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