Full transcript
0:00Imagine this . It's Monday morning , the
0:03practice is full and then the phone
0:05rings .
0:06The classic .
0:07Exactly . It's excited parents , their
0:09son has fallen off his bike , a front
0:11tooth has broken off , his lip is
0:12bleeding , everyone is in a panic .
0:14Hmm .
0:15And in moments exactly like these , when
0:17adrenaline and chaos reign supreme , one
0:19requires a cool head and , most
0:20importantly , an absolutely reliable and
0:22systematic roadmap to navigate the
0:24situation .
0:24Absolutely . We spent the week digging
0:27deep into all the documents on dental
0:29trauma that you sent us . And honestly ,
0:32it's like detective work in the
0:34emergency room . That's
0:35it . That is
0:36why we want to put together a clinical
0:38roadmap today , one that will guide you
0:40step by step through a stressful
0:41situation of this kind . From the first
0:44question on the phone to the right
0:45treatment decision . And this roadmap is
0:48significantly more than just a simple
0:51checklist . You can see it as a kind of
0:53lifeline . In the hustle and bustle of a
0:56trauma , every minute counts . Every
0:59single detail that is overlooked can
1:00end up dramatically worsening the
1:02long-term prognosis of a tooth .
1:04So you're also protecting yourself .
1:06Exactly .
1:07A structured approach does not only
1:08serve to protect the tooth , but it also
1:10protects you legally . It creates the
1:12best possible conditions for healing
1:14and transforms a potentially chaotic
1:16situation into what is a controlled and
1:18highly professional sequence of events .
1:21The goal is to be able to say at the
1:23end that we did everything possible .
1:25Okay , let's unpack this . Let's stick
1:28with our young cyclist . The parents are
1:30on the phone . The boy is probably
1:32shocked . Before we can even take a look
1:33at the tooth ourselves , the triage
1:35process is already beginning over the
1:37telephone .
1:37Right . What questions are absolutely
1:40crucial in the first few seconds ? Well ,
1:43the medical history begins immediately
1:46and here are the classic WFs : " Your
1:48best friend , what , how , where and when
1:51did it happen ? " Okay ,
1:52so that gives us an idea of the energy
1:54of the impact . Was it a simple fall or
1:58a high-speed collision ?
2:01And where might sound unimportant at
2:02first , but it isn't , right ?
2:04Not at all . That's crucial for
2:06insurance issues . Was it a school
2:08accident or a commuting accident ? That
2:10has to be properly documented .
2:12And then comes the question of when and
2:14time . I assume that is the factor that
2:16puts the most pressure on you .
2:18That is the absolutely critical factor .
2:21Time is the biggest enemy of the
2:22periodontium . Is it
2:24really the biggest enemy ?
2:25Yes . It becomes particularly dramatic
2:27in the case of avulsion , i.e. when the
2:29tooth has been completely knocked out .
2:30Here we have to be extremely specific
2:32on the phone right away . Now , how is it
2:35stored ? The survival chances of the
2:38sensitive cells on the root surface are
2:39dependent one hundred percent upon the
2:41outcome of this specific answer . In
2:44your documents , the tooth rescue box is
2:46referred to as the gold standard , but
2:48hardly anyone has one in their cupboard
2:50at home .
2:52So what are the practical instructions
2:54for the parents on the phone ? The
2:56pragmatic instruction is as follows :
2:58find a moist medium and you must do it
3:00very quickly . The best alternative to
3:03the rescue box is cold hair milk . It
3:05possesses a suitable pH value and also
3:08a good level of osmolarity .
3:11Okay , ham .
3:12Esotonic saline solution would also be
3:14great . And if none of those things are
3:16available , which is quite likely the
3:18case , then your own saliva is going to
3:20be the next best option for you . So
3:22take the tooth in your mouth , place it
3:24on your cheek , and drive off
3:25immediately .
3:26And what is the absolute no ? The
3:28absolute worst thing that you can do is
3:30to wrap the tooth inside of a
3:31completely dry tissue .
3:32Okay . And what about the tooth itself ?
3:35You have the urge to clean it .
3:37Absolutely not . That is the second
3:40critical point that you have to convey
3:41on the phone . Please only touch the
3:44tooth by the crown , never by the root .
3:47Why is that so important ? The cells
3:49there are like a paper-thin , living
3:51skin . Any attempt to brush or to scrape
3:54the root will destroy these cells ,
3:56which eliminates the potential chance
3:57for a successful biological healing
3:59process .
4:00I understand .
4:01According to the sources , dry storage
4:02for a duration of more than 60 minutes
4:04is described as having an almost
4:06hopeless prognosis . These two
4:08instructions , store in a moist place
4:10and do not touch the root , are
4:11basically life-saving for the tooth .
4:14All right , we have treated the tooth ,
4:16but the patient is certainly more than
4:19just his tooth . The subject of
4:21traumatic brain injury is also given a
4:23very , very high priority within these
4:24documents . That's
4:25an absolute showstopper . Before we even
4:28begin to dive into the detailed dental
4:30work , we must be absolutely certain
4:31that there is no overriding danger
4:33present in the situation .
4:34So recognize the red flags . Exactly . So
4:37we ask very specific questions : Was
4:39there a loss of consciousness , even for
4:41a few seconds ? Is there a gap in memory
4:44? Are the parents or the patient
4:47complaining of nausea , vomiting , severe
4:49headaches , these are warning signs .
4:52Those are absolute red flags . If even
4:54one of these questions is answered with
4:56yes , immediate clarification in an
4:58emergency room has priority . In that
5:00case , the forceps are of secondary
5:02importance . Only once that has been
5:04clarified do we turn our attention to
5:06the oral cavity and clarify tetanus
5:07protection and any bleeding tendencies .
5:10So , the medical history is complete .
5:12Fortunately , our cyclist is responsive ,
5:14there are no signs of traumatic brain
5:16injury , and the tooth was transported
5:18in milk in an exemplary manner . Now
5:20he's sitting in the dental chair .
5:22Exactly .
5:23We already have a lot of information .
5:26How does this knowledge shape the
5:28clinical findings that follow ?
5:30It shapes them completely . We now have
5:32hypotheses that we are testing . The
5:35examination is like putting together a
5:37puzzle . You start systematically from
5:40the outside in .
5:42So , first we look at the face , which
5:44means beginning with the extraoral
5:45findings . We check the face , the lips ,
5:48and the chin . Are there any signs of
5:50swelling , any bruising , or perhaps some
5:52lacerations present ? And here is a
5:54specific detail from your sources that
5:55came as quite a surprise to me . You're
5:58supposed to palpate the lips to look
6:00for tooth fragments . Does that really
6:03happen ?
6:03More often than you think . Upon a hard
6:06impact , a sharp-edged fragment can act
6:08just like a small projectile and
6:09penetrate deep into the surrounding
6:11soft tissue areas .
6:12Warwin .
6:13And finding this fragment is of great
6:14importance , because it could be exactly
6:16the piece that we might need later for
6:18a reattachment , which means sticking it
6:20back on again .
6:21Okay .
6:22Then you carefully palpate the jawbone .
6:26If you feel a step or observe an
6:27abnormal mobility , you might even hear
6:29crepitus , which is that fine , crunching
6:31noise that acts as a strong indicator
6:32for a potential bone fracture . Exactly .
6:36And very importantly , the function ,
6:37does the mouth still open properly ? Is
6:40the bite still correct ? A sudden
6:41disruption of the occlusion serves as a
6:43strong indication that a jaw fracture
6:45may be present . Okay , from the outside
6:47in . Now for the intraoral findings . I
6:50imagine that would be quite a
6:52challenging situation to handle with a
6:53bleeding and frightened child . And it
6:54is .
6:55That's why you need a strict systematic
6:57approach .
6:57How do you approach it ? You work your
6:59way from coarse to fine . First , look at
7:03the hard tooth substance . Where are the
7:06fracture lines ? Is there any missing
7:07substance ? Is there a red dot somewhere
7:10? That would be the pulper , the nerve .
7:12Right . That would be a sign of an
7:15exposed pulp . Then comes the
7:17sensitivity test , although this is
7:19often not conclusive directly after a
7:21trauma , because the tooth is in shock .
7:23And after the tooth itself , we then
7:25find its foundation , which is the
7:27periodontium . What do we look for here ?
7:30Here we look for loosening and
7:31displacement . Is the tooth mobile ? Is
7:34it in the wrong position ? Is there
7:36bleeding from the sulcus of the
7:38periodontal pocket ?
7:39All signs of damage . Exactly . And then
7:42there is a very specific test which
7:44your sources highlight , namely the
7:46percussion test , which consists of the
7:48careful tapping of the tooth itself .
7:50And this metallic tapping sound is
7:52described there . That sounds very
7:54specific . What does this sound tell us ?
7:56This sound is meant to send a little
7:58shiver running down your entire spine .
8:00Oh ,
8:00a healthy tooth sounds dull when it is
8:02tapped , because the periodontium acts
8:04to cushion the force of the impact . A
8:07high , bright , metallic sound means that
8:09this cushioning is missing . The tooth
8:12is rigidly connected to the bone . And
8:14that can have two causes ,
8:16right ? Either it has been pressed into
8:19the bone by the accident , which is
8:20called intrusion , or , representing a
8:22feared late consequence , it begins to
8:24fuse in a bony manner with the jaw bone
8:26, a process which is referred to as
8:27ankylosis .
8:29And ankylosis in a growing child is a
8:31catastrophe ,
8:32an absolute catastrophe , because it
8:33means the tooth is no longer able to
8:34grow along with the rest of the jaw as
8:36the child develops . This sound is
8:38therefore a vital diagnostic piece of
8:40the puzzle ,
8:41and even after you have completed all
8:43these clinical tests , you will still
8:44require an X-ray image , I assume .
8:46Absolutely . The X-ray is the view
8:49beneath the surface . Only then will we
8:51be in a position
8:52to assess root fractures or possible
8:52injuries to the bone . Without an X-ray ,
8:57the findings are incomplete and , of
8:58course , complete photographic
8:59documentation is invaluable . Okay , now
9:04things are getting really specific . The
9:07detective work is complete . We have all
9:08the findings . Now we have to make a
9:11diagnosis . Let's start with the
9:14fractures . Sure . We'll proceed
9:16logically from simple to complex . The
9:19most harmless variant is an enamel
9:21infraction , which is simply a crack in
9:24the enamel or , alternatively , a pure
9:26enamel fracture . In this case , a check
9:28or smoothing of the edge is usually
9:30sufficient . Things get more
9:31exciting when our cyclist brings the
9:33broken piece with him . Let's assume
9:36it's an uncomplicated crown fracture .
9:38So the enamel and dentin are affected ,
9:41but the nerve is not exposed . In
9:43this case , quick action is required
9:44because the dentin is exposed . You have
9:47to imagine it like thousands of little
9:49tubes that lead directly to the nerve .
9:52An open highway for bacteria .
9:54Exactly . These tubes must be sealed
9:57quickly and in a way that is impervious
9:58to bacteria . And the most elegant
10:01method is reattachment . If the fragment
10:03fits properly , you can simply reattach
10:05it again by using a modern form of
10:06adhesive technology .
10:08And what if we have bad luck and a
10:09small blood-red dot becomes visible
10:11right in the middle of the fracture ? In
10:13other words , a complicated crown
10:15fracture .
10:15Then the game changes completely . Now
10:17we are fighting for the survival of the
10:19nerve . The prognosis depends on many
10:22factors . How long was the pulper
10:24exposed ? How big is the opening ? And
10:27crucially , has root growth already been
10:30completed ? There are various options
10:32available , ranging from applying a
10:34simple band-aid to the wound , to a
10:36pulpotomy , where the uppermost inflamed
10:37part of the nerve is removed , all the
10:39way up to a complete root canal
10:41treatment . I imagine that crown root
10:44fractures , which often run at an angle ,
10:46are particularly difficult .
10:47These are among the most thankless
10:49injuries . The preservation of the tooth
10:52depends here solely on the depth to
10:54which the fracture line extends below
10:55the gum level ,
10:56which determines if the tooth can still
10:58be effectively treated .
10:58Exactly . However , the fracture is often
11:01so deep that achieving a bacteria-tight
11:03restoration is impossible , and
11:04extraction remains the only viable
11:06option for the tooth .
11:07With regard to pure root fractures , the
11:08available documentation makes a very
11:10clear and distinct separation . Yes , and
11:12this is crucial between a transverse
11:15fracture and a longitudinal fracture .
11:17Okay , a transverse fracture , i.e.
11:19horizontal through the root , has an
11:22astonishingly good prognosis . If the
11:24upper fragment is properly stabilized ,
11:26the individual parts can often
11:27successfully heal back together . A
11:29longitudinal fracture , i.e. a vertical
11:31crack , is almost always a death
11:33sentence for the tooth .
11:35Always . That sounds so final . Why is it
11:37so much worse ? Because a vertical crack
11:40creates a permanent and unsealable
11:42entry point for bacteria , which extends
11:44along the entire length of the tooth
11:46root . It cannot be cleaned or filled .
11:50It inevitably leads to chronic
11:51inflammation and bone loss .
11:53So the tooth has to be removed to
11:55protect the bone ?
11:56Unfortunately , yes . That is usually the
11:58only sensible treatment .
11:59Okay , those were the broken teeth . But
12:02what about those who do not break , but
12:04instead choose to keep moving ? The
12:06second large group is dislocation
12:09injuries . What is the overriding goal
12:12here ?
12:12Here , it almost always involves two
12:13things . The gentle repositioning of the
12:16tooth back into its original anatomical
12:18position and the subsequent
12:19stabilization of the tooth by using a
12:21dental splint . Providing rest for
12:23healing .
12:23Exactly . The mildest forms are the
12:26concussion , which is a pure shaking ,
12:28and the subluxation , which refers to a
12:30loosening of the structure . In these
12:32cases , simply resting the tooth , i.e.
12:33soft food , is often sufficient . Then it
12:35becomes more dramatic . Lateral
12:37dislocation , extrusion , when the tooth
12:39has slipped out , and as a special case ,
12:41the intrusion , when the tooth has been
12:43pushed into the surrounding bone .
12:45Right . In the case of lateral
12:48displacement and extrosion , the
12:49procedure is clear : reposition and
12:51splint . Introduction is the greatest
12:54challenge . The tooth is wedged in the
12:57bone and the treatment depends on the
12:59age .
13:00Massive . For a young patient with an
13:02open apex , it is common to simply wait
13:04and see . There is a good chance of
13:07spontaneous re-eruption . It will come
13:09out again on its own .
13:10Exactly . For an adult patient with a
13:12closed apex , it is dangerous to wait
13:14due to the potential risk of developing
13:15ankylosis . In this case , the tooth must
13:18be actively brought back into position ,
13:20either by using orthodontic or surgical
13:22methods .
13:22And the worst case scenario is then
13:24avulsion . The tooth is completely next
13:26to the patient .
13:27This is where the medical history comes
13:28full circle . The race against time is
13:31most obvious here . We clean the wound ,
13:33rinse out the socket and replant the
13:35tooth , which means that we are going to
13:37reinsert it back into place .
13:38Even if the prognosis may be poor .
13:41Yes , even then , every single month that
13:43we successfully preserve the tooth also
13:44preserves the vital jawbone within this
13:46aesthetically sensitive region of the
13:48mouth . This creates a significantly
13:50more favorable starting point for any
13:52subsequent treatment . Preserving the
13:54bone is almost more important here than
13:56the tooth itself .
13:58The word splinting has been mentioned
14:00countless times now , and one of the
14:02biggest aha moments for me was that not
14:03all splints are the same .
14:06Absolutely not . The wrong splint at the
14:09wrong time can actively damage the
14:11healing process . That seems to be a
14:13massive takeaway .
14:15This is an absolutely critical point
14:16which defines the way we approach
14:18modern trauma management . A fundamental
14:21distinction must be made between two
14:23types of splints .
14:24Okay .
14:25For almost all dislocation injuries ,
14:26meaning whenever the periodontium needs
14:28to heal , we are using a flexible splint
14:30in our clinical practice today . This is
14:33often just a thin wire which is secured
14:34in place by using a series of small
14:36composite dots . And why flexible ? The
14:40fascinating thing is that this splint
14:42allows a certain physiological
14:44micromovement . This minimal stimulus
14:47stimulates the healing of the fibers . A
14:50completely rigid fixation would be more
14:52likely to result in ankylosis in this
14:54specific case . The duration of
14:56splinting is also short , usually one to
14:58three weeks . And the exact opposite of
15:01that is what we call the rigid splint .
15:03Exactly . A rigid , i.e. stiff splint is
15:06always indicated when bone needs to
15:08heal , for example in the case of a
15:10fracture of the alveolar process or
15:12also in the case of some root fractures
15:14Absolute rest is required here .
15:16Absolute rest so that the bone
15:18fragments can grow together .
15:20Accordingly , the duration of splinting
15:21is also significantly longer here , up
15:23to several months . The choice of splint
15:26is therefore a conscious biological
15:27decision . Let's summarize .
15:30What does all this mean for you in your
15:33practice ? For me , the most important
15:36realization is that when you are in
15:38such a stressful situation , you require
15:40a clear and systematic roadmap to
15:42follow .
15:43Yes ,
15:44from asking the right question on the
15:46phone to a complete diagnosis to
15:48choosing the right splint . Each step
15:51builds logically on the previous one .
15:54Exactly . The primary goal in an acute
15:56situation is to preserve the tooth and
15:58the surrounding structures . But what
16:01you must not forget is aftercare .
16:03So the case is not over . Not at all .
16:06A trauma patient is not a patient who
16:08is discharged after three weeks of
16:09splint removal and never seen again .
16:12Regular clinical and radiological
16:14check-ups conducted over many years are
16:15absolutely crucial for detecting silent
16:17killers , such as root resorption or a
16:19creeping pulp necrosis , at a
16:20sufficiently early stage .
16:21This is a very important point . And
16:24that , for me , raises one final ,
16:26further-reaching question that extends
16:28well beyond the scope of purely dental
16:30medicine . We have focused heavily on
16:32the technical aspects of the treatment
16:33so far ,
16:34but we must remember that there is
16:35still a human being behind it all .
16:36An injury to the front teeth ,
16:38especially in a young child , is not
16:40merely a strictly medical problem .
16:42Restoring function and aesthetics is
16:44one thing , but the restoration of
16:45self-confidence and overcoming the
16:46trauma of a facial injury — that is a
16:48complex process which goes
16:49significantly further than just the
16:50removal of the splint from the face
16:52after the initial surgery has been
16:53completed . And as practitioners , we
16:55should perhaps ask ourselves what role
16:57we play in this process , which often
16:58takes much longer than the period
17:00required for purely biological healing
17:01to occur .