Dental Trauma: Acute Management ofLuxation and Displacement Injuries

Jason Munro(Powerpoint Novice)

Contents:-

1)Aims of Treatment of luxation injuries2)Types of Injuries and treatment thereof3)Conclusions4)References

Aim Of Treatment of Luxation/Displacement Injuries

● Main aim is restoration of appearance and function.● To rehabilitate the patient ASAP to save teeth.● Longer term: preserve bone and soft tissues (? Implants)● ACT FAST to reduce unwanted side effects :- most cases will

embark patient in restorative cycle.● THE DENTAL TRAUMA GUIDE● www.dentaltraumaguide.org● International Association Of Dental Traumatology (IADT)2012

published revised guidlines.

Types of Injury

1. CONCUSSION

● Mild stretching/crushing of tooth supporting tissues.

● TOOTH NOT LOOSENED.

Clinically:- TTP not mobile

Radiographically:- No change, PDL fine

Treatment of Concussion

● Primary and Secondary teeth:- Reassure● :-Soft diet 2/52● :- usual OH● :-Monitor Pulp 1 year

2. SUBLUXATION

● Tooth loosened in socket● Not displaced

● Clinically:- TTP and mobile● Not displaced so no premature

contacts.● Pathognomonic sign bleeding

from gingival crevice due to tearing of PDL. Radiographically:- Normal

● PDL●

Treatment Of Subluxation

Secondary teeth:- Reassure :-Soft diet 2/52, Usual OH :- +/- Flexible splint for 2/52 esp. if TTP Splint with 0.018” SS OT wire and comp. Resin, on adjacent uninjured teeth. :-Monitor pulpal response for 1 year.

Primary teeth:- Monitor, but if near exfoliation and airway risk, XLA.

3. Extrusive Luxation

● Displaced in an Occlusal Direction.

● Clinically:- Tooth appears longer than adjacent tooth

● :-Usually moblie and often in premature contact.

● Radiographically:- Widened PDL (variable)

● Treatment of Secondary teeth. :-Digital repositioning under LA (Watch winding movement to bypass clott) :-Check occlusion(bite together) :-Temp. Splint(Triad from Dentsply) and radiograph :-Flexible splint for 2/52, 0.018”SS.OT+Comp. Resin. :-Normal OH.ASAP with dilute CHX 0.2%M/W :-Follow up for 5 years.

● Treatment of Primary teeth. :- Mild(<3mm) Reposition or allow to recover. :-Severe(>3mm) Reposition, but XLA if secondary tooth close.

4.Lateral Luxation.

● Tooth displaced palatally/lingually● Almost always with dento-alveolar #.

● Clinically:-Unable to bite together.Apex can be pushed labially and trapped in front of alveolus if it's #'d. Locks tooth in position. Tooth is firm(unlike extrusion)

● Radiographically:- Difficult to image. Shows widened and narrowed PDL space.

Treatment of Secondary teeth. :-Digital repositioning under LA(LA as for XLA) :-Free apex first; pressure high in sulcus; then reposition labially. :-Note OT repositioning difficult if apex still infront of alveolus. :-Get patient to bite :-Temp. resin splint on inc. edges :- Radiograph :-Flexible splint ,0.018”SS.OT wire and composite for 4/52. :-Soft diet;Usual OH and CHX 0.2%M/W :-5 year follow up.

Treatment of Primary teeth. :-No ooclusal interferences- leave to reposition. :-Mild- grind tooth :-Severe- XLA

5. Intrusive Luxation

● Tooth displaced apically into socket.● Almost always associated with dento-alveolar fracture or even

comminution(pulverisation) of alveolus.

● Clinically:-Incisal edge more apical than other teeth(short clinical crown) :-Gingival margin often disrupted. :-Firm and locked in :-Metallic/ankylotic on percussion(no need to do this)

● Radiographically:-Loss of PDL space. :-Cemento-enamel junction; (CEJ)more apically placed.

● Treatment of Secondary teeth.:-Mild and immature (up to 3mm intrusion) monitor for few weeks. If no better, digitally reposition under LA before ankylosis.:-Mild and close apex, digital reposition under LA.

Severe and immature(>7mm) and closed(3-7mm), digital repositioning under LA. Check occlusion;Temp. Splint; then radiograph, then Flexible splint for 4/52Multiple teeth:- start next to uninjured tooth and work aroundUse a SELFIE(pre-op)Soft diet and usual OH. 5 Year follow up. Likely to need RCT.Digital repositioning better than OT.

● Treatment of Primary teeth.● :-Labially through plate -leave

:-XLA if into secondary tooth germ.

6. Avulsion

● Total displacement out of socket.● Not always in isolation.● Often apical 1/3 root #, fragment retained.

● Clinically:-Severed nerves and blood vessels. PDL torn. :- Exposed root surface.

● Radiographically:- MT socket :- +/- Dentoalveolar#:- +/-Apical 1/3 of root

● Treatment of Secondary teeth.:-Dependant on stage of root formation and extra-oral dry time. Prognosis directly related to EODT.

● Best outcome:- Pick up by crown :-Reinsert within 5 minutes(only with competent person) :-Bite on handkerchief then go to GDP :-Verify position then Flex. Splint 2/52 :-Closed Apex- RCT within 7/10days :-Open Apex-Monitor for revascularization; if none and 2 clear signs of necrosis->RCT

● <60mins EODT:-Store in HANKS balanced salt sln(Save-a-tooth) :-MILK(up to 6hrs)->GDP->rinse with saline :-Replant under LA->temp. Splint;rad then Flex.splint for 2-4weeks dependant on EODT :-RCT ASAP within 7-10 days

● Open apex :- aim for revascularization.

● >60 minutes EODTIf the tooth has been out for some time AND if time allows, RCT before replantation.Must remove necrotic PDL cells first:-1)Soak tooth in up to 5% Sodium Hypochlorite sln for 5 minutes2)Soak tooth in 2%Sonium Fluoride sln for 20 minutes

● Reimplant tooth;splint; rad, then Flexi.Splint for up to 4weeks

● RCT ASAP for mature and immature teeth.

Antibiotic use for Avulsed Teeth.

● Questionable? Reduces risk of root resorbtion.● Guildlines suggest 100mg Doxycycline bd 1/52 for children over 12

and adults.( under 12years and Pregnant women DO NOT use due to discolouration of developing teeth)

● Penicillin V or Amoxycillin can be used instead, with Erythromycin used for those allergic to Pen.

Endodontic considerations.

● RCT ASAP->Sterile canal therefore single visit edno.

However if large infalmmatory response with enhanced resorption risk use intra-canal dressing-

● eg. Odontopaste:- Corticosteroid and antibiotic( contains Clindamycin, and unlike Ledermix will not stain dentine)

Poor prognosis replantation?No such thing, according to Prof. Kenny from Toronto, who suggests EO RCT then reimplant. This allows for bony healing for a future Dental Implant.

● In growing patients KUO for infraocclusion suggesting ankylosis which may require decoronation.

Contraindications to replantation

1)Primary teeth due to risk of damage to secondary teeth.

2)Secondary tooth if there are more urgent/life threatening injuries.

3)Poor prognosis secondry teeth with caries or bone loss due to perio. disease.

4)Medical conditions eg. Severely immunocompromised

General Advice for ALL Traumatic Injuries

● Soft diet for ~4 weeks● Good OH +/- use of dilute CHX M/W eg soft tissue injuries● Avoid contact sports for 3/12● Follow-up.● Make patients aware of sequelae :-signs of swelling;colour

change;increased mobility or pain.

● See Dental Trauma UK members leaflet. www.dentaltrauma.co.uk

Conclusion

● Timely and appropriate treatment offers the best prognosis.

● MUST know what to do with and Avusled secondary toothgives the best chance of long term survival and preservation of the

patients smile

References

● Dental Update 2016;43:812-824● Dental Trauma Guide. www.dentaltraumaguide.org● IADT. www.iadt-dentaltrauma.org/forprofessionals.html● Clinical Dentistry Crispian Scully 4th edition.

Thank you.