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DENTAL TRAUMA: TICK TOCK!
Jan Mitchell, DDS, M.Ed, MAGD Georgia Health sciences university
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References:
Guidelines
American Association of Endodontics
American Association of Pediatric Dentistry
Andreason, JO. Traumatic Dental Injuries: A Manual
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Before you get to the teeth…
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Trauma Evaluation:General
1. Vital signs- record BP, pulse (rule out internal bleeding)
2. Consciousness evaluation:
Ask what happened?…can’t remember=concussion
Ask did you lose consciousness? Any = concussion
Determine if alert and oriented x 3
1. Where are you?
2. What day is it?
3. Who is the president?
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Trauma Evaluation: Extraoral
1. Bruising:
Over mastoid?
Around eyes with no eye trauma?
May indicate basal skull fracture.
Refer after dental stabilization
Battle’s Sign
“Raccoon eyes”
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Trauma Evaluation: Extraoral 2. Any fluid from nose or ears?
Blot with gauze or coffee filter
Look for “halo sign” of CSF
But refer if in doubt!
3. Check overall facial contours
Orbital rim intact?
Zygomatic arches even?
Border of mandible intact?
4. If there are lacerations, look for foreign objects. Consider rads of soft tissue
“Halo Sign”
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Cranial Nerve exam
1. Sight:
Vision normal?
Follow finger in all directions,
both eyes even in far upward?
Flash penlight in one eye –
other pupil constricts?
2. Smell:
Test with coffee or eugenol
Ask assistant to bring coffee can or eugenol, cotton-tipped applicator, penlight.
Top down
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Cranial Nerve exam 3. Hearing
Rub fingers together near ear
Can they hear it on each side?
4. Have patient:
Raise eyebrows
Squeeze eyelids
Smile
Pucker lips
Pout
Shrug shoulders
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Cranial Nerve exam 5. Evaluate speech- normal or hoarse?
6. Stroke face with stick end of cotton tip
Forehead
Cheek
Chin
7. “Open mouth, stick out tongue”
Tongue deviation?
Stroke uvula with cotton tip-elevates?
Lightly stroke soft palate- gag reflex normal?
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Intraoral Exam
Soft tissue injuries
Occlusal plane aligned? Occlusion normal? Tooth alignment normal?
Alveolar fractures?
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Radiographs?
Consider soft tissue radiographs if suspect foreign body
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Radiographs?
If teeth displaced or fractured, take PA’s
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OK, now you can look at the teeth….
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Classification schemes for fractured teeth:
Forget Ellis Class…
The WHO system – much more sensible!
But the bottom line is:
Is it a hard tissue or PDL injury?
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Ask yourself: Hard tissue or PDL?
Hard Tissue Injuries:
Crown fracture
+ Pulp exposure
Root fracture
PDL Injuries:
Luxation
PDL only Concussion
Subluxation
+ Socket fracture Intrusive
Lateral
Extrusive
Avulsion
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Get to the right page…
From AAE and AAPD 2004
Evidence based recommendation on how to diagnose, treat and follow up
Don’t even try to learn this stuff!!!
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Make multiple copies, laminate, place in: Front desk Treatment room Home- they will call you!
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Tooth
Root
Hard Tissue Injuries
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Crown Fractures
Pulp involved or not?
No pulp exposure = Uncomplicated
Pulp exposure = Complicated
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Crown Fracture:Uncomplicated
No pulp exposure
Enamel only: Smooth sharp edges
Dentin exposed: Bonded composite
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Crown Fracture:Complicated
With pulp exposure
Stage of tooth development?
Time since trauma?
How much PDL injury?
Restorative tx plan?
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Crown Fracture: Complicated
Stage of tooth
development?
If root end not formed, do a vital pulp procedure
Not comfortable with this? Get to an endodontist ASAP
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Crown Fracture: Complicated
Time elapsed since
trauma?
After 24 hours, more likely to be contaminated.
Direct pulp cap not as successful, consider Cvek pulpotomy.
Cvek M, JOE 1982
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Crown Fracture: Complicated
Periodontal injury?
Pulp compromised- more mature the tooth, worse chance of pulp survival.
Andreasen JO, 1970
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Crown Fracture: Complicated
Restorative Tx Plan?
Vital pulp therapy risky:
Better results if minimal restorative follows
Don’t bother when expensive and extensive care is planned…endo is more predictable.
Andreasen JO, 1970
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Case 1. Kaitlin
Immature tooth
Trauma resulted in large pulp exposure 36 hours ago
Bleeding from the sulcus noted
Will need crown
What do you think is the best treatment?
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Case 1. Kaitlin
Apexogenesis
Partial Pulpotomy
Bonded restoration until root formation complete
Future plan:
Endodontic therapy
Crown
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Crown-Root Fracture
Pulp involved?
No = Uncomplicated
Yes = Complicated
Key determinant is restorability
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Case 2. Eugene
What do you think is the best treatment?
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Case 2. Eugene
High smile line- Crown lengthening not a good option
Extrusion an option- may result in narrow neck of crown
Implant- but not yet!
Given the age of pt, may temporize, then plan implant.
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Root Fracture
Not common <3% of dental injuries
Usually oblique facial to palatal
Treat:
1. Reposition
2. Hard splinting 7-14 days, maybe longer if bone fx.
Complex- probably best to refer to Endodontist after stable.
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Luxation or Displacement
Avulsion
Periodontal Ligament Injuries
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Luxation Injuries: Consequences
Pulp:
Neuro-vascular supply to
pulp affected
Results:
Altered or total loss of vitality
Can cause canal obliteration
(calcification). Most often:
Open apices
Extrusive, lateral luxation
Rigid splinting
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Luxation Injuries: Consequences
Attachment damage:
Surface- local, if no
stimulus heals within
14 days
Replacement- clasts
resorb bone, blasts lay
down new = ankylosis
Inflammatory- necrotic
pulp leak toxins,
causes resorption of
root and bone
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Injuries to PDL: 1.Concussion
Concussion = “Bumped”
Dx- Sore, no displacement
Sensitive to percussion
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Injuries to PDL: 2. Subluxation
“Bumped” + bleeding from gingival crevice
Dx- Still no displacement
Tx- + Stabilize with flexible splint for comfort
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Injuries to PDL: 3.Extrusion
Dx- Elongated in socket
Tx- Reposition, stabilize with flexible splint
Follow up per AAE recommendations
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Injuries to PDL: 4. Lateral
Dx- Elongated in socket, very percussion sensitive
Tx- Stabilize with flexible splint
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Case 3: Duane
“I kissed my wrench.”
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Case 3: Duane
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Case 3: Duane
How will you treat this case?
Pre-Op Radiographs
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Case 3: Duane
Flexible splint
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Case 3: Duane
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Case 3: Duane
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Injuries to PDL: 5.Intrusive
Dx- Apical displacement into alveolus
Most damaging! Extensive trauma to PDL and cementum
Pulp necrosis likely- follow closely
Ankylosis almost a certainty
Tx- Stabilize with flexible splint
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Injuries to PDL
Paint a realistic picture of the prognosis for these kind of injuries
Expect
Endo tx
Possible ankylosis
Resorption
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Avulsion and Replantation
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Avulsion and Replantation
PDL
Damaged along entire surface
Time is critical for cell death
Pulp
Neurovascular supply severed
Always get pulpal necrosis
Revascularization possible in immature teeth
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Avulsion and Replantation
Variables:
Primary tooth vs Permanent tooth
Immature (open apex) vs. Mature tooth
Rapid replantation vs Delayed replantation
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Avulsion and Replantation
“Replantation of primary teeth is
not justified due to the risk of pulp
necrosis and possible interference
with the development of the
permanent successors.”
Andreasen JO, Andreasen FM 1994
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Avulsion and Replantation
Permanent Tooth
Dry time < 60 min OR in transport media
Flexible splint 1-2 weeks
Tooth already replanted
Closed apex
Start Endo
Open apex
Don’t start Endo
Dry time > 60 min
Flexible splint 4-6 weeks
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Avulsion and Replantation
Permanent Tooth
Dry time < 60 min OR in transport media
Flexible splint 1-2 weeks
Tooth already replanted
Flexible splint 1-2 weeks
Closed apex
Start Endo
Open apex
Don’t start Endo
Dry time > 60 min
Flexible splint 4-6 weeks
For all, treatment determined by apex
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Questions?