Dental Trauma and Resorption

Pulpal Sequelae Following Trauma

• Raising a flap, removal of granulation tissue, and direct repair can be attempted for pulpal sequelae following trauma.

External Resorption

• Radiographically, external resorption appears as a loss of periodontal ligament (PDL) with no radiolucent areas visible.
• There are three types of external resorption: surface (transient), replacement, and inflammatory.
• Replacement resorption is usually due to irreversible damage to the cementum, leading to ankylosis, and is often associated with a high percussion note.
• Inflammatory resorption is frequently related to pulp necrosis and can often be halted by appropriate endodontic management.

Root Canal Obliteration

• Occurs in 6–35% of luxation-type injuries.
• Prophylactic endodontic treatment is not necessary, as pulp necrosis occurs in only 13–16% of cases.
• A high rate of success (80%) has been reported for subsequent RCT, despite a hairline or no root canal detectable on X-ray.

Management of Missing Incisors

• Missing upper anterior teeth are noticed by the general public before other types of malocclusion.
• The aim of treatment is to provide a 32|23 smile.
• Management involves either recovery or maintenance of space for prosthetic replacement, or orthodontic space closure.

Endodontic Treatment

• Under a rubber dam, the necrotic pulp should be extirpated.
• The working length is set 1–2mm short of the radiographic apex (unless vital pulp tissue is encountered earlier).
• Narrow files are used to negotiate any undercuts.
• The canal should be filled with a radiopaque non-setting calcium hydroxide (e.g. Hypocal™ or Ultracal®) to the apex and sealed.

Calcific Apical Barrier

• The average time for a calcific barrier to be formed is 9 months.
• Then the canal can be filled.

Obturation

• A large GP point (a conventional point upside down) can be used.
• The point should be warmed in a flame before pressing into place and then lots of laterally condensed points used to obtain a good seal.
• Alternatively, thermoplasticized GP (e.g. Obtura®) can be used.

Resorption

• Resorption is commonly seen after avulsion, luxation, intrusion, or extrusion.
• Internal resorption is associated with chronic pulpal inflammation, which results in resorption of dentine from the pulpal surface.
• Dressing the tooth with calcium hydroxide appears to help arrest the resorption.

Viability of Pulp

• Seepage of pulp breakdown products into PDL will contribute to the development of inflammatory resorption.
• Revascularization is possible in a tooth with an open apex which is replaced within 30 minutes.
• Teeth with closed apices and longer extra-alveolar times should be considered non-vital.

Immediate Treatment

• Avoid handling the root surface.
• If the tooth is contaminated, hold the crown and agitate gently in saline.
• Place the tooth in the socket.
• If it does not readily seat, get the patient to bite on gauze for 15–20 minutes.
• Compress buccal and lingual alveolar plates.
• Splint a curved piece of light wire (a light twist-flex SS wire is ideal) to acid-etched enamel of affected and adjacent teeth using temporary crown material.

Intermediate Treatment

• Review splinting.
• Stop if the tooth appears firm, continue for further week if still mobile.
• If still mobile after 2 weeks, check nothing has been overlooked, e.g. root # or loss of vitality.
• If the apex is closed (or tooth with open apex, but extra-alveolar period >30 minutes), extirpate the pulp within 7–10 days, clean the canal.
• If an intermediate dressing is required or monitoring inflammatory resorption, place an initial intra-canal dressing of calcium hydroxide.