Sequela trauma Flashcards
Discuss the complications which may arise from trauma to the permanent teeth
Loss of vitality
Periapical inflammation
Arrest of root development
Root resorption
Inflammatory (external/internal)
Replacement
Pulp canal obliteration
Loss of vitality clinically
History
(symptoms of irreversible pulpitis)
Sulcus-swelling, tenderness, sinus
Discoloured – often progressively grey
TTP
Mobile
Negative to sensibility tests
Majority are –ve immed after trauma
Most will respond within 3 months
Loss of vitality radiographically
Periapical radiolucency
Resorption (Int/ Ext)
Arrested root development
Loss of vitality treatment
Endodontic therapy
(At least 2 clinical signs before commencing RCT)
Periapical inflammation
Transient apical breakdown
Transient apical breakdown
> 4% of mature teeth following luxation injuries
Mimics apical resorption
Ambivalent clinical + radiographic signs - delay endodontic treatment
Monitor closely
May be present up to 2-3 months after trauma
Arrest of root development happens when
If necrosis affects root sheath before root development complete then no further growth
Arrest of root development- radiographically
majority- failure of pulp canal to mature and reduce in size
If sequential radiographs not available compare to root development of contra lateral tooth
Root resorption
Types
Inflammatory (surface/external/internal/cervical)
Replacement resorption (ankylosis)
Root resorption- external inflammatory -aetiology
non vital pulp
Mainly seen with avulsion and intrusion injuries (possible with lateral luxation, extrusion and subluxation)
Initiated by PDL damage and propagated by necrotic pulp/ pdl
Root resorption- external inflammatory- radiographically
Punched out areas of resorption
Loss of root surface, loss of adjacent bone, radiolucent area
Pdl expansion
May be evident from 3 weeks
Root resorption- external inflammatory- treatment-
Extirpation, debridement, non-setting Calcium hydroxide
Root resorption- internal inflammatory-Aetiology
– chronic pulpal inflammation
Internal root resorption radiographically
Ballooning of walls of root canal
Root resorption- internal inflammatory- progression –
rapid, may cause perforation of root surface
Root resorption- internal inflammatory- treatment-
extirpation, debridement,
Non-setting Calcium Hydroxide dressing
Cervical resorption
Damage to root surface in cervical region
Propagated by necrotic pulp or perio disease
Pink spot
Cervical resorption- treatment
Curette defect and
restore +/-RCT
Root resorption -Replacement (Ankylosis)- Aetiology –
– extensive damage to PDL and cementum (Intrusion/avulsion)
Results in bony union between alveolar socket and root surface
Root resorption -Replacement (Ankylosis)- radiographically
Loss of periodontal space, bone in direct contact with root
Usually evident within 2 mths -1 yr
Root resorption -Replacement (Ankylosis)- clinically
detected by distinctive high “metallic” note
Root resorption -Replacement (Ankylosis)-treatment
– No effective treatment
Extraction/root burial
Cannot be moved orthodontically
Replacement resorption- See px when?
6 weeks post injury, 18 months, 32 months,
Replacement resorption- radiographically
difference in incisal levels
Pulp canal obliteration is the…
Progressive hard tissue formation within pulp cavity – narrowing of root canal
Thin thread of pulp tissue remains
More common in immature teeth and following luxation injuries
Pulp canal obliteration clinically-
Opaque/ yellow crown
Reduced response to vitality testing
Pulp canal obliteration- treatment-
Conservative approach
Trauma follow up
Varies by injury in guidelines
See IADT guidelines (essential reading)
May increase if equivocal findings
Dental trauma review
Date and time
Trauma Colour
Grey/brown- pulp necrosis
Yellow- pulp canal obliteration
Pink- internal resorption, bleed into dentine
Trauma soft tissues clinically is shown by
Swelling
Tenderness
Erythema
Sinus
Trauma review mobility
Assess between 2 ends of metal instrument
One labial, one palatal
Vertical
TTP/tone
Check TTP with metal instrument
Vertical
Tone
Hi
Replacement resorption
intrusion
Cracked cup
root fracture
Trauma review Ethyl chloride
Cotton wool held in tweezers applied to centre of labial surface of tooth (Avoid gingivae)
Newly erupted teeth may not respond
May need repetitions for reliability in children
After injury up to 3/12 for response
Trauma review electric pulp tester
Isolate teeth with cotton wool
Lip electrode applied
Tip dipped in toothpaste
Raise hand on first sensation
Avoid any restorations
Trauma review tests
ethyl chloride and electric pulp tester
Uncomplicated crown fracture
Fractures confined to enamel and dentine
Uncomplicated crown fracture prognosis
Pulp necrosis 54% if no dentinal coverage
8% if dentine protected
Complicated crown fracture
Tx
Apexogenesis procedure - Vital/Cvek pulpotomy
Complicated crown fracture prognosis
Success rates 80 – 96%
Better prognosis than direct pulp cap for immature permanent teeth exposed>24 hrs
5 year pulp survival and outcomes after intrusion
see tables
Root fractures-
Healing influenced by-
Position of fracture line
Degree of displacement of coronal fragment
Necrosis of pulp usually only coronal fragment and coronal to #line
Coronal fracture
Healing outcomes root fractures
Hard tissue formation
Fibrous
Bone and connective tissue
Non-union-inflammatory/granulation
Necrosis of coronal portion
Survival of a tooth with a fracture
Prognosis improves as distance from gingival margin increases
Avulsion Outcomes what is important and what is not
Extra – oral time is critical
Storage medium important
PDL survival is critical- resorption at 1year best predictor of survival
Pulp death is less important
Avulsion Outcomes- what affects prognosis
Dry storage - decreases prognosis
Contamination – decreases prognosis
Prolonged splint time increases replacement resorption
Informed consent -Severe injuries – intrusions/avulsions
At least 8 – 12 visits
Time off school / parents work
Cost to NHS
Unpredictable outcome
Consider treatment options carefully
Parents must be fully informed regarding nature of injuries, treatment, sequelae and long term prognosis
Complications of
primary teeth
Pulpal necrosis – commonest complication
Root resorption
Pulpal canal obliteration
Replacement resorption
Pulpal necrosis in the primary dentition- clinically
Grey colour/ sulcus/ history/ mobile/ TTP
Transient - intrapulpal bleed,
vital tooth, colour resolves
persists, implies non vital (but may be uninfected)
Pulpal necrosis in the primary dentition- radiographically
Failure of pulp cavity to reduce
Periapical area
Pulpal necrosis in the primary dentition-
treatment
Extraction recommended
Endodontic treatment occasionally- specialist
Options discussed with parent
Informed consent
Pulp Canal Obliteration in primary dentition- Clinically
yellow / opaque crown
Pulp Canal Obliteration in primary dentition-Radiography
Pulp canal narrowing
Pulp Canal Obliteration in primary dentition
Treatment
Usually exfoliates
If periapical inflammation - recommend extraction
Discuss with parents – informed consent
Replacement resorption- ankylosis - Clinically
Below occlusal level
Ensure no non-nutritive sucking
Replacement resorption- ankylosis -Radiographs are taken to…
Confirm presence of replacement resorption
Assess position of permanent tooth
Replacement resorption- ankylosis
Treatment
Monitor - may resorb
Extraction
If pathology, delayed eruption, displacement
Injuries to developing dentition following trauma to primary teeth
studies…
Studies suggest 12 – 69% of primary trauma affect successor
Depends on type and severity of injury, high with intrusions
Most damage occurs before 3 yrs of age during its developmental stage
Injuries to developing dentition following trauma to primary teeth
see all the photos of the labelled teeth
Hypomin/ hypoplasia of enamel
Crown / root dilaceration
Odontoma – like formation
Root duplication
Arrest of root development
Disturbance in eruption
Sequestration of tooth germ
Injuries to developing dentition following trauma to primary teeth
Avulsion
Subluxation
Lateral luxation
Intrusion
Alveolar/jaw fracture
Periapical pathology
Follow up-
Injuries to developing dentition following trauma to primary teeth-
Avulsion
Subluxation
Lateral luxation
Intrusion
Alveolar/jaw fracture
Periapical pathology
Monitor eruption pattern - delayed, ectopic
Advice to parents
