Treatment of Dentoalveolar Injuries
After conducting a thorough history and clinical and radiologic examinations, the dentist should he able to determine whether the treatment plan for the patient’s type of injury is WIthin the clinician’s range of expertise. There may be several circumstances tha t render an otherwise
minor injury untreatable by the dentist alone. A problem the dentist frequently encounters is the uncooperative patient, most commonly a child. The combination of the traumatic episode and the child’s fear of the
dentist may render a simple surgical procedure impossible without general anesthesia. Another difficulty is the patient with multiple medical problems When dentists do not feel they can effectively manage a patient because of surgical difficulty, anesthesia requirement, concorrutant medical problems, or other reasons, an oral and maxillofacial surgeon should immediately be consulted for assistance with treatment.
Primary teeth that have been injured are generally treated in a manner similar to that for permanent teeth. However, in many instances, the lack of cooperation by the child results in treatment compromises and, frequently,
extraction of the damaged tooth. If this occurs.
Crown craze or crack. Because the cracks are limited to the enamel (i.e., enamel infraction) and usually stop before reaching the dentinoenamei junction, no treatment is usually indicated. However, because any force to
the tooth can result in injury to the pulp and periodontal tissues, periodic follow-up examinations are valuable (see .Fig. 23-9). Multiple cracks may be sealed with an unfilled resin to prevent their becoming stained.
If a considerable amount -of dentin is exposed, the pulp must be protected. Measures to seal the dentinal tubules and promote secondary dentin deposition by the pulp can be undertaken. Calcium hydroxide has been the
traditional material applied to the exposed dentin before the fractured part is covered with ~ suitable restoration, most commonly a composite with or without add etching. Current recommendations are the placement of a
dentin-bonding agent or glass ionomer cement over the exposed dentin, followed by the placement of a resin composite restoration.sGlass ionomer cements chemically bind to dentin, fadlitating placement and restoration.
The status of pulp vitality at periodic follow-up visits dictates what the final treatment plan will be. If pulp and periodontal health are satisfactory, no more intervention is necessary other than for esthetic reasons.
Crown-root fracture. The treatment of ‘crown-root fractures depends on the location of the fracture and localanatomic variance. If the coronal fragment is still in place,it must be removed to assess the depth to which
the fracture has gone. If the fracture does not descend too far apically (and the tooth is therefore restorable) and if the pulp has not been exposed, the tooth is treated as, . alreadydiscussed for crown fracture. . Depending on the apical extent of the fracture, it may be necessary to perform periodontal procedures to make the apical margin of the fracture accessible for restorative procedures. Alternatively, orthodontic extrusion of the
root can make it accessible for restorative procedures. If the pulp is involved and the tooth is restorable, endodontic treatment is implemented. If, on the other hand, the tooth is not restorable, removal is indicated. If a concomitant alveolar.fracture is fourid, the extraction may be deiayed for several weeks to permit the fracture to heal and thus prevent undue loss of alveolar bone at the time of extraction (see Fig. 23-11).
Intrusion. Traumatic intrusion of teeth indicates that the alveolar socket has sustained a compression fracture to permit the new tooth position. On percussion the tooth emits a metallic sound similar to an ankylosed
‘tootb~istinguishing it from a partially erupted or unerupted tooth. The intrusion may be so severe that the tooth actually appears to be missing on clinical exarnination, Traumatic tooth Intruston is-less frequent than lat-‘
eral displacements; when seen, it usually involves maxillary teeth. This type of nonavulsive tooth displacement has the worst prognosis (see Fig. 23-13, A).
The treatment of intruded teeth is controversial. Some clinidans favor surgically repositioning and splinting them; however, this treatment has resulted in serious periodontal and pulpal consequences. Others feel that, if left alone, many intruded teeth will reerupt. Others use o thodontic forcesto assist reeruption of the tooth (Fig. 2 -15).
When orthodontic assisted eruption is used, the tooth should be extruded slowly, over a 3- to 4-week period. Once the tooth is in position within the dental arch, it is splinted for 2 to 3 months. Recent evidence suggests that
immediate appli ation of orthodontic forceis necessary to prevent ankylosis in the intruded position.” The decision to perform endodontic treatment is based on the followup findings of each individual case.
If a deciduous tooth has been intruded to the point that it is touching the follicle of’ a succedaneous tooth, the deciduous tooth should be removed as atraumatically as possible. IT the deciduous tooth is not in direct proximity to the succedaneous tooth, a period of observation should be followed, because reeruption is common. If the dentist is in doubt about the position of a deciduous tooth, removal is a sound prophylactic approach that belps to ensure the health of the succedaneous tooth.
Extrusion. Extruded teeth can usually be manually seated back into their sockets if the injury was very recently. After replacement of the tooth within. the Socket, splinting for 1 to 3 weeks is usually necessary, as is
endodontic treatment (discussed later) (see Fig. 23-13, B) (Fig. 23-16).
Therefore when the dentist receives a call from a patient, parent, teacher, or other responsible person regarding a totally avulsed tooth, the dentist should direct the caller to .nnse the tooth immediately with the
patient’s saliva, tap water, or saline solution and· replant ‘ the tooth. The patient should hold the tooth by the crown, while trying to not touch “theroot, and then hold the tooth in place and go immediately to the dentist. If the patient cannot replace the tooth, it should be placed
into an appropriate medium until care by a dentist can be delivered. Many storage mediums have been recom- . mended, including water, the vestibule of the mouth, physiologic saline, milk, and cell culture media in specialized containers. Water is the least desirable because it is hypotonic and causes cell lysis. Saliva keeps the tooth moist but is not ideal because of incompatible osmolality and pH and the presence of bacteria. The most ideal stor- . age medium is Hanks Balanced Salt Solution, which can
be purchased as part of a commercial tooth preserving system (Save-A-Tooth, Biologic Rescue Products, Conshohocken, PA). Many schools, sporting venues, and ambulances have these kits on hand for use in cases of
tooth ‘avulsion. If this solution is not available, milk is considered the best alternative storage medium because it .Is readily available at or near an.acddent site, it has a pH and osmolarity compatible to. vital cells, and it is relatively free of bacteria. Milk has been shown to effectively ,
maintain the vitality of peIiodontalligament cells.
If the tooth has been out of the socket for more than 20 minutes, it should not be replanted until after it has been placed into Hanks Balanced Salt Solution for 30 minutes and then in doxycycline (1 mg/20 cc saline) for
5 minutes. The tooth should then be replanted and splinted. Soaking the tooth in Hanks Solution seems to reduce the incidence of ankylosis by improving the survival of periodontal cells on the root. The solution also
helps cleanse debris from the root and dilutes bacteria. The doxycycline helps inhibit bacteria in the pulpal lumen, which reduces a major obstacle to revascularlization. Even teeth that were stored in milk or saline should
undergo this regimen before implantation.
A technique that serves admirably for the stabilization of avulsed teeth is the use of an acid-etched composite system (see Fig. 23-15) (Fig. 23-18). Awire of moderate stiffness but that still has sorrte flexibility, such as braided orthodontic \-‘dre,is adapted to the facial surfaces of one or
two teeth on each side of the avulsed tooth. The fewer teeth required to stabilize the avulsed tooth, the more physiologic movement that can be imparted to the replanted tooth during function, If braided orthodontic wire is unavailable, any wire-even a paper clip-will suffice.The
facial surfaces of both the avulsed and the adjacent teeth are acid-etched, and the wire is cemented to them with composite. This technique makes cleansing the teeth easy, , because the wire is away from the gingiva. The wire can be readily removed, and most dentists have the necessary supplies and instrumentation available for its use.
The duration of stabilization (Table 23-1) should be as short a time as necessary for the tooth to become reattached, usually 7 to 10 days. Studies have shown that the more rigid and the longer the stabilization, the more root resorption that can be expected.
Patients who have no recollection of a’ tetanus booster within the past 5 to 10 years should be referred to their physician for one. The use of antibiotics (i.e., penicillin) for 7 to 10 days is appropriate.
The patient should be told that .several outcomes are possible after replantation. The best result to be expected is a relatively normal, functional tooth that will in most instances require endodontic therapy (described later). owever, varying amounts of root resorption and ankylosis may occur. The development of’ these signs will determine the prognosis of the tooth. Although acute dental infection is rare; it can lead to loss of th~ replanted tooth. These patients must be followed carefully at
regular and frequent intervals for some time after replantation.
Andreasen! lists the following five factors to be considered before replanting avulsed teeth:
‘I. The avulsed tooth should have no advanced periodontal
2. The alveolar socket should be reasonably intact to provide
a seat for the avulsed tooth.
3. There should be no orthodontic contraindications,
such as significant crowding of teeth.
4. The extraalveolar period should be considered; periods . exceeding 2 hours are usually associated with poor results. If the tooth is replanted within the first 30 , minutes, excellent results can be expected.
S. The stage of root development should be evaluated. Survival of the pulp is possible in teeth with incomplete root formation if replantation is accomplished within 2 hours after injury.
If the tooth to be replanted is not favorable for replantation, as determined by these factors, the patient should be made aware that the prognosis will be worse. One should keep in mind the alternatives to replantation in
cases where the factors involved are unfavorable, such as teeth with existing periodontal disease, large restorations, alveolar disruption, and long’ extraalveolar duration. Today the use of dental implants can offer patients who suffered tooth avulsion an option that was not available
in the past. In hopeless cases, one might elect to defer tooth replantation for placement of a dental implant once the alveolus has healed.
The treatment of this type of injury, as for any fracture, is first to place the segment into its proper position and then to stabilize it until osseous healing occurs. This procedure may be very simply performed with digital
pressure applied after an appropriate anesthetic is.admin
istered (Fig. 23-19). Frequently, however, ‘splintenng of the dentoosseous segment margins makes repositioning extremely ‘difficult, and open surgical treatment might then be required.
In teeth with apical foramina” that are. wide open, endodontic treatment may be delayed for several weeks while careful follow-up examinations, including pulp vitality tests, determine its necessity. when the apices are,
open, it is likely that rcvascularization of the root canal system will occur. If root canal therapy appears necessary,apexification procedures with use of calcium hydroxide can be used before filling of the root canal’ system with a permanent filling material. The technique of apexification
is illustrated in Fig. 23-21.