Tooth Trauma

Traumatic Injuries to the Teeth: 

Traumatic Injuries to the Teeth Scott A. Schwartz, Colonel, USAF, DC

Traumatic Injuries to the Teeth: 

Traumatic Injuries to the Teeth Crown Fractures Crown-Root Fractures Root Fractures Luxation Injuries Avulsion

Traumatic Injuries to the Teeth: 

Traumatic Injuries to the Teeth Root Fracture Update

Traumatic Injuries to the Teeth: 

Traumatic Injuries to the Teeth Root Fracture Update Management of the Avulsed Tooth

Root Fracture Update: 

Root Fracture Update Clinical examination Tooth usually slightly extruded Tooth frequently displaced lingually

Root Fracture Update: 

Root Fracture Update Clinical examination Tooth usually slightly extruded Tooth frequently displaced lingually

Root Fracture Update: 

Root Fracture Update Clinical examination Diagnosis entirely dependent upon radiographic examination

Emergency Management: 

Emergency Management Periapical radiographs Standard XCP radiograph Increased vertical angulation

Emergency Management: 

Emergency Management Periapical radiographs Standard XCP radiograph Increased vertical angulation

Emergency Management: 

Emergency Management Reposition coronal fragment

Emergency Management: 

Emergency Management Previous recommendation Rigid splinting for 2-3 months

Emergency Management: 

Emergency Management Previous recommendation Rigid splinting for 2-3 months New recommendation Splinting for 3 weeks

Root Fracture Healing: 

Root Fracture Healing

Root Fracture Complications: 

Root Fracture Complications Pulp necrosis Coronal segment  20 to 44%

Root Fracture Complications: 

Root Fracture Complications Pulp necrosis Coronal segment  20 to 44% Apical segment  0%

Root Fracture Complications: 

Root Fracture Complications Pulp necrosis Coronal segment  20 to 44% Apical segment  0%

Root Fracture Complications: 

Root Fracture Complications Pulp necrosis Coronal segment  20 to 44% Apical segment  0% Pulp canal obliteration  69%

Root Fracture Complications: 

Root Fracture Complications Pulp necrosis Coronal segment  20 to 44% Apical segment  0% Pulp canal obliteration  69% Root resorption  60%

Root Fracture Treatment: 

Root Fracture Treatment Summary Reposition and splint for 3 weeks !!

Root Fracture Treatment: 

Root Fracture Treatment Summary Reposition and splint for 3 weeks !! Monitor with pulp tests and radiographs

Root Fracture Treatment: 

Root Fracture Treatment Summary Reposition and splint for 3 weeks !! Monitor with pulp tests and radiographs Do not initiate endodontic treatment unless there are signs of pulp necrosis

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth Overview Periodontal Ligament Responses Treatment Considerations Pulpal Prognosis/ Endodontic Rationale Treatment Regimen

Avulsed Permanent Teeth: 

Avulsed Permanent Teeth Incidence 0.5% to 16% of traumatic injuries Main etiologic factors Fights Sports injuries Automobile accidents

Avulsed Permanent Teeth: 

Avulsed Permanent Teeth Maxillary central incisor Most commonly avulsed tooth Mandibular teeth Seldom affected Most frequently involves a single tooth

Avulsed Permanent Teeth: 

Avulsed Permanent Teeth Most common age - 7 to 11 Permanent incisors erupting Loosely structured PDL

Avulsed Permanent Teeth: 

Avulsed Permanent Teeth Associated injuries Fracture of alveolar socket wall

Avulsed Permanent Teeth: 

Avulsed Permanent Teeth Associated injuries Fracture of alveolar socket wall Injuries to the lips and gingiva

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth What tissue should be our primary concern? Pulp?

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth What tissue should be our primary concern? Pulp? Socket?

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth What tissue should be our primary concern? Pulp? Socket? PDL?

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth Ultimate goal PDL healing without root resorption

Management of the Avulsed Tooth: 

Management of the Avulsed Tooth Ultimate goal PDL healing without root resorption Most critical factor Maintaining an intact and viable PDL on the root surface

Periodontal Ligament Responses: 

Periodontal Ligament Responses Surface Resorption Replacement Resorption (Ankylosis) Inflammatory Resorption Andreasen JO, Hjorting-Hansen E. Replantation of teeth II. Histological study of 22 replanted anterior teeth in humans. Acta Odontol Scand 1966;24:287-306.

Periodontal Ligament Responses: 

Periodontal Ligament Responses Surface resorption Superficial resorption cavities Mainly in cementum Complete repair of PDL

Periodontal Ligament Responses: 

Periodontal Ligament Responses Replacement resorption (Ankylosis) Direct union of bone and root Resorption of root - Replacement with bone Direct result of loss of vital PDL

Periodontal Ligament Responses: 

Periodontal Ligament Responses Inflammatory resorption Resorption of cementum and dentin Inflammatory reaction in the periodontal ligament

Etiology: 

Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules

Etiology: 

Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules Pulp necrosis

Etiology: 

Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules Pulp necrosis Toxic products from the pulp provoke an inflammatory response in the PDL

Periodontal Ligament Responses: 

Periodontal Ligament Responses Surface resorption

Periodontal Ligament Responses: 

Periodontal Ligament Responses Surface resorption Replacement resorption (Ankylosis)

Periodontal Ligament Responses: 

Periodontal Ligament Responses Surface resorption Replacement resorption (Ankylosis) Inflammatory resorption

Treatment Considerations: 

Treatment Considerations Extraoral time Extraoral environment Root surface manipulation Management of the socket Stabilization

Extraoral Time: 

Extraoral Time Shorter time = Better prognosis * < 30 min  10% resorption > 90 min  90% resorption Andreasen JO, Hjorting-Hansen E. Replantation of teeth I. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand 1966;24:263-86.

Extraoral Time: 

Extraoral Time Shorter time = Better prognosis * < 30 min  10% resorption > 90 min  90% resorption * depending on storage medium Andreasen JO, Hjorting-Hansen E. Replantation of teeth I. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand 1966;24:263-86.

Extraoral Environment: 

Extraoral Environment Viability of PDL cells is critical

Storage Media: 

Storage Media Tap Water Dry Saliva Saline Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53. Poor results

Storage Media: 

Storage Media Tap Water Dry Saliva Saline Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53. Good protection for 2 hrs Poor results

Milk As A Storage Medium: 

Milk As A Storage Medium Physiologic osmolality Markedly fewer bacteria than saliva Readily available

Storage Media - Milk vs. Saliva: 

Storage Media - Milk vs. Saliva Storage for 2 hrs Periodontal healing almost as good as immediate replantation Blomlof L, et al. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912-6.

Storage Media - Milk vs. Saliva: 

Storage Media - Milk vs. Saliva Storage for 2 hrs Periodontal healing almost as good as immediate replantation Storage for 6 hrs Saliva  extensive replacement resorption Milk  healing almost as good as immediate replant Blomlof L, et al. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912-6.

Cell Culture Media: 

Cell Culture Media Eagle’s Medium Hank’s Balanced Salt Solution

Hank’s Balanced Salt Solution: 

Hank’s Balanced Salt Solution Proper pH and osmolality Reconstitutes depleted cellular metabolites Washes toxic breakdown products from the root surface

Organ Transplant Storage Media: 

Organ Transplant Storage Media Viaspan Dramatically prolongs the storage of human organs Expensive Not readily available

Storage Media Comparison: 

Storage Media Comparison Viaspan Complete healing after 6 and 12 hrs Good for extended storage periods (72 and 96 hrs) Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank’s balanced salt solution. Endod Dent Traumatol 1992;8:183-8.

Storage Media Comparison: 

Storage Media Comparison Viaspan Complete healing after 6 and 12 hrs Good for extended storage periods (72 and 96 hrs) Hank’s balanced salt solution Healing results similar to Viaspan Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank’s balanced salt solution. Endod Dent Traumatol 1992;8:183-8.

Recommended Storage Media: 

Recommended Storage Media 1. Socket (immediate replantation) 2. Cell culture medium 3. Milk 4. Physiologic saline 5. Saliva

Root Surface Manipulation: 

Root Surface Manipulation Attempt to retain PDL cell viability Do not curette root surface Avoid caustic chemicals Van Hassel HJ, Oswald RJ, Harrington GW. Replantation 2. The role of the periodontal ligament. J Endodon 1980;6:506-8.

Root Surface Manipulation: 

Root Surface Manipulation Extraoral dry time determines handling

Root Surface Manipulation: 

Root Surface Manipulation Extraoral dry time < 1 hr PDL healing is still possible Handling recommendations Keep root moist Do not handle root surface Gentle debridement

Root Surface Manipulation: 

Root Surface Manipulation Extraoral dry time > 1 hr Loss of PDL cell viability inevitable Treatment recommendations Remove tissue tags Soak in accepted dental fluoride solution for 20 min

Fluoride Treatment: 

Fluoride Treatment 1.0-2.4% topical fluoride solution Sodium fluoride (Andreasen) Stannous fluoride (Krasner) 20 minute soak

Management of the Socket: 

Management of the Socket Remove contaminated coagulum in socket Irrigate with sterile saline

Management of the Socket: 

Management of the Socket Examine socket  If fracture is evident Reposition fractured bone with a blunt instrument

Management of the Socket: 

Management of the Socket Replant using light digital pressure

Stabilization: 

Stabilization Splint Definition  a rigid or flexible device used to support, protect, or immobilize teeth, preventing further injury Types Acid etch composite Cross-suture

Acid Etch Composite Splints: 

Acid Etch Composite Splints Interproximal composite

Acid Etch Composite Splints: 

Acid Etch Composite Splints Composite with arch wire

Acid Etch Composite Splints: 

Acid Etch Composite Splints Composite with monofilament nylon

Acid Etch Composite Splints: 

Acid Etch Composite Splints Functional Splint 20-30 lb monofilament nylon Bonded with composite Allows physiologic movement Antrim DD, Ostrowski JS. A functional splint for traumatized teeth. J Endodon 1982;8:328-31.

Cross-Suture Splint: 

Cross-Suture Splint Indications No adjacent teeth to splint to Unmanageable traumatized children

Cross-Suture Splint: 

Cross-Suture Splint

Splinting Time: 

Splinting Time Effect of splinting time 7 days 30 days Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg 1982;53:557-66.

Splinting Time: 

Splinting Time Recommended time 7 to 10 days Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg 1982;53:557-66.

Pulpal Prognosis: 

Pulpal Prognosis Stage of root development Dry storage time Storage media Antibiotics

Stage of Root Development: 

Stage of Root Development Mature roots ( < 1.0 mm) Revascularization 0% Kling M, et al. Endod Dent Traumatol 1986;2:83-9. Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.

Stage of Root Development: 

Stage of Root Development Mature roots ( < 1.0 mm) Revascularization 0% Immature roots (> 1.0 mm) Revascularization 18-34% Kling M, et al. Endod Dent Traumatol 1986;2:83-9. Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.

Revascularization: 

Revascularization Loss of blood supply to pulp

Revascularization – Day 4: 

Revascularization – Day 4 Coronal pulp Extensive ischemic injury

Revascularization – Day 4: 

Revascularization – Day 4 Coronal pulp Extensive ischemic injury Apical pulp Initial revascularization

Revascularization – 4 Weeks: 

Revascularization – 4 Weeks Pulp status Revascularization Reinnervation New odontoblastic layer

Revascularization: 

Revascularization Typical sequela Pulp canal obliteration

Dry Storage Time: 

Dry Storage Time As dry storage time increases Pulp survival decreases Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Endod Dent Traumatol 1995;11;59-68.

Storage Media: 

Storage Media Nonphysiologic storage Minimal chance of pulp revascularization Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Endod Dent Traumatol 1995;11;59-68.

Storage Media: 

Storage Media Nonphysiologic storage Minimal chance of pulp revascularization Physiologic storage HBSS, milk, saline, saliva Improved chance of pulp revascularization Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Endod Dent Traumatol 1995;11;59-68.

Pulpal Prognosis - Antibiotics: 

Pulpal Prognosis - Antibiotics Systemic antibiotics Pulp revascularization is not increased Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling M, Fatti P. Endod Dent Traumatol 1990;6:157-69.

Pulpal Prognosis - Antibiotics: 

Pulpal Prognosis - Antibiotics Systemic antibiotics Pulp revascularization is not increased Topical antibiotics Beneficial effect Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Endod Dent Traumatol 1990;6:170-6.

Pulpal Prognosis - Antibiotics: 

Pulpal Prognosis - Antibiotics Topical Doxycycline Decreased microorganisms in pulpal lumen Increased pulp revascularization Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Endod Dent Traumatol 1990;6:170-6.

Pulpal Prognosis - Antibiotics: 

Pulpal Prognosis - Antibiotics Recommendation Topical Doxycycline 1 mg in 20 ml physiologic saline 5 minute soak Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Endod Dent Traumatol 1990;6:170-6.

Endodontic Rationale: 

Endodontic Rationale Mature root - 4 weeks Very limited revascularization

Endodontic Rationale: 

Endodontic Rationale Mature root - 4 weeks Very limited revascularization Ischemic coronal pulp with great risk of infection !!!

Endodontic Rationale – Mature Root: 

Endodontic Rationale – Mature Root Pulpectomy  7-14 days

Endodontic Rationale – Mature Root: 

Endodontic Rationale – Mature Root Calcium hydroxide placement

Endodontic Rationale – Mature Root: 

Endodontic Rationale – Mature Root Calcium hydroxide Antibacterial Increases pH in dentin Favors mineralization over resorption Tronstad L, Andreasen JO, et al. pH changes in dental tissues after root canal filling with calcium hydroxide. J Endodon 1981;7:17-21.

Endodontic Rationale – Mature Root: 

Endodontic Rationale – Mature Root Treatment recommendation Ca(OH) 2 therapy for as long as practical, usually 6-12 months Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Association of Endodontists, 1995.

Specific Treatment Regimen: 

Specific Treatment Regimen Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Association of Endodontists, 1995.

Specific Treatment Regimen: 

Specific Treatment Regimen Root Development Closed apex Open apex Extraoral Dry Time One hour or less More than one hour Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Association of Endodontists, 1995.

Treatment Flowchart: 

Treatment Flowchart < 1 hr > 1 hr Extraoral Dry Time Apex Maturity Closed Open Open or Closed Pulpectomy7-14 days Observe Option : Extraoral RCT Pulpectomy 7-14 days

Emergency Treatment: 

Emergency Treatment Replantation technique Local anesthetic, if necessary Radiograph to verify position Check occlusion Physiologic splint

Emergency Treatment: 

Emergency Treatment Additional Considerations Analgesics

Emergency Treatment: 

Emergency Treatment Additional Considerations Analgesics Chlorhexidine

Emergency Treatment: 

Emergency Treatment Additional Considerations Analgesics Chlorhexidine Tetanus Refer to physician for tetanus prophylaxis prn Rothstein RJ, Baker FJ. Tetanus: Prevention and treatment. J Am Med Assoc 1978;240:675-6.

Emergency Treatment: 

Emergency Treatment Additional Considerations Analgesics Chlorhexidine Tetanus Antibiotics

Antibiotics: 

Antibiotics Penicillin 500 mg qid for 4-7 days Andreasen JO. Atlas of replantation and transplantation of teeth. Philadelphia: W.B. Saunders Co., 1992;57- 92.

Antibiotics: 

Antibiotics Tetracycline vs. amoxicillin  in a replacement resorption model Tetracycline had better anti-resorptive properties Sae-Lim V, Wang CY, Choi GW, Trope M. The effect of systemic tetracycline on resorption of dried replanted dogs’ teeth. Endod Dent Traumatol 1998;14:127-32.

Antibiotics: 

Antibiotics Tetracycline vs. amoxicillin  in an inflammatory root resorption model Tetracycline had better anti-bacterial properties Sae-Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs’ teeth. Endod Dent Traumatol 1998;14:216-20.

Antibiotics: 

Antibiotics Recommendation “Tetracycline could be considered as an alternative to amoxicillin after avulsion injuries.” Sae-Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs teeth. Endod Dent Traumatol 1998;14:216-20.

Tetracycline Use In Young Children: 

Tetracycline Use In Young Children Tetracycline staining Not a problem since avulsed maxillary anteriors have already erupted and are not susceptible to staining At worst, posterior teeth might be stained Remote possibility with 7-10 day prescription Sae-Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs’ teeth. Endod Dent Traumatol 1998;14:216-20.

Avulsion Sequelae: 

Avulsion Sequelae Closed Apex Extraoral dry time 1 hour or less

Avulsion Sequelae: 

Avulsion Sequelae Closed Apex Extraoral dry time more than 1 hour

Avulsion Sequelae: 

Avulsion Sequelae Open Apex Extraoral dry time 1 hour or less

Avulsion Sequelae: 

Avulsion Sequelae Open Apex Extraoral dry time more than 1 hour

Avulsion Management: 

Avulsion Management Be prepared - Dental Trauma Kit Immerse tooth in a physiologic storage medium to “buy time” Determine extraoral dry time Follow AAE Guidelines