Current Concepts in Management of Dentoalveolar Trauma

Dr. Armaghan MirzaFCPS Resident

Oral & Maxillofacial Surgeryde’Montmorency College of Dentistry

•Any injury to teeth or their supporting structures is grouped under the domain

of dentoalveolar injuries.

Dentoalveolar Injuries

Enamel Dentine Pulp Periodontal Membrane Alveolar bone

Etiology and Predisposing Factors

Predisposing factors

Male > Female Malocclusion - Class II division I Proclined teeth Contact sports Interpersonal violence Leisure activities e.g. cycling, skateboarding Handicaps Falls / Convulsive seizures e.g. epilepsy Endotracheal intubation Non Accidental Injuries ( NAI ) Child abuse

Review of Literature

Incidence of Orodental Injury 4-33% Peak age for Primary Dentition 1.5 - 3.5 yrs Peak age for Permanent Dentition 9- 10 yrs M : F ratio 2.5:1 to 3:1 Most commonly affected tooth Maxillary

central Incisor

By the age of 14 yrs, 55% have experienced trauma to dentition.

Classification Tooth fracture

1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival

--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm

2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival

--- ii) Subgingivalb) Diagonal --- i) Supragingival

--- ii) Subgingivalc) Vertical

3) Root fracture --- Apical third--- Middle third--- Coronal third

Classification Tooth fracture

1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival

--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm

2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival

--- ii) Subgingivalb) Diagonal --- i) Supragingival

--- ii) Subgingivalc) Vertical

3) Root fracture --- Apical third--- Middle third--- Coronal third

Classification Tooth fracture

1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival

--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm

2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival

--- ii) Subgingivalb) Diagonal --- i) Supragingival

--- ii) Subgingivalc) Vertical

3) Root fracture --- Apical third--- Middle third--- Coronal third

Classification Tooth fracture

1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival

--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm

2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival

--- ii) Subgingivalb) Diagonal --- i) Supragingival

--- ii) Subgingivalc) Vertical

3) Root fracture --- Apical third--- Middle third--- Coronal third

Classification Tooth fracture

1) Uncomplicated crown fracturesa) Enamel --- including cracksb) Enamel and Dentine --- i) Supragingival

--- ii) Subgingivalc) Enamel, dentine & freshly exposed pulp less than 2mm

2) Complicated crown fracture( involving pulp)a) Horizontal --- i) Supragingival

--- ii) Subgingivalb) Diagonal --- i) Supragingival

--- ii) Subgingivalc) Vertical

3) Root fracture --- Apical third--- Middle third--- Coronal third

Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement

4) Avulsion Alveolar bone injuries

1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible

Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration

Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement

4) Avulsion Alveolar bone injuries

1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible

Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration

Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement

4) Avulsion Alveolar bone injuries

1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible

Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration

Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement

4) Avulsion Alveolar bone injuries

1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible

Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration

Periodontal injuries1) Concussion2) Subluxation3) Displacement Extrusive Displacement Intrusive Displacement Lateral Displacement

4) Avulsion Alveolar bone injuries

1) Crushing or compression associated with tooth displacement2) Fracture of alveolar wall3) Fracture of alveolar process4) Fracture of maxilla or mandible

Injuries to the soft tissues1) Contusion 2) Abrasion 3) Laceration

Management

Initial Assessment Confident and sympathetic approach by both doctor

and nurse to ensure that the parents feel the situation is under control and also helps the patient to calm down

History takinga) When did the accident occur?b) Where did the accident occur?c) How did the accident occur?d) Has the child any other symptoms?e) Have the lost teeth being accounted for?

Presenting Complaint

Tooth sensitive to hot and cold Sharp tooth Mobile tooth / teeth Oral pain Oral bleeding Malocclusion

Investigations

X-raysa) Dental ---periapicals, occlusal, Lateral Ceph.b) Jaw fractures --- Orthopantomogram, PA facec) Lips --- Periapical, Lateral Cephalogram

( foreign bodies, tooth fragment)

d) Chest X- rays--- Aspirated tooth or tooth fragment Vitality test Transillumination

Enamel fracture

With pulp vitalitySmooth fracture surfacePlace protective varnishPlace fluoride gel Without pulp vitality:Endodontic treatment

Enamel and dentin fracture

Restoration with Composite and / or GIC

Enamel and Dentine fracture with Pulpal Exposure < 2 mm Not contaminated with saliva etc. Presenting within 24 hours.

Pulp caping with calcium hydroxide plus crown restoration with composite

> 2 mm Contaminated Presenting after 24 hours

Pulpotomy with 2mm of pulp removed dressed with calcium hydroxide plus restoration.

Old exposure with pulpal necrosis Pulpectomy and endodontic therapy

Crown and root fracture

Without pulp exposure Remove the fracture segment Restoration With pulp exposure Remove the fractured segment Endodontic treatment followed by restoration

Root fracture

Primary dentition Without mobilityPreserve and should exfoliate normally

With mobility or cervical third fractureShould be removed without attempt to remove apical fragment

Root fracture

Permanent dentition Consider level of fracture

EndodonticEndodontic and apicectomyEndodontic, apicectomy and restoration (post and core, crown and implant)

Alveolar bone injuries

Reduction ---- Finger manipulation Fixation ---- Dental occlusal splints /

Direct wiring / Arch bar splinting / Plating/Acid etch composite

Immobilization --- 4 weeks

When alveolar bone component not present 2-3 weeks (Subluxation, displacement & avulsion)

Periodontal Injuries

Subluxation Displacement Avulsion

Management i) Reductionii) Immobilization --- 2-3 weeks

Gingival Injuries

Cover abrasions with antiseptic pack Suture lacerations

Acute trauma of deciduous teeth

Intrusion ----i) wait & observe if not disturbing the permanent tooth budii) extraction if possible risk of damaging the permanent tooth

bud Extrusion --- Extraction Subluxation --- Conservative ( soft diet) Avulsion --- Do not attempt to reimplant

Immobilization period for traumatized teeth Root fracture

Middle and apical third 4 weeks Cervical third 2 months

Avulsion Immature

Extra alveolar time < 60 minutes; Flexible splint 2 weeks Extra alveolar time > 60 minutes very poor prognosis

Mature Extra alveolar time < 60 minutes 2 weeks Extra alveolar time > 60 minutes 6 weeks

Luxation Concussion Splint optional (10 days) Subluxation Splint optional (10 days) Extrusion Splint for 3 weeks Lateral luxation Splint for 3-4 weeks Intrusion; Immature 3 – 4 weeks Intrusion; Mature 2 weeks

Post-operative Care

Antibiotics & Analgesics Liquids followed by soft diet – 4 weeks Nutritional supplements ( 2000 – 2200 Cal/day,

comprising proteins, fat and carbohydrates ) Maintenance of Oral hygiene

( antimicrobial mouthwashes e.g.0.2% Chlorhexidine ) Follow up every 3 months upto 1 year

Complications

Immediate ----- Bleeding (hematoma) Swelling Malocclusion

Late ---- Infection Mal union Non union Root resorption (external /

internal) Root ankylosis

Management options for traumatic intrusion of teeth

Mild < 3mm ---- Passive repositioning Moderate 3-6mm ---- Passive repositioning

---- Active repositioning (Immediate traction)

Severe > 6mm ---- Immediate repositioning ( Surgical reduction)

---- Extraction / Immediate root canal treatment ---- Extraction

Resorption

Lower prevalence when the period of dryness less than or equal to 5 mins

Prevalence of resorption with no visible contamination57.1%

Prevalence of resorption for contaminated tooth but washed clean75%

Prevalence of resorption for contaminated tooth but rubbed clean87.5%

Prevalence of resorption with visible contamination present100%

Avulsion

Recommended guidelines: Extra-alveolar time: within 30 mins Storage media: Hanks Balanced Salt solution>saline>saliva>milk Root treatment: Prereplantation treatment of root surface with

fluoride resists the resorption by forming flouroapatite.

Pre-replantation Treatment

Presenting within 2 hours: Closed Apex: HBSS for 30 minutes Open Apex: HBSS for 30 minutes , 1mg/20ml

Doxycycline soltn. for 5 minutes Presenting after 2 hours:,

Remove PDL by scraping or soaking in NaOCl for 30 minutes

Endodontic debridement, cleaning and shaping of the canal in hand

Soak in citric acid soltn for 3minutes, 1% Stannous Fluoride for 5 minutes and 1mg/20ml Doxycycline soltn. for 5 minutes

Obturate with GP

Avulsion

Injured socket Shouldn’t be debrided Clot shouldn’t be disturbed Gentle irrigation with saline Immobilization period: Splinting for 2-3 weeks Endodontic treatment: Tooth with open apex: no endodontic Rx Tooth with closed apex: within 14 days with

calcium hydroxide upto 9-12 months Periodic follow up with x rays, vitality tests and

color changes upto 2 years.

Emergency management outside surgery

Wash the tooth gently with water Avoid touching root Reimplant tooth immediately Bite on a handkerchief to hold the tooth in

place If unable to reimplant tooth, should put in the

saline / milk

Avulsion of teethIndicators of poor prognosis Extra alveolar time > 60 minutes Undesirable storage medium e.g. tap water Improper handling of root surface

Prevention of dentoalveolar injuries

Educate and empower the dental team to provide first aid care

Encourage the use of custom mouth guards during contact sports

Thank You

!for not walking out

Dentoalveolar Injury Duration of Immobilization

Mobile Tooth 7-10 Days

Tooth displacement 2-3 Weeks

Root fracture 2-4 Months

Replanted tooth(mature) 7-10 Days

Replanted tooth (immature) 3-4 Weeks