Trauma 4 - long term follow up Flashcards
list possible complications of trauma to primary teeth
pulpal necrosis (most common)
pulpal obliteration
root resorption
damage to the successors
what are general signs of pulpal necrosis?
persistent grey colour that does not fade
what are radiographic signs of pulpal necrosis?
no reduction in size of pulp cavity
periapical inflammation
what are clinical signs of pulpal necrosis?
tenderness
sinus
suppuration
swelling
what treatment to do with a primary tooth with pulpal necrosis?
xLA if signs of infection
what gives a tooth with pulpal necrosis its grey colour?
blood going into the tubules of the tooth - haemorrhage
disruption of blood supply
what is a sinus tract a sign of?
infection
what is pulpal obliteration?
a condition characterized by the pronounced deposition of hard tissue along the internal walls of the root canal that fills most of the pulp system leaving it narrowed and restricted
what are clinical signs of pulpal obliteration?
yellow/ opaque colour
what are radiographic signs of pulpal obliteration?
pulp chamber shrinks
what treatment do you do for a tooth with pulpal obliteration?
nothing is asymptomatic
xLA if signs of infection
what are radiographic signs of root resorption?
root resorption
what are clinical signs of root resorption?
possible mobility
what treatment to do for a tooth with root resorption?
xLA if signs of infection
what are the ways in which a successor tooth can be damaged following trauma?
primary tooth trauma (12-68% incidence)
jaw fracture (19-69% incidence)
at what age is the most damage produced to successor tooth? and why?
3 years old
tooth germ is still in developmental stage
what type of injury carries the most risk to successor teeth?
intrusive luxation
damage to successor tooth can result in?
delayed eruption or failure of eruption
ectopic eruption
damage to successor teeth at the age of 2-7 years can cause what appearance?
white/ yellow-brown enamel hypomineralisation
white/ yellow-brown enamel hypomineralisation and circular enamel hypoplasia
damage to successor teeth at age of 2 years can cause what appearance?
crown dilaceration
damage to successor teeth at age 1-3 years can cause what appearance?
odontoma-like malformation
what affect does damage to the successor tooth at age 2-5 years have on the root?
root duplication
root dilaceration
what affect does damage to the successor tooth at the age of 5-7 to the root?
arrest of root formation - partial/complete
what is root dilaceration?
deviation of root shape from the normal long axis formation (change in angulation)
has the potential to inhibit eruption
how would you treat root dilaceration?
depends on its severity
tx planning may involve paediatric/ orthodontic and oral surgery input
or
surgical/ orthodontic realignment or possible xLA
how may root dilaceration lead to resorption?
roots could be rubbing against other roots
list complications of trauma to permanent teeth
pulp necrosis
resorption
ankylosis
replacement resorption
external resorption
internal resorption
what to look for clinically in a permanent tooth with pulpal necrosis?
no response to sensibility testing
greyish discolouration
patient symptoms
what to look for radiographically in a permanent tooth with pulpal necrosis?
periradicular inflammation/ infection
what does transient apical breakdown present as radiographically?
small radiolucent ‘cap’ around apex
what is transient apical breakdown?
in response to trauma, a repair process in the pulp and periapical area of teeth
tooth may be discoloured and no response to sensibility testing
resolves without treatment
questions you must ask yourself when deciding upon treatment of a permanent tooth with pulpal necrosis?
is there acute infection?
does the tooth have a closed apex?
how developed is the root?
what must you not do if you are starting RCT within 2 weeks of re-implanting an avulsed tooth? what should you do instead?
do not use calcium hydroxide as it may contribute to replacement resorption
use ledermix and start RCT with a splint in situ if present
why should you only place calcium hydroxide in a root canal for 4 weeks?
it degrades collagen structure, weakening flexural strength of dentine over time
how do you treat a tooth with pulpal necrosis that has an open apex?
create apical stop or encourage root to continue to develop (regenerative endodontic technique)
what can be used to create an apical stop?
MTA apical barrier formation
what is completed in visit one for treatment of a tooth with an open apex and pulpal necrosis?
extripate pulp with NaCl
establish working length
place calcium hydroxide
what is completed in visit 2 for treatment of a tooth with an open apex and pulpal necrosis?
ensure no signs of infection
irrigate with NaCl and citric acid
flush with H2O (prevents discolouration)
place MTA 4-6mm
what is completed in visit 3 for treatment of a tooth with open apex and pulpal necrosis?
complete obturation with thermoplastic GP
what depth of MTA should be dressed to create an apical plug?
4-6mm
why is calcium hydroxide not idea for apical barrier formation?
time consuming to get a result
changes composition/ structure of dentine; higher incidence of cervical root fracture
what is regenerative endodontic technique?
activating stem cells to recreate dental pulp
allows continues root growth
reactionary dentine forms in the root canal and pulp chamber, what does this look like radiographically?
pulp chamber and root canal shrinking
reactionary dentine forms in the root canal and pulp chamber, what does this look like clinically?
tooth may darken (yellowing)
reduced response to sensibility tests
reactionary dentine forms in the root canal and pulp chamber, how do you treat this?
monitor
can be very hard to access/ find canal
only treat if signs of infection
how may you treat a darkened tooth?
internal bleaching on RCT
veneer/ crown
why may reactionary dentine form in the root canal?
trauma triggers odontoblasts to lay down reactionary dentine
what does the process of reactionary dentine formation indicate?
tooth is still vital
what is pulp canal obliteration?
end point of root canal narrowing - whole canal becomes sclerosed
do you treat pulp canal obliteration?
no just monitor
pt must be aware that tooth may darken
however
if pulp gets restricted at apical portion it becomes necrotic - endo tx
what are types of tooth resorption?
external inflammatory resorption
cervical resorption
internal resorption
replacement resorption
what occurs as a result of replacement resorption?
ankylosis
what is inflammatory resorption caused by?
multi nuclear giant cells being stimulated and sustained
what teeth may external inflammatory resorption occur in?
necrotic pulps and associated infection associated by intrusions and re implantation (but may occur with all types of trauma)
describe the external inflammatory resorption process
initiated by PDL damage and propagated by necrotic pulpal products diffusing down the dentinal tubules into PDL
giant cells activated in PDL - stimulated by infected canal
what does external inflammatory resorption appear as?
‘punched out’ areas of resorption on external root surface
what happens if external inflammatory resorption is left untreated?
whole tooth destroyed within months
clinical signs of external inflammatory resorption
mobility
how to treat external inflammatory resorption?
if restorable, RCT and monitor
(pulp extripation and non setting CaOH until infection controlled then permanent root filling)
review radiographically
explain the process of cervical resorption
damage to cervical region
inflammation caused by PDL microflora or infected root canal
treatment for cervical resorption
necrotic pulp - start RCT
treatment may involve curettage of apical region and resorption defect
what causes internal inflammatory resorption?
chronic pulpal inflammation - very infrequent complication
explain the process of internal inflammatory resorption
root canal having necrotic, infected pulp above the ballooning
resorption caused by inflammatory response from vital pulpal tissue trying to clear away and revascularise the necrotic portion
infected necrotic pulp may cause activation of underlying vital tissue
progresses rapidly and causes perforation of root surface
what does internal inflammatory resorption present as clinically?
‘pink spot’
discolouration if the resorption affects coronal 1/3 of canal
what does internal inflammatory resorption present as radiographically?
round, symmetrical radiolucency usually centered on canal
canal walls are NOT superimposed (unlike external resorption)
how do you manage internal inflammatory resorption?
endodontic tx - dress with CaOH
what is ankylosis?
fusion of the root and surrounding bone
what is replacement resorption?
root structure is removed and replaced by investing bone tissue - there is no infection and no inflammation
what is the main difference between inflammatory resorptions and replacement resorption?
there is no infection and inflammation in replacement resorption
when does replacement resorption occur?
after large luxation or avulsion injuries
what type of luxation injuries are at higher risk of replacement resorption?
intrusive and lateral resorption
why does replacement resorption occur?
when more than 20% of the PDL is damaged before replanting or repositioning, bone cells are able to colonise root surface faster than PDL
what is the long term complication of replacement resorption?
crown falls out - bone turnover is slow so dentine replaces bone, after few years there will be no root and crown will fall out, tooth then integrated into bone and remodelled in the normal bone remodelling process
signs of replacement resorption and ankylosis?
no mobility, solid
metallic tone on percussion
no distinct dermarcation between bone and tooth radiographically
replacement resorption and ankylosis treatment
if pt has fully grown, can monitor
in growing patients, tooth may be infraoccluded, inhibiting alveolar growth
if gingival margin discrepancy exceeds 1-2m, may have to decoronate tooth below bone level and remove any root filling material to promote alveolar growth
list 9 tests for tooth vitality
colour
EPT
thermal test
transillumination
TTP
mobility
sinus/ alveolar tenderness
history
radiographic exam
what determines pulp vitality?
presence of an intact blood supply - NOT an intact nerve supply
what is mobility pathognomic of?
periapical infection
what classification is used to assess mobility?
Miller classification
what may TTP indicate?
apical periodontitis
what investigation is useful for detecting craze lines?
transillumination
if available, fibre optic transillumination
what does EPT test?
pulpal sensory nerve supply - not true pulp vitality
how common is pulp necrosis as a result of root fractures?
20%
how to treat root fractures?
apical 1/3 and mis 1/3 root fracture - treat up to point of fracture
MTA at fracture line
if apical portion becomes non vital, surgical removal
coronal 1/3 root fracture - splinting coronal segment, xLA coronal and apical portion, xLA coronal portion
