Trauma Dentoalveolar

• Definisi

  Dentoalveolar injury is injury related to tooth or tooth-supporting structures (gingiva, periodontal ligament (PDL), alveolar bone).

• AVULSION OF TEETH (GOLDEN PERIOD LESS THAN 60’)

  • PHYSIOLOGIC STORAGE MEDIA INCLUDE E.G. TISSUE CULTURE MEDIUM AND CELL TRANSPORT MEDIA. EXAMPLES OF OSMOLALITY BALANCED MEDIA ARE HBSS, SALINE AND MILK. SALIVA CAN ALSO BE USED.

    1. CLEAN THE ROOT SURFACE AND APICAL FORAMEN WITH A STREAM OF SALINE AND SOAK THE TOOTH IN SALINE THEREBY REMOVING CONTAMINATION AND DEAD CELLS FROM THE ROOT SURFACE.
    2. ADMINISTER LOCAL ANESTHESIA.
    3. IRRIGATE THE SOCKET WITH SALINE.
    4. EXAMINE THE ALVEOLAR SOCKET. IF THERE IS A FRACTURE OF THE SOCKET WALL, REPOSITION IT WITH A SUITABLE INSTRUMENT.
    5. IRRIGATE THE TOOTH WITH DOXYCICLIN
    6. REPLANT THE TOOTH SLOWLY WITH SLIGHT DIGITAL PRESSURE. DO NOT USE FORCE.
    7. SUTURE GINGIVAL LACERATIONS, IF PRESENT.
    8. VERIFY NORMAL POSITION OF THE REPLANTED TOOTH BOTH CLINICALLY AND RADIOGRAPHICALLY.
    9. APPLY A FLEXIBLE SPLINT FOR UP TO 2 WEEKS, KEEP AWAY FROM THE GINGIVA.
    10. ADMINISTER SYSTEMIC ANTIBIOTICS
    11. CHECK TETANUS PROTECTION
    12. GIVE PATIENT INSTRUCTIONS
    13. INITIATE ROOT CANAL TREATMENT 7–10 DAYS AFTER REPLANTATION AND BEFORE SPLINT REMOVAL (SEE ENDODONTIC CONSIDERATIONS).

  • Keep tooth moist

    • HANK’S BALANCED SALT SOLUTION (HBSS) OR
    • COLD MILK OR
    • SALINE OR
    • SALIVA (BUCCAL VESTIBULE)
    • WATER (THE LAST CHOICE)
    • SAVE TOOTH FOR 20 MINUTES TO 6 HOURS

  • Socket Evaluation before replantation

    

  • Buccal plate

    

  • DON’T TOUCH ROOT AREA !

    

Klasifikasi

• Klasifikasi Andreasen (1981)/ WHO

  • FRAKTUR PADA JARINGAN KERAS GIGI DAN PULPA

    • crown infraction

      Fraktur/retakan enamel yang tidak lengkap tanpa kehilangan substansi gigi.

    • uncomplicated crown fracture

      Fraktur yang terbatas pada enamel atau melibatkan enamel dan dentin tanpa memperlihatkan pulpa.

    • complicated crown fracture

      raktur yang melibatkan enamel dan dentin dengan terbukanya pulpa.

    • Uncomplicate crown root fracture

      Fraktur yang melibatkan email, dentin, dan sementum tanpa terbukanya pulpa

    • complicated crown root fracture

      fraktur yang melibatkan enamel, dentin, dan sementum dengan terbukanya pulpa.

    • root fracture

      Fraktur yang melibatkan dentin, sementum, dan pulpa

    

    

    

  • CEDERA PADA JARINGAN PERIODONTAL

    • Concussion

      cedera pada jaringan penyangga gigi tanpa terlihat adanya pelebaran jaringan periodontal namun sensitive jika diperkusi

      • CF

        • There is no abnormal loosening or displacement of the tooth, but there is increased tenderness to percussion

        The tooth appears elongated and is excessively mobile

      • Treatment

        • Reposition the tooth by gently re-inserting It into the tooth socket.
        • Stabilize the tooth for 2 weeks using a flexible splint.
        • root canal treatment is indicated.

    • Subluxation

      cedera pada struktur pendukung gigi dimana terdapat peningkatan mobilitas gigi tetapi tidak ada kehilangan gigi

    • intrusive Luxation (central dislocation)

      Pergerakan gigi ke dalam tulang alveolar dengan fraktur soket alveolar. Perawatan ini kontroversial karena dilakukan dengan pembedahan dan memposisikan kembali gigi yang terintrusi dan disarankan splinting awal diikuti oleh ekstrusi ortodontik dari gigi yang terkena

      • CF

        The tooth is displaced axially into the alveolar bone.

      • Treatment

        • Teeth with incomplete root formation allow eruption without intervention initiate orthodontic repositioning.
        • If tooth is intruded more than 7mm, reposition surgically or orthodontically

    • Extrusive luxation (peripheral dislocation partial avulsion)

      dislokasi sebagian atau tidak penuh dari gigi keluar dari soket alveolar

    • Lateral luxation

      Pergerakan gigi ke segala arah kecuali sepanjang sumbu vertical, terjadi bersama dengan fraktur dengan retensi segmen akar tetapi hilangnya segmen mahkota.

      • CF

        The tooth is displaced, usually in a palatal/lingual or labial direction.

      • Treatment

        • Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it into its original location.
        • Stabilize the tooth for 4 weeks using a flexible splint

        

    • retained root fracture

      Fraktur dengan retensi segmen akar tetapi hilangnya segmen mahkota

    • Exarticulation (complete avulsion)

      Terjadi ketika seluruh gigi dipindahkan keluar dari soket alveolar.

    

    

    

  • CIDERA PADA TULANG PENYANGGA GIGI

    • comminution of alveolar soket

      Crushing and compression of the alveolar socket. This condition is found together with intrusive and lateral luxation

    • frakture pada dinding alveolar soket

      A fracture contained to the facial or lingual socket wall.

    • fraktur proccecus alveolaris

      A fracture of the alveolar process, which may or may not involve the alveolar socket.

    • fraktur mandibula/maxilla2

      A fracture involving the base of the mandible or maxilla and often the alveolar process (jaw fracture). The fracture may or may not involve the alveolar socket.

    

• Klasifikasi ELLIS & DAVEY

  • I Simple crown fracture with little or no dentin affected
  • II Extensive crown fracture with considerable loss of dentin, but with the pulp not affected.
  • III Extensive crown fracture with considerable loss of dentin and pulp exposure.
  • IV A tooth devitalized by trauma with or without loss of tooth structure.
  • V Teeth lost as a result of trauma.
  • VI Root fracture with or without the loss of crown structure.
  • VII Displacement of the tooth with neither root nor crown fracture
  • VIII Complete crown fracture and its displacement.
  • IX Traumatic injuries of primary Teeth.

  

  

  

• Management

  • Primary Dentition

    • Crown fracture

      

    • Root Fracture

      

    • Management of displacement injuries

      

  • Permanent Dentition

    • Crown Fracture

      

    • Root fracture

      

    • Luxation Injuries

      

    • Avulsion

      

    • Alveolar Fractures

      

• TREATMENT PLANNING FOR DENTOALVEOLAR Fracture

  • Conservative
    • Enamel Fractures (Crown Infraction)
    • Crown Fracture without Pulp Involvement
    • Crown Fracture with Pulp Involvement
  • Conservative/ Surgery
    • Root Fracture Conservative / surgery

• STABILIZATION PERIOD FOR DENTOALVEOLAR INJURIES

  Untitled

  • Check occlusion before splinting

    

• DENTAL WIRING TECHNIQUES FOR SPLINTING

  • Direct Interdental Wiring

    • Essig’s wiring

      • indikasi

        • To stabilize dento-alveolar fracture
        • As anchoring device for MMF(maxilomandibular fixation)
        • Suffcient number of teeth on either side of fracture line

      • kontraindikasi

        • fraktur akar
        • gigi desidui pada masa periode geligi campuran

      • syarat

        harus ada jumlah gigi yang cukup di kedua garis fraktur untuk dijadikan sebagai penyangga

      • ESSIG’S WIRING CAN BE USED TO STABILIZE THE DENTOALVEOLAR FRACTURES IN INDIVIDUAL DENTAL ARCHES,

      • THE LUXATED TEETH ALSO CAN BE STABILIZED USING THIS WIRING.

      • Requirement

        • REQUIREMENTS FOR THIS TYPE OF WIRING IS THAT THERE SHOULD BE SUFFICIENT NUMBER OF TEETH ON EITHER SIDE OF THE FRACTURE LINE TO TAKE THE ANCHORAGE.

      • THE LUXATED TEETH SHOULD BE PUSHED BACK INTO THEIR SOCKETS AND THE STABILIZATION AREA CHOSEN SHOULD BE AT LEAST 3 TEETH AWAY FROM THE FRACTURE LINE.

      • THE WIRE IS PASSED AROUND THE NECKS OF THE CHOSEN TEETH, ONE END GOING FROM BUCCAL TO LINGUAL AND OTHER END GOING LINGUAL TO BUCCAL IN EACH INTERDENTAL SPACE OF THE TEETH (3 TEETH AWAY FROM THE FRACTURE LINE).

      

    • Gilmer’s wiring

      • Indication

        Indication: First aid method for achieving temporary immobilization of fractured fragment

      • Gilmer’s wiring is a direct wiring method of intermaxillary fixation between the maxillary and mandibular teeth

      • this is the most common, simple and practical method, as it secures the teeth and stabilizes the jaw properly

      • few firmt eeth in the maxilla as well in the mandible are chosen. at least one tooth anterior and one posterior to the fracture should be available for wiring to assure proper stabilization.

      

      

    • Risdon wiring

      • Indikasi
        • Primary and early mixed dentition—when anatomy of the teeth does not allow for maxillomandibular fxation with arch bar
      • Risdon's Wiring adalah metode fiksasi wire horisontal yang umum digunakan
      • Pada metode kali ini biasanya molar kedua di kedua regio dipilih sebagai gigi penyangga

      

      

  • Indirect interdental wiring

    • IVY EYELETS WIRING

      • indikasi

        • Primary and early mixed dentition—when dental status does not allow for maxillomandibular fxation with arch bar fxation

        fiksasi intermaksilar

        • Ivy eyelet wiring mencakup dua gigi yang berdekatan

      • procedure

        • THE IVY LOOP EMBRACES THE TWO ADJACENT TEETH.
        • A LOOP IS FORMED IN THE CENTER OF THE WIRE AROUND THE BEAK OF A TOWEL CLIP OR SHANK OF A DENTAL BUR AND TWISTED THRICE WITH TWO TAIL ENDS.
        • SUCH IVY LOOPS CAN BE PREFORMED AND STORED IN COLD STERILIZING SOLUTION, SO THAT THEY ARE AVAILABLE IN EMERGENCY SITUATION. THE TWO TAIL ENDS OF THE EYELET ARE PASSED THROUGH THE INTERDENTAL SPACE OF THE SELECTED TWO TEETH FROM BUCCAL TO LINGUAL SIDE.
        • ONE END OF THE WIRE IS PASSED AROUND THE DISTAL TOOTH LINGUALLY AND BROUGHT OUT FROM THE DISTAL INTERDENTAL SPACE OVER THE BUCCAL SIDE AND THREADED THROUGH THE PREVIOUSLY FORMED LOOP.

      

      

  • Continuous wiring

    • indikasi

      fiksasi interdental

    • HERE THE FOUR POSTERIOR QUADRANTS ARE USED FOR WIRING.

    • FOUR PIECES OF 26 GAUGE, 20 CM LONG WIRES ARE REQUIRED AND PIECE OF SOLDER WIRE OR ANY THICK WIRE IS REQUIRED TO MAKE THE LOOPS.

    • A PIECE OF SOLDER WIRE IS ADAPTED TO THE BUCCAL SURFACE OF THE TEETH IN THE FIRST QUADRANT, WHERE THE WIRING IS STARTED.

    • THE 20 CM LONG PRESTRETCHED WIRE IS FOLDED INTO EQUAL PARTS, ONE PART IS KNOWN AS STATIONARY WIRE, WILL BE ADAPTED ON THE BUCCAL SIDE STARTING FROM MIDLINE GOING BACKWARD TO SECOND MOLAR (OR LAST EXISTING TOOTH IN THE ARCH).

    • THE OTHER END OF THE WIRE (WORKING END) IS THEN BROUGHT DISTAL TO THE SECOND MOLAR AND TAKEN AROUND IT ON THE LINGUAL SIDE.

    

  • ARCHBAR FIXATION

    • Indikasi
      • For temporary stabilization of fracture in emergency cases before the definitive treatment
      • For fixation of avulsed or mobile teeth and dento-alveolar fractures
      • As a tension band in combination with internal fixation of fractures
      • As an integral part of skeletal suspension wiring
      • Preoperatively and postoperatively, to maintain/guide occlusion or to restrict mandibular movements for a recommended period of time
      • Intraoperatively, to maintain teeth in proper occlusion during fracture fixation
      • Long-term fxation in conservative management
    • THE MOST POPULAR ONE AND COMMONLY USED IS THE ERICH‘S ARCH BAR.
    • IT IS A PREFABRICATED ARCH BAR WITH HOOKS INCORPORATED ON THE OUTER SURFACE WITH FLAT MALLEABLE STAINLESS STEEL METAL STRIP.
    • IT PROVIDES AN EFFECTIVE, QUICK AND INEXPENSIVE METHOD OF FIXATION.
    • EACH ARCH BAR IS TO BE FIXED TO THE UPPER AND LOWER DENTAL ARCHES.
    • ON THE UPPER JAW, THE HOOKS ARE ARRANGED IN AN UPWARD DIRECTION. THE BAR IS ATTACHED TO THE LOWER JAWWITH THE HOOKS IN A DOWNWARD DIRECTION.