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The traumatic injuries of permanent teeth and complex therapy

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Presentation on theme: "The traumatic injuries of permanent teeth and complex therapy"— 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%

4

5

6 Injuries Playground - school

7

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: the permanent teeth
the alveolar bone the soft tissues

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

19 Classification of dental injuries Pedodontics and Orthodontics textbook
Luxatio totalis dentis permanentis Luxatio partialis dentis permanentis Intrusio Fractura coronae dentis permanentis Fractura radicis dentis permanentis

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

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

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

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
(axial dislocation)

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

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

28 Fractura radicis dentis permanentis
Root fracture Fractura radicis dentis permanentis

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

30 Complex therapy

31 Actions out of surgery:
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
Treatment of the injuries: Avulsion 1. Luxatio totalis dentis permanentis Instructions pulpy diet toothcleaning with soft toothbrush 0,1 % chlor-hexidine Supplementary therapy Antibiotic treatment Tetanus (immunization status?)

35 Treatment of the injuries: Avulsion Luxatio totalis dentis permanentis
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
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
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 : surgical or orthodontic reposition splint root canal treatment

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

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

43 Treatment of the injuries: Fractura coronae dentis permanentis
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
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) 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
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
time root development small 1 – 2 hours open or closed apex direct pulp capping larger than 1 mm more, than 3 hours open apex pulpotomy x-large long time closed apex pulpectomy

49 Regular re-call!!! 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
fracture in cervical third: Worst prognosis Elimination of coronal part root canal treatment orthodontic extrusion restoration Extraction + implantation fracture in middle third: Reposition of coronal part Splint ( 1-2 months ) Root canal filling Transradicular fixation can be an option (silver point)

51 Treatment of the injuries: Root fracture
Fracture in apical third observation, In case of necrosis - Ca(OH)2, - Final root canal filling after healing If coronal part is dislocated - reposition and fixation for 1 month

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 Possible consequences of traumatic injuries
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

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 months confused, frightened child parents and child don’t tell the same story anamnesis is not in accordance with the result of clinical examination recurring injuries

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

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

64 Treatment plan Slow reposition of dislocated teeth with fixed orthodontic appliance (1 year ) 13 rct ; transradicular fixation (silver point) /temporary/ Frequent control of all the upper anterior teeth first patological sign - rct 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 Sign of root resorption Needle control
RCF control

68 Result of treatment

69 Thank you for your kind attention!


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