3 Permanent

• Outcome is dependent on

  • proper diagnosis
  • prompt Tx
  • appropriate follow yp
• most common

  crown fractures and luxations
• What is the key aim of Tx?

  preserve pulp vitality
• Assessment ?

  • baseline rad essential
  • in emergency can act in best interest so Px not required
  • PA or USO
  • Photos for medicolegal
  • sensibility tests
• what should be splinted for 4 weeks

  lateral and intrusive luxation
• what should be splinted for 2 weeks if mobile

  subluxation, extrusive luxation and avulsion
• What injuries need repositioning

  lateral luxation, extrusive luxation and avulsion
• Concussion?

  • tooth immobile 
  • TTP
  • Likely responsive to sensibility tests
  • No radiographic abnormalities
  • No Tx required 
  • Home care advice 
  • Refer to dentist for follow up - monitor for life
• Subluxation?

  • mobile but not displaced
  • TTP
  • bleeding from gingival crevice
  • no rad abnormalities
  • splint only is +++ mobile
  • home care
  • refer to dentist for monitoring
• Extrusion?

  • tooth looks elongated
  • +++ mobility
  • unlikely to respond to sensibility tests
  • LA and reposition with gentle digital pressure
  • splint
  • home care advice
  • refer to dentist for follow up within 2 weeks
• Intrusion ?

  • tooth pushed upwards into gum
  • immobile
  • unlikely to respond to sensibility tests
  • home care advice
  • refer to dentists for follow up

  mature root = less than 3mm = let re erupt

  more than 3mm = reposition

  immature root = allow to re erupt
• Lateral luxation?

  • displacement labially or palatally
  • often immobile
  • widened PDL
  • LA and reposition w/ gentle digital pressure
  • splint
  • home care
  • dentist follow up
• splinting ?

  • short term
  • holds tooth passively and flexibly
  • aims to immobilise tooth in correct position
  • prevents more trauma and allows healing
  • include 1 tooth either side of injury
• What is the best option for splinting

  up to 4mm diameter ortho wire and composite

  if necessary can use paperclip
• Splinting Technique?

  1. length of wire and pre bend to fit across mid-third of labial surface 
  2. Ensure surfaces are clean 
  3. Etch and bond each labial surface 
  4. Place 3mm diameter “blob” of composite 
  5. Position wire in to composite 
  6. Apply blob over the top if required 
  7. Light cure 
• What do you need to ensure when splinting?

  • composite smooth to prevent PRF
  • composite away from GM
  • end of wire enclosed
• Avulsion prognosis?

  dependent on:

  • root maturity
  • extra alveolar dry time
  • storage medium
• Avulsion Tx

  Almost always replant, carry out emergency Tx and immediate ref to dentist
• When should you exercise caution/not replant and avulsed tooth?

  • MH: immunocompromised, cardiac issues
  • Poor cooperation
  • Cognitive impairment
  • Severe caries/ perio 
• Phone advice

  • keep child + adult calm
  • hold tooth by crown - dont touch root
  • if dirty rinse in milk for 10 secs
  • replace in socket w firm pressure and orientate right way - will have to describe this to them !
  • if clot already forming needs +++ pressure
  • bite gentle on cotton pack

  can also place in milk and saliva (saliva best esp if from person whos tooth it is) and attend practice immediately
• Why shouldnt you touch and avulsed tooth's roots

  disturbs pdl fibres
• Tx if replanted at scene?

  1. dont remove
  2. clean area
  3. verify position
  4. rads
  5. LA
  6. splint
  7. home care
  8. ABx/tetanus = GP
  9. dentist for follow up
• If tooth replanted the wrong way can we remove?

  NO - too similar to XLA for DHT
• Tx if NOT replanted at scene ?

  1. handle by crown only
  2. rinse w saline
  3. LA
  4. irrigate socket w saline
  5. replant w firm digital pressure
  6. rads
  7. splint
  8. home care
  9. ABx or tetanus = GP
  10. dentist follow up
• General considerations ?

  • pt interest
  • cooperations
  • MH
  • OH
  • Caries
  • Perio status
  • Ortho
• Local considerations/factors?

  • extent of injury
  • condition of tooth
  • storage medium
  • extra alveolar dry time
• replantation and intrusion have what % pupal survival after 5 years if they have a closed apex

  0%
• most likely -> least likely to heal injuries

  1. concussion
  2. subluxation
  3. extrusion
  4. lat luxation
  5. intrusion
  6. replantation
• uncomplicated crown fracture ?

  involves enamel +/- dentine

  1. account for missing pieces
  2. baseline rads/photos
  3. reattachment possible?
  4. caoh if close to pulp
  5. exposed dentine = GIC bandage
  6. restore with composite but only if Px if not can only do GIC
  7. home care
  8. dentist follow up
• complicated crown fracture?

  involves pulp

  • missing fragment
  • baseline rad / photos
  • direct pulp cap w CaOH
  • GIC / composite bandage
  • home care
  • refer to dentist for follow up
• Root fracture options?

  1. apical third
  2. mid third
  3. coronal third

  rads needed to detect where fracture is
• Repositioning favours ... ?

  healing, reduces risk of necrosis
• Tx root fracture on immature/mature teeth?

  1. reposition w LA
  2. Splint
  3. Home care
  4. ref to dentist for follow up
• Apical and mid root fracture splinting time

  4 weeks
• Coronal root fracture splinting time

  up to 4 months
• Root resorption?

  • serious destructive complication
  • can follow trauma to primary and permanent
  • primary = extract
  • permanent = may respond to specialist Tx