Oral and Maxillofacial Surgery Department

Faculty of Dental Medicine Universitas Airlangga

DENTAL TRAUMATOLOGY

DENTAL TRAUMATOLOGY

n DENTAL TRAUMATOLOGY à Branch of dentistry¨Epidemiology¨Etiology¨Prevention¨Assessment¨Diagnosis¨Management of trauma to the jaw and

surrounding tissues

nDENTAL TRAUMA¨Simple¨Complex à management may be

interdiciplinary or multidiciplinary

n Traumatic injuries are typically quick, sudden, and unexpectedà Clinicians must be prepared to render appropriate emergency care any time

TRAUMAn NON INTENTIONAL INJURY:

¨Domestic, recreational, sport, work, vehicular related injury (are not inflicted on purpose by one’s self or another person

n INTENTIONAL INJURY :¨Suicide, homicide, domestic abuse, war,

terrorism and other such injuries that are purpose fully inflicted

n There are basiccaly 2 types of injuries to dentition :¨Hard tissue injuries :

nTeeth, alveolar bone, and other facial bones.

¨Soft tissues injuries :nFacial skin, lips, mucosa (cheeks

and periodontium) soft tissues of the hard ad soft palate, and tongue.

Hard tissues injuries

n Tooth injuries¨Crown fracture :

nEnamel infraction.nComplicated crown fracturenUncomplicated crown fracture

¨Rooth fractures :n Crown-root fracturen Intraalveolar root fractures

¨Luxation injuriesn Concussionn Subluxationn Lateral luxationn Intrusionn Extrusive luxationn Avultion (or exarticulation)

n Alveolar injuries

Soft tissue injuries

PATIENT ASSESSMENT

n MEDICAL EMERGENCY CONSIDERATIONn ORAL EMERGENCY CONSIDERATIONn Patient Historyn Soft tissue clinical examination

¨Extraoral examination¨ Intraoral examination

n Soft tissue Radiographic examinaton

n Hard tissue clinical examination¨Alveolar bone¨Teeth

n Observationn Mobilityn Percussionn Pulp vitalityn Laser doppler flowmetry

n Hard tissue radiographic examination¨Teeth¨Alveolar Bone

n PEDIATRIC CONSIDERATIONn GERIATRIC CONSIDERATION

CROWN FRACTURESn CLASISIFICATIONn ETIOLOGICAL FACTORSn DIAGNOSIS AND CLINICAL FINDINGSn RADIGRAPHIC FINDINGSn BOLOGICAL CONSIDERATIONS AND

TREATMENT PRINCIPLESn ENAMEL INFRACTIONS AND ENAMEL

FRACTURES¨ Diagnosis¨ Histopatology¨ Treatment¨ Prognosis

n ENAMEL-DENTIN FRACTURE WITHOUT PULP INVOLVEMENT (UNCOMPLICATED CROWN FRACTURES)¨Diagnosis¨Histopatology¨Treatment

n Restoration (Composite Buildup)n Reattachment of Coronal Segment

¨Prognosisn Restoration by Composite Buildupn Reattachment of Coronal Segment

n ENAMEL-DENTIN FRACTURE WITH PULP INVOLVEMENT (COMPLICATED CROWN FRACTURES)¨ Diagnosis¨ Histopatology¨ Factors Influencing Choice of Treatment¨ Treatment : Mature and Immature Teeth

n Direct Pulp Cappingn Pulpotomy (Partial or Coronal)n Coronal Pulpotomyn Deep Pulpotomyn Deep Pulpotomyn Follow-up to Pulp Capping and Pulpotomy

¨ Pulp-Capping Agents¨ Prognosis

n TREATMENT TECHNIQUES FOR NONVITAL TEETH ¨Mature Teeth¨ Immature Teeth

n Apexificationn Apexification : Techniquen Apipcal Barrier : Technique

n RESTORATION OF IMMATURE ROOTS

n CROWN FRACTURES IN PRIMARY TEETH¨Clinical Appearance¨Radiographic Appearance¨Biological Considerations¨Uncomplicated Crown Fractures (No Pulp

Exposure)¨Complicated Crown Fractures (Pulp

Exposure)n Incidencen Treatment Options

¨ Direct pulp cappping : technique¨ Partial pulpotomy or Cvek Technique¨ Pulpotomy (Partial/Coronal)¨ Pulpectomy¨ Extraction

INTRA ALVEOLAR ROOT FRACTURES

n TERMINOLOGY AND EPIDEMIOLOGY

n CLINICAL PRESENTATION

n RADIOGRAPHIC PRESENTATION

n HEALING CLASSIFICATIONS

n SEQUELAE¨Pulp Survival with Canal Obliteration¨Internal resorption¨External Resorpsion¨Loss of Crestal Bone

n HEALING PARAMETERS¨Fracture Location¨Diastasis¨Tooth Maturity¨Gender

n MANAGEMENT¨Splinting¨Endodontic Treatment¨Treating the Coronal Fragment¨Treating the Coronal Fragment and Removing

the Apical Fragment¨Treating the Coronal and Apical Fragments at

the Same Time¨Removing the Corhnal Fragment and Treating

the Apical Fragmentn Crown-Root Fracturesn Coronal Root Fractures

n PEDIATRIC CONSIDERATION

LUXATION INJURIES

n CLASIFICATION¨Concussion¨Subluxation¨Lateral Lucation¨Extrusive Luxation¨Intrusive Luxation¨Avulsion

n ETIOLOGY AND EPIDEMIOLOGYn DIAGNOSIS OF LUXATION INJURIES :

RADIOGRAPHIC AND CLINICAL ASPECTS¨Concussion¨Subluxation¨Lateral Lucation

n Lateral Luxation Without Apical Displacementn Lateral Luxation With Apical Displacement

¨Extrusive Luxation¨ Intrusive Luxation

n TREATMENT OF LUXATION INJURIES¨Emergency Treatment

nGeneral Treatment ConsiderationsnRepositioning

¨Concussed and Subluxated Teeth¨Laterally Luxated Teeth

nWithout Apical DisplacementnWith Apical Displacement

¨Repositioning Extruded Teeth¨Repositioning Intruded Teeth

nSpontaneous EruptionnSurgical Crown UncoveringnSurgical Extrusion

¨Splinting¨Suturing Soft Tissue Lacerations¨Additional Considerations,

Prescriptions, and Instructions to the Patient

n Posttrauma Follow-up Evaluations and Treatment¨Recall Frequency¨Endodontic Evaluation and Treatment

n Mature Teeth (Closed Apex)n Immature Teeth (Open Apex)

n SEQUELAE OF LUCATION INJURIES¨Types¨Pulpal

n Periradicularn Diagnostic Means to Detect Sequelae

on Follow-up

n EXPECTED HEALING OUTCOME OF LUXATION INJURIES

AVULTIONSn ETIOLOGY AND EPIDEMIOLOGYn KEY ISSUES ASSOCIATED WITH PROGNOSIS AND

MANAGEMENT OF AVULSED TEETH¨ Pulpal Damage : Comparing Mature and Immature Teeth¨ Periodontal Damage

n EMERGENCY MANAGEMENT OF AVULSION INJURIES¨ At the Site of the Injury (Outside the Dental Office)

n Immediate Replantationn Transport Medium Before Replantation

¨Emergency Management at the Dental Officen Patient Examination : Clinical and Radiographic

Aspectsn Socket Manipulationn Root Manipulation

¨Extraalveolar dry time less than 1 hour or tooth stored in a proper storage medium : Closed Apex

¨Extraalveolar dry time less than 1 hour or tooth stored in a proper storage medium : Open Apex

¨Extraalveolar dry time Greater than 1 hour : Closed Apex

¨Extraalveolar dry time Greater than 1 hour : Open Apex

¨Splinting¨Endodontic Treatment Issues at The

Emergency Visit¨Systemic Treatment

n Antibioticsn Analgesics

¨ Instructions to the Patient¨Prognosis Assessment at the Emergency Visit

n SEQUELAE OF AVULSION INJURIES¨Consequences of Pulpal Necrosis¨Consequences of Periodontal Damage :

External Root Resorptionn Surface Root Resorptionn Replacement Root Resorptionn Inflammatory Root Rsorptionn Cervical Root Resorption

n POSTTRAUMATIC FOLLOW-UP AND MANAGEMENT¨Need for Endodontic Treatment¨Treatment Options for Open Apex

Teeth that Failed to Revascularizen Apexificationn One versus two step Apexificationn Pulpal Regenerations Modalities

n EXPECTED HEALING OUTCOME OF AVULTIONS¨Epidemiological Data¨Signs of Nonhealing¨Treatment Options

n AVULSED PRIMARY TEETH

ALVEOLAR FRACTURES

n EPIDEMIOLOGY AND ETIOLOGYn TERMINOLOGY AND CLASSIFICATION

¨Comminution of the alveolar socket¨Fracture of the alveolar socket wall¨Fracture of the alveolar process¨Fracture of the mandible or maxilla

n CLINICAL AND RADIOGRAPHIC FINDINGS

n TREATMENT¨Antibiotic Treatment and Tetanus

Prophylaxis¨Reduction¨Fixation and Immobilization

n Composite Retained Wire Splintn Arch Barsn Acrylic Splintn Orthodontic Appliancesn Plate-and-Screw Fixation

¨Rehabilitation

n HEALING¨Sequence of Fracture Healing

n COMPLICATIONS¨Malocclusion¨Loss of Alveolar Bone¨Loss of Teeth

n PROGNOSIS AND OUTCOME ASSESSMENT¨The prognosis of alveolar fractures

depends on the following factors :n Time interval between injury and fixation of

alveolar fracturen Type of alveolar fracturen Associated dental injury (luxation or avulsion)

to the teeth in the fractured segmentn Stage of root development of the teeth

involvedn The health of the periodontal tissuesn The presence of significant communication of

bone and teeth.

n PEDIATRIC CONSIDERATIONS

SOFT TISSUE INJURIES AND MANAGEMENT

n EPIDEMIOLOGY OF SOFT TISSUE INJURIES

n ETIOLOGY OF SOFT TISSUE INJURIES

n MANAGEMENT OF SOFT TISSUE INJURIES¨THE FACE

n Immediate Treatment of Facial TraumanComplementary Treatment for Facial

Trauma

¨THE LIPS

¨CYANOACRYLATES AND THEIR DENTAL APPLICATIONSnClinical Examination of the LipsnRadiographic Examination of the Lips

¨TECHNIQUE FOR CLOSING LIP WOUNDS WITH CYANOCRYLATESnAdvantages of CyanoacrylatesnDisadvantages of Cyanoacrylates

¨THE MUCOSA

¨THE LABIAL FRENUM

¨THE TONGUE

¨HEALING MECHANISM OF ORAL SOFT TISSUE WOUNDSn Wound healing can be separated into 4 different

phases :¨ Hemostasis¨ Inflammatory response¨ Proliferation¨ Remodeling

n Wound healing could be affected by :¨ Local factors¨ Regional factors¨ Systemic factors¨ Miscellaneous factors

THE LAW AND DENTAL TRAUMA

n DENTAL LAWS AND LICENSING REGULATIONS

n LEGAL ISSUES¨Standards of Care¨Unprofessional Conduct¨Violations of Statues

n CONSENT ISSUES¨ Informed Consent/Refusal

n Informed Consentn Informed Refusal

n BURDEN OF PROOF n CAUSATIONn CONDUCT OF OTHERSn GOOD FAITH SETTLEMENTn NATURE OF INJURYn NATURE OF TRAUMA

n STANDARDS FOR TRAUMA CASESn GOOD SAMARITAN DEFENSESn NONINTENTIONAL

INJURY/ACCIDENT/SPORTING CASESn ABUSE AND BATTERY CASES

¨Confidentiality and Privileges¨ Immunity¨Failure to Report¨Recognition of Abuse

n Child Abusen Abuse of the Elderly or Disabled

n IATROGENIC TRAUMA CASES

THE PSYCHOLOGICAL IMPACT OF DENTAL INJURIES

n THE LITERATURE ON PSYCHOLOGICAL REACTIONS TO PHYSICAL INJURIES

n REVIEWING EMOTIONAL AND BEHAVIORAL SYMPTOMS THAT MAY ACCOMPANY DENTAL INJURIES¨ Acute Stess Disorder¨ Posttraumatic Stress Disorder¨ Other Signs of Distress

n IMPLICATIONS FOR THE DENTIST IN PROVIDING SUPPORT TO A PSYCHOLOGICALLY AFFECTED PATIENT

OROFACIAL TRAUMA PREVENTION

n ATHLETIC MOUTHGUARDSn ORTHODONTIC AND MIXED DENTITION

CONSIDSERATIONSn COMPLIANCE AND ACCEPTANCE OF

MOUTHGUARDSn ROLE OF THE DENTIST IN OROFACIAL TRAUMA

PREVENTIONn MOUTHGUARD FABRICATIONSn ATHLETIC TEAM DENTISTSn SMOKELESS TOBACCOn EATING DISORDERS

REFERENCES

n Fonseca RJ, Walker RV, Betts NJ, Dexter H. Oral and Maxillofacial Trauma. Vol. 1. WB. Saunders. Philadelphia. 1997.

n Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby Elsevier. 2007.