accidents and emergencies with dental fractures

accidents and emergencies

1. بسم الله الرحمن الرحيم Accidents and emergencies Done By : GDP/ Hajar nabil Under The supervision of : P rof/ Dr / K haled barakat

2. Dentoalveolar trauma : Deciduous teeth (‘milk teeth ’) : Alveolar fractures are very rare in children and occur in relation to high velocity. • Always exclude NAI ( non accidental injury ) (particularly in the non- mobile child).

3. Management of complications in deciduous teeth Avulsed deciduous tooth : Do not re- implant Needs assessment if balancing extractions are required to prevent centre - line shift Intruded deciduous tooth damaging developing permanent tooth bud : The tooth can spontaneously re- erupt over time The developing permanent tooth may be bent ( dilaceration ) prevents normal eruption . Surgery may be required to aid eruption later on so monitor eruption times.

4. Permanent teeth : Luxation ‘loosening’ injuries : Needs splinting . Lateral luxation/ intrusion/ extrusion : fractures reduced and the tooth splinted . Severely intruded teeth (>6 mm in adults) require surgical repositioning and orthodontics. painkillers , antibiotics, and a mouthwash prescription .

5. Permanent teeth : Avulsion : chances of saving the tooth rapidly decrease with the amount of time that it has spent out of the mouth tooth fractures :

6. Dentoalveolar infections : initial infection originates from : Pulpal origin Soft tissue origin ( peridontally – pericoronally ) majority of dentoalveolar infections are mixed anaerobic– aerobic . Based on mode of involvement: - direct involvement in ( 1ry spaces) -indirect involvement in (2ry spaces)

7. 1ry potential fascial spaces & locations : primary fascial spaces & locations : vestibular buccal sublingual submandibular Canine • Sub mental maxillary sinus & nasal passage . palatal

8. secondary fascial spaces • Masticator( submasseteric-Pterygomandibular - Superficial and deep temporal)

9. secondary fascial spaces Retropharyngeal • Lateral pharyngeal • Prevertebral Transvers surgical cut at in oblique angle

10. secondary fascial spaces Parotid space infection

11. Specific infections : Ludwig’s angina : a bilateral cellulitis affecting sublingual and submandibular spaces -emergency decompression/ -drainage as soon as possible. Commence IV antibiotics ± steroids in the meantime. Periorbital cellulitis : Mainly originates from canine space infection Specially upper canine .

12. Assessment Take a history of the toothache and associated symptoms Search for: • Airway compromise • Raised FOM (floor of the mouth) • Restricted tongue protrusion • ‘Hot potato voice • Pain on turning the head • Trismus

13. • Temperature >38.5°C— ‘swinging pyrexia’ with abscess. • Cardiovascular— tachycardia, postural hypotension. • Blood abnormalities— raised white cell count, CRP. • Abscess: localized collection of pus swelling : • Oedema . • Cellulitis

14. Management • OPG (occasionally USS or CT is required). • WCC , CRP, and glucose. Consider cultures. • IV access and rehydrate. • Commence IV broad- spectrum antibiotics. • Consider corticosteroids in severe swelling . • Keep NBM (nil by mouth) • incision and drainage and extraction of causative teeth .

15. incision and drainage :

16. The aim is to keep the abscess cavity open, allowing further exudates to drain. Possible materials: • Yates’ drain (corrugated plastic) • Sterile glove finger • Ribbon gauze. Secure the drain with a non- absorbable suture . Pulling or ‘shortening’ the drain out in stages postoperatively allows the cavity to gradually close up behind it.

17. Post- extraction complications Bleeding : • Primary haemorrhage — at time of extraction . • Reactionary haemorrhage — up to 24 hours. • Secondary haemorrhage — >24 hours after extraction. Management : Remove all clots and see where the bleeding point is . consider haematology and coagulation blood tests . LA + adrenaline .

18. Clean the socket and pack it with resorbable cellulose Suture the socket tightly with a horizontal mattress suture of 3- 0 braided resorbable suture or black silk .

19. Pain : Dry socket Retained root or bone spicules Damage to adjacent tooth giving pulpal pain Dislocated mandible Hematoma Fractured bone Osteomyelitis (late) Osteonecrosis . Paraesthesia / anaesthesia Swelling Oro- antral communication

20. Head and neck soft tissue infections : Viral infection Spreading infection Localized infections -Shingles Herpes zoster infection - Erysipelas infection of skin Necrotizing fasciitis - - Cellulitis - Periorbital cellulitis - Carbuncle/ furuncle/ folliculitis : Impetigo - - Infected/ inflamed epidermoid (sebaceous) cyst - Chronic draining sinus

21. Chronic draining sinus Infected/ inflamed epidermoid (sebaceous) cyst Impetigo golden crust Erysipelas Necrotizing fasciitis

22. Salivary gland disease : Sialaden salivary gland. inflammation sialadenitis . atrophy sialectasis . Contrast investigation a sialogram . stones sialolithiasis .

23. Trauma Obstruction Infection nerve injury require formal exploration in theatre Disrupted ducts Disrupted ducts need re- anastomosis and stent insertion in theatre. A plastic cannula sheath inserted into the duct intra- orally can demonstrate a transected duct when it appears in the wound. Salivary gland stones swelling submandibular gland due to blockage of Wharton’s duct . Mucoceles & mucous retention cysts ranula Bacterial Staphylococcus aureus Prompt IV co- amoxiclave Viral Mumps , HIV cytomegalovirus (CMV) Epstein– Barr virus (EBV) para - influenza virus.

24. Miscellaneous conditions Facial nerve palsy Bleeding gums Pericoronitis Earring tear