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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_20_библиотеки_им_акад_М_И_Перельмана
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BACKGROUND INFORMATION 1
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Management ofAvulsion Injuries
Transport Media forAvulsed Teeth
• HBSS is the most favorable storage medium but is
rarely available
• Cold milk is the best option after HBSS. Tooth
should be placed in a small cup of milk and then
the cup placed in a bowl of ice
• Saline solution or saliva are the next options if cold
milk is not immediately available
• Water should not be used, it is hypotonic and will
quickly kill periodontal ligament (PDL) cells
Systemic Antibiotics
•
Doxycycline (a semisynthetic tetracycline) is the first
choice due to potential antiresorptive properties. It is
Figure 4.7.3 Intraoral photographs showing replantation of
avulsed tooth.
OrOfacial Trauma
contraindicated in children under the age of 12 due
to potential tooth discoloration
In children under 12 years old, penicillin VK is
•
recommended
Teeth withExtraoral Dry Time Greater
Than60Minutes
• Poor prognosis for survival, ankylosis and replacement resorption is the expected outcome
• Soaking the tooth in fluoride for 20 minutes prior to
replantation may delay but not prevent replacement resorption
• Decoronation of the tooth to preserve the alveolar
bone is recommended if teeth become ankylosed
and infrapositioned greater than 1
mm
(Cohenca etal. 2007)
K. Comprehensive Treatment
• See Flowchart E: Tooth Avulsion at the end of thiscase
• Maxillary right permanent central incisor: examine
socket for alveolar fracture and reposition with end of
mirror, if needed. Rinse root carefully with saline and
replant with digital pressure (Figure4.7.3)
• Apply flexible splint, including adjacent teeth, using
50 lb monofilament fishing line or light, passive
orthodontic wire for up to two weeks based on
mobility, using light or self‐cured composite
(Figure4.7.4)
• Verify tooth position radiographically
• Suture gingival/lip lacerations (if indicated)
• Advise acetaminophen or ibuprofen for pain as needed
• Prescribe systemic antibiotics
• Oral PenVK (20–50 mg/kg/day in four divided doses)
for seven days
Figure 4.7.4 Intraoral photograph showing flexible splint.
Discharge Instructions
Chlorhexidine mouth rinse twice daily for two weeks
•
• Soft diet until splint is removed
• Maintain good oral hygiene
• Return to clinic within 7 to 10 days of replantation for
follow‐up
• Perform pulpectomy if avulsed tooth has a closed
apex: fill canal with Ca(OH)2 for two to four weeks,
then obturate with gutta‐percha
• Close monitoring is indicated in first year
Follow‐Up Treatment
• Clinical exam in postoperative months 1, 3, 6, and 12,
and then yearly
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Clinical Cases inPediatric Dentistry 169
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• Radiographic exam in six to eight weeks to rule out
root resorption. Repeated at six and 12 months
• Restoration of involved teeth with composite
• Orthodontic consult
• Endodontic consult
• Continue dental recalls every six months
L. Prognosis andDiscussion
• Maxillary right permanent central incisor (avulsed):
prognosis for long‐term tooth survival depends on
maintaining vitality of PDL fibers on the root. Goal
isto preserve PDL vitality by minimizing extraoral
time and storing tooth in physiologic media until
replantation
• Maxillary left permanent central incisor (subluxated):
tooth should be monitored clinically and radiographically for pulp vitality and pulpectomy performed if it
becomes nonvital
M. Common Complications andAlternative
Treatment Plans
• Ankylosis with replacement root resorption is the
most common complication in avulsed teeth. Signs
include loss of mobility, high percussion tone, and
radiographic disappearance of lamina dura and PDL
space. Decoronation of the tooth to preserve alveolar
bone is recommended if teeth become infrapositioned greater than 1 mm (Cohenca etal. 2007)
• Inflammatory root resorption can occur if the pulp is
not extirpated from mature avulsed teeth within three
weeks. Toxic byproducts of necrosis provoke an
FUNDAMENTAL POINT 2
Possible Outcomes Following Avulsion
• Immature teeth with open apices may revascularize, so pulp extirpation should be deferred
until clinical and radiographic signs of pulp
necrosis are apparent
• Decoronation of the tooth to preserve alveolar
bone is recommended if teeth become ankylosed and infrapositioned greater than 1 mm
(Cohenca etal. 2007)
Revascularization of immature teeth is most
likely to occur if replantation occurs within 15
minutes. Covering the root with topical minocycline hydrochloride microspheres (Arestin™)
or soaking in a 1% doxycyline solution prior to
replantation disinfects the apical tissues and
enhances revascularization; however, the
extraoral period should not be extended if
these are not immediately available
inflammatory reaction at the PDL that can destroy the
root within weeks. Radiographic evidence of inflammatory resorption includes typically ragged resorption
of lateral root surface and possibly the apical area. The
pulp canal should be thoroughly cleansed and disinfected. A calcium hydroxide dressing is then placed as
an intracanal medicament for two months. Obturation
of the canal with gutta‐percha is completed when
radiographs confirm that the resorption is stopped
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Self‐Study Questions
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OrOfacial Trauma
1. When is tetanus prophylaxis indicated following
a tooth avulsion/replantation?
2. What are the most important principles in the
initial management of an avulsed permanent tooth?
3. How does the management of an avulsed immature (open apex) permanent tooth differ from that of
a mature tooth?
4. How can the prognosis for revascularization of an
avulsed immature incisor be improved?
5. What are the important principles in the
management of an ankylosed permanent tooth?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 171
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Self‐Study Answers
1. If the patient has not had a tetanus toxin booster
within five years
2. Maintaining the vitality of the PDL by minimizing
the extraoral period and providing immediate
replantation if possible (preferred). If that is not
possible, transporting the tooth to the dentist in
physiologic media such as HBSS or cold milk with
replantation as soon as possible
3. Besides maintaining the vitality of PDL fibers,
an additional goal in managing avulsed immature
incisors is to promote revascularization of the pulp
canal with vital tissue to achieve complete root maturation (apexogenesis). Therefore, pulp extirpation
Bibliography
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12.
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
should be deferred unless clinical and radiographic
signs of pulp necrosis are apparent
4. By minimizing the extraoral period to less than
15 minutes and by soaking the tooth in a 1% doxycycline solution for five minutes before replantation.
This disinfects the apical tissues and significantly
enhances the likelihood of revascularization
5. An ankylosed tooth in a growing child will
become infrapositioned (“submerged”) as the child
grows. Decoronation should be considered inthese
cases to prevent a periodontal defect (which could
involve adjacent teeth) and to preserve alveolar
bone
Cohenca A, Cohenca N, Stabholz A. 2007. Decoronation – a
conservative method to treat ankylosed teeth for preservation of alveolar ridge prior to permanent prosthetic reconstruction: literature review and case presentation. Dent
Traumatol 23:87–94.
172 Clinical Cases inPediatric Dentistry
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Case 8
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Soft Tissue Injury Management
Figure 4.8.1 Facial photograph.
A. Presenting Patient
• Seven‐year-, nine‐month‐old African‐American male
(Figure4.8.1)
• Presenting as an emergency
B. Chief Complaint andHistory ofPresent Injury
• Father states, “My son fell at school and scraped his
mouth”
• Child was running in halls at school and fell one hour
ago. Injury was witnessed by classmates and teacher.
There was no loss of consciousness
C. Social History
• Patient has two siblings, ages 12 and 16
• Mother is the primary caregiver
• Middle-class family
OrOfacial Trauma
FUNDAMENTAL POINT 1
Health History forOral Soft Tissue Injury
• Confirm that tetanus immunizations are up to
date. If last tetanus booster was five or more
years prior and wound is contaminated with soil/
debris, another tetanus toxoid booster is indicated
(American Academy of Pediatrics 2011)
• Rule out closed head injury and refer for medical
consult if the patient is positive for any of the
following (Centers for Disease Control and
Prevention 2017):
Amnesia
Nausea/vomiting
Headache
Lethargy/irritability/confusion
Loss of consciousness
E.
Medical Consult
Not applicable
•
F. Dental History
• Child has seen dentist every six months since age two
• Good oral hygiene habits, with some adult supervision
• Normal diet
• Uses fluoridated toothpaste twice daily
• Lives in optimally fluoridated area
• No history of trauma before today
• Very cooperative for oral examination
D. Medical History
• History of mild seasonal‐induced asthma for which he
takes a bronchodilator (β2 agonist) as needed
• Allergic to penicillin
• No known food allergies, vaccinations are up to date
G. Extraoral Exam
• No significant findings
• Soft tissue injuries should only be addressed once
any hard tissue (bony, dental) injuries have been ruled
out (Armstrong 2000)
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H. Intraoral Exam
Soft Tissues
• Gingival tissue avulsion and degloving noted around
the maxillary permanent central incisors (Figure4.8.2)
Hard Tissues
• No significant findings
Occlusal Evaluation ofMixed Dentition
• Class II molar
Other
• Caries‐free dentition
• Maxillary right permanent central incisor was
unerupted according to father
• Current pain rating per child 6/10 but he is playful and
interactive
Discharge Instructions
• Avoid manipulation of injured segment until instructed
otherwise. Watch for clinical signs such as presence
of parulis or fistula
• Take over‐the‐counter analgesics as required
• Nonalcoholic chlorhexidine mouth rinse prescribed to
keep tissues clean
• Child may continue to brush teeth as usual
• Soft diet for one week
Follow‐Up Treatment
• One‐week post injury: all teeth test normally
(Figure4.8.3)
• Five months post injury: all teeth test normally
(Figure4.8.4)
Figure 4.8.2 Intraoral photograph showing degloving injury.
I. Diagnostic Tools
• Maxillary occlusal and periapical radiographs of
maxillary permanent central incisors show no significant findings
• Vitality tests: Deferred
• Take adequate radiographs to clearly show all involved
teeth
• Rule out other injuries, e.g. root fractures, alveolar
fractures
J. Diagnosis
Avulsion and degloving of gingival tissue
K. Treatment
• Mechanical cleansing of wound with sterile water
Figure 4.8.3 One‐week follow‐up intraoral photograph.
Figure 4.8.4 Five‐month follow‐up intraoral photograph.
L. Prognosis andDiscussion
• Prognosis for uneventful and normal healing
depends on adherence to basic soft tissue surgical
principles, such as decontamination of area
through irrigation, and good wound edge management. In this case, due to the avulsion of soft
tissue, this wound could not be adequately sutured
so was allowed to heal by secondary intention,
which is the migration of granulation tissue to
direct healing. Careful mechanical irrigation/
debridement are of consequence in tissue healing.
All teeth involved in injury must be reassessed for
potential pulpal injury, which may not surface
immediately
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OrOfacial Trauma
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M. Complications andAlternative
TreatmentPlan
• If this child had lost consciousness at school, medical
clearance would be warranted prior to proceeding
with treatment of dental injuries
BACKGROUND INFORMATION 1
Management ofOral Soft Tissue Trauma
• Parents and patients must be made aware that
there is potential for localized tissue color change
and contour change due to damage to melanocytes, as well as compromise of muscle attachments in deeper lesions (Essen etal. 2004)
• Adequate debridement of tissues and allowance
for abscess drainage in conjunction with appropriate empirical antibiotic therapy are all basic principles of soft tissue infection management. Factors
such as low oxygen tension can directly influence
tissue healing (Fung etal. 2003)
• If this child returned with a soft tissue infection, clinical
signs observed could include purulent exudate from site
of injury, localized tissue necrosis, and fever. Management
would involve careful debridement of the local area and
empirical use of antibiotics and analgesics for pain
Soft tissue suturing, if possible, prepares the
•
wound for healing and promotes healing by primary
intention (Peterson etal. 1993)
• Resorbable sutures, such as polyglycolic gut, are
often used. However, resorbable sutures may
cause localized inflammatory reactions which can
delay healing and thus are not used or recommended on the skin (Peterson etal. 1993)
• There is no evidence indicating that the routine
suturing of minor tongue lacerations has any
positive effect on healing. Uncontrollable hemorrhage and potential for airway compromise are the
only immediate reasons for suturing a minor tongue
laceration (Ud‐din and Gull 2007)
Self‐Study Questions
1. In this case, is gingival repigmentation a clinical
measure of successful treatment?
2. If the gingival tissue had merely been lacerated
and an associated tooth luxation noted, which
injury should be treated first?
3. What are some local factors that may influence
soft tissue healing?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 175
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Self‐Study Answers
1. No. Studies (Esen etal. 2004) have demonstrated
that ablation of gingival melanocytes may result
in loss of pigmentation. Melanocyte repopulation
of traumatized tissues are thought to originate in
the free gingivae. In this case, the avulsion of the
marginal and free gingivae could eliminate the
potential source for melanocytes
2. All bony and dental injuries should be treated
first to give the practitioner a good perspective on
Bibliography
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12.
Armstrong BD. 2000. Lacerations of the mouth. Emerg Med
Clin North Am 18:471–80.
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
the true extent of the soft tissue injury. Treating the
soft tissue injury first also leads to the potential
of tissue re‐injury during treatment of tooth
displacements
3. Local factors that may influence soft tissue
healing include low oxygen tension to the region
and corresponding ischemia, infection, and
localizededema
Esen E, Haytac MC, Oz IA et al. 2004. Gingival melanin pig-
mentation and its treatment with the CO2 laser. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 98(5):522–7.
Fung HB, Chang JY, Kuczynski S. 2003. A practical guide to the
treatment of complicated skin and soft tissue infections.
Drugs 63(14):1459–80.
Peterson L, Ellis E, Hupp J, Tucker M. 1993. Contemporary Oral
and Maxillofacial Surgery, 2nd edition. St Louis: Mosby.
Ud‐din Z, Gull S. 2007. Should minor mucosal tongue lacera-
tions be sutured in children? Emerg Med 24:123–4.
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Flowchart A: Intrusion Injuries
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Root tip
displaced into
permanent tooth bud
Yes
Extract
Advise parents
of potential damage
to permanent tooth
Follow-up in 4 weeks, 6–8 weeks, 6 months and 1 year and
Primary Dentition
All treatment is ideal and assumes
patient has manageable behavior.
Recommendations also assume
radiographs (occlusal, periapical
and lateral anterior taken where
No
Root tip is displaced
towards or through buccal
cortical plate
Monitor for spontaneous
re-eruption.
Advise parents of potential
damage to permanent tooth
annually until permanent successor erupts.
Advise parents of possible damage to permanent teeth
appropriate)
NoYes
Permanent Dentition
Up to 7 mm: allow for spontaneous
re-eruption or consider surgical luxation.
>7 mm: surgical or orthodontic repositioning
Closed apex
up to 3 mm intrusion
Allow for
spontaneous
re-eruption
Follow-up in 4 weeks, 6–8 weeks, 6 months and 1 year
Rx: chlorhexidine rinse, analgesics
Monitor for signs of pathology with radiographs
Closed apex
3–7 mm intrusion
Surgical or orthodontic
reposition and CaOH
pulpectomy within
3 weeks
No
Yes
Apex Open
No
Greater than
7 mm intrusion
Yes
Surgically reposition,
stabilize with passive
physiological splint for
4 weeks.
CaOH pulpectomy within
3–4 weeks of injury
Reproduced with permission of the American Academy of Pediatric Dentistry
Anne O’Connell, Andrew Spading, Trauma and Sports Dentistry (Chapter 9), pg. 177–190. In: The Handbook of Pediatric Dentistry, AAPD, 5th Ed., Nowak
and Casamassimo, 2018.
Trauma Treatment Algorithms, Chapter 9, Fig. 1-5, pg. 183–85
Clinical Cases inPediatric Dentistry 177
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Flowchart B: Root Fractures
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Fracture
located in coronal
third of root
Primary Dentition
Yes
No
Is coronal segment
mobile?
No
No splint required
Clinical and radiographic follow up in 6–8 weeks.
advise parents of possible injury/damage to
Annual review:
permanent teeth
All treatment is ideal and
assumes patient has
manageable behavior.
Recommendations also assume
appropriate preoperative radiographic
survey has been accomplished
Yes
Extract coronal
segment. Leave
apical segment
if not visible/
easily removed
Permanent Dentition
No splint required
Rx: chlorhexidine rinse, analgesics
Clinical and radiographic follow up 4 weeks,
Endodontic therapy only to fracture line
Continued root development likely
Is there separation of
No
Root fracture location
Coronal third: splint 4 months
consider orthodontic extrusion
or decoronation
Mid or apical third: passive,
physiologic splint for 4 weeks
6–8 weeks, 6 months.
Annual review for 5 years.
if necrosis occurs.
segment mobile?
Splint required to
approximate segments
the fragments?
Is the coronal
Yes
Reproduced with permission of the American Academy of Pediatric Dentistry
Anne O’Connell, Andrew Spading, Trauma and Sports Dentistry (Chapter 9), pg. 177–190. In: The Handbook of Pediatric Dentistry, AAPD, 5th Ed., Nowak
and Casamassimo, 2018.
Trauma Treatment Algorithms, Chapter 9, Fig. 1-5, pg. 183–85
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