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 Avulsed Tooth
What tissue should be Ultimate goal our primary concern? PDL healing without Pulp? root resorption Socket? PDL?
Management of the Managing Mature Tooth Avulsed Tooth Extraoral DRY Time < 1 Hour
Ultimate goal Objective is to maintain PDL cell vitality PDL healing without root resorption Place in HBSS during history & exam Most critical factor Handle by crown and gently replant Maintaining an intact Splint 1 – 2 weeks and viable PDL on the root surface Remove pulp in 7-14 days Place CaOH Obturate canal if no signs of RR in 4 – 6 months
Management of Root Surface Management of the Socket
Gently aspirate without entering Objective is to socket maintain PDL cell If clot present use saline vitality irrigation Keep moist in HBSS Do not curette socket Do not handle root Do not vent socket surface If alveolar bone collapsed, use blunt instrument to reposition Gently remove persistent debris Manually compress bony plates after replantation Management of Soft Tissues Tightly suture any soft tissue lacerations, particularly in the cervical region
Splinting Splinting - Home Care
Use fish line/acid-etch resin; soft arch wire/resin; No biting on splinted ortho brackets with passive teeth arch wire; suture as last resort. Soft diet Circumferential wire Maintenance of good splints contraindicated oral hygiene Maintain splint 10-14 days; longer if tooth demonstrates excessive mobility
Antibiotics?? Adjunctive Drug Therapy
Hammarstrom, L. et al., Endod Dent Traumatol 1986; Considerations parenteral antibiotics prior to extraction and immediately following replantation resulted in less inflammatory resorption Systemic antibiotics: in monkeys. Prevents bacterial invasion of the necrotic pulp and inflammatory resorption; route & timing If < 12 y/o pen v (250 mg/kg/d in 4 divided doses x 7 days) Sae-Lim V. et al., Endod Dent Traumatol 1998; If ≥ 12 y/o doxycycline (100 mg q 12 h first day, Tetracycline decreases root resorption by affecting the motility then 50 mg q 12 h days 2 – 10) of the osteoclasts and reduces effectiveness of collagenase Tetanus consultation within 24 hours Cvek M. et al. Endod Dent Traumatol 1990; Chlorhexidine mouth rinses Soaking teeth in topical doxycycline prior to replantation enhances revascularization NSAIDs to inhibit bone resorption & pain relief Endodontic Treatment Mature Tooth < 1 Hour DRY Time
Remove pulp in 7-14 days
Place CaOH
Obturate canal in 2-4 weeks
PROGNOSIS IS BEST FOR REIMPLANTED TEETH IF : Extra-Oral period is minimal Periodontal ligament is not traumatized If not replanted the transport and soaking solution is HBSS Endo therapy is not done in the hand before reimplantation An appropriate splint is applied for 1 week Tooth # 7 avulsed at age 10. Extraoral in water for CaOH pulpectomy is completed in 1 wk 30 mins. Replanted and endo 14 days later.
Age 14. #7 ankylosed November 7, 2017 #7 decoronated, October 24, 2016
Bourguignon C. and Sigurdsson A. Preventive strategies for traumatic dental injuries. Dent Clin North Am 53:729-749, 2009.
Mouthguards reported to reduce dental injuries up to 90% in contact sports Laminated thermoplastic mouthguards are dimensionally most stable No ethically feasible in vivo models to complete prospective studies No evidence to support claims that mouthguards prevent neck or cerebral brain injuries