A Road to Managing Dental Trauma with Predictable Results

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Dental trauma can range from minor enamel injuries to significant loss of teeth and hard and soft tissues. When faced with such emergencies, the clinician must consider
surgical, restorative, endodontic, and periodontal implications and make quick decisions on a treatment that can lead to the best long term result. In this presentation,
Dr. H. Ryan Kazemi will review various types of dental injuries and a simplified map to choosing the most appropriate treatment quickly and easily. In addition, he will discuss complicating factors and treatment concepts.

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A Road to Managing Dental Trauma with Predictable Results

  1. 1. a road map to managing dental trauma! with predictable outcomes h. ryan kazemi, dmd! oral and maxillofacial surgeon! bethesda, MD
  2. 2. to view this presentation facialart.com/presentations
  3. 3. academyforsportsdentistry.org join
  4. 4. common causes falls playground accident abuse bicycle mva assaults altercations athletic injuries
  5. 5. predisposing factors abnormal occlusions overjet > 4 mm labially inclined incisors lip in competence short upper lip mouth breathing
  6. 6. mechanism of injury timing bleeding? loc? history
  7. 7. account for all teeth tissue teeth position lacerations examination teeth! mobilities extent of! injury
  8. 8. alveolar bone embedded FB submandibular! duct parotid duct examination FOM teeth! fractures tongue nerves vessels facial! wounds facial! fractures
  9. 9. vitality test! - short term! - long term examination- teeth percussion! - pain ! —> injury to periodontal ligament! - sound —> dull (subluxated) or hard metallic (locked) teeth! color day 0 day 28 2 months 3 months 0 29.4% 82.35% 94.11% positive responsiveness in pulp tests
  10. 10. panorex radiographs periapical CBCT root fractures degree of extrusion or intrusion periodontal disease root development size of pulp chamber & canal jaw fractures tooth fragments caries
  11. 11. oral! surgeon team communication endodontist restorative! dentist
  12. 12. hard dental tissue & pulp periodontal! tissue supporting! bone gingiva or oral mucosa
  13. 13. hard dental tissue & pulp periodontal! tissue supporting! bone gingiva or oral mucosa crown infraction! uncomplicated crown fracture! complicated crown fracture! uncomplicated crown-root fracture! complicated crown-root fracture! root fracture
  14. 14. hard dental tissue & pulp impact to only enamel! transillumination for dx! upper incisor labial aspect! —> no treatment! vitality check & f/u! if non vital at time of exam, observe crown infraction
  15. 15. hard dental tissue & pulp enameloplasty! composite restoration crown fracture uncomplicated- enamel only
  16. 16. hard dental tissue & pulp seal dentin tubules! promote secondary dentin deposition! calcium hydroxide liner over dentin and composite restoration! monitor vitality crown fracture uncomplicated- enamel & dentin glass ionomer CaOH2 solubility in water —> dissolution
  17. 17. hard dental tissue & pulp enamel & dentin with exposure of pulp! ! treatment options:! pulp capping! partial pulpotomy! endodontic treatment crown fracture complicated- enamel & dentin with exposure of pulp
  18. 18. hard dental tissue & pulp tooth is sound & small exposure! ! ! pulp capping! (CH or MTA) crown fracture complicated- enamel & dentin with exposure of pulp
  19. 19. MTA- mineral trioxide aggregate! •forms CH that releases ca ions for cell attachment and proliferation! •creates an antibacterial environment with its alkaline PH! •modulated cytokine production! •encourages differentiation and migration of hard tissue producing cells! •forms hydroxyapatite on MTA surface and provides a biological seal Pitt-Ford and Patel: Most pulps capped with MTA were free of inflammation and showed calcified bridge after 5 months
  20. 20. hard dental tissue & pulp ! immature teeth with open apex! ! ! cervical pulpotomy! (MTA / CH) crown fracture complicated- enamel & dentin with exposure of pulp 2-4 mm most require pulpectomy after root development is completed
  21. 21. pulpotomy & capping MTA or Biodentine courtesy: Dr. Pirooz Zia
  22. 22. Biodentine™: a dentin substitute indicated for use in:! ! crown for temporary enamel restorations! permanent dentin restorations! deep or large carious lesions! deep cervical or radicular lesions! pulp capping or pulpotomy! used in the root for root and furcation perforations! internal and external resorptions! apexification! retrograde surgical filling. biodentine! bioactive dentin substitute
  23. 23. sets in 10 - 12 minutes! ! natural micro mechanical anchorage for excellent sealing properties without surface preparation.! ! similar mechanical properties and mechanical behavior as human dentin.! ! 3.5mm aluminum radiopacity for easy short and long term follow-up. biodentine! bioactive dentin substitute
  24. 24. hard dental tissue & pulp ! mature teeth with closed apex! ! ! pulpectomy & endodontic tx crown fracture complicated- enamel & dentin with exposure of pulp
  25. 25. hard dental tissue & pulp treatment depending on amount of root remaining! primary teeth —> extract! permanent teeth —>! > extract: too apical / vertical! > rct / ortho eruption! > rct and submerge root! > extraction / site graft! > extraction / immed. implant crown-root fractures uncomplicated (no pulp exposure)
  26. 26. uncomplicated! crown fracture uncomplicated! crown root fracture restored extracted
  27. 27. extraction with no grafting per patient 3 months
  28. 28. loss of buccal plate
  29. 29. 1!! graft
  30. 30. 6 months
  31. 31. 2!! implant
  32. 32. 3!! provisional! for 3 m 4!! final
  33. 33. hard dental tissue & pulp crown-root fractures complicated (pulp exposure) treatment depending on amount of root remaining! primary teeth —> extract! permanent teeth —>! > extract: too apical / vertical! > rct / ortho eruption! > rct and submerge root! > extraction / site graft! > extraction / immed. implant
  34. 34. no bone no implant
  35. 35. hard dental tissue & pulp 75% involve centrals! 40% with alveolar bone fx! primary teeth —> if no mobility, may preserve and allow normal exfoliation. If mobile, then extract root fractures
  36. 36. hard dental tissue & pulp permanent teeth! apical third level! ! no mobility- prognosis good with minimal treatment.! coronal aspect may remain vital and no endo treatment may be necessary. root fractures
  37. 37. hard dental tissue & pulp root fractures permanent teeth! mid-root level! ! may have fair prognosis! needs splinting: 2-3 month! check vitality continually! resorption in 60% within 1y! ! >> immediate implant / graft! >> site graft / delayed implant
  38. 38. hard dental tissue & pulp root fractures permanent teeth! high-root level! ! poor prognosis! atraumatic extraction! ! >> immediate implant / graft! >> site graft / delayed implant
  39. 39. healing by ‘calcific callus’ courtesy: Dr. Pirooz Zia
  40. 40. is buccal! bone intact?
  41. 41. buccal bone intact
  42. 42. tooth fracture! (adult) above bone at bone below bone no pulp exposure pulp exposure minor! fracture sig! fracture buccal bone no buccal bone restore pulpectomy restore crown length or ortho eruption treat same as below bone fracture extract! graft implant extract! implant! graft
  43. 43. hard dental tissue & pulp periodontal! tissue supporting! bone gingiva or oral mucosa concussion! subluxation (loosening)! intrusive luxation (central dislocation)! extrusive luxation (partial avulsion)! lateral luxation! retained root fracture! exarticulation (complete avulsion)
  44. 44. periodontal! tissue tooth is tender to touch! no mobility! percussion sensitive! no treatment! check vitality later as necrosis can develop in several weeks to months concussion
  45. 45. periodontal! tissue bleeding is common! percussion sensitive! positive mobility! treatment: non-rigid splint for 7-10 days! monitor for pulp complications subluxation
  46. 46. periodontal! tissue compression into socket! impaction to complete disappearance in alveolus! significant damage to pdl! high incidence of external resorption, pulp necrosis, marginal bone loss! percussion- dull metallic intrusive luxation
  47. 47. periodontal! tissue treatment options! ! re-erupt if immature tooth! immediate repositioning (high resorption / bone loss)! low-force ortho reposition! extraction! primary teeth —> extract intrusive luxation
  48. 48. periodontal! tissue apex displaced out of socket with NV rupture! pdl space is widened! dull percussion sound! primary tooth —> extract extrusive luxation
  49. 49. periodontal! tissue treatment- permanent teeth! manipulate into socket! nonrigid splint 1-2 weeks! ! >> within few hours of injury! >> after 33 hours- increased rate of pulp necrosis extrusive luxation
  50. 50. periodontal! tissue often with bone fracture! reposition & compress! splint 2-8 weeks! endo tx lateral luxation
  51. 51. incomplete root formation! ! endo treatment may not be necessary
  52. 52. endodontic consult
  53. 53. periodontal! tissue fracture of root at cervical or deeper! treatments:! >> extract / implant / graft! >> extract / graft! >> endo / submerge! >> endo / ortho eruption retained root fracture
  54. 54. periodontal! tissue extract, implant, graft! if! buccal bone intact! gingival margin is ideal! can achieve primary implant stability! tissue not traumatized / infected retained root fracture
  55. 55. periodontal! tissue extract & graft! if! buccal bone is not intact! bone loss has occurred! primary implant stability can not be achieved! tissue is traumatized retained root fracture
  56. 56. periodontal! tissue rct & submerge! (preserve tissue)! if! no bone fracture! patient growth incomplete! adult patient with soft tissue loss (goal is to regenerate soft tissue) retained root fracture
  57. 57. periodontal! tissue rct & ortho eruption! (to augment tissue)! if ! no bone fracture! soft tissue is apical to adjacent gingival margin! vertical bone loss (good bone level on adjacent tooth) retained root fracture
  58. 58. best tissue preservation! ! immediate implant! bone graft in gap! immediate provisional to support soft tissue
  59. 59. periodontal! tissue 15% of permanent teeth! 7-13% of primary teeth! maxillary incisors! most common age 7-10! treatment goal: maintain vitality of cells (pulp & pdl) avulsion (exarticulation)
  60. 60. periodontal! tissue time avulsion (exarticulation) within! 30 minutes
  61. 61. periodontal! tissue other factors for success! ! width & length of root canal! stage of root development! type of storage medium! degree of oral trauma avulsion (exarticulation)
  62. 62. periodontal! tissue treatment options! ! re-implantation! immediate implant / graft! site graft / delayed implant avulsion (exarticulation)
  63. 63. periodontal! tissue Andreasen & Hjorting-Hansen! ! after 2 years or more, 90% of teeth re-implanted within 30 minutes exhibit no discernible resorption of roots! 95% resorption if > 2 hours avulsion (exarticulation) re-implantation
  64. 64. resorption in avulsion cases courtesy: Dr. Pirooz Zia
  65. 65. periodontal! tissue early re-implantation is key! instructions if at site of injury! 1. inspect tooth for debris! 2. hold only by crown! 3. cleanse with milk or saliva! 4. put tooth into socket! 5. hold with light pressure! 6. come to office avulsion (exarticulation)
  66. 66. periodontal! tissue storage! ! buccal vestibule! under tongue! milk! hanks balanced salt solution! NO TAP WATER avulsion (exarticulation)
  67. 67. periodontal! tissue avulsion (exarticulation) medium ph osmolarity saline 7.0 295 tap water 7.5 12 salive 6.3 110-120 viaspan 7.4 320 gatorade 3.0 280-360 milk 6.75 275 coconut water 6.2 288 blood plasma 7.2-7.4 290 hank’s bss 7.0 270-290 hypotonic
  68. 68. periodontal! tissue assessment! ! history! type of injury! how long ago?! ‘dry time’! exam site! accountability of teeth! type of storage medium avulsion (exarticulation) re-implantation
  69. 69. periodontal! tissue primary teeth! ! do not! re-implant avulsion (exarticulation) re-implantation
  70. 70. periodontal! tissue conditions before! re-implantation! ! tooth without perio disease! socket intact! no ortho issues- crowding! less than 30 minutes! stage of root development (incomplete >> within 2 h) avulsion (exarticulation) re-implantation
  71. 71. periodontal! tissue treatment- closed apex! (dry time < 30 min; tooth in medium 20 min to 6 h)! ! irrigate tooth if with debris! clean coagulum with saline! re-implant and press! splint while patient in occlusion! nonrigid splint for 1-2 wk! if bone fx —> splint 3-4 wk! suture lacerations avulsion (exarticulation) re-implantation
  72. 72. periodontal! tissue treatment- closed apex! (dry time > 60 min)! ! irrigate tooth if with debris! clean coagulum with saline! immerse tooth in sodium fluoride solution- 5 minutes! re-implant and press! keep patient in occlusion! nonrigid splint for 4-6 wks avulsion (exarticulation) re-implantation
  73. 73. periodontal! tissue Post treatment- closed apex! ! doxycycline or penicillin vk for 7 days! chlorhexidine rinse for 1 week! assess tetanus vaccination! soft diet 2 weeks! initiate pulpectomy within 7-14 days avulsion (exarticulation) re-implantation
  74. 74. periodontal! tissue treatment- open apex! (dry time < 30 min; tooth in medium 20 min to 6 h)! ! irrigate tooth if with debris! tooth in doxycycline (100 mg / 20 cc saline) for 5 minutes! clean coagulum with saline! re-implant and press! keep patient in occlusion! nonrigid splint for 1-2 wk avulsion (exarticulation) re-implantation
  75. 75. periodontal! tissue treatment- open apex! (dry time > 60 min)! ! reimplantation usually not indicated (per american association of endodontics)! may follow same protocol as closed apex (McIntyre, Lee, Trope- permanent tooth replantation following avulsion- pediatric dent 31:137, 2009) avulsion (exarticulation) re-implantation
  76. 76. periodontal! tissue post treatment- open apex! ! doxycycline or penicillin vk for 7 days! chlorhexidine rinse for 1 week! assess tetanus vaccination! soft diet 2 weeks! monitor every 4 weeks + pulp test + X-rays! apexogenesis over next 12-18 months? avulsion (exarticulation) re-implantation
  77. 77. periodontal! tissue follow-up procedures avulsion (exarticulation) re-implantation time closed apex open apex 1-2 weeks initiate endo treatment endo or monitor for vascularity 2-3 weeks clinical & x-ray eval clinical & x-ray eval 3-4 weeks clinical & x-ray eval clinical & x-ray eval 6-8 weeks clinical & x-ray eval clinical & x-ray eval 6 months clinical & x-ray eval clinical & x-ray eval 1 year clinical & x-ray eval clinical & x-ray eval yearly for 5 years clinical & x-ray eval clinical & x-ray eval
  78. 78. hard dental tissue & pulp periodontal! tissue supporting! bone gingiva or oral mucosa comminution of the alveolar socket! fracture of the alveolar socket wall! fracture of the alveolar process! fractures of the mandible or maxilla
  79. 79. supporting! bone reduce with digital manipulation! if tooth can not be preserved, extract and graft site to preserve tissue comminution- alveolar bone
  80. 80. supporting! bone reduce! rigid splint for 4 weeks! primary teeth- may not need any treatment fracture of socket wall
  81. 81. supporting! bone closed reduction! open reduction if segment is notably displaced! stabilization for 4 weeks! check teeth vitality and monitor fracture- alveolar process
  82. 82. hard dental tissue & pulp periodontal! tissue supporting! bone gingiva or oral mucosa laceration of gingiva or oral mucosa! contusion of gingiva or oral mucosa! abrasion of gingiva or oral mucosa
  83. 83. gingiva or oral mucosa management! ! debridement! irrigate NS! re-approximate! primary closure lacerations
  84. 84. splinting! techniques
  85. 85. splinting- acid etch resin splint light cured preferred to allow time! bridge: resin or wire (28g)
  86. 86. splinting- semirigid splint resin with waxed dental floss, suture, flexible braided ortho wire or monofilament nylon line! kevlar! fiber splints (fiber force)- use with protemp material for more movement! flexible wire composite splints! titanium splints
  87. 87. splinting- semirigid splint fiber splints
  88. 88. splinting- semirigid splint
  89. 89. hard dental tissue & pulp periodontal! tissue supporting! bone gingiva or oral mucosa multi-system injuries • tooth avulsion! • fracture alveolar bone! • extrusive luxation! • lacerations! • crown fractures
  90. 90. surgical order! ! inside-out! downward-up 1. extract fractured teeth! 2. debridement of avulsion site! 3. reduce dentoalveolar fracture segment! 4. splint teeth / alveolar segment! 5. graft extraction / avulsion site! 6. closure of lacerations
  91. 91. thank you facialart.com/presentations

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