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The traumatic injuries of permanent teeth and complex therapy Dr. Katalin Déri Semmelweis Egyetem Department of Pedodontics and Orthodontics.

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Presentation on theme: "The traumatic injuries of permanent teeth and complex therapy Dr. Katalin Déri Semmelweis Egyetem Department of Pedodontics and Orthodontics."— Presentation transcript:

1 The traumatic injuries of permanent teeth and complex therapy Dr. Katalin Déri Semmelweis Egyetem Department of Pedodontics and Orthodontics

2 Risk Angle II/1 Predisposing factors:   overjet   protrusion of upper incisors   insufficient lip closure

3 Injuries Sport related - 1.5% -3.5%

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6 Injuries Playground - school

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8 Injuries Fights

9 Injuries Car accident

10 Age distribution Therapeutic significance 8-13 years the highest incidence Peak at the age of 10

11 Sex

12 Incidence of injured teeth in %

13 Anamnesis  general anamnesis  circumstances of injury  black-out, amnesia, headache, nausea, vomit  previous injuries : consequences, complications  dental anamnesis

14 Most important questions  When?  Time past between the injury and the treatment  Where?  Risk of infection  How?  Mechanism of the injury, polytrauma

15

16 Clinical examination  Extraoral examination  Intraoral examination  Photo documentation  X-ray

17 Type of injuries Traumatic injuries involving: Traumatic injuries involving: the permanent teeth the permanent teeth the alveolar bone the alveolar bone the soft tissues the soft tissues

18 Classification of dental injuries (International Association of Dental Traumatology, 2001) 1. Coronal fracture 2. Coronal and root fracture 3. Root fracture 4. Fracture of processus alveolaris 5. Luxations and avulsion (contusion, subluxation, lateral luxation, extrusion, intrusion, avulsion) (contusion, subluxation, lateral luxation, extrusion, intrusion, avulsion)

19 Classification of dental injuries Pedodontics and Orthodontics textbook 1. Luxatio totalis dentis permanentis 2. Luxatio partialis dentis permanentis 3. Intrusio 4. Fractura coronae dentis permanentis 5. Fractura radicis dentis permanentis

20 Avulsion : complete displacement of a tooth Luxatio totalis dentis permanentis

21 Luxatio partialis dentis permanentis loosening of the tooth or a partial displacement of the tooth out of its socket loosening of the tooth or a partial displacement of the tooth out of its socket a. a. subluxation b. b. lateral luxation c. c. extrusion a. b. c. a. b. c.

22 Luxatio partialis dentis permanentis Displacement Luxatio partialis dentis permanentis Displacement subluxation: sensitive to touch slightly mobile no displacement bleeding extrusion: axial (and lateral) displacement mobile clinical examination

23 Luxatio partialis dentis permanentis Displacement lateral luxation: lateral displacement locked in the alveolar bone no mobility not sensitive ankylotic signs

24 Luxatio partialis dentis permanentis - luxatio lateralis

25 3. Intrusion displacement of the tooth into the alveolar bone displacement of the tooth into the alveolar bone (axial dislocation) (axial dislocation)

26 Fractura coronae dentis permanentis Fractura coronae dentis permanentis Types of coronal fracture Most frequent injury enamel only enamel and dentine with the pulp exposed

27 Fractura coronae dentis permanentis  fracture without complication  complicated fracture (with pulp exposition)

28 Fractura radicis dentis permanentis Root fracture

29 Fractura radicis dentis permanentis 1. cervical third 2. middle third 3. apical third +1.axial fracture

30 Complex therapy

31 Treatment of the injuries: Avulsion 1. Luxatio totalis dentis permanentis Actions out of surgery:   Suitable storage: in wet agent physiological saline saliva milk Dentosafe-Zahnrettungsbox

32 Treatment of the injuries: Avulsion Aim: replantation as soon as possible the ligaments and cells loose their vitality after 1 hour Preparation of the tooth and the alveolar socket Replantation Stabilization – using the neighboring teeth for splinting acrylic splint composite bonding with orthodontic archwire brackets Woundtreatment ( debridement, suturing, hemorrhage control)

33 Prognosis: max. 1 hour extra-alveolary Fixation: closed apex 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

34 Treatment of the injuries: Avulsion 1. Luxatio totalis dentis permanentis n n Instructions pulpy diet toothcleaning with soft toothbrush ,1 % chlor-hexidine   Supplementary therapy Antibiotic treatment Tetanus (immunization status?)

35 Treatment of the injuries: Avulsion Luxatio totalis dentis permanentis n n If replantation is not possible ( e.g.: in the case of loss of the tooth ) Temporary solution: acrylic bridge orthodontic appliance (with an acrylic tooth) Final solution: orthodontic treatment implantation combined treatment

36 Treatment of the injuries: Avulsion Luxatio totalis dentis permanentis Temporary solution

37 Healing 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

38 Treatment of the injuries: Displacement 2. Luxatio partialis dentis permanentis Subluxation no need to splint for stabilization observation - x-rax (1 year) root canal treatment (pathological sign)

39 Treatment of the injuries: Displacement 2. Luxatio partialis dentis permanentis lateral luxation extrusion reponation ( following the injury ) fixation for 2-3 weeks later : orthodontic reposition root canal treatment ( in case of the tooth with closed apex )

40 Treatment of the injuries: 3. Intrusion  Open apex : there is a chance of spontaneous re-eruption  Closed apex : 1. surgical or orthodontic reposition 2. splint 3. root canal treatment

41 Treatment of the injuries: 3. Intrusion orthodontic or surgical reposition

42 Treatment of the injuries: Fractura coronae dentis permanentis n The treatment of crown fracture depends on which third of the crown is injured

43 Treatment of the injuries: Fractura coronae dentis permanentis a. a. Enamel injuries: Minor enamel fractures : polishing, fluoride solution ELMEX Larger enamel fractures (1-2mm or more): composite restoration

44 Treatment of the injuries: Fractura coronae dentis permanentis b. b. Enamel – dentine injuries without pulp exposition - immature tooth Calcium hydroxide liner Temporary crown ( celluloid, acrylic ) – 1 year (GIC) – protective covering X – ray control Final restoration (closed apex) b. b. Enamel – dentine injuries without pulp exposition -mature tooth Final restoration

45 Fractura coronae dentis permanentis temporary crown - incisal restoration

46 Rebonding of fractured crown

47 Treatment of the injuries: Fractura coronae dentis permanentis c. c. Pulp exposition Important: size of the pulp exposure time between the injury and the treatment root development

48 Treatment of the coronal fracture in case of pulp exposition expositiontime root development small1 – 2 hours open or closed apex direct pulp capping larger than 1 mmmore, than 3 hoursopen apexpulpotomy x-largelong timeclosed apexpulpectomy

49 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!!!

50 Treatment of the injuries: Root fracture a. a. fracture in cervical third: Worst prognosis Elimination of coronal part root canal treatment orthodontic extrusion restoration Extraction + implantation b. b. fracture in middle third: Reposition of coronal part Splint ( 1-2 months ) Root canal filling Transradicular fixation can be an option (silver point)

51 c. c. Fracture in apical third observation, In case of necrosis - Ca(OH)2, In case of necrosis - 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: Root fracture

52 Fractura radicis dentis permanentis Healing Soft tissue hard tissue granule tissue

53 Possible consequences of traumatic injuries Peripheral (external) root resorption Trauma with damage to the periodontal structures, pulp may not become involved  Macrophages, osteoclasts   In cases of severe trauma, with some degree of displacement of the tooth  Diagnosis – 1 week after injury

54 Possible consequences of traumatic injuries Inflammatory root resorption  Trauma with damage to the periodontal AND pulp tissues  Bacterial toxines  Rapid, progressive  Intrusion, replantation  Diagnosis – 2-4 weeks after the injury  Severe cases – total root resorption in 1 month

55 Possible consequences of traumatic 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

56 Possible consequences of traumatic 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

57 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 traumatic injuries

58 Prevention 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

59 Prevention Mouthguard: Confectional Prefabricated Individual

60 Education!!!

61 Warning - Child abuse!!!! 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 examination result of clinical examination recurring injuriesrecurring injuries

62 Case report 20 years old boy 20 years old boy Street fight Street fight oral surgery ambulance – ‘’dental splint’’ oral surgery ambulance – ‘’dental splint’’ orthodontic clinic – 3 days after orthodontic clinic – 3 days after still very mobile upper front teeth still very mobile upper front teeth

63 Radiographs  13 root fracture in middle third  13, 12, 11, 21, 22, 23 extrusion, palatal dislocation palatal dislocation  all upper anterior teeth are very mobile  except 13, all upper anterior teeth show vitality

64 Treatment plan Slow reposition of dislocated teeth with fixed orthodontic appliance (1 year ) Slow reposition of dislocated teeth with fixed orthodontic appliance (1 year ) 13 rct ; transradicular fixation (silver point) /temporary/ 13 rct ; transradicular fixation (silver point) /temporary/ Frequent control of all the upper anterior teeth Frequent control of all the upper anterior teeth first patological sign - rct first patological sign - rct After debonding – fix and removable retainer After debonding – fix and removable retainer

65 Treatment

66 13 transradicular fixation (silver point and endomethason) after treatment 2 months later

67 Pulpal necrosis of 22 Needle control RCF control Sign of root resorption

68 Result of treatment

69 Thank you for your kind attention!


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