the traumatic injuries of permanent teeth and complex therapy dr. katalin déri semmelweis egyetem...
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The traumatic injuries of permanent teeth and complex therapy
Dr. Katalin Déri
Semmelweis EgyetemDepartment of Pedodontics and Orthodontics
Risk Risk
• Angle II/1
• Predisposing factors:
overjet
protrusion of upper incisors
insufficient lip closure
InjuriesInjuriesSport related - 1.5% -3.5%Sport related - 1.5% -3.5%
InjuriesInjuriesPlayground - schoolPlayground - school
InjuriesInjuriesFightsFights
InjuriesInjuriesCar accidentCar accident
Age distributionAge distributionTherapeutic significance
8-13 years the highest incidence
• Peak at the age of 10
SexSex
0
25
50
75
100
Boys - 153 Girls - 59 All - 212
Clinical data
0,0 22,5 45,0 67,5 90,0
Upper central incisors- 85.39%
Upper lateral incisors -10.06%
Lower central incisors- 3.57%
Lower lateral incisors -0.97%
Incidence of injured teeth in %Incidence of injured teeth in %
AnamnesisAnamnesis general anamnesisgeneral anamnesis
circumstances of injurycircumstances of injury
black-out, amnesia, headache, black-out, amnesia, headache, nausea, vomitnausea, vomit
previous injuries : consequences, previous injuries : consequences, complicationscomplications
dental anamnesisdental anamnesis
Most important Most important questionsquestions
When?When? Time past between the injury and the treatmentTime past between the injury and the treatment
Where?Where? Risk of infectionRisk of infection
How?How? Mechanism of the injury, polytraumaMechanism of the injury, polytrauma
0
9
18
26
35
0 day 1 day 2 days 5 days 1 week 2 weeks 3 weeks 4 weeks 6 weeks 2 months 6 months 1 year 3 years
Time elapsed after injury
Clinical examinationClinical examination
Extraoral examinationExtraoral examination
Intraoral examinationIntraoral examination
Photo documentationPhoto documentation
X-rayX-ray
Type of injuriesType of injuries
• Traumatic injuries involving:Traumatic injuries involving:
the permanent teeththe permanent teeth
the alveolar bonethe alveolar bone
the soft tissuesthe soft tissues
Classification of dental injuriesClassification of dental injuries(International Association of Dental Traumatology, 2001)(International Association of Dental Traumatology, 2001)
1.1. Coronal fractureCoronal fracture
2.2. Coronal and root fractureCoronal and root fracture
3.3. Root fractureRoot fracture
4.4. Fracture of processus alveolarisFracture of processus alveolaris
5.5. Luxations and avulsionLuxations and avulsion• (contusion, subluxation, lateral luxation, extrusion, intrusion, (contusion, subluxation, lateral luxation, extrusion, intrusion,
avulsion)avulsion)
Classification of dental Classification of dental injuriesinjuriesPedodontics and Orthodontics textbookPedodontics and Orthodontics textbook1.1. Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis
2.2. Luxatio partialis dentis Luxatio partialis dentis permanentispermanentis
3.3. IntrusioIntrusio
4.4. Fractura coronae dentis Fractura coronae dentis permanentispermanentis
5.5. Fractura radicis dentis Fractura radicis dentis permanentispermanentis
Avulsion Avulsion : complete displacement of a tooth : complete displacement of a tooth
Luxatio totalis dentis Luxatio totalis dentis permanentispermanentis
Luxatio partialis dentis Luxatio partialis dentis permanentispermanentis
loosening of the tooth or a loosening of the tooth or a partial displacement of the partial displacement of the tooth out of its sockettooth out of its socket
a. subluxation
b. lateral luxation
c. extrusion
a. b. a. b. c. c.
Luxatio partialis dentis Luxatio partialis dentis permanentispermanentisDisplacementDisplacement
• subluxation:
• sensitive to touch
• slightly mobile
• no displacement
• bleeding
• extrusion:
• axial (and lateral) displacement
• mobile
clinical examination
Luxatio partialis dentis Luxatio partialis dentis permanentispermanentisDisplacementDisplacement
• lateral luxation:
• lateral displacement
• locked in the alveolar bone
• no mobility
• not sensitive
• ankylotic signs
Luxatio partialis dentis Luxatio partialis dentis permanentis - luxatio permanentis - luxatio lateralislateralis
3.3. Intrusion Intrusion
displacement of the displacement of the tooth into the tooth into the alveolar bonealveolar bone
(axial dislocation)(axial dislocation)
Fractura coronae dentis Fractura coronae dentis permanentispermanentis Types of coronal fracture
• Most frequent injury
enamel onlyenamel only enamel and dentineenamel and dentineenamel and dentineenamel and dentinewith the pulp exposedwith the pulp exposed
Fractura coronae dentis Fractura coronae dentis permanentispermanentis
fracture without fracture without complicationcomplication
complicated fracture (with complicated fracture (with pulp exposition)pulp exposition)
Fractura radicis dentis Fractura radicis dentis permanentispermanentisRoot fracture
Fractura radicis dentis Fractura radicis dentis permanentispermanentis
1.1. cervical thirdcervical third
2.2. middle thirdmiddle third
3.3. apical thirdapical third
+1.+1. axial fractureaxial fracture
Complex therapyComplex therapy
Treatment of the injuries: AvulsionTreatment of the injuries: Avulsion1. 1. Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis
• Actions out of surgery:
Suitable storage: in wet agent
1. physiological saline
2. saliva
3. milk
4. Dentosafe-Zahnrettungsbox
Treatment of the injuries: Treatment of the injuries: AvulsionAvulsion
Aim: replantation as soon as possible• the ligaments and cells loose their vitality after 1
hour
1. Preparation of the tooth and the alveolar socket
2. Replantation
3. Stabilization – using the neighboring• teeth for splinting
• acrylic splint
• composite bonding with orthodontic archwire
• brackets
4. Woundtreatment (debridement, suturing, hemorrhage control)
Prognosis: max. 1 hour extra-alveolary
Fixation: closed apex - 7-10 days
• open apex - 2 weeks (neurovascular reanastomosis)
In mature tooth with closed apex, or in immature tooth with open apex but time elapsed > 30 min.
• In 1 week root canal treatment - Ca(OH)2 should be placed
• to prevent the initiation of inflammatory root resorption
Treatment of the injuries: Avulsion1. Luxatio totalis dentis permanentis
Instructions1. pulpy diet
2. toothcleaning with soft toothbrush
3. 0,1 % chlor-hexidine
Supplementary therapy1. Antibiotic treatment
2. Tetanus (immunization status?)
Treatment of the injuries: AvulsionTreatment of the injuries: Avulsion Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis
If replantation is not possible ( e.g.: in the case of loss of the tooth )
1. Temporary solution:
• acrylic bridge
• orthodontic appliance (with an acrylic tooth)
2. Final solution:
• orthodontic treatment
• implantation
• combined treatment
Treatment of the injuries: AvulsionTreatment of the injuries: Avulsion Luxatio totalis dentis permanentisLuxatio totalis dentis permanentis
Temporary solution
Healing after replantationHealing after replantation
regeneration of the gingiva
revascularisation of the ligaments
renewal of the Sharpey ligaments
open apex - revascularisation and reinnervation
• Cave: high bacterial contamination- healing is limited or impossible
Treatment of the injuries: Treatment of the injuries: DisplacementDisplacement2. 2. Luxatio partialis dentis permanentisLuxatio partialis dentis permanentis
• Subluxation
•no need to splint for stabilization
•observation - x-rax (1 year)
•root canal treatment (pathological sign)
Treatment of the injuries: Treatment of the injuries: DisplacementDisplacement2. 2. Luxatio partialis dentis permanentisLuxatio partialis dentis permanentis
• lateral luxation
• extrusion
1. reponation ( following the injury )
• fixation for 2-3 weeks
2. later : orthodontic reposition
3. root canal treatment ( in case of the tooth with closed apex )
Treatment of the injuries:Treatment of the injuries: 3. Intrusion3. Intrusion
Open apex : there is a chance of Open apex : there is a chance of spontaneous re-eruption spontaneous re-eruption
Closed apex :Closed apex :
1.1. surgical or orthodontic repositionsurgical or orthodontic reposition
2.2. splintsplint
3.3. root canal treatmentroot canal treatment
Treatment of the injuries:Treatment of the injuries: 3. Intrusion3. Intrusion
orthodontic or surgical repositionorthodontic or surgical reposition
Treatment of the injuries:Treatment of the injuries:Fractura coronae dentis Fractura coronae dentis permanentispermanentis
The treatment of The treatment of crown fracture crown fracture depends on which depends on which third of the crown third of the crown is injuredis injured
Treatment of the injuries:Fractura coronae dentis permanentis
a. Enamel injuries:
1. Minor enamel fractures : polishing, fluoride solution ELMEX
2. Larger enamel fractures (1-2mm or more): composite restoration
Treatment of the injuries:Treatment of the injuries:Fractura coronae dentis permanentisFractura coronae dentis permanentis
b. Enamel – dentine injuries without pulp exposition - immature tooth
1. Calcium hydroxide liner
2. Temporary crown ( celluloid, acrylic ) – 1 year (GIC) – protective covering
3. X – ray control
4. Final restoration (closed apex)
b. Enamel – dentine injuries without pulp exposition -mature tooth
• Final restoration
Fractura coronae dentis Fractura coronae dentis permanentis temporary crown - permanentis temporary crown - incisal restorationincisal restoration
Rebonding of fractured crownRebonding of fractured crown
Treatment of the injuries:Treatment of the injuries:Fractura coronae dentis Fractura coronae dentis permanentispermanentis
c. Pulp exposition• Important:
1. size of the pulp exposure
2. time between the injury and the treatment
3. root development
Treatment of the coronal fracture in case of pulp exposition
exposition timeroot
development
small 1 – 2 hours
open or closed apex
direct pulp capping
larger than1 mm more, than 3 hours open apex pulpotomy
x-large long time closed apex pulpectomy
Direct pulpcapping - Ca(OH)2/ MTA
Pulpotomy – partial or total elimination of coronal pulp tissue
sterile round steel bur or excavator
haemorrhage control
Ca(OH)2/MTA + GIC /polikarboxilate cement
Pulpectomy – elimination of all the pulp tissue -
Ca(OH)2
Final root canal filling (closed apex)
Regular re-call!!!
Treatment of the injuries:Treatment of the injuries: Root fracture Root fracturea. fracture in cervical third:
• Worst prognosis
1. Elimination of coronal part
• root canal treatment
• orthodontic extrusion
• restoration
2. Extraction + implantation
b. fracture in middle third:
1. Reposition of coronal part
2. Splint ( 1-2 months )
3. Root canal filling
4. Transradicular fixation can be an option (silver point)
c. Fracture in apical third
• observation,
• In case of necrosis - In case of necrosis - Ca(OH)2, Ca(OH)2,
• - Final root canal filling after healing- Final root canal filling after healing
• If coronal part is dislocated If coronal part is dislocated
• - reposition and fixation for 1 month - reposition and fixation for 1 month
Treatment of the injuries:Treatment of the injuries: Root fracture Root fracture
Fractura radicis dentis Fractura radicis dentis permanentis Healingpermanentis Healing
Soft tissue hard tissue
granule tissue
Possible consequences of Possible consequences of traumatic injuriestraumatic injuries
Peripheral (external) root resorptionPeripheral (external) root resorption
• Trauma with damage to the periodontal structures, pulp may not become involved
MacrophaMacrophagesges , osteoclast , osteoclastss
In cases of severe trauma, with some degree of displacement of the tooth
Diagnosis – 1 week after injuryDiagnosis – 1 week after injury
Possible consequences of Possible consequences of traumatic injuriestraumatic injuries
Inflammatory root resorptionInflammatory root resorption
Trauma with damage to the periodontal AND pulp Trauma with damage to the periodontal AND pulp tissuestissues
BaBacterial toxinescterial toxines
Rapid, progressive Rapid, progressive
Intrusion, replantationIntrusion, replantation
Diagnosis – 2-4 weeks after the injuryDiagnosis – 2-4 weeks after the injury
Severe cases – total root resorption in 1 monthSevere cases – total root resorption in 1 month
Possible consequences of Possible consequences of traumatic injuriestraumatic injuries
Ankylosis injury to the periodontal ligament and subsequent
inflammation
associated with invasion by osteoclastic cells
cement resorption – repaired by bone regeneration
mechanical lock / fusion between alveolar bone and root surface
Diagnosis:
Radiological : 2 months
Clinical: 1month – typical ankylotic sound for percussion
Possible consequences of Possible consequences of traumatic injuriestraumatic injuries
• Pulpal necrosis
• signs:
• discoloration
• no response for vitality test
• sensitive for percussion
• periapical laesion
• if 2 of them presents - root canal treatment –Ca(OH)2
• Obliteration
• Calcific metamorphosis of the dental pulp ( progressive canal calcification / dystrophic calcification)
• Although the radiograph may give the illusion of complete obliteration, an extremely fine root canal and remnants of the pulp will persist
• yellowish opaque colour of the crown
• rct can be done if necessary
Possible consequences of Possible consequences of traumatic injuriestraumatic injuries
PreventionPrevention
• Protectors
• Requirements:
cover of the teeth, gingiva, alveolar bone
do not influence the relation of jaws
do not disturb breathing
resistant and durable
hygienic
possible application on fixed orthodontic appliances
PreventionPrevention
• Mouthguard:
• Confectional
• Prefabricated
• Individual
Education!!!Education!!!
Warning - Child Warning - Child abuse!!!!abuse!!!!
Signs:Signs:
• time elapsed after the injury: weeks or monthstime elapsed after the injury: weeks or months• confused, frightened childconfused, frightened child• parents and child don’t tell the same storyparents and child don’t tell the same story• anamnesis is not in accordance with theanamnesis is not in accordance with the
result of clinical examinationresult of clinical examination• recurring injuriesrecurring injuries
Case reportCase report• 20 20 years old boyyears old boy
• Street fightStreet fight
• oral surgery ambulance – ‘’dental splint’’oral surgery ambulance – ‘’dental splint’’
• orthodontic clinic – 3 days afterorthodontic clinic – 3 days after
• still very mobile upper front teethstill very mobile upper front teeth
RadiographsRadiographs
13 13 root fracture in middle thirdroot fracture in middle third13, 12, 11, 21, 22, 23 13, 12, 11, 21, 22, 23 extrusionextrusion, , palatal dislocationpalatal dislocationall upper anterior teeth are very mobileall upper anterior teeth are very mobile
except except 13, all 13, all upper upper anterior anterior teeth teeth show show vitalityvitality
Treatment planTreatment plan• Slow reposition of dislocated teeth with fixed Slow reposition of dislocated teeth with fixed
orthodontic appliance (1 year )orthodontic appliance (1 year )
• 13 13 rct ; transradicular fixation (silver point) rct ; transradicular fixation (silver point) /temporary//temporary/
• Frequent control of all the upper anterior teethFrequent control of all the upper anterior teeth
• first patological sign - rctfirst patological sign - rct
• After debonding – fix and removable retainerAfter debonding – fix and removable retainer
TreatmenTreatmentt
13 transradicular fixatio13 transradicular fixationn((silver point and endomethasonsilver point and endomethason))
after treatmentafter treatment 22 months later months later
Pulpal necrosis of Pulpal necrosis of 22 22
Needle Needle controlcontrol
RCF controlRCF controlSign of rootSign of root resorptio resorptionn
Result of Result of treatmenttreatment
Thank you for Thank you for youryour kind kind attention!attention!