5 – Traumatology (Adult)

5

Traumatology (Adult)

Ann M. Boyle, DMD, MA, and Kenneth G. Seckler, DMD

In cases of trauma to the dentition, a comprehensive medical history and a history of the traumatic incident are essential. The medical history should include immunization status, allergies, conditions that require pre-medication with prophylactic antibiotics, and any other specific medical problems or systemic conditions that require special consideration in the rendering of dental care.Awell-documented history of the traumatic incident provides valuable information about the location, nature, and extent of the injuries; the probability of contamination; the best choice of treatment based on time factors; and the prognosis for recovery.

Since trauma sufficient to create dental injury could have created more extensive damage, it is important to rule out neurologic involvement or other systemic injury. Determine whether the patient was unconscious or has experienced headache, nausea, or vomiting. Obtain a history of past trauma to the dentition and determine whether any treatment has already been rendered. Inquire about the nature, severity, and duration of any dental pain and whether there has been a change in occlusion.

Basic Evaluation Procedures

Step 1 The clinical examination begins by visually observing the patient’s general status. Because injury beyond the dental hard and soft tissues should be ruled out, check for signs of neurologic or systemic injury. Even if the patient cannot remember a period of unconsciousness, observe closely for signs of head injury, such as confusion, incoherence, abnormal eye movements , dilated pupils, or clear fluid or blood coming from the nose or ears. Also note respiration difficulties and check blood pressure and pulse rate.
Step 2 The extraoral examination should note the location and extent of abrasions, contusions, lacerations, swelling, or asymmetry. Palpate the lacerated soft tissues carefully for tooth fragments or debris, although they may be difficult to detect. Observe opening and closing movements for asymmetry as an indication of possible dislocation or condylar fracture. Palpate the mandible and other facial bones for discontinuity that would indicate fracture . A wound under the chin may be associated with symphysis or condylar fracture as well as fractures to the teeth.
Step 3 Intraorally, check the oral mucosa and gingiva for lacerations, swellings, and bleeding sites. Assessment of the dentition will require clear visibility. Remove blood and debris using irrigation and suction. Avoid use of the air syringe. Begin evaluation of the dentition by noting fractures, exposed dentin, and exposed pulp. When the teeth are intact, transillumination through the teeth faciolingually as well as parallel to the long axis will aid in identifying infractions.
Test for mobility in both vertical and horizontal directions, keeping in mind that newly erupted teeth and partially resorbed primary teeth may have been mobile prior to the trauma. When testing for mobility, pay attention to adjacent teeth as well as the tooth being tested. Several teeth moving together may indicate alveolar fracture. Placing a finger over the alveolar plate while testing mobility can also help identify crown/root fractures.
Look for displaced teeth and note the direction and extent of displacement . Confirm changes in tooth position by checking for occlusal abnormalities. Percussion of displaced teeth for tenderness and pain will help determine whether there is damage to the periodontal ligament, while a “metallic” tone elicited on percussion indicates that the displaced tooth has become wedged against bone.
Pulp testing may not yield conclusive evidence for pulpal vitality in recently traumatized teeth, but it will establish a baseline measure for future comparison at follow-up visits.
The color of each tooth should be noted, since color change may accompany loss of vitality.
Step 4 The radiographic examination should include a soft tissue radiograph for any area where a penetrating laceration may contain pieces of tooth or other foreign bodies. Besides revealing the stage of root formation for younger patients, radiographs of the injured teeth may provide conclusive evidence of root fracture and corroborate luxation injuries. An occlusal exposure provides a superior view for revealing lateral luxations, root fractures, and alveolar fractures. Three periapical exposures directing the beam central to the injured area and medial and lateral to it should, because of the changes in angle, be able to reveal root fractures and dislocations.
Step 5 Finally, when possible, a photographic record of the patient’s injuries can provide helpful documentation for insurance claims, legal claims, or treatment planning.

Complicated Crown Fracture

Evidence of pulpal exposure will be a visible bleeding site on the fractured surface. The patient may experience pain with exposure to air, thermal change, or function. Sharp edges and poor esthetics may also be reported by the patient.

Treatment

Treatment decisions will vary depending on the size of the exposure, the amount of time since the injury, the evidence of luxation injury, the stage of root development, and the potential restorative need for a post.

For teeth with immature root development, the goal of treatment should be to preserve the vital pulp tissue despite injury and contamination so that root development may proceed to completion (Fig 5-5). For teeth with mature root development, preservation of pulpal vitality may not be possible if there has been a displacement injury, due to disruption of vascular supply to the fractured tooth (Fig 5-6).

Step 1 Pulp capping with calcium hydroxide is indicated only for small exposures with minimum time since injury. Because microleakage will compromise pulp vitality, the restoration placed over the calcium hydroxide must achieve an effective seal. A composite resin, when properly bonded, will resist microleakage. For temporary restoration, zinc oxide-eugenol (ZnOE) cement will provide the best seal, but will interfere with the polymerization of subsequently placed composite resin materials.
Step 2 A pulpotomy is indicated when contaminated and inflamed pulpal tissue is limited to the most coronal area of the pulp and can be removed to expose vital tissue capable of repair. The extent of inflamed tissue that must be removed will vary depending on the length of time since the injury, size of exposure, and patient response to the trauma. Usually an exposure of less than 24 hours can be successfully treated by a partial pulpotomy to a depth of 2 mm apical to the fracture site (Fig 5-7).
e9780867155297_i0159.jpg

Fig 5-5 Treatment decisions for complicated crown fractures on teeth with immature roots.

e9780867155297_i0160.jpg

Fig 5-6 Treatment decisions for complicated crown fractures on teeth with mature roots.

Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 5 – Traumatology (Adult)
Premium Wordpress Themes by UFO Themes