Our face is the most exposed part of our body. As such, it is also the most vulnerable part of our body. It is here that our sense of sight, smell, hearing and taste resides, in addition to the general sensation of touch. In Singapore, trauma facial injuries are often the result of road traffic accidents and sports.Fortunately, our brain is hardwired to protect the face when danger is imminent. The neck muscles turn the face away and the arms are raised to cover the face. These are instinctive reaction. In Singaauma facial injuries are often the result of road traffic accidents and sports. However, when trauma is not avoided and facial injury is inflicted, all the above mentioned organs may be affected. The teeth, especially, the front teeth, often takes the brunt of the force, resulting in avulsion (the whole tooth being dislodged), subluxation (partial dislodgement or loosening) or fracture. Can these teeth be saved?
Not all teeth that are damaged due to trauma need to be extracted. In fact, many of them can be saved. If the damage is minimal, the long term prognosis is very good. On the other hand, some are best extracted early to minimize damage to the underlying bone so that dental implants can be placed as replacement.
1. Fractured tooth
A tooth can be fractured either horizontally or vertically. Vertical fractures typically happens when someone falls onto his chin and the upper and lower teeth are smashed against each other. The tooth splits open, separating it into left and right halves. Thees vertically fractured teeth cannot be saved and early extraction and replacement with dental implants is the treatment of choice. However, horizontally fractured teeth have a much better chance of being saved. Horizontal fracture of a tooth results in the crown being separated from the root. If the fracture occurs above the gum level ie the part of the tooth that is still stuck in the bone is sticking out, the chances of saving the tooth is very high. The tooth will need a root canal treatment to clean up and seal the canal. Thereafter, a porcelain crown can be made to fit over it. The long term prognosis of such teeth is very good. However, if the fracture occurs below the bone level, the prognosis will be guarded. Root canal treatment can be done but restoration of the remaining tooth with a crown will be difficult due to a lack of tooth structure to support a crown. Usually, a crown lengthening procedure will be needed to expose more of the root so as to provide sound tooth structure over which to build a crown. However, lengthening the crown means shortening the root and that in turn will have an impact over the longevity of the tooth. It such circumstances, extraction of the tooth and replacement with a dental implant will give a more predictable outcome.
2. Avulsed tooth
Teeth that are completely knocked out the mouth have a very guarded prognosis. Attempts can be made to re-implant the tooth if the tooth is not fractured. In young children where the apex of the root is still open, re-implantation has a better chance of success. This also depends on the length of time the tooth is outside the mouth, how the tooth is handled and stored while waiting for re-implantation. Diagnosis in such a situation is not an exact science. If the tooth has been out of the mouth for a hour or so, the chances of successful re-implantation is slim and replacement with a dental implant may be a better option. If the tooth is well preserved after avulsion and reimplantation is done, there is still a risk of external resorption of the tooth. For those who prefer to keep their natural teeth, re-implantaiton can be done on the understanding that the prognosis is guarded and that further treatment will be needed should there be external resorption of the tooth.
This is where the tooth is displaced from its original position but still remains inside the socket. Such teeth usually do not require extraction. They can be re-positioned back to their original position under local anesthesia and splinted together with orthodontic arch wire and composites. Root canal treatment is usually needed to prevent internal resorption. The orthodontic wire is kept for six weeks. Although prognosis is generally good, there is still a possibility of external resorption. Should that happen, the tooth will still need to be extracted and be replaced with a dental implant.
4. Fracture of the alveolar bone
Sometimes, even when the teeth look displaced, there is no damage to the teeth. Instead, the bone holding on to the teeth ie the alveolar bone may be fractured. When it is the bone that is fractured, the teeth can usually be save. While a fractured tooth does not have the ability to heal itself, fractured bone can and do heal when it is properly realigned and immobilised. In such cases, the teeth can be re-aligned back to their original position, guided by the biting position. Once the teeth are back in place, they can be immobilized with wires. Keeping the teeth fixed in that position will allow the bone to heal in the correct position.
Natural teeth vs Dental implants
For those teeth that are damaged beyond repair, the decision making is straightforward. Extraction and replacement with dental implants can be done at the same time in most situations. Sometimes, an temporary crown can even be placed on the implant from day 1. However, for those teeth that can be saved, there are more factors to consider. Personally, I would recommend keeping your natural teeth even if the prognosis is guarded. Even if the saved teeth eventually give way, you can still fall back on implants. However, that would mean additional time and cost. Implants are fairly predictably successful and some patients may opt for a more definitive solution instead of saving the teeth and hoping that they last. Ultimately, the decision whether to keep such damaged teeth or to remove them and replace with dental implants is the patient's choice.