Transcript Treatment of dento – alveolar injuries

Dr. Mohammad A. Barayan
Definition :
Injury which is limited to the teeth
and supporting structures of the
alveolus.
N.B Boys are three times more
at risk than girls.
Causes :
1- Traffic Accident.
2- Falls.
3- During Epileptic seizures.
4- Sport injuries.
Diagnosis
History
Clinical
examination
Vitality test
Radiographic
Examination
1) Personal history
2) medical history
3) Previous dental history
4) History of trauma (when ,how ,where )
1) When did the accident occur ?
The shorter the time between accident and
treatment the better prognosis.
2) where did the accident occur ?
If the accident occurred in dirty place prophylactic tetanus
is indicated
3) how did the injury occur ?
Direct force under the chin → → condylar fracture
Direct force to teeth → → Crown F, Root F, displacement
Extraoral Examination
Laceration ; Abrasions ; Contusions on the head and
neck can be noted visually
Any asymmetries including deviation in mouth
opening.
Intraoral Examination
Soft tissue ( tongue ; gingiva .. )
Teeth ( displacement ; mobility ; tooth fracture ;
colour change )
Vitality test just following traumatic injury
often given false negative response
Types of vitality test
1) Thermal pulp test
cold test
heat test
2) Electrical pulp test
3) Cavity test
*soft tissue injuries
1- Determination of child immunization status:•If the child had received a primary immunization
activated with booster injection of toxoid .
•Unimmunized child can be protected by tetanus
antitoxin.
2- Adequate debridment of the wound
1- stage of root formation
2- presence of root fractur
3- periapical radiolucencies
4- injury of the supporting periodontal membrane
(degree of intrusion or extrusion o the tooth)
5- size of the pulp
N. B. If a jaw fracture is suspected extaoral radiographs
indicated (panoramic and lateral oblique views )
Ellis classification:
Class I:
crack or fracture of E only
Class II:
fracture of E , D with out pulp exposure
Class III:
fracture of E , D with pulp exposure
Class IV:
Fracture line passes beneath the gingival margin
Class V:
Root fracture
a) vertical
b) horizontal
(apical , middle , cervical)
Class I :
1- a crack of the enamel without
loss of tooth structure.
Do not require immediate treatment.
2- fracture of enamel only
smoothing the sharp edge
regular vitality test , radiograph
Class II :
Immediate treatment of the crown is
required to:
1) protect the pulp
2) restore the esthetics and function.
Cover the expose of the dentine by a
layer of calcium hydroxide to
reparative dentine formation.
A- Reattachment of tooth fragment.
B- Acid-etch composite resin
restoration
Class III :
The treatment depends on many factors
such as:
1) vitality of the exposed pulp.
2) Size of the exposure.
3) Time elapsed since the exposure.
4) Degree of root maturation.
5) Restorability of the fractured
crown.
The main objective of treatment is to
maintain the vitality of the tooth.
Small exposure
Early
Open
Close
Direct pulp
capping
Large exposure
Late
Early
Late
open
closed
open
closed
open
pulpoto
my
pulpecto
my
Pulpoto
my
pulpecto
my
Pulpe
ctomy
pulpecto
my
pulpecto
my
Closed
pulpec
Apexifi tomy
cation
Apexification :
Class IV :
Treatment usually involve removing
the loose fragment .
1- tooth can be extruded
orthodontically
2- crown lengthening to
gain access to placement of
restoration.
Class v :
1) Horizontal Root fracture
When the fracture occur near the
apical 1/3, the prognosis is more
favourable than the middle or cervical 1/3
because :
1) more alveolar support
2) immobilization of the tooth is much easier
Treatment of root fracture depends upon :
1) Condition of the pulp
2) amount of mobility or the level of the fracture line
(A) apical 1/3 root fracture
1) reduction , splinting the
tooth
2)the tooth should be checked
periodically for vitality and
radiograph.
(B) middle 1/3 root
fracture :
1) reduction , splinting the tooth
2)the patient recall 2-3 months , checked
the vitality ,radiograph
3)if the tooth non vital and no healing the
following treatment is performed:
a) R C T of both fragments
b) apical fragment removed
surgically
c) intraradicular pin to stabilize
both segments
(C) cervical 1/3 root fracture :
1)reductin , splinting the tooth
2)recall the patient periodically and checked
the vitality and radiograph
3)if there is radiolucent and pulp necrosis the
following treatment is performed
a) extraction the tooth
b) removed the apical fragment and
endo-osseous implant placed
c) orthodontic extrusion
d) if the fracture is 1-2mm infrabony
remove the coronal segment and
osteoplasty to expose the root
2) vertical root fracture :
• usually the prognosis is not favorable
• treatment of V R F :
1)extraction of the tooth
2)using co2 laser and ND:YAG laser beam
* Concussion
• A mild blow to the tooth resulting in mild
sensitivity requires little or no treatment
• Need only regular vitality test
*subluxation
• Mobility of the tooth without displacement
• Tooth may be sensitive to percussion
• If mobility is extensive
splint the tooth
using the acid –etch splinting technique.
• Regular vitality test and radiograph
• 1) lateral luxation
• 2) intrusive luxation
• 3) extrusive luxation
• 4) avulsion
1) Lateral luxation :
• Displacement of the tooth in any
direction other than the axial one
• If the patient comes immediately
•
after trauma reposition, splinting
Once the tooth have solidified in
their position orthodontic
treatment is required
1) Intrusion:
• Displacement the tooth into the socket
A) primary tooth:
will re-erupted over a period of few
months. If the intruded tooth is in contact
with underlying permanent tooth should
be remove
B) permanent tooth:
• a) immediate surgical repositioning ,
splinting
• b) orthodontic extrusion
• c) incomplete root formation the tooth
will erupt spontaneously
2) Extrusion :
• Partially displacement the tooth out of the socket .
A) primary tooth: Treatment usually extracted
B) permanent tooth :
• reposition and splinting
• If the vitality of tooth is lost start root treatment
immediately placing calcium
• hydroxide in the canal for 6-12 month followed
permanent filling.
3) Avulsion:
• Complete displacement of the tooth
from the socket .
• There are tow important factors to be
consider in cases of avulsion
•
1)time between the injury and treatment
• 2)condition under which the tooth have
been restored
• The tooth must be kept moist to
prevent damage to the fibers of PDL
• In many cases the initial patient contact is by
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phone
The tooth should be handled by the crown
The tooth should be placed in suitable storage
medium (milk, unsalted water, lens solution )or
in buccal vestibule or under the tongue .
At the dental office :
a) information about tetanus immunization
should be obtained
b) replantation , splinting for 1_2weeks but in
immature apices 2-3weeks
c) calcium hydroxide should be placed
d) RCT
• Small fracture through the alveolar
process.
there may be concomitant injuries
(crown, root fracture and soft tissue) managed by referral
to an oral and maxillofacial surgery .
• Treatment: redaction , splinting
Types of splinting :
1)
2)
3)
4)
acid_etched composite splinting
Interdental wiring
( vacuum_formed plastic) splint
arch bare splint
• More rigid and the longer the stabilization,
the more root resorption , ankylosis that
can be expected .
Stabilization periods for dentoalveolar injury
Dentoalveolar injury
1) Mobile tooth
2) Tooth displacement
3)Root fracture
4) Avulsion
5) Alveolar fracture
Duration of
immobilization
7 _ 10 days
2 _ 3 weeks
2 _ 4 months
7 _ 10 days
4 _ 6 weeks