2. Traumatic Injuries, Cracked Teeth and vertical root fractures (VRF)

3. Fact Most dental trauma occurs in 7_12 age range
And most trauma occurs in the anterior region of the mouth, maxilla>mandible

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

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

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

7. 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?

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

9. 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 asymptomatic 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.

10. And now, Regeneration?
Revascularization of immature permanent teeth utilizing a mixture of antibiotics(3 weeks), creating a blood clot w/in the RCS which produces development of the tooth structure

11. 3.Horizontal Root Fracture

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

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

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

15. 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?
Assess vitality in 4 weeks

16. Extrusion Luxation Injury
Elongated mobile tooth
Cl. II mobility or greater
Radiographs show increased apical periodontal space
Manually reposition
Reposition tooth + Flexible splint (2 weeks)
Assess vitality in 4 weeks

17. 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

18. 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

19. Titanium Trauma Splint
Medaris AG, Basel Switzerland

21. 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

22. 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 (4 weeks)
Assess vitality in 4 weeks

23. 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 (>4 weeks)
Tooth with open apex may spontaneously re-erupt.

24. 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

25. 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”) in order to..
Prevent ankylosis
Prevent external root resorption
To replant or not? should be “decent tooth”: No point in replanting THIS one

26. 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!!*

27. 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

28. To replant or not
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

29. First Aid Instructions
Handle by crown only
Pick off debris with tweezers
Replant tooth if possible
_________________________________
If not, transport in appropriate medium:
“HBSS (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

30. 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 (7-10 days)
RX antibiotics

31. 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.

32. 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

33. 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”
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?

34. 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.

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

36. 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

37. 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

40. Flare-ups

41. Flare-ups
A flare-up is an acute exacerbation of an asymptomatic pulp/or periapical pathosis after the initiation or continuation of root canal treatment.

42. Patient Presentation
Pain
Pain and swelling

43. Factors Mechanical Immunological Psychological state chemical
Emotional state
Gender
Microbial
Immunological
Psychological state
Regulation of periapical inflammation

44. Incidence
1.4 to 19%
20 to 40%

45. Age of Patient?
There is a lack of agreement concerning the influence of age on the incidence of flare-up.
40_59 year(most)
Under the age of 20(least)

46. Gender and Flare-ups
Women(most)

47. Systemic conditions
Host resistance
Allergy

48. Anatomic Location
Mandibular teeth
premolars

49. Anxiety

50. Preoperative History of the Tooth

51. Number of Treatment Visits

52. Causes of Inter-Appointment Pain
Mechanical
Chemical
Microbial injury

53. Re-Treatment Cases
13.6% flare-up

54. Strategies to Prevent Flare-ups
Anxiety Reduction
Behavioral Intervention
Occlusal Reduction

55. Pharmacologic Strategies for Flare-up
Antibiotic
NSAIDs and Acetaminophen
Long-acting Local Anesthetics

56. Patient Instructions
By the Clock
NOT
PRN

57. Indications for Antibiotic Therapy Systemic involvement
Compromised host resistance
Fascial space involvement

58. Treatment of Endodontic Flare-ups
Diagnosis and Definitive Treatment
Drainage Through the Coronal Access Opening
I&D
Instrumentation
Trephination( For severe pain without visible swelling)