6. Diagnosis and esthetic treatment of dental caries

dental fractions occur more likely in what population

dental fractions occur more likely in what population

children

Children: 80% likelihood for dental trauma

Over 21 years: 78%

what type teeth are most likely to break for children and adults?

incisors

what type teeth are the least likely to break/experience trauma?

posterior teeth because they are covered by the cheeks

etiology of dental fractures/trauma

•falls (31-64%)
•sports injuries (40%) •cycling accidents (19%)
•traffic accidents (8%) •physical violence (7%)----must be reported when suspected

epidemiology of dental fractures/trauma

•permanent (6-58%)>primary (9-41%) •in permanent dentition: males>females
•simple crown fracture of the maxillary central incisors
•>75% of tooth fractures in upper jaw and more than 1/2 of these involve central incisors, followed by lateral incisors and canines

mouth guard prevention

mouth guards are mostly recommended for athletes, especially for those in contact sports (football/water polo)

prefabricated mouth guards are not recommended/accurate. molding (hot water) mouth guards are not recommended, but better than prefabricated. mouth guards made in the dental office are the best

clinical classification of traumatic dental injuries

• Injuries to the hard dental tissues and the pulp
• Injuries to the periodontal tissue
• Injuries to the supporting bone
• Injuries to gingiva or oral mucosa

Injuries to hard dental tissues and the pulp

•enamel infraction •enamel fracture (uncomplicated crown fracture)
•enamel-dentin fracture (uncomplicated crown fractue)
•complicated crown fracture •uncomplicated crown-root fracture •complicated crown-root fracture

uncomplicated vs complicated fractures

uncomplicated means the pulp is not involved. complicated means the pulp is involved

injuries to the periodontal tissues

•concussion •subluxation (loosening)
•extrusive luxation (peripheral dislocation, partial avulsion)
•lateral luxation •intrusive luxation (central dislocation in the socket)
•avulsion (exarticulation, tooth out of socket)

what is another method of diagnosing fractures/trauma besides a radiograph?

CT scanning

questions to ask relating to the injury

How did the injury occur? When did the injury occur? Was there a period of unconsciousness? Is there any disturbance in the bite? Is there any reaction in the teeth to cold and/or heat exposure?

if a fractured tooth fragment has no pulp exposure, how should you handle the fragment

keep it moist (wet paper towel) and bring it to the dentist within the hour.

PAST _______ it is hard to reattach a tooth fragment after losing it

1 hour

pulp vitality tests

sensitivity: testing the vitality of the nerves

vitality test: laser/ultrasound doubler to test the blood flow

vitality

the test of blood flow through the pulp

clinical examination of a fracture

1. Examine the face, lips and oral muscles for soft tissue lesions. 2. Palpate the facial skeleton for signs of fractures.
3. Inspect the dental trauma region for fractures, abnormal tooth position, tooth mobility and abnormal response to lateral and vertical percussion.
4. Pulp testing (usually electrometric) completes the clinical examination.

radiographic examination of dental trauma

Periapical radiograph with a 90° horizontal angle with central beam through the tooth in question. Occlusal Periapical radiograph with lateral angulations from the mesial or distal aspect of the tooth in question.

________are almost ALWAYS preferred to see diff angles to assess the fracture

CT scans

infraction

An incomplete fracture (crack) of the enamel without loss of tooth structure. patients may experience sensitivity.

infraction clinical & radiographic findings and treatment

Clinical findings An incomplete fracture (crack) of the enamel without loss of tooth structure.

Radiographic findings No radiographic abnormalities

Treatment In case of marked infractions, etching and sealing with resin prevent discoloration of the infraction lines (allow resin to penetrate for a while)

how does infraction usually occur

patients may crack open a can with their tooth which causes small cracks in the enamel, usually easily stained and hard to fix that staining.

enamel fracture

A fracture confined to the enamel with loss of tooth structure. small fragment missing that can be rebonded if the fracture is present

enamel fracture clinical & radiographic findings and treatment for

Clinical findings A complete fracture of the enamel with no visible sign of exposed dentin.

Radiographic findings Enamel loss is visible.

Treatment If the tooth fragment is available, it can be bonded to the tooth Restoration with composite resin

enamel fracture most commonly occurs where

central incisors

_________ is hard to restore with composite and thus a silicone index may be preferred

enamel fracture

can take an impression of a stone cast if you have it and then perform a wax up

enamel/dentin fracture

A fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp.

enamel dentin fracture clinical & radiographic findings and treatment

Clinical findings A fracture confined to enamel and dentin with loss of tooth structure, but not exposing the pulp.

Radiographic findings Enamel-dentin loss is visible

Treatment If the tooth fragment is available, it can be bonded to the tooth Restoration with composite resin (same as enamel fracture)

a silicone index helps restore the ______ surface of the tooth

palatal

primary morphology of anterior teeth includes

tooth contours, line angles, shadow areas and V shaped grooves

8 steps to anterior facial morphology and texturing

1. margins
2. 3 vertical planes
3. line angles
4. vertical depression
5. horizontal depression
6. fine vertical grooves
7. fine horizontal grooves
8. perikymatas
(Review pic in notes)

secondary morphology of anterior teeth

initial polishing (fine silicone points), texture (perikymata), final luster (felter disc and polishing paste)

before adding a stint to a fractured tooth and fragment, what should you attach the fragment to the tooth with?

composite (on facial, round ball)

enamel dentin pulp fracture---complicated crown fracture

A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.

enamel dentin pulp fracture clinical & radiographic findings and treatment

Clinical findings A fracture confined to enamel and dentin with loss of tooth structure and exposing the pulp. (bleeding may be present)

Radiographic findings Enamel-dentin loss is visible

Treatment (dependent on patients age) Pulp capping, partial pulpotomy, or pulpectomy follow by: If the tooth fragment is available, it can be bonded to the tooth. Direct restoration with composite resin. Indirect restoration.

difference between younger and older patients in enamel dentin pulp fracture tx

older patients likely will need a pulpectomy where younger patients should be able to undergo a partial pulpotomy which only removes the exposed pulp and caps the rest

______ should be avoided for an enamel dentin pulp fracture

indirect restorations. crown should be avoided if possible, composite is always preferred for these kind of fractures

crown root fracture without pulp involvement (uncomplicated crown root fracture)

A fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp.

crown root fracture without pulp involvement clinical & radiographic findings and treatment

Clinical findings A fracture involving enamel, dentin, and cementum with loss of tooth structure, but not exposing the pulp (fracture is towards the root

Radiographic findings Apical extension of fracture usually not visible

Treatment Temporary stabilization or removal of the loose tooth fragment. Gingivectomy, ostectomy, orthodontic extrusion, or extraction follow by the adequate restorative treatment. (avoid extraction if possible)

crown root fracture with pulp involvement (complicated crown root fracture)

A fracture involving enamel, dentin, and cementum with loss of tooth structure, and exposure of the pulp.

crown root fracture with pulp involvement clinical & radiographic findings and treatment

Clinical findings A fracture involving enamel, dentin, and cementum and exposing the pulp (fraction of coronal and root pulp involved)

Radiographic findings Apical extension of fracture usually not visible

Treatment Temporary stabilization or removal of the loose tooth fragment. Endodontic treatment, gingivectomy, ostectomy, orthodontic extrusion, or extraction follow by the adequate restorative treatment.

root fracture

A fracture confined to the root of the tooth involving cementum, dentin and the pulp.

root fracture clinical & radiographic findings and treatment

Clinical findings The coronal segment may be mobile and in some cases displaced. Transient crown discoloration (red or grey) may occur. Bleeding from the gingival sulcus may be noted

Radiographic findings The fracture involves the root of the tooth and is in a horizontal or oblique plane.

Treatment Rinse the exposed root surface with saline before repositioning. Reposition the coronal segment of the tooth as soon as possible. Stabilize the tooth with a flexible splint for 4 weeks. (tx is dependent on the root fracture apically and the stint)

concussion

An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion. the neurovascular supply is in tact

concussion clinical & radiographic findings and treatment

Clinical findings The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility Sensibility tests are likely to give positive results (bleeding/edema in a few areas. no damage to PDL)

Radiographic findings No radiographic abnormalities

Treatment No treatment is needed Monitor pulpal condition for at least 1 year. The patient should avoid pressure on that tooth for 4-6 weeks

subluxation

An injury to the tooth-supporting structures resulting in increased mobility, but without displacement of the tooth.

subluxation clinical & radiographic findings and treatment

Clinical findings The tooth is tender to touch or tapping and has increased mobility; it has not been displaced. Bleeding from the gingival sulcus confirms the diagnosis.

Radiographic findings Radiographic abnormalities are usually not found

Treatment Normally no treatment is needed; however, a flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks

extrusion

An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth in labial direction usually, and OTHER than(NOT) axial, lateral, mesial, distal, etc. (root exposure)

extrusion clinical & radiographic findings and treatment

Clinical findings The tooth appears elongated and is excessively mobile Sensibility tests will likely give negative results

Radiographic findings Increased periodontal ligament space apically

Treatment Clean the exposed root surface with saline. Reposition the tooth by gently re-inserting It into the tooth socket Stabilize the tooth for 2 weeks using a flexible splint

lateral luxation

Displacement of the tooth other than axially

lateral luxation clinical & radiographic findings and treatment

Clinical findings The tooth is displaced, usually in a palatal or labial direction. It will be immobile to percussion test. Fracture of the alveolar process present

Radiographic findings The widened periodontal ligament space is best seen on eccentric or occlusal exposures

Treatment Rinse the exposed root surface with saline before repositioning. Apply a local anesthesia because of alveolar process involvement. Reposition the tooth with forceps or with digital pressure. Stabilize the tooth for 4 weeks using a flexible splint.

intrusion

Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution (force fracture) or fracture of the alveolar socket.

intrusion clinical & radiographic findings and treatment

Clinical findings The tooth is displaced axially into the alveolar bone It is immobile, and percussion may give a high, metallic

Radiographic findings The The periodontal ligament space may be absent. The cemento-enamel junction is located more apically.

Treatment Spontaneous eruption If no movement within few weeks, initiate orthodontic repositioning If tooth is intruded more than 7 mm, reposition surgically or orthodontically. regular followup

avulsion

The tooth is completely displaced out of its socket. Clinically the socket is found empty or filled with a coagulum.

avulsion clinical & radiographic findings and treatment

Clinical findings Complete displacement of the tooth out of its socket.

Radiographic findings If suspicion of a possible intrusion, root fracture, alveolar fracture or jaw fracture an occlusal radiograph should be taken to confirm the diagnosis.

Treatment It is based on the apex formation (open or close) and time the tooth stay out of the dental socket. endo could be required.

differential diagnosis

•DD(primary) for tooth fractures: dental infections, displacements, avulsions
•permanent teeth mostly fractured •primary teeth mostly displaced •primary teeth: fracture has to be differentially diagnosed with the physiological root resorption •permanent teeth: usually accurate diagnosis - clinical and radiographic examination

prognosis

•consequence of fractured tooth depends on: type of the injury, delay in treatment, quality of treatment •favorable outcome: normal healing of the pulp and periodontal tissues •initial healing process - 1-2 weeks •minor fractures restrict to the enamel - best prognosis
•deeper untreated fractures - may result in infection and abscess

discoloration can sometimes occur as well

complications

•pulp necrosis (most common; primary teeth with necrosis - extraction; permanent teeth - endodontic treatment)
•crown discoloration
•peri-apical abscess
•pulpal obliteration
•development of fistulas •internal or external root resorption (can result in loss of tooth)

best treatment outcomes are always better for __________

uncomplicated crown fractures