CHAPTER 24: SOFT TISSUE & DENTOALVEOLAR INJURIES

ppt

7-11 years of age

greatest incidence of soft tissue & dentoalveolar injuries

soft tissue injuries

abrasion, contusion, laceration

abrasion

• causes:

  • by friction between an object and a soft tissue surface

  • iatrogenic example:

    • shank of a rotating bur accidentally touches the oral mucosa

• key features:

  • surface wound

  • bleeding from damaged capillaries

• tx:

  • copious saline irrigation

  • topical anesthetic for pain relief

contusion

aka: bruise

indicates that some amount of tissue disruption has occurred within the tissues

results in subcutaneous or submucosal hemorrhage without a break in the soft tissue surface

• causes:

  • by a blunt object

• key features:

  • bruise

  • tissue disruption

  • no surface break

• tx:

  • no treatment is required

  • in the early stages:

    • application of ice

    • pressure dressings

laceration

most frequent type of soft tissue injury

a tear in the epithelial and subepithelial tissues

• commonly caused by a sharp object

  • knife & luxator

• common sites:

  • lips, tongue, gingiva

  • alveolar mucosa

  • floor of the mouth

• key features:

  • bruise

  • tissue disruption

  • no surface break

• tx:

  • repositioning of tissues & suturing

tx for soft tissue lacerations that need to be sutured

• gingiva, alveolar mucosa, floor of the mouth

  • closed in 1 layer

  • mucosal layer

• tongue or lip involving muscle

  • closed in 2 layers

  • muscle & mucosal layer

• entire thickness of the lip

  • closed in 3 layers

  • oral, muscle, dermal layer

• key principle:

  • all tissue layers should be properly positioned

  • number of layers depends on the location and depth of the laceration

tx for soft tissue laceration with hard tissue injury

treat hard tissue first!

sutures may loosen or tear during manipulation

once lost, tissue closure is harder on a second attempt

4 major steps in managing soft tissue injuries

• cleansing

  • necessary to prevent any remaining debris

  • used by soap, brush, saline irrigation

• debridement

  • removal of contused and devitalized tissue from a wound

  • removal of jagged pieces of surface tissue to enable linear closure

• hemostasis

  • use of clamping and tying with ligatures

  • cauterization with an electrocoagulation unit

• closure

  • use of sutures

  • not all wounds need to be sutured

clinical evaluation of dentoalveolar injury

1st: the extent of injury to the tooth

2nd: determine clinically if the tooth is stable, loosened or completely displaced from the socket

3rd: by digital manipulation, evaluate any suspected alveolar fracture

4th: radiographically, assess the stage of development of the root end of the tooth.

class I ellis classification

fracture of the enamel

class II ellis classification

fracture of enamel and dentin

class III ellis classification

fracture involving enamel, dentin, pulp

class IV ellis classification

fracture involving CEJ (nonvital tooth ; discolored)

class V ellis classification

avulsed tooth

class VI ellis classification

root fracture (may or may not involve the crown)

class VII ellis classification

luxation injuries (tooth displacement without fracture)

class VIII ellis classification

complete crown loss (fracture of the crown en masse)

class IX ellis classification

traumatic injuries to primary teeth

5 indications of pulp capping

the exposure is small

the patient is seen soon after injury

the patient had no root fractures

the tooth has not been displaced

no large or deep fillings exist that might indicate chronic inflammation within the pulp

dentoalveolar injuries

intrusion

extrusion

avulsion

concussion

subluxation

crown craze

crown fracture

alveolar fractures

crown-root fracture

lateral displacement

horizontal root fracture

concussion

not loosened, not displaced

clinically tooth will be tender

damage to tooth without injury to supporting structures

tx: dis-occlude

subluxation

loosened but not displaced

clinically tooth will be tender

damage to tooth with injury to supporting structures

tx: splint for 2 weeks

crown craze

aka: crack

normally limited to the enamel (ex: enamel infraction) and usually stop before reaching the dentinoenamel junction

• tx:

  • periodic follow-up examinations

  • sealed with unfilled resin

crown fracture

treatment is determined by depth of tooth tissue involvement

see pic for management

crown-root fracture

treatment depends on the location of the fracture and local anatomic variance

see pic for management

horizontal root fracture

treatment is determined by position of the fracture in relation to the gingival crevice

• for cervical 3rd:

  • prognosis is worst due to exposure to oral environment

  • remove tooth fragment, endo treatment, post and core

• for middle 3rd:

  • reposition and immobilization

• for apical:

  • prognosis is best esp in the absence of masticatory forces

  • reposition and immobilization

intrusion

socket sustains a compression fracture, causing the tooth to be displaced into a new position

• for permanent teeth:

  • minimal intrusion → allow the tooth to re-erupt spontaneously

  • severe intrusion → reposition orthodontically or surgically

• for primary teeth:

  • if the tooth touches the permanent tooth follicle → remove the deciduous tooth atraumatically

  • if it does not touch the permanent tooth follicle → observe and monitor the tooth

extrusion

displacement of the tooth out of its socket

• if injury was recent & mild:

  • can be seated back into its socket

  • then splint for 1-3 weeks

lateral displacement

• minimal

  • tooth is slightly displaced

  • no alveolar fracture

  • tx:

    • manual repositioning, splinting

• severe

  • tooth is severely displaced with alveolar fracture

  • tx:

    • reposition tooth and bone

    • splinting, suturing

tooth displacements

avulsion

most important factor → time

complete displacement of the tooth out of its socket

• recommended storage media:

  • water

    • least desirable

    • hypotonic → causes cell lysis

  • saliva

    • keeps the tooth moist but is not ideal

    • incompatible osmolality and pH

    • contains bacteria

  • milk

    • best readily available alternative

    • compatible pH and osmolarity

    • helps maintain the vitality of PDL cells

  • hank’s balanced salt solution (HBSS)

    • most ideal storage medium

replant if the tooth has been out of its socket for less than 20 mins

should be immediately rinsed in saline and replanted by the dentist

replant if the tooth has been out of its socket for more than 20mins

place into hanks balanced salt solution for 30mins (this reduces incidence of ankylosis)

then in doxycycline (1mg / 20mL saline) for 5mins (this inhibits bacteria in the pulpal lumen)

replant and splint

5 factors considered before replanting avulsed teeth by Andreasen & Hjorting-Hansen

the avulsed tooth should have no advanced periodontal disease.

the alveolar socket should be reasonably intact to provide a seat for the avulsed tooth

no orthodontic contraindications (ex: significant crowding of teeth should exist)

extra-alveolar period should be considered

• periods exceeding 2 hours → poor results

• replanted within the first 30mins → excellent results

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

alveolar fractures

may occur independently or concomitantly with tooth injuries

• tx as with any fracture:

  • first, place the segment into its proper position

  • then, stabilize it until osseous healing occurs

• 2 factors necessary for healing:

  • reduction of fracture

    • restoration of the bony segments to their proper anatomic location

  • fixation of fracture

    • immobilization of the bony segments at the fracture site

• in cases of tooth trauma

  • it is safe to assume that the pulp will undergo necrosis regardless of treatment.

acceptable methods used to stabilize the segment in alveolar fractures

simplest is to ligate an arch bar to the teeth both mesial and distal to the segment and within the fractured alveolar segment

use of an acid-etched arch wire → also acceptable

in cases of tooth trauma, when to do root canal?

if the apex of a mature tooth has moved more than 1mm in any direction, pulpal degeneration will occur

in cases of tooth trauma, when to do root canal if apex is close?

endodontic treatment be done after 2 weeks

helps minimize inflammatory root resorption by eliminating nonvital tissue from the pulp

in cases of tooth trauma, when to do root canal if apex is open?

endodontic treatment may be delayed for several weeks

observe, do follow-up exams bc chance of revascularization is high so no need for rct

if not, do apexification

• revascularization → return of blood flow to the pulp after an injury

• apexification → for a non-vital immature permanent tooth with an open apex

years it take for the roots to fully form after the eruption of primary & permanent teeth

primary → 1-2 years

permanent → 2-3 years

stabilization periods for dentoalveolar injuries

classification of dentoalveolar injuries