BDS 11138 Endodontic Management After Traumatic Injuries PDF

Endodontic management after traumatic injuries BDS 11138 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To detail the classification of traumatic injuries 2. To explain how traumatic injuries affect the pulp 3. To explain how to manage traumatic injuries and what factors af...

Endodontic management after traumatic injuries BDS 11138 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To detail the classification of traumatic injuries 2. To explain how traumatic injuries affect the pulp 3. To explain how to manage traumatic injuries and what factors affect the treatment plan 4. To define concepts of apex closure and explain how to manage traumatised immature teeth Objectives: On completion of this lecture, the student should have: 1. An understanding of what are traumatic injuries and how to manage them 2. An understanding of how age, time and extension of injury change the treatment plan I- Infraction II- Crown fractures 1- Uncomplicated 2- Complicated III- Crown-Root fractures 4- Classification IV- Root fractures Coronal, middle or apical 1- Concussion 2- Subluxation V- Laxative injuries 3- Lateral luxation 4- Extrusion VI- Avulsion 5- Intrusion V- Laxative injuries Definition & Diagnosis: Damage occurred to the PDL and cementum ranging from localized tear to generalized damage 30% to 44% Laxative injury Displacement Mobility Percussion 1- Concussion    2- Subluxation     (labially, lingually, proximally)   4- Extrusion  (coronal)   5- Intrusion  (apical into the alveolus)   3- Lateral luxation Subluxation, extrusive, lateral luxation & intrusion Definitions 1 through 5 describe injuries of increasing magnitude in terms of intensity of the injury and subsequent sequelae V- Laxative injuries Consequences of pulpal damage due to laxative injuries: 1- Pulp canal obliteration Diagnosed within the first year after injury More frequent in teeth  with open apex  with extrusive and lateral luxation 2- Pulp necrosis lead to infection of the root canal 3- Pulp space infection & root resorption Microbial toxins pass through dentinal tubules To the apical pulp tissues external inflammatory root resorption internal inflammatory root resorption V- Laxative injuries Management: I- Concussion & subluxation  Follow up (weeks 3,6,12 months and yearly)  Responses to sensitivity tests should be investigated and noted  When the pulp is unresponsive patients should be recalled on a regular basis and monitored for any additional signs of infection V- Laxative injuries Management: II- Lateral & extrusive luxation:  Should be repositioned as soon as possible & stabilized using flexible splint  Splinting for 2- 4 weeks Immature Waiting for signs of revascularization is strongly recommended Mature If pulp necrosis is anticipated RCT should be initiated as early as 2 weeks after the injury to avoid root resorption V- Laxative injuries Management: III- Intrusion: Immature May revascularize and are less likely to lose vitality and it will spontaneously re-erupt The tooth is gradually repositioned (orthodontically or with sudden forceps adjustment) Mature Flexible splint for 4 weeks Then, root canal treatment should be initiated (2-3 weeks after repositioning) Intracanal medication with Ca(OH) is recommended to avoid root resorption VI- Avulsion Definition: The tooth is completely displaced from its socket  attachment damage and pulp necrosis (maxillary central incisor is the most involved tooth due to its location and conical root) Factors affecting treatment Extraoral time The sooner the better Tooth handling Do not scrub Storage medium Maintain the periodontal ligament in a viable state VI- Avulsion Management: 1- Emergency management at the accident site 1- Replace the tooth in the socket or partly into the socket. 2-Then let the patient bite down gently on a piece of cloth to move the tooth back to its normal, or nearly normal position 3- Bring the patient to the dental office If not possible Place in an appropriate storage media Hank’s Balanced Salt Solution Milk Saline Saliva (vestibule or container) Water VI- Avulsion Management: 2- Emergency management at the dental office 1- Preparation of the socket 2- Preparation of the root 3- Replant & construct a functional splint 4- Management of the soft tissues 5- Adjunctive therapy The aim is to replant the tooth with a minimum of irreversibly damaged cells (that will cause inflammation) and the maximal number of periodontal ligament cells that have the potential to regenerate and repair the damaged root surface. VI- Avulsion Management: 2- Emergency management at the dental office 1-Preparation of the socket  Clinical & radiographic examination of the socket  Debris removal with gentle saline rinsing  If a blood clot is present, it is gently suctioned with no curettage to the socket  If the alveolar bone has collapsed a blunt instrument should be inserted carefully into the socket in an attempt to reposition the wall VI- Avulsion Management: 2- Emergency management at the dental office Closed apex Extraoral dry time < 60 minutes Open apex 2- Preparation of the root Closed apex Extraoral dry time > 60 minutes Open apex 2- Preparation of the root Extraoral dry time < 60 minutes Closed apex  Root should be rinsed of debris with water or saline and replanted gently  A dry time of 15-20 minutes is considered optimal, and periodontal healing would be expected  For more than 20 minutes but less than 60 minutes the root surface consists of some cells with the potential to regenerate and some that will act as inflammatory stimulators Open apex  Gently rinse off debris  Soak in doxycycline for 5 minutes or cover with minocycline  Replant In open apex revascularization of the pulp & continued root development are possible 2- Preparation of the root Extraoral dry time > 60 minutes Closed apex  Remove the periodontal ligament by placing in acid for 5 minutes  remove the tissue that would initiate inflammatory response  Soak in fluoride (2% stannous fluoride for 5 minutes)  Replant Enamel matrix protein (Emdogain) could be beneficial: a) makes the root more resistant to resorption b) stimulates the formation of new periodontal ligament from the socket 2- Preparation of the root Extraoral dry time > 60 minutes Open apex Replant? If yes do as closed apex and endodontic treatment performed outside, better than long term apexification 3- Replant & construct a functional splint Semirigid (physiologic) fixation for 1 to 2 weeks (avulsion + alveolar fractures 4 to 8 weeks) The splint should: 1- Allow for physiologic movement of the tooth during healing to decrease incidence of ankylosis 2- Not impinge on the gingiva 3- Not prevent maintenance of oral hygiene in the area Teeth replanted using manual pressure Radiograph verify the position of the tooth and as a reference for followup Adjust the bite no traumatic occlusion After the splint is in place Titanium trauma splint (TTS) 4- Management of the soft tissues  Soft tissue lacerations of the socket gingiva should be sutured  Care must be taken to clean the wound thoroughly before suturing 5- Adjunctive therapy  Systemic antibiotic: at emergency visit till splint removal ,to prevent bacterial invasion of necrotic pulp and subsequent inflammatory resorption.  Tetracycline: (decrease root resorption) affect motility of osteoclasts and reduce effectiveness of collagenase.  Chlorhexidine rinse, analgesics and Tetanus booster VI- Avulsion Management: 3- Second visit  Should take place 1 to 2 weeks after the emergency visit  Focus on the prevention or elimination of irritants from the root canal space to avoid bone and root resorption  At this appointment, the splint is removed Closed apex Extraoral dry time < 60 minutes Open apex Second visit Closed apex Extraoral dry time > 60 minutes Open apex VI- Avulsion Management: 3- Second visit Extraoral dry time < 60 minutes Closed apex  RCT with an intracanal medicament over period of 1 to 2 weeks  Ca(OH)2 or Ledermix (corticosteroid & tetracycline): move via dentinal tubules and shut down inflammatory response to prevent root resorption Open apex  Look for signs of revascularization (vitality or sensitivity tests)  If signs of root resorption or clinical signs (pain on percussion and palpation)  apexification VI- Avulsion Management: 3- Second visit Extraoral dry time > 60 minutes Closed apex  Same way as teeth that had an extraoral time of less than 60 minutes Open apex If Replanted  If endodontic treatment was not performed out of the mouth  apexification VI- Avulsion Sequelae of replantation: 1- Healing with normal periodontal ligament 2- Surface resorption; small superficial cavities in cementum than dentin, that heal by secondary cementum 3- Ankylosis (replacement resorption) it is a very slow and continuous process of resorption of both cementum and dentin and replaced by bone until loss of tooth (If it occurs during the jaw growth period, the tooth may be in infra-occlusion) 4- Inflammatory resorption radiographically appear as a bowl shape resorptive areas Cracks & fractures Definition:  Crack is defined as a partial discontinuity in a material that may propagate and eventually lead to a complete discontinuity, known as a fracture  There are three categories of cracks and fractures: cracked and fractured cusps, cracked and split teeth, and vertical root fractures  Cracks are often associated with UNOBSERVED TRAUMA  UNOBSERVED TRAUMA is a traumatic event that the patient cannot remember or due to normal or excessive occlusal forces that are applied without the patient’s awareness Cracks & fractures Diagnostic challenge:  None of the three entities necessarily exhibits a radiographic manifestation in the early stages  Symptoms may be present for several months before an accurate diagnosis is made Complications: 1- catastrophic fracture of the tooth or cusp 2- significant periradicular bone loss associated with a vertical root Diagnostic adjuncts: fracture 1- Tooth slooth 2- Magnification using loupes or microscopes 3- Dyes, such as methylene blue 4- Transillumination 5- Periodontal probing VRF pockets are tight, so inserting a flexible probe into these pockets causes pressure blanching of the surrounding tissues Aims: The educational aims of this lecture are: 1. To detail the classification of traumatic injuries 2. To explain how traumatic injuries affect the pulp 3. To explain how to manage traumatic injuries and what factors affect the treatment plan 4. To define concepts of apex closure and explain how to manage traumatised immature teeth Objectives: On completion of this lecture, the student should have: 1. An understanding of what are traumatic injuries and how to manage them 2. An understanding of how age, time and extension of injury change the treatment plan Reading material: Students are advised to read details at: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapters 20-21) 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. (chapter24) 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. Thank You