Dental Trauma Diagnosis And Crown Fractures PDF

Dental Trauma Diagnosis and Crown Fractures Asgeir Sigurdsson, cand odont, MS Chairman of the Department of Endodontics NYU College of Dentistry Past President of International Association of Dental Traumatology [email protected] www.iadt-dentaltrauma.org Dental Trauma Contradictions in the treat...

Dental Trauma Diagnosis and Crown Fractures Asgeir Sigurdsson, cand odont, MS Chairman of the Department of Endodontics NYU College of Dentistry Past President of International Association of Dental Traumatology [email protected] www.iadt-dentaltrauma.org Dental Trauma Contradictions in the treatment of traumatic dental injuries and ways to proceed in dental trauma research. ”Almost all treatment procedures used for dental traumas are still today not evidence-based, a fact, which makes it difficult to analyze the long-term outcome of healing and its relationship to treatment.” (Andreasen et al 2010) Dental Trauma Contradictions in the treatment of traumatic dental injuries …. For ethical reasons, it will be difficult to perform randomized studies on trauma victims! We will therefore be forced in the future to rely on experimental animal studies supported by clinical observational studies. (Andreasen et al 2010) Dental Trauma Prevalence Believed that between 20 and 30% of all 18 years old have sustained injury to their teeth. 2/3 are mild such that there is no permanent damage to the teeth. 1/3 are severe enough to potentially cause a permanent damage. Andreasen et al 1972 Fosberg & Tedestam 1990 Dental Trauma World traumatic dental injury prevalence and incidence, a meta-analysis – One billion living people have had traumatic dental injury! “Dental trauma is a neglected condition which could rank fifth if it was included in the list of the world’s most frequent acute/chronic diseases and injuries.” (Petti S, Glendor U, Andersson L 2018) Dental Trauma World traumatic dental injury prevalence and incidence, a meta-analysis “Traumatic dental injuries would be the fifth most prevalent disease or injury after: permanent caries, tension-type headache, iron-deficiency anaemia, age-related and other hearing loss AND preceding migraine and genital herpes.” (Petti S, Andreasen JO, Glendor U, Andersson L, Lancet 2018) Guidelines of IADT Available on www.IADT-dentaltrauma.org Guidelines of IADT Available: And as a app in Apple and Play Store –”ToothSOS” Clinical Procedures Adherence to the IADT guidelines for treatment of dental trauma may lead to more favorable outcomes when compared to cases treated without compliance to the guidelines: When IADT guidelines were followed: - Complication rates were significantly lower than for cases treated without adherence to the guidelines. - The Results indicate that early follow-up visits are essential to promptly treat complications. (Bücher K et al. 2013) Dental Trauma Age Distribution Two peaks in incidence - 2 to 4 years of age - 8 to 14 years of age Andreasen & Ravn 1972, HayrinenöImmonen et al 1990 Dental Trauma Prevalence If a child or teenager has very severe overjet (8 mm or more in vertical direction) then the incidence increases up to 50 – 60%. Many contend that this group requires early orthodontic intervention to reduce the risk of trauma – has not been well confirmed in studies partly because of trauma often occurring prior to early intervention. Forsberg & Tedestam 1993 Ehmer U et al. 1999 Prevalence and Incidence of Dental Trauma Incidence of dental trauma among adolescents: a prospective cohort study. 2 year follow-up, 416 (1/2 with history of trauma), aged 11-13 years. History of previous trauma: 4.85 times greater odds ratio for additional trauma compared to the non-trauma group. P = 0,005 after adjusting for incisal overjet, lip coverage and mother's schooling. (Ramos-Jorge ML. et al. 2008) Violence and abuse: core competencies for identification and access to care Violence and abuse is a significant public health problem, especially for females. Injuries to the head, neck, and/or mouth are clearly visible to the dental team during examination. Every one that deals with dental trauma should be familiar with diagnostic tools and surveys for identifying victims of all ages. (Thompson LA et al. 2013) Impact of treated/untreated traumatic dental injuries on quality of life among Brazilian schoolchildren A cross-sectional study on 668 schoolchildren. Child-OIDP demonstrated that schoolchildren with untreated dental injury were more likely to experience an impact on 'eating and enjoying food', 'smiling and showing teeth', and 'overall score’ No difference between uninjured and those with treated injury. (Ramos-Jorge, J et al 2014) Dental Trauma Which teeth are most likely to be involved? 1. Central upper incisors (40 – 60%) 2. Lateral upper incisors (20-30%) 3. Lower incisors (20-30%) Traumatic Injuries Diagnosis of dental trauma Traumatic Injuries üFact finding üClinical exam üRadiographic exam üPulpal tests Traumatic Injuries ü Fact finding 1. Patient's name, age, sex, address, and contact numbers and for young pt. weight. 2. Any CNS symptoms after the injury? Traumatic Injuries ü CNS issues: Meta-analysis: - The mean prevalence of intracranial haemorrhage after mild head injury was 8% (95% confidence interval 3% to 13%) in 13 studies with 12,750 patients. - Loss of consciousness or post traumatic amnesia occurred in 61% to 100% of patients in individual studies (most commonly 100%). (Hofman PA et al. 2000) Traumatic Injuries ü CNS issues: - Fluids from ear/nose. - Loss of/or diminished conciseness. - Situational confusion. - Headache getting worse. - Nausea / vomiting. - Behavioral changes / unexplained irritation. - Ataxia. - Blurred vision / uneven pupils. - Lack of concentration. - Change in breathing. - Difficulty of speech / slurred speech. Traumatic Injuries ü CNS issues: Remember: Epidural Hematoma can be with a late onset of symptoms! Pt. appears quite normal, then in minutes, hours or even days later symptoms appear. Traumatic Injuries ü Fact finding 1. Patient's name, age, sex, address, and contact numbers and for young pt. weight. 2. Any CNS symptoms after the injury? 3. General health. 4. WHEN did injury occur? 5. WHERE did injury occur? 6. HOW did injury occur? 7. Treatment elsewhere. 8. History of previous dental injuries. Traumatic Injuries ü Fact finding 9. Is there any disturbance in the bite? 10. Do the teeth react to thermal changes, sweet or sour sensitivity? 11. Are the teeth sore to touch, or during eating? 12. Is there spontaneous pain from the teeth? Traumatic Injuries ü Clinical Exam Extra and intra oral observation Extra and intra oral palpation Note any midline deviation - both in appearance and in movement Traumatic Injuries üClinical exam (Ignatius ET et al. 1992) Why do we take radiographs immediately after a dental trauma? üTo assess the situation üTo be able to decide on appropriate treatment üTo have a base line to compare to Why do we take radiographs immediately after a dental trauma? Need to take: üSeveral radiographs üQuality radiographs with minimal distortion üReproducible radiographs Guidelines of IADT Radiographic examination for every injury, incl. crown fractures: As a routine, several angles are recommended: 1. One parallel periapical radiograph aimed through the midline to show the two maxillary central incisors. 2. One parallel periapical radiograph aimed at the maxillary right lateral incisors (should also show the right canine and central incisor). 3. One parallel periapical radiograph aimed at the maxillary left lateral incisor (should also show the left canine and central incisor). Guidelines of IADT Radiographic examination for every injury, incl. crown fractures: As a routine, several angles are recommended: 4. One maxillary occlusal radiograph. 5. At least one parallel periapical radiograph of the lower incisors centered on the two mandibular centrals. However, other radiographs may be indicated if there are obvious injuries of the mandibular teeth (eg, similar periapical radiographs as above for the maxillary teeth, mandibular occlusal radiograph). Traumatic Injuries üRadiographic exam All teeth and tissue possibly involved, including supportive bone. Radiographs Any time there is a suspicion of a horizontal root fracture several radiographs with different vertical angulations needs to be taken! Radiographs What is appropriate radiograph? - Investigate the trauma! - Conclude on possible injuries - Then look for more injuries! Radiographs What is appropriate radiograph? - Investigate the trauma! - Conclude on possible injuries - Then look for more injuries! Why not CBCT? A CBCT investigation of dental trauma is probably best evaluation! However: - access to the machine has to be immediate, not refer to another practice. - ALARA principle (As Low As Reasonable Achievable) for radiation, remember even LFV covers large portion of the head of young individuals. - Most radiologist do not recommend using CBCT for follow-ups. Sensibility tests Cold test is most effective Place cold on incisal 1/3 if possible. False negatives common soon after injury. Needs to be repeated at all recall appointments! - > At least two signs and symptoms are necessary of make the diagnosis of necrotic pulp. Aim of Treatment in Dental Trauma Regain or maintain pulp vitality !!! Dental Trauma Crown Injuries Types of trauma: üCrown infraction üUncomplicated crown fracture üComplicated crown fracture üUncomplicated crown-root fracture üComplicated crown-root fracture Crown Fractures Crown Infraction Clinical Presentation Craze lines “Use fiber optic light” Crown Infraction Treatment: Baseline Sensibility tests Radiographs: Peri-apical film indicated if other signs or symptoms are present Uncomplicated Crown Fracture Uncomplicated Crown Fracture Incidence Most commonly reported dental injury!! Estimated to be up to 1/3 –1/2 of all dental injuries Uncomplicated Crown Fracture Biologic Consequences: Minimal!! Pulp will most likely defend it self* *unless we, the dentists, mess things up! Uncomplicated and Complicated Crown Fracture Treatment 1.Account for tooth fragment Uncomplicated and Complicated Crown Fracture Treatment 1.Account for tooth fragment 2. Sensibility tests Sensibility tests should be done prior to any treatment! - Remember Cold is most reliable Uncomplicated and Complicated Crown Fracture Treatment 1. Account for tooth fragment 2. Sensibility test 3. Radiographic evaluation: - periapical, - occlusal, - eccentric, - radiograph of lip/cheek if skin is broken. Uncomplicated Crown Fracture Treatment 1.Account for tooth fragment 2. Sensibility tests 3. Radiographic evaluation 4. Esthetic repair * * If there is not time for an esthetic repair, a glass-ionomer or composite bandage should be placed on the exposed dentin at the initial visit. Uncomplicated Crown Fracture Treatment 4. Esthetic repair: Dentin bonding Vs. Ca(OH)2 base Uncomplicated Crown Fracture Young human teeth (n=353): Odontoblast numbers and dentine repair activity was more influenced by cavity variables, than of cavity filling materials or patient factors. The most important variable was the remaining dentine thickness; below 0.25mm the numbers of odontoblasts decreased by 23%, and minimal reactionary dentine repair was observed. (I. About et al. 2001) Uncomplicated Crown Fracture When remaining dentine thickness was less than 0.5 mm, but not exposing the pulp, the % of viable odontoblasts was found to be: calcium hydroxide (100%), polycarboxylate (82.4%), zinc oxide eugenol (81.3%), composite (75.5%), enamel bonding resin (49.5%) (I. About et al. 2001) Uncomplicated Crown Fracture Treatment 4. Esthetic repair. If it is estimated that there is more than 0.5 to 1mm into the pulp then there is no need for additional pulpal protection! Dentin Bonding of Fragments The key is to get the best approximation possible: - Etch and dry (don’t over dry!!) both pieces - Use minimal bond and no Ca(OH)2 coverage if remaining dentin on the pulpal side is > 0.5mm - If pulpal coverage is less than 0.5 mm then Ca(OH)2 coverage over the deepest part and the corresponding area of the broken piece has to be dimpled appropriately. Dentin Bonding of Fragments Effect of dehydration and rehydration intervals on fracture resistance of reattached tooth fragments using a multimode adhesive Bovine teeth n=84 Conclusion: Rehydrating a tooth fragment for 15 minutes before bonding with a multimode adhesive appears to maintain sufficient moisture to increase reattachment strength. (Poubel DLN. et al. 2017) Uncomplicated Crown Fracture Follow-up 6-8 weeks and 1 year Incl: Sensibility test and Radiographic evaluation Crown Fractures Crown Infraction Uncomplicated crown fracture Complicated crown fracture Complicated crown fracture Definition Crown fracture involving enamel, dentin and pulp Complicated Crown Fracture Treatment 1. Account for tooth fragment 2. Sensibility test 3. Radiographic evaluation: - periapical, - occlusal, - eccentric, - radiograph of lip/cheek if skin is broken. Vital Pulp Therapy Requirements for success 1. Capping of healthy pulp 2. Bacteria tight coronal seal 3. ? Capping material ? Complicated Crown Fractures Biologic Consequences 1st 24 to 48 hours - minimal inflammation of 1-2 mm and pulpal proliferation Necrosis certain if no treatment Complicated crown fracture • 1st 24 to 48 hours Pulpal Proliferation Minimal Inflammation Complicated Crown Fracture Direct capping: 5% NaOCl in a cotton pellet: Causes chemical amputation of the blood coagulum Removes the damaged pulp cells, dentin chips and other debris. Provides hemorrhage control with minimal damage to the “normal” pulp tissue underneath. (Hafez AA, Cox CF et al. 2002) Vital Pulp Therapy Requirements for success ? Capping material ? Calcium hydroxide: Complicated Crown Fracture Calcium Hydroxide (Ca(OH)2): Action unknown, possible due to the high pH (11-12) combined with inhibition of bacterial proliferation and effect on endotoxins. Ca(OH)2 can not be used to treat an existing pulpitis - it has no direct curative effect on inflammation, - it does not appear to contribute Ca++ to the bridge formation. 1 - 1 1/ 2 mm High speed diamond bur with copious water cooling Ca(OH)2 paste Dycal Vital Pulp Therapy Requirements for success ? Capping material ? Calcium hydroxide: Mineral Trioxide Aggregate (MTA): Mineral Trioxide Aggregate (MTA): Has been shown to be very biocompatible and fairly good sealant when placed as a pulp capping agent. The pulp will react to the MTA with mild reaction followed by a dentin bridge. However not recommended any longer in anterior teeth because of potential staining of the remaining crown. Complicated Crown Fracture Biodentine Evolution of reparative dentin formation of ProRoot MTA, Biodenitne and BioAggregate using micro-CT and immuohistochemistry Results suggest that calcium silicate-based pulp-capping material induce favorable effects on reparative process during vital pulp therapy and those could be considered as alternatives to ProRoot MTA After 6 months, regardless of blood exposure, Biodentine exhibits superior color stability compared to MTA. (Kim J et al 2016, Palma PJ et al 2019) Complicated Crown Fracture Follow-up 6-8 weeks and 1 year Incl: Sensibility test and Radiographic evaluation Thank you for your attention Asgeir Sigurdsson [email protected]