Dentoalveolar Trauma

Investigations

It can be useful to obtain a periapical radiograph or an OPG to assess the status of the roots, specifically the presence of a root fracture. You should also check the surrounding soft tissues for any lacerations/foreign bodies. Tooth or restoration fragments can become lodged in the soft tissues such as lips/cheeks.
If the patient has fractured or avulsed the tooth and they cannot account for the whereabouts of the tooth fragment/teeth, it is recommended to obtain a chest x-ray to ensure they have not inhaled it.

Management

Not all dentoalveolar fractures require splinting therefore we have specified some of the criteria to aid the decision making process:
1) Extrusion – reposition, generally extrusion injuries should be splinted however if the extrusion is >5mm, the tooth will likely be extracted
2) Intrusion – reposition and splinting. If the degree of intrusion is >4mm, the tooth will may require surgical/orthodontic repositioning however this is not done acutely
3) Lateral luxation – reposition in socket and splint
4) Mobility – generally mobile teeth should be splinted as they pose an airway risk and for pain reduction. If the tooth has minimal mobility (less than 2mm of mobility in any direction) then advise conservative management i.e. soft diet
5) Crown fracture – does not require splinting. If there is a significant fracture extending into the dentine and/or pulp, a temporary dressing should be applied to the fractured surface.
6) Root fracture - depending on the level of the fracture, these may require splinting.
Following acute management of all dental trauma, patients should be referred to their dentist for ongoing monitoring and treatment.

With regards to alveolar fractures, they should be reduced manually under local anaesthetic and the teeth in the region of the fracture should be splinted for effective reduction. Conversely, the patient can be brought back to a clinic where dental impressions can be taken for the fabrication of a suck down splint. If there is an extensive alveolar fracture which is not amenable to closed repositioning and if surgical repair is deemed necessary, ORIF of the fracture can be performed under GA.

How to splint teeth under LA

Equipment required

1) Basic dental kit (mirror, probe, flat plastic)
2) Local anaesthetic
3) Saline
4) All in one etch, prime, bond (lollipop)
5) Wire
6) Wire cutters
7) Composite
8) Light cure
9) Gauze

The procedure

1) Administer local anaesthetic buccally and palatally/lingually
2) Irrigate the tooth and surrounding tissues as there will likely be dried blood which will compromise bonding
3) Reposition/re-implant the tooth if required. Try to ensure it is positioned at the same height as the adjacent teeth and in line with them. If you are unsure about what the normal position is, reposition the tooth and show the patient in a mirror to confirm/adjust
4) Measure the length of your wire – it should extend across 3-5 teeth i.e. the injured tooth and 1-2 teeth either side. Cut the wire to the desired length
5) Ensure the tooth surface is dry and proceed to etch, prime and bond the teeth. Light cure for 15-20 seconds
6) Apply composite on the labial surface of the injured tooth and push the wire into the composite to submerge it. Light cure for 20 seconds. Apply further composite over the wire to secure it
7) Repeat step 6 for the adjacent teeth and ensure the sharp ends of the wire are covered with composite to prevent soft tissue injury.
8) Advise the patient regarding pain relief and to book an appointment with his/her own dentist for a review as the splint must be removed in 2-4 weeks [4].
Important: Never re-implant a deciduous (baby) tooth. If baby teeth are loose and pose an airway risk or causing discomfort, they should be removed. If trauma to deciduous teeth occurs, parents should always be warned of damage to permanent dentition and this should be followed up by the dentist.

References