CD3: Traumatic injuries to permanent teeth

30%

how many percent of children/teens in the USA will have tooth injuries?

maxillary central incisors

Which teeth are the most commonly injured?

unexpectedly

One feature common to all patients presenting with acute dental trauma is the fact that they come to us ....

WHEN did the injury occur

The answer to this question will imply a time factor, which could influence the choice of treatment

wash the patients face

The first step in the examination procedure, is to ...

pulp testing

done to serve as baseline, but not always accurate immediately following trauma

3 months

When will pulp testing be considered accurate?

CBCT

which radiograph should be considered the imaging modality of choice for diagnosis and management of limited dento-alveolar trauma, root fractures, luxation, and/or displacement of teeth and localized alveolar fractures, in the absence of other maxillofacial or soft tissue injury that may require other advanced imaging modalities

crown fracture, crown-root, root fracture (7%), alveolar fracture

types of tooth fractures

crown fracture

the vast majority (75%) of traumatic injuries is...

uncomplicated crown fracture

Enamel fracture or enamel-dentin fracture that does not involve the pulp

Diagnosis:

•PA radiograph(s)

•Evaluate size of pulp chamber and stage of root development

•Pulp test

maintain pulp vitality, restore normal esthetic and function

What are the goals for an uncomplicated crown fracture

repaire, no NS-RCT needed

Treatments for an uncomplicated crown fracture

complicated crown fracture

Enamel-dentin fracture with pulp exposure

positive vitality tests, exposed pulp, normal mobility, percussion test, one occlusal and 2 PA, radiographs of lip (if tooth fragment not found)

Clinical assessments and findings for complicated crown fracture

size, hemostasis possible, growth stage/apical development

Factors determining treatment of pulp exposure

short exposure period after trauma, not associated with PDL injury, small exposure

pulp capping indications (Cover the pulp with Ca(OH)2/ MTA)

maintain vitality, pulp cap/partial pulpotomy

Treatment for a complicated crown fracture with an open immature apex

crown root fracture

Fracture involves enamel, cementum and dentin, May or may not expose the pulp

Diagnosis:

•2+ PA radiographs

•Pulp test

coronal fragment

for a crown root fracture treatment, what may be stabilized to adjacent teeth for emergency treatment?

Gingivectomy, ortho or surgical extrusion

crown root fracture treatment necessary to restore the tooth

Pulp capping or Pulpotomy, NS-RCT (for mature)

In a crown root fracture, what treatment do we use on an immature tooth? For a mature tooth?

Root fracture

Fracture involving dentin, cementum, and the pulp

•The coronal fragment is usually mobile and sometimes displaced

•The apical segment is usually not displaced

Prognosis:

•Apical 1/3>Middle 1/3> Cervical 1/3

Diagnosis:

•2+ PA radiographs taken at different angles

•(Or CBCT scan…)

Root fracture

Which fracture does not involve the enamel?

reduction of fractured segments, immobilization of coronal segment, splint 3-4 weeks, endo tx (if pulp necrosis occurs)

root fracture treatment

25%

What is the prognosis percentage for pulp necrosis in a horizontal root fracture

4 weeks

Follow up time for splint removal in the apical third and mid root

4 months

follow up time for splint removal with a root fracture near the cervical area

usually not

Are alveolar fractures usually treated by general dentists/endodontists?

alveolar fracture

Diagnosis:

When the mobility of one tooth is tested, several teeth move

•Hematoma in the adjacent attached gingiva or mucosa

•Pano radiograph/CBCT

Treatment:

•Reposition

•Splint

Concussion

Definition:

•No displacement

•No mobility

•Usually sensitive to percussion and/or tender to touch

Flexible splint ( is optional - can be used for the comfort of the patient for 7-10 days)

Treatment for tooth concussion

Subluxation ("loosening")

Definition:

•Tooth is tender to touch and mobile, but not displaced

•Hemorrhage from gingival sulcus possible

Diagnosis:

•2+ PA radiographs

•No radiographic abnormalities

Treatment:

•Flexible splint is optional – 7-10 days

Extrusion ("partial avulsion")

Definition:

•Elongated, mobile tooth

•Partial displacement of the tooth out of socket.

•Angulated radiograph: increased PDL space apically

Treatment:

•Reposition

•Stabilize tooth with flexible splint for 1-2 weeks

•if pulp necrosis for complete root formation-> endo

Lateral Luxation

Definition:

•Displacement of a tooth buccally or lingually

•Usually accompanied by fracture of socket

•Usually locked into bone

•Not tender to touch, not mobile

Diagnosis:

•2+ angulated PA radiographs

•(CBCT?)

reposition tooth, radiograph, stabilize tooth splint 1-2 weeks

lateral luxation treatment

Intrusion

Definition:

•Apical displacement of tooth into the alveolar bone

•Tooth is driven into the socket, compressing the PDL

•Tooth appear to be shortened or missing

•Severe type of luxation injury

Spontaneous reposition/re-eruption

treatment for intrusion in teeth with immature root formation

reposition, endo in the first 2 weeks, prognosis is poor

treatment for intrusion in teeth with mature root formation

soft food for 1 week, chlorhexadine rinse for 2 weeks

For intrusion, what is an important instruction you need to give to your patient

Follow-up procedures

Avulsion

Definition:

•The tooth is separated from socket completely

•PDL torn

Severed neurovasculature, Crushed and torn pdl, Damage to the alveolar bone, cementum and gingival tissues, Viable PDL cells on most of the root surface

What occurs when a tooth is avulsed

Minimize extra-alveolar time (Immediate replantation = best prognosis)

what is the most critical factor in healing an avulsed tooth

maintain the PDL cells (prevent them from drying out)

what is the goal of the practitioner replanting an avulsed tooth?

Hank’s Balanced Salt Solution (HBSS)

What is the best form of avulsed tooth storage media?

Revascularization of the PDL, Splicing of ruptured Sharpey's fibers

How does a replanted tooth heal?

false, CROWN only

T or F: For first aid in an avulsed tooth, handle the tooth by the root only

revascularization of the pulp

In an open immature apex, the goal of the extra-oral dry time <60 mins it for...

for 1-2 weeks with Flexible wire of a diameter up to 0.016in or 0.4 mm

How long do you splint an open immature apex? What should the diameter be for the wire?

within 7-10 days

When should endodontic treatment be preformed for a closed mature apex?

poor prognosis

Does a delayed replantation have a poor or strong long term prognosis?

ankylosis related root resorption

What is the expected outcome in a delayed replantation?

4-6 weeks

For closed mature apex: extra oral dry time being greater than 60 minutes, how long would we splint the teeth

???

Possible exam question “Why are we applying fluoride?”

YES

For a Closed (mature) Apex that has been out of the mouth for >60 mins, Could you do the Endo before replanting?!

Tetracycline

what has the additional benefit of decreasing root resorption by affecting the motility of the osteoclasts and reducing the effectiveness of collagenase?

Nylon fishing line (0.13-0.25 mm)

What can be used to create a flexible splint?

splinting time for various types of injuries

1-2 months

During the obturation of an avulsed/traumatized tooth, how long should Calcium Hydroxide be in place for?

<30mins

What extraoral dry time presents the best prognosis for an avulsed tooth?

33%

Teeth with immature apex have how much percent chance of revascularization?

tetracycline, stannous fluoride (NaF)

What are some root surface treatments for avulsed teeth?

c. Position in the arch (This type of fracture involves enamel, dentin, and pulp)

Which of the following factors does not need to be considered when evaluating a crown fracture with pulp exposure?

a. Extent of fracture

b. Stage of root development

c. Position in the arch

d. Time since the injury

c. 4 weeks (Initial treatment for root fractures should be of acute priority for best results)

How long should horizontal root fractures be splinted, if the Fracture is in the apical 1/3?

a. Splinting is not indicated

b. 7 -10 days

c. 4 weeks

d. 4 months

pulp necrosis, pulp canal obliteration, root resorption

What are some Complications Following Traumatic Injuries?

intrusion

Which has the worst prognosis of luxation injuries in terms of pulp survival?

no

Are pulpal necrosis and periapical disease a common complication of PCO?

yellow discoloration

what can be a common finding in teeth with pulpal obliteration but does not imply the presence of pulp or periapical disease

asymptomatic

>2/3 of teeth with pulpal obliteration are...

1% to 27%

The incidence of pulp necrosis following PCO is variable ranging from_____ ______, but is generally considered low

clinical symptoms and/or definite radiographic findings suggestive of periapical disease

When are root canal treatments indicated?

non-vital (Internal) bleaching

If root canal treatment is required and there are aesthetic concerns, which technique can be considered?

true

T or F: Teeth with Pulp Canal Obliteration requiring root canal treatment are challenging

root resorption

Loss of pre-cementum, cementoblasts and epithelial rest of Mallassez à denuded root surface à hard tissue resorbing cells remove damaged periodontal ligament and cementum

Internal root resorption

characterized by resorption of the internal aspect of the root by multinucleated giant cells

Surface resorption (Localized injury), Inflammatory root resorption, Replacement root resorption (Ankylosis)

External Root Resorption types

Surface Resorption (Localized injury)

Localized injury to PDL or cementum, Local inflammatory response, Periodontal healing and root surface repair will occur within 14 days, May or may not be radiographically visible, No treatment is required

Surface Resorption (Localized injury)

Clinical evaluation:

-No significant signs

-Transient condition/ self limiting (no treatment needed!)

-Normal physiologic response, no significant inflammation

-Spontaneous destruction and repair process on root surface

Inflammatory Root Resorption

Clinical evaluation:

-Asymptomatic

-Necrotic pulp

-Progression: inward and lateral but leaving canal intact

-Resorption may begin 2-12 wks after trauma

-Transient/progressive (most likely requires RCT)

Inflammatory Root Resorption

•Damage of the periodontium

•Bacteria within tubules

•2-visit NS-RCT with Ca(OH)2 can arrest resorptive process and promote healing

Replacement resorption (Ankylosis)

•Severe damage to the periodontium (Intrusion, Avulsion)

•“Fusion” of the tooth root with the adjacent alveolar bone

•Diagnosis:

-Tooth is immobile

-High percussive tone

-No visible PDL space

•Treatment:

-Cannot be arrested or repaired

•Survive for a number of years

fusion of the alveolar bone and the root surface

In replacement resorption, Repair is accomplished with

disappearance of the normal PDL space

Radiographically Replacement Resorption is characterized by what and continuous replacement of root substance with bone?

d. All of the above

Which of the following traumatic events Can cause injury to the periodontium?

a. Concussion

b. Intrusion

c. Extrusion

d. All of the above