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Traumatic Injuries, Cracked Teeth and vertical root fractures (VRF)

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Presentation on theme: "Traumatic Injuries, Cracked Teeth and vertical root fractures (VRF)"— Presentation transcript:

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2 Traumatic Injuries, Cracked Teeth and vertical root fractures (VRF)

3 Fact Most dental trauma occurs in 7_12 age range Most dental trauma occurs in 7_12 age range And most trauma occurs in the anterior region of the mouth, maxilla>mandible And most trauma occurs in the anterior region of the mouth, maxilla>mandible

4 1. Crown FX without Pulp exposure NO PROBLEM, RELAX AND RESTORE

5 Complicated Crown FX with Pulp Exposure Pulp Cap? OR: EXTIRPATION if root is fully formed Partial IF w/in 24hrs

6 2. Crown-Root Fracture sometimes fractures at an angle Angular Fracture: Is this restorable?

7 Remember, In all trauma, the primary purpose of our treatment is to keep the pulp vital, if at all possible, ESPECIALLY if apex is open In all trauma, the primary purpose of our treatment is to keep the pulp vital, if at all possible, ESPECIALLY if apex is open WHY? WHY?

8 Pulpotomy – Immature Apex If Vital = “Apexogenesis”*

9 Apexogenesis vs Apexification Dealing with the immature root Apexogenesis (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 apex (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 apex as well as thickening of the RC walls as well as thickening of the RC walls RCT maybe needed later BUT not if tooth remains asymptomatic AND vital Apexification (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 3-18mo (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 3-18mo RCT ALWAYS NEEDED HERE* and is less predictable due to thinner walls Object of either treatment is to allow for roofing over of apex and allow RCT to be done at a later date.

10 And now, Regeneration? Revascularization of immature permanent teeth utilizing a mixture of antibiotics(3 weeks), creating a blood clot w/in the RCS which produces development of the tooth structure Revascularization of immature permanent teeth utilizing a mixture of antibiotics(3 weeks), creating a blood clot w/in the RCS which produces development of the tooth structure

11 3.Horizontal Root Fracture

12 Root FX (Horizontal) What do you do here? Try to reposition and splint 2-4 wks, check for vitality q 30 days

13 4. Luxation Injuries ( MOST COMMON OF ALL DENTAL INJURIES) 30-44% Concussion Concussion Subluxation Subluxation Extrusion Extrusion Lateral Lateral Intrusion Intrusion WORST CASE SEQUELAE? PULP NECROSIS EXTERNAL/INTERNAL ROOT RESORPTION Possible tooth loss AVULSION

14 Concussion Luxation Injury Least severe of Luxation injuries No displacement of tooth nor excessive mobility Tooth tender to touch “Bruised PDL” No radiographic abnormalities Assess vitality in 4 wks

15 Subluxation Luxation Injury Tooth tender to touch & slightly mobile (1+) but not displaced Possible hemorrhage from gingival crevice No radiographic abnormalities Damage to supporting structures? Assess vitality in 4 weeks

16 Extrusion Luxation Injury Elongated mobile tooth Cl. II mobility or greater Radiographs show increased apical periodontal space Manually reposition Reposition tooth + Flexible splint (2 weeks) Assess vitality in 4 weeks

17 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 wks OR: 4-6# fishing line bonded to teeth -Currently, titanium trauma splint (TTS) is recommended

18 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. 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 healing Maintaining a slight degree of tooth mobility appears to be beneficial to PDL healing

19 Titanium Trauma Splint Medaris AG, Basel Switzerland

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21 TTS splint Insert picture of same Insert picture of same Splinting of traumatized teeth with a new device:TTS (Titanium Trauma Splint) Splinting of traumatized teeth with a new device:TTS (Titanium Trauma Splint) Medartis AG, Basel, Switzerland Medartis AG, Basel, Switzerland Von arx T, etal Dent Traumatol, ’01;17: Von arx T, etal Dent Traumatol, ’01;17:180-84

22 Lateral Luxation Injury Displaced laterally & often locked in bone Not tender to touch, not mobile Alveolus fractured Percussion test: high metallic sound (ankylosis) Increased PDL space best seen on eccentric or occlusal radiographs Anesthetize & reposition + Flexible splint (4 weeks) Assess vitality in 4 weeks

23 Intrusion Luxation Injury External root resorption likely Most severe of luxations*** Tooth appears shorter: displaced into alveolar bone PDL destruction/alveolar crushing) Beware of ankylosis/resorption/ pulp necrosis is all but certain in mature teeth*** Not tender to touch, not mobile Percussion test: high metallic sound Radiographs not always conclusive Slightly luxate with forceps or band and move orthodontically. Splinting is not usually necessary (>4 weeks) Tooth with open apex may spontaneously re-erupt.

24 Treatment of intrusion luxation Closed apex needs ortho. or surgical repositioning and probable RCT in 1-3 weeks Closed apex needs ortho. or surgical repositioning and probable RCT in 1-3 weeks In 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

25 5. Avulsion Tooth is knocked completely out of mouth Tooth is knocked completely out of mouth Viability of the PDL must be preserved for success Viability of the PDL must be preserved for success Extra-oral dry time is CRITICAL ”*** Extra-oral dry time is CRITICAL ”*** Must be replaced in socket ASAP (15-20”) in order to.. Must be replaced in socket ASAP (15-20”) in order to.. Prevent ankylosis Prevent ankylosis Prevent external root resorption Prevent external root resorption To replant or not? should be “decent tooth”: No point in replanting THIS one

26 Replant? TX is aimed at minimizing the inflammation from the two main consequences of avulsion, namely; attachment damage and pulpal infection that inevitably results TX is aimed at minimizing the inflammation from the two main consequences of avulsion, namely; attachment damage and pulpal infection that inevitably results The SINGLE most VIP factor in achieving a favorable outcome is the SPEED at which a clean tooth is properly replanted The SINGLE most VIP factor in achieving a favorable outcome is the SPEED at which a clean tooth is properly replanted Keeping the attached PDL moist is VIP!!* Keeping the attached PDL moist is VIP!!*

27 Replantation guidelines If tooth is out of the mouth less than 15-20”, replant according to guidelines If tooth is out of the mouth less than 15-20”, replant according to guidelines If 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 guidelines If 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 guidelines If tooth is out > 60” and not stored, there is usually one outcome: resorption and probable loss If tooth is out > 60” and not stored, there is usually one outcome: resorption and probable loss If the pt is pre adolescent, the tooth may become infraoccluded (ankylosed) as he/she grows older If the pt is pre adolescent, the tooth may become infraoccluded (ankylosed) as he/she grows older HOW FAST IS FAST? 5”, 30” 60”, TAKE YOUR PICK, it depends on whose book you read!

28 To replant or not 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 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 predictable If root is incompletely formed and replantation is rapid, vitality may be maintained but is not predictable

29 First Aid Instructions Handle by crown only Handle by crown only Pick off debris with tweezers Pick off debris with tweezers Replant tooth if possible Replant tooth if possible _________________________________ _________________________________ If not, transport in appropriate medium: If not, transport in appropriate medium: “HBSS (Hank’s Balanced Salt solution) “HBSS (Hank’s Balanced Salt solution) OR “Via Span” (if available) OR “Via Span” (if available) OR milk if above not available OR milk if above not available OR place in vestibule (saliva) & Report to dental office ASAP OR place in vestibule (saliva) & Report to dental office ASAP

30 Once in Dental office: Take films to make sure there is no alveolar FX & that adjacent teeth are OK Take films to make sure there is no alveolar FX & that adjacent teeth are OK “Save-a-tooth” (Hank’s Balanced Salt solution) “Save-a-tooth” (Hank’s Balanced Salt solution) OR “Via Span”, milk, saline OR “Via Span”, milk, saline Gently clean socket Gently clean socket Replant and check occlusion Replant and check occlusion Splint (7-10 days) Splint (7-10 days) RX antibiotics RX antibiotics

31 Avulsion Injury What NOT to do! Do Not Do Not Handle by root Handle by root Scrub root Scrub root Allow tooth to dry Allow tooth to dry Submerge the tooth in water (tap water is hypotonic> and will cause cell rupture) Submerge 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.

32 If over 60” “dry time” Remove remnants ofPDL by soaking in acid for 1” Remove remnants ofPDL by soaking in acid for 1” Soak in Stannous Fl for 5” Soak in Stannous Fl for 5” No harm done to go ahead and complete endo ASAP No harm done to go ahead and complete endo ASAP Splint Splint

33 Immature Tooth: Open Apex, revascularization is possible if out less than 30-60” Replant as above EXCEPT different Replant as above EXCEPT different Soak tooth in Doxycycline (1mg/20cc saline)

34 Ankylosis A problem following trauma and long term rigid splinting 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 teeth Tooth is solidly fixed and has a high metallic ring when percussing. Does not erupt with other teeth May lead to massive external resorption & loss of tooth May lead to massive external resorption & loss of tooth Internal= appearance of “aneurysm” w/in canal. Internal= appearance of “aneurysm” w/in canal.

35 Complications with Replanted avulsed teeth & Possibly with Rigid Long-Term Splinting Ankylosis (Replacement Resorption) Ankylosis (Replacement Resorption)

36 Vertical Root Fracture Vertical Root Fracture Look for ‘J’-Shaped apical lesion Look for Drop-off Pocket if.... VRF difficult to confirm radiographically –UNLESS separation of segments occurs

37 Transillumination Restoration Removal + Staining Other methods of discovering VERTICAL ROOT FRACTURE A surgical exploration is usually the only other way to confirm presence of VRF*

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40 Flare-ups

41 Flare-ups A flare-up is an acute exacerbation of an asymptomatic pulp/or periapical pathosis after the initiation or continuation of root canal treatment. A flare-up is an acute exacerbation of an asymptomatic pulp/or periapical pathosis after the initiation or continuation of root canal treatment.

42 Patient Presentation Pain Pain Pain and swelling Pain and swelling

43 Factors Mechanical Mechanical chemical chemical Emotional state Emotional state Gender Gender Microbial Microbial Immunological Psychological state Regulation of periapical inflammation

44 Incidence 1.4 to 19% 1.4 to 19% 20 to 40% 20 to 40%

45 Age of Patient? There is a lack of agreement concerning the influence of age on the incidence of flare-up. There is a lack of agreement concerning the influence of age on the incidence of flare-up. 40_59 year(most) 40_59 year(most) Under the age of 20(least) Under the age of 20(least)

46 Gender and Flare-ups Women(most) Women(most)

47 Systemic conditions Host resistance Host resistance Allergy Allergy

48 Anatomic Location Mandibular teeth Mandibular teeth premolars premolars

49 Anxiety

50 Preoperative History of the Tooth

51 Number of Treatment Visits

52 Causes of Inter-Appointment Pain Mechanical Mechanical Chemical Chemical Microbial injury Microbial injury

53 Re-Treatment Cases 13.6% flare-up 13.6% flare-up

54 Strategies to Prevent Flare-ups Anxiety Reduction Anxiety Reduction Behavioral Intervention Behavioral Intervention Occlusal Reduction Occlusal Reduction

55 Pharmacologic Strategies for Flare-up Antibiotic Antibiotic NSAIDs and Acetaminophen NSAIDs and Acetaminophen Long-acting Local Anesthetics Long-acting Local Anesthetics

56 Patient Instructions By the Clock By the Clock NOT NOT PRN PRN

57 Systemic involvement Systemic involvement Compromised host resistance Compromised host resistance Fascial space involvement Fascial space involvement Indications for Antibiotic Therapy

58 Treatment of Endodontic Flare- ups Diagnosis and Definitive Treatment Diagnosis and Definitive Treatment Drainage Through the Coronal Access Opening Drainage Through the Coronal Access Opening I&D I&D Instrumentation Instrumentation Trephination( For severe pain without visible swelling) Trephination( For severe pain without visible swelling)

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