Dr. Sigurdsson - Trauma 2 PDF

Luxation Dental Injuries Trauma part 2 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] Luxation Injuries Forces on Teeth During Traumatic Injury Extrusion Co...

Luxation Dental Injuries Trauma part 2 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] Luxation Injuries Forces on Teeth During Traumatic Injury Extrusion Concussion Subluxation Lateral Luxation Intrusion Forces on Teeth During Traumatic Injury Luxation injury Concussion Subluxation Lateral Luxation Intrusion Extrusion Always causes damage to the PDL. May cause a damage to the pulp. Luxation Injuries Concussion - No abnormal loosening - Reaction to percussion Luxation Injuries Subluxation - Abnormal loosening but no displacement - Reaction to percussion - Often negative Sensibility Luxation Injuries Concussion / Subluxation Treatment inside the office: - Rule out root fracture (Radiographs) Adjust occlusion – splint only for patient comfort. - Baseline Sensibility tests Luxation Injuries Follow-up Subluxation 2 weeks 4 weeks 6-8 weeks 6 months 1 year All appointments incl: Sensibility test and Radiographic evaluation Luxation Injuries Luxation Treatment outside the office: Reposition tooth if easy - otherwise refer to dental office ASAP Luxation Injuries Luxation Treatment inside the office : 1. Radiographs at 3 vertical angles. 2. Reposition 3. Functional splint 2 weeks Luxation Injuries Lateral Luxation Apical translocation? Two possibilities: - Apex in its original location - Apex moved facially Luxation Injuries Apical translocation: Luxation Injuries Apical translocation: FORCE Luxation Injuries Apical translocation: FORCE Luxation Injuries Apical translocation: FORCE Luxation Injuries Apical translocation: Traumatic Injuries Lateral Luxation Pulpal Prognosis: Note no difference made between apical translocation or not % Survival 100 80 60 40 20 0 Open Apex Closed Apex 1 yr. 5 yr. 10 yr. Andreasen and Vestgaard Pedersen 1985 Traumatic Injuries Extrusion and Lateral Luxation Treatment: - Anesthesia (? vasoconstrictor). - Reposition the tooth into normal position. - Confirm the position with radiograph. - Splint for 2 weeks if needed. - Initiate root canal therapy as soon as symptoms indicate. Luxation Injuries Follow-up Extrusive luxation 2 weeks; splint removal 4 weeks 6-8 weeks 6 months 1 year and yearly for 5 years All appointments incl: Sensibility test and Radiographic evaluation Traumatic Injuries Intrusion Pulpal Prognosis: % Survival 100 80 60 40 20 0 Open Apex Closed Apex 1 yr. 5 yr. 10 yr. Andreasen and Vestgaard Pedersen 1985 Intrusion Treatment options Permanent teeth: - Spontaneous re-eruption. - Orthodontic forced eruption. - Surgical reposition. Intrusion Treatment options Permanent teeth: - Spontaneous re-eruption. Is relatively rare in permanent teeth unless the intrusion was minor and the apex was not completely formed. So orthodontics or surgical reposition is almost always needed and should be initiated within few days! (Andreasen et al 2002) Intrusion Treatment options Permanent teeth: - Surgical reposition. Is quick and cost effective way. Can cause additional damage to the tooth and alveolar bone. Intrusion Follow-up 2 weeks; splint removal 4 weeks 6-8 weeks 6 months 1 year and then yearly for min 5 years. All appointments incl: Sensibility test and Radiographic evaluation Intrusion Follow-up Overall the prognosis for intrusion is poor due to: - crushing of the PDL cells on the root surface - high pulpal necrosis - difficulty in accessing the root canal space if it is not possible to reposition the tooth relatively quickly Clinical Management of the Avulsed Tooth Avulsion One of the few real emergency situation in dentistry. At the site of the injury give the following advise: ü Keep the patient calm. ü Find the tooth and pick it up by the crown. ü If the tooth is dirty, wash briefly under cold running water and replant. ü If replant not possible place the tooth in a glass of milk or other suitable storage medium. ü Seek emergency dental treatment immediately. Avulsion Known Factors Affecting Prognosis: üTime out of the socket üStorage condition üSplinting technique and time üCondition of the alveolus üStage of root development Avulsed tooth Success rate vs. Extraoral Dry Time % Success 100 80 60 40 20 0 0 30 45 60 75 90 105 Time in minutes 120 135 150 PDL cell Death vs. Extraoral Dry Time PDL Cell Death (in 000's) 800 700 60 40 20 0 0 30 45 60 75 90 105 Time in minutes 120 135 150 Emergency Management Outside the dental office Best TX - Replant if possible Emergency Management Outside the dental office Place in appropriate storage medium - specialized media - milk - saline - vestibule of mouth - (((water))) Milk Is Good! Has physiological osmolarity (230-270 mOsm/kg). pH is in physiological range (6.5-6.9). Can provide some nutrients to cells. Pasteurized milk has very low bacterial count. (Blomlöf et al. 1981) Emergency Visit Root Preparation Mature Tooth Immature Tooth Dry time < 60 min > 60 min Emergency Visit Root Preparation Immature Tooth True dry time* > 60 min * not in suitable storage medium Long term prognosis is very poor. - Delay the root resorption as long as possible by soaking the tooth in fluoride. - Endo can be done extra orally. - The tooth likely to be in infra-occlusion and therefore decoronation is likely to be needed at later time. Emergency Visit Inside the dental office Splint 35 lb monofilament fishing line Guidelines of IADT What is new? Any physiological and hygienic splint acceptable; monofilament fishing line 16 to 25 lbs! Splinting Time: Type of Injury Splinting Time Subluxation 2 weeks Extrusive luxation 2 weeks Avulsion 2 weeks Lateral luxation 2 weeks Root fracture (middle 1/3) 4 weeks Alveolar fracture 4 weeks Root fracture (cervical 1/3) 4 months (Andersson et al. 2012) Emergency Visit Patient instructions Patient compliance with follow-up visits and home care contributes to satisfactory healing following an injury. Parent and/or guardians of young patients should be advised regarding care of the replanted tooth for optimal healing and prevention of further injury. • Avoid participation in contact sports. • Soft diet for up to 2 weeks. Thereafter normal function as soon as possible. • Brush teeth with a soft toothbrush after each meal. • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Second Visit 7-10 days in case of closed apex Treatment Objective Prevent or treat pulpal infection Second Visit 7-14 days in case of closed apex - At this visit it is recommended to access the root canal, remove the necrotic pulp and place calcium hydroxide (Ca(OH)2). - Best to do this prior to removing the splint. - If there is no signs of infection obturation could be completed after two to three weeks of Ca(OH)2 - Best is to permanently restore the tooth immediately after obturation. Consequences of Tooth Avulsion Pathologic root resorption due to dental injuries is always (at least initially) inflammatory in origin. It is either: Self-limiting if the only stimulus for the resorption is the injury itself. Progressive if after the initial injury an additional stimulus is present or there is a severe damage to the protective layer. Diagnosis of Root Resorption Root Resorption Diagnosis of root resorption: - Multiple radiographs with different angulations: Root Resorption Internal vs. External Root Resorption Internal resorption is rare in permanent teeth. External root resorption particularly sub – epithelial resorption is often misdiagnosed as internal resorption. Root Resorption External Root Resorption Surface Resorption ØLocalized injury to PDL and/or cementum ØNo significant inflammatory changes in PDL ØSelf limiting ØSpontaneous repair with cementum ØNot related to contents of root canal ØHard to detect on radiograph Surface Root Resorption It is important to not mis-interpret these cases as progressive in nature. If the pulp is vital but some surface changes on the root are seen on a radiograph: - no treatment should be performed - a wait and see attitude taken - allow spontaneous healing to take place! Root Resorption External Root Resorption Replacement Resorption ØFusion of alveolar bone with root surface ØAbsence of vital PDL ØContinuous replacement of tooth substance ØNo cementum repair ØNo direct relationship with content of root canal ØTooth structure fuse with bone on radiograph Osteoclasts try to resorb the dentin like any other bone Cementum tries to grow and cover the defect Replacement Root Resorption It is important to remember that only the initial inflammatory resorption is pathologic and the subsequent osseous replacement should be considered physiologic. Therefore there is no known way to reverse the process without affecting normal bone turnover in the whole body. Root Resorption External Root Resorption Inflammatory Resorption ØInjury to PDL and cementum ØSignificant inflammation of PDL ØContinuous replacement of tooth substance ØNo cementum repair ØDirect relationship with content of root canal – bacteria! ØTooth structure and bone loss on radiograph Squeal of Attachment Damage Inflammation !!! Inflammation and Root Resorption Peri-radicular Periodontitis Bone resorption Root resorption * occurs when pulp is “heavily” infected (takes time) Inflammatory Root Resorption How can one treat these things? Inflammatory Root Resorption All evidence point to the fact that this type of root resorption is caused by inflammation, - that is in many, if not most, cases driven by bacteria. Treatment of Resorption Calcium Hydroxide-Ca(OH)2 Current recommendations include instrumentation and placement of Ca(OH)2 into the root canal space within 7-14 days following replantation. And left in for several weeks or months, or until signs of healing are seen. At The Site of The Accident First aid for avulsed teeth at the place of accident: “An avulsed permanent tooth is one of the few real emergency situations in dentistry” “In addition to increasing the public awareness by, for example, mass media campaigns, healthcare professionals, guardians and teachers should receive information on how to proceed following these severe unexpected injuries. “ Best prevention is pt. education, both on risky behavior as well as what to do in case of injury! (JO Andreasen et al. 2012) At The Site of The Accident www.iadt-dentaltrauma.org (JO Andreasen et al. 2012) Thank you for your attention Asgeir Sigurdsson [email protected]