Alveolar-dental trauma: epidemiological etiological data and classifications

Introduction :

Anatomical reminder
DATA Epidemiology of dental trauma III-Etiological data of dental trauma
Trauma classifications

A-Classification of RGEllis and KWDavey (1970) B-Classification of P.Vanek (1980)

C-WHO recommended Andreasen classification used V-Examination of the trauma patient

Anamnesis
Clinical examination:

3 – Radiological examination

VI-Clinical forms of trauma

A-Traumas to hard tissues and pulp tissues 1-Coronary fractures:

Coronal fractures without pulp exposure: 1-1-1 Cracks :
1. Enamel fractures:
2. Coronal enamel-dentin fractures :
Coronal fractures involving the pulp tissue: 2-Coronoradicular fractures :
Root fractures:

B-Traumas to bone and periodontal tissues

-1-Concussion:

Subluxation:
Extrusion:
Lateral dislocation 5-Extrusion

Expulsion
Alveolar bone fractures:

C-Trauma to the gum or oral mucosa:

-1 -Abrasion :

-2-Contusion :

-3-Laceration :

VII-Complications of trauma in adults 1- pulp complications:

1-1 Pulp necrosis:

1-2- Calcium degeneration 1-3- internal resorption

periodontal complications 2-1-Surface resorption
1. External resorption of inflammatory type
2. Ankylosis or replacement resorption ankylosis VIII- Management of dental trauma
Coronary fractures:

1-I-Coronary fracture without pulp exposure 1-1-1- Crack

enamel fractures
Coronal enamel-dentin fractures

1-2Coronary fracture involving the pulp tissue 2-Coronoradicular fractures

Root fractures
Concussion and Subluxation 5-Extrusion

6-lateral dislocation 7-Intrusion

8- expulsion

restraint
IADT2020 Recommendations

CONCLUSION

Introduction :

Trauma is very present in our daily practice and often takes the form of an emergency.

Patients often present in a state of distress, hence the need to reassure them and adopt the best course of action.

Immediate management of traumatic lesions determines the long-term prognosis of the tooth and its longevity in the arch.

Anatomical reminder

The tooth is composed of 3 hard tissues:

enamel
dentin
cementum

The periodontium is formed by:

cementum
The periodontal disease
the alveolar bone,

pulp cells are the origin of dentin,
The periodontium allows the tooth a certain range of movement within the socket.
The sulcular epithelium and the junctional epithelium constitute a barrier to the oral environment
The biological space is about 2mm
When it erupts into the oral cavity, 2/3 of the root length is built and its apical end is immature.

Hertwig’s sheath cells play an important role in root development, which continues for 3 years.

DATA Epidemiology of dental trauma

Worldwide, 16 to 40% of children aged 6 to 12 are affected by dental trauma.

A significant proportion of dental trauma is linked to sports activities, activities in schools or on playgrounds, traffic accidents or acts of violence (WHO, 2003)

Frequency

At least 2 out of 10 children between 8 and 11 years old
Boys are 3 times more likely to suffer injuries than girls.
Preferably in the maxilla 9 times out of 10
The central incisor is particularly affected: 8 times out of 10 it is involved in more than 85% of cases of adult trauma.

Etiological data of dental trauma
Sex

Boys are more prone to trauma than girls (sports, fights, etc.)

Orthodontic risk factors
- Open lip
- Vestibulo-version of the maxillary incisors >30°
- An overhang >6mm
- Mouth ventilation
- A short upper lip that does not fulfill its protective role increases the risk of a protrusion of more than 4 mm.
Risky sports

All sports are at risk, with dento-maxillary trauma representing 5 to 6% of accidents recorded across all disciplines. That said, some of them are more violent.

Boxing	++++
Martial arts	++++
Rugby	++++
Hockey	++++
Handball	+++
Bicycle / Mountain bike	+++
Skateboard / Roller	+++
Soccer	++
Squash	++
Basketball	++
Skiing/Snowboarding	++
Gymnastics	++
Horse riding	++
Volleyball	+

According to Droz et al. 2002

Accidents in hospitals:
- Intubation and Tracheal Endoscopy

In very young children may have consequences on the germs of the permanent tooth

Neurological accidents
- diseases (Parkinson’s disease, epilepsy, cerebral palsy)
- Disability
- Coma
Obesity
Emotionality and concentration: stressed children present more trauma 8-Violence and abuse
Trauma classifications

A-Classification of RGEllis and KWDavey (1970)

Class 1 : Coronal fracture limited to the enamel and possibly to a small portion of dentin

Class 2 : coronal fracture extending to the dentin, without pulp exposure

Class 3 : coronal fracture extending to the dentin, with pulp exposure

Class 4 : pulp necrosis of traumatic origin with or without loss of coronal tissue

Class 5 : tooth dislocation

Class 6 : root fracture with or without loss of the coronal portion

Class 7: Tooth displacement without fracture

Class 8 : complete coronal fracture

B-Classification of P.Vanek (1980)

Class I : apparent absence of loss of coronary structure

Division 1 : Crack in the enamel not reaching the enamel-dentin junction

Division 2 : Enamel cracking associated with tooth mobility

Division 3 : pulp sensitivity tests initially negative then becoming positive again.

Immature apex

Division 4 : pulp necrosis, radiological image of mature apex with absence of periradicular lesion

Class II : Simple coronal fracture: coronal fracture without pulp exposure

Division 1 : coronal fracture of the enamel possibly associated with limited exposure of the dentin

Division 2 : coronal fracture involving enamel and dentin

Class III: Complicated coronal fracture: coronal fracture with pulp exposure

Division 1 : limited pulp exposure, positive pulp sensitivity tests, immature apex

Division 2 : significant pulp exposure, positive pulp sensitivity tests, immature apex

Division 3: Pulp necrosis, immature apex

Division 4: Mature Apex

Class IV : complete coronal fracture

Class V : oblique coronal-radicular fracture

Division 1 : lesion involving the anterior teeth

Division 2 : lesion affecting the posterior teeth, involving a lingual or vestibular cusp

Class VI : Root Fracture Division 1 : Apical Division 2 : Medial Division 3 : Coronal

Class VII : Dislocations Division 1 : Concussion Division 2 : Subluxation Division 3 : Intrusion Division 4 : Extrusion Division 5 : Lateral Dislocation

Class VIII: Traumatic Avulsion

C-Andreasen classification recommended by WHO currently in use

Hard tissue injuries
- Dental injuries: fractures

– Enamel infringement (cracking)

-Uncomplicated coronal fracture (without pulp exposure)

-Complicated coronal fracture (with pulp exposure)

-Coronoradicular fracture (uncomplicated or complicated)

-Intra-alveolar root fracture

periodontal lesions: dislocations

-Concussion

-Subluxation

-extrusive dislocation

– Lateral dislocation

– Intrusive dislocation

-Expulsion

Bone injuries: fracture

-Comminuted fracture of the alveolus

-Fracture of an alveolar wall

– Fracture of the alveolar process

– Fracture of the jaws

Soft tissue injuries:
- Abrasion
- Contusion
- Laceration

-Facial lesions

-Lip lesions

-Lesions of the oral mucosa

-Labial frenulum lesions

-Tongue lesions

Examination of the trauma patient
Anamnesis

Question 1: How did the trauma occur? Question 2: Where did the shock occur?

Question 3: When did the trauma occur?

Clinical examination:

In an emergency, the first objective is to determine whether the child should be seen by a structure other than the dental practice (hospital or other).

Clinical signs	Associated risks
Loss of consciousness then return to alertness then slowly sinks	Temporal fracture with subdural hematoma
Headache and vomiting	Head trauma
Prolonged epistaxis (nosebleeding)	Fractured nose
Ear bleeding	Head trauma
Deep contaminated skin and mucosal wounds	Damage to underlying structures and infection
Bleeding in sheets	Venous involvement
Bleeding in jets (emergency+++)	Arterial damage

A-Exoral examination:

Inspect wounds on the face, lips and chin to determine whether stitches are necessary
Palpate the bony edges and TMJ for possible fractures.

#Points to assess before the dental examination.

Search for a possible foreign body, especially in the lip or tongue.

The dental fragment in this case could not be recovered during the trauma

B-Endo-oral examination:

Soft tissue examination : looking for laceration, hematoma, loss of substance

Examination of the occlusion : looking for its disturbance (inversion of the articulation, deviation of the mouth opening)

Examination of hard tissues : looking for loss of substance (cracks, coronal fractures with or without pulp involvement), change in tooth color), dental mobility

Examination of traumatized teeth : Three tests are performed:

Mobility
Percussion
Thermal sensitivity tests 1- Mobility:

In axial direction : indicates an apical section of the pulp vascularization.
In horizontal direction :
- an alveolar fracture (if the horizontal mobility of a tooth causes the mobility of adjacent teeth)
- a root fracture {the degree of mobility provides information on the location of the root fracture)

Percussion

It allows you to assess sensitivity and sound.

-Sensitivity to axial percussion reveals damage to the periodontal ligament and/or the pulp vascular network .

– A metallic sound during horizontal percussion indicates an intrusion or lateral dislocation . This clinical sign, reassessed during the recall sessions, allows a diagnosis of ankylosis to be made.

-A dull sound diagnoses a Subluxation or extrusion .

Evaluation of thermal sensitivity

When sensitivity tests are performed immediately after trauma, a negative response may be recorded.

This should not lead to a decision for immediate endodontic intervention.

In fact, some teeth can respond positively several months after the trauma.

Such a “false” response is due to the stunning of the vascular-nervous bundle.

In cases of dislocation, the tooth can respond positively sometimes only one year after the trauma.

Immature teeth do not respond consistently to sensitivity tests due to late establishment of the sensory network.

3 – Radiological examination :

Several incidences will be necessary:-

Extraoral radiography:

dental panoramic
facial mass x-ray (case of severe trauma)
Small lateral x-ray (lips, cheeks, tongue)

Intraoral x-rays : several angles are recommended:

orthocentric
occlusal
Eccentric (mesial or distal)

Clinical forms of trauma

A-Traumas to hard tissues and pulp tissues 1-Coronary fractures:

Coronal fractures without pulp exposure: 1-1-1 Cracks :

It is an incomplete fracture of the enamel without loss of enamel substance.

Diagnosis:

Highlighted by transillumination, the light beam is directed perpendicular to the axis of the tooth, onto the vestibular mucosa, at the level of the attached gum. These cracks are often associated with other trauma (notably luxation), which must be investigated.

Clinical signs:

They may be nonexistent. Sometimes the patient complains of a slight sensitivity to cold.

Enamel fractures:

Diagnosis:

Enamel loss is most often located at the mesial or distal angle of the traumatized tooth.

Although the structural loss is not extensive, these injuries should not be minimized, as they may be associated with trauma to the supporting tissues.

Clinical signs :

Positive cold test.
Slightly painful percussion test.

Coronal enamel-dentin fractures :

These are the most frequent traumas to the permanent incisors; they mainly affect the mesial angle.

Diagnosis :

A more or less extensive loss of substance is observed. These fractures generally affect 1 or 2 teeth. They may be associated with damage to the periodontal ligament (subluxation or extrusion).

Clinical signs:

They manifest themselves by:

dentin hyperesthesia (pain from changes in temperature, acids, sugars);
pain when chewing.

Radiological signs:

The radiological examination makes it possible to objectify:

the root building stage;
the volume of the pulp;

-the relationship between the pulp and the fracture.

Coronal fractures involving the pulp tissue:

These traumas result in varying degrees of pulp exposure. The treatment decision depends on:

From the stage of root evolution
From the size of the exhibition
the time elapsed between the time of the trauma and the visit to the office

Coronal-radicular fractures :

All dental tissues are affected:

Enamel, dentin, cementum, and most often the pulp. They can be classified into two categories depending on the involvement of pulp tissue.

Simple coronal-radicular fractures without pulp tissue damage :

Rare, they represent only 1% of coronal-radicular fractures.

Complicated coronal-radicular fractures : where the pulp tissue is involved.

Clinical diagnosis :

Most often the fracture line is oblique, going from the incisal edge (vestibular surface) to the cervical edge (palatal or lingual surface).
The clinical symptoms are not very significant. Indeed, only chewing mobilizes the pieces: the pain is not spontaneous but functional.
Pulp exposure is inconsistent.

Radiological examination:

Its interpretation is very difficult. In fact, in the palatal area, the fragments are very close and the fracture line is perpendicular to the central ray, therefore less visible.
It is preferable to use several incidences and in particular mesially and distally decentered shots (mesial and distal angulations of 20° compared to the first shot centered on the tooth).

4-Root fractures:

Mature teeth++++++
Immature teeth, due to periodontal laxity, have more accidents such as luxation or expulsion.
A root fracture most often results from a horizontal shock.

Clinical diagnosis:

The tooth may appear either in normal position, extruded or displaced.
These fractures may be associated with alveolar trauma, coronal fractures and/or soft tissue injury .
The degree of mobility depends on:

-the severity of the trauma;

-the location of the fracture line.

The fracture line can be located in the coronal third, the middle third, or the apical third.

-If the fracture line is located in the coronal third, mobility is significant.

-If the fracture line is located in the apical third, the tooth shows little or no mobility.

In this case, the root fracture is often a discovery of the X-ray examination.

-The pulp vitality test can be positive or negative.

-The percussion test may give a metallic sound marking the lateral dislocation of the coronary fragment.

-Discoloration of the crown may exist (pinkish tint), due to hemorrhage. However, this sign can also be reversible.

X-ray examination :

It requires several shots:

-an occlusal image showing the oblique fractures of the apical third;

– a retro-alveolar image allowing observation of more coronal fractures.

The fracture lines of the apical and middle thirds have a more oblique line while the fracture line of the coronal third is most often horizontal.

B-Traumas to bone and periodontal tissues

-1-Concussion:

It is the shaking of the dental organ
head-on collision.
The damage created to the periodontal ligament and pulp tissue is benign.

Diagnosis: Clinical examination:

no mobility and no abnormal displacement compared to the contralateral teeth
.A small hemorrhage and slight edema may exist in the periodontium,
The percussion test may cause slight tenderness and chewing may be slightly painful.
Pulp tests are positive because the neurovascular system of the pulp tissue is intact.

X-ray examination:

No radiographic abnormalities are revealed

2-Subluxation:

The impact of the shock is stronger than in concussion.
Some desmodontal fibers may then be broken.
There is swelling and hemorrhage in the periodontal ligament.

Diagnosis:

Clinical examination:

Abnormal mobility in the vestibulolingual direction compared to the contralateral teeth.
A little bleeding is visible at the gingival sulcus.
The percussion test produces a rather dull sound and can be painful. The patient complains of having an elongated tooth and discomfort when chewing.
Pulp vitality tests are positive.

X-ray examination

It is not very explicit and does not show any movement of the tooth in its socket.

Extrusion:

An oblique impact displaces the tooth partially out of its socket. The apex is forced, usually toward the buccal alveolar wall.

Diagnosis:

Clinical examination

The crown of the tooth is usually intact but displaced out of its socket, most often in a lingual position.
It is only retained by the palatal desmodontal fibers,
The tooth appears longer than the contralateral ones.
It has great mobility. This mobility can be reduced if the trauma occurred several days previously.
The root is intact, but may be more or less exposed.
The percussion test triggers slight pain and a dull sound.

Immediate pulp tests are most often negative.
There is still bleeding at the periodontal ligament.

X-ray examination :

It requires taking an occlusal image and two retro-alveolar images.
A more or less significant thickening of the desmodontal space in the apical region is observed, proving the movement of the tooth.

2-4-Lateral dislocation :

Diagnosis:

Clinical examination:

The tooth appears displaced laterally and firmly locked in its new position.
The dental crown is often forced into a lingual or palatal position and the occlusion may be disturbed.
Most often, there is a clinically evident alveolar fracture.
The percussion test often produces a metallic sound and is sometimes painful.
Pulp vitality tests are most often negative.
Mobility may be normal or increased.

X-ray examination

You have to practice combining several shots.

Retro-alveolar images provide information on pulp volume and the stage of root development.
Occlusal incidence provides important information about movement.
Finally, the lateral view allows us to observe a possible fracture of the vestibular bone plate.

Intrusion :

This is the most severe form of tooth displacement.
The shock, most often axial, forces the tooth into its socket, generally causing it to perforate.
The neurovascular system of the tooth suffers considerable damage which can cause pulp necrosis generating inflammatory resorption

Diagnosis:

Clinical examination:

There is a difference in height between the free edge of the traumatized tooth and the contralateral one
In some cases, especially for immature permanent teeth, the crown may disappear completely.
Mobility is most often normal. Sometimes the tooth seems stuck in its socket.
The percussion test is painful: the tooth being stuck in its socket gives off a metallic sound.
Pulp vitality tests are most often negative

X-ray examination:

It consists of taking three photos:

– the occlusal image and two retro-alveolar images.

Expulsion:

According to statistical studies, these injuries concern 8.7 to 30.2% of all dental accidents.
Expulsion is much more common in immature permanent teeth. Their shorter roots and greater ligament laxity cause the tooth to be expelled even if the impact was not very violent.

Diagnosis:

Clinical examination:

If the tooth is found, the entire root must be checked (possibility of a root fracture of the apical third, the fragment remaining in the socket).
If the tooth has not been found, an X-ray examination is necessary to make the differential diagnosis with a total intrusion
X-ray examination:
It consists of an occlusal image and two retro-alveolar images.
It may or may not reveal the existence of an associated alveolar fracture.

2-6- Fractures of the alveolar bone:

Bone fractures predominate in the anterior region and result from a violent shock affecting several teeth.
Dental trauma often associated with this is lateral dislocation and/or expulsion, and more rarely, root fractures.

Diagnosis:

Displacement of teeth and bone fragment.

Existence of a hematoma.
Significant mobility.
The percussion test emits a dull sound.

X-ray examination:

The fracture line can be located at different levels from the marginal edge to the apex of the teeth

C-Trauma to the gum or oral mucosa:

-1 -Abrasion : superficial cut of the mucous membrane

-2-Contusion : bruise generally produced by a blunt object and not causing lesions of the mucous membrane but a hematoma

-3-Laceration : more or less deep wound of the mucous membrane resulting from a sharp object

Complications of trauma in adults 1- pulp complications:

1-1 Pulp necrosis:

In the face of high intensity trauma, the apical vascular system is severely affected and the pulp tissue exhibits ischemia and hemorrhage leading to necrosis.

Calcium degeneration

Considered as an anarchic deposition of dentin in the pulp tissues leading in the long term to a total obliteration of the pulp chamber

internal resorption

The causative factor appears to be chronic irreversible pulp inflammation

periodontal complications 2-1-Surface resorption:

The displacements cause lesions of the periodontal ligament, the main consequences of which are root resorptions; these are lacunar resorptions located on the root surface and limited to the cementum.

External resorption of inflammatory type

This mode of resorption is characterized histologically by the presence of lobular areas of dentin and cementum resorption associated with significant modifications of the surrounding periodontal tissue

Ankylosis or replacement resorption ankylosis

Represents the fusion between the dental root and the alveolar bone by disappearance of the desmodontal space; the phenomenon is not progressive.

Replacement resorption is progressive; the tooth is integrated into the bone remodeling process, gradually resorbed and replaced by alveolar bone tissue.

Management of dental trauma 1-Coronary fracture
Coronal fracture without pulp exposure 1-1-1- Crack
- The therapy consists of abstention or the placement of a sealant at the fracture line to prevent external dyes from causing dyschromia.
- Monitoring of pulp vitality every month for 6 to 8 weeks

The prognosis : it is excellent, this trauma does not cause serious pulp consequences.

enamel fractures
- When enamel loss is minimal, therapy

Consists of polishing or coronoplasty of the edges of the enamel followed by fluoridation or the application of a sealant

Pulp vitality monitoring will be carried out one month later, then at 3 months, then every 6 months.

Prognosis: excellent

Coronal enamel-dentin fractures
- Immediate emergency treatment

Its aim is to prevent secondary damage to the pulp tissue (thermal shock, bacterial invasion)

The temporary restoration can be: a bonded composite band or a light-curing glass ionomer

Definitive treatment

It aims to achieve the following objectives:

Seal exposed dental tubules tightly
Restore aesthetics and function
Do not harm pulp tissue

Two therapeutic options are available to the practitioner:

Bonding of the fragment or composite restoration

Prognosis: The risk of pulp necrosis varies from 1 to 6% and depends on several factors:

Associated periodontal trauma
The stage of root development
The proximity of the fracture line and the pulp tissue
The treatment carried out (if no treatment has been carried out, 54% of necrosis is observed, while dentin protection reduces this side effect to 8%)

1-2Coronary fracture involving the pulp tissue

The treatment decision depends on:

of the stage of root evolution
of the size of the exhibition
the time elapsed between the time of the trauma and the visit to the office.

Mature teeth

If the exposure is minimal and recent, direct styling or partial pulpotomy can be considered.

However, the prognosis is poor and this technique should be considered an emergency treatment.

If the pulp exposure is more extensive and older, or if root canal anchoring is necessary for reconstruction, conventional gutta-percha endodontic treatment is the technique of choice.

Immature teeth

The main objective in the case of an immature tooth is the preservation of pulp vitality in order to allow root formation or “apexogenesis” under physiological conditions.

Different techniques are possible, all conditioned by:

the size of the pulp exposure;
the time elapsed between the time of the trauma and the consultation. Apexogenesis techniques are:

direct styling
partial pulpotomy,
cervical pulpotomy.
when the pulp is no longer alive. The objective then must be to induce closure of the root by forming an apical barrier in order to allow, later, a conventional canal obturation.
These are the so-called “ apexification ” techniques.

Coronal-radicular fractures
1. Simple coronal root fracture A-Superficial fracture line:

The goal of treatment is to maintain the pulp vitality of the tooth and preserve marginal periodontal health:

Remove the fragment
Polishing the tooth
Hygiene motivation + chlorhexidine mouthwash
A week later the tooth can be restored using a composite or by bonding the fragment

B- Deeper fracture line

the objective of the treatment is to obtain a supragingival limit

The fracture line is exposed by gingivoplasty and/or osteotomy
Polishing the dentin surface
Protection of the dentin surface can be achieved (glass ionomer)
Two to three weeks later, the gingival healing is achieved and the tooth is restored using bonding techniques.

Complicated coronal-radicular fracture:

The pulp problem and the periodontal problem must be treated individually and a prosthetic restoration must be carried out in the best possible conditions.

Endodontic phase :

Mature teeth: perform endodontic treatment.
Immature teeth: Appropriate pulp therapies are performed (direct capping, partial or cervical pulpotomy, partial pulpectomy)
Orthodontic phase:

Implementation of orthodontic traction which must be carried out for 4 to 6 weeks
Restraint for 2 to 3 months.
Restoration using composite or prosthesis.

Root fractures

The two essential factors are the degrees of maturation of the apex and the more or less coronal situation of the fracture line

Fracture line of the apical third

This is the most favorable situation because in the majority of cases we observe neither mobility nor displacement of the fragments
Abstention and surveillance are the rule
Middle third fracture line

The treatment consists of:

the reduction of the fracture line, the realignment of the two fragments objectified radiologically
the application of a retainer
The restraint is left in place for 3 months
Fracture line of the coronal third

If the fracture line is supraalveolar, the apical fragment can, depending on its length, be extruded orthodontically, a prosthesis is then made after endodontic treatment and inlay core
If the prognosis is unfavorable, extraction and implant alternatives are considered.
In case of non-communication with the oral environment and if the displacement is of little intensity, abstention and monitoring are recommended especially if the tooth is immature

FOLLOW UP

Pulp vitality tests are carried out at 3 weeks, 6 weeks and 2 months, 6 months and then every 6 months for 5 years.
If the tests are positive, the retainer can be removed after 3 to 6 months
In case of necrosis of the coronal fragment, endodontic treatment is carried out.

PROGNOSIS

Two factors influence the prognosis:

The stage of root development.

In cases of trauma to teeth with open apexes, little necrosis of the pulp tissue is observed and generally the healing of the fracture line occurs by the appearance of hard tissue between the two fragments.

The persistence of pulp vitality can be explained by the revascularization of the pulp from the desmodium te

The displacement of the coronal fragment and the resulting response of the pulp tissue.

After the trauma, the pulp tissue of the fragment

Coronary can either remain alive, revascularize, or necrotize.

Concussion and Subluxation

Concussion

It can range from abstention to adjusting the occlusion, if it is traumatic.
Possible prescription of a soft diet for 1 to 2 weeks

Follow up

Pulp vitality is monitored for 1 to 2 months.

Prognosis

It is generally excellent.

Subluxation

It consists of adjusting the occlusion if it is traumatic.
Prescription of a soft diet.
Restraint is not always necessary, except for the patient’s comfort. It will not last more than 1 to 2 weeks,

Follow up

Monitoring of pulp vitality for 6 months.

Prognosis

He is good.

Extrusion

The key factor in healing extrusion trauma depends on optimal and atraumatic repositioning of the tooth.

The tooth is repositioned in its socket using gentle digital pressure.
The retention keeps the tooth in its physiological position
The restraint is kept for 2 to 3 weeks

FOLLOW UP

Monitoring of pulp vitality is necessary as well as taking X-rays in order to objectify the appearance or not of root resorption.
Monitoring will take place at 3 weeks, 2 months, 6 months, then every 6 months for 4 years.

PROGNOSIS

It depends on two main factors: repositioning
and the stage of root development.

lateral dislocation

It consists above all in the repositioning of the tooth in its initial alveolar position.

Repositioning can be done using two techniques:

Digital repositioning
Repositioning using a forceps

a support is necessary and maintained for 3 to 4 weeks
Orthodontic repositioning is recommended when the patient consults after 48 hours

FOLLOW UP

One week, one month, every three months for one year. The patient must be followed for a period of at least five years.

PROGNOSIS

This trauma causes a high percentage of pulp necrosis, especially in teeth with firm apexes and in cases of displacement greater than 2 mm. This pulp necrosis is often associated with inflammatory root resorption.

Intrusion

It depends mainly on the stage of root development

Immature teeth

A spontaneous re-eruption is generally observed which can take several weeks.
Pulp vitality should be checked at 3 weeks,

6 weeks, 2 months, 6 months then every 6 months for at least 5 years.

An X-ray examination must be carried out during these checks.
Orthodontic treatment

If the tooth does not spontaneously re-erupt within four weeks, extrusion should be undertaken with light orthodontic forces

Mature teeth

If the displacement is minimal (less than a third of the dental crown), natural re-eruption can occur.
Pulp vitality is monitored and in case of mortification, endodontic treatment is carried out.
If the displacement is significant, physiological re-eruption is random. Repositioning of the tooth can be done by surgical means (forceps

+retention for 4 to 8 weeks) or orthodontic, before ankylosis occurs

settles down.

FOLLOW UP

Teeth are checked at 3 weeks, 6 weeks, 2 months, 6 months and then every 6 months for 5 years.

PROGNOSIS

After 5 years, a high rate of pulp necrosis (100% for mature teeth and 50% for immature teeth) and resorption (70% for mature teeth and 58% for immature teeth) is observed.

the expulsion

The success of the treatment depends on the survival of the desmodontal cells allowing the reattachment of the periodontal ligament.

First phase: emergency treatment

the tooth is placed in a suitable environment
If it is soiled, clean it with a sterile compress soaked in the same solution, holding it by the crown and not by the root so as not to damage the cells on the root surface.
Examine the alveolus. In case of alveolar fracture; it is necessary to reposition the alveolar bone wall
Rinse the alveolus gently with physiological serum to remove the clot.
Extra alveolar time less than 60 min

Mature apex: the tooth is gently repositioned in the socket

Extra-alveolar time less than 60 min Immature apex:
Periodontal repair and vascularization are possible, immersion of the tooth in a doxycycline solution (1 mg diluted in 20 ml of physiological serum) significantly increases the rate of revascularization
reimplantation is carried out as for the mature tooth

Extra alveolar time greater than 60 min mature or immature teeth ligament cells are damaged there is no urgency to reimplant
endodontic treatment can be done extraorally
The therapy aims to increase root resistance to resorption phenomena, the root is delicately freed from necrotic cells, immersed for 20 minutes in a 2.4% sodium fluoride solution (pH 5.5)
the tooth is rinsed for 2 minutes with physiological serum and reimplanted
A soft retainer is placed for 1 to 2 weeks from 6 to 8 weeks in the event of an alveolar fracture.
Motivation for hygiene
Chlorhexidine mouthwash for 7 to 10 days
Antibiotic + painkiller
Firm diet to stimulate the periodontal ligament

Second phase: endodontic phase Mature tooth

A week later, the patient is seen again and the pulp tissue is removed. Pulp necrosis can thus be anticipated and the pulp degradation products, which generate inflammatory resorption, eliminated.
Root canal debridement is performed with 2.5% hypochlorite and
an intermediate root canal filling with calcium hydroxide is performed.
The definitive endodontic treatment with gutta percha can be carried out after 12 months,

Immature tooth

Revascularization and re-innervation of the pulp tissue can be expected. However, clear clinical signs of recovery of vitality may not appear until two months later. Endodontic treatment using calcium hydroxide is only initiated if pathology appears on X-rays (resorptions or apical lesions).

Follow up

At 1 week, 3 weeks, 6 weeks:

vitality tests;
percussion test: a metallic sound suggests ankylosis; – reduced mobility also suggests ankylosis, starting in the 3rd week;

-retro-alveolar x-rays to look for ankylosis (8th week) or inflammatory resorption. At 2 months, 6 months, then every year.

the restraint:

The aim of retention is to promote pulp and periodontal repair, by maintaining traumatized teeth in their physiological position.

Restraint must respect several principles:

Be immediately feasible, without a laboratory step
Be aromatic during its installation and removal
Maintain the tooth in its original physiological position
Allow adequate fixation throughout the immobilization period
Do not damage periodontal tissue and allow proper hygiene
Do not create occlusal interferences
Allow the implementation of necessary endodontic therapy
Be aesthetically acceptable

In the 1970s, the same principles of retention were applied to dental trauma as to bone fractures. Many of these types of retention are obsolete, not only because of the difficulties of their production and/or removal, but also because of the damage they cause to the supporting tissues (bone and periodontium).

Figure-of-eight or ladder ligatures create periodontal trauma due to the inability to maintain adequate hygiene.
Ligated metal plates are too rigid and can cause inflammation of the pulp and periodontal tissues resulting in internal and/or external root resorption.
Furthermore, it does not allow stimulation of the periodontal ligament.
They increase the risk of ankylosis
Operating protocol:

Careful cleaning of all teeth to remove blood pigments, while maintaining the latter in the event of excessive mobility
Isolation of the field by rolls of salivary cotton and surgical aspiration. In the event of excessive gingival bleeding, apply compression.
Adhesion is after etching then application of a self-etching adhesive which has the advantage of reducing the number of phases
Creation of the retention with an orthodontic wire (0.3 A 0.4)
The wire is adjusted to the shape of the arch and then is bonded first to your most distal undamaged teeth with a flowable composite.
the latter included in the contention, taking great care to verify their position by an X-ray
Careful polishing to prevent plaque buildup

Recommendation to the patient :

Perfect hygiene
chlorhexidine mouthwash

Removal of the restraint

The removal of the retainer is very easy using a diamond burr mounted on a turbine and under spray
Once the wire is exposed, it is removed
Polishing of the vestibular surfaces can be carried out either on the same day as its removal, or later if the periodontal ligament has not fully recovered its integrity.