Sunday, October 22, 2017

Orthodontic Procedures after Trauma

Department of Pediatric Dentistry
Langone Medical Center

Resident’s Name: Albert Yamoah                                                                                                Date: 10/25/2017
Article Title: Orthodontic Procedures after Trauma
Author(s): Henry W. Fields, John R. Christensen,
Journal: Pediatric Dentistry
Date: 2013
Major Topic: Orthodontics, Trauma
Type of Article: Review of
Main Purpose: This review considers oral trauma and its relationship to orthodontics with respect to prevention. Simplified biomechanics are presented to aid treatment
§ Published studies continuously supporting increased trauma risk with increasing OJ and inadequate lip coverage
§ Forsberg and Tedestam showed that these factors increased susceptibility to traumatic dental injury:
o Angle class II malocclusion,
o OJ exceeding 4 mm
o Short upper lip
o Incompetent lips
o Mouth breathing
§ Bauss et al reported similar findings with increased OJ and inadequate lip coverage doubling risk of trauma
§ Imperative to stress importance of mouth guard in prevention of oral injuries
§ Design of mouthguard should not lock teeth in position
§ Most commonly used mouth guard (boil and bite) not fully appropriate unless refit at short intervals, which is inconvenient
§ UNC and UF RCT studies show little evidence to recommend routine early orthodontic treatment for increased OJ as preventive measure
o When using trauma-prone groups, both studies found no differences in the proportion of new trauma among the groups,
o There was a significant increase in the control group trauma during phase 1 in the UNC study
Ortho as an adjunct to Post-Trauma treatment:
§ Primary treatment: Urgent care provided as soon as possible after traumatic incident
o Displaced tooth repositioned properly and splinted to hold tooth in position
o Active orthodontic treatment is not part of primary care
§ Secondary treatment: Consists of monitoring pulp and periodontal tissues for healing and treatment
o Involves orthodontic treatment of displaced teeth
o Primary goal for clinician is to provide treatment that will maximize healing capabilities of both pulpal and PDL tissues
o Outcomes vary depending on amount of tooth displacement, developmental stage of tooth, and splinting times and methods
o Treatment of tooth displacement becomes more complicated when time interval between trauma and treatment is extended
o Orthodontic treatment of displaced teeth can help in multiple ways:
§ Tooth can be repositioned with extremely light force compared with heavier and more forceful digital manipulation
§ Ortho may aid healing in cases with damage to socket architecture
§ Ortho may be more calming to patient, affording better patient management
§ Specific Indications for Orthodontic Treatment
o Trauma Ortho kit:
§ Hand instruments
§ Cheek retractors
§ Self-etching primer or traditional etchant
§ Self-ligating or twin brackets
§ Flexible NiTi wire
§ Cell phone for sending/receiving photos of injury
o Laterally luxated teeth can be moved immediately
o Treatment of avulsed teeth is time dependent – the sooner the tooth is replaced, the better the prognosis
o Treatment for dental intrusion is based on tooth’s stage of development
o Immature tooth suggested to monitor tooth and wait 4-6 weeks for spontaneous re-eruption
o Mature tooth suggested that a more immediate approach to repositioning should be considered
o When the tooth is intruded less than or equal to 6–7 mm, orthodontic treatment is generally the first choice
o Intrusion greater than 6–7 mm immediate surgical repositioning and orthodontic repositioning are the obvious choices
§ Surgical repositioning usually favored due to magnitude of required movement, number of appointments, and time limit imposed to open tooth for pulpal therapy
§ Extraction also may need to be considered
§ Teeth experiencing trauma during orthodontic treatment are significantly more likely to have pulpal necrosis than orthodontic only or trauma only teeth
§ Teeth with extrusion, intrusion, or lateral luxation were significantly more likely to have pulpal necrosis than teeth experiencing injury only to the crown
§ Depending on extent of injury and current stage of orthodontic treatment, clinician may elect to discontinue treatment, modify treatment, or finish as planned
§ Of significant concern is how teeth should be moved during immediate post-trauma period
o Most likely it will be either facial movement of lingually positioned or extrusion of intruded incisors
o In both instances, clinician wants method that is compatible with tissue, hygienic, efficient with light, sustained forces, and easy to fabricate
o Most practitioners gravitate to elastomeric chains, multiloop archwires, superelastic flexible continuous wires, or superelastic segmental overlay wires
§ Tertiary treatment: Addresses the ramification of orthodontic treatment for previously traumatized teeth
§ Timing of orthodontic treatment after trauma is an unresolved issue
§ Kindelan et al suggest 3 months of waiting before orthodontic treatment for minor injuries and 6 months to 1 year for more severe injuries, on the basis of expert opinion
§ There are several kinds of trauma that patients may have encountered in the past
§ For patients with complete root formation and crown only trauma, the most frequent type of trauma – tipping movements – resulted in a significant increase in both pulp pathology (7%) and root resorption (28%) when compared with orthodontic treatment for nontraumatized teeth and control teeth
§ Previously traumatized teeth that are intruded with orthodontics have significantly more pulpal necrosis, and those with total pulpal obliteration are significantly more likely to have necrosis than those without or those having partial obliteration
§ Endodontically Filled Teeth: Teeth with previous pulpal pathology including those with a history of trauma, when observed and deemed to be asymptomatic and free from inflammatory and replacement resorption, can be moved orthodontically with little consequence
o Some data show these teeth have less apical, orthodontically induced root resorption than contralateral control teeth
Orthodontics Related to Tertiary Care (Interdisciplinary) Posttrauma Treatments
§ Tertiary care is provided months to several years after trauma when the outcome of the trauma is evident
§ Orthodontic treatment can be integrated with other disciplinary care to provide innovative solutions after trauma
o In situ transplantation of traumatically affected teeth
o Traditional tooth transplantation of premolar teeth to anterior segments
o Substituting teeth for the missing tooth so that implants or fixed or removable prosthodontics are not required
o Injured tooth can be decoronated, leaving root portion to help maintain bone until growth is complete and implant is placed
Level of Evidence/Comments:  Level V – Review of RCTs, qualitative studies, and descriptive studies

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