4 Fact Most dental trauma occurs in 7_10 age range And most trauma occurs in the anterior region of the mouth, maxilla>mandible
5 1. Crown FX without Pulp exposure NO PROBLEM,RELAX AND RESTORE
6 Complicated Crown FX with Pulp Exposure=VPT @80% IFw/in 24hrsPartialFullOR:EXTIRPATION if root is fully formedPulp Cap?
7 2. Crown-Root Fracture sometimes fractures at an angle Angular Fracture: Is this restorable?
8 Remember,In all trauma, the primary purpose of our treatment is to keep the pulp vital, if at all possible, ESPECIALLY if apex is openWHY?
9 Pulpotomy – Immature Apex If Vital = “Apexogenesis”*
10 Apexogenesis vs Apexification Dealing with the immature root (Vital Pulp) best to treat w pulpotomy. The idea is to allow the vital pulp to remain vital and complete the development of the root apexas well as thickening of the RC wallsRCT maybe needed later BUT not if tooth remains symptomatic AND vitalApexification(Necrotic Pulp) Hoping to get closure of the apex (& there is NO wall thickening) to be able to later do a proper RC seal via obturation. CaOH + time is proper tx over 3-18moRCT ALWAYS NEEDED HERE* and is less predictable due to thinner wallsObject of either treatment is to allow for roofing over of apex and allow RCT to be done at a later date.
11 And now, Regeneration?Revascularization of immature permanent teeth utilizing a mixture of antibiotics, creating a blood clot w/in the RCS which produces development of the tooth structureBanchs F, Trope M“Revascularization of immature permanentteeth w PN & apical periodontitis….JOE, 196; 2004
12 Vertical FX of Crown>Root @ 3% of all dental injuries Generally if crack extends to the pulpal floor (molar), the tooth will be lostMost commonly cracked tooth – Distal of Mandibular second molar –– May need to STAIN crown to see crackWHY?Look for “Drop-Off” Pocket at base of Crack site
13 Insert occlusal view of MMR/DMR fracture to supplement previous slide Because, endo/perio lesion can mimic VRF radiogragraph
19 Horizontal Root Fracture Tends to be Readily apparent – especially after separationXS Mobility a good clueIs this salvageable?Prognosis is very poor
20 Root FX (Horizontal)What do you do here? Try to reposition and splint 2-4 wks, check for vitality q 30 days
21 4. Luxation Injuries (MOST COMMON OF ALL DENTAL INJURIES) 30-44% text p630 ConcussionSubluxationExtrusionLateralIntrusiveWORST CASE SEQUELAE?PULP NECROSISEXTERNAL/INTERNALROOT RESORPTIONPossible tooth lossAVULSION
22 Concussion Luxation Injury Least severe of Luxation injuriesNo displacement of tooth nor excessive mobilityTooth tender to touch “Bruised PDL”No radiographic abnormalitiesVIP!!! Assess vitality in 4 wks
23 Subluxation Luxation Injury Tooth tender to touch & slightly mobile (1+) but not displacedPossible hemorrhage from gingival creviceNo radiographic abnormalitiesDamage to supporting structures?VIP!!! Assess vitality in 4 weeks
24 Extrusion Luxation Injury Elongated mobile toothCl. II mobility or greaterRadiographs show increased apical periodontal spaceManually repositionReposition tooth + Flexible splint MANDATORY 7-10 days ?VIP!!! Assess vitality in 4 weeks
25 What is a flexible splint? -Allows physiologic movement of the teeth in order to minimize ankylosis-In the past, .028 gauge ortho wire bonded to tooth for 7-10 days unless alveolar FX had occurred. Then 4-8 wksOR: 4-6# fishing line bonded to teeth-Currently, titanium trauma splint (TTS) is recommended see p643, text
26 Semi-rigid or flexible splinting Experimental studies in non-human primates have demonstrated that rigid splinting ,especially for prolonged periods, leads to ankylosis &/or external resorption.Maintaining a slight degree of tooth mobility appears to be beneficial to PDL healingVon Arx T, etal Splinting of Traumatized teeth with a new device:TTS; Dent Traumatol 2001;17:180-84
29 TTS splint Insert picture of same Splinting of traumatized teeth with a new device:TTS (Titanium Trauma Splint)Medartis AG, Basel, SwitzerlandVon arx T, etal Dent Traumatol, ’01;17:180-84
30 Lateral Luxation Injury Displaced laterally & often locked in boneNot tender to touch, not mobileAlveolus fracturedPercussion test: high metallic sound (ankylosis)Increased PDL space best seen on eccentric or occlusal radiographsAnesthetize & reposition+ Flexible splint MANDATORY 4-8 weeksVIP!!! Assess vitality in 4 weeks
31 Intrusion Luxation Injury External root resorption likely Most severe of luxations***Tooth appears shorter: displaced into alveolar bonePDL destruction/alveolar crushing) Beware of ankylosis/resorption/pulp necrosis is all but certain in mature teeth***Not tender to touch, not mobilePercussion test: high metallic soundRadiographs not always conclusiveSlightly luxate with forceps or band and move orthodontically.Splinting is not usually necessaryTooth with open apex may spontaneously re-erupt.
32 Treatment of intrusion luxation Closed apex needs ortho. or surgical repositioning and probable RCT in 1-3 weeksIn all LUXATION and especially INTRUSION injuries, the apical neurovascular bundle and attachment apparatus will be affected to some degree>>>loss of vitality & internal/external resorption
33 5. Avulsion Tooth is knocked completely out of mouth Viability of the PDL must be preserved for successExtra-oral dry time is CRITICAL 30-60”***Must be replaced in socket ASAP (15-20”) (text p641) in order to..Prevent ankylosisPrevent external root resorptionTo replant or not? should be “decent tooth”: No point in replanting THIS one
34 Replant?TX is aimed at minimizing the inflammation from the two main consequences of avulsion, namely; attachment damage and pulpal infection that inevitably resultsThe SINGLE most VIP factor in achieving a favorable outcome is the SPEED at which a clean tooth is properly replantedKeeping the attached PDL moist is VIP!!*
35 Replantation guidelines HOW FAST IS FAST? 5”, 30” 60”, TAKE YOUR PICK, it depends on whose book you read!If tooth is out of the mouth less than 15-20”, replant according to guidelinesIf tooth was out and placed in cold milk or other physiological solution w/in 15-20” & available for replantation w/in 30”, replant and follow guidelinesIf tooth is out > 60” and not stored, there is usually one outcome: resorption and probable lossIf the pt is pre adolescent, the tooth may become infraoccluded (ankylosed) as he/she grows older
36 To replant or not (cont) If the root of the avulsed tooth is not completely formed, the prognosis for survival and revascularization is possible if not left out>60”If root is incompletely formed and replantation is rapid, vitality may be maintained but is not predictableKenny DH etal; Medicolegal aspects of replanting permanent teeth. J Can Dent Assoc 71:245-48, 2005
37 First Aid Instructions Handle by crown onlyPick off debris with tweezersReplant tooth if possible_________________________________If not, transport in appropriate medium:“Save-a-tooth” (Hank’s Balanced Salt solution)OR “Via Span” (if available)OR milk if above not availableOR place in vestibule (saliva) & Report to dental office ASAP
38 Once in Dental office:Take films to make sure there is no alveolar FX & that adjacent teeth are OK“Save-a-tooth” (Hank’s Balanced Salt solution)OR “Via Span”, milk, salineGently clean socketReplant and check occlusionSplintRX antibiotics
39 Avulsion Injury What NOT to do! Do NotHandle by rootScrub rootAllow tooth to drySubmerge the tooth in water (tap water is hypotonic> and will cause cell rupture)AAE has a Flow Chart Outlining Current Treatment Management Protocols of both Luxation and Avulsion cases ..www. aae.org.
40 If over 60” “dry time” Remove remnants ofPDL by soaking in acid for 1” Soak in Stannous Fl for 5”No harm done to go ahead and complete endo ASAPSplintPray
41 Immature Tooth: Open Apex, revascularization is possible if out less than 30-60” Replant as above EXCEPT differentSoak tooth in Doxycycline (1mg/20cc saline)<replantation for 5” text,p642Monitor pulp vitality closely (q 30 d or until root development is confirmed)Vital Open apex will NOT necessarily require RCT UNLESS pulp becomes necrotic.What if it does? Do we do apexogenesis then?
42 Case History16 yr., African-American male presents with avulsed teeth and deep puncture wound or lip# 7 and # 8 intact30 minutes post assault (60 minutes=critical)Patient is lucid, responsive, with no apparent neurological impairmentMedical history non-contributory
43 Ankylosis A problem following trauma and long term rigid splinting Tooth is solidly fixed and has a high metallic ring when percussing. Does not erupt with other teethMay lead to massive external resorption & loss of toothInternal= appearance of “aneurysm” w/in canal.
44 Complications with Replanted avulsed teeth & Possibly with Rigid Long-Term Splinting Ankylosis (Replacement Resorption)
45 7. Plug for PreventionMouth guards***Many of the injuries we discussed could be prevented through the aggressive promotion and use of mouth guards.Every child should wear one for most active play.Every adult involved in sports should wear one.Become Involved in your Community! Begin the Service if not available in your area.