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.
Being Prepared for Dental Emergencies
- Never treat a stranger. Always obtain a thorough medical history prior to initiating treatment. A history of the incident is also essential to making treatment decisions.
- Use an exam checklist. In the confusion surrounding the emergency, a checklist ensures that nothing is overlooked.
- Be alert. Trauma to the adult dentition is usually associated with a head trauma. Observe the patient’s state, and check for signs of head injury beyond damage to the dentition and oral soft tissues.
- Be thorough. In cases with lacerations, check the soft tissue carefully for tooth fragments or debris. When checking for tooth mobility, observe for signs of alveolar fracture.
- Be cautious. Tests for pulp vitality are not reliable immediately following injury. Do not make treatment decisions on the basis of these diagnostic tools.
- Document fully. Good written records, quality radiographs, and clinical photographs may be needed for insurance or legal purposes.
- Follow up. The course of healing for traumatized teeth is not reliably predictable. Regularly reevaluate the status and vitality of the injured dentition.
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.|
Crown fractures are typically caused by concussive contact from falls, sports, auto accidents, and altercations. The anterior teeth are most frequently involved. The fractures may be associated with other injuries, such as soft tissue laceration and subluxation. The force of a blow severe enough to cause fracture may also have caused displacement that can affect pulpal and periodontal status. The pain or discomfort reported immediately is usually the result of concussive injury. Fractures limited to the anatomic crown can be placed in three categories. Infraction is an incomplete fracture of enamel without loss of tooth structure (Fig 5-1). Uncomplicated fracture may involve loss of structure limited to enamel or including both enamel and dentin (Fig 5-2). A fracture large enough to expose the pulp is called a complicated crown fracture (Fig 5-3).
In the case of infraction the crown is intact. Crack lines in vertical, horizontal, or oblique directions may or may not be visible in direct light. The patient may have pain on function.
Infraction injuries to tooth structure are most easily visualized by directing a fiberoptic light source along the long axis of the tooth (Fig 5-4).
|Step 1||In infraction injuries, where the fracture appears to be limited to the enamel, definitive treatment may not be required.|
|Step 2||Dentinal vulnerability to bacterial contamination via the fracture line might eventually compromise the pulp and should be a concern . Seal the fracture line using a resin-bonding procedure.|
|Step 3||If there is pain on function, relieve the occlusion.|
|Note:||While the incidence of pulpal necrosis following these injuries is very low, recall visits should be scheduled at 1, 3, 6, and 12 months, and annually. Examination should include pulp vitality tests and periodic radiographs. The stage of root development, extent of associated luxation injury, size of the fracture, and timing and type of treatment are all factors that can affect the prognosis.|
Uncomplicated Crown Fracture
In uncomplicated fractures, a section of tooth is missing. There may be pain on function or with thermal change, and complaints related to sharp edges or poor esthetics.
Simple crown fractures involving enamel or enamel and dentin are easily seen. In both cases, periapical radiographs should be checked to assess periodontal ligament spaces for evidence of displacement.
|Step 1||For minimal loss of enamel, where the patient is not concerned about esthetics, smoothing and polishing the sharp edges may be sufficient.|
|Step 2||When dentin has been exposed, the tubules must be sealed with a dentin-bonding agent to prevent eventual bacterial invasion of the pulp.|
|Step 3||For more extensive fractures, the broken piece may be reattached using a resin-bonding procedure, or composite resin can be used to replace missing structure.|
|Step 4||If the patient is experiencing pain on function, the occlusion should be adjusted.|
|Note:||While the incidence of pulpal necrosis following these injuries is markedly low, recall visits should be scheduled at 1, 3, 6, and 12 months, and annually. Examination should include pulp vitality tests and periodic radiographs. The stage of root development, extent of associated luxation injury, size of the fracture, and timing and type of treatment are all factors that can affect the prognosis .|
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.
Clinical observation of a cleansed fracture site will readily indicate any pulpal exposure. Radiographic examination is important in revealing the size of the pulp and the stage of root development, which is particularly important in making treatment decisions.
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).|
Partial pulpotomy procedure
- Administer local anesthesia and isolate with a rubber dam.
- Use intermittent application of a high-speed diamond rotary instrument with copious water spray to remove inflamed pulpal tissue. Begin with a partial pulpotomy: Excavate to a minimum depth of 2 mm. If hemostasis cannot be achieved within 5 minutes with gentle pressure, increase depth in 1-mm increments until hemostasis can be achieved.
- Once hemostasis is achieved, fill excavation with hard-setting calcium hydroxide to a level even with the fracture site.
- Acid etch, prime, bond, and complete placement of composite resi/>