Written by John J. Nazzaro, DMD Friday, 29 February 2008 19:00
Most dentists deal with emergencies on a regular basis, and being prepared can make a challenging situation quite easy. At times, decisions must be made promptly when an emergency arises. Making the right choice can be very rewarding; making the wrong one can be quite disappointing. Sometimes the least amount of treatment can be the best decision to make.
Many dental experts will tell you about the “perfect day of scheduling,” but I will tell you about the “realistic day of scheduling.” We try to put all morning emergencies at the end of the morning session and the afternoon emergencies at the end of the day. However, what happens when all of your emergency slots are booked, you have nowhere to put another emergency, and you have to be somewhere at the end of the day…like a meeting or just being home with your children? At times, your emergency visits have to be shortened, and you only have a limited amount of time to treat an emergency patient.
This article describes 2 emergency situations similar to those many of us have experienced over time, and how they were treated in an efficient manner.
CASE NO. 1
Figure 1. The morning after the accident.
Figure 2. Closeup of lower lip and fractured incisors.
Figure 3. Exposed pulps; no bleeding present.
Figure 4. Central incisor fragments to be bonded. (Note the pulp horn concavities.)
Figure 5. The smaller fragments were discarded due to poor fit.
Figure 6. Patient approximately 2 weeks postoperatively.
In October 2006, a 12-year-old girl presented to my office with both central incisors fractured off, exposing pulp in teeth Nos. 8 and 9. This occurred the night before at 10 pm when she slipped in the bathroom and landed headfirst onto its tile floor (Figures 1 and 2).
The patient’s mother called my office the following morning. The fractured teeth had been left in a piece of tissue paper for 10 hours and were completely dehydrated upon inspection in my office (Figures 3 and 4). The periapical and panorex radiographs were normal, no mobilities were found, and the patient was not in any pain. The fractured pieces were examined prior to preparing for reattachment, rinsed off with water, and tried in for fit and confirmation of correct alignment.
The enamel on the central incisors as well as the fractured pieces were treated with 37% phosphoric acid etch, then rinsed with water. Next, Clearfil Protect Bond (Kuraray Dental) was used. The Primer was placed onto the enamel and dentin of the fractured teeth and loose pieces for 20 seconds, then air-dried. The Bond was placed on the same sites.
If the pieces had fit perfectly together, I could have cured everything together at this point. The Bond alone would be strong enough to hold the teeth together. However, there were some pieces of tooth fragment that would not fit back properly (Figure 5). The small fragments of tooth structure were left out, and in their place StarFlow Flowable Composite (Danville Materials) was used. I then cured everything together at this point, as one would do with a veneer case. No bleeding occurred at any time during this procedure (Figure 6).
No postoperative problems had been reported as of the time this article was written; both teeth remained vital and had not discolored.
CASE NO. 2
|Figures 7a to 7c. Case No. 2: Top radiograph taken November 30, 2001, depicts fracture entering the pulp chamber of the central incisor; middle radiograph depicts fractured tooth immediately after reattachment; and bottom radiograph shows no signs of infection 6 years later.|
A 10-year-old boy presented to my office following a karate class. The patient caught a karate chop to the face, which fractured tooth No. 8. This was a similar situation to Case No. 1, but only one tooth was involved. The fractured piece was reattached as follows: I sandblasted the tooth and fragments with a Micro-Etcher (Danville Materials), then I placed 37% phosphoric acid etch onto the enamel; wait 10 seconds, then rinse and dried. Photo Bond (Kuraray Dental) was then applied, followed by StarFill 2B (Danville Materials); reattach tooth fragment, then cure.
Radiographs taken on November 30, 2001, show pulpal involvement, then the tooth after reattachment of the tooth fragment. A follow-up radiograph was taken 6 years later (Figures 7a to 7c). At a 6-year follow-up, the tooth had not discolored, was not infected, and had no symptoms.
Two cases involving efficient treatment of emergency patients have been described. With proper technique and materials, such emergencies can be handled amidst a busy clinical schedule.
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