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Common Sequelae of Trauma • Management of Complicated Crown Fractures • Management of Luxation Injuries COMMON REACTIONS of TEETH to TRAUMA

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Common Sequelae of Trauma • Management of Complicated Crown Fractures • Management of Luxation Injuries COMMON REACTIONS of TEETH to TRAUMA Acute Management of Dental Limitations of trauma research Injuries in Children Ethical - Patients can’t be randomized to “trauma” and “no trauma” groups Animal models – limited clinical applicability to humans Retrospective case series studies Individual case reports Randomized post-injury treatment interventions Comparability of injuries studied Dennis J. McTigue, DDS, MS Andreasen, JO et al. Contradictions in the treatment of traumatic dental AAO-AAPD Joint Winter Conference injuries and ways to proceed in dental trauma research. Dent Traumatol February 10, 2018 2010; 26:16-22 Guidelines for Treatment International Association of Dental Traumatology Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012;28 I. Fractures and luxations of permanent teeth II. Avulsion of permanent teeth III. Primary teeth American Association of Endodontists Recommended guidelines for the treatment of traumatic injuries. Chicago: AAE; 2013 www.AAE.org • Common sequelae of trauma • Management of complicated crown fractures • Management of luxation injuries COMMON REACTIONS OF TEETH TO TRAUMA PULPAL HYPEREMIA (REVERSIBLE PULPITIS) PULP CANAL OBLITERATION PULP NECROSIS RAPID INFLAMMATORY RESORPTION REPLACEMENT RESORPTION (Ankylosis) Andreasen, F.M., et al: Occurrence of Pulp Canal Obliteration After Luxation Injuries in the Permanent Dentition. Endo. Dent. Traumatol. 3:103, 1987 Sample - 637 luxated incisors Observation period - 6 months to 10 years PULPAL CANAL OBLITERATION (PCO) - RESULTS PCO dependent on type of injury PCO dependent on stage of root development PN subsequent to PCO was uncommon (1%) PCO occurs later than PN (12 mos. vs 3mos) PCO increased with bands / resin fixation Rapid Inflammatory Resorption Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules Tronstad, L., "Root Resorption - Etiology, Terminology and Clinical Manifestations", Endo. Dent. Traumatol. 4: 241-252, 1988. Etiology Etiology Inflammatory Inflammatory resorption resorption Surface resorption of Surface resorption of cementum exposing cementum exposing dentinal tubules dentinal tubules Pulp necrosis Pulp necrosis Toxic products from the pulp provoke an inflammatory response in the PDL Replacement Resorption Direct union of bone and root Resorption of root - Replacement with bone Direct result of loss of vital PDL MANAGEMENT OF TRAUMATIC INJURIES TO YOUNG PERMANENT TEETH TREATMENT ALTERNATIVES IN COMPLICATED FRACTURES OF PERMANENT TEETH DIRECT PULP CAP: small exposure, < 24 hours PARTIAL PULPOTOMY (CaOH or MTA) preferred tx; larger exposures, > 24 hours PULPECTOMY: closed apex Andreasen FM, Andreasen JO. Crown fractures. In: Andreasen JO, Andreasen FM, Complicated (Class III) Fx Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. 280-305. International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2007:23 CALCIUM HYDROXIDE TECHNIQUE PARTIAL PULPOTOMY 1) Gently Remove Dentin and Pulp to 1-2 mm 2) Use Copious Irrigation 96% SUCCESS WITH PULPS EXPOSED 3) Cover Pulp with CaOH 1 HOUR TO 90 DAYS Cvek, M.: A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture, J. Endo., Vol. 4, #8, Aug. 1978, pgs 232-237. CRITERIA FOR SUCCESS 1) No clinical signs or symptoms 2) No radiographic pathology 3) Continued development of immature roots 4) Formation of calcific barriers 5) Sensitivity to electrical stimulation MANAGEMENT OF LUXATION CONCUSSION INJURIES TO THE YOUNG PERMANENT DENTITION An injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth but with marked reaction to percussion. Subluxation (loosening) Concussion Treatment: Inform patient & parent about An injury to the potential sequelae; tooth-supporting structures with Monitor abnormal loosening, but without Subluxation Tx: displacement of the Splint ?? tooth F/U in 2 weeks; Radiograph at 1 month SPLINTS SHOULD: 1) Be passive and atraumatic 2) Be durable 3) Be flexible Primate studies have demonstrated that rigid and/or 4) Allow for vitality testing and prolonged splinting may lead to extensive PDL healing endodontic access complications, like ankylosis and replacement resorption. Andreasen, J. A time-related study of PDL healing and root resorption activity 5) Be easy to apply and remove after replantation of mature permanent incisors in monkeys. Swed Dent J 4:101- 110, 1982 Andersson L, et al. Effect of masticatory stimulation on dentoalveolar ankyosis after experimental tooth replantation. Endod Dent Traumatol 1:13-16, 1985 Splinting Use fish line/acid-etch resin; soft arch wire/resin; ortho brackets with passive arch wire; suture as last resort. Circumferential wire splints contraindicated Splinting - Home Care No biting on splinted teeth Soft diet Maintenance of good oral hygiene Intrusive Luxation (central dislocation) A displacement of the tooth into the alveolar bone. This injury is accompanied by von Ark, T. et al. Splinting of traumatized comminution or teeth with a new device: TTS (Titanium Trauma Splint) Dent Traumatol 17:180-184, fracture of the 2001 alveolar socket. Intrusion Treatment Controversy Andreasen JO et al. : Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Endo. Dent. Traumatol. 22:99-111, 2006. Wigen, et al. Intrusive luxation of permanent incisors in Norwegians aged 6-17 years: a retrospective study of treatment and outcome. Dent Traumatol 24:612-618, 2008 Ebelseder et al. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Endod Dent Traumatol 16:34-39, 2000 Kenny, et al. Avulsions and Intrusions: the controversial displacement injuries. JCDA 69:291-297, 2003. 2 days post- 3 weeks post- intrusion intrusion 3 weeks post-intrusion 1 Week Post-intrusion 20 weeks post-intrusion 8 weeks post-intrusion Intrusive Luxation Tx: OPEN APEX If < 7 mm allow spontaneous repositioning; ortho extrusion if no movement within 2-4 weeks If > 7 mm reposition surgically or orthodontically CLOSED APEX < 3 mm allow spontaneous eruption; ortho extrusion or surgical reposition if no movement within 2-4 weeks 3 – 7 mm reposition orthodontically or surgically >7 mm reposition surgically & splint for 2 weeks Chlorhexidine mouthrinse Remove pulp & fill with CaOH < 2-3 weeks Complete endo fill in 1 - 2 months if no resorption Antibiotics not helpful EXTRUSIVE LUXATION (Peripheral dislocation, partial avulsion) A partial displacement of the tooth out of its socket. Andreasen J. et al. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol 18:116-128, 2002 Andreasen J. et al. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1:207-220, 1985 Andreasen J. et al. The relationship between pulpal dimensions and the development of pulp necrosis after luxation injuries in the permanent dentition. Endod Dent Traumatol 2:90-98, 1986 Extrusive Luxation Tx: Reposition tooth ASAP; best prognosis if completed within 2 hours Light splint for 2 weeks Remove pulp & fill with CaOH within 7-14 days Chlorhexidine mouthrinse Complete endo fill in 1 - 2 months if no inflammatory resorption Lateral Luxation A displacement of the tooth in a direction other than axially. This is accompanied by comminution or fracture of the alveolar socket. Pre-op 1 week post-op 7 months post-op Andreasen, JO, et al. Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th ed. Pg. 418 Lateral Luxation Tx: Reposition tooth ASAP; best prognosis if completed within 2 hours Light splint for 3 - 4 weeks Remove pulp & fill with CaOH within 7-14 days Chlorhexidine mouthrinse Complete endo fill in 1 - 2 months if no inflammatory resorption Exarticulation (complete avulsion) A complete displacement of the tooth out of its Andreasen J. et al. Replantation of 400 socket. avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 11:51-58, 1995 Andersson L and Bodin I. Avulsed human teeth replanted within 15 minutes – a long-term clinical follow-up study. Endod Dent Traumatol 6:37-42, 1990 Treatment of the Avulsed Permanent Tooth I. Management at site of injury II. Transport media III. Management in dental office IV. Adjunctive drug therapy considerations V. Endodontic treatment VI. Restoration of the avulsed tooth Management at Site of Injury Recommended Storage Media 1. Socket (immediate Replant immediately, replantation) if possible. If 2. HBSS contaminated, rinse. 3. Milk 4. Physiologic saline When cannot be 5. Saliva replanted, place tooth in best transport Andersson, L. et al. International Association of Dental Traumatology medium available. guidelines for the management of dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology 2012; 28:88-96. Blomlof L. Milk and saliva as possbile storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J. 8:1-26, 1981 Management of the Management of the Avulsed Tooth Avulsed Tooth What tissue should be What tissue should be our primary concern? our primary concern? Pulp? Pulp? Socket? Management of the Management of the Avulsed Tooth
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