Treatment of dento-alveolar injuries

1. Treatment of dento-alveolar injuries Dr. Mohammad A. Barayan

2. Definition : Injury which is limited to the teeth and supporting structures of the alveolus. N.BBoys are three times more at risk than girls. Causes : 1- Traffic Accident. 2- Falls. 3- During Epileptic seizures. 4- Sport injuries.

4. (1)History 1)Personal history 2) medical history 3) Previous dental history 4) History of trauma (when ,how ,where )

5. History of trauma 1) When did the accident occur ? The shorter the time between accident and treatment the better prognosis. 2) where did the accident occur ? If the accident occurred in dirty place prophylactic tetanus is indicated 3) how did the injury occur ? Direct force under the chin →→ condylar fracture Direct force to teeth → → Crown F, Root F, displacement

6. (2)Clinical Examination Extraoral Examination Laceration ; Abrasions ; Contusions on the head and neck can be noted visually Any asymmetries including deviation in mouth opening. Intraoral Examination Soft tissue ( tongue ; gingiva .. ) Teeth ( displacement ; mobility ; tooth fracture ; colour change )

7. (3)Vitality test Vitality test just following traumatic injury often given false negative response Types of vitality test 1)Thermal pulp test cold test heat test 2) Electrical pulp test 3)Cavity test

8. Treatment • *soft tissue injuries • 1- Determination of child immunization status:- • If the child had received a primary immunization activated with booster injection of toxoid . • Unimmunized child can be protected by tetanus antitoxin. • 2- Adequate debridment of the wound

9. (4)Radiographic Examination 1- stage of root formation 2- presence of root fractur 3- periapical radiolucencies 4- injury of the supporting periodontal membrane (degree of intrusion or extrusion o the tooth) 5- size of the pulp N. B. If a jaw fracture is suspected extaoral radiographs indicated (panoramic and lateral oblique views )

10. Classification of tooth fracture Ellis classification: Class I: crack or fracture of E only Class II: fracture of E , D with out pulp exposure Class III: fracture of E , D with pulp exposure Class IV: Fracture line passes beneath the gingival margin Class V: Root fracture a) vertical b) horizontal (apical , middle , cervical)

11. Class I : 1- a crack of the enamel without loss of tooth structure. Do not require immediate treatment. 2-fracture of enamel only smoothing the sharp edge regular vitality test , radiograph

12. Class II : Immediate treatment of the crown is required to: 1) protect the pulp 2) restore the esthetics and function. Cover the expose of the dentine by a layer of calcium hydroxide to reparative dentine formation. A- Reattachment of tooth fragment. B- Acid-etch composite resinrestoration

13. Class III : The treatment depends on many factors such as: 1) vitality of the exposed pulp. 2) Size of the exposure. 3) Time elapsed since the exposure. 4) Degree of root maturation. 5) Restorability of the fractured crown. The main objective of treatment is to maintain the vitality of the tooth.

15. Apexification :

16. Class IV : Treatment usually involve removing the loose fragment . 1- tooth can be extruded orthodontically 2- crown lengthening to gain access to placement of restoration.

17. Class v : • 1) Horizontal Root fracture • When the fracture occur near the apical 1/3, the prognosis is more favourable than the middle or cervical 1/3 because : • 1) more alveolar support • 2) immobilization of the tooth is much easier • Treatment of root fracture depends upon : • 1) Condition of the pulp • 2) amount of mobility or the level of the fracture line

18. (A) apical 1/3 root fracture 1) reduction , splinting the tooth 2)the tooth should be checked periodically for vitality and radiograph.

19. (B) middle 1/3 root fracture : 1) reduction , splinting the tooth 2)the patient recall 2-3 months , checked the vitality ,radiograph 3)if the tooth non vital and no healing the following treatment is performed: a) R C T of both fragments b) apical fragment removed surgically c) intraradicular pin to stabilize both segments

20. (C) cervical 1/3 root fracture : 1)reductin , splinting the tooth 2)recall the patient periodically and checked the vitality and radiograph 3)if there is radiolucent and pulp necrosis the following treatment is performed a) extraction the tooth b) removed the apical fragment and endo-osseous implant placed c) orthodontic extrusion d) if the fracture is 1-2mm infrabony remove the coronal segment and osteoplasty to expose the root

21. 2) vertical root fracture : usually the prognosis is not favorable treatment of V R F : 1)extraction of the tooth 2)using co2 laser and ND:YAG laser beam

22. * Concussion • A mild blow to the tooth resulting in mild sensitivity requires little or no treatment • Need only regular vitality test

23. *subluxation • Mobility of the tooth without displacement • Tooth may be sensitive to percussion • If mobility is extensive splint the tooth using the acid –etch splinting technique. • Regular vitality test and radiograph

24. Displacement of anterior teeth : • 1) lateral luxation • 2) intrusive luxation • 3) extrusive luxation • 4) avulsion

25. 1) Lateral luxation : • Displacement of the tooth in any direction other than the axial one • If the patient comes immediately after trauma reposition, splinting • Once the tooth have solidified in their position orthodontic treatment is required

26. 1) Intrusion: • Displacement the tooth into the socket A) primary tooth: will re-erupted over a period of few months. If the intruded tooth is in contact with underlying permanent tooth should be remove B) permanent tooth: • a) immediate surgical repositioning , splinting • b) orthodontic extrusion • c) incomplete root formation the tooth will erupt spontaneously

27. 2) Extrusion : Partially displacement the tooth out of the socket . A) primary tooth: Treatment usually extracted B) permanent tooth : reposition and splinting If the vitality of tooth is lost start root treatment immediately placing calcium hydroxide in the canal for 6-12 month followed permanent filling.

28. 3) Avulsion: Complete displacement of the tooth from the socket . There are tow important factors to be consider in cases of avulsion 1)time between the injury and treatment 2)condition under which the tooth have been restored The tooth must be kept moist to prevent damage to the fibers of PDL

29. In many cases the initial patient contact is byphone • The tooth should be handled by the crown • The tooth should be placed in suitable storage medium (milk, unsalted water, lens solution )or in buccal vestibule or under the tongue . • At the dental office : • a) information about tetanus immunization should be obtained • b) replantation , splinting for 1_2weeks but in immature apices 2-3weeks • c) calcium hydroxide should be placed • d) RCT

30. Alveolar fracture • Small fracture through the alveolar process. there may be concomitant injuries (crown, root fracture and soft tissue) managed by referral to an oral and maxillofacial surgery . • Treatment: redaction , splinting

31. Types of splinting : 1) acid_etched composite splinting 2) Interdental wiring 3) ( vacuum_formed plastic) splint 4) arch bare splint • More rigid and the longer the stabilization, the more root resorption , ankylosis that can be expected .

32. Stabilization periods for dentoalveolar injury

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34. Thank you