FEATURE 34 structures facial suchthe as infraorbital the rim, examination done can be by gently palpating of traumatised the . Ageneral facial made for short the and long-term management arch fractures and to partly ensure aclear plan is fractures such as mandible, orbital or zygomatic other such as brain injuryand facial systematic assessment. Partly is this to eliminate acutely, it is important to and perform adetailed When managing dental trauma, especially soft tissuesandteeth clinical examination oftheface, history andcarryoutathorough 1. confdence. help update your knowledge and your boost management and signpost it will resources to highlight main the principles of dental trauma outcomes for patient. the Tis article aims to phase, result as will this inimproved long term manage dental trauma, acute inthe especially dental professionals to understand how to best on guidelines. revised based It is important for to alack of or experience updated knowledge ingeneral practice.especially Tis is mainly due challenging and experience overwhelming very Te management of dental trauma a can be general practice Dental trauma managementin practice in general dental trauma to managing step guide A step-by-

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tooth is critical as early intervention can Table 1 Recommended splinting time for each type of dental injury improve outcomes. Efective management is dependent on achieving good local anaesthesia.2 Type of injury Splinting time Tis difers according to the type of injury. In this section, the most complex injuries and Lateral luxation 4 weeks those which have been recently updated will be Extrusion 2 weeks outlined. For information on those which are not covered in this section refer to the Dental Intrusion 4 weeks Trauma Guide3 for detailed information about dental trauma management and the updated Alveolar fracture 4 weeks IADT guidelines.4,5,6 Avulsion (EODT <60 minutes) 2 weeks Splinting Avulsion (EODT >60 minutes) 2 weeks Te following dental injuries in the permanent dentition require splinting: avulsion, intrusion, Apical 1/3 root fracture 4 weeks extrusion, lateral luxation, alveolar fractures and displaced root fractures. Non rigid or Mid 1/3 root fractured 4 weeks fexible splint placement aims to immobilise and stabilise the tooth in the correct position Cervical 1/3 root fracture 4 months (rigid splinting is recommended) to avoid further damage and allow healing. In Type of injury Splinting time the primary dentition splinting is indicated if there are signs of alveolar fracture. Each type of Lateral luxation 4 weeks dental injury requires a diferent splinting time otherwise the risk of ankylosis increases. Table 1 Extrusion 2 weeks summarises the length of time needed to splint the traumatised tooth for each type of injury. Intrusion 4 weeks Te most common method of splinting is Alveolar fracture 4 weeks using composite and wire (wire of a diameter up to 0.016” or 0.4 mm stainless steel is ideal) Avulsion (EODT <60 minutes) 2 weeks placed one tooth either side of the injured tooth. Make sure to reposition the tooth, check Avulsion (EODT >60 minutes) 2 weeks the occlusion, take a radiograph to ensure the splinted tooth is correctly positioned in the Apical 1/3 root fracture 4 weeks socket and lastly, splint the traumatised teeth.5 Mid 1/3 root fractured 4 weeks Afer the specifc splinting time is over, the splint and composite should be removed, and long- Cervical 1/3 root fracture 4 months (rigid splinting is recommended) term management initiated. For detailed step by step emergency management of each type of injury and a clinical guide to simple splinting It is crucial to note that based on the recent Complicated fractures refer to the Saving Smiles Practitioners’ Toolkit,1 update of the IADT guidelines 2020,5 all isolated If there is pulpal exposure, all attempts should the article by Chauhan et al.2 and the updated avulsion injuries are now splinted for two weeks be made to maintain tooth vitality. Under local IADT guidelines.4,5,6 regardless of the extra oral dry time (EODT). In anaesthesia and isolation, 2-3 mm of pulp cases of associated alveolar four tissue is removed through the exposure using Avulsion weeks of splinting is advised. a small round diamond bur. Using a cotton A permanent avulsed tooth must always be Endodontic treatment must be initiated wool pledget soaked in sodium hypochlorite reimplanted. An avulsed tooth should be picked within two weeks before the splint is removed apply pressure to clean the area and stop the up by the crown. If it is dirty, it must be gently in teeth with closed apices. In teeth with open bleeding then apply non-setting calcium rinsed in milk, saline or the patient’s saliva apices, there is a high chance that pulp space hydroxide or MTA. Ten apply glass ionomer before immediate reimplantation. Te patient revascularisation may occur. Terefore, root and restore the tooth by either reattaching must bite on a handkerchief to hold the tooth canal treatment should only be initiated if there the fragment or build up with composite. in place. If reimplantation at the accident site is are clinical and radiographic signs of pulp If the pulp does not stop bleeding remove not possible the tooth must be stored in either necrosis on follow up examination.5 a further 1 mm and apply pressure until milk, saliva or saline until reimplantation by haemostasis is achieved. If haemostasis of a clinician. Once the patient has attended the Uncomplicated crown fractures pulp cannot be achieved, it indicates that the clinic, confrm the repositioning of the tooth In enamel-dentine fractures without pulpal pulp is irreversibly infamed, and a full pulp both clinically and radiographically. Correct exposure or uncomplicated crown fractures, tissue removal or extirpation is required. For any mispositioning using gentle fnger pressure if the fragment is available it can be reattached more information on how to carry out the under local anaesthesia up to 48 hours afer the using resin composite, otherwise the tooth Cvek partial pulpotomy technique to preserve incident. If the tooth has not been reimplanted should be restored using direct composite tooth vitality and for guidance on how to treat at the site, clean the socket frst and remove any placement which is preferred over temporary other fracture types refer to the Saving Smile blood clots.5 glass ionomer bandage.2 Practitioners’ Toolkit.1 www.nature.com/BDJTeam BDJ Team 35 © 2021 The Author(s), under exclusive licence to British Dental Association FEATURE

Table 2 Recommended recall intervals from time of injury for fractures and secondary specialist services can be considered luxation injuries for a second opinion or long-term treatment. In conclusion, at times dental trauma can Injury type Follow up times be complicated to manage, however, dental professionals have the skills and resources Complicated and uncomplicated crown available to be able to confdently manage these 3 months, 6 months, yearly fractures cases. An important point to remember is that Complicated and uncomplicated crown- when treating children, the focus should be 3 months, 6 months, yearly root fractures the child and not the tooth. In the early stages of management, the child is ofen upset from Root fractures 4 weeks, 3 months, 6 months, yearly the experience of dental trauma and dental treatment at this point can lead to dental Intrusion 4 weeks, 3 months, 6 months, yearly anxiety. Some cases are more complex, and it is important to note that there is always the 2 weeks, 6 weeks, 3 months, 6 months, Extrusion option to refer or to liaise with a local paediatric yearly specialist if needed. 2 weeks, 4 weeks, 2 months, 6 months, Avulsion EODT <60 minutes yearly References 2 weeks, 4 weeks, 2 months, 6 months, Avulsion EODT >60 minutes 1. Greater Manchester Local Dental Network. yearly Saving Smiles. Improving outcomes Lateral luxation 4 weeks, 3 months, 6 months, yearly following dental trauma. Practitioners’ Toolkit. First Edition, Spring 2017. Available at: https://www.dental-referrals. Root fractures the long term is also vital to the successful org/wp-content/uploads/2017/08/Saving- Under local anaesthesia, the coronal fragment management of these cases. Te aim of recall Smiles-V8.pdf (accessed February 2021). should be digitally repositioned then check is to monitor healing and to check signs and 2. Chauhan R, Rasaratnam L, Alani A, Djemal the occlusion before splint placement. For symptoms of necrosis. Table 2 summarises S. Adult dental trauma: what should the apical and middle third fractures, four weeks of injury specifc follow up times. Te aim of long- dental practitioner know? Prim Dent J 2016; non-rigid splinting is needed but cervical third term management is to maintain pulp vitality 5: 70-81. fractures require four months.4 and therefore at each review appointment 3. Dental Trauma Guide. Evidence based discolouration, mobility, tenderness to palpation treatment guide. Available at: www. Give appropriate aftercare advice and percussion, sinus, sensibility testing and dentaltraumaguide.org (accessed February Appropriate afercare advice includes: sof diet radiographic assessment are needed.1,2 2021). for 2-4 weeks, maintain good oral hygiene, Endodontic therapy should only begin if 4. Bourguigno C, Cohenca N, Lauridsen gently brush 2 x times daily as normal, rinse there are two or more signs (discolouration, E et al. International Association of gently with mouthwash 2-3 tender to percussion, buccal tenderness, Dental Traumatology guidelines for the times daily for 14 days, take painkillers as and presence of sinus, negative response to management of traumatic dental injuries: when required, fnish the course of antibiotics sensibility testing and radiographic evidence of 1. Fractures and luxations. Dent Traumatol if prescribed, avoid participation in contact periapical radiolucency or widening of PDL) or 2020; 36: 314–330. sport and follow up tetanus status with your symptoms (spontaneous pain or pain on biting) 5. Fouad A F, Abbott P V, Tsilingaridis GP (if injury happened where there was soil). of loss of vitality or . However, G et al. International Association of Consider giving a patient information leafet, in intrusion and avulsion injuries endodontic Dental Traumatology guidelines for the of which there are a number available, to help treatment (extirpation) should be started within management of traumatic dental injuries: them retain the information.7 In addition, it is 7-10 days in teeth with closed apices. Obturation 2. Avulsion of permanent teeth. Dent important to inform the patient or the parent of can be completed once the splint has been Traumatol 2020; 36: 331–342. the possible sequalae of primary or permanent removed. For root fractures root canal therapy is 6. Day P, Flores M T, O’Connell A et al. dental trauma. carried out up to the fracture line.1,2 International Association of Dental Note that the use of systemic antibiotics afer Traumatology guidelines for the avulsion and reimplantation is recommended 6. Consider referral to secondary management of traumatic dental injuries: to prevent infection, as ofen the avulsed care for long term management 3. Injuries in the primary dentition. Dent tooth becomes contaminated by bacteria and All general dental practitioners should be Traumatol 2020; 36: 343-359. it will also help to decrease the occurrence of competent in assessment, diagnosis and 7. East Kent Hospitals University NHS infammatory root resorption. Amoxicillin is management of dental trauma. Te acute Foundation Trust. Dental trauma considered as frst line.5 management can have a signifcant impact on patient information leafet. September the long-term prognosis of the traumatised 2020. Available at: https://www.ekhuf. 5. Appropriate clinical follow-up and tooth; therefore, it is essential that dentists nhs.uk/patients-and-visitors/services/ long-term management make all eforts to manage all dental injuries restorative-dentistry-service/patient- Generally, afer acute management of the immediately and in the long term. However, leafets/?entryid103=494011 (accessed dental injury regular review at specifc time in higher risk injuries such as lateral luxation, February 2021). intervals is important. Not only is this important intrusion and dento-alveolar fractures where in the short term but close monitoring in management can be challenging referral to https://doi.org/10.1038/s41407-021-0623-y

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