Bicycle trauma dental fracture and luxation

Bicycle accidents may be very dangerous for teeth, causing fractures, luxations and avulsions. In these cases we must preserve tooth structure as much as possible.

T.S. 17 y.o. had a bicycle accident reporting multiple injuries in the arms, the knees and in particular in the face. Went to the local hospital ER, he received some stitch on the upper lip; no pharmacological therapy was given.

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Fig.1
The patient came to our office after more than 12 hours; at first, local anesthesia was performed just to relief the pain. 11 and 22 were fractured (Enamel-dentin fracture), 21 was palatally displaced (Lateral luxation). No fragment available.

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Fig.2
Then an OPT was taken in order to look for eventual bone fractures.

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Fig.3
Tooth 21 was manually repositioned, then splinted with a flexible fiber.
A self etch dental adhesive, followed by a thin flowable resin layer, was placed on fracture lines on 11 and 22, in order to provide a good sealing.
Antibiotic and anti-inflammatory therapy was prescribed.

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Fig.4
Four weeks later, splint was removed. Vitality test were performed, with positive results on 11 and 22, negative on 21. Gingival probing is physiological, considering the gingivitis due to non perfect oral hygiene because of the splint.
Very likely, 21 lost vitality because of the luxation, but at this moment the tooth was stable and asymptomatic, so we decided not to perform the root canal treatment yet.

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Fig.5
21 and 22 immediately after splint removal.

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Fig.6
Rubber dam is mandatory when performing adhesive procedures.

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Fig.7
Close up image of the fracture line on 11.

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Fig.8
The fracture line was smoothed and a short straight bevel was made. A fender wedge is helpful to avoid touching proximal teeth.

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Fig.9
Same preparation was made on 22.

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Fig.10
The first palatal layer was applied using a silicon key made on a wax up.
A posterior sectional matrix can be very helpful to create the interproximal wall. Its curvature helps you to give a correct shape and a good contact area.

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Fig.11
Simplifying is the key: just one body mass (Asteria A2B, Tokuyama).

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Fig.12
Using Asteria, we must use just body mass on apical and medial third. Only in the incisal third we should use enamel composite (Asteria NE, Tokuyama).

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Fig.13
Only A2B mass was used to restore 22.

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Fig.14
After contouring, finishing and polishing procedures, rubber dam was removed.

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Fig.15
22 immediately after rubber dam removal.

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Fig.16
14 days control. All teeth are asymptomatic; 21 is still not responding to vitality test.

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Fig.17
In this picture we can appreciate crack lines on tooth 21 enamel.

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Fig.18
The single layer restoration on 22.

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Fig.19
14 days check-up.

Conclusions

It is always important to be as conservative as possible; always try to use available fragments in fractured teeth. If there are no fragments, direct composite restorations should be the first choice to evaluate.
Vitality of tooth 21 will be periodically tested; if needed, a root canal treatment will be performed.

Bibliography

1. Andreasen JO, Andreasen FM, Andersson L. Textbook andcolor atlas of traumatic injuries to the teeth, 4th edn. Oxford,UK: Wiley-Blackwell; 2007.
2. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012; 28: 66-71.
3. Erratum in Dent Traumatol. 2012;28: 499.
4. Andreasen FM, Vestergaard Pedersen B. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1985; 1: 207–220.
5. Grandini R, Pagni L, Pagavino G, De Fraia E. Using the coronal fragment for the repair of anterior tooth fracture. Quintessence Int Dent Dig 1985;10:839–45 and 925–33.

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