قراءة
عرض

Pedodontics

Lec.8 fifth stage
Dr. Sara Medhat Al.Dabbagh
Methods of Clinical Examination
Visual examination :
Any leakage of straw colored fluid from the nose, bruising, hemorrhage or laceration of the soft tissue or swelling.
Type of fracture
Discoloration of the tooth
Oral hygiene
Occlusion
Deviation in the path of mandible during mouth opening
The clinical examination should be conducted after the teeth in the area of injury have been carefully cleaned of debris. A piece of cotton moistened with saline or hydrogen peroxide can be used to clean the teeth and surrounded area. When the injury has resulted in a fracture of crown, the dentist should observe the amount of tooth structure that has been lost and should look for evidence of pulp exposure.

Digital examination

Tenderness of the tooth to gentle percussion
Mobility of the tooth
Vitality test of the injured tooth by thermal or electrical pulp tester.
Immediately after trauma, it does not give response to vitality test. Reexamine the tooth after 6 weeks and if the child does not give response this is an indicator that the tooth is non vital. The injured tooth should be performed and the teeth in the immediate area, as well as those in the opposing arch, should be tested. When the electric pulp tester is used, the dentist should first determined the normal reading by testing an uninjured tooth on the opposite side of the mouth and recording the lowest number at which the tooth responds, if the injured tooth more current than dose a normal tooth, the pulp may be undergoing degenerative change, where as if it required less current, pulpal inflammation is usually indicated. Pulp testing following traumatic injuries is controversial issue. These procedure require cooperation and a relaxed patient in order to avoid false reaction. However, this is often not possible during initial treatment of injured patients, especially children. Furthermore, the electric pulp test is frequently unreliable, even on normal teeth when apices are incompletely formed.


The thermal test is also somewhat helpful in determining the degree of pulpal damage after trauma. Although there are difficulties with the thermal test, it is probably more reliable than the electric pulp test in testing primary incisors in young children. Failure of a tooth to respond to heat indicates pulpal necrosis. The response of a tooth to a lower degree of heat than is necessary to elicit response in adjacent teeth is an indication of inflammation. Pain occurring when ice is applied to a normal tooth will subside when the ice is removed. A more painful and often lingering reaction to cold indicates a pathologic change within the pulp, the nature of which can be determined when the reaction is correlated with other clinical observations. The failure of a pulp to respond immediately after an accident is not an indication for endodontic treatment.

Radio graphical examination

The examination of traumatized teeth cannot be considered complete without a radiograph of the injured tooth, the adjacent teeth, and sometimes the teeth in the opposing arch. In search of fractured tooth fragment, it may be necessary to obtain radiograph of the soft tissue surrounding the injury site.
Radiographs are taken for:
Base line evaluation
Medico legal records
Follow up evaluation (comparison with the records in future). Frequent, periodic radiographs reveal evidence of continued pulp vitality or adverse changes that take place within the pulp or the supporting tissues. In young teeth in which the pulp recovers from the initial trauma, the pulp chamber and canal decrease in size coincident with the normal formation of secondary dentin. After a period of time an inconsistency in the true size or contour of the pulp chamber or canal compared with that of adjacent teeth may indicate a developing pathologic condition.
To assess the size of pulp chamber and proximity to the fracture line. The relative sizes of the pulp chamber and canal should be carefully examined.
Determine the stage of root development (the stage of apical development often indicates the type of treatment).
Presence of root fracture or alveolar bone fracture. A root fracture as a result of the injury or one previously sustained can be detected by a careful examination of the radiograph. However, the presence of root fracture may not influence the course of treatment, particularly if the fracture line is in the region of apical third.
To ascertain the position of traumatized tooth and its relationship to the unerupted teeth in the area (dislocation of the teeth).
Periodontal ligament condition
Pre-exiting pathological condition
Extra oral radiographs help in diagnosis of jaw fractures, complex injuries to identify the extent and location of all injuries.
Soft tissue radiographs are helpful in determining displacement of tooth fragment in to adjacent soft tissue.

Emergency treatment of soft tissue injury

Injury to the teeth of children is often accompanied by:
Open wounds of the oral tissues
Abrasion of the facial tissue
Puncture wounds
The dentist must recognize the possibility of the development of tetanus after the injury and must carry out adequate first-aid measures. Primary immunization is usually a part of medical care during first 2 years of life. However, primary immunization cannot be assumed-it must be confirmed by examination of the child’s medical record. When the child who has had primary immunization receives an injury from an object that is likely to have been contaminated, the antibody-forming mechanism may be activated with a booster injection of toxoid. An unimmunized child can be protected through passive immunization or serotherapy with tetanus antitoxin (tetanus immune globulin).
The dentist examine the child after an injury should determine the child’s immunization status, debridement, suturing and hemorrhage control of open soft-tissue should be carried out.


Emergency treatment and temporary restoration of fractured teeth without pulp exposure
Crown craze or crack
These are minute cracks extending throughout the labiolingual surface, usually resulting from direct trauma to a tooth. These craze areas involve enamel alone or both enamel and dentin.
A trauma to a tooth that causes a loss of only a small portion of enamel should be treated as carefully as one in which greater tooth structure is lost. The emergency treatment of minor injuries in which only the enamel is fractured may consist of no more than smoothing the rough, jagged tooth structure. However, without exception, a thorough examination should be conducted.
The patient should be reexamined at 2 weeks and again at 1 month after the injury, if the tooth appears to have recovered at that time, continued observation at the patient’s regular recall appointments should be the rule.
Sudden injuries with a resultant extensive loss of tooth structure and exposed dentin require an immediate temporary restoration or protective covering (to avoid further damaging of the pulp from thermal or bacteria which can transmitted to the pulp through dentinal tubule). In addition to the complete diagnostic procedure. In this type of injury, initial pulpal hyperemia and the possibility of further trauma to the pulp by pressure or by thermal or chemical irritants must be reduced. In addition, if normal contact with adjacent or opposing teeth has been lost, temporary restoration or protective covering can be designed to maintain the arch integrity. Because providing an adequate permanent restoration may depend on maintaining the normal alignment and position of teeth in the area, this part of treatment is as important as maintaining the vitality of the teeth.
Several restorations that will satisfy these requirements can easily be fabricated.
There are factors which affect the treatment:
The time dentin has been exposed
The thickness of the dentin covering the pulp
The stage of the development of the root

If thick layer of dentin cover that pulp

A direct pulp capping is indicated to cover the dentinal tubule by Ca (OH)2 and hold the medication by means of retainer. Use an orthodontic band (or one of the followings: acrylic crown (which is good for esthetic). Celluloid crown, stainless steel crown, cupper ring). Then fill the gap with cement and ask the patient to come after some time to check the vitality, the mobility, and the band should stay 6-8 weeks if everything is all right then restore the teeth.
If the patient has class 2 near the pulp
If the patient come immediately do pulp capping
If the patient come later on then we consider it as exposure and we do root canal filling because the thin layer of dentin left is not enough to protect the pulp from infection.

Fragment restoration (reattachment of tooth fragment)

Occasionally the dentist may have the opportunity to reattach the fragment of a fractured tooth using resin and bonding techniques. This procedure is atraumatic and seems to be the ideal method of restoring the fractured crown. Sealing the injured tooth and aesthetically restoring its natural contour and color are accomplished simply and constitute an excellent service to the patient.
The procedure provides an essentially perfect temporary restoration that may be retained a long time in some cases. It is not often that the fractured tooth fragment remains intact and is recovered after an injury, but when this happens, the dentist may consider the reattachment procedure. The tooth requires no mechanical preparation because retention is provided by enamel etching and bonding techniques. If little or no dentin is exposed, the fragment and the fractured tooth enamel are etched and reattached with bonding agents and materials.
For the exposed dentin of the fractured tooth should be covered by a thin layer of hard-setting calcium hydroxide to remain as sedative dressing between the tooth and restored fragment. A portion of dentin in the fragment was removed to provide space for the calcium hydroxide. The fragment soaked in etchant, and the fractured area also etched. After through rinsing and drying of all etched enamel, the fragment and the etched portion were painted with a light curing sealant material bonding agent was recommended.
The selected shade of composite resin was used to fill the prepared void in the fragment, and it was then carefully seated into its correct position and held firmly while the material was light-cured. Subsequent radiographs and vitality tests indicated that the tooth had probably responded favorably.


Temporary bonded resin restoration
The excellent marginal seal and retention derived from the application of esthetic restorative materials to etched enamel surfaces have revolutionized the approach to the restoration of fractured anterior teeth. These bonding techniques are highly successful and versatile in many situations involving anterior trauma. It may not be advisable to restore an extensive crown fracture with a finished aesthetic resin restoration on the day of the injury because it is usually best not to manipulate the tooth more than is absolutely necessary to make a diagnosis and provide emergency treatment. Also, such emergencies are usually treated at unscheduled appointments, and this treatment should be carried out as efficiently as possible to prevent significant disruption of the dentist’s scheduled appointments. A temporary restorative resin restoration can be placed efficiently and is often the treatment of choice.
Conventional bonding procedures are used for application of the restorative resin material as a protective covering at the fracture site. As a short term temporary restoration, it requires little or no finishing and does not need to restore the tooth to normal contour. After an adequate recovery period an aesthetic resin restoration may be completed, often without removal of all the temporary resin material. However, the outer surfaces of temporary restoration should be removed before applying the new material. The margins of the new restoration should extend beyond the margins of temporary restoration and onto newly erupted enamel.




رفعت المحاضرة من قبل: Mustafa Shaheen
المشاهدات: لقد قام 10 أعضاء و 211 زائراً بقراءة هذه المحاضرة








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