DENTAL TRAUMATOLOGY

Oral and Maxillofacial Department Faculty of Dental Universitas Airlangga DENTAL TRAUMATOLOGY n DENTAL TRAUMATOLOGY à Branch of dentistry ¨Epidemiology ¨Etiology ¨Prevention ¨Assessment ¨Diagnosis ¨Management of trauma to the jaw and surrounding tissues n DENTAL TRAUMA ¨Simple ¨Complex à management may be interdiciplinary or multidiciplinary n Traumatic are typically quick, sudden, and unexpected à Clinicians must be prepared to render appropriate emergency care any time TRAUMA n NON INTENTIONAL : ¨ Domestic, recreational, sport, work, vehicular related injury (are not inflicted on purpose by one’s self or another person n INTENTIONAL INJURY : ¨ Suicide, homicide, domestic abuse, war, terrorism and other such injuries that are purpose fully inflicted n There are basiccaly 2 types of injuries to dentition : ¨Hard tissue injuries : nTeeth, alveolar bone, and other facial bones. ¨Soft tissues injuries : nFacial skin, lips, mucosa (cheeks and periodontium) soft tissues of the hard ad soft palate, and tongue.

Hard tissues injuries n Tooth injuries ¨Crown fracture : nEnamel infraction. nComplicated crown fracture nUncomplicated crown fracture ¨Rooth fractures :

n Crown-root fracture n Intraalveolar root fractures ¨Luxation injuries

n n Subluxation n Lateral luxation

n Intrusion n Extrusive luxation n Avultion (or exarticulation) n Alveolar injuries

Soft tissue injuries PATIENT ASSESSMENT n MEDICAL EMERGENCY CONSIDERATION n ORAL EMERGENCY CONSIDERATION n Patient History n Soft tissue clinical examination ¨ Extraoral examination ¨ Intraoral examination n Soft tissue Radiographic examinaton

n Hard tissue clinical examination ¨ Alveolar bone ¨ Teeth n Observation n Mobility n Percussion n Pulp vitality n Laser doppler flowmetry n Hard tissue radiographic examination ¨ Teeth ¨ Alveolar Bone

n PEDIATRIC CONSIDERATION n GERIATRIC CONSIDERATION CROWN FRACTURES n CLASISIFICATION n ETIOLOGICAL FACTORS n DIAGNOSIS AND CLINICAL FINDINGS n RADIGRAPHIC FINDINGS n BOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES n ENAMEL INFRACTIONS AND ENAMEL FRACTURES ¨ Diagnosis ¨ Histopatology ¨ Treatment ¨ Prognosis n ENAMEL-DENTIN FRACTURE WITHOUT PULP INVOLVEMENT (UNCOMPLICATED CROWN FRACTURES) ¨ Diagnosis ¨ Histopatology ¨ Treatment n Restoration (Composite Buildup) n Reattachment of Coronal Segment ¨ Prognosis n Restoration by Composite Buildup n Reattachment of Coronal Segment n ENAMEL-DENTIN FRACTURE WITH PULP INVOLVEMENT (COMPLICATED CROWN FRACTURES) ¨ Diagnosis ¨ Histopatology ¨ Factors Influencing Choice of Treatment ¨ Treatment : Mature and Immature Teeth n Direct Pulp Capping

n Pulpotomy (Partial or Coronal)

n Coronal Pulpotomy

n Deep Pulpotomy n Deep Pulpotomy

n Follow-up to Pulp Capping and Pulpotomy ¨ Pulp-Capping Agents ¨ Prognosis

n TREATMENT TECHNIQUES FOR NONVITAL TEETH ¨ Mature Teeth ¨ Immature Teeth n Apexification n Apexification : Technique n Apipcal Barrier : Technique n RESTORATION OF IMMATURE ROOTS n CROWN FRACTURES IN PRIMARY TEETH ¨ Clinical Appearance ¨ Radiographic Appearance ¨ Biological Considerations ¨ Uncomplicated Crown Fractures (No Pulp Exposure) ¨ Complicated Crown Fractures (Pulp Exposure) n Incidence n Treatment Options ¨ Direct pulp cappping : technique ¨ Partial pulpotomy or Cvek Technique ¨ Pulpotomy (Partial/Coronal) ¨ Pulpectomy ¨ Extraction

INTRA ALVEOLAR ROOT FRACTURES n TERMINOLOGY AND EPIDEMIOLOGY n CLINICAL PRESENTATION n RADIOGRAPHIC PRESENTATION n HEALING CLASSIFICATIONS n SEQUELAE ¨Pulp Survival with Canal Obliteration ¨Internal resorption ¨External Resorpsion ¨Loss of Crestal Bone

n HEALING PARAMETERS ¨Fracture Location ¨Diastasis ¨Tooth Maturity ¨Gender n MANAGEMENT ¨ Splinting ¨ Endodontic Treatment ¨ Treating the Coronal Fragment ¨ Treating the Coronal Fragment and Removing the Apical Fragment ¨ Treating the Coronal and Apical Fragments at the Same Time ¨ Removing the Corhnal Fragment and Treating the Apical Fragment n Crown-Root Fractures n Coronal Root Fractures

n PEDIATRIC CONSIDERATION LUXATION INJURIES n CLASIFICATION ¨Concussion ¨Subluxation ¨Lateral Lucation ¨Extrusive Luxation ¨Intrusive Luxation ¨Avulsion n ETIOLOGY AND EPIDEMIOLOGY n DIAGNOSIS OF LUXATION INJURIES : RADIOGRAPHIC AND CLINICAL ASPECTS ¨ Concussion ¨ Subluxation ¨ Lateral Lucation n Lateral Luxation Without Apical Displacement n Lateral Luxation With Apical Displacement ¨ Extrusive Luxation ¨ Intrusive Luxation

n TREATMENT OF LUXATION INJURIES ¨Emergency Treatment n General Treatment Considerations n Repositioning ¨Concussed and Subluxated Teeth ¨Laterally Luxated Teeth n Without Apical Displacement n With Apical Displacement

¨Repositioning Extruded Teeth ¨Repositioning Intruded Teeth n Spontaneous Eruption n Surgical Crown Uncovering n Surgical Extrusion ¨Splinting ¨Suturing Soft Tissue Lacerations ¨Additional Considerations, Prescriptions, and Instructions to the Patient

n Posttrauma Follow-up Evaluations and Treatment ¨ Recall Frequency ¨ Endodontic Evaluation and Treatment

n Mature Teeth (Closed Apex) n Immature Teeth (Open Apex) n SEQUELAE OF LUCATION INJURIES ¨ Types ¨ Pulpal n Periradicular n Diagnostic Means to Detect Sequelae on Follow-up

n EXPECTED HEALING OUTCOME OF LUXATION INJURIES AVULTIONS n ETIOLOGY AND EPIDEMIOLOGY n KEY ISSUES ASSOCIATED WITH PROGNOSIS AND MANAGEMENT OF AVULSED TEETH ¨ Pulpal Damage : Comparing Mature and Immature Teeth ¨ Periodontal Damage n EMERGENCY MANAGEMENT OF AVULSION INJURIES ¨ At the Site of the Injury (Outside the Dental Office) n Immediate Replantation n Transport Medium Before Replantation

¨ Emergency Management at the Dental Office n Patient Examination : Clinical and Radiographic Aspects n Socket Manipulation n Root Manipulation ¨ Extraalveolar dry time less than 1 hour or tooth stored in a proper storage medium : Closed Apex ¨ Extraalveolar dry time less than 1 hour or tooth stored in a proper storage medium : Open Apex ¨ Extraalveolar dry time Greater than 1 hour : Closed Apex ¨ Extraalveolar dry time Greater than 1 hour : Open Apex

¨ Splinting ¨ Endodontic Treatment Issues at The Emergency Visit ¨ Systemic Treatment n Antibiotics n Analgesics ¨ Instructions to the Patient ¨ Prognosis Assessment at the Emergency Visit n SEQUELAE OF AVULSION INJURIES ¨Consequences of Pulpal Necrosis ¨Consequences of Periodontal Damage : External Root Resorption

n Surface Root Resorption n Replacement Root Resorption n Inflammatory Root Rsorption n Cervical Root Resorption n POSTTRAUMATIC FOLLOW-UP AND MANAGEMENT ¨Need for Endodontic Treatment ¨Treatment Options for Open Apex Teeth that Failed to Revascularize n Apexification n One versus two step Apexification

n Pulpal Regenerations Modalities n EXPECTED HEALING OUTCOME OF AVULTIONS ¨ Epidemiological Data ¨ Signs of Nonhealing ¨ Treatment Options n AVULSED PRIMARY TEETH

ALVEOLAR FRACTURES

n EPIDEMIOLOGY AND ETIOLOGY n TERMINOLOGY AND CLASSIFICATION ¨ Comminution of the alveolar socket ¨ Fracture of the alveolar socket wall ¨ Fracture of the alveolar process ¨ Fracture of the mandible or maxilla n CLINICAL AND RADIOGRAPHIC FINDINGS n TREATMENT ¨ Antibiotic Treatment and Tetanus Prophylaxis ¨ Reduction ¨ Fixation and Immobilization n Composite Retained Wire Splint n Arch Bars n Acrylic Splint n Orthodontic Appliances n Plate-and-Screw Fixation ¨ Rehabilitation

n HEALING ¨ Sequence of Fracture Healing n COMPLICATIONS ¨ Malocclusion ¨ Loss of Alveolar Bone ¨ Loss of Teeth n PROGNOSIS AND OUTCOME ASSESSMENT ¨ The prognosis of alveolar fractures depends on the following factors : n Time interval between injury and fixation of alveolar fracture n Type of alveolar fracture n Associated dental injury (luxation or avulsion) to the teeth in the fractured segment n Stage of root development of the teeth involved n The health of the periodontal tissues n The presence of significant communication of bone and teeth. n PEDIATRIC CONSIDERATIONS SOFT TISSUE INJURIES AND MANAGEMENT n EPIDEMIOLOGY OF SOFT TISSUE INJURIES n ETIOLOGY OF SOFT TISSUE INJURIES n MANAGEMENT OF SOFT TISSUE INJURIES ¨THE FACE n Immediate Treatment of n Complementary Treatment for Facial Trauma

¨THE LIPS ¨CYANOACRYLATES AND THEIR DENTAL APPLICATIONS n Clinical Examination of the Lips n Radiographic Examination of the Lips

¨TECHNIQUE FOR CLOSING LIP WITH CYANOCRYLATES n Advantages of Cyanoacrylates n Disadvantages of Cyanoacrylates

¨THE MUCOSA ¨THE LABIAL FRENUM

¨THE TONGUE ¨ HEALING MECHANISM OF ORAL SOFT TISSUE WOUNDS n healing can be separated into 4 different phases : ¨ Hemostasis ¨ Inflammatory response ¨ Proliferation ¨ Remodeling n could be affected by : ¨ Local factors ¨ Regional factors ¨ Systemic factors ¨ Miscellaneous factors THE LAW AND DENTAL TRAUMA n DENTAL LAWS AND LICENSING REGULATIONS n LEGAL ISSUES ¨ Standards of Care ¨ Unprofessional Conduct ¨ Violations of Statues n CONSENT ISSUES ¨ Informed Consent/Refusal n Informed Consent n Informed Refusal n BURDEN OF PROOF n CAUSATION n CONDUCT OF OTHERS n GOOD FAITH SETTLEMENT n NATURE OF INJURY n NATURE OF TRAUMA n STANDARDS FOR TRAUMA CASES n GOOD SAMARITAN DEFENSES n NONINTENTIONAL INJURY/ACCIDENT/SPORTING CASES n ABUSE AND BATTERY CASES ¨ Confidentiality and Privileges ¨ Immunity ¨ Failure to Report ¨ Recognition of Abuse n Child Abuse n Abuse of the Elderly or Disabled n IATROGENIC TRAUMA CASES THE PSYCHOLOGICAL IMPACT OF DENTAL INJURIES n THE LITERATURE ON PSYCHOLOGICAL REACTIONS TO PHYSICAL INJURIES n REVIEWING EMOTIONAL AND BEHAVIORAL SYMPTOMS THAT MAY ACCOMPANY DENTAL INJURIES ¨ Acute Stess Disorder ¨ Posttraumatic Stress Disorder ¨ Other Signs of Distress n IMPLICATIONS FOR THE DENTIST IN PROVIDING SUPPORT TO A PSYCHOLOGICALLY AFFECTED PATIENT OROFACIAL TRAUMA PREVENTION n ATHLETIC MOUTHGUARDS n ORTHODONTIC AND MIXED DENTITION CONSIDSERATIONS n COMPLIANCE AND ACCEPTANCE OF MOUTHGUARDS n ROLE OF THE DENTIST IN OROFACIAL TRAUMA PREVENTION n MOUTHGUARD FABRICATIONS n ATHLETIC TEAM DENTISTS n SMOKELESS TOBACCO n EATING DISORDERS

REFERENCES n Fonseca RJ, Walker RV, Betts NJ, Dexter H. Oral and Maxillofacial Trauma. Vol. 1. WB. Saunders. Philadelphia. 1997. n Berman LH, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby Elsevier. 2007.