The traumatic injuries of permanent teeth and complex therapy

(1)

The traumatic injuries of

permanent teeth and complex

therapy

Dr

.

Katalin Déri

Semmelweis Egyetem

Department of Pedodontics and Orthodontics

(2)

Risk

•

Angle II/1

• Predisposing factor:Predisposing factor:

✂

overjet_overjet

✂

protrusion of upper _{protrusion of upper}

incisors

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Injuries

Sport related - 1.5% -3.5%

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Injuries

Playground - school

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Injuries

Fights

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Injuries

Car accident

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Age distribution

Therapeutic significance

8-13 years the highest incidence

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Sex

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Incidence of injured teeth in %

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Anamnesis

general anamnesis

circumstances of injury

black-out, amnesia, headache, nausea,

vomit

previous injuries : consequences,

complications

dental anamnesis

(14)

Most important questions

When?

• Time past between the injury and the treatmentTime past between the injury and the treatment

Where?

• Risk of infectionRisk of infection

How?

• Mechanism of the injury, polytraumaMechanism of the injury, polytrauma •

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Clinical examination

Extraoral examination Extraoral examination Intraoral examination Intraoral examination Photo documentation Photo documentation X-ray X-ray

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Type of injuries

• Traumatic injuries involving:Traumatic injuries involving: ■ _{the permanent teeth}_{the permanent teeth}

■ _{the alveolar bone}_{the alveolar bone} ■ _{the soft tissues}_{the soft tissues}

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Classification of dental injuries

(International Association of Dental Traumatology, 2001)

1.

1. Coronal fracture

Coronal fracture

2.

2. Coronal and root fracture

Coronal and root fracture

3.

3. Root fracture

Root fracture

4.

4. Fracture of processus alveolaris

_{Fracture of processus alveolaris}

5.

5. Luxations and avulsion

_{Luxations and avulsion}

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Classification of dental injuries

Pedodontics and Orthodontics textbook

1.

1. Luxatio totalis dentis permanentis

_{Luxatio totalis dentis permanentis}

2.

2. Luxatio partialis dentis permanentis

Luxatio partialis dentis permanentis

3.

3. Intrusio

_Intrusio

4.

4. Fractura coronae dentis permanentis

_{Fractura coronae dentis permanentis}

5.

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Avulsion

Luxatio totalis dentis permanentis

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Luxatio partialis dentis permanentis

■ _{loosening of the tooth or a partial}_{loosening of the tooth or a partial}

displacement of the tooth out of

its socket

a.

a. subluxationsubluxation

b.

b. lateral luxationlateral luxation

c.

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Luxatio partialis dentis permanentis

Displacement

• subluxation: subluxation:

•

sensitive to touchsensitive to touch

•

mobilemobile

•

no displacementno displacement

•

bleedingbleeding

• extrusion: extrusion:

•

axial displacementaxial displacement

•

mobilemobile

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• lateral luxation: lateral luxation:

•

lateral displacementlateral displacement

•

locked in the alveolar bone locked in the alveolar bone

•

no mobilityno mobility

•

not sensitive not sensitive

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Luxatio partialis dentis permanentis -

luxatio lateralis

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3.

3. Intrusion

_Intrusion

■ _{displacement of the tooth}_{displacement of the tooth}

into the alveolar bone

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Fractura coronae dentis permanentis

Types of coronal fracture

Types of coronal fracture • Most frequent injuryMost frequent injury

enamel only

enamel only _{enamel and dentine}_{enamel and dentine} enamel and dentineenamel and dentine

with the pulp exposed

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Fractura coronae dentis permanentis

n _{fracture without complication}_{fracture without complication} n _{complicated fracture (with pulp}_{complicated fracture (with pulp}

exposition)

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Fractura radicis dentis permanentis

Root fracture

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Fractura radicis dentis permanentis

1.

1. cervical third

_{cervical third}

2.

2. middle third

_{middle third}

3.

3. apical third

_{apical third}

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Complex therapy

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Treatment of the injuries: Avulsion

1.

1. Luxatio totalis dentis permanentis

Luxatio totalis dentis permanentis

• Actions out of surgery:Actions out of surgery:

 Suitable storage: in wet agentSuitable storage: in wet agent

1.

1. physiological salinephysiological saline

2. 2. salivasaliva 3. 3. milkmilk 4. 4. Dentosafe-ZahnrettungsboxDentosafe-Zahnrettungsbox

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Treatment of the injuries: Avulsion

■

Aim:

replantation as soon as possible

• the ligaments and cells loose their vitality the ligaments and cells loose their vitality

after 1 hour

1.

1. Preparation of the tooth and the alveolaPreparation of the tooth and the alveolar socketr socket

2.

2. ReplantationReplantation

3.

3. Stabilization Stabilization – using the neighboring– using the neighboring

• teeth for splintingteeth for splinting • _{acrylic splint}_{acrylic splint}

• _{composite bonding with orthodontic archwire}_{composite bonding with orthodontic archwire} • _brackets_brackets

(33)

Prognosis: max.

Prognosis: max. 1 hour1 hour extra-alveolary extra-alveolary Fixation: closed apex -

Fixation: closed apex - 7-10 days7-10 days

• open apex -open apex - 2 weeks 2 weeks (neurovascular reanastomosis) (neurovascular reanastomosis)

In mature tooth with closed apex, or in immature tooth with

open apex (time elapsed > 30 min.)

In 1 week root canal treatment -

In 1 week root canal treatment - Ca(OH)Ca(OH)2 2 should be placedshould be placed

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Treatment of the injuries: Avulsion

1.

1. Luxatio totalis dentis permanentis

Luxatio totalis dentis permanentis

■

Instructions

1.

1. pulpy dietpulpy diet

2.

2. toothcleaning with soft toothbrushtoothcleaning with soft toothbrush

3.

3. 0,1 % chlor-hexidine 0,1 % chlor-hexidine



Supplementary therapy

1.

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Treatment of the injuries: Avulsion

Luxatio totalis dentis permanentis

■ If replantation is not possible If replantation is not possible ( e.g.: in the case ( e.g.: in the case

of loss of the tooth )

1.

1. Temporary solution:Temporary solution:

• acrylic bridgeacrylic bridge

• orthodontic applianceorthodontic appliance

2.

2. Final solution:Final solution:

• orthodontic treatmentorthodontic treatment • implantationimplantation

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Treatment of the injuries: Avulsion

Luxatio totalis dentis permanentis

Temporary solution

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Healing after replantation

 _{regeneration of the gingiva}_{regeneration of the gingiva}

 _revascul_revascul_ar_ar_{isation of the ligaments}_{isation of the ligaments}  _{renewal of the Sharpey ligaments}_{renewal of the Sharpey ligaments}

 _{open apex - revascularisation and reinnervation}_{open apex - revascularisation and reinnervation} •

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Treatment of the injuries: Displacement

2.

2. Luxatio partialis dentis permanentis

Luxatio partialis dentis permanentis

•

Subluxation

• no need to splint for stabilization

no need to splint for stabilization

• observation - x-rax

observation - x-rax

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Treatment of the injuries: Displacement

2.

2. Luxatio partialis dentis permanentis

Luxatio partialis dentis permanentis

• lateral luxationlateral luxation

• extrusionextrusion

1.

1. reponation ( following the injury )

_{reponation ( following the injury )}

f

fixation for 2-3 weeksixation for 2-3 weeks

1.

1. later : orthodontic reposition

later : orthodontic reposition

3.

3. root canal treatment ( in case of the tooth

_{root canal treatment ( in case of the tooth}

with closed apex )

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Treatment of the injuries:

3. Intrusion



Open apex : a chance of spontaneous

re-eruption



Closed apex :

1.

1. surgical or orthodontic reposition

_{surgical or orthodontic reposition}

2.

2. splint

_splint

3.

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Treatment of the injuries:

3. Intrusion

orthodontic and surgical reposition

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Treatment of the injuries:

Fractura coronae dentis

permanentis

■ The treatment of The treatment of

crown fracture

depends on which

third of the crown is

injured

(43)

Treatment of the injuries:

Fractura coronae dentis

permanentis

a.

Enamel injuries:

_{Enamel injuries:}

1.

1. Minor enamel fractures : polishing,

_{Minor enamel fractures : polishing,}

fluoride solution ELMEX

2.

2. Larger enamel fractures (1-2mm or

_{Larger enamel fractures (1-2mm or}

more): composite restoration

(44)

Treatment of the injuries:

Fractura coronae dentis permanentis

b.

Enamel – dentine injuries without pulp

_{Enamel – dentine injuries without pulp}

exposition

1.

1. Calcium hydroxide liner

_{Calcium hydroxide liner}

2.

2. Temporary crown ( celluloid, acrylic ) –

_{Temporary crown ( celluloid, acrylic ) –}

1 year

3.

3. X – ray control

_{X – ray control}

4.

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Fractura coronae dentis permanentis

temporary crown - incisal restoration

(46)

Rebonding of fractured crown

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Treatment of the injuries:

Fractura coronae dentis

permanentis

c.

Pulp exposition

_{Pulp exposition}

•

Important:

1.

1. size of the pulp exposure

_{size of the pulp exposure}

2.

2. time between the the injury and the

_{time between the the injury and the}

treatment

3.

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Treatment of the coronal fracture in

case of pulp exposition

exposition time root developme nt small 1 – 2 hours open or closed apex direct pulp capping larger than

1 mm more, than 3 hours open apex pulpotomy

(49)

Treatment of the injuries:

Root fracture

a.

a. fracture in cervical third:fracture in cervical third:

1.

1. root canal treatment + restorationroot canal treatment + restoration

2.

2. extraction + implantationextraction + implantation

3.

3. orthodontic extrusionorthodontic extrusion

b.

b. fracture in middle thfracture in middle third:ird:

a.

a. repositionreposition

b.

b. splint ( 6 weeks )splint ( 6 weeks )

c.

c. root canal treatmentroot canal treatment ( in case of necrosis) ( in case of necrosis)

d.

d. observation observation

1.

1. fracture in apical third:fracture in apical third:

2.

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Fractura radicis dentis permanentis

Healing

Soft tissue, hard tissue

granule tissue

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Prevention

(52)

Prevention

• Mouthguard:Mouthguard: • ConfectionalConfectional • PrefabricatedPrefabricated • IndividualIndividual

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Education!!!

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Warning - Child abuse!!!!

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