Orthodontic Procedures after Trauma

Citation: Fields HW, Christensen JR. Orthodontic procedures after trauma. Pediatr Dent. 2013;35(2):175-83.
Type of study: Review of current literature ~2013
Purpose: To discuss the relationship between oral trauma and orthodontics including its prevention, and care of permanent teeth. It reviews the available evidence regarding orthodontics as an adjunct to post-oral trauma treatment for permanent teeth.

PREVALENCE of dental trauma General population approx. 10-13%, however in patients with +5to 7mmoverjet that increases to 23-29%, however these patients tend to suffer trauma before they are ready for orthodontic intervention.

Prevention of dental trauma for active or potential orthodontic patients: MOUTHGUARD

  • most effective when worn properly
  • consider compliance, material type and method of construction
  • *a different design is required for active orthodontic patients: should not lock teeth in position but have a smooth flat occlusal surface so tooth movement can continue. Should also protect soft tissue.
  • boil and bite mouthguards: can use but will frequently need to be re-fitted
  • there is little evidence to recommend routine early ortho Tx for increased OJ as a preventive measure for trauma



Orthodontics as an adjunct to post-trauma Treatment

PRIMARY Treatment: urgent care provided asap.

  • Time dependent
  • Involves management of crown fractures +/- pulp exposures, repositioning of displaced teeth and splinting.

SECONDARY Treatment

  • Monitor pulp and periodontal tissues for healing
  • Ortho Rx for displaced teeth ( assess development, displacement , splint times and methods)
  • Active treatment with Light forces
  • Brackets and wires can be less traumatic to reposition teeth in a fearful child. (SL brackets and super light NiTi)

Lateral Luxation

  • Move immediately after assessment for supporting teeth. (teeth can be repositioned within 3-5days) (SL brackets and super light NiTi)
  • Most cases the teeth are pushed lingually and a crossbite may present, therefore consider bite blocks.
  • concomitant alveolar fracture, add a rigid beta titanium or SS wire to stabilize
  • Expect tooth to be repositioned in 3-5 days
  • Keep orthodontic wire on as splint after tooth is repositioned.

Avulsion

  • Time dependent
  • Hydraulic pressure of blood in socket prevents complete seating, therefore use same technique as lateral luxation (SL brackets and super light NiTi)
  • Tx: place tooth into socket, place a bracket on. use solid adjacent teeth for anchorage. 012 or 014 NiTi, expect complete seating in 3-5 days.

Intrusion: orthodontic Tx if tooth is mature and moderately intruded 3 -7 mm

  • Study on dogs showed that the sooner ortho Tx is initiated, the less the degree of replacement resorption
  • Ortho repositioning also results in less destruction of marginal gingival tissue vs. surgical repositioning w forceps other intrusion cases:
  • Assess development of tooth – immature-
  • Monitor and wait for re-eruption (4-6wks) yield least pulp and PDL complications
  • Assess development of tooth – mature-
  • Mature and mild intrusion (3 mm or less): monitor for 3 weeks. Don't go over 3 weeks as ankylosis can develop, also access to pulp therapy is compromised
  • Mature and severe intrusion (> 7 mm): surgically reposition with forceps. may consider ortho repositioning as an adjunct

TERTIARY CARE: To address the sequelae of previously traumatized teeth. Post-trauma tx.

  • is multidisciplinary


Approaches include:

  • Transplantation in situ: surgical reorientation of tooth + bonding a bracket for traction
  • Transplantation of premolar into region of lost incisor: premolar must have an immature root, it is placed in infraooclusion. orthodontic movement begins 3-4 months after surgery. this technique is only possible within a certain window of time
  • Substituting teeth for a lost tooth: asymmetric tooth movement is required. consider anchorage and TADS.
  • Decoration in cases where implants are considered.
  • Timing of ortho tx is unresolved. Consider 3 months of waiting before ortho tx for minor injuries, and 6-12 months for major injuries.
  • Complete root formation + trauma only to crown: ortho tipping leads to an increase in pulp pathology + root resorption
  • Ortho extrusion for displacement injuries: sig. more pulpal pathology
  • Ortho intrusion for previously traumatized teeth: sig. more pulpal necrosis, esp if these teeth already have total pulpal obliteration

Moving of previously traumatized teeth will likely have at least pulpal pathologic changes. Periodic radiographic monitoring of affected teeth should be conducted.


Trauma during ortho Tx: teeth that have experienced trauma at the time of ortho Tx are more likely to have pulpal necrosis than teeth that are only experiencing either trauma or ortho Tx.

  • displacement injuries (extrusion, intrusion, lateral luxation) are more likely to have pulpal necrosis than injuries only to the crown
  • total pulpal obliteration is a significant factor contributing to pulpal necrosis consider reassessing the case after traumatic injury. may discontinue, modify Tx, or finish Tx based on assessment

Trauma during ortho Tx: Teeth that have experienced trauma at the time of ortho Tx are more likely to have pulpal necrosis than teeth that are only experiencing either trauma or ortho Tx.

Displacement injuries (extrusion, intrusion, lateral luxation) are more likely to have pulpal necrosis than injuries only to the crown

  • Total pulpal obliteration is a significant factor contributing to pulpal necrosis consider reassessing the case after traumatic injury. may discontinue, modify Tx, or finish Tx based on assessment
  • Timing of ortho Tx is unresolved. Consider 3 months of waiting before ortho Tx for minor injuries, and 6-12 months for major injuries.
  • Complete root formation + trauma only to crown: ortho tipping leads to an increase in pulp pathology + root resorption
  • Ortho extrusion for displacement injuries: sig. more pulpal pathology
  • Ortho intrusion for previously traumatized teeth: sig. more pulpal necrosis, esp if these teeth already have total pulpal obliteration
  • Moving of previously traumatized teeth will likely have at least pulpal pathologic changes. Periodic radiographic monitoring of affected teeth should be conducted.

Endodontically filled teeth: can be orthodontically moved with little consequence.

These teeth have less orthodontically-induced root resorption in the apical region than control teeth.


Post Traumatic Injury-Interdisciplinary care Is multidisciplinary and approaches include

  • transplantation in situ: surgical reorientation of tooth + bonding a bracket for traction
  • transplantation of premolar into region of lost incisor: premolar must have an immature root, it is placed in infraooclusion. orthodontic movement begins 3-4 months after surgery. this technique is only possible within a certain window of time
  • substituting teeth for a lost tooth: asymmetric tooth movement is required. consider anchorage +/-TADS.
  • decoronation in cases where implants are considered in long term

Conclusion:

Level of evidence for orthodontic care with regards trauma is not high, the recommended approaches are based on the available literature.
Prevention of orofacial trauma should be strongly advocated for, mouthguards are recommended for contact sports.

Orthodontic treatment can aid in secondary and tertiary management of trauma; tertiary care will be multidisciplinary. Be aware of teeth with a history of trauma as they are at a higher risk of pulpal and periodontal pathologies when subjected to orthodontic teeth movement and should be more frequently monitored clinically and radiographically. Light forces for movement of traumatized teeth is favoured.




Related Articles

Skip to toolbar