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Traumatic injuries

TRAUMATIC DENTAL INJURIES ARE THOSE INVOLVING THE TEETH ,THE ALVEOLAR PORTION OF MAXILLA AND MANDIBLE AND THE ADJACENT SOFT TISSUES.

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Traumatic injuries

  1. 1. BY- Dr. Prathamesh Fulsundar
  2. 2. TRAUMATIC DENTAL INJURIES TDI -ARE THOSE INVOLVING THE TEETH ,THE ALVEOLAR PORTION OF MAXILLA AND MANDIBLE AND THE ADJACENT SOFT TISSUES
  3. 3. ALARMING STATISTICS • Constitute 5-9% of total injuries • Prevalence of TDI in primary dentition -11-30% • Prevalence of TDI n permanent dentition -5-30% • Boys to girls ~ 2:1 • Age - 6-18 years • Teeth involved: 11and 21 -37% 31 and 41 -18% 32 and 42 -6% 12 and 22 -3%
  4. 4. Etiology • Falls due to incomplete coordination. • Sports activities. • Road accidents. • Domestic violence and abuse • Fights and assaults • Mental retardation, epilepsy. • Developmental defect in enamel and dentine. • Class II Division 1 Malocclusion • Overjet 3-6mm or more
  5. 5. Peoples’ attitude towards TDI • Mostly affect milk teeth hence not an issue • Little knowledge regarding different types of injury • Go and see family doctor in such injury • Dentist charge a lot of money • Knocked out teeth is a waste • If stored –wrap in tissue or cotton • No psychological impact on children of fractured teeth
  6. 6. INJURIES TO THE HARD TISSUES AND PULP Enamel infraction Enamel fracture Enamel dentin fracture Complicated crown fracture Uncomplicated crown-root fracture Complicated crown- root fracture Root fracture INJURIES TO PERIODONTAL TISSUES Concusion Subluxation Extrusive luxation Lateral luxation Intrusive luxation Avulsion INJURIES TO SUPPORTING BONE Comminution of jaws alveolar socket wall Fractures of jaws alveolar socket wall Fracture of jaws alveolar process Fracture of mandible or maxilla INJURIES TO GINGIVA AND ORAL MUCOSA Laceration Contusion Abrasion INTERNATIONAL CLASSIFICATION OF DISEASES(1992)
  7. 7. EMERGENCY MANAGEMENT AT THE SITE OF INJURY FRACTURED TOOTH Look for the broken piece Hold the crown and not the root Place the piece in a cup with patient’s saliva or cold milk NEVER PUT THE TOOTH IN WATER Take the piece and visit dentist immediately MOBILE/DISPLACED TOOTH Ask the patient to gently close the mouth and bring the teeth together slowly and carefully If the displacement is minor the tooth will move to the normal position If the patient cannot bite down do not force closure See the dentist immediately KNOCKED OUT TOOTH Look for the tooth Hold the crown only ,do not touch the root Rinse the permanent tooth in tap water for only 10 seconds Put it back in socket If cannot ,then place in saliva or cold milk NEVER PUT THE TOOTH IN WATER Go to the dentist immediately
  8. 8. MANAGEMENT OF TDI INJURIES TO THE HARD TISSUES AND PULP ENAMEL INFRACTION ENAMEL FRACTURE ENAMEL DENTIN FRACTURE COMPLICATED CROWN FRACTURE In case of marked infractions, etching and sealing with resin to prevent discoloration of the infraction lines. Otherwise, no treatment is necessary. Contouring or restoration with composite resin depending on the extent and location of the fracture. •If a tooth fragment is available, it can be bonded to the tooth. • Otherwise perform a provisional treatment by covering the exposed dentin with glass- Ionomer or a more permanent restoration using a bonding agent and composite resin, or other accepted dental restorative materials • If the exposed dentin is within 0.5mm ofthe pulp (pink, no bleeding) place calcium hydroxide base and cover with a material such as a glass ionomer. •In young patients with immature, still developing teeth, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. Also, this treatment is the choice in young patients with completely formed teeth. ● Calcium hydroxide is a suitable material to be placed on the pulp wound in such procedures. ● In patients with mature apical development, root canal treatment is usually the treatment of choice, although pulp capping or partial pulpotomy also may be selected. ● If tooth fragment is available, it can be bonded to the tooth. ● Future treatment for the fractured crown may be restoration with other accepted dental restorative materials.
  9. 9. INJURIES TO THE HARD TISSUES AND PULP UNCOMPLICATED CROWN- ROOT FRACTURE COMPLICATED CROWN-ROOT FRACTURE ROOT FRACTURE Emergency treatment ● As an emergency treatment a temporary stabilization of the loose segment to adjacent teeth can be performed until a definitive treatment plan is made. Emergency treatment ● As an emergency treatment a temporary stabilization of the loose segment to adjacent teeth. ● In patients with open apices, it is advantageous to preserve pulp vitality by a partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide compounds are suitable pulp capping materials. In patients with mature apical development, root canal treatment can be the treatment of choice. ● Reposition, if displaced, the coronal segment of the tooth as soon as possible. ● Check position radiographically. ● Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months). ● It is advisable to monitor healing for at least one year to determine pulpal status. ● If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth. Non-Emergency Treatment Alternatives ● Fragment removal and gingivectomy (sometimes ostectomy) Removal of the coronal fragment with subsequent endodontic treatment and restoration with a post- retained crown. This procedure should be preceded by a gingivectomy and sometimes ostectomy with osteoplasty. This treatment option is only indicated in crown-root fractures with palatal subgingival extension. ● Orthodontic extrusion of apical fragment Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown. ● Surgical extrusion Removal of the mobile fractured fragment with subsequent surgical repositioning of the root in a more coronal position. ●Root submergence An implant solution is planned, the root fragment may be left in situ. ●Extraction Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable in very deep crown-root fractures, the extreme being a vertical fracture
  10. 10. INJURIES TO PERIODONTAL TISSUES CONCUSION SUBLUXATION LATERAL LUXATION Crushing injury to apical vasculature and periodontal ligament with inflammatory edema and without abnormal loosening or displacement Injury to tooth supporting structure with abnormal loosening but without displacement of teeth clinically. Displacement of tooth in any direction other than axial ● No treatment is needed. ● Monitor pulpal condition for at least one year. Normally no treatment is needed, however a flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks. ● Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it into its original location. ● Stabilize the tooth for 4 weeks using a flexible splint. ● Monitor the pulpal condition. ● If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption.
  11. 11. INJURIES TO PERIODONTAL TISSUES EXTRUSIVE LUXATION INTRUSIVE LUXATION AVULSION ● Reposition the tooth by gently re-inserting It into the tooth socket. ● Stabilize the tooth for 2 weeks using a flexible splint. ● In mature teeth where pulp necrosis is anticipated or if several signs and symptoms indicate that the pulp of mature or immature teeth became necrotic, root canal treatment is indicated. Teeth with incomplete root formation ● Allow eruption without intervention ● If no movement within few weeks, initiate orthodontic repositioning. ● If tooth is intruded more than 7mm, reposition surgically or orthodontically. Teeth with complete root formation: ● Allow eruption without intervention if tooth intruded less than 3mm. If no movement after 2-4 weeks, reposition surgically or orthodontically before ankylosis can develop. ● If tooth is intruded 3-7 mm, reposition surgically or orthodontically. ● If tooth is intruded beyond 7mm, reposition surgically. ● The pulp will likely become necrotic in teeth with complete root formation. Root canal therapy using a temporary filling with calcium hydroxide is recommended and treatment should begin 2-3 weeks after repositioning. ● Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with a flexible splint for 4 weeks. •The tooth is placed in saline •If contaminated ,the root surface is cleansed with stream of saline •The socket is examined for evidence of fracture.The alveolus is also cleansed with a flow of saline to remove contaminated coagulum •Tooth to be reimplanted using slight digital pressure with light pressure. The reimplanted tooth should fit loosely in the alveolus •Suture gingival laceration •Apply splint for 1 week only as prolonged splinting of replanted tooth causes root resorption •Proper repositioning can now be evaluvated by the occlusion of tooth •Verify position radiographically •Tetanus prophylaxis is important •If apical foramen is closed then perform endodontic therapy after one week prior to removal of splint
  12. 12. Case I
  13. 13. Case II
  14. 14. Case III

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