2 Traumatic Injuries, Cracked Teeth and vertical root fractures (VRF)
3 Fact Most dental trauma occurs in 7_12 age range 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 @80% IFw/in 24hrsPartialFullOR:EXTIRPATION if root is fully formedPulp Cap?
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 openWHY?
8 Pulpotomy – Immature Apex If Vital = “Apexogenesis”*
9 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 asymptomatic 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.
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
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% ConcussionSubluxationExtrusionLateralIntrusionWORST CASE SEQUELAE?PULP NECROSISEXTERNAL/INTERNALROOT RESORPTIONPossible tooth lossAVULSION
14 Concussion Luxation Injury Least severe of Luxation injuriesNo displacement of tooth nor excessive mobilityTooth tender to touch “Bruised PDL”No radiographic abnormalitiesAssess vitality in 4 wks
15 Subluxation Luxation Injury Tooth tender to touch & slightly mobile (1+) but not displacedPossible hemorrhage from gingival creviceNo radiographic abnormalitiesDamage to supporting structures?Assess vitality in 4 weeks
16 Extrusion Luxation Injury Elongated mobile toothCl. II mobility or greaterRadiographs show increased apical periodontal spaceManually repositionReposition 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 wksOR: 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.Maintaining a slight degree of tooth mobility appears to be beneficial to PDL healing
21 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
22 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 (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 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 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 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
25 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”) in order to..Prevent ankylosisPrevent external root resorptionTo 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 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!!*
27 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
28 To replant or notIf 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
29 First Aid Instructions Handle by crown onlyPick off debris with tweezersReplant tooth if possible_________________________________If not, transport in appropriate medium:“HBSS (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
30 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 occlusionSplint (7-10 days)RX antibiotics
31 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.
32 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 ASAPSplint
33 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”Monitor 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?
34 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.
35 Complications with Replanted avulsed teeth & Possibly with Rigid Long-Term Splinting Ankylosis (Replacement Resorption)
36 Vertical Root Fracture Look for ‘J’-Shaped apical lesionLook for Drop-off Pocket ifVRF difficult to confirm radiographically –UNLESS separation of segments occurs
37 Other methods of discovering VERTICAL ROOT FRACTURE A surgical exploration is usually the only other way to confirm presence of VRF*TransilluminationRestoration Removal + Staining