth.

Primary TeethA crown-root fracture in primary teeth usuallydictates extraction.



Fractures of roots have been calledintraalveolar root fractures, horizontalroot fractures and transverse rootfractures.

Radiographically, a root fracture isvisualized if the x-ray beam passesthrough the fracture line.Because these fractures often are

transverse-to oblique(involving pulp, dentin, and cementum),they may be missed if the central beam'sdirection is not parallel or close to parallelto the fracture line so a steep verticalangulations is added to the normal

angulation about (45 degrees)

Root fractures



The more cervical the fracture is the more mobility and the more chance of pulpnecrosis isIf the coronal segment is mobile splinting is indicated

initial treatment includes repositioning of thecoronal segment (if displaced) andstabilization by splinting. Repositioning ofthe coronal segment may be as easy asapplying finger pressure to the crown to alignthe segment, or it may be more complicated,requiring orthodontic approaches. When thecoronal segment has been repositioned, itmust be stabilized to allow repair of theperiodontium



Stabilization may beaccomplished by theuse of orthodontic wireand acid-etched resin.

Splinting time must besufficient to allowcalcification to takeplace up to 12 weeks

Managing these fractures endodontically is difficult , must be referred to

an endodontist



1.Rct for coronal and apical parts2.Rct for coronal part and apical part is left untreated orsurgically removed3.Apexification at the fracture site before root canal

treatment for coronal part apical part Is left4. Intraradicular splint by using a post to stabilize twosegments5.Endodontic implant where the apical part of the implantwill replace the surgically removed apical part

6.Root extrusion and endo treatment after removal ofcoronal part

Managing root fractures endodontically

In case of primary teeth coronal part is removed and the apical part is left any

attempt of Removal will endanger the successor



LUXATION INJURIES

The cause is usually a sudden impact, such as a blow or strikinga hard object during a fall

1.Concussion. The tooth is sensitive topercussion only. There is no increase in

mobility The pulp may respondnormally to testing, and no radiographicchanges are found.

2.Subluxation. sensitive to percussion andalso have increased mobility. Often

sulcular bleeding is present, indicatingvessel damage and tearing of theperiodontal ligament. No displacement isfound, and the pulp may respond normallyto testing. Radiographic findings areunremarkable.

concussion



3.Extrusive luxation. These teeth have been

partially displaced from the socket along the

long axis have greatly increased mobility,

and radiographs show displacement.

4.Lateral luxation. Trauma has displaced

the tooth lingually, buccally, mesially, or

distally, that is out of its normal position

away from its long axis.

5.Intrusive luxation. Teeth are forced into their sockets in an axial

(apical) direction they have decreased mobility and resemble

ankylosis



1. concussion injuriesno immediate treatment is necessary. The patient should allow the tooth to"rest" (avoid biting) until sensitivity has subsided.

Treatment of Luxation Injuries

2.Subluxations may likewise require notreatment unless mobility is moderate; if mobility isgraded 2, stabilization may be necessary.

3.Extrusive and lateral luxation injuries require repositioning and splintingThe length of time needed for splinting varies with the severity of injury.

Extrusions may need only 2 to3 weeks, whereas luxations that involve bonyfractures need up to 8 weeks.' Root canal treatment isindicated for teeth with a diagnosis of irreversible pulpitis or pulp necrosis.



Treatment of intrusive luxation injuries depends on root maturity If the toothis incompletely formed with an open apex, it may re-erupt. If it isfully developed, active extrusion will be necessary soon after the injury,usually by an orthodontic appliance. In extreme cases of intrusion, in whichthe tooth has been totally embedded into the alveolus surgical repositioningmay be necessary.

Root canal treatment is indicated for intruded teeth with theexception of those with immature roots, in which case the pulp mayrevascularize.



If the tooth appears foreshortened on the film,the apex is oriented toward the x-ray cone. Thereforethese teeth should present no danger to the permanent successor andmay be left to re-erupt. If the tooth appears elongated, the apex isoriented toward the permanent successor and may pose a risk to thepermanent tooth bud. The tooth should be carefully extracted

Radiographs provide valuable information

Concussion and subluxation injuries require no treatment.

Teeth with lateral and extrusive luxations may beleft untreated, or extracted depending on the

severity of injury.Teeth with intrusive luxations are evaluated todetermine the direction of intrusion.

Primary teeth



An avulsed tooth is one that has been totally displaced out of itsalveolar socket. If the tooth is replanted soon after avulsionthe periodontal ligament has a good chance of healing. Time out ofsocket and the storage media used are the most critical factors in

successful replantation. It is important to preservethe periodontal ligament cells and the fibers attached to the rootsurface by keeping the tooth moist and minimizing handling of theroot.

Key points in restoring avulsed teeth:1.Rinse in water for 10 min2.No scrubbing of the tooth3.Replacing the tooth in socket gently4. Hold it in place by the patients fingers take the patient to the dentist

Avulsions



If immediate replantation is not possible

The tooth should be transported in such away as to keep it moist.

The best transport medium is a commercially available storage-transport medium or physiologic saline (usually neither is available);milk is an excellent alternative Saliva is acceptable for maintainingroot surface cell vitality

1. The tooth is placed in a cup of physiologic saline.2. The area of injury is radiographed, looking for evidence of alveolarfracture.3. The avulsion site is examined carefully for any loose bone fragmentsthat may be removed.

Replantation within 1 hour:



4. The socket is gently irrigated with saline toremove contaminated clot5. In the cup of saline, the tooth is graspedwith extraction forceps by the crown to avoid handling the root.6. The tooth is examined for debris, which, if present, is gently removed with gauze

moistened with saline.7. The tooth is replaced into the socket

8. Proper alignment is checked Soft tissue lacerationsare tightly sutured9. The tooth is stabilized for 1 to 2 weeks

with a splint10. Antibiotics should be prescribed11. Supportive care is given; a soft diet andmild analgesics are prescribed

Root canal treatment is indicated for mature teeth and should be done

optimally after 1 week and before the splint is removed



Immature teeth with wide-open apices; they mayrevascularize but must be evaluated at regular intervals of2,6, and 12 months after replantation.

Replantation more than 1 hour after avulsion. If atooth has been out of the alveolar socket for morethan 1 hour (and not kept moist in a suitablemedium), periodontal ligament cells and fiberswill not survive regardless of the stage of root development.

Therefore treatment efforts before replantationinclude treating the root surface with fluoride to slow the resorptin process

1. The area of tooth avulsion is examined andradiographs are examined for evidence of

alveolar fractures.2. Debris and pieces of soft tissue adhering tothe root surface are removed.3. The tooth is soaked in a 2.4% solution ofsodium fluoride (acidulated to pH 5.5) for5 to 20 minutes.



4. The pulp is extirpated, and the canal iscleaned, shaped, and filled while the tooth isheld in a fluoride-soaked piece of gauze.5. The socket is irrigated

with saline Anesthesia may be necessaryfirst.6. The tooth is gently replanted into thesocket, checking for proper alignment andocclusal contact.7. The tooth is splinted for 3 to 6 weeks

Sequelae to Replantation

1,Surface resorption

They are repaired by deposition of newcementum, which represents healing.

2.Inflammatory resorptionDue to pulp necrosis and PDL injurycan be prevented by RCT

3.Replacement resorption: toothstructure is resorbed and replaced bybone

This result in ankylosis where bone fusesdirectly to the root surface the tooth lackphysiologic mobility, failure of the tooth toerupt alongwith adjacent teeth (leading infraocclusionin young individuals), and a "solid" metallic

sound when percussed.

Primary teeth aren’t replanted

For risk of endangering successor



Immediately after replantation

After two years and the root started to resorb

Treating the surface with fluoride before replantation slows down

the replacement resorption (in 50% of pts) which results in infraocclusion

as the patient grows

Management of Traumatized Teeth

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