BDS 11137 Endodontic Management After Traumatic Injuries PDF

Endodontic management after traumatic injuries BDS 11137 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 11137 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: 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  A traumatic injury to the tooth results in damage to many dental and periradicular structures, making the management and consequences of these injuries multifactorial  Most dental trauma occurs in the 7-12-year-old age group and is mainly due to falls and accidents  It occurs primarily in the anterior region of the mouth, affecting the maxillary more than the mandibular jaw 1- History and examination  Any period of unconsciousness, amnesia, headache, nausea or vomiting may indicate cerebral involvement so patient should be referred immediately for medical examination  A full account of when, where, and how the injury occurred must be recorded WHEN Time interval between injury and presentation can influence the choice of treatment (replantation of avulsed teeth) WHERE The place may suggest possible contamination of open wounds and the need for tetanus prophylaxis HOW The way the injury occurred may give some indication of the type and the extent Clinical examination should include assessment of the soft tissues and facial skeleton Disturbances to occlusion Indicate alveolar fracture or condylar displacement Soft tissue injury Must be examined properly for possible presence of a foreign body Bleeding from a nonlacerated gingiva Indicate periodontal damage Discoloration after the injury Indicate hemorrhage within the pulp Mobility & percussion Damage to the supporting tissues Unaffected teeth should always be included in the examination and investigations 2- Pulp response to trauma  Subsequent to traumatic injury, the conduction capability of the nerve endings is disturbed  So traumatized tooth is vulnerable to false negative readings  It may take as long as 9 months for normal blood flow to return to the coronal pulp of a traumatized fully formed tooth Positive response Negative response No response Positive response Pulp degeneration Pulp healing Tests must be repeated at 3 weeks; at 3, 6, and 12 months; and at yearly intervals after trauma 3- Radiographic examination Imaging may reveal 1- root fractures or bone fractures 2- subgingival crown fractures 3- tooth displacements 4- root resorptions 5- embedded foreign objects in cases of soft tissue laceration RG of the lip revealed a portion of the crown still in the lip The International Association of Dental Traumatology (IADT) has recommended taking at least four different radiographs for almost every injury. 1- Direct 90-degree on the axis of the tooth 2- Two radiographs with different vertical angulations 3- Occlusal film Cone Beam Computed Tomography CBCT is a useful diagnostic adjunct for traumatic injuries Example Panoramic RG taken on a patient with history of dentoalveolar trauma. Upper left central incisor shows arrested root development with a periapical radiolucency Sagittal view from CBCT imaging revealed that 1- tooth had arrested root development, 2- large PA radiolucency, 3- extensive root resorption along the palatal surface that was not evident on the panoramic image 4- fractured palatal portion that extended just apical to the crest of bone. 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 I- Infraction Definition: An incomplete fracture or a crack in the enamel, without loss of tooth structure Diagnosis: Transillumination to detect cracks or sharp edges Management:  Meticulous follow-up over a 5-year period  If, at any follow-up examination  the reaction to sensitivity tests changes  on RG assessment: 1- signs of apical or periradicular periodontitis develop 2- the root appears to have stopped development or is obliterating Endodontic intervention should be considered II- Crown fractures 1- Uncomplicated crown fracture Definition: fracture of the enamel only or the enamel and dentin without pulp exposure (one third to one half of all reported dental trauma) Diagnosis: sensitivity to air, cold & hot Management: All exposed dentinal tubules need to be closed as soon as possible this is done by: 1- the broken-off piece (available and possible to be reattached) 2- full composite restoration. This prevents any ingress of bacteria into the tubules and reduces the patient’s discomfort Remaining dentine thickness More than 0.5 mm thick Etching, bonding & composite restoration Less than 0.5 mm thick Protective layer of hardsetting calcium hydroxide II- Crown fractures 2- Complicated crown fracture Definition: involves enamel, dentin, and pulp (0.9% to 13% of all dental injuries) Diagnosis: pulp exposure & bleeding Pulp reaction Hemorrhage at the site of the pulp wound & superficial inflammatory response Destructive (necrotic) Proliferative (pulp polyp) In the first 24 hours the inflammation does not extend more than 2 mm into the pulp II- Crown fractures 2- Complicated crown fracture Management: 1- Vital pulp therapy, comprising pulp capping, partial pulpotomy, or full pulpotomy (apexogensis) 2- Pulpectomy The choice of treatment depends on: 1- The stage of development of the tooth 2- The time between trauma and treatment 3- Concomitant periodontal injury 4- The restorative treatment plan 1- The stage of development of the tooth  Immature tooth  vital pulp therapy should always be attempted (apexogensis) (open apex, thin dentinal walls that are susceptible to fracture)  Mature tooth  under optimal conditions, vital pulp therapy can be carried out successfully (pulp capping, pulpotomy) Requirements for Success of vital pulp therapy: 1- Noninflamed pulp (the optimal time for treatment is in the first 24 hours) 2- Bacteria-tight seal 3- Pulp dressing (calcium hydroxide & MTA) Continued root development after partial pulpotomy at 18 months Stage of root development Mature Immature Non-vital Vital Vital pulp therapy Vital Non-vital Vital pulp therapy RCT Revascularization 2-The time between trauma and treatment Within 48 hours After 48 hours No more than a 2-mm depth of pulpal inflammation Bacterial contamination of the pulp increase (inflammation progressing apically) 3- Concomitant periodontal injury compromises the nutritional supply of the pulp especially in mature teeth 4- The restorative treatment plan Simple Complex restoration Vital pulp therapy RCT (pulpectomy) III- Crown root fractures Definition: fracture involving enamel, dentin and cementum with or without pulp exposure Diagnosis: tenderness to percussion mobility of the coronal fragment Emergency Temporary stabilization of the loose segment to adjacent teeth until a definitive treatment plan is made Non-Emergency Removal of the coronal crown-root fragment Management III- Crown root fractures Definitive treatment plan Fragment removal Gingivectomy (sometimes osteotomy) Orthodontic extrusion Surgical extrusion Extraction In patients with open apices, it is advantageous to preserve pulp vitality by a partial pulpotomy IV- Root fractures Definition: fracture of the cementum, dentin, and pulp (less than 3% of all dental injuries) Diagnosis:  Clinical mobility of the tooth.  Pain on biting and tenderness to percussion  Radiographic examination (three angled radiographs 45°, 90°, 110°)  Displacement of the coronal segment and its extent is usually indicative of the location of the fracture None  apical fracture Severe  cervical fracture IV- Root fractures Classification According to their number: a- Single: One Line of fracture. b- Multiple: More than one Line of fracture. According to their location: a- Apical b- Midroot c- Cervical According to their direction: a- Horizontal fracture: Fracture line at right angle with the long axis of the tooth b- Vertical fracture: Fracture line at the same direction to the long axis of the tooth c- Chisel fracture: Fracture line is at different level, evenly beveled having a chisel like appearance. IV- Root fractures Management:  No mobility or displacement  no treatment.  Mobility or displacement  emergency treatment involves repositioning of the segments in a close proximity as possible and splinting for 2-4 weeks with functional (semirigid) splint  Follow up 3, 6, 12 month and yearly for 5 years IV- Root fractures Treatment options I- Coronal root fractures Possible Good prognosis Not possible Extraction of the coronal segment Reapproximation Length of the remaining root is evaluated (orthodontic eruption) IV- Root fractures Treatment options Apical root fractures 1- In case of apical root fracture without displacement & mobility no treatment & follow up (clinically, radiographically & sensitivity tests) 2- The coronal fragment may be endodontically treated and restored. The apical segment usually remains vital and does not require treatment. IV- Root fractures Treatment options Apical root fractures 3- The coronal fragment may be endodontically treated and restored. The apical segment is surgically removed & retro fill is performed 4- The coronal segment in the previous cases could be treated as an immature root and hence apexification and MTA barrier could be applied to enhance closure of the apical widest part Mid root fractures  RCT for both segments when both parts are necrotic and splinting (RCT through the fracture is extremely difficult) IV- Root fractures Healing Patterns 1- Healing with calcified tissue  Fragments are in a close position with little mobility  calcified callus 2- Healing with interproximal connective tissue  If there is slight separation & mobility.  Connective tissue creeps between the fractured segments IV- Root fractures Healing Patterns 3- Healing with interproximal bone and connective tissue 4- Interproximal inflammatory tissue without healing The first three healing patterns are considered successful 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