| Edward L. Kasper, D.D.S. | Wilson P. Heaton, D.D.S. | Bradley C. Wright, D.D.S. |
| Carlo G. Pagni, M.B,. B.Ch., B.A.O., B.D.S., F.D.S.R.C.S. (Eng.) | ||
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TREATMENT OF DENTOALVEOLAR INJURIES Welcome to the Kasper, Heaton, Wright and Associates web site. This Current Article section is new and will feature surgical updates for your information and review. The articles will change quarterly and will address different aspects of oral and maxillofacial surgery. If you have a topic that would be of interest to you and your colleagues, please send us an e-mail. All articles will be archived for later reference. The goal of treatment of Dentoalveolar injuries is to preserve the functional state of teeth, bone and gingiva. The decision to retain or extract injured teeth should be made with an overall treatment plan in mind. It is often the case that teeth involved in dentoalveolar trauma, while unsalvageable as teeth, may be useful in helping to preserve the alveolar ridge as the bony injury heals. Generally, conservation of structures is advocated where at all feasible. Tooth Injuries Crown infraction, where the enamel layer is cracked, generally requires no treatment other than periodic assessment of pulpal vitality with a view to possible endodontic therapy if necessary. Crown fractures account for @ 60% to 70% of traumatic injuries seen in the dental office. General guidelines for the treatment of dental injuries are: Class 1 (enamel) Smooth sharp edges and observe Relieve occlusion Class II (enamel and dentin) Calcium hydroxide base or light-cured glass ionomer liner/base on dentin Restore with acid-etch resin Class III (pulp exposure) Vital pulp
Calcium hydroxide direct pulp cap for small exposures within 24 hours Incomplete apex: calcium hydroxide pulpotomy for large exposures within 24h or small exposures over 24 hours old Closed apex: root canal therapy for large exposures or small exposures over 24 hours old Nonvital pulp Incomplete apex: apexification Closed apex: root canal therapy Class IV (root) Vertical: extract Apical or middle third: splint for 12 wk only if excessive mobility Cervical third: root canal therapy and orthodontic extrusion of segment or extraction In crown-root fractures treatment depends on several factors, including the location of the fracture, the apical extent of the fracture, and whether the pulp is involved. Emergency treatment of this type of fracture includes stabilization of the coronal fragment to the adjacent teeth and removal of loose fragments before definitive treatment can begin. In fractures that are longitudinal, or where the coronal fragment constitutes more than one third of the clinical root, extraction is generally recommended. Fractures at or above the cervical margin are generally restorable. One further factor to consider is whether the root is fully formed or not. If the root is not fully formed a pulpotomy should be performed with a calcium hydroxide base, and the tooth should be followed radiographically for the closure of the apex. After closure, definitive root canal therapy can be performed Root fractures usually occur in fully formed teeth and are usually oblique. Treatment of root fractures depends on the level of the fracture and the orientation of the fracture. Vertically fractured teeth should be extracted. Roots fractured in the apical or middle third are usually not splinted unless they are very mobile. If they are mobile rigid splinting is the treatment of choice for up to 12 weeks. Root canal therapy may then be performed on the coronal portion if there are signs of pulpal necrosis. It may be appropriate to perform an apicoectomy. Fracture of the cervical third of the root may be treated by orthodontic extrusion or extraction. Rapid extrusion can be performed in a 2-4 week period after which the tooth should remain in retention for 4-6 weeks prior to restoration. Dental injuries may also be described as displacement injuries or avulsion injuries. Following are some currently accepted guidelines for the treatment of these injuries: Treatment of Avulsion Within 2 Hours Minimize extraoral period, replant at accident site if possible Do not remove periodontal ligament Minimize handling, transport in Hank's solution or whole milk Do not remove blood clot from socket Antibiotic coverage for 7-10 days Chlorhexidine rinse Analgesics Oral hygiene Need for tetanus prophylaxis Maintain splint for 7-10 days Closed Apex Replant and splint after soaking in Hank's solution for 30 min Fill canal with calcium hydroxide at splint removal appointment Incomplete Apex Replant and splint after soaking in Hank's solution for 30 min and in a 1 mg/20 mL doxycycline solution for 5 min
After 2 Hours Same as above Closed or Incomplete Apex Remove periodontal ligament by either scraping or soaking in sodium hypochlorite solution for 30 min Endodontic debridement, cleaning, and shaping of the canal in the hand Soak tooth: citric acid solution for 3 min, 1% stannous fluoride solution for 5 min,and 1 mg/20 mL doxycycline solution for 5 min Obturate with gutta-percha Replant and splint Treatment of Displacement Injuries Subluxation (loosening): occlusal adjustment, observation, and vitality testing Intrusion Incomplete root development: allow to re-erupt Complete root development: reposition and splint, calcium hydroxide root canal therapy I have tried to outline some of the current ways of classifying dentoalveolar injuries and of treating some of them. In a follow-up article, I will describe the treatment of other dentoalveolar injuries and the prognosis for the recovery from such injuries. |
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