Download The traumatic injuries of permanent teeth and complex therapy

The traumatic injuries of
permanent teeth and complex
therapy
Dr. Katalin Déri
Semmelweis Egyetem
Department of Pedodontics and Orthodontics
Risk
•
Angle II/1
•
Predisposing factors:
 overjet
 protrusion of upper
incisors
 insufficient lip closure
Injuries
Sport related - 1.5% -3.5%
Injuries
Playground - school
Injuries
Fights
Injuries
Car accident
Age distribution
Therapeutic significance
8-13 years the highest incidence
•
Peak at the age of 10
Sex
Clinical data
100
75
50
25
0
Boys - 153
Girls - 59
All - 212
Incidence of injured teeth in %
Upper central incisors
- 85.39%
Upper lateral incisors 10.06%
Lower central incisors
- 3.57%
Lower lateral incisors 0.97%
0,0
22,5
45,0
67,5
90,0
Anamnesis
 general anamnesis
 circumstances of injury
 black-out, amnesia, headache, nausea,
vomit


previous injuries : consequences,
complications
dental anamnesis
Most important
questions

When?

Time past between the injury and the treatment




Where?
Risk of infection
How?
Mechanism of the injury, polytrauma
Time elapsed after injury
35
26
18
9
0
0 day
1 day
2 days
5 days
1 week
2 weeks 3 weeks 4 weeks 6 weeks 2 months 6 months
1 year
3 years
Clinical examination




Extraoral examination
Intraoral examination
Photo documentation
X-ray
Type of injuries
•
Traumatic injuries involving:

the permanent teeth

the alveolar bone

the soft tissues
Classification of dental injuries
(International Association of Dental Traumatology, 2001)
1. Coronal fracture
2. Coronal and root fracture
3. Root fracture
4. Fracture of processus alveolaris
5. Luxations and avulsion
•
(contusion, subluxation, lateral luxation, extrusion, intrusion,
avulsion)
Classification of dental injuries
Pedodontics and Orthodontics textbook
1. Luxatio totalis dentis permanentis
2. Luxatio partialis dentis permanentis
3. Intrusio
4. Fractura coronae dentis
permanentis
5. Fractura radicis dentis permanentis
Luxatio totalis dentis permanentis
Avulsion : complete displacement of a tooth
Luxatio partialis dentis permanentis

loosening of the tooth or a
partial displacement of the
tooth out of its socket
a.
subluxation
b.
lateral luxation
c.
extrusion
a.
b.
c.
Luxatio partialis dentis permanentis
Displacement

clinical examination
•
subluxation:
•
sensitive to touch
•
slightly mobile
•
no displacement
•
bleeding
•
extrusion:
•
axial (and lateral) displacement
•
mobile
Luxatio partialis dentis permanentis
Displacement
•
lateral luxation:
•
lateral displacement
•
locked in the alveolar bone
•
no mobility
•
not sensitive
• ankylotic signs
Luxatio partialis dentis permanentis
- luxatio lateralis
3. Intrusion

displacement of the
tooth into the alveolar
bone
(axial dislocation)
Fractura coronae dentis permanentis
Types of coronal fracture
enamel only
•
enamel and dentine
Most frequent injury
enamel and dentine
with the pulp exposed
Fractura coronae dentis
permanentis

fracture without complication

complicated fracture (with pulp
exposition)
Fractura radicis dentis permanentis
Root fracture
Fractura radicis dentis permanentis
1. cervical third
2. middle third
3. apical third
+1.axial fracture
Complex therapy
Treatment of the injuries:
Avulsion
1. Luxatio totalis dentis permanentis
•

Actions out of surgery:
Suitable storage: in wet agent
1. physiological saline
2. saliva
3. milk
4. Dentosafe-Zahnrettungsbox
Treatment of the injuries:

•
Avulsion
Aim: replantation as soon as
possible
the ligaments and cells loose their vitality after 1
hour
1. Preparation of the tooth and the alveolar socket
2. Replantation
3. Stabilization – using the neighboring
teeth for splinting
•
•
acrylic splint
•
composite bonding with orthodontic archwire
•
brackets
4. Woundtreatment (debridement, suturing, hemorrhage control)
Prognosis: max. 1 hour extra-alveolary
Fixation: closed apex - 7-10 days
•
open apex - 2 weeks (neurovascular
reanastomosis)
In mature tooth with closed apex, or in immature tooth with
open apex but time elapsed > 30 min.
•
In 1 week root canal treatment - Ca(OH)2 should be placed
•
to prevent the initiation of inflammatory root resorption
Treatment of the injuries:
Avulsion
1. Luxatio totalis dentis permanentis

Instructions
1.
pulpy diet
2.
toothcleaning with soft toothbrush
3.
0,1 % chlor-hexidine

Supplementary therapy
1.
Antibiotic treatment
2.
Tetanus (immunization status?)
Treatment of the injuries:
Avulsion
Luxatio totalis dentis permanentis

If replantation is not possible ( e.g.: in the case
of loss of the tooth )
1. Temporary solution:
•
acrylic bridge
•
orthodontic appliance (with an acrylic tooth)
2. Final solution:
•
orthodontic treatment
•
implantation
•
combined treatment
Treatment of the injuries:
Avulsion
Luxatio totalis dentis permanentis
Temporary solution
Healing after replantation

regeneration of the gingiva

revascularisation of the ligaments

renewal of the Sharpey ligaments

open apex - revascularisation and reinnervation
•
Cave: high bacterial contamination- healing is limited
or impossible
Treatment of the injuries:
Displacement
2. Luxatio partialis dentis permanentis
•
Subluxation
• no need to splint for stabilization
• observation - x-rax (1 year)
• root canal treatment (pathological sign)
Treatment of the injuries:
Displacement
2. Luxatio partialis dentis permanentis
•
•
1.
lateral luxation
extrusion
reponation ( following the injury )
•
fixation for 2-3 weeks
2.
later : orthodontic reposition
3.
root canal treatment ( in case of the tooth with
closed apex )
Treatment of the injuries:
3. Intrusion

Open apex : there is a chance of
spontaneous re-eruption

Closed apex :
1. surgical or orthodontic reposition
2. splint
3. root canal treatment
Treatment of the injuries:
3. Intrusion
orthodontic or surgical reposition
Treatment of the injuries:
Fractura coronae dentis
permanentis

The treatment of
crown
fracture
depends on which
third of the crown is
injured
Treatment of the injuries:
Fractura coronae dentis
permanentis
a. Enamel injuries:
1. Minor enamel fractures : polishing,
fluoride solution ELMEX
2. Larger enamel fractures (1-2mm or
more): composite restoration
Treatment of the injuries:
Fractura coronae dentis permanentis
b.
Enamel – dentine injuries without pulp exposition
- immature tooth
1.
Calcium hydroxide liner
2.
Temporary crown ( celluloid, acrylic ) – 1 year (GIC) –
protective covering
3.
X – ray control
4.
Final restoration (closed apex)
b.
Enamel – dentine injuries without pulp exposition
-mature tooth
•
Final restoration
Fractura coronae dentis permanentis
temporary crown - incisal restoration
Rebonding of fractured crown
Treatment of the injuries:
Fractura coronae dentis
permanentis
c. Pulp exposition
•
Important:
1. size of the pulp exposure
2. time between the injury and the
treatment
3. root development
Treatment of the coronal fracture in
case of pulp exposition
exposition
time
root
development
open or
closed
apex
direct pulp
capping
small
1 – 2 hours
larger than
1 mm
more, than 3 hours
open apex
pulpotomy
x-large
long time
closed apex
pulpectomy
Direct pulpcapping - Ca(OH)2/ MTA
Pulpotomy – partial or total elimination of coronal pulp tissue
sterile round steel bur or excavator
haemorrhage control
Ca(OH)2/MTA + GIC /polikarboxilate cement
Pulpectomy – elimination of all the pulp tissue Ca(OH)2
Final root canal filling (closed apex)
Regular re-call!!!
Treatment of the injuries:
a.
fracture in cervical third:
•
Worst prognosis
1.
Elimination of coronal part
Root fracture
• root canal treatment
• orthodontic extrusion
• restoration
2.
Extraction + implantation
b.
fracture in middle third:
1.
Reposition of coronal part
2.
Splint ( 1-2 months )
3.
Root canal filling
4.
Transradicular fixation can be an option (silver point)
Treatment of the injuries:
Root fracture
c. Fracture in apical third
•
observation,
•
In case of necrosis - Ca(OH)2,
•
- Final root canal filling after healing
If coronal part is dislocated
•
•
- reposition and fixation for 1 month
Fractura radicis dentis permanentis
Healing
Soft tissue
hard tissue
granule tissue
Possible consequences of
traumatic injuries
Peripheral (external) root resorption
•



Trauma with damage to the periodontal structures, pulp
may not become involved
Macrophages , osteoclasts
In cases of severe trauma, with some degree of
displacement of the tooth
Diagnosis – 1 week after injury
Possible consequences of
traumatic injuries
Inflammatory root resorption

Trauma with damage to the periodontal AND pulp tissues

Bacterial toxines

Rapid, progressive

Intrusion, replantation

Diagnosis – 2-4 weeks after the injury

Severe cases – total root resorption in 1 month
Possible consequences of
traumatic injuries
Ankylosis

injury to the periodontal ligament and subsequent
inflammation

associated with invasion by osteoclastic cells

cement resorption – repaired by bone regeneration

mechanical lock / fusion between alveolar bone and root surface

Diagnosis:

Radiological : 2 months

Clinical: 1month – typical ankylotic sound for percussion
Possible consequences of
traumatic injuries
•
Pulpal necrosis
•
•
signs:
•
discoloration
•
no response for vitality test
•
sensitive for percussion
•
periapical laesion
if 2 of them presents - root canal treatment –Ca(OH)2
Possible consequences of
traumatic injuries
•
Obliteration
•
Calcific metamorphosis of the dental pulp
( progressive canal calcification / dystrophic
calcification)
•
Although the radiograph may give the illusion of
complete obliteration, an extremely fine root canal
and remnants of the pulp will persist
•
yellowish opaque colour of the crown
•
rct can be done if necessary
Prevention
•
Protectors
•
Requirements:

cover of the teeth, gingiva, alveolar bone

do not influence the relation of jaws

do not disturb breathing

resistant and durable

hygienic

possible application on fixed orthodontic appliances
Prevention
•
Mouthguard:
•
Confectional
•
Prefabricated
•
Individual
Education!!!
Warning - Child abuse!!!!
Signs:
•
•
•
•
•
time elapsed after the injury: weeks or months
confused, frightened child
parents and child don’t tell the same story
anamnesis is not in accordance with the
result of clinical examination
recurring injuries
Case report
•
20 years old boy
•
Street fight
•
oral surgery ambulance – ‘’dental splint’’
•
orthodontic clinic – 3 days after
•
still very mobile upper front teeth
Radiographs
except
13, all
upper
anterior
teeth show
vitality
13 root fracture in middle third
13, 12, 11, 21, 22, 23 extrusion,
palatal dislocation
all upper anterior teeth are very mobile
Treatment plan
•
Slow reposition of dislocated teeth with fixed orthodontic
appliance (1 year )
•
13 rct ; transradicular fixation (silver point) /temporary/
•
Frequent control of all the upper anterior teeth
•
•
first patological sign - rct
After debonding – fix and removable retainer
Treatment
13 transradicular fixation
(silver point and endomethason)
after treatment
2 months later
Pulpal necrosis of 22
Sign of root resorption Needle
control
RCF control
Result of
treatment
Thank you for your kind
attention!