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DENTALTRAUMATIC

INJURIES

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Nitrous Oxide NotContraindicated

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Predisposing Factors

u> 90% of All Injuries• Protrusion of Anterior Teeth

• Poor Lip Coverage

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MouthguardsuGirls as Well as Boys

uOff - the - Shelf Vs.Individualized

uColors

uNeurological Protection

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Legal ConsiderationsuDetailed Records

uStandardized FormsuConsistant InformationuProfessional Responsibility

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Medical IssuesuNever Treat a Stranger

uNeurological AssessmentuAbove All Else, Do NoHarm

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InappropriateTreatments

uEndo in HanduSnip Root TipuScrub Root Surface

uSoak in Fluoride

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Head InjuryuMedical Emergency

uPriorities•Patient before dental!

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Neurological Assessment

uAware X 3 ?uLoss of Consciousness?

uNausea or Vomiting?uP E R R L A ?

uDrowsy ?uBlurred Vision?uHighway Patrol...

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Other Medical Issues

uCurrent Meds?

uOther Pathology?uTetanus Status ( DPT)

• 10 years...

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Antibiotic Necessityu Bacterial Endocarditis

Prophylaxis

u Soft Tissue “Through andThrough”

u Avulsion: Prevent RootResorption

u Dentoalveolar Infections Later

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Trauma TreatmentPriorities

uNo Further Damage...

uSave the Tooth

uSave the VitalityuCompromised PDL - Crush

Sequellae

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Types of Injuries

uConcussionuFractureuLuxationuIntrusionuExtrusionuAvulsionuRoot Fracture

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Fracture Classifications

uA Picture is Worth AThousand Words

uClass I, II, and III

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Locate FragmentuANYONE SEE IT?

uIN THE LACERATION?

uRADIOGRAPHIC LOCATION

uAVOID PROBING IFPOSSIBLE

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Endodontic Considerationsu Direct Pulp Cap

• 1 of 2 reasonable applications

• Mechanical (surgical) exposure

u Larger Exposure - Pulpotomy• Primary - Formocresol

• Permanent - Calcium Hydroxide

• Partial Pulpotomy?

u Necrotic• Complete pulpectomy

• Obturation

– Interim

– Permanent

u Apexification• Permanent Dentition

• Ca(OH)2

• GP Final

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Radiographic Needs

uPeriapical Views• Two Required

uLateral Radiograph• Primary Anterior Intrusions

uPanorex• Suspect Major Bony Fractures

– Subcondylar

– Mandibular

– LaFort Types

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Concussive SequellaeuFracture Dissipates Energy

• Diminished Pulpal Shock

uAdjacent Teeth• Future Prognosis

uWarning to Patient / Parents

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Luxation InjuriesuReposition

• Crossbite

uPotential for RootResorption

uStabilization

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Adequate Isolation

uRubber Dam• no clamp• premaxilla

• contiguous holes

uCotton Rolls and Saliva Ejector

uDri-Angles

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Splints: Appropriate Use

uEasy to ApplyuHygienic

• Patient can maintain

uAdequate StabilizationuEase of Removal

• for doctor

• for patient

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Splinting TimesuLuxations 7-10 Days

uAvulsions 7-10 DaysuRoot Fractures 3 monthsuAll Are Estimates;Frequent Revision

– Andreasen & J of Trauma

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Intrusive InjuriesuStatus of Periodontal Ligament

uStatus of Alveolar Bone

uStatus of Pulp

uReposition???

uOrthodontic Repositioning

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Reposition STAT

Root Resorption

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Orthodontic Repositioning

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Primary VersusPermanent

uDifferent Pulpal PrognosisuRecovery LikelihooduDangers of Sequellae

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Primary AnteriorIntrusion

uInto Follicle?uApex Through Cortical Plate?

uReasonable Expectation ofRe-eruption?

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Apical Penetration ofCortical Plate

uReposition?uExtract?

uPulpectomy...

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Primary AnteriorIntrusions

uRe-eruption Probability• 6-12 months = 50%?• Ankylosis....Extract Stat!

uPulpectomy Necessary?

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ReplantationProtocol

uOn Siteu15 Minute Window … MAX!uClean Gross DebrisuHold in PositionuSeek Dental CareuIf MUST Transport > Milk

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ContraindicateduEndondontics in Hand

uScrape/Scrub Root Surface

uSoak in 10% SnF• Unless exarticulated > 1 Hour

uSnip Root Tip

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Primum Non Nocere - Galen

Milk Still A Far Second Choice

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Dental ReplantationProtocol

uCheck for Full Replantation

uOcclusion

uStabilize

uFollow-up• Short-term• Long-term

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Root ResorptionuReplacement

• Ankylosis

uInflammatory• Disappearance of root

uCalcium Hydroxide TemporaryObturation

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Apexogenesis andResorption Prevention

uCalcium Hydroxide Obturation• 3-10 Day window

uInstrumentation and Complete CleansingCritical

uReplace at 3 and 6 months

uIf No Contradicting Signs/Symptoms - Final FilluLong Term Observation

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ReplantationResearch

uDoxycycline soakuHank’s Balanced Salt

Solution

uShortened or No SplintTimes

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Root FractureuPrognosis Location Dependent

• The More Apical the Better

uLong Bone Model of Repair• Longer Splint Time

uEndodontics?• Complete?

• Partial Coronal Fragment

uLong Term Observation

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Sequellae to Traumau To the Involved Teeth

• External Resorption• Internal Resorption

• Ankylosis• Loss of Vitality

– Root Dilaceration, Canal Dystyrophic Calcification

u To Succedaneous Teeth• Damage to Follicle

– Timing Critical– Hypoplasias, Demineralization,etc.

• Root Dilaceration• Loss of Tooth

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Replacement Options

uShort Term:• Removable: “Kiddie” Partial

• Fixed: Orthodontic Band Retained

uLong Term• Etch Retained Bridge

• FPD

uEventual: Implant or FPD

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Childrens’ Hospital of New York New York Presbyterian

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It’s Over...Thank You !