ENDO Traumatic Injuries Flashcards
apical injuries may result in ___ and ___
swelling and bleeding that involves the PDL
T or F:
teeth with apical injuries are not sensitive to percussion
false
apical displacement with injury to vessels entering the apical foramen may lead to ___
pulpal necrosis
T or F:
during vitality testing after traumatic injuries, it is only necessary to test the injured teeth
false, you want to test the vitality of all the teeth in the area
after a traumatic injury, what might happen if you test vitality immediately after the injury?
- frequently yields a false negative response
- these data serve as a baseline for future reference, so the test results may be unreliable for 6-12 months
- tests should be repeated at 3 weeks, 3 months, 6 months, and 12 months, and yearly intervals after that
what is the purpose of continual vitality tests on teeth with traumatic injuries?
to establish a trend as to the physiologic status of the pulps
describe false negative pulp vitality test results from teeth involved in traumatic injuries
- all current pulp testing methods detect only the responsiveness and not the vitality of the pulp (vitality is determined by integrity of its blood supply)
- sensitivity tests for nerve function do not indicate the presence or absence of blood circulation within the pulp
- in traumatic injury, the neural response from the pulpal sensory nerves may be disrupted, but the vascular supply may be intact
___ is an incomplete crack of enamel without the loss of tooth structure
infraction
which classification of uncomplicated fracture involves enamel only (enamel chipping and incomplete fractures or cracks)?
ellis class I enamel fracture
what is the treatment for an ellis class I enamel fracture?
grinding and smoothing the rough edges or restoring lost structure
what is the prognosis for an ellis class I enamel fracture?
good
which classification of uncomplicated fracture is considered a fracture involving enamel and dentin only?
ellis class II crown fracture without pulp involvement
what is the treatment for an ellis class II fracture?
restoration with a bonded resin technique
what is the prognosis for an ellis class II fracture?
good unless accompanied by a luxation injury
which classification of complicated fracture involves enamel, dentin, and exposure of the pulp?
ellis class III crown fracture with pulp involvement
what distinguishes an uncomplicated fracture from a complicated fracture?
whether there is pulp involvement or not
in the treatment for an ellis class III fracture, what determines whether vital pulp therapy or RCT is appropriate?
- stage of development of the tooth (vital pulp therapy for immature tooth due to advantages of maintaining vital pulp)
- time between accident and treatment (<24 hours, initial reaction of pulp is proliferative with <2mm pulp inflammation; >24 hours, chances of direct bacterial contamination increase)
- periodontal injury compromises nutrient supply of the pulp
- restorative treatment plan (more complex plan may require RCT)
which type of root fracture may show bleeding from the sulcus?
horizontal
what are the 2 biologic consequences of a horizontal root fracture?
- when a root fractures horizontally, the coronal segment is displaced, but generally the apical segment is not. pulp necrosis of the coronal segment (25%) may result from displacement
- because the apical pulp circulation is not disrupted, pulpal necrosis in the apical segment is rare
why should you avoid only taking one radiograph when diagnosis horizontal root fractures?
- root fractures are usually oblique (facial to palatal), so one radiograph may miss it
- one occlusal film and three PA films (one at 0 degrees, then one at +15 degrees, and one at -15 degrees from the vertical axis of the tooth)
what are the healing patterns of horizontal root fractures described by andreasen and hjorting-hansen?
- healing with calcified tissue (ideal healing is calcific healing, where a calcific callus is formed at the fracture site on the root surface and inside the canal wall)
- healing with interproximal connective tissue
- healing with bone and connective tissue
- interproximal inflammatory tissue without healing (considered unsuccessful, typical when the coronal segment loses its vitality)
with horizontal root fractures that have maintained the vitality of the pulp, the main goal of treatment is ___. what is the treatment and prognosis?
- to enhance the healing process
- prognosis improves with quick treatment, close reduction of the root segments, and splinting
- splint as soon as possible, depending on location of the fracture and mobility
what is the prognosis of a horizontal coronal root fracture?
- poor
- if the fracture occurs at the level of or coronal to the crest of the alveolar bone, the prognosis is extremely poor
what is the treatment for a horizontal coronal root fracture?
- stabilize the coronal fragment with rigid splint for 6-12 weeks
- if reattachment of the fractured fragment is impossible, extraction of the coronal segment is indicated; the apical segment may be carried out by orthodontic forced eruption or by periodontal surgery
what is the treatment for a horizontal midroot fracture?
- stabilize for 3 weeks
- apexification may be indicated if pulpal necrosis occurs and the pulp lumen is wide at the apical extent of the coronal segment
- in rare cases when both coronal and apical pulps are necrotic, endodontic tx through the fracture is difficult, and necrotic apical segments can be removed surgically
in horizontal midroot fractures, pulp necrosis occurs in ___% of root fractures
25% (mostly limited to coronal segment)
what is the prognosis of a horiztonal apical root fracture?
- have the best prognosis in the apical third
- pulp is mostly vital and the tooth has little or no mobility
what characteristics of root fractures determine prognosis?
- improves as fracture approaches apex (more apical, better prognosis)
- horizontal is better than vertical
- nondisplaced is better than displaced
- oblique is better than transverse
___ is the dislocation of a tooth from its alveolus resulting from acute trauma
luxation (ellis class V)
in concussion of a tooth, is there displacement? mobility? sensitivity to percussion? response to pulp testing? does pulp blood supply recover?
- no displacement
- normal mobility
- sensitive to percussion
- generally responds to pulp testing
- pulp blood supply is likely to recover
what is the treatment for concussion of a tooth?
- take baseline vitality tests and radiographs
- occlusal adjustment
- no immediate treatment is needed; let tooth “rest” (avoid bite) then follow up
___ is when a tooth has been injured and is loosened but not displaced
subluxation
what is the treatment for subluxation?
- take baseline vitality tests and radiographs
- occlusal adjustment
- splint for 1-2 weeks if mobile
what is the pulpal outcome of subluxation with closed vs open apices?
- pulpal necrosis rate of 6% with closed apices
- more favorable with open apices
___ is an injury that results in a tooth that is partially extruded from its socket
extrusive/lateral luxation
extrusive/lateral luxation is occasionally accompanied by ___
alveolar fracture
in lateral extrusion, usually the crown is displaced ___, and the root apex is displaced ___
palatally, labially
what is the treatment for extrusive/lateral luxation?
- radiographs
- reposition teeth
- physiologic splint
- endodontic treatment if necessary (or observe for revascularization for open apices)
what is the pulpal outcome for extrusive/lateral luxation for closed apices?
- extrusive luxation - 65% rate of pulpal necrosis
- lateral luxation - 80% rate of pulpal necrosis
___ is apical displacement of the tooth
intrusive luxation
what is the treatment for intrusive luxation for open vs closed apices?
- open apices - allow to reerupt
- closed apices - orthodontic reposition, surgical reposition, endodontic treatment
what is the pulpal outcome for intrusive luxation?
96% rate of pulpal necrosis
___ is the complete separation of a tooth from its alveolus by traumatic injury
avulsion (exarticulation; ellis class VI)
what is the preferred treatment for an avulsed tooth?
- reimplantation immediately if possible (improves PDL healing and prevents root resorption)
- if on-site reimplantation is not possible, extra-alveolar dry time must be considered
what is the success rate for reimplantation of an avulsed tooth when extra-alveolar dry time is less than 15 minutes? 30 minutes? more than 60 minutes?
- <15 minutes 90%
- 30 minutes 50%
- > 60 minutes <10%
what are the storage media options for a tooth that has been avulsed?
- optimal storage environment maintain and reconsistute metabolites (viaspan, hank’s balanced salt solution)
- wet just maintains viability (milk, saline, saliva [hypotonic - cell lysis], water [least desirable, hypotonic - cell lysis and inflammation])
what is the proper management in the dental office of an avulsed tooth with a closed apex with extraoral dry time <60 minutes and tooth stored in a special storage medium, milk, or saliva?
- do not handle the root surfaces and do not curette the socket
- remove coagulum from socket with saline and examine alveolar socket
- reimplant tooth slowly with slight digital pressure
- stabilize with semirigid (physiologic) splint for 7-10 days
- administer systemic antibiotic
- refer to physician to evaluate need for tetanus booster
what is a proper systemic antibiotic regimen for a patient with an avulsed toot that has been reimplanted?
penicillin QID for 7 days or doxycycline BID for 7 days at appropriate dose for patient age and weight
what is the proper management in the dental office of an avulsed tooth with a closed apex with extraoral dry time >60 minutes?
- remove debris and necrotic PDL
- remove coagulum from socket with saline and examine alveolar socket
- immerse tooth in a 2.4% sodium fluoride solution with pH of 5.5 for 5 minutes
- reimplant tooth slowly with slight digital pressure
- stabilize with a semirigid (physiologic) splint for 7-10 days
- administer systemic antibiotic
- refer to physician to evaluate need for tetanus booster
what is the proper management in the dental office of an avulsed tooth with an open apex and extraoral dry time <60 minutes with tooth stored in a special storage medium, milk, or saliva?
- if contaminated, clean the root surface and apical foramen with a stream of saline
- place the tooth in doxycycline (1mg/20ml saline)
- remove coagulum from socket with saline and examine alveolar socket
- reimplant tooth slowly with slight digital pressure
- stabilize with semirigie (physiologic) splint for 7-10 days
- administer systemic antibiotic
- refer to physician to evaluate need for tetanus booster
what is the proper management in the dental office of an avulsed tooth with an open apex and extraoral dry time >60 minutes?
reimplantation is usually not indicated
if a tooth is avulsed and is able to be reimplanted, when should endodontic treatment be performed?
7-10 days after reimplantation
what is the endodontic protocal for an avulsed tooth that had been reimplanted with extraoral time <60 minutes and a closed apex?
- endodontic treatment is initiated at 7-10 days
- if endodontic tx is delayed or signs of resorption are present, long-term calcium hydroxide treatment is given before RCT
what is the endodontic protocal for an avulsed tooth that had been reimplanted with extraoral time <60 minutes and an open apex?
- endodontic treatment should be avoided, and signs of revascularization should be checked
- at the first sign of an infected pulp, the apexification procedure is begun
what is the endodontic protocal for an avulsed tooth that had been reimplanted with extraoral time >60 minutes and a closed apex?
- same protocol as with dry time less than 60 minutes
- endodontic treatment is initiated at 7-10 days
- if endodontic tx is delayed or signs of resorption are present, long-term calcium hydroxide treatment is given before RCT
what is the endodontic protocal for an avulsed tooth that had been reimplanted with extraoral time <60 minutes and an open apex?
-if endodontic treatment was not performed out of the mouth, the apexification procedure is initiated
what are the 3 types of external resporption that result from attachment damage?
surface resorption, replacement resorption (ankylosis), and cervical resorption (extracanal invasion resorption, subepithelial external root resorption)
___ resorption is a transient phenomenon that is extremely common, self-limiting, and reversible
surface
in cases of surface resorption, as a result of ___ to the cementum surface, the root surface undergoes spontaneous destruction and repair. when does repair occur?
- mechanical damage
- repair occurs within 14 days; this is clinically significant
what is the cause of replacement resorption (ankylosis)? what % of reimplanted teeth does this occur in?
- PDL damage (nonviable PDL)
- occurs in 61% of reimplanted teeth
what is the radiographic evidence for replacement resorption (ankylosis)?
continuous replacement of lost root with bone, no radiolucency (loss of cementum, dentin, and PDL with ingrowth and fusion of bone to the root defect)
what is the clinical evidence for replacement resorption (ankylosis)?
- progressive submergence with growth (leading to infraocclusion)
- metallic sound on percussion
is replacement resorption (ankylosis) reversible?
no - dental treatment cannot stop the progression of ankylosis
what are the causes of cervical resorption (extracanal invasive resorption, subepithelial external root resorption)?
sulcular infection from either physical injuries (trauma, ortho, perio tx), chemical injuries (nonvital bleaching), or idiopathic
what is the radiographic evidence for cervical resorption?
- MD mimics the appearance of cervical caries adjacent to an infrabony defect
- BL shows a radiolucency over the well-defined outline of the canal
- ragged, asymmetric, and irregular “moth-eaten” appearance
most misdiagnoses of resorptive defects are made between what 3 diagnoses?
internal root resorption, cervical caries, and cervical resorption
what is the clinical evidence for cervical resorption?
- crestal bony defect associated with the lesion
- pink spot possible (owing to granulation tissue in the cerivcal dentin undermining the crown enamel)
- pulp vitality testing is WNL
the location of cervical resorption is at the ___ level of the tooth and usually begins at the ___
attachment, CEJ
what is the treatment for cervical resorption?
surgical removal of granulation tissue and repair with restoration
what are 3 causes of apical neurovascular supply damage?
- pulp canal obliteration (calcific metamorphosis)
- pulpal necrosis
- inflammatory resorption
___ makes up 27% of complications after luxation
pulp canal obliteration (calcific metamorphosis)
pulp canal obliteration (calcific metamorphosis) occus with increased likelihood with what 3 things?
immature teeth (open apices), intrusions, and severe crown fractures
what is the frequency of pulpal necrosis based on injury type (intrusion, extrusion, lateral luxation, subluxation, and concussion)
concussion 2% < subluxation 6% < extrusion 65% < lateral luxation 80% < intrusion 96%
what is the cause of inflammatory resorption?
pulp necrosis (bacteria and toxins enter dentinal tubules, pH is lowered, and inflammatory root resorption ensues)
what is the radiographic evidence of inflammatory resorption? how long after trauma does it present?
- bowl-shaped resorption involving cementum and dentin
- occurs 3 weeks after trauma
inflammatory resorption typically is located where?
at the apical third of the root, sometimes progresses to the entire root
inflammatory resorption and replacement root resorption are most commonly associated with ___ injuries
luxation
