Dental Traumatology

Trauma is common in the oral area and includes 5% of all injuries people seek treatment. Among all facial injuries, the most common trauma is crown fractures and dental injuries, where luxations occur. An appropriate post-injury treatment plan is important for a good prognosis. [1]

According to the severity of trauma; enamel cracks, uncomplicated crown fractures, complicated crown fractures, crown-root fractures, root fractures, concussions, subluxation, lateral luxation, intrusion, extrusion, avulsion are observed in the teeth.

Enamel crack: No substance loss in the tooth. It is usually caused by a blow to the upper incisors. It does not require treatment, but tooth vitality should be checked. Topical fluorine can be applied for protection. The prognosis is excellent. [2]

Uncomplicated crown fracture: Vitalometric and radiographic examination should be done to ensure that the pulp is not affected by trauma. If the fracture is only at enamel level, sharp edges are mulled with burs. If it also includes broken dentine, direct composite restoration is performed. [3] If the broken piece is brought by the patient, it can be adhered to the tooth surface with adhesives.

Complicated crown fracture: It also includes the broken pulp. The purpose of treatment is primarily to maintain the vitality of the tooth. For this reason, continuity of vitality should be ensured by first trying kuafaj (pulp capping). However, if negative response is obtained as a result of repeated vitality controls, canal treatment should be started. If trauma occurs in young permanent teeth whose root tip is not closed, apexification treatment is applied.

Crown root fracture: Contains broken enamel, dentin and root structure. Pulp may or may not be exposed. The findings show that the tooth is loose but still connected. The position of the fracture line in the cement can vary from the upper edge of the alveolar bone to the inner edge of the alveolar bone, and there is often bleeding in the periodonium and pulp. [4]

Multiple radiographic angles may be required to detect fracture lines at the root. In its treatment, attempts to stabilize the loose segments of the tooth by binding may be advantageous temporarily. [one]

If the fracture is longitudinal and follows the long axis of the tooth or covers the coronal and more than 1/3 of the root, it cannot be restored and tooth extraction is recommended. For the restoration, root extrusion is required according to the severity of the fracture. Orthodontic or surgical extrusion can be done.

Root fracture: The coronal segment can be mobile and displaced. The tooth may be sensitive to percussion. The fracture may not be seen on the radiograph taken immediately after the injury. It usually becomes visible after 1-2 weeks. More than one angled radiographs may be required for diagnosis. The sensitivity test can give negative results initially, indicating pulpal damage; It is recommended to follow the pulp viability.

The relationship between the root fracture line and the gingival pocket determines the treatment to be made. If the root fracture is in the apical region, the coronal part is not displaced and immobile. Therefore, no treatment is applied to the teeth. [5]

If displaced, it is necessary to reposition the coronal segment of the tooth. Its position should be checked radiographically. The tooth is stabilized with a flexible splint for 4 weeks. If the root fracture is close to the cervical region of the tooth, it is useful to perform stabilization for a longer period of time (up to 4 months). [6]

Pulpal healing should be followed. If necrosis occurs in the pulp, the following methods can be applied. Endodontic treatment is performed on the coronal part and the apical part is removed surgically. The coronal piece is removed and the apical piece is hairdressed. Then the root is tried to be raised by orthodontic extrusion. Endodontic treatment is applied to the coronal part and the apical part is not touched. [7]

Confusion: In clinical findings, the tooth is sensitive to percussion. Dental mobility is normal and there is no juvenile bleeding. There is no radiographic abnormality. There is no need for treatment.

Subluxation: Tooth mobility increased, but no displacement. Bleeding may occur in the gums. Radiographic abnormalities are usually absent. There is no need for treatment. Pulpal prognosis should be followed. Splint can be applied for 2 weeks for patient comfort.

Lateral luxation: The tooth was generally displaced in the palatal / lingual or labial direction. The periodontal ligament is detached and damaged. In its treatment, the tooth is returned to its original position under local anesthesia. Splint is applied for 4 weeks. Pulpal status should be monitored. If pulp becomes necrotic, canal treatment is indicated to prevent root resorption. [8]

Intrusion: It is the displacement of the tooth into the bone. In milk teeth, this displacement may be towards the underlying dental germ. The tooth is immobile and can give a high metallic (ankylotic) sound in percussion. The tooth appears clinically shorter than other teeth. The periodontal ligament space on the radiograph may not be in the whole or part of the root.

In the treatment, spontaneous eruption is expected if the milk tooth is buried in the labial bone, but if the lower permanent tooth is displaced towards the germ, gravity is applied. Spontaneous eruption is expected in the teeth whose root development is not completed. If it does not occur within 3 weeks, orthodontic extrusion is applied. In the teeth whose root development is completed, the tooth is repositioned as soon as possible by orthodontic or surgical extrusion. Pulp is usually necrotic and root canal treatment with calcium hydroxide is recommended to keep the tooth in the mouth. [9]

Extrusion: It is the displacement of the tooth out of the socket. The tooth appears elongated and extremely mobile. Periodontal ligament space on the radiograph increased in the apical. If the treatment is delayed in the extruded teeth, the tooth is fixed in its new position. In this regard, the reposition of the tooth should be done quickly. In late cases, repositioning can also be performed orthodontically. [10] Splint is applied for 2 weeks. Canal treatment with calcium hydroxide should be started before removing the splint.

Avulsion: The tooth is completely out of the socket. Avulse milk teeth are not recommended to be reimplanted in case of damage to the permanent teeth below.

The main condition for prognosis is that the time outside the socket of the tooth is as short as possible and stored in the correct environment during this time. Avulsed tooth should be stored in milk or saliva until it is brought to the physician. It is the least desired condition to be stored in water.

Very few periodontal ligament cells can remain viable in the tooth that stays dry outside the mouth for more than 60 minutes. If the tooth is replaced within 30 minutes, success is 90%, 50 minutes in 60 minutes, 25% in 90 minutes, and if it is replaced after 2 hours, the chance of success is less than 20%. After reimplantation, the patient should be prescribed antibiotics and consulted for a tetanus vaccine.

In the teeth where the root tip is closed;

Avulse tooth has been stored in a suitable liquid or remained dry for less than 60 minutes; the tooth is cleaned with saline or chlorhexidine. It is reimplanted and splinted for 2 weeks with a flexible splint. Root canal treatment with calcium hiroxide should be done within 7-10 days after reimplantation and without removing the cyplint.

If the time spent in the dry outside of the mouth outside the mouth is more than 60 minutes; prognosis is poor. The clot in the socket is cleaned with saline. After the periodontal tissue residues that have lost their vitality on the tooth are removed, they are kept in a 2% sodium fluoride solution for 20 minutes. Root canal treatment can be done with calcium hiroxide before or after reimplantation. The tooth is gently reimplanted with finger pressure. Then a flexible splint is applied for 4 weeks.

In the teeth where the root tip is not closed;

Avulse tooth has been stored in a suitable liquid or remained dry for less than 60 minutes; The applications made before reimplantation are the same with the root tip closed teeth. After reimplantation, revascularization is tried but if it is not successful, root canal treatment is applied. It should be splinted with a flexible splint for 2 weeks.

If the time spent in the dry outside of the mouth outside the mouth is more than 60 minutes; prognosis is poor. Applications before reimplantation are similar to the root tip closed teeth. Canal treatment is performed and splinted for 4 weeks. [12]

References

[1] Flores, MT; Andersson, L. ;Guidelines for the management of traumaticdental injuriesI. Fractures and luxations of permanent teeth. Dental Traumatology, 2007, 23, 66-71

[2] Miomir Cvek, Jens O. Andreasen, Mette K. Borum ; Healing of 208 intraalveolar root fractures in patients aged 7–17 years. Dent Traumatol 2001, 17, 53–62.

[3] Kinoshita S, Kojima R,TaguchiY, NodaT. ; Tooth replantation after traumatic avulsion: a report of 10 cases. Dent Traumatol 2002, 18, 153-156.

[4] Ayhan E. , Ön Bölge Dental Travmalar ve Tedavilerinde kullanılan fiksasyon yöntemlerinin klinik araştırması, Doktora tezi 1999

[5] Bellekçi D. Travmaya uğrayan dişlerin tedavileri, Bitirme Tezi, Ege Üniversitesi Diş Hekimliği Fakültesi, 2000

[6] Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol 2004;20:192–202.

[7] Hürmüzlü F. , Travma sonucu kırılan üst santral dişlerde orijinal diş parçasının yeni adeziv sistem ile yapıştırılması, Cumhuriyet Üniversitesi Diş Hekimliği Dergisi; , 2002, 5, 89-91.

[8] Pişkin, Beyser ;Duransoy, Gözde ; Travmatik Dental Yaralanmayı Takiben Oluşan Kök Rezorpsiyonu. E.Ü. Diş Hek. Fak. Derg. 2005, 26, 161-164

[9] Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55–68.

[10] Flores, MT; Andersson, L. ; Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth teeth. Dental Traumatology, 2007, 23, 130-136.

[11] https://dentaltraumaguide.org

[12] Aksay B. , Turgut M , Altay N. , Avülsiyon Yaralanmaları, Hacettepe DişHekimliği Fakültesi Dergisi, 2009, 33, 3, 69-77.