10. Trauma in permanent teeth Flashcards
When does root formation normally occur?
Root formation is normally complete 3 years after eruption
How can you get damage to the PDL?
- if the tooth is pushed into the root surface, there is crushing of the PDL and so the neurovascular bundle is crushed and you may see bleeding at the root surface
- if the tooth is extruded, you will get stretching of the PDL
What can damage to the PDL cause?
- ## may lead to external resorption of the root
Why does resorption occur and what is the outcome of it dependent on?
- damage to precementum or PDL
- osteoclastic damage to root surface
- outcome depends on size resorptive defect and presence/absence of inflammation
What are the 3 types of external root resorption?
- repair related resorption- often seen in ortho tx, PDL membrane space is trying to be redistributed, self-limiting
- ankylosis related replacement root resorption
- infection related resorption- pulp necrosis and inflammatory response
What does ankylosis related replacement root resoprtion appear like on radiograph?
- often get complete obliteration of the PDL space in places
- radiopacities indicative of bone on the root surface
What does repair related root resorption look like on radiograph?
- some root surface radiolucency but it is not continuing
- redistribution of the PDL membrane space
What is transient apical breakdown in bone?
Transient apical breakdown has been reported to occur in cases in which a periapical radiolucency develops and resolves without treatment following luxation injury.
- there is no permanent damage to the pulp
- if you repeated x ray you will see redistribution of PDL space
What special investigations do you need to do?
- appropriate radiographs
- sensibility testing (neural activity)- baseline and subsequent
- vitality (pulpal response)- pulse oximeter, doppler/laser flowmetry
What is the effect of trauma on the pulp?
- get disruption of blood supply
- pulp tissue becomes infarct
- coagulation necrosis occurs
- if there is bacteria you get infection related necrosis. Diminished in tooth with closed apex.
- if there is no bacteria you get revascularisation or regeneration/repair. There is opportunity to revascularise in a tooth with open apex.
What is the treatment for concussion?
- take radiograph and sensibility test
- monitor 4 weeks and 1 year clinical and radiographic
What is the definition of subluxation?
- injury to the tooth supporting structures with abnormal loosening but without displacement of the tooth
What are the clinical findings seen in subluxation?
- tender
- increased mobility
- bleeding from gingival crevice
- may not respond to sensiblility tests
What is the treatment for subluxation?
- normally monitor
- if increased mobility splint for 2 weeks
What time periods do you monitor subluxation?
- 12 weeks, 6 months and 1 year
- take 2 radiographic views
When should you do root canal for subluxation cases?
- a false negative response may be present for several months- do not extirpate solely on no response
- if signs of pulp necrosis/infection/AAP or inflammatory resorption commence root canal treatment
- open apex is more likely to revascularise
What is the definition of extrusive luxation?
- displacement of the tooth out of its socket in an incisal/axial direction
What are the clinical findings of extrusive luxation?
- tooth appears elongated
- increased mobility
- likely to have no response to sensibility tests
What radiographs do you take for extrusive luxation?
- 2 views
- often see increased PDL space
- need to take 2 views before you replace the tooth as you need to make sure there is no root fracture
What is the treatment for extrusive luxation?
- reposition under LA
- splint 2 weeks (may require 4 weeks if fracture of marginal bone)
- if pulp becomes necrotic and infected, start endo treatment
How often do you do clinical and radiographic reviews for extrusive luxation?
4 weeks, 8 weeks, 12 weeks, 6 months, 1 year and then yearly for 5 years
What can happen to the pulp in extrusive luxation?
- pulp canal obliteration can occur
- this is normal signs of a vital tooth
- however, in small percentage of cases the tooth may become necrotic and non-vital so may see apical radiolucency so RCT needs to be commenced
- pulp survival and pulp obliteration is higher in open apex
What is lateral luxation?
- displacement of the tooth in any lateral direction (labially or palatally), usually associated with compression of the alveolar socket wall/cortical bone
What are clinical features of lateral luxation?
- displaced palatally or labially
- usually associated with fracture of bone
- immobile as the apex of the root is locked in
- percussion will give it a high metallic sound
- likely to have no response to endofrost due to damage to the neurovascular pulp tissue
What radiographs do you take for lateral luxation?
2 views
When do you clinically and radiographically review lateral luxation?
- 4 weeks, 8 weeks, 12 weeks, 6 months, 1 year and then yearly for 5 years
What is the treatment for lateral luxation?
- need to reposition the tooth
- involves pushing down at the apex and crown to disimpact it and move it back into the socket
- splint it for 4 weeks
How will a mature/immature apex affect the outcome of treatment in lateral luxation?
- immature- may revascularise
- mature- will become necrotic so need to do endo to prevent inflammatory resorption
When do you refer lateral luxation?
- if you are unable to reposition, you need to refer on the same day
What is the definition of intrusive luxation?
- displacement of the tooth in apical direction into alveolar bone
- worst prognosis as the pDL more likely to be crushed and shearing of cementum layer on the root
What are the clinical findings of intrusive luxation?
- immobile
- highly metallic sound
- likely no response to sensibility testing
What radiographs do you take for intrusive luxation?
- one PA
- 2 additional radiographs at different angulations
What is the treatment for intrusive luxations in child under 18 with closed apex?
- splint the tooth for 4 weeks
- closed apex will need extirpation within 2-3 weeks
What is the treatment for intrusive luxation in a open apex? (child)
- will often spontaneous reposition
- if it does not after 4 weeks then do orthodontic repositioning
- need to monitor open apex for pulp necrosis as the more severe the injury, the more likely the tooth loses vitality
What are the long terms risks if someone has intrusive luxation?
- all at risk of ankylosis related replacement root resorption
What is the treatment for closed apex where degree of intrusion is up to 3mm?
- often spontaneously repositions
- if after 8 weeks it has not then surgically reposition
What is the treatment for closed apex where degree of intrusion is 3-7mm?
- either orthodontic or surgical repositioning
What is the treatment for closed apex where degree of intrusion is more than 7mm?
- surgical repositioning
At what times do you do clinical and radiographic reviews for intrusive luxations?
4 weeks, 8 weeks, 12 weeks, 6 months, 1 year, and then yearly for 5 years
How do you treat intrusive luxation in an adult, ie. over 17?
- cannot wait and monitor in these cases
- all intrusions should be treated with orthodontic extrusion as early as possible
- disimpaction +- surgical positioning can be considered in acute phases of injury for moderate to severe cases
Highlight differences between surgical and orthodontic repositioning?
Repositioning imposes a slightly increased risk of late complications compared to orthodontic extrusion
No significant differences between orthodontic and surgical repositioning healing outcomes; the surgical technique is much less time demanding
No significant differences in a 1 day delay in repositioning
No repositioning was found to result in superior healing results especially up to the age of 12 (and even up to 17 years
What is the treatment for avulsion?
- appropriate emergency management and treatment is important for good prognosis
- all attempts should be made to reimplant. Need to consider poor cooperation and complex medical history.
What are the steps to follow if a tooth has been avulsed?
- Keep the patient calm.
- Find the tooth and pick it up by the crown (the white part). Avoid touching the root. Attempt to place it back immediately into the jaw.
- If the tooth is dirty, rinse it gently in milk, saline or in the patient’s saliva and replant or return it to its original position in the jaw.
- It is important to encourage the patient/guardian/teacher/other person to replant the tooth immediately at the emergency site.
- Once the tooth has been returned to its original position in the
jaw, the patient should bite on gauze, a handkerchief or a napkin to hold it in place.
What is the order of preference of what you should put an avulsed tooth in?
- need to put the tooth in something quickly to avoid dehydration of the root surface which can occur in a few minutes, and allow the PDL to be retained
- milk, HBSS, saliva, saline
- water is a poor medium but it is better than letting it air dry
What factors does the treatment of avulsion depend on?
extent of injury, ie. damage to the PDL
- time out of the mouth
- extra alveolar dry time of more than 30 mins is not great
- storage medium that it is placed in
condition of teeth
- immature vs mature
At what time is an avulsed tooth most likely viable?
If the EADT is less than 15 mins
At what time is an avulsed tooth viable but compromised?
- if it has been placed in the appropriate storage medium
- total EADT is less than 60 mins
At what time is an avulsed tooth non-viable?
- EADT of more than 60 mins
What treatment do you do if the tooth has been reimplanted and has a CLOSED APEX and the person comes for an appt?
- Clean injured area with water/saline/CHX
- Verify the correct position. If wrong, consider repositioning within 48 hours.
- Administer LA- caution with vasoconstrictor as you want blood supply to the area to promote healing
- Splint for 2 weeks
- Initiate RCT within 2 weeks- as the apex is closed you will to do this to avoid infection related resorption
- Check tetanus
- Consider systemic antibiotics
What systemic antibiotics may you prescribe for avulsed tooth?
- over 12- tetracyline
- under 12- penicillin
What treatment do you do for a tooth with a closed apex where the tooth has been kept in storage medium with EADT of under 60 mins?
If visible root contamination rinse with Saline/ HBSS
Administer LA
Irrigate socket with sterile saline
Look out for alveolar fractures / clots
Reimplant –slight digit pressure
Verify position, splint for 2 weeks
Initiate RCT 2 weeks
Check tetanus and consider Abs
What treatment do you do for a tooth with a closed apex where the tooth has been kept in storage medium with EADT of more than 60 mins?
If visible root contamination rinse with Saline/ HBSS. Place in storage medium whilst taking history
Administer LA
Irrigate socket with sterile saline
Look out for alveolar fractures / clots
Reimplant –slight digit pressure
Verify position, splint for 2 weeks
Initiate RCT 2 weeks
Check tetanus and consider Abs
What is the problem with delayed reimplantation?
- poorer long term prognosis
- PDL becomes necrotic and therefore not expected to regenerate
What is the expected outcome of delayed reimplantation, ie. what type of resorption?
- ankylosis related replacement root resorption
Why do we still reimplant teeth that have been delayed?
- restore at least temporarily for aesthetics and function
- maintain alveolar bone contour, height and width
What is the difference in tx for an avulsed tooth if the tooth has an open apex?
- similar to closed apex but the pulp has the ability to revascularise. This could lead to further root development.
- therefore, you need to monitor the tooth for inflammatory resorption. This occurs rapidly in children, so if in doubt then extirpate.
- THEREFORE IF SIGNS OF INFECTION RELATED RESORPTION, EXTIRPATE
Why are systemic antibiotics prescribed in avulsion cases?
- little evidence for their use
- however reduces risk of contamination
- use of them has been recommended to prevent infection related reactions and decreased occurence of inflammatory root resorption
What is the material of a splint used?
- stainless steel
- or nylon fishing wire
How long is the splint that is used?
0.16 inches or 0.4mm for SS
- 0.13-0.25mm for nylon fishing line
What is the splint bonded with?
Composite
- should be flexible and passive to allow physiological tooth movement
What teeth do you splint to?
- attach it to the 2 neighbouring teeth which have not been affected
- avoid marginal gingiva
How long do you splint for?
- 2 weeks
- or if associated alveolar fracture, you use a RIGID splint for 4 weeks
What medicaments do you place in canal if you are doing endo for avulsion case?
- calcium hydroxide as intracanal medicament for up to 1 month
- corticosteroid +/- antibiotic should be placed for up to 6 weeks
When should you refer ankylosis related replacement resorption?
- may see infraocclusion if this has occured
- if the step defect is greater than 1mm, refer the person
What is the order of best to least 5 year survival rate after PDL injury for the injuries?
- concussion
- subluxation
- extrusion
- lateral luxation
- intrusion
- avulsion
What clinical things do you check when a patient presents with uncomplicated enamel or enamel and dentine fracture?
- check loss of tooth structure
- check that the pulp is not exposed
- check for other injuries
- locate the fragment if you can
What may it mean if a uncomplicated enamel or enamel/dentine fracture has tenderness?
- that there may be associated luxation injury or root fracture
What radiographs do you take for uncomplicated enamel or enamel/dentine fracture?
- baseline long cone periapical radiograph
- may need to take another view if suspect other injury
What treatment can you provide for uncomplicated enamel or enamel/dentine fracture?
- aim is to preserve pulp vitality
- seal exposed dentinal tubules
- identify lost fragment
- if fragment located consider reattachment
- use composite, GIC bandage or restore
When do you review uncomplicated enamel or enamel/dentine fracture?
- 6-8 weeks
- 1 year
What are the advantages of reattaching an incisor fragment?
- conservative
- have reduced wear
- good colour match and stability
- tooth colour maintained
- may need to rehydrate the tooth in saline first for 20 minutes
- may need to bevel fracture line and fill with resin
What is the first line of treatment for complicated fracture?
- pulp cap or pulpotomy
- extirpation is not the first line unless the tooth is requiring a post to restore
- the aim is to preserve pulp vitality
What are factors to consider when dealing with a complicated fracture?
- size of exposure- if it is less than 0.5mm you may want to do direct pulp cap with CAOH2
- time since trauma- do not put cold over the exposed pulp
- is pulp vital or non-vital
- open apex or closed apex
When do you review complicated fractures with radiographs?
- 6 to 8 weeks
- 3 months
- 6 months
- 1 year
What is the order of treatment you should undertake as the size of exposure and time since injury increases?
- Direct pulp capping- if less than 0.5mm or less than 24 hours
- Pulpotomy- partial (Cvek) or conventional (coronal)
- Low level?
- Pulpectomy
What is the definition of apexogenesis?
- the formation/completion of normal apical root development through the preservation of radicular pulp vitality
- therefore want to do pulp capping or vital pulpotomy
What is a partial cvek pulpotomy?
- preservation of cell rich coronal pulp tissue
What are the indications for partial cvek pulpotomy?
- exposure of more than 0.5mm but less than 4mm
- inflamed pulp tissue at exposure site
- exposure for more than 24 hours but less than 9 days
- previous trauma with pulp exposure
What are the treatment steps for a partial cvek pulpotomy?
- LA and isolate (use a rubber dam)
- Disinfect - swab tooth with CHX
- Remove 1-3mm of pulp and irrigate
- Apply gentle pressure with wet CWP
- Remove more pulp if bleeding persists
- Apply setting CaOH2 or biodentine or MTA over pulp
- Ensure good seal, eg. GIC and restore tooth
When do you use a conventional pulpotomy?
- if Cvek pulpotomy fails
What are the disadvantages of conventional pulpotomy?
- large access cavity weakens the crown
- pulp obliteration occurs in 50%
What are the steps for conventional pulpotomy?
- same as Cvek pulpotomy
- removal of infected pulp to level of CEJ with water cooled air turbine
If a tooth devitalised, what tx do you do for mature apex?
RCT
If a tooth devitalised, what tx do you do for an immature apex?
- apexification (create false bottom of tooth)
- root canal treatment
What types of materials can you use for apexification?
- non-setting CAOH2
- mineral trioxide aggregate (1 step apical closure)
How often do you change CAOH2 and how long does it take to form a barrier?
- 3 monthly dressing changes
- 9-24 months to form calcific barrier
What are the treatment stages for doing a pulpectomy?
- LA and isolate using rubber dam
- Create access
- Remove pulp using barbed broaches and bottle brushes
- Working length radiograph
- Irrigate canal with sodium hypochlorite solution
- Place non-setting CAOH2- TAKE RADIOGRAPH
- Cotton wool pledget
- Ensure good seal with GIC/kalzinol- leave for one month
In which cases should you carry out a pulpectomy?
- non-vital pulp
- in closed or open apex
What are the problems with calcium hydroxide?
- the caoh2 can dehydrate the dentinal walls which increases the risk of root fracture
- root end closure with CAOH requires at least 3 months
- risk of infection/fracture
What is MTA made up of?
- portland cement 75%
- gypsum 5%
- bismuth oxide- 20%
What are the advantages and disadvantages of MTA?-
- good results
- high PH
- very biocompatible
- very expensive- 40-50£ per gram
- has bismuth oxide in it which can react with with sodium hypochlorite to cause brown staining
What are the steps on how to do root end closure with MTA?
- Use LA and isolate with rubber dam
- Irrigate with sodium hypochlorite
- Dry with paper points
- MTA carrier to deposit 3-5mm at apex
- Condense with schilder plugger/GP master point
- check radiograph
- Then back fill with thermafill gutta percha (ensure at least 1mm below the CEJ)
- GIC
- Restore access cavity
What is biodentine?
- bioactive dentine substitute
- calcium-silicate based formulation
- mechanical properties to dentine
- tight seal
What is the definition of a root fracture?
- a fracture of the root involving dentine, pulp and cementum
- fracture can be horizontal, oblique or combination
At which locations can you have root fractures on the root?
- apical third
- mid third
- gingival third
- gross comminution- multiple fracture lines along the root surface
Which root fracture has better prognosis- supra or sub crestal?
- supracrestal is above the bone and then long term prognosis is poor
- subcrestal means there may be potential for union
What clinical signs may you see when there is a root fracture?
- coronal segment may me mobile and displaced
- TTP
- bleeding from gingival sulcus
- pulp sensibility may be negative
What views do you take if you suspect a root fracture?
LCPA
USO
Need 2 views
What treatment do you do if a pt comes in with a root fracture?
- if the fragment is displaced, then reposition
- check repositioning radiographically
- splint for 4 weeks, HOWEVER, if it is cervical may need splinting for 4 months
- monitor healing
- pulp necrosis if occurs usually only affects the coronal portion
What do you do if there is a cervical fracture in a mature tooth between the root?
- if it is supracrestal and cervical, the fragment may be very mobile
- you may need to remove the coronal fragment and RCT it followed by post crown or other options
What are the 3 types of healing you can get after a root fracture?
- Healing by calcification
- Healing by CT and/or bone
- No healing- inflammatory tissue
What root fractures have the best survival from best to least?
- Apical third
- middle third
- Gingival third
What are the treatment options for an uncomplicated crown root fracture?
- stabilisation of loose fragment
- orthodontic extrusion
- surgical extrusion
- RCT
- root submergence
- intentional replantation
- extraction
What are tx options for a complicated crown root fracture?
- if immature tooth try to preserve vitality
- if mature, extirpate and restore
- can be difficult to gain good coronal seal and hence may need to refer
What are tx options for crown-root fractures?
- Stabilise coronal fragments (splint)
- Remove coronal fragment
- Surgical exposure of fracture line
- Orthodontic/ surgical exposure of the # line * Extract / maintain the root
- If the pulp is exposed, then pulp therapy is also necessary
What are the rules about combined injuries?
Crown-fractured teeth, with or without pulp exposure and with a concomitant luxation injury, experience a greater frequency of pulp necrosis and infection.
Since prognosis is worse in combined injuries, the more frequent follow-up regimen for luxation injuries prevails over the less frequent regime for fractures.
What are the aims of regeneration endodontics?
To regenerate pulp like tissue, ideally the pulp-dentine complex
Regenerate damaged coronal dentine e.g. following carious exposure
Regenerate resorbed root, cervical or apical dentine
How does regeneration endodontics work?
- root canal regeneration via blood clotting
- scaffold implantation via growth factor
- injectable scaffold delivery (hydrogel)
What is autotransplantation best for?
- anterior tooth loss in growing child
- most successful in immature teeth
Which teeth are best at autotransplantation?
- lower 5’s, 3’s, lower 4’s, upper 5’s
What is the ideal level of root development for autotransplantation?
1/2 to 3/4 root development
What normally happens to the pulp in autotransplantation?
- pulp canal obliteration usually follows
- RCT sometimes needed subsequent to transplant
