Trauma of Young Permanent Teeth

Question 1

What are the 3 main principles of luxation injury management?

Answer 1

1. Reduction
   - Reposition teeth and tissues to their original position
2. Fixation – via splinting
3. Endodontic monitoring
   - Pulpal status
   - Periodontal healing/non-healing

Question 2

What are the aims of fixation?

Answer 2

Aims to stabilise and maintain teeth position to
- Optimise healing outcomes for pulp and PDL
- Improve function and provide comfort

Question 3

What must be done before splinting and after repositioning?

Answer 3

Post-positioning x-ray to verify position

Question 4

What must be taken note of when suturing gingiva as part of the reduction step?

Answer 4

Gingiva must be sutured back in correct position if not there will be tissue healing by secondary intention => ugly

Question 5

How long are permanent teeth splinted for and what are the recommended follow up timingss?

Answer 5

Splint for 4 weeks

Follow up intervals (post-trauma)
- 2 weeks
- 4 weeks (remove splint)
- 8 weeks
- 12 weeks
- 6 months
- 1 year
- yearly for at least 5 years

Question 6

Describe the process of splinting

Answer 6

After post-positioning x-ray
- Bend wire to sit passively on teeth
- Attach flexible wire splint to teeth with CR

Question 7

For lateral luxation injury, what is the recommended definitive treatment?

Answer 7

• For teeth with complete root formation, pulp will likely become necrotic.
• At 2 week post injury, should commence RCT.
• Remove pulp and place corticosteroid-AB or Ca(OH)2 as intracanal medicament – prevent inflammatory external resorption
• Complete obturation at 4 week post injury recall (remove splint after obturation completed)

Question 8

What are possible sequelae of trauma in permanent dentition?

Answer 8

1. Loss of vitality
2. Internal/external root resorption
3. Pulpal calcification/obliteration
4. Ankylosis/replacement resorption

Question 9

Rank the types of traumatic injuries by their chance of pulp necrosis

Answer 9

1. Intrusion
2. Lateral luxation/Extrusion
3. Concussion/Subluxation

Question 10

What is the pathogenesis of inflammatory resorption?

Answer 10

Occurs due to pulp necrosis:
- Stimulus from infected pulp space will transverse the root and sustain inflammation around the root
- Inflammatory resorption will continue til the whole root is resorbed

Question 11

Why is there a need for endodontic monitoring post-trauma?

Answer 11

• Protective layer of pre-cementum is damaged during trauma
• Inflammation due to injury occurs which can cause 3 kinds of resorption
  1. Inflammatory resorption
  2. Surface resorption
  3. Replacement resorption

Question 12

What is the pathogenesis of surface resorption?

Answer 12

Occurs when PDL cells are still viable
- Cementum healing can occur – only surface resorption

Question 13

What is the pathogenesis of replacement resorption?

Answer 13

Occurs when large surface of PDL has been damaged
- Replacement resorption will take over inflammatory resorption (bone fills space) => ankylosis
- Occurs in severe injuries: intrusion, avulsion, lateral luxation

Question 14

What may be a presentation of ankylosis?

Answer 14

Ankylosed tooth is infraoccluded – adjacent teeth have grown with alveolus

Question 15

What should be noted about teeth with pulp canal obliteration?

Answer 15

pulp canal obliteration => slender neurovascular bundle => ortho movement will ↑ risk of tooth becoming non-vital

Question 16

What should be included in a diagnosis of root fracture?

Answer 16

• Single/multiple
• Horizontal/vertical
• Level: apical/middle/coronal ⅓
• Degree of separation between fragments (radiographically)

Question 17

What is the treatment for root fracture?

Answer 17

1. Reduce fracture & splint
2. Pulp protection: Cvek pulpotomy (1-2mm) then
   - Ca(OH)2
   - MTA (causes discolouration)
   - Biodentine
3. Seal off access cavity with CR
4. 4 week review: splint removal &
   restore aesthetics
   - If fracture is located cervically, stabilisation for a longer period of time (up to 4 months) may be needed

Question 18

What are the possible healing outcomes for root fractures?

Answer 18

• Hard tissue union
• Interposition of CT
• Interposition of bone & CT
• Granulation tissue (coronal pulp necrosis)
  => worst outcome – appears as RL at fracture radiographically

Question 19

Describe transient apical breakdown

Answer 19

• Occurs after luxation injuries
• Injured tissues undergo spontaneous repair in pulp & periapical area
• Followed by surface resorption &/or obliteration of pulp canal
• No permanent damage to pulp

Question 20

How do teeth with transient apical breakdown present?

Answer 20

• PARL
• No response to vitality tests
• Grey discoloration
• No other symptoms

Question 21

What is the treatment for intrusion injuries for permanent teeth with complete root formation?

Answer 21

If tooth intruded <3mm: allow re-eruption without intervention
If no re-eruption within 8 weeks
- Reposition surgically and splint for 4 weeks
- Reposition orthodontically before ankylosis develops

If tooth intruded 3mm or more: reposition surgically

Pulp will almost always become necrotic – pulpect should be done at 2 weeks