1. Lecture 9, Traumatic Injuries, Cracked Teeth and vertical root fractures (VRF)
Ch1 (24-32), Ch16( )

2. Abbreviation guide FX=fracture PN=pulp necrosis
B4=before or prior to..
TX=treatment
VPT=vital pulp therapy
VIP=very important

3. Outline: I. Crown Fracture 2. Crown-root fractures
3. Vertical/Horizontal Root Fracture
4. Luxation
5. Avulsion
6. Resorption
7. Prevention

4. Fact Most dental trauma occurs in 7_10 age range
And most trauma occurs in the anterior region of the mouth, maxilla>mandible

5. 1. Crown FX without Pulp exposure
NO PROBLEM,
RELAX AND RESTORE

6. Complicated Crown FX with Pulp Exposure=VPT
@80% IF
w/in 24hrs
Partial
Full
OR:
EXTIRPATION if root is fully formed
Pulp Cap?

7. 2. Crown-Root Fracture sometimes fractures at an angle
Angular Fracture: Is this restorable?

8. Remember,
In all trauma, the primary purpose of our treatment is to keep the pulp vital, if at all possible, ESPECIALLY if apex is open
WHY?

9. Pulpotomy – Immature Apex If Vital = “Apexogenesis”*

10. Apexogenesis vs Apexification Dealing with the immature root
(Vital Pulp) best to treat w pulpotomy. The idea is to allow the vital pulp to remain vital and complete the development of the root apex
as well as thickening of the RC walls
RCT maybe needed later BUT not if tooth remains symptomatic AND vital
Apexification
(Necrotic Pulp) Hoping to get closure of the apex (& there is NO wall thickening) to be able to later do a proper RC seal via obturation. CaOH + time is proper tx over 3-18mo
RCT ALWAYS NEEDED HERE* and is less predictable due to thinner walls
Object of either treatment is to allow for roofing over of apex and allow RCT to be done at a later date.

11. And now, Regeneration?
Revascularization of immature permanent teeth utilizing a mixture of antibiotics, creating a blood clot w/in the RCS which produces development of the tooth structure
Banchs F, Trope M
“Revascularization of immature permanent
teeth w PN & apical periodontitis….
JOE, 196; 2004

12. Vertical FX of Crown>Root @ 3% of all dental injuries
Generally if crack extends to the pulpal floor (molar), the tooth will be lost
Most commonly cracked tooth – Distal of Mandibular second molar –
– May need to STAIN crown to see crack
WHY?
Look for “Drop-Off” Pocket at base of Crack site

13. Insert occlusal view of MMR/DMR fracture to supplement previous slide
Because, endo/perio lesion can mimic VRF radiogragraph

14. If untreated, a crack will widen into a split

15. 3. Vertical Root Fracture
Look for ‘J’-Shaped apical lesion
Look for Drop-off Pocket if
VRF difficult to confirm radiographically –UNLESS separation of segments occurs

16. Other methods of discovering VERTICAL ROOT FRACTURE A surgical exploration is usually the only other way to confirm presence of VRF*
Transillumination
Restoration Removal + Staining

19. Horizontal Root Fracture
Tends to be Readily apparent – especially after separation
XS Mobility a good clue
Is this salvageable?
Prognosis is very poor

20. Root FX (Horizontal)
What do you do here? Try to reposition and splint 2-4 wks, check for vitality q 30 days

21. 4. Luxation Injuries (MOST COMMON OF ALL DENTAL INJURIES) 30-44% text p630
Concussion
Subluxation
Extrusion
Lateral
Intrusive
WORST CASE SEQUELAE?
PULP NECROSIS
EXTERNAL/INTERNAL
ROOT RESORPTION
Possible tooth loss
AVULSION

22. Concussion Luxation Injury
Least severe of Luxation injuries
No displacement of tooth nor excessive mobility
Tooth tender to touch “Bruised PDL”
No radiographic abnormalities
VIP!!! Assess vitality in 4 wks

23. Subluxation Luxation Injury
Tooth tender to touch & slightly mobile (1+) but not displaced
Possible hemorrhage from gingival crevice
No radiographic abnormalities
Damage to supporting structures?
VIP!!! Assess vitality in 4 weeks

24. Extrusion Luxation Injury
Elongated mobile tooth
Cl. II mobility or greater
Radiographs show increased apical periodontal space
Manually reposition
Reposition tooth + Flexible splint MANDATORY 7-10 days ?
VIP!!! Assess vitality in 4 weeks

25. What is a flexible splint?
-Allows physiologic movement of the teeth in order to minimize ankylosis
-In the past, .028 gauge ortho wire bonded to tooth for 7-10 days unless alveolar FX had occurred. Then 4-8 wks
OR: 4-6# fishing line bonded to teeth
-Currently, titanium trauma splint (TTS) is recommended see p643, text

26. Semi-rigid or flexible splinting
Experimental studies in non-human primates have demonstrated that rigid splinting ,especially for prolonged periods, leads to ankylosis &/or external resorption.
Maintaining a slight degree of tooth mobility appears to be beneficial to PDL healing
Von Arx T, etal Splinting of Traumatized teeth with a new device:TTS; Dent Traumatol 2001;17:180-84

27. Titanium Trauma Splint
Medaris AG, Basel Switzerland

29. TTS splint Insert picture of same
Splinting of traumatized teeth with a new device:TTS (Titanium Trauma Splint)
Medartis AG, Basel, Switzerland
Von arx T, etal Dent Traumatol, ’01;17:180-84

30. Lateral Luxation Injury
Displaced laterally & often locked in bone
Not tender to touch, not mobile
Alveolus fractured
Percussion test: high metallic sound (ankylosis)
Increased PDL space best seen on eccentric or occlusal radiographs
Anesthetize & reposition
+ Flexible splint MANDATORY 4-8 weeks
VIP!!! Assess vitality in 4 weeks

31. Intrusion Luxation Injury External root resorption likely
Most severe of luxations***
Tooth appears shorter: displaced into alveolar bone
PDL destruction/alveolar crushing) Beware of ankylosis/resorption/
pulp necrosis is all but certain in mature teeth***
Not tender to touch, not mobile
Percussion test: high metallic sound
Radiographs not always conclusive
Slightly luxate with forceps or band and move orthodontically.
Splinting is not usually necessary
Tooth with open apex may spontaneously re-erupt.

32. Treatment of intrusion luxation
Closed apex needs ortho. or surgical repositioning and probable RCT in 1-3 weeks
In all LUXATION and especially INTRUSION injuries, the apical neurovascular bundle and attachment apparatus will be affected to some degree>>>loss of vitality & internal/external resorption

33. 5. Avulsion Tooth is knocked completely out of mouth
Viability of the PDL must be preserved for success
Extra-oral dry time is CRITICAL 30-60”***
Must be replaced in socket ASAP (15-20”) (text p641) in order to..
Prevent ankylosis
Prevent external root resorption
To replant or not? should be “decent tooth”: No point in replanting THIS one

34. Replant?
TX is aimed at minimizing the inflammation from the two main consequences of avulsion, namely; attachment damage and pulpal infection that inevitably results
The SINGLE most VIP factor in achieving a favorable outcome is the SPEED at which a clean tooth is properly replanted
Keeping the attached PDL moist is VIP!!*

35. Replantation guidelines
HOW FAST IS FAST? 5”, 30” 60”, TAKE YOUR PICK, it depends on whose book you read!
If tooth is out of the mouth less than 15-20”, replant according to guidelines
If tooth was out and placed in cold milk or other physiological solution w/in 15-20” & available for replantation w/in 30”, replant and follow guidelines
If tooth is out > 60” and not stored, there is usually one outcome: resorption and probable loss
If the pt is pre adolescent, the tooth may become infraoccluded (ankylosed) as he/she grows older

36. To replant or not (cont)
If the root of the avulsed tooth is not completely formed, the prognosis for survival and revascularization is possible if not left out>60”
If root is incompletely formed and replantation is rapid, vitality may be maintained but is not predictable
Kenny DH etal; Medicolegal aspects of replanting permanent teeth. J Can Dent Assoc 71:245-48, 2005

37. First Aid Instructions
Handle by crown only
Pick off debris with tweezers
Replant tooth if possible
_________________________________
If not, transport in appropriate medium:
“Save-a-tooth” (Hank’s Balanced Salt solution)
OR “Via Span” (if available)
OR milk if above not available
OR place in vestibule (saliva) & Report to dental office ASAP

38. Once in Dental office:
Take films to make sure there is no alveolar FX & that adjacent teeth are OK
“Save-a-tooth” (Hank’s Balanced Salt solution)
OR “Via Span”, milk, saline
Gently clean socket
Replant and check occlusion
Splint
RX antibiotics

39. Avulsion Injury What NOT to do!
Do Not
Handle by root
Scrub root
Allow tooth to dry
Submerge the tooth in water (tap water is hypotonic> and will cause cell rupture)
AAE has a Flow Chart Outlining Current Treatment Management Protocols of both Luxation and Avulsion cases ..www. aae.org.

40. If over 60” “dry time” Remove remnants ofPDL by soaking in acid for 1”
Soak in Stannous Fl for 5”
No harm done to go ahead and complete endo ASAP
Splint
Pray

41. Immature Tooth: Open Apex, revascularization is possible if out less than 30-60”
Replant as above EXCEPT different
Soak tooth in Doxycycline (1mg/20cc saline)<replantation for 5” text,p642
Monitor pulp vitality closely (q 30 d or until root development is confirmed)
Vital Open apex will NOT necessarily require RCT UNLESS pulp becomes necrotic.
What if it does? Do we do apexogenesis then?

42. Case History
16 yr., African-American male presents with avulsed teeth and deep puncture wound or lip
# 7 and # 8 intact
30 minutes post assault (60 minutes=critical)
Patient is lucid, responsive, with no apparent neurological impairment
Medical history non-contributory

43. Ankylosis A problem following trauma and long term rigid splinting
Tooth is solidly fixed and has a high metallic ring when percussing. Does not erupt with other teeth
May lead to massive external resorption & loss of tooth
Internal= appearance of “aneurysm” w/in canal.

44. Complications with Replanted avulsed teeth & Possibly with Rigid Long-Term Splinting
Ankylosis (Replacement Resorption)

45. 7. Plug for Prevention
Mouth guards***
Many of the injuries we discussed could be prevented through the aggressive promotion and use of mouth guards.
Every child should wear one for most active play.
Every adult involved in sports should wear one.
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