------------------------------------------------------------------------------- TITLE: DENTAL ASPECTS OF MAXILLOFACIAL TRAUMA SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: December 6, 1989 RESIDENT PHYSICIAN: Mark L. Nichols, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. DENTAL ANATOMY A. PRIMARY OR DECIDUOUS DENTITION 1. PRESENT FROM AGES 2 - 7 YEARS 2. ERUPTION BEGINS AT 6 1/2 MONTHS AND ENDS AT 30 MONTHS 3. EACH ARCH (TWENTY TOTAL TEETH) CONTAINS: (4) INCISORS (2) CANINES (2) FIRST MOLARS (2) SECOND MOLARS 4. DIFFERENCES WITH PERMANENT DENTITION: a. SMALLER, WITH NARROWER AND LARGER ROOTS b. LIGHTER c. BELL SHAPED CROWN, CONSTRICTED NECK d. LARGER PULP CHAMBER, WIDER ROOT CANAL e. ROOTS PHYSIOLOGICALLY RESORB* f. NO PREMOLARS OR THIRD MOLARS g. ENAMEL CONSTANT THICKNESS, NON-TAPERED* * PROBLEM IF PLACEMENT IN IMF B. PERMANENT DENTITION 1. ERUPTION AGES 6 -21 YEARS 2. EACH DENTAL ARCH ( 32 TOTAL TEETH ) CONTAINS: (4) INCISORS (2) CANINES (4) PREMOLARS (6) MOLARS 3. DIFFERENCES WITH PRIMARY DENTITION: a. SCALLOPED AS OPPOSED TO STRAIGHT INCISAL SURFACE b. MAMELONS ON PERMANENT INCISORS INDICATIVE OF PRESENCE OR ABSENCE OF WEAR, THUS AN OCCLUSAL GUIDE C. THE TOOTH 1. THE CROWN a. ANATOMIC - THAT PORTION COVERED BY ENAMEL b. CLINICAL - THAT PORTION OF THE ANATOMIC CROWN NOT COVERED BY GINGIVA c. COMPOSITION: 1. ENAMEL - 97% INORGANIC MATERIAL, HARD AND BRITTLE 2. DENTIN - CONTAINS VASCULAR SYSTEM OF TUBULES FROM THE DENTINOENAMEL JUNCTION TO THE PULP CAVITY - FRACTURES EXTENDING TO THE DENTIN MAY ALLOW BACTERIA TO TRAVERSE THE TUBULES LEADING TO PULPITIS AND TOOTH DEATH - GROWTH AND VITALITY OF TOOTH DEPENDANT ON THIS LAYER - IT IS EXTREMELY PAIN SENSITIVE 2. THE ROOT a. COMPOSITION: DENTIN COVERED BY CEMENTUM b. ROOT CANAL - BEGINS AT THE APICAL FORAMEN AND CONTINUES INTO THE DENTIN LAYER AS A PULP CHAMBER - CARRIES A NEUROVASCULAR BUNDLE TO THE PULP, NOURISHES THE DENTIN - CLOSE PROXIMITY OF PULP HORNS TO TOOTH SURFACE IN CHILDREN, GREATER RISK OF DEVITALIZATION IN CROWN FRACTURES 3. PERIODONTAL SUPPORTING STRUCTURES a. INTERDENTAL PAPILLAE / GINGIVA - SERVES TO COVER TRANSVERSE COLLAGENOUS FIBERS AND LIGAMENTS WHICH ATTACH TO BONE, TEETH AND OTHER FIBERS. - RECEDES WITH AGE, MAY EXPOSE SIGNIFICANT AMOUNT OF CEMENTUM, CONTRIBUTE TO LOOSENING AND LOSS OF TOOTH - IMPORTANT NOT TO DAMAGE THESE STRUCTURES WHEN PASSING WIRES, PREFER PASSING 28 GAUGE WIRE USING DENTAL FLOSS TO PASS IT AROUND THE TOOTH. b. PERIODONTAL MEMBRANE (PERIODONTIUM) - PROVIDES FIBROUS UNION BETWEEN CEMENTUM AND ALVEOLUS. - FUNCTIONS AS A LIGAMENT TO ALLOW FOR TOOTH MOTION UNDER STRESS, PROVIDING FIRM FIXATION - TRAUMA MAY LEAD TO EDEMA OF THE MEMBRANE, ELEVATING THE TOOTH CAUSING PREMATURE TOOTH CONTACT ON CLOSURE, PATIENT COMPLAINS OF IMPROPER FIT WITHOUT A FRACTURE. c. ALVEOLAR BONE - MAXILLARY ALVEOLAR PROCESS SUPPORTS THE UPPER DENTAL ARCH, COMPRISED OF FACIAL AND PALATAL PLATES UNITED BY A COARSE CANCELLOUS BONY FRAMEWORK. BLOOD SUPPLY - TERMINAL DIVISION OF SUPERIOR ALVEOLAR ARTERY INNERVATION - MAXILLARY DIVISION OF TRIGEMINAL POSTERIOR, MID AND ANTERIOR SUPERIOR ALVEOLAR NERVES - MANDIBULAR ALVEOLI OR SOCKETS COMPRISED OF MORE COMPACT BONE THAN THE MAXILLA WITH STRONGER FACIAL AND LINGUAL PLATES. BLOOD SUPPLY - INFERIOR ALVEOLAR ARTERY INNERVATION - INFERIOR ALVEOLAR NERVE, A BRANCH OF THE MANDIBULAR DIVISION OF THE TRIGEMINAL. d. CEMENTUM D. IMPORTANCE OF TOOTH FORM 1. RACIAL DIFFERENCES: a. CAUCASIANS - OVERLAP OF INCISORS b. BLACKS - INCISORS DIRECTLY APPROXIMATE 2. INCISORS: a. SINGLE, NARROW, TAPERED ROOT - EASY SUBLUXATION UNDER IMF (POOR CHOICE FOR FIXATION) b. MAXILLARY INCISORS BROADER MESIODISTALLY THAN MANDIBULAR COUNTERPARTS. MAXILLARY TEETH 1/2 TOOTH DISTAL TO THE CORRESPONDING MANDIBULAR TEETH, OCCLUDE WITH TWO TEETH IN THE OPPOSITE ARCH 3. CANINES: a. CONICAL SHAPE, STRONG AND HEAVY ROOTS, GREAT STRENGTH b. USEFUL AS A GUIDE IN OCCLUSAL RELATIONSHIPS, TO ESTABLISH IMF, OR FOR RETAINING PROSTHESES 4. PREMOLARS: a. MAY HAVE 1-3 CUSPS, TRANSITIONAL TEETH, CROWN HAS FEATURES OF CANINES AND MOLARS 5. MOLARS: a. HAVE 3 ROOTS - (2) BUCCAL, (1) PALATAL b. HAVE 4 CUSPS WITH FLAT OCCLUSAL SURFACES c. FIRST MOLAR IMPORTANT - LARGE SIZE, EARLY ERUPTION AND FIRM FIXATION, THUS A CORNERSTONE FOR ESTABLISHING OCCLUSION, GOOD POINT OF FIXATION IN IMF. d. MANDIBULAR FIRST AND SECOND MOLARS UNLIKE THEIR MAXILLARY COUNTERPARTS HAVE ONLY 2 ROOTS. THIRD MOLARS MAY HAVE UP TO 4 ROOTS AND BE DIFFICULT TO EXTRACT. II. NOMENCLATURE AND ORIENTATION A. NOMENCLATURE 1. TEETH ARE NUMBERED RIGHT TO LEFT IN THE MAXILLA (1-16), BEGINNING WITH THE THIRD MAXILLARY MOLAR AND LEFT TO RIGHT IN THE MANDIBLE (17-32), USING THE QUADRANTIC OR DENTAL FORMULA. THIS SERVES TO DIVIDE THE DENTITION INTO QUADRANTS. B. ORIENTATION 1. RELATIONSHIP TO THE MID-SAGITTAL PLANE OF THE HEAD WHICH SERVES TO DIVIDE THE MAXILLARY AND MANDIBULAR ARCHES EQUALLY. 2. TERMINOLOGY: a. MESIAL - PROGRESSION TOWARDS THE MID-SAGITTAL PLANE b. DISTAL - PROGRESSION AWAY FROM THE MID-SAGITTAL PLANE c. LABIAL - TOOTH SURFACE FACING THE LIP d. LINGUAL - TOOTH SURFACE FACING THE TONGUE e. PALATAL - TOOTH SURFACE FACING THE PALATE IN THE MAXILLA f. INCISAL - THAT SURFACE OF THE INCISORS WHICH APPROXIMATES THE OPPOSITE DENTAL ARCH g. OCCLUSAL - SURFACE OF THE PREMOLARS AND MOLARS THAT APPROXIMATES THE OPPOSITE DENTAL ARCH III. OCCLUSION A. RELATES THE TEETH OF ONE DENTAL ARCH TO THOSE ON THE OPPOSITE ARCH. B. MAXILLARY TEETH OVERLAP THOSE IN THE MANDIBULAR ARCH 1. OVERBITE - THE VERTICAL COMPONENT OF OVERLAP 2. OVERJET - THE HORIZONTAL COMPONENT OF OVERLAP C. MAXILLARY CANINES, PREMOLARS AND MOLARS ARE LABIAL AND BUCCAL TO THEIR MANDIBULAR COUNTERPARTS. 1. THE PALATAL CUSP OF THE MAXILLARY MOLARS OCCLUDES WITH THE GROOVES OF THE MANDIBULAR MOLARS. 2. IN GENERAL: THE MAXILLARY TEETH ARE 1/2 TOOTH FACIAL AND DISTAL TO THE CORRESPONDING MANDIBULAR DENTITION. 3. ARTICULAR FACETS ARE FLAT OCCLUSAL SURFACES OF THE TOOTH AT POINTS OF CONTACT OCCURRING SECONDARY TO WEAR. AN IMPORTANT GUIDE TO ASSIST IN DETERMINING PRE-TRAUMA OCCLUSION. IF THE FACETS ALIGN THEN ONE MAY FEEL MORE CONFIDENT THAT OCCLUSION IS SATISFACTORY. D. ANGLE'S CLASSIFICATION 1. E.H. ANGLE, ORTHODONTIST (1898) 2. BASED ON THE RELATIONSHIP OF THE 1ST MAXILLARY MOLAR TO THE 1ST MANDIBULAR MOLAR. 3. CLASS I - NEUTRO-OCCLUSION a. MESIOBUCCAL CUSP OF THE MAXILLARY 1ST MOLAR INTERDIGITATES WITH THE BUCCAL GROOVE OF THE MANDIBULAR 1ST MOLAR. b. FOUND IN APPROXIMATELY 73% OF ALL PATIENTS 4. CLASS II - DISTO-OCCLUSION a. MESIOBUCCAL CUSP OF THE MAXILLARY 1ST MOLAR IS MESIAL TO THE BUCCAL GROOVE OF MANDIBULAR 1ST MOLAR. b. FOUND IN APPROXIMATELY 24% OF ALL PATIENTS c. MANDIBLE APPEARS SLIGHTLY RETRUSIVE, MAXILLA APPEARS PROTRUSIVE. 5. CLASS III - MESIO-OCCLUSION a. MANDIBULAR 1ST MOLAR GROOVE LIES MESIAL TO THE MESIOBUCCAL CUSP OF THE MAXILLARY 1ST MOLAR. b. FOUND IN APPROXIMATELY 3% OF ALL PATIENTS c. MANDIBULAR PROGNATHISM OR UNDERBITE F. NORMAL OCCLUSAL RELATIONSHIPS 1. RESTING OCCLUSION - TEETH SEPARATED 1-2MM AT REST OCCLUSAL SURFACES NOT CONTACTING 2. CENTRIC OCCLUSION - RELATIONSHIP BETWEEN UPPER AND LOWER DENTAL ARCHES THAT EXISTS WHEN MAXIMAL JAW OPPOSITION OCCURS. (EX: IMF) 3. ARTICULATION - DYNAMIC RELATIONSHIP OF THE DENTAL ARCHES DURING MASTICATION. IV. PRE-OPERATIVE CONSIDERATIONS A. EXAMINATION 1. CHECK FOR MISSING OR FRACTURED TEETH 2. ESTABLISH THE TYPE OF OCCLUSION a. ANGLE'S CLASSIFICATION b. EDENTULOUS - SIMILAR RELATIONSHIP BETWEEN ARCHES AS IN ANGLE'S CLASSIFICATION 1. LINE OF HARMONY - PROFILE, A STRAIGHT LINE FROM THE SUPRAORBITAL RIM, SUBNASAL AREA, LOWER LIP AND CHIN. CORRELATE WITH ANGLE'S CLASS. SUSPECT CLASS II OCCLUSION IF LINE DOESN'T TOUCH LOWER LIP OR CHIN WITH THE SUBNASAL AREA BEING ANTERIOR TO THE LINE. SUSPECT CLASS III IF LINE DOES NOT TOUCH THE SUBNASAL AREA OR LOWER LIP AND THE CHIN IS ANTERIOR. CLASS I - TANGENT TO ALL AREAS. c. PRE-ACCIDENT PHOTOS - MAY HELP IN DISCERNING OCCLUSION. 3. CLINICAL AND RADIOGRAPHIC EXAMINATION a. FOR CARRIES AND PERIODONTAL DISEASE b. EXTRACT TOOTH IF GROSS DECAY AND NOT NEEDED FOR IMF c. IF PERIODONTAL DISEASE, MAY INDICATE POOR NUTRITION OR METABOLIC DISEASE, EX. DIABETES; IF FROM POOR HYGIENE MAY REFLECT POOR FUTURE COMPLIANCE. IF ADVANCED PERIODONTAL DISEASE, SHOULD CONSIDER OTHER FORMS OF IMF: ARCH BARS WITH CIRCUMANDIBULAR WIRING EXTERNAL PIN FIXATION, OR EXTRACT REMAINING TEETH AND CONSTRUCT SPLINTS. 4. RADIOGRAPHS a. LOCATE APICES OF DENTITION b. LOCATE INFERIOR ALVEOLAR NERVES - PREOP GUIDE TO LOCATION OF DRILL HOLES c. LOOK FOR ROOTS WITHOUT CROWNS - INDICATIVE OF FRACTURED DENTITION - A SOURCE OF INFECTION SHOULD EXTRACT d. EVALUATE BRIDGEWORK / CROWN WORK - REMOVE LOOSE PROSTHESIS V. INTRA-OPERATIVE ASPECTS A. INTERMAXILLARY FIXATION / IMF 1. UPPER AND LOWER ARCH BARS - LIGATE FROM CUSPID TO SECOND MOLAR 2. AVOID GINGIVAL PAPILLAE WHEN PASSING WIRES 3. USE 28 GAUGE WIRE ATTACHED TO DENTAL FLOSS FOR GENTLE PASSAGE. 4. ISOLATED TEETH - LIGATE BY PLACING A WIRE MESIALLY AND DISTALLY BENEATH THE ARCH BAR AND LOOPING WIRE AROUND ARCH BAR ON ONE SURFACE. ALSO MAY LIGATE USING 2 WIRES IN A BOOT-LACE FASHION, ONE WIRE ABOVE ARCH MESIALLY OTHER BELOW DISTALLY, THE OTHER WIRE IN AN OPPOSITE CONFIGURATION. AID TO WIRE RETENTION. 5. TWIST WIRE SUCH THAT THE DIRECTION OF TWIST BINDS THE ARCH BAR (NOT THE TOOTH). 6. ANTERIOR TEETH - IF LIGATED SHOULD BE REINFORCED VIA PASSING A WIRE THROUGH THE PYRIFORM APERTURE AND AROUND THE MAXILLARY ARCH. CIRCUMANDIBULAR WIRING AROUND ARCH BAR IF LIGATING MANDIBULAR INCISORS. 7. IMF ACHIEVED BETWEEN ARCH BARS VIA ELASTICS OR WIRES. a. ELASTICS - PROVIDE CONSTANT TRACTION, PREVENTS MOBILITY OF FRACTURED SEGMENT, UNLIKE WIRES WHICH CAN LOOSEN OR STRETCH. EASIER TO CUT IN EMERGENCY. b. DISADVANTAGE OF ELASTICS - UNCOMFORTABLE TO PATIENT, CONSTANT TRACTION MAY LOOSEN TEETH IF NOT IN GOOD OCCLUSION. c. WIRES - ADVANTAGE IF NO OPPOSING TEETH, AND TOOTH IS NEEDED FOR IMF. B. LOOSE TEETH 1. REMOVE IF OUT OF SOCKET 2. SALVAGE IF IN SOCKET, NOT IN FRACTURE LINE a. STABILIZE TO ARCH BAR VIA LIGATION b. FIRMLY SEAT TOOTH IN SOCKET BY PUSHING IT INTO SOCKET WHILE TIGHTENING LIGATURE c. PREVENT LOOSENING BY LOOPING WIRE AROUND OCCLUSAL OR INCISAL SURFACE FROM LINGUAL TO BUCCAL SURFACE - TOOTH WILL REQUIRE ROOT CANAL THERAPY - HIGH INCIDENCE OF ROOT RESORPTION C. EXTRACTING TEETH 1. UNIVERSAL 150 FORCEPS - UPPER TEETH UNIVERSAL 151 FORCEPS - LOWER TEETH 2. PROCEDURE: a. DISSECT GINGIVA OFF CROWN WITH A PERIOSTEAL ELEVATOR UNTIL BONE IS REACHED b. GRASP TOOTH FIRMLY WITH FORCEPS, STABILIZING ALVEOLUS WITH THE OPPOSITE HAND, MOVE TOOTH UNTIL PERIODONTAL LIGAMENT RUPTURES. MOVE BUCCAL TO LINGUALLY IF A POSTERIOR TOOTH AND LABIAL TO LINGUAL IF AN ANTERIOR TOOTH. GRADUALLY INCREASE PRESSURE AS TOOTH LOOSENS UNTIL IT IS PULLED. c. COMPRESS ALVEOLUS WITH FINGER PRESSURE USING GAUZE d. INSPECT TOOTH ROOT FOR FRACTURE, IF ROOT TIP LEFT IN SOCKET CAN OFTEN REMOVE WITH SUCTION OR A SMALL INSTRUMENT. D. LOSS OF DENTAL RESTORATION - FILLING: 1. CAN CONFUSE WITH DENTAL CARIES 2. PROBE AREA WITH A NEEDLE - IF SOFT SUSPECT CARIES IF HARD AND / OR MINOR CARIES - SALVAGE TOOTH VI. POST-0PERATIVE ASPECTS A. PULPAL DISEASE 1. SEEN IN FRACTURED OR DECAYING TEETH 2. PAIN IS A PREDOMINANT SYMPTOM 3. DENTINOBLASTS RESPONSIBLE FOR DENTIN FORMATION ARE THE FIRST CELLS TO BE INJURED. 4. THERE IS AN ALTERED RESPONSE TO PAINFUL STIMULI - IN DURATION AND PATTERN. NORMALLY IF STIMULUS IS REMOVED, PAIN CEASES. 5. STAGES OF RESPONSE TO INJURY: a. HYPEREMIA - INITIAL, VASODILATATION, EDEMA, INCREASED PRESSURE WITHIN THE PULPAL CHAMBER b. INFLAMMATION - SECONDARY, WITH EXUDATION, INFLAMMATORY CELL INFILTRATION, IRREVERSIBLE LEADS TO ABSCESS OR CHRONIC DISEASE 6. PAIN IS POORLY LOCALIZED, IF IT BECOMES WELL LOCALIZED SUSPECT PERIODONTAL TISSUE INVOLVEMENT. 7. TOOTH EVALUATION - TESTS a. VITALOMETER TESTING - CURRENT TRANSMITTED TO A TOOTH - IF ABSENCE OF A SENSORY RESPONSE, OR RESPONSE OF A HIGHER OR LOWER THRESHOLD THAN THE CONTROL RESPONSE - PATHOLOGIC b. THERMAL TESTING - APPLY HOT OR COLD STIMULUS TO TOOTH - EVALUATE SENSORY RESPONSE c. PERCUSSION - TAP TOOTH WITH A MIRROR HORIZONTALLY AND VERTICALLY, NORMALLY NO DISCOMFORT - PAIN ON VERTICAL PERCUSSION - PERIAPICAL DISEASE - PAIN ON HORIZONTAL PERCUSSION - PERIODONTAL DISEASE - PAIN ALSO PRODUCED IF TOOTH IN TRAUMATIC OCCLUSION OR IF IN A FRACTURE LINE d. LOCAL ANESTHESIA - INFILTRATE AREA AROUND ROOT TIP WITH LIDOCAINE - CAN LOCALIZE USUALLY TO 1 OR 2 TEETH - DIFFICULT IN THE MANDIBLE e. TRANSILLUMINATION - LOSS OF TRANSLUCENCY IN CASES OF IRREVERSIBLE PULPITIS 7. TEST RESULTS IN DISEASE STATES a. NORMAL TOOTH - STIMULUS REMOVED FROM TOOTH, DISCOMFORT QUICKLY ABATES - PAIN GRADUALLY INCREASES AS THE STIMULUS IS MAINTAINED b. HYPEREMIA - STATE OF IRRITABILITY - SUDDEN RESPONSE OF TOOTH TO STIMULUS (COLD) - PAIN, RAPID ONSET, LASTING A MINUTE AFTER REMOVAL OF STIMULUS - HEAT APPLICATION REVERSES PAIN INDUCED BY COLD - VITALOMETRY - TOOTH RESPONDS BELOW NORMAL THRESHOLD - PERCUSSION - NON-TENDER c. PULPITIS - STATE OF INCREASED PRESSURE WITHIN THE PULPAL CHAMBER - NOT AFFECTED BY COLD STIMULUS - PAIN SEVERE AND PROLONGED WHEN WARM STIMULUS APPLIED, REMAINING AFTER THE STIMULUS IS REMOVED - PAIN CAN BE SPONTANEOUS WITHOUT A STIMULUS - DENTINOBLASTS - NON-VIABLE - PATIENT USUALLY SEEN SIPPING ICE WATER TO RELIEVE PAIN (REDUCES EXPANSION OF PULP CAVITY). - CONDITION AGGRAVATED BY LYING DOWN OR BENDING OVER (INCREASED VASCULAR PRESSURE) - VITALOMETRY - INCREASED THRESHOLD WHEN DENTINOBLASTS DESTROYED OR NO RESPONSE - NO PERCUSSION TENDERNESS - LEADS TO ABSCESS FORMATION - PERCUSSION TENDERNESS - TOOTH DISCOLORATION IN TIME - TREATMENT: EXTRACTION OR ROOT CANAL THERAPY, ANTIBIOTICS 8. ORAL CARE AFTER IMF a. HYGIENE 1. EVALUATE PATIENT EVERY 7-10 DAYS 2. REMOVE AND REPLACE ELASTICS 3. SPRAY MOUTH WITH PEROXIDE USING A POWER SPRAYER FOLLOWED BY A MOUTHWASH 4. INSTRUCT PATIENT TO RINSE AFTER EACH INGESTION OF LIQUID FOOD TO MINIMIZE DEPOSITS. WATER PIK DEVICE HELPFUL IN REDUCING PLAQUE. b. OTHER 1. AFTER 3 WEEKS - REMOVE ELASTICS, ALLOW PATIENT TO OPEN MOUTH, PREVENTS TMJ ANKYLOSIS 2. APPLY BONE WAX TO OFFENDING AREAS OF ARCH BAR IF MUCOSAL IRRITATION 3. ESTABLISH FRACTURE STABILITY - HAVE PT. BITE ON A TONGUE BLADE, IF PAINFUL, MAY REQUIRE ADDITIONAL PERIOD OF FIXATION. 4. GRADUALLY RESUME DIET - NORMAL MASTICATION BY END OF FIRST WEEK OUT OF ELASTICS 5. REMOVE ARCH BARS IN OFFICE USING TOPICAL ANESTHESIA - 4% LIDOCAINE OR CETACAINE 6. CUT WIRES FLUSH TO MINIMIZE TRAUMA DURING REMOVAL, MANDIBULAR WIRES ARE REMOVED BY PULLING DOWN, MAXILLARY WIRES REMOVED BY PULLING UPWARD 7. GINGIVITIS - RESUME GENTLE BRUSHING, GRADUAL PROGRESSING TO NORMAL, USE FLOSS, DENTAL FOLLOW-UP AT 10-14 DAYS POST REMOVAL FOR PROPHYLAXIS/PERIODONTAL CHECK 8. FOLLOW-UP 3 WEEKS AFTER REMOVAL OF IMF VII. DENTAL INJURIES A. TRAUMA WITHOUT VISIBLE FRACTURE 1. PULP INJURY a. TOOTH CONCUSSION - DAMAGE TO BLOOD VESSELS OF PULP b. CROWN MAY BE DISCOLORED OR PULP MAY DIE c. CLINICAL: SORENESS, NORMAL VITALITY, EARLY INCREASED SENSITIVITY TO PERCUSSION, NORMAL RADIOGRAPHY d. TREATMENT: NONE NECESSARY, DENTAL FOLLOW-UP, AVOID DIRECT STRESS ON THE TOOTH B. UNCOMPLICATED CROWN FRACTURES 1. ENAMEL ONLY FRACTURES a. MAY BE ASYMPTOMATIC OR COMPLAIN OF INCREASED SENSITIVITY TO TEMPERATURE CHANGE OR TOUCH b. MOST REPAIRABLE VIA GRINDING AND RECONTOUR c. SOME MODERATE FRACTURES REQUIRE ACID-ETCH BONDING/RESTORATION (TOOTH COLORED PLASTIC) d. GROSS ENAMEL FRACTURES MAY REQUIRE A CROWN 2. ENAMEL + DENTIN FRACTURES a. HYPERSENSITIVE TO COLD AND TOUCH b. EXAMINE FOR PULP EXPOSURE - MINUTE EVIDENCE OF BLOOD FROM FRACTURED SURFACE c. DENTIN EXPOSURE(YELLOW), PROTECT WITH CALCIUM HYDROXIDE (DYCAL PASTE) - STIMULATES REPARATIVE DENTIN FORMATION, COVER WITH POLYCARBOXYLATE CEMENT, VARNISH OR NAIL POLISH, SEALS TOOTH TO PREVENT BACTERIAL INVASION. d. FOLLOW PATIENT VIA PULP VITALITY TESTING, IF AFTER 8 WEEKS PULP IS NON-VITAL, TOOTH WILL REQUIRE ENDODONTIC THERAPY. 3. COMPLICATED CROWN FRACTURES a. USUALLY PARTIAL OR COMPLETE CROWN FRACTURE WITH EXPOSED PULP b. SIMILAR TO ABOVE, USUALLY REQUIRES ENDODONTIC THERAPY IN THE FORM OF PULPOTOMY (REMOVAL OF CORONAL PULP) c. RESTORATION IS THEN PLACED OVER THE CROWN C. CROWN AND ROOT FRACTURES 1. INVOLVE ALL LAYERS: ENAMEL, DENTIN, CEMENTUM, WITH OR WITHOUT PULP EXPOSURE 2. ANTERIOR TEETH - MOST FRACTURES OF THIS TYPE INVOLVE THE PULP 3. ENDODONTIC THERAPY - ROOT CANAL SHOULD BE PERFORMED WITH REMOVAL OF THE CROWN, REPLACING THE CROWN WITH A POST FOR A TEMPORARY RESTORATION 4. POSTERIOR TEETH - CROWN / ROOT FRACTURES USUALLY ONLY INVOLVE A BUCCAL OR LINGUAL CUSP WITH OR WITHOUT PULP EXPOSURE. a. NO PULP EXPOSURE: RESTORE BY CONVENTIONAL METHODS b. PULP EXPOSURE: ENDODONTIC THERAPY REQUIRED D. ROOT FRACTURES 1. CLASSIFIED BY LOCATION a. APICAL THIRD b. MIDDLE THIRD c. CORONAL THIRD 2. CHARACTERISTICS: a. APICAL OR MIDDLE THIRD FRACTURE 1. PULP VITALITY MAY PERSIST FOR LONG PERIODS 2. PHYSIOLOGIC RESPONSE OF PULP TO TRAUMA IS CALCIFICATION 3. USUALLY ASYMPTOMATIC 4. IF ENDODONTIC THERAPY REQUIRED, CALCIFICATION MAY IMPEDE APICAL SURGERY b. CORONAL FRACTURES 1. CLOSE PROXIMITY OF GINGIVAL TISSUES 2. PULP MORE SUSCEPTIBLE TO BACTERIAL INVASION, INFECTION AND PULP NECROSIS c. TESTING: 1. PULP MAY TEST AS NON-VITAL FOR VARIABLE PERIOD FOLLOWING TRAUMA 2. PULP TESTS THEREFORE NOT RELIABLE FOR FIRST FEW MONTHS POST-INJURY 3. ENDODONTIC THERAPY IS PERFORMED BASED ON OTHER CLINICAL OR RADIOGRAPHIC SIGNS AND SYMPTOMS 3. TREATMENT - PROGNOSIS: APICAL > MIDDLE > CORONAL a. APICAL THIRD 1. IMMOBILIZE TOOTH IF MOBILE, REDUCE OCCLUSION TO MINIMIZE FURTHER TRAUMA 2. ENDODONTIC THERAPY IS INDICATED CONFINED TO THE CORONAL SEGMENT ONLY IF: SYMPTOMS DEVELOP, TESTING REVEALS A LACK OF VITALITY, OR X-RAY REVEALS INCREASED CALCIFICATION 3. REMOVE THE APICAL FRAGMENT ONLY IF CLINICAL OR RADIOGRAPHIC SIGNS OF DISEASE b. MIDDLE THIRD 1. STABILIZE TOOTH, REDUCE OCCLUSION 2. OTHERWISE SIMILAR TO APICAL, SPLINTS MAINTAINED UNTIL MOBILITY NO LONGER A PROBLEM 3. ENDODONTIC THERAPY IF REQUIRED MAY HAVE TO BE PERFORMED ON BOTH CORONAL AND OR APICAL SEGMENTS 4. IF UNABLE TO PERFORM ENDODONTIC THERAPY ON THE APICAL SEGMENT OR IF DISEASE DEVELOPS AROUND THE SEGMENT THEN SURGICAL REMOVAL OF THE FRAGMENT REQUIRED C. CORONAL THIRD 1. SIMILAR TO APICAL 2. IF PULP NECROSES OR FRACTURE FAILS TO HEAL CORONAL SEGMENT IS REMOVED AND ENDODONTIC THERAPY IS PERFORMED ON THE RADICULAR SEGMENT 3. THE ROOT IS EXTRUDED ORTHODONTICALLY AND THEN RESTORED E. LUXATIONS 1. FORCE ABSORBED BY THE TOOTH AND SUPPORTING STRUCTURES WITHOUT APPARENT FRACTURE OR LOSS OF TOOTH STRUCTURE 2. PULP TESTS NEGATIVE 3. RADIOGRAPHIC WIDENING OF PERIODONTAL LIGAMENT SPACE 4. COLOR MAY CHANGE 5. HIGH RISK OF PULPAL COMPLICATIONS 4. TYPES OF LUXATIONS: a. CONCUSSION - NO DISPLACEMENT b. SUBLUXATION - MINOR MOBILITY, NON-DISPLACED FROM ALVEOLUS, NO SPECIFIC TREATMENT REQUIRED FOR a AND b - DENTAL FOLLOW-UP TO ASSESS VITALITY c. LUXATION - PHYSICAL DISPLACEMENT OF THE TOOTH FROM INJURY 1. TYPES - LATERAL - INTRUSIVE - INWARD (RARE) - EXTRUSIVE - OUTWARD 5. TREATMENT a. MINOR LUXATIONS < 5mm - REPOSITIONING WITH OR WITHOUT SPLINTING (2-8 WEEKS) b. MAJOR LUXATIONS - NEUROVASCULAR AND PERIODONTAL INJURY, IRREVERSIBLE PULP DAMAGE, SPLINT FOR 4-6 WEEKS, IF VITALITY DOES NOT RETURN IN 8-12 WEEKS OR EVIDENCE OF PULP PATHOLOGY - ROOT CANAL IS REQUIRED. c. PRIMARY DENTITION - CONCUSSION OR SUBLUXATION REPOSITION OR STABILIZE, IF COMPLETE EXTRUSION EXTRACT TO PROTECT DEVELOPING PERMANENT DENTITION F. AVULSION 1. COMPLETE DISPLACEMENT OF TOOTH FROM SOCKET 2. PROGNOSIS BETTER IF LESS TIME TO REPLANTATION 3. INSTRUCTIONS TO PATIENT: a. RINSE TOOTH IN TAP WATER, DON'T SCRUB b. GENTLY RE-INSERT THE TOOTH INTO THE SOCKET AS CLOSE TO ORIGINAL POSITION AS POSSIBLE, BITE DOWN ON A PIECE OF CLOTH c. DENTAL REFERRAL 4. IF IMMEDIATE IMPLANTATION NOT POSSIBLE, PLACE TOOTH IN NORMAL SALINE, MILK OR PLACE IN ORAL VESTIBULE OR UNDER TONGUE 5. EXAMINE TOOTH FOR DEBRIS AND FRACTURE PRIOR TO REPLANTATION, HANDLE ONLY BY THE CROWN, REPLANT FIRMLY AFTER REMOVING BLOOD AND DEBRIS FROM SOCKET 6. CHECK PROPER POSITION IN SOCKET VIA RADIOGRAPHS, OCCLUSION, ADJACENT TEETH 7. TREATMENT OF CHOICE IS SPLINTING WITH STABILIZATION FOR 7-14 DAYS WITH WIRE OR MONOFILAMENT LINE VIA ACID ETCH BONDING. 8. REIMPLANTATION IS UNDESIRABLE IF TOOTH IS: a. CARIOUS b. FRACTURED IN THE MID / CORONAL 1/3 OF ROOT c. ALVEOLAR SOCKET FRACTURE / ADVANCED PERIODONTAL DISEASE 9. ANTIBIOTICS: PENICILLIN V 500MG QID X 7 DAYS 10. CHECK TETANUS STATUS 11. AVOID AGGRESSIVE USE OF REPLANTED TOOTH 12. ENDODONTIC THERAPY - ROOT CANAL IS USUALLY REQUIRED 13. PROGNOSIS: AVERAGE LIFE SPAN OF REPLANTED TOOTH IS ABOUT 5-10 YEARS, SUCCESS IS INVERSELY PROPORTIONAL TO TIME THE TOOTH IS OUT OF THE MOUTH 14. BEST SUCCESS: REIMPLANTATION WITHIN 30 MINUTES, SIGNIFICANT ROOT RESORPTION SEEN IN TEETH REPLANTED AFTER 2 HOURS G. ENDODONTIC TREATMENT OF TRAUMATIZED PRIMARY TEETH 1. CROWN FRACTURES a. SAME TREATMENT AS PERMANENT b. IF PHYSIOLOGIC ROOT RESORPTION HAS STARTED AND CHILD IS UNCOOPERATIVE - EXTRACT 2. ROOT FRACTURES a. ENDODONTIC TREATMENT NOT INDICATED b. CORONAL FRAGMENT IS EXTRACTED AND APICAL FRAGMENT IS LEFT IN PLACE AND ULTIMATELY RESORBS 3. LUXATED OR REPLANTED TEETH WITH PULP NECROSIS - EXTRACTION IS TREATMENT OF CHOICE 4. EXTRUDED TEETH OR TEETH WITH PULP CANAL OBLITERATION AND NECROSIS - EXTRACTION IS TREATMENT OF CHOICE H. ORTHODONTIC TREATMENT OF TRAUMATIZED TEETH 1. IF PERIODONTAL LIGAMENT INTACT WITHOUT PERIODONTAL INFLAMMATION OR INFECTION - TOOTH CAN BE MOVED WITH SAME PROGNOSIS IN REGARD TO ROOT RESORPTION AS NON- TRAUMATIZED TEETH. I. TEETH IN FRACTURE LINES 1. RULE: LEAVE TOOTH IF LOCATED WITHIN A FRACTURE LINE AND ITS PRESENCE WOULD AID MAINTENANCE OF OCCLUSION AND ANATOMIC REDUCTION OF THE MANDIBLE. 2. REMOVE IF TOOTH ROOTS ARE FRACTURED ESPECIALLY A POSTERIOR TOOTH 3. REMOVE IF NEAR FRACTURE LINE AND: a. FRACTURE ENTERS TOOTH PULP b. CROWN FRACTURES SECONDARY TO CARIES c. PERIAPICAL INFECTION PRESENT d. TOOTH PREVENTS ADEQUATE REDUCTION 4. TOOTH EXTRACTION - CURETTE THE SOCKET TO REMOVE RESIDUAL ROOT TIPS, OTHERWISE INCREASED RISK OF INFECTION 5. SHOULD EXTRACT UNERUPTED THIRD MOLARS IN THE REGION OF A MANDIBULAR ANGLE FRACTURE, EXTRACT INTRA-ORALLY BECAUSE OF THE EFFECTS OF THE TOOTH ON FRACTURE REDUCTION. 6. PROGNOSIS OF TEETH LEFT IN FRACTURE LINE a. INFECTION IN FRACTURE LINE 5-29% b. PULP NECROSIS 5-25% c. PULP CANAL OBLITERATION 2-5% d. PROGRESSIVE ROOT RESORPTION 1-3% e. LOSS OF MARGINAL BONE SUPPORT 11-12% -------------------------------------------------------------------------------- BIBLIOGRAPHY 1. Andreason, J.O.; Traumatic Injuries of The Teeth, 2nd. Ed. Copenhagen, Muskgaard, Philadelphia, Saunders; 1981 2. Antrim, D.D.; et. al.; Treatment of Endodontic Urgent Care Cases, Urgent Care; Dent Clin North Am , 30:3 549-572, July 1986, Saunders, Philadelphia. 3. Castellano, N. ; Dental Aspects of Maxillofacial Trauma, Symposium on Trauma to The Head and Neck; Otolaryngol Clin North Am., 1983 August 16(3) p. 509-524. 4. Dingman, R.O. and Natvig, P.: Surgery of Facial Fractures. Philadelphia, Saunders, 1964. p. 111-131. 5. Holt, G.R.: Maxillofacial Trauma, Chapter 19; in Cummings, C. Otolaryngology - Head and Neck Surgery, Vol. 1 , 1986, pp. 333-343, Mosby, Toronto. 6. 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