HistoryHistory

1. Patient name, age etc1. Patient name, age etc 2. When did the occur?2. When did the occur? 3. Where did injury occur?3. Where did injury occur?

4. How did injury occur?

5. Previous treatment

HistoryHistory

66. Medical . Medical historyhistory 7. Subjective complaints:7. Subjective complaints: aa. . Did trauma causes amnesia, un-con. vomiting or headache.Did trauma causes amnesia, un-con. vomiting or headache.

b. Is there any disturbance in bite which imply: tooth luxation, b. Is there any disturbance in bite which imply: tooth luxation, alveolar fracture , jaw fracture, or fracture of the TMJ.alveolar fracture , jaw fracture, or fracture of the TMJ. c. Reaction to thermal or other stimuli.c. Reaction to thermal or other stimuli.

Clinical examination :Clinical examination :PProvides all information necessary to make correct rovides all information necessary to make correct diagnosis and design an appropriate treatment plandiagnosis and design an appropriate treatment plan

Before initiating the C.E. the areas should Before initiating the C.E. the areas should be cleaned of all debris and blood.be cleaned of all debris and blood.

Clinical Examination should Clinical Examination should include:include:

1: Injury to the soft tissues. (Intra & Extra1: Injury to the soft tissues. (Intra & Extra)) 2: Presence of foreign material or tooth 2: Presence of foreign material or tooth

structure.structure.

2: Presence of foreign material or tooth structure

Clinical Examination should Clinical Examination should includeinclude

3: Bony fracture3: Bony fracture 4: Hemorrhage into floor of the mouth J Fra.4: Hemorrhage into floor of the mouth J Fra. 5: Cracks and Craze lines, fracture, pulp 5: Cracks and Craze lines, fracture, pulp

exposureexposure 6: Displacement of the tooth in any direction 6: Displacement of the tooth in any direction

Clinical Examination should Clinical Examination should include:include:

7: Abnormal, horizontal and vertical mobility.7: Abnormal, horizontal and vertical mobility. 8: Injury to PDL.8: Injury to PDL. 9: Abnormalities in the occlusion.9: Abnormalities in the occlusion. 10: Percussion test10: Percussion test 11: Reaction of teeth to sensibility testing:11: Reaction of teeth to sensibility testing:

11: Reaction of teeth to sensibility testing:11: Reaction of teeth to sensibility testing:

11. Heat. Heat 2. Cold, ethyl chloride, carbon dioxide snow -78, 2. Cold, ethyl chloride, carbon dioxide snow -78,

dichlorodifluoromethane -28.dichlorodifluoromethane -28. 3. Electric pulp tests:3. Electric pulp tests: Before initiating vitality testing, the following factors should be Before initiating vitality testing, the following factors should be

considered:considered: A. erupting non-injured teethA. erupting non-injured teeth B. testing should be conducted away from the gingival areaB. testing should be conducted away from the gingival area C. splinted and crowned teeth.C. splinted and crowned teeth. D. since pt. adapt sustained E C, pain threshold should be determined D. since pt. adapt sustained E C, pain threshold should be determined

by rapid, steady increase in current rather than slow, gradual increase. by rapid, steady increase in current rather than slow, gradual increase.

Radiographic ExaminationRadiographic Examination

1. Four films

Some points to be consideredSome points to be considered

1. Four films1. Four films 2. Fracture Line are usually obliquely positioned. 2. Fracture Line are usually obliquely positioned.

10-15 apical or coronal.10-15 apical or coronal. 3. A bend in a film Tracing P ligament around the 3. A bend in a film Tracing P ligament around the

root.root. 4. After six week another x-ray.4. After six week another x-ray.

Root FractureRoot Fracture

Complex healing pattern, E,D,P,C,PDLComplex healing pattern, E,D,P,C,PDL After age of 10 years ( incomplete root, resilient supportive structure ) After age of 10 years ( incomplete root, resilient supportive structure ) Types of fractureTypes of fracture Healing events depends on :pulp cut off, bacteria invasionHealing events depends on :pulp cut off, bacteria invasion Types of healing eventsTypes of healing events Treatment include repositioning and splintingTreatment include repositioning and splinting Prognosis depends on degree of displacement of the coronal fragment Prognosis depends on degree of displacement of the coronal fragment

and the stage of root developmentand the stage of root development

Concussion and SubluxationConcussion and Subluxation

Concussed Tooth is tender to percussion due to edema and Concussed Tooth is tender to percussion due to edema and Hemorrhage in PDLHemorrhage in PDL

Subluxated Tooth is tender to percussion and abnormally loose due to Subluxated Tooth is tender to percussion and abnormally loose due to rupture of PDL , gingival hemorrhage around the gingival marginrupture of PDL , gingival hemorrhage around the gingival margin

Treatment:Treatment: adjustment of occlusionadjustment of occlusion soft dietsoft diet splinting for the comfort of the pat. Does not prompt healingsplinting for the comfort of the pat. Does not prompt healing repeated sensibility testingrepeated sensibility testing

Extrusive luxationExtrusive luxation

E xtrusive Luxation :Partial displacement of the tooth out of its socketE xtrusive Luxation :Partial displacement of the tooth out of its socket X-ray: revealed increased P L space at peri-apical regionX-ray: revealed increased P L space at peri-apical region Clinical findings:Clinical findings: extrusive tooth appear elongateextrusive tooth appear elongate bleeding from PL bleeding from PL percussion is dullpercussion is dull increase mobilityincrease mobility tenderness to percussiontenderness to percussion sensibility test is -ve sensibility test is -ve pulp necrosis 15%-59%pulp necrosis 15%-59%

Lateral LuxationLateral Luxation

Lateral lux: eccentric displacement of the tooth accompanied with Lateral lux: eccentric displacement of the tooth accompanied with comminuted fracture or fracture of the alveolar socketcomminuted fracture or fracture of the alveolar socket

X-ray findings: reveals P space apically only by occlusal viewX-ray findings: reveals P space apically only by occlusal view Clinical findings:Clinical findings: crown displaced palatalycrown displaced palataly usually of socket wall and root apex lockedusually of socket wall and root apex locked percussion test metallic soundpercussion test metallic sound little mobilitylittle mobility pulp necrosis 58%pulp necrosis 58% temporary breakdown of the marginal bone within 2-4 weeks, extendtemporary breakdown of the marginal bone within 2-4 weeks, extend splinting 2 monthssplinting 2 months

Intrusion LuxationIntrusion Luxation

Displacement of the tooth deeper into the alveolar bone with Displacement of the tooth deeper into the alveolar bone with comminuting or fracture of the alveolar bone. comminuting or fracture of the alveolar bone.

Clinical findings:Clinical findings: the affected tooth appears shorter than the contra lateral tooth the affected tooth appears shorter than the contra lateral tooth high metallic sound in percussionhigh metallic sound in percussion no mobilityno mobility x-ray: PL space partially or totally disappearsx-ray: PL space partially or totally disappears pulp necrosis 63% in immature teeth and 100% in mature ones.pulp necrosis 63% in immature teeth and 100% in mature ones.

Diagnosis TreatmentConcussion −Tooth is tender to percussion(TTP) but is not displaced or mobile; no radiographic abnormalities.

Monitor pulpal status for 1 year.

Subluxation −Tooth is TTP and has increased mobility but is un-displaced. Radiographic abnormalities not normally found.

Flexible splint for up to 2 weeks.

Extrusive Luxation –Tooth displaced axially out of alveolar bone with mobility monitor pulpal status. but still retained within socket. Radio-graphically tooth appears elongated with increased apical PDL space.

Reposition, flexible splint for 2 weeks,

Lateral Luxation –Tooth is horizontally displaced, usually in palatal/lingual direction. Immobile, and usually gives high, metallic note on percussion.

Reposition with finger pressure, disengaging from bony lock with forceps applied to the crown if required, flexible splint for 4 weeks, monitor pulpal status.

Intrusive Luxation –Tooth displaced axially into alveolar bone. Tooth is immobile and may give high, metallic sound on percussion. PDL space may be absent from all or part of the root on radiographs. Can be subdivided into mild, moderate and severe intrusion

Incomplete root formation − Allow spontaneous re-eruption; if no movement in 3 weeks, rapid orthodontic repositioning. Complete root formation − Reposition orthodontically or surgically as soon as possible. Extirpate and dress with non-setting calcium hydroxide paste.

avulsionavulsion Maxillary incisors (prominent)Maxillary incisors (prominent) Children 7-10 years oldChildren 7-10 years old Success rate 4-50%Success rate 4-50% Two important aspects in the successful treatment:Two important aspects in the successful treatment: A. the condition under which the tooth has been preserved. B A. the condition under which the tooth has been preserved. B

the time interval between the injury and the treatment the time interval between the injury and the treatment The following condition to be considered before R.A.T:The following condition to be considered before R.A.T: A. The avulsed tooth should be without advanced P.diseasA. The avulsed tooth should be without advanced P.diseas B. The alveolar process should be intact to provide a seat B. The alveolar process should be intact to provide a seat C. Their should be no orthodontic contraindicationC. Their should be no orthodontic contraindication D. The stage of root development should be evaluatedD. The stage of root development should be evaluated

To provide the best chance of success, the PL cells should To provide the best chance of success, the PL cells should be kept in the most physiologically healthy status as be kept in the most physiologically healthy status as possible.possible.

If the avulsed tooth does not replanted within 60-120 min., If the avulsed tooth does not replanted within 60-120 min., the PL cells undergo necrosis then root resorption begins the PL cells undergo necrosis then root resorption begins and leads to the loss of pre-cementum layer. Because PL and leads to the loss of pre-cementum layer. Because PL cells deprived from its blood supply and depletion of the cells deprived from its blood supply and depletion of the stored cell metabolites. stored cell metabolites.

Storage mediaStorage media

Water and saline are damaging to PL cells (one hour)Water and saline are damaging to PL cells (one hour) Milk (low fat) limited in benefit (two hours)Milk (low fat) limited in benefit (two hours) Hank’s Balance Saline Solution (HBSS) (Save-A-tooth sys)Hank’s Balance Saline Solution (HBSS) (Save-A-tooth sys) Gingival fluid storage media not available commercially Gingival fluid storage media not available commercially Emdagon is an enamel matrix derivative gel Promote Emdagon is an enamel matrix derivative gel Promote

regeneration of periodontal ligament cells (60 minutes). regeneration of periodontal ligament cells (60 minutes).

Time Mature root Immature root

>15 m Clean with HBSS 5% doxycycline 5 minutes

15 m-24H (G.M) Implant immediately 5% Doxy. 5 minutes

15 m-24 H

<24 H

(B.M) HBSS 30 minutes

Dry media Shaving PL30 m Sod.HypEndo. TreatCitric acid 3 m5% Doxy 5mCanal dried then Ca(OH)2Replanted Gatta P. months filling

HBSS 30 m then 5% Doxy 5 m

The same as mature root

Complication of primary teeth Complication of primary teeth injuries on developing permanent injuries on developing permanent

teethteeth white or brown discoloration of the permanent tooth with or without white or brown discoloration of the permanent tooth with or without

hypoplastic defects;hypoplastic defects; dilaceration of the crown of the tooth causing eruption disturbance or dilaceration of the crown of the tooth causing eruption disturbance or

failure .failure . dilaceration of the root of the tooth causing eruption disturbance or dilaceration of the root of the tooth causing eruption disturbance or

failure; odontome-like formation.failure; odontome-like formation. partial or total failure of root development;partial or total failure of root development; total failure of tooth development .total failure of tooth development .