• Concussion
This is the mildest form of luxation injury, and it is characterized by sensitivity to percussion only. No displacement takes place, and there is no mobility as a result of the injury. Concussion is probably present in most cases of crown, root, and crown- root fractures. Usually no treatment is required. The teeth should be monitored periodically to evaluate pulpal status. Many of these teeth will give a false negative response to pulp testing in the initial stages. This is primarily due to the shock to the neurovascular complex and resolves over time .In most cases there is complete recovery. Pulpal status should be evaluated over a periord of months and endodontic therapy should be instituted only if the vitality status is negative consistently or the patient has symptoms of irreversible pulpitis.
This is the mildest form of luxation injury, and it is characterized by sensitivity to percussion only. No displacement takes place, and there is no mobility as a result of the injury. Concussion is probably present in most cases of crown, root, and crown- root fractures. Usually no treatment is required. The teeth should be monitored periodically to evaluate pulpal status. Many of these teeth will give a false negative response to pulp testing in the initial stages. This is primarily due to the shock to the neurovascular complex and resolves over time .In most cases there is complete recovery. Pulpal status should be evaluated over a periord of months and endodontic therapy should be instituted only if the vitality status is negative consistently or the patient has symptoms of irreversible pulpitis.
• Subluxation
When a tooth, as a result of trauma, is sensitive to percussion and has increased mobility, it is classified as subluxated. Electric pulp test results may be either no response or positive; if they are the former, damage to the apical neurovascular bundle is more severe, and pulpal recovery becomes questionable, except in developing teeth.Treatment initially may be none, except to recommend minimal use, or it may be necessary to stabilize the tooth for a short period of time (2 to 3 weeks) to promote periodontal ligament recovery and reduction in mobility.
• Relieve occlusion
• Splint NOT required
•Unless marked loosening (subluxation)
•Review pulpal status for upto 2 years.
•Prognosis
Prognosis is usually good. The incidence of post operative complications is enumerated below.
• Lateral Luxations
Traumatic injuries may result in displacement of a tooth labially, lingually, distally, or mesially. Such displacement is called lateral luxation, and it is often very painful,particularly when the displacement results in the tooth being moved into a position of premature occlusion. The tooth is highly mobile and is likely to be continually traumatized by contact with opposing teeth, owing to the premature occlusal condition, all of it contributing to patient discomfort and severe tooth mobility Initial, urgent care for lateral luxation cases includes:
1) Repositioning the tooth and stabilization, if the tooth is mobile after being repositioned.
2) Repositioning a laterally luxated tooth may require pressure application at the apical end of the root in the direction of the root apex’s original location or by partially extracting the tooth with forceps prior to repositioning.
3) The splinting, if needed, should be non-rigid and may need to be in place for 3 to 4 weeks, depending on how soon the supporting tissues recover.Longer periods of rigid splinting up to 8 weeks are required if there is concomitant fracture of bone.
4) Definitive treatment for laterally luxated teeth includes root canal therapy, except in developing teeth, which may revascularize.
5) The prognosis for lateral luxation is good if proper endodontic therapy is performed when indicated.
• Extrusive Luxation
Displacement of a tooth axially in a coronal direction results in a partial avulsion. The tooth is highly mobile and is likely to be continually traumatized by contact with opposing teeth, owing to the premature occlusal condition, all of it contributing to patient discomfort and severe tooth mobility).
Immediate urgent care consists of:
1) Repositioning the tooth, usually more easily accomplished than in lateral luxation, and stabilizing it by a functional splint for 4 to 8 weeks.
2) The relatively long stabilization period is to allow realignment of the periodontal ligament fibers supporting the tooth. It is important during this period that gingivitis be prevented. Gingival inflammation will negate any attempt of the tissue to repair itself.
3) During recovery, progress can be monitored by periodontal probing. When reattachment has occurred, probing depth should be similar to pre-trauma depth.
Intrusive Luxation
A tooth may be pushed into its socket, resulting in a very firm, almost ankylosed tooth.Such intrusive luxations require diverse treatment approaches depending on the stage of tooth development: little or no treatment for very immature teeth, aggressive initial treatment for more mature teeth.Endodontics — In cases of intrusive luxation of developing, immature teeth, the theory behind not doing anything initially is based on the expectation that a tooth with a wide open apex has the potential to re-erupt spontaneously and establish a normal occlusal alignment within a few weeks or months.
Treatment Protocol
A) Reposition immediately
Reasons
i)Avoids pressure necrosis of periodontal ligament and hence less chance for external replacement resorption
ii) Fully developed teeth unlikely to erupt
iii) Allows access to root canals. Fully developed teeth need immediate endodontic treatment to prevent inflammatory resorption
iv) Avoids surgery for orthodontic extrusion to attach brackets, wires
B) Other Options:
i)Allow to re-erupt spontaneously. This is only likely in incompletely developed tooth
ii) Orthodontic extrusion
1) Later — if no re-eruption spontaneously
2) Complicates early management
3) Splint — Rigid ( Fig 36.56). this is usually required -
a) Since there is a concomitant bone fracture
b) For 6 - 8 weeks
4) Suture soft tissues
5) Endodontic treatment
Should be immediately — IF fully developed tooth Same regime as for avulsed teeth is to be followed and done.
To prevent inflammatory resorption
6) If incompletely developed — monitor pulp.
7) The exception to endodontic treatment is when spontaneous eruption takes place in young, developing teeth. Every effort should be made to promote revascularization of pulps in traumatized, developing teeth to allow continued root formation.
9) Review regularly
When a tooth, as a result of trauma, is sensitive to percussion and has increased mobility, it is classified as subluxated. Electric pulp test results may be either no response or positive; if they are the former, damage to the apical neurovascular bundle is more severe, and pulpal recovery becomes questionable, except in developing teeth.Treatment initially may be none, except to recommend minimal use, or it may be necessary to stabilize the tooth for a short period of time (2 to 3 weeks) to promote periodontal ligament recovery and reduction in mobility.
• Relieve occlusion
• Splint NOT required
•Unless marked loosening (subluxation)
•Review pulpal status for upto 2 years.
•Prognosis
Prognosis is usually good. The incidence of post operative complications is enumerated below.
• Lateral Luxations
Traumatic injuries may result in displacement of a tooth labially, lingually, distally, or mesially. Such displacement is called lateral luxation, and it is often very painful,particularly when the displacement results in the tooth being moved into a position of premature occlusion. The tooth is highly mobile and is likely to be continually traumatized by contact with opposing teeth, owing to the premature occlusal condition, all of it contributing to patient discomfort and severe tooth mobility Initial, urgent care for lateral luxation cases includes:
1) Repositioning the tooth and stabilization, if the tooth is mobile after being repositioned.
2) Repositioning a laterally luxated tooth may require pressure application at the apical end of the root in the direction of the root apex’s original location or by partially extracting the tooth with forceps prior to repositioning.
3) The splinting, if needed, should be non-rigid and may need to be in place for 3 to 4 weeks, depending on how soon the supporting tissues recover.Longer periods of rigid splinting up to 8 weeks are required if there is concomitant fracture of bone.
4) Definitive treatment for laterally luxated teeth includes root canal therapy, except in developing teeth, which may revascularize.
5) The prognosis for lateral luxation is good if proper endodontic therapy is performed when indicated.
• Extrusive Luxation
Displacement of a tooth axially in a coronal direction results in a partial avulsion. The tooth is highly mobile and is likely to be continually traumatized by contact with opposing teeth, owing to the premature occlusal condition, all of it contributing to patient discomfort and severe tooth mobility).
Immediate urgent care consists of:
1) Repositioning the tooth, usually more easily accomplished than in lateral luxation, and stabilizing it by a functional splint for 4 to 8 weeks.
2) The relatively long stabilization period is to allow realignment of the periodontal ligament fibers supporting the tooth. It is important during this period that gingivitis be prevented. Gingival inflammation will negate any attempt of the tissue to repair itself.
3) During recovery, progress can be monitored by periodontal probing. When reattachment has occurred, probing depth should be similar to pre-trauma depth.
Intrusive Luxation
A tooth may be pushed into its socket, resulting in a very firm, almost ankylosed tooth.Such intrusive luxations require diverse treatment approaches depending on the stage of tooth development: little or no treatment for very immature teeth, aggressive initial treatment for more mature teeth.Endodontics — In cases of intrusive luxation of developing, immature teeth, the theory behind not doing anything initially is based on the expectation that a tooth with a wide open apex has the potential to re-erupt spontaneously and establish a normal occlusal alignment within a few weeks or months.
Treatment Protocol
A) Reposition immediately
Reasons
i)Avoids pressure necrosis of periodontal ligament and hence less chance for external replacement resorption
ii) Fully developed teeth unlikely to erupt
iii) Allows access to root canals. Fully developed teeth need immediate endodontic treatment to prevent inflammatory resorption
iv) Avoids surgery for orthodontic extrusion to attach brackets, wires
B) Other Options:
i)Allow to re-erupt spontaneously. This is only likely in incompletely developed tooth
ii) Orthodontic extrusion
1) Later — if no re-eruption spontaneously
2) Complicates early management
3) Splint — Rigid ( Fig 36.56). this is usually required -
a) Since there is a concomitant bone fracture
b) For 6 - 8 weeks
4) Suture soft tissues
5) Endodontic treatment
Should be immediately — IF fully developed tooth Same regime as for avulsed teeth is to be followed and done.
To prevent inflammatory resorption
6) If incompletely developed — monitor pulp.
7) The exception to endodontic treatment is when spontaneous eruption takes place in young, developing teeth. Every effort should be made to promote revascularization of pulps in traumatized, developing teeth to allow continued root formation.
9) Review regularly
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