Permanent Tooth Trauma Flashcards
What is root dilaceration?
Deviation of root shape from the normal long axis formation
What are the radiographic signs of root dilaceration?
Signs of root malformation/change in angulation (however this is not always evident depending on orientation of radiographic image)
What is the main clinical signs of root dilaceration?
Delayed eruption/ failure to erupt
What are the treatment options for a tooth with root dilaceration?
Either:
1. Surgical/orthodontic realignment
2. Extraction
3. Do nothing (sometimes this is the least traumatic option if the tooth is asymptomatic and not causing issues)
What complications can arise in permanent teeth from trauma? (List 5)
- Pulp necrosis
- Resorption (internal, external and replacement)
- Ankylosis
- Discolouration
- Root fracture
What are the 6 S’s that indicate pulpal necrosis?
Shade
Sinus tract
Suppuration
Swelling
Symptoms
Spacing on radiographic apex
What are the three main signs of healthy root development?
- Apex closing
- Narrowing of root canal
- Absence of pathology
Why is it inappropriate to use calcium hydroxide as a dressing for RCT within 2 weeks of re-implanting an avulsed tooth?
This may contribute to replacement resorption as calcium hydroxide degrades collagen structure, weakening flexural strength of dentine over time.
To carry out an apexification on an immature permanent tooth, what is involved in “visit one”?
- Access canal
- Place rubber dam
- Extripate the pulp with NaCl as irrigant
- Establish definitive working length
- Place calcium hydroxide
To carry out an apexification on an immature permanent tooth, what is involved in “visit two”?
If no signs of infection;
1. Place rubber dam
2. Access canal
3. Use microscope to visualise canal to apical foramen
4. Irrigate with NaCl and citric acid
5. Final flush with sterile water to prevent discolouration
6. Dry canal
7. Place MTA as apical barrier (4-6mm)
To carry out an apexification on an immature permanent tooth, what is involved in “visit three”?
Complete obturation with thermoplastic GP
What is pulp canal obliteration?
Where the root canal becomes completely sclerosed due to reactionary dentine formation as a result of trauma.
What are clinical signs of pulp canal obliteration?
Yellow discolouring of crown of tooth
What are 4 types of inflammatory root resorption?
- External inflammatory resorption
- Cervical resorption
- Internal resorption
- Replacement resorption
How would you treat inflammatory resorption?
Pulp extripation
What causes inflammatory resorption?
Multi nuclear giant cells that are stimulated as part of the inflammatory response. Sustained stimulation causes these cells to resorb tooth structure.
What initiates external inflammatory resorption?
Damage to PDL and propagated by infected necrotic pulpal products diffusing down the dentinal tubules into PDL.
What is the radiographic sign of external inflammatory root resorption?
Change in external contour of tooth
What can be a clinical sign of excessive external inflammatory root resorption?
Mobility
What is the treatment for external inflammatory root resorption?
Commence RCT and monitor.
What causes internal inflammatory resorption?
Chronic pulpal inflammation. Resorption is caused by the inflammatory response from the vital pulpal tissue trying to clear away and revascularising the necrotic portion.
How do you treat internal inflammatory resorption?
RCT
What is ankylosis?
Fusion of the root to the surrounding bone
What is replacement resorption?
The process by which the root structure is removed and replaced by investing bone tissue
How does replacement resorption differ from inflammatory resorptions?
There is no infection and inflammation
What type of trauma injuries usually cause replacement resorption which can lead to ankylosis?
Large luxation or avulsion injuries
What are clinical signs of replacement resorption and ankylosis?
- Will appear solid, no natural mobility.
- Characteristic metallic tone on percussion
What are radiographic signs of replacement resorption and ankylosis?
There will be no distinct demarcation between the bone and tooth radiographically (absence of PDL)
What are the 9 tests commonly used in dentistry to test for tooth vitality?
- Colour
- EPT
- Thermal
- Transillumination
- TTP
- Mobility
- Sinus/alveolar tenderness
- History
- Radiographic assessment
What does mobility in an axial direction (up and down or side to side) indicate?
Periapical pathology
In what % of root fractures does pulpal necrosis occur?
20%
How would you treat apical fractures up (apical 1/3 and mid 1/3)?
RCT up to the point of fracture and no further. MTA apical stop may be required.
How would you treat a coronal 1/3 fracture?
Options:
1. Splinting coronal segment
2. Extracting the coronal and apical portion
3. Extracting coronal portion
What are the 5 most likely causes of tooth discolouration following trauma?
- Pulp necrosis
- Discolouration following RCT
- Localised discolouration of permanent tooth following primary tooth trauma
- Discolouration of restoration following trauma treatment
- Pulp canal obliteration
By UK law, can you bleach discoloured teeth under the age of 18?
No, patient must be 18 years of age or older.
What treatment should be provided for a tooth that is discoloured due to necrotic pulp?
Commence RCT to minimise the chance of infection/resorption. (This may or may not solve discolouration, but is essential to preserve the tooth)
Why would discolouration following RCT occur? (Give 4 reasons)
- The pulp ad not been fully removed from the coronal aspect
- Blood has leached into dentinal tubules
- Gutta percha has not been adequately reduced in the pulp chamber so is showing through
- Dark material (e.g. fuji pink) has been used to seal access cavity
How would you treat discolouration due to RCT, where the pulp hasn’t been fully removed from the coronal aspect?
Open the access cavity and clean out remnants (being careful not to remove excessive tooth structure)
How would you treat discolouration due to RCT, where blood has leached into dentinal tubules?
Internal bleaching
How would you treat discolouration due to RCT, where the gutta percha hasn’t been adequately reduced in he pulp chamber, so is showing through?
Carefully open access cavity and reduce gutta percha to the level of the CEJ.
How would you treat discolouration due to RCT, where dark material has been used to seal the access cavity?
Replace with a more aesthetic material
How can we undertake a composite addition?
- freehand
- Crown form
- Wax up and matrix (extensive cases)
- Lab made composite
What appliances can be used as a space retainer if we wish to maintain space where there is a lost tooth?
Either a removable appliance or a resin-retained bridge
What are the 5 treatment options available for management of a discoloured tooth?
- Accept
- Free hand composite veneer
- Lab processed porcelain veneer
- Crown
- Combined with existing endodontic treatment:, non-vital bleaching if over 18 years old
What are the 5 available management options of a fractured tooth?
- Composite resin restoration or veneer
- Crown (>18’s)
- Post, core and crown (>18’s)
- Crown lengthening (as an adjunct to one of the options above)
- Orthodontic extrusion for future post, core crown restoration.
What are the two options available for management of a missing tooth?
- Maintain the space
- Allow space to close
What technique is normally used to manage a traumatised tooth that has an enamel/dentine/pulp fracture?
A vital pulpotomy
What medicaments can be used to treat the healthy pulp tissue after partial pulpotomy?
Non-setting calcium hydroxide or non-staining calcium silicate (MTA).
What are the two main objectives of a partial pulpotomy?
- Maintain tooth vitality
- Allow root development to continue
How can you arrest bleeding of a healthy pulp? (2 options)
- Use cotton wool pledger soaked in sterile saline
- Use adrenaline free LA
How does calcium hydroxide treat the pulp?
- Promotes calcification repair
- Has antibacterial properties
What is a “composite bandage”?
A temporary dressing placed on a tooth immediately after an enamel dentine fracture or enamel dentine pulp fracture that has undergone pulpotomy
What are the 9 tests, in a trauma table, that should be carried out to test vitality of a tooth?
- Colour
- EPT
- Cold test
- Transillumination
- TTP
- Mobility
- Sinus
- alveolar tenderness
- Radiographic examination
Why would a tooth initially look pink in colour?
This could be cervical resorption
