Root fracture Reposition –As soon as possible –Check position radiographically –Flexible splint, 4 weeks –Cervical fracture: up to 4 months Follow-up –1 yr at least –Pulp necrosis RCT for coronal fragment
Alveolar bone fracture Pano Treatment –Reposition –Stabilization: 4 weeks
Follow-up procedures Trauma4 w 6-8 w 4 M6 M1 Y5 Y Crown Fr. Crwon-root Fr. Root Fr.RS Alveolar Fr.RS RS: removal of splints
Unfavorable outcomes Symptomatic Negative response to pulp testing Radiographic –Signs of apical periodontitis –No continuing root development in immature teeth. –Radiolucency adjacent to fracture line. –External inflammatory resorption
Treatment guidelines for luxation injuries
Concussion No treatment is needed. Monitor pulpal condition for at least 1 year Subluxation Flexible splint, 2 weeks
Lateral luxation Reposition –Disengage tooth with forceps –Gently reposition into original location Stabilization –Flexible splint, 4 weeks Monitor the pulpal condition
Intrusive luxation Incomplete root formation –Allow spontaneous repositioning to take place within 3 weeks –Rapid orthodontic repositioning Complete root formation –To be repositioned either orthodontically or surgically as soon as possible. –RCT with Ca(OH) 2 dressing within 3 weeks
Unfavorable outcomes Symptomatic –Crown discoloration Negative response to pulp testing Radiographic –No continuing root development in immature teeth –Periradicular radiolucencies –Breakdown of marginal bone –External inflammatory resorption or replacementresorption
Treatment guidelines for avulsed permanent teeth
Tooth with Closed / Open apex 1. The tooth has been replanted prior to the arrival of patient 2. The tooth has been kept in storage media (HBSS, milk, saline or saliva); or the extr-aoral dry time < 60 min 3. Extra-oral dry time > 60 min
Tooth has been replanted Do not extract the tooth Clean the area with water spray, saline, or CHX.
Tooth has been kept in media Clean root surface with a stream of saline and place the tooth in saline Cover root surface with Arestin TM –Minocycline HCl microspheres –For tooth with open apex Remove the coagulum from socket with a stream of saline. Reposition the fractured socket wall Replant the tooth slowly with slight digital pressure.
Extra-oral dry time > 60 min Delayed replantation Remove attached soft tissue with gauze. RCT prior to replantation, or 7–10 days later –Through open apex Remove the coagulum from the socket Reposition the fractured socket wall Immerse the tooth in 2% NaF, 20 min Replant the tooth slowly with slight digital pressure.
Reposition Suture gingival lacerations if present. Verify position of the tooth both clinically and radiographically. Flexible splint, 2 weeks –4 weeks for delayed replantation
Systemic antibiotics Tetracycline (Doxycycline) for 7 days –Risk of discoloration –Not recommended for age < 12 y/o Phenoxymethyl Penicillin (Pen V)
If the tooth has contacted soil, and if tetanus coverage is uncertain, refer to physician for evaluation and need for a tetanus booster.
Patient instruction For all patients with dental trauma Soft diet, 2 weeks. Brush teeth with a soft toothbrush after each meal. 0.12% CHX mouth rinse, bid, 1 week
Root canal treatment RCT 7–10 days after replantation and before splint removal. –RCT prior to delayed replantation Place Ca(OH) 2 dressing until RCF –1 month Open apex: only when pulp necrosis
Follow-up procedures RS: removal of splint Yearly after 1-year follow-up Replantation1 w2 w3 w4 w3 M6 M1 Y immediateRS DelayedRS
Unfavorable outcome Symptomatic –Excessive mobility –No mobility with metallic percussion sound –Crown in infra-occlusal position Resorption –inflammatory, infection-related –Ankylosis-related replacement resorption