· Web viewIn these instances a transient radiographic radiolucency is seen as a response to in-growth of new ... We do root canal treatment with a material other than Gutta

Alakyaz Assadorian Dr. Ahmad El-Ma'aita Cons 3 – Sheet 20

Management of Traumatic Dental Injuries

What would you do?

If a patient came to you with a broken or an avulsed tooth, it is very important to rule out any systemic complications such as intra-cranial haemorrhage before thinking about the dental management.

Aetiology :

1. Falls - most common reason for facial trauma in general 2. Traffic injuries3. Acts of violence 4. Sports accidents

- Aetiology differs among different age groups; Adults Traffic injuries and Violence Pediatrics Falls (due to their incomplete motor skills)

Prevalence and Incidence:

Peak in two age groups, according to the literature:

a) Primary teeth: age 2-3 y when they still learn how to walk (fall a lot) and motor coordination is still developing

b) Permanent teeth: age 9-10 y when vigorous/violent playing and sports become more frequent

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Incidence has been estimated to be;

Around 1.3 – 4% of school children are subjected to some sort of facial trauma

and 0.4% among the population

Tissues affected by dento-alveolar trauma are: (The most important information)

A- Hard tissues: Teeth and bone (e.g. root fracture and displacement)B- Soft tissues – visible laceration (gingiva, oral mucosa, tongue, lips, cheeks)C- The pulp (loss of blood supply)D- The periodontium (PDL and cementum)

The hard tissues, soft tissues and the pulp are important factors to consider, however, they are under our control. In other words, if we see a fractures tooth we can restore it, if we see soft tissue laceration we can suture it or do a graft. The ONLY factor that is out of our control is the periodontium and probably it is the most deciding factor of the consequences (we will explain about it more in details later in this lecture).

The doctor showed us a figure showing the nowadays trauma classification of Andresen and Andresen!

o Concussion: injury to the supporting tissues without displacement without mobilityo Subluxation: injury to the supporting tissues without displacement with mobilityo Extrusion: partial displacement of the tooth out of the socket o Lateral luxation: displacement either anteriorly or posteriorly (protruded or retruded

teeth) and are usually accompanying with alveolar fracture o Intrusion: when the tooth is pushed into the socketo Avulsion: total displacement of the tooth out of the socketo Infarction: a crack line without loss of substance

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Loss of tooth substance: (Continued on the same figure)

o Enamel fractureo Enamel – Dentine fractureo Enamel – Dentine – Pulp fracture o Crown root fractures without pulp exposure (uncomplicated)o Crown root fractures with pulp exposure (complicated)o Root fractureo Alveolar fracture

The PDL :

The PDL, as mentioned above, is one the tissues that can be affected in trauma injuries. It is the most important one and the deciding factor of the consequences; to see whether we will end up with resorption or not, as well as the thing that most people don’t consider.

The PDL can suffer one of two injury types which have different consequences on the management and its outcome:

1- Separation injury: Cleavage of intercellular structures (collagen and intercellular substance) with limited damage to the cells in the area of trauma.Wound healing can arise from existing cellular systems with minimal delay.

2- Crushing injury:There is extensive damage to both cellular and intercellular systems.The damaged tissue must be removed by macrophages and/or osteoclasts before the traumatized tissue can be repaired.Several weeks are added to healing process and this is reflected in the recommended splinting period.

e.g.: Lateral luxation (retrusion) case of an upper central tooth is shown in the slides, where two kinds of injuries occurred to the PDL depending on their position;a. Cleavage: only separation of the PDL occurred without injuring the cellsb. Crushing: cellular injury is involved

So, which of these is worse? Crushing! Because in cleavage injuries we can replant the tooth or reposition it using force and the fibers will heal, but in case of crushing injuries, the cells have to die, resorb, and undergo inflammatory process followed by healing at a later stage.

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Wound Healing:

1- Early wound healing events:

The immediate events include bleeding from ruptured vessels followed by coagulation.Platelets in the coagulum play a significant role by:a- Assisting the transformation of fibrinogen to fibrin b- Releasing growth factors (e.g. PGDF and TGF-Beta) which initiate the wound

healing process.Thereafter, an influx of neutrophilic leukocytes (PMNLs) and macrophages occurs.Neutrophils are concerned with infectionMacrophages clean the area of damaged tissue and foreign bodies, assisting the PMNLs in defending against or combating microbial colonization, and finally in taking over the platelets' role in directing wound healing events.

2- Later wound healing events:

Revascularization of ischemic tissue and formation of new tissues in case of tissue loss. Wound healing takes place by a coordinated movement of cells into the traumatized area, where macrophages form the healing front, followed by endothelial cells and fibroblasts.Vascular loops are formed in a stroma of tissue dominated by immature collagen (Type III) and proliferating fibroblastsThese calls are synchronized via chemical signals released by the involved cells and the surrounding tissue.This phenomenon is known as the wound healing module and appears to advance in the pulp and periodontium at a speed of approximately 0.5 mm/day.

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Summary of wound healing; in early events the pulp extends, blood coagulates, platelets start working and they release growth factors which direct the healing process, macrophages and Neutrophils are active in the early stages; in later stages, we have revascularization of the area, progressive formation of vascular loops. This whole process is known as the healing module which has been estimated to progress at a rate of 0.5 mm per day. This process is important to consider when we think of the revascularization of the pulp.

Wound healing in uncomplicated luxation injuries (only separation injuries of the PDL and Pulp):

PDL:

After 1 week, new collagen formation starts to unite the severed PDL fibers which leads to initial consolidation of a luxated or a replanted tooth; which is why splinting in these cases are done for only 1-2 weeks because it is of enough duration to have new fibers formed already.

After 2 weeks, repair of the principal fibers is so advanced that approximately two-thirds of the mechanical strength of the PDL has been restored.

Pulp: in luxated teeth with a severed vascular supply (loss of blood supply), ingrowth of new vessels (revascularization or revitalization) into the pulps starts 4 days after injury and proceeds with a speed of approximately 0.5 mm per day in teeth with open apices.

Revascularization is markedly influenced by:

1. The size of the apical foramen, being complete and predictable in teeth with open apices (greater than or equal 1.0 mm which is equivalent to k-file size 100), and rare in teeth with a narrow apical foramen (less than 0.5 mm which is equivalent to k-file size 50).

2. The colonization of bacteria in the ischemic pulp tissue which jeopardize the chanes of revascularization (the most significant factor that can arrest the revascularization process)

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The origin of these bacteria can be:

- Invasion from dentinal tubules via a crown fracture- Invasion along the blood clot in a severed PDL- Via the blood stream (anachoresis)

Wound healing in complicated luxation injuries:

In complicated luxation injuries (crushing of desiccation of the PDL), the consequences may result in root resorption. The cells that have been crushed need to be absorbed or got rid of by the macrophages and then the whole inflammatory reaction follows.

This depends on many factors.

Teeth are found inside sockets very close to alveolar bone, and the cementum histological structure is very similar to bone, i.e. both are made of hydroxyapatite (around 70% of cementum is made of hydroxyapatite). Bone undergoes continuous remodeling (resorption and remodeling by osteoclasts and osteoblasts), but what is it that stops these osteoclasts and osteoblasts (that are in close proximity to the cementum) from remodeling the cementum? The very thin layer of pre-cementum which is an organic tissue that has not been mineralized yet

Therefore, loss of this protective pre-cementum (as in crushing traumatic injuries) with the loss of protecting cement-blast layer and the epithelial rests of Malassez along the root surface will expose the proper cementum to the actual osteoclasts leading to its resorption and then deposition of something else.

When these layers disappear, there is free access for osteoclasts and macrophages to remove damaged PDL and cementum on the root surface (they remove the dead cells).

Further events are subsequently determined by three factors:

- Eventful exposure of dentinal tubules (extent of damage)- Content of the pulp, whether it is ischemic and sterile or necrotic and infected.- Presence of adjacent vital cementoblasts

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Repair-related (surface) resorption:

In cases of damage to the layer of the PDL closest to cementum (minimal damage without exposure of dentinal tubules), the site will be resorbed by macrophages and osteoclasts, and results in a saucer-shaped cavity on the root surface.

If this cavity is not in contact with dentinal tubules and the adjacent cementoblast layer is intact, the cementoblasts will compete with the osteoclasts and eventually this resorption cavity is repaired by new cementum and insertion of new Sharpey's fibers.

The ligament width is normal and follows the contours of the defect.

Therefore, this process is temporary and we see it as an incidental finding on an x-ray. If we follow up the tooth, it disappears as it is only a temporary resorption process.

Infection-related (inflammatory) resorption:

In the event that the initial resorption was more extensive and penetrated the cementum and exposed dentinal tubules toxins from bacteria present in the dentinal tubules and there is continuous stimulation which is the infection inside the root canal which can diffuse via the exposed tubules to the PDL.

This results in a more extensive inflammatory reaction and continuation of the osteoclastic process and an associated inflammation in the PDL leading to resorption of the lamina dura and adjacent bone along with resorption of tooth structure.

This process is known as "External Inflammatory root resorption" and is usually progressive until the root canal is exposed, we may lose the whole tooth in a matter of months.

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Therefore it is really important to consider this after trauma, if we know that the pulp will not regenerate and that we have lost the vitality of the pulp, we need to do root canal treatment within a week or two to prevent external inflammatory root resorption, because if bacteria are eliminated from the root canal and/or dentinal tubules by proper endodontic therapy, the resorptive process will be arrested and reversed.

The resorption cavity will then be filled in with cementum or bone, according to the type of vital tissue found next to the resorption site (PDL or bone marrow-derived tissue).

It is important to be able to differentiate between internal and external inflammatory root resorption:

Internal Inflammatory Root Resorption

External Inflammatory Root Resorption

Clinically (Upon pulp test) Vital pulp (still responds) Necrotic pulp

Location On X-raysInternal and Coronal

(due to the coronal necrotic pulp and vital apical pulp)

External

Outline of Canal on X-rays Outline is totally lost Outline is preserved

Angled X-rays Always centered -

Note:Management is the same for both cases; which is RCT. Internal resorption is easy to manage if it has not perforated, because if you remove the vital apical pulp you stop further internal resorption. But sometimes when we have perforation, it will bleed massively and be more difficult to manage.

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Ankylosis-related (replacement) resorption:

In cases of extensive damage to the innermost layer of the PDL, competitive healing events will take place whereby healing from the socket wall (creating bone via bone marrow-derived cells (and healing from adjacent PDL next to the root surface (creating cementum and Sharpey's fibers) will take place simultaneously.

With cases of moderate injuries (1-4 mm^2), an initial Ankylosis is formed.

This can later be replaced with new cementum and PDL, if allowed functional mobility by the use of a semi-rigid splint, or no splinting (transient Ankylosis).

In this way resorption of the initial Ankylosis site may occur.

With larger injuries (more than 4 mm^2) transient or progressive Ankylosis occurs.

This leads to the tooth becoming an integral part of the bone remodeling system.

The entire process includes osteoclastic resorption dependent on bone remodeling processes.

All of these processes are very active in children and leads to gradual infra-occlusion and arrested development of the alveolar process.

In children, this combination of resorption processes leads to loss of ankylosed teeth within 1-5 years.

In older individuals, replacement resorption is significantly slower and often allows the tooth to function for longer periods of time (i.e. 5-20 years).

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Transient marginal and apical breakdown of bone:

In situations where compression of the PDL has occurred (e.g. lateral luxation and intrusion), macrophage/ osteoclasts removal of traumatized tissue prior to periodontal healing often results in a transient marginal breakdown that is manifested by formation of gingival granulation tissue at the site of compression and a transient radiographic breakdown of the lamina dura at the site involved.

After 2-3 months the periodontium will usually be reformed.

Likewise, in the apical region a transient apical breakdown may occur in teeth with closed apices in cases where pulp healing takes place after luxation injuries (i.e. extrusion, lateral luxation).

In these instances a transient radiographic radiolucency is seen as a response to in-growth of new tissue into the pulp canal.

Permanent marginal breakdown:

The causes of permanent marginal breakdown are the same as described for transient marginal breakdown.

However, possibly due to infection or the size of the initial damage, healing does not take place.

In some cases bone sequestration may occur. Permanent marginal breakdown may be seen after lateral luxations, avulsion, intrusion, alveolar fracture and jaw fractures.

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Examination and Diagnosis:

Patient comes to you with a lot of saliva, maybe mud and debris or whatever, so you need to respect the dignity of the patient, and clean their face and the oral cavity with water or saline. You need to calm the patient.

If there are soft tissue wounds, a mild detergent should be used.

This cleaning will make the patient feel more comfortable and facilitate extra-oral and oral examination.

Make a short medical and dental history:

The medical history should reveal possible allergies, blood disorders and other information that may influence treatment. If there is any medical finding you need to stop at it.

The dental history should indicate previous dental traumas, information which may explain radiographic findings such as pulp canal obliteration or apical pathology.

Then it is important to ask specific questions:

When did the injury occur?

This is important for medico-legal purposes in other countries. For example if a child had fallen yesterday but attended your clinic today with his dad, you need to report them immediately, because child abuse is four parts; physical, verbal, sexual and negligence – this falls under negligence.

Legal implications?

In avulsion cases, the most critical factor is the extent of extra-oral time, and the extra-oral storage condition becomes very decisive for later treatment.

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Where did the injury occur?

Legal implication if the story that the patient is telling does not coincide with what you see then there is a medico-legal aspect. And possibility of contamination; if the patient fell at home in a clean environment or in the street where the need of anti-tetanus may be reviewed.

How did the injury occur?

Identification of the impact zones, to exclude fractures elsewhere. And Legal implications, if any.

Was there a period of unconsciousness? (The most important question)

Amnesia, nausea and vomiting may hint for intra-cranial haemorrhage and require medical attention. Sometimes the patients will not volunteer to tell you this information, if they tell you that do not remember what happened, medical attention becomes a must at this stage.

Is there any disturbance in the bite?

Luxation injury? Alveolar or jaw fracture? Fracture of the condylar region?

Is there any reaction in the teeth to cold and/or heat exposure?

Exposed dentine and/or pulp?

Examination:

1. Extra-orally:

- Examine; the face, lips and oral muscles for soft tissue lesions.- Palpate the facial skeleton for signs of fractures.

2. Intra-orally:

- Intra-oral Inspection: of the dental trauma region for fractures, abnormal tooth position. This is an important step, as some injuries are visible to the eye.

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- Mobility

- Percussion; to see whether the tooth is tender to percussion AND to determine the sound; normal percussion sound is dull, so if there was high metallic sound upon percussion we know that the tooth is entrapped/locked in the bone – so it is either a retrusive lesion or there is an alveolar fracture.

- Pulp testing; depends on the age of the patient and is very important. We usually do it as a reference record by taking progressive records every time we see the patient and we compare them. The best pulp test to do in trauma cases is the electric pulp test.

- Radiographic examination; we need multiple radiographic procedures to exclude/detect any further root fracture or displacement of the tooth in its socket. The standard of care is an occlusal view OR 2 angles of Periapical radiographs OR 3 angles or Periapical radiographs is the best.A steep occlusal exposure: lateral luxations, apical and mid-root fractures and alveolar fractures.The standard Periapical: cervical root fractures as well as other tooth displacements.Radiographic examination of the soft tissue lesions

- Photographic registration would be helpful

WWW.DENTALTRAUMAGUIDE.ORG;

We need to memorize the above link; because knowing how to get the needed information is part of learning. This is a very helpful website for Andresen and Andresen that includes everything we need to know about dental trauma. It is probably bit too much but we need to know what we need to know.

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The website includes; patient examination, trauma path finder, primary teeth (we have no time to cover them), and permanent teeth (which we will discuss)

Concussion:

Neurovascular supply is intact; there is no displacement and no mobility, but we have slight tenderness. No treatment is needed; only soft diet and pain killers.

Note that the management is the same no matter the direction of force (whether labially or palatally)

Subluxation:

It is pretty much the same as concussion, with bleeding from the gingival sulcus. No treatment is needed.

If it is severely subluxated, with no displacement but mobility, you ought to splint it.

Extrusion:

The tooth is pushed out of the socket but not all the way, so the neurovascular supply will be lost and we lose the vitality. The periodontal ligament undergoes separation injury mainly, with crushing injury of the periodontal ligament in certain parts.

Diagnostic tests;

- Visibility: the tooth appears elongated and it could be associated with either proclination or retroclination

- Mobility test: excessively mobile- Percussion test: tender - Pulp test: usually negative. (But we have to be cautious with the pulp test especially

with young patients because even on normal teeth some pulp tests may not give you any credible results)

- Radiograph: as shown on the website

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Management:

You clean the area, make sure you reposition the tooth properly , get rid of the blood by rinsing with chlorhexidine. If you have any lacerations or soft tissue injuries you can suture them, then you decide which type of splint you need.

- Notes about Splints:1. Why do we need a splint? To fix the tooth in its place.2. What type of splints we need? A semi-rigid splint.

Rigid Semi-Rigid

Associated with higher risk of Ankylosis Allows for micro-movements

Reduces our chances of revascularizing the pulp

Allows for better circulation in the periodontium and the pulp

3. We have two kinds of wire splinting; wire splinting and resin splinting.

We chose the wire splinting; which is very easy – we acid etch, adapt the wire labially, place the composite, cure it and that is it. (We do not put the wire lingually because it will affect the bite. I.e. we accept compromised aesthetics for the time period of splinting)

Duration of splinting depends on the injury. In extrusive injuries we don’t need a long period of time 1-2 weeks are enough because the main type of injury in the PDL is separation, other injuries may need more splinting period.

When you see the patient next time you do pulp test again then you follow up after 2-4 weeks you do pulp test again; if it remains non-vital or if you know already that this tooth is non-vital then you do a root canal treatment.

There is an additional option which calculates the prognosis based on the database of the patient on this website, which is fantastic but luxury more than anything else.

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Lateral luxation:

Usually associated with alveolar fracture

Because we have more serious damage to the periodontium and the bone, we need longer splinting time of 4 weeks.

Management is pretty much the same; we need LA because we need to pull the tooth out of its entrapment socket and reposition it into its original socket and this could be painful. Sometimes you can do it with your finger and other times you need forceps as if you are taking a tooth out.

The other type of splint is the resin splint which is also easily applicable and needs acid etching.

During these four weeks of splinting we need to monitor the healing of the pulp and the periodontal tissue. To monitor the healing of the pulp (especially in open apices cases of 7-8 year old patients where we have better chances of revascularization and regeneration);

1. We can do regular pulp testing (even if it could not give us any incredible reading)2. We can take multiple x-rays to monitor if there is continued growth of the root –

meaning the pulp is vital.

Signs of necrotic pulp are: Discoloration and Continuous negative readings in every time we do pulp test. In the case of a necrotic pulp we need to do RCT.

If the tooth is fully formed with a closed apex, the chances are of regeneration are reduced, so a continued lack of response is evidence of pulp necrosis, so we do RCT after 1 week to avoid external inflammatory root resorption.

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Avulsion: (MOST IMPORTANT!)

Most important about avulsion is public awareness and school teachers education on how to deal with avulsion because the first 60 minutes are considered critical and will determine whether the tooth is savable or not.

So what the patient does during these 60 minutes is much more important than what we do at our clinic. We should be able to answer phone calls and give advice over the phone.

Advice given to the patient should include the following tips:

- Hold the tooth from the crown and rinse it under running water to clean the roots from contamination

- Replant the tooth in its socket (the school teacher should be able to do that)- Bite on a piece of tissue paper or whatever- Bring the patient to the dental clinic immediately

If they have supposedly replanted the tooth improperly in the socket, it still needs proper repositioning but at least we know it was not stored in an extra-oral condition, so the periodontal ligaments still attached to the root are still vital.

The type of injury to the periodontium in cases of avulsion is separation so if we reposition it new collagen fibers will be attached and we will save the tooth. The problem arises when:

1. Extra-oral time exceeds 60 minutes (this is the most critical factor);Anything less than 60 minutes is manageable, anything more than 60 minutes we know that the fibers have to die and get replaced with bone and we have to be prepared to deal with Ankylosis.

2. Root apex is fully developed (we have a closed apex);Degree of root formation affects chances of pulp regeneration – an open apex tooth has better chances of regeneration, while in closed apices we have to expect pulp necrosis.

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Treatment:

Depends on the same critical factors, so we have to choose the category based on;

a. Either open or closed apexb. If closed apex;

1. Patient came with tooth already replanted2. Tooth in patient's hand but less than 60 minutes extra-oral time have passed3. Tooth in patient's hand but more than 60 minutes extra-oral time have passed

Important note: If we have avulsion with pulp exposure, we deal with the PDL injury first which should be our priority. Then we deal with the pulp exposure, which in this case is tricky, since we are pushing it to expect regeneration – the doctor would open an access cavity in this case, dress it with something then make a decision if he will do root canal or not later on.

For the management of category B2; where we have a closed apex, with less than 60 minutes extra-oral time:

- We hold the tooth from the crown, rinse it and replant it- We take an x-ray to make sure that it is in the correct position- We choose the type of splint- We give antibiotics; because there is evidence that tetracycline in particular reduces

the chances of Ankylosis and external inflammatory root resorption. Therefore, although they have no massive effect on the pulp, we still have to cover the patient with something.

- We check if the patient has not been vaccinated against tetanus, we give anti-tetanus.

- If it’s a closed apex and we do not anticipate the pulp to be regenerated we go for RCT.

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For the management of category B3; where we have a closed apex, with more than 60 minutes extra-oral time:

We know it is a game over!

- We need to rub off the PDL and everything else that is attached to the root using a piece of gauze

- We leave it to soak in 2% potassium fluorides or sodium fluorides or anything that can retard Ankylosis for twenty minutes

- We replant the tooth and splint it – expecting Ankylosis to occur- We do root canal treatment with a material other than Gutta Percha, because the

tooth will eventually disappear and we do not want Gutta Percha hanging there. Therefore, we need to seal it with another material that can resorb such as iodine with calcium hydroxide, so that by the time the Ankylosis process reaches the pulp space this material will be resorbed and we would have preserved the socket and the alveolar bone.

- We do implant, as the area is ready with a lot of bone to recieve the implant

Is Ankylosis a problem?

1. It is; as it can lead to infra-occlusion because it retards the growth. And eventually the root will resorb leaving the crown hanging there in the soft tissues which can be easily removed if you pull it with your fingers. This process could take up to 20 years in a fully matured tooth.

2. It is not; because the ankylosed area will be ready to receive an implant.

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Abrasion of skin, mucosa and gingiva:

A superficial wound produced by rubbing and scraping of the mucosa or skin leaving a raw, bleeding surface which, however, remains partly covered with epithelium.

The presence of epithelium is important as healing consists of proliferation of a new epithelial cover from the remaining basal layers of the epithelium and appendices.

Contusion of skin, mucosa and gingiva:

A bruise without a break in the skin or mucosa by impact with a blunt object represented as a subcutaneous or submucosal tissue haemorrhage.

A contusion may be isolated to soft tissue or indicate an underlying bone fracture.

Laceration of skin, mucosa or gingiva:

Is a shallow or deep wound in the mucosa resulting from a tear, usually produced by a sharp object.

Lacerations will disrupt blood vessels, nerves and sometimes muscles, hair follicles and salivary glands.

The most frequent affected sites are lips, oral mucosa and gingiva. More seldom the tongue is involved.

Penetrating lip wounds:

These are penetrating lacerations from skin to mucosa.

The presence of foreign bodies is very common

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Avulsion of skin, mucosa or gingiva:

Tissue avulsion cases (loss of tissue) are rare but seen in association with bite injuries or as a result of a very deep and extended abrasion.

Treatment principles for soft tissue wounds:

Mechanical manipulation of the wound

An important general principle is the need for meticulous cleansing and debridement of oral and cutaneous wounds, as presence of bacteria and especially foreign bodies increases the risk of healing complications.

Wound approximation using tension-free sutures is essential for rapid healing.

Antibiotics and tetanus prophylaxis treatment:

A controversial issue

No reliable randomized studies in regard to oral wounds have been published.

The few studies reported seem to indicate that superficial lacerations do not benefit from antibiotic treatment.

Penetrating lip lesions possibly need antibiotic coverage to lower the risk of inflammatory complications.

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The current recommendations for using antibiotics appear to be:

Antibiotics should be given in the following situations:

- Heavy contaminated wound- Compromised wound cleansing, e.g. restricted vascularity of the injured tissue- Delayed treatment, more than 24 hours- Injuries penetrating through the lip of the cheek- Human and animal bite wounds- Simultaneous extensive bone surgery such as open reduction of a bone fracture- When the general defense system of the patient is compromised, e.g. insulin-

dependent diabetes and immune-compromised patients- Patients with risk of infective endocarditis such as cardiac valves or cardiac

reconstruction, valvar dysfunction/malformation or previous endocarditis.

Tetanus prophylaxis:

In cases of contaminated wounds, tetanus prophylaxis should be considered.

Check if the patient is immunized

If more than 5 years since last immunization have elapsed, a booster dose should be considered

Splinting:

The application of a splint is indicated in all cases where repositioning has been performed after a luxation or avulsion injury and root or alveolar bone fracture.

Several studies have shown that a flexible splint may optimize pulp and PDL healing.

Two general types of splint exist in this category:

1. A flexible temporization material splint2. A flexible wire/fiber composite splint

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Flexible temporization material splint:

The splinting material is applied in a thin layer. A temporization material (e.g. Protemp) is used, whereby a semi-rigid splint is created.

During polymerization of the splinting material, the patient may occlude to ensure correct repositioning of the tooth.

Keep the splint away from the gingiva to permit optimal oral hygiene.

At the end of the fixation period, the splint is removed with either a scaler or a bur.

The enamel is then lightly polished to re-establish a smooth surface

Flexible wire/fiber composite splint:

A number of wire/fiber systems including orthodontic wire, twist flex wire, fiber (Ribbond) and titanium plates

It is important that the reinforcing wires/fibers are placed inside the composite material for labial bonding of the injured and adjacent teeth.

Bonded orthodontic brackets can also be used. This form of splinting has the advantages in multiple tooth injuries that the various splinting periods can be respected without removing the splint.

The composite material is removed with a bur and the enamel is then polished

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Splinting times:

Subluxation 2 weeks Extrusive Luxation 2 weeksAvulsion 2 weeksLateral luxation 4 weeksRoot fracture (apical and middle third) 4 weeksAlveolar bone fracture 4 weeksRoot fracture (cervical third) 4 months

Please get back to the slides for illustrations

Please check out the poster – which explains the management in cases of avulsion

Please get back to the website www.dentaltraumaguide.org for illustrations and videos

and everything related to trauma.

Good luck

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Documents

· Web viewIn these instances a transient radiographic radiolucency is seen as a response to in-growth of new ... We do root canal treatment with a material other than Gutta