Clinical


Immediate management A traumatic injury to the dentoalveolar complex is an upsetting and worrying injury to any patient. It can also be a stressful occurrence for the dentist which, thankfully may present relatively rarely in general practice. Patients often present with multiple soft


and hard tissue injuries and in the first instance, it can be difficult to identify and diagnose the injuries. A calm approach is essential at this early stage, both to reassure the patient and to avoid missing any important detail during this initial examination (Fig ı). The emergency management should


commence with cleaning of the injured site. This can readily be accomplished using some sterile gauze soaked in chlorhexidine. It is wise to avoid using compressed air and water from the ‘3inı’ syringe in the first instance to avoid startling an already nervous patient and to avoid disruption of the injured soft tissues. Although rare, this may lead to introduction of air into the soft tissues leading to a surgical emphysema. Initial assessment of the injured site


should be done by visual inspection, noting any malposed and fractured teeth, with attention paid to any previous treatment which may have been carried out. This should be followed by careful digital palpation of the site taking care to identify any step deformities or mobility of the alveolar bone. This may be indicative of luxated teeth or fracture of the alveolar bone. Priority should always be given to treatment to encourage bony union during healing as the consequences of poor healing can be catastrophic.


Imaging Radiographs are an essential tool in the diagnosis of dental trauma and a decision on which types and angles must be taken at the initial assessment appointment. As a rule of thumb, periapical radiographs of the maxillary anterior teeth (3-3) should be taken following a moderate injury to the maxillary anterior teeth. A decision on whether to take radiographs of the corresponding mandibular teeth can be taken depending on the results of the clinical examination and the perceived severity of the injury. Location of tooth fragments within the soft tissues is best done using a combination of digital palpation along with reduced exposure of a large periapical film. More recently, cone beam CT has been used in the diagnosis of traumatic injuries, offering the advantage of three-dimensional assessment of displaced and injured teeth (Patel et al. 2007). This can offer great benefit in


the case of dento-alveolar fractures and luxated teeth, often difficult to identify on standard periapical radiographs.


Classification of injuries Classification of dental trauma is often complicated by the concomitant injury of multiple tissues. A thorough understanding of the tissues at risk of injury is critical to facilitate correct diagnosis and management of these injuries. As aforementioned, priority should be given to the treatment of any bony injury in order to minimize the risk of more severe complications later. A proposed classification of traumatic injuries in increasing order of severity therefore is shown in Table ı.


Repositioning and splinting Adequate anaesthesia must always be achieved prior to any clinical intervention post trauma. This is essential to allow for adequate manipulation of injured tissues and to avoid adding to the patient’s stress. Repositioning of luxated teeth should begin with an understanding of how the injury has occurred and how this may have altered the position of the root within the alveolar housing. Frequently, the apices of luxated teeth may be ‘locked’ into the alveolar bone. Re-positioning, therefore, requires a firm but controlled force on the alveolar bone in


Table 1 INJURY Enamel +/-


dentine fracture Concussion


Subluxation Lateral luxation Intrusion Extrusion Avulsion


Dento-alveolar fracture


DESCRIPTION


Fracture of enamel and/or dentine


No movement of tooth


Movement of tooth without displacement


Tooth displacement


Tooth forced into socket


Tooth


forced outwards from socket


Tooth completely removed from socket


Fracture of bony housing


PRESENTATION Fractured tooth


Tooth TTP


Tooth TTP + possible bleeding from sulcus


Incorrect position of tooth/occlussal discrepancy


Infra-occluded or ‘disappeared’ tooth


Tooth appears longer than adjacent teeth


Tooth no longer in place/in storage medium/missing


Mobility of whole bony segment if severe


order to manipulate the tooth into position. A clicking sound is often heard when this is done correctly. Palpation of the overlying soft tissues afterwards to assess labial contour helps to confirm this. It is imperative in the case of avulsed


teeth that they are first gently cleaned under running water while holding the tooth by the clinical crown. This ensures removal of any gross debris prior to an attempt at re-implantation. Storage medium and extra-oral dry time are two critical prognostic factors in the outcome following avulsion injuries, with literature suggesting the risk of replacement resorption being much higher in those teeth with a dry time of greater than 60 minutes (Andreasen ı98ı, Andersson et al. ı989). Patients should also be advised to store avulsed teeth in either milk or saliva (possibly even intra- orally) as opposed to in water. Ideally, an attempt at re-implantation should be made immediately although this may prove difficult in terms of positioning and angulation for those not familiar with the situation. Other storage media (Khademi et al. 2008) have also been proposed. However, they may not be readily available at the time of injury (Figs 2 and 3). A variety of splinting protocols have


been proposed for the stabilisation of injured tissues (Table 2). Basic biological principles should be


Continued » TREATMENT


Protect pulp + restore


Monitor Fig 4b Monitor


Reposition, splint & review


Depends on


severity/stage of development


Reposition, splint & review


If available, clean, re-implant & splint


Splint & review


Ireland’s Dental magazine 25


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