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Management of Dental Injuries in Children
Management of Dental Injuries in Children
Dennis J. McTigue, DDS, MSAlabama Academy of Pediatric Dentistry
February 5, 2016
Dennis J. McTigue, DDS, MSAlabama Academy of Pediatric Dentistry
February 5, 2016
Limitations of trauma researchLimitations of trauma research Ethical - Patients can’t be randomized to “trauma”
and “no trauma” groups
Animal models – limited clinical applicability to humans
Retrospective case series studies Individual case reports
Randomized post-injury treatment interventions
Comparability of injuries studied
Andreasen, JO et al. Contradictions in the treatment of traumatic dental injuries and ways to proceed in dental trauma research. Dent Traumatol 2010; 26:16-22
Guidelines for TreatmentGuidelines for Treatment International Association of Dental Traumatology
Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012;28I. Fractures and luxations of permanent teeth II. Avulsion of permanent teethIII. Primary teeth
American Association of EndodontistsRecommended guidelines for the treatment of traumatic injuries. Chicago: AAE; 2013 www.AAE.org
HISTORY:HISTORY:
Patients name, Age, Sex, Address, and Phone Number
Medical History and Assessment of General Health
TETANUS PROTECTION PROTOCOLTETANUS PROTECTION PROTOCOL
Immunization completed plus booster within 5 years - no treatment
Greater than ten years since immunization -toxoid
Between 5 & 10 years since immunization and dirty wound - toxoid
No history of immunization and dirty wound - toxoid and antitoxin
http://www.health.state.mn.us/divs/idepc/diseases/tetanus/hcp/tetwdmgmt.htmlhttp://www.health.state.mn.us/divs/idepc/diseases/tetanus/hcp/tetwdmgmt.html
WHEN did the accident occur?
WHERE did the accident occur?
HOW did the accident occur?
RULE OUT:Child Abuse
CNS Injury
Child AbuseChild Abuse Annual US estimate – 1.5 million cases
Ratio of nonreported to reported = 100: 1
40-60% Abusers were abused as children
High rates with special needs patients
Most prevalent in age group 0-24 months
Diagnostic Evaluation for AbuseDiagnostic Evaluation for Abuse
Red Flags in the History:Injury incompatible with child’s developmental
abilities
Absent, changing, or evolving history
Delay in seeking medical care
Triggering event that precipitates loss of control in caregiver
Family crisis or stress
Prior history of abuse in caregiver
Bruising and LocationBruising and LocationNon‐Intentional Intentional
Forehead Ears
Vertex of chin Neck
Elbows Upper arms/legs
Knees/Shins
Child AbuseChild Abuse Bruising:
If bruising is seen in a non-ambulatory child or in non-prominent soft tissue locations on the body - consideration should be given to abuse or some other underlying condition
Bites:Patterns of bites vary in tooth shape, arch impression and
intercuspid distance depending on whether the bite was inflicted by a child (<30 mm) or an adult
Dentists are mandated reporters
CENTRAL NERVOUS SYSTEM INJURY
CENTRAL NERVOUS SYSTEM INJURY
Tecklenburg, F., and Wright, M.: Minor head trauma in the pediatric patient. Ped. Emer. Care Vol. 7, #1, pgs. 40-47, 1991.
AAP Clinical Practice Guidelines: The Management of Minor Head Injury in Children. Pediatrics Vol. 104, #6, pgs 1407-1415 , 1999;http://aappolicy.aappublications.org/cgi/content/full/pediatrics;104/6/1407
Signs of Increased Intracranial Pressure
Signs of Increased Intracranial Pressure
DIZZINESS
NAUSEA
VOMITING
HEADACHE
LETHARGY OR IRRITABILITY
LOSS OF MEMORY
PUPIL SIZE AND REACTION TO LIGHT
LOSS OF CONSCIOUSNESS
RECORD SYMPTOMS REPORTED BY PATIENTRECORD SYMPTOMS REPORTED BY PATIENT
Spontaneous Pain
Reaction to Thermal Change
Disturbances in Occlusion
CLINICAL EXAMCLINICAL EXAM
RECORD:
Extraoral Wounds and Palpation of Facial Skeleton
Injuries to intraoral soft tissues
Chin Trauma correlated with:Chin Trauma correlated with:
Posterior crown fractures
Mandibular condylar fractures
Cervical spine injury
Bertolami, C.N. and Kaban, L.B.: Chin trauma: a clue to associated mandibular and cervical spine injury, Oral Surg. Feb. 1982, pgs. 122-126.
Examine tooth crowns for fracture, pulp exposure, or color changeExamine tooth crowns for fracture, pulp exposure, or color change
Record displacement of teeth
RECORD:RECORD:
Mobility of Teeth or Alveolar Fragments
Sensitivity to Percussion
Abnormalities in Occlusion
Reaction to Vitality Tests
REACTION OF TEETH TO VITALITY TESTSREACTION OF TEETH TO VITALITY TESTS
A. Carbon Dioxide Snow B. Tetrafluoroethane (Endo
Ice) C. Electric Vitalometers
Weisleder, et al. The validity of pulp testing. JADA 140:1013-1017, 2009. Weisleder, et al. The validity of pulp testing. JADA 140:1013-1017, 2009.
ANDREASEN FM, ANDREASEN JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations.Endod Dent Traumatol 1985;5:160-169.
ANDREASEN FM, ANDREASEN JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations.Endod Dent Traumatol 1985;5:160-169.
ANDREASEN FM, ANDREASEN JO, TSUKIBOSHI M. Examination and Diagnosis of Dental Injuries.In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. pp. 255-279.
ANDREASEN FM, ANDREASEN JO, TSUKIBOSHI M. Examination and Diagnosis of Dental Injuries.In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. pp. 255-279.
RADIOGRAPHIC EVIDENCE OF PATHOLOGYRADIOGRAPHIC EVIDENCE OF PATHOLOGY
2 Weeks - Pulpal Necrosis
3 Weeks - Inflammatory Resorption (External and Internal)
6 Weeks - Replacement Resorption (Ankylosis)
COMMON REACTIONS OF TEETH TO TRAUMACOMMON REACTIONS OF TEETH TO TRAUMA PULPAL HYPEREMIA (PULPITIS)
INTERNAL HEMORRHAGE
PULP NECROSIS
PULP CANAL OBLITERATION
INFLAMMATORY RESORPTION . . . . a) Internal b) External
REPLACEMENT RESORPTION (Ankylosis)
PULPAL HYPEREMIA (PULPITIS)
INTERNAL HEMORRHAGE
PULPAL CANAL OBLITERATION (PCO) - RESULTSPULPAL CANAL OBLITERATION (PCO) - RESULTS
PCO dependent on type of injury PCO dependent on stage of root
development PN subsequent to PCO was uncommon
(1%) PCO occurs later than PN (12 mos. vs
3mos) PCO increased with bands / resin fixation
Oginni, et al. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol 25:620-625; 2009
Oginni, et al. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol 25:620-625; 2009
276 teeth with PCO
Measured color, EPT, mobility & percussion
Yellow discoloration in 67%
PA lesions and negative EPT in 33%
Normal PA and EPT in 31%
Small PA changes/high normal EPT in 36%
EtiologyEtiology
Inflammatory resorption Surface resorption of
cementum exposing dentinal tubules
Pulp necrosis
Toxic products from the pulp provoke an inflammatory response in the PDL
Replacement ResorptionReplacement Resorption
Direct union of bone and root
Resorption of root - Replacement with bone
Direct result of loss of vital PDL
Primary Pulp Exposure TX optionsPrimary Pulp Exposure TX options
Partial pulpotomy in immature incisor Ram D, Holan G. Partial pulpotomy in a traumatized primary
incisor with pulp exposure. Pediatr Dent 16:44-48, 1994
Pulpotomy when no resorption has begun Flores M. Traumatic injuries in the primary dentition. Dent
Traumatol 18:287-298, 2002
Pulpectomy with resorbable paste – 20% deflections of succeeding permanent incisorsColl et al. 1996, Flaitz et al. 1989
Extraction
Howley B, Seale N. et al. Pulpotomy versus pulpectomy for carious vital primary incisors: randomized controlled trial. Pediatr. Dent. 34:112E 2012
Howley B, Seale N. et al. Pulpotomy versus pulpectomy for carious vital primary incisors: randomized controlled trial. Pediatr. Dent. 34:112E 2012
Matched pairs carious vital primary incisors received either FC pulpotomy or CaOH RCT
74 teeth followed clinically and radiographically for up to 23 months
Success in 89% of FC pulpotomies and 73% in RCT. No significant difference between.
Subluxation (loosening)Subluxation (loosening)
An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth
Intrusive Luxation(central dislocation)Intrusive Luxation(central dislocation)
A displacement of the tooth into the alveolar bone.
This injury is accompanied by comminution or fracture of the alveolar socket.
Injuries to Developing TeethInjuries to Developing Teeth
Discoloration of the enamel
Enamel hypoplasia
Crown or rootdilaceration
Arrested Development
Sequestration of tooth germ
Disturbance in eruption
Injury to developing successorsInjury to developing successors
20% Assuncao, et al 2009
25% Sennhenn-Kirchner, et al 2006
Mild hypoplasia most common (~75%)
Most frequently following intrusions, then avulsions
Children aged 1 – 3 years at greatest risk
Limited diagnostic value of lateral anterior film? Holan G, et al. Pediatr Dent 2002Limited diagnostic value of lateral anterior film? Holan G, et al. Pediatr Dent 2002
Total spontaneous re-eruption: 40 – 60 % Partial re-eruption: 40%Pulp necrosis or root resorption: 50%PCO: 50%
Gondim et al. 2005, Borum et al. 1998, Holan et al. 1999
Total spontaneous re-eruption: 40 – 60 % Partial re-eruption: 40%Pulp necrosis or root resorption: 50%PCO: 50%
Gondim et al. 2005, Borum et al. 1998, Holan et al. 1999
Intrusive LuxationIntrusive Luxation
Allow to reerupt if apex is displaced toward or through labial plate
Extract if apex is displaced into developing tooth
International Association of Dental TraumatologyGuidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012:28;174-182
International Association of Dental TraumatologyGuidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012:28;174-182
No evidence to support loss of space when primary anterior teeth are lost after primary canines erupt.
No evidence to support loss of space when primary anterior teeth are lost after primary canines erupt.
MANAGEMENT OF TRAUMATIC INJURIES TO YOUNG PERMANENT TEETH
MANAGEMENT OF TRAUMATIC INJURIES TO YOUNG PERMANENT TEETH
Capp, et al. Reattachment of rehydrated dental fragment using two techniques. Dent Traumatol 25:95-99, 2009
Capp, et al. Reattachment of rehydrated dental fragment using two techniques. Dent Traumatol 25:95-99, 2009
Remove dentin from coronal fragment before bonding
Rehydrate fragment in water for 30 minutes prior to bonding
Place chamfer on buccal and lingual surfaces after the fragment is bonded
Garoushi et al. Fracture resistance of fragmented incisal edges restored with fiber-reinforced composite. J Adhes Dent 8:91-95, 2006
Garoushi et al. Fracture resistance of fragmented incisal edges restored with fiber-reinforced composite. J Adhes Dent 8:91-95, 2006
Akgun et al. Ribbond for treatment of complicated crown fractures: Report of 3 cases. J Clin Ped Dent. 2012
TREATMENT ALTERNATIVES IN CLASS III FRACTURES OF PERMANENT TEETH
TREATMENT ALTERNATIVES IN CLASS III FRACTURES OF PERMANENT TEETH
DIRECT PULP CAP: small exposure, < 24 hours
PARTIAL PULPOTOMY (CaOH or MTA) preferred tx; larger exposures, > 24 hours
PULPECTOMY: closed apexAndreasen FM, Andreasen JO. Crown fractures. In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. 280-305.
International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2007:23
Andreasen FM, Andreasen JO. Crown fractures. In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. 280-305.
International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2007:23
CALCIUM HYDROXIDE PARTIAL PULPOTOMYCALCIUM HYDROXIDE PARTIAL PULPOTOMY
96% SUCCESS WITH PULPS EXPOSED
1 HOUR TO 90 DAYS
Cvek, M.: A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture, J. Endo., Vol. 4, #8, Aug. 1978, pgs 232-237.
TECHNIQUETECHNIQUE 1) Gently Remove Dentin and Pulp to 1-2 mm
2) Use Copious Irrigation
3) Cover Pulp with CaOH
MTA PulpotomyMTA Pulpotomy
Witherspoon, D. Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth.J Endod. 2008 Jul;34
Witherspoon, D. Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth.J Endod. 2008 Jul;34
Zhu W, et al. Endodontic treatment with MTA of a mandibular first premolar with open apex: case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jul;106(1):e73-5
Zhu W, et al. Endodontic treatment with MTA of a mandibular first premolar with open apex: case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jul;106(1):e73-5
What does it contain?What does it contain?
Tricalcium silicate
Dicalcium silicate
Tricalcium aluminate
Tetracalcium aluminoferrite
Calcium sulfate
Bismuth oxide
So it is Portland CementSo it is Portland Cement
IndicationsIndications
Pulp cap
Pulpotomy
Open apices
Revascularization
Perforations
Resorptions
Root-end
Why MTA?Why MTA?
Biocompatible
Low cytotoxicity
No mutagenicity
Periodontal regeneration
Cemental regeneration
Pulpal regeneration
Excellent seal
PulpotomyPulpotomy
Clinical Procedures
• MTA
• moist pellet
• temp filling
• 1 week perm filling
• check vitality every 3 to 6 months
Clinical Procedures
• MTA
• moist pellet
• temp filling
• 1 week perm filling
• check vitality every 3 to 6 months
MTA partial pulpotomyMTA partial pulpotomy
AdvantageGood success rate
DisadvantagesCostRe-entryDiscolorationMaterial manipulation
Biodentine pulpotomyBiodentine pulpotomy
Martens L, et. al. Pulp management after traumatic injuries with a tricalcium silicate-based cement (BiodentineTM): a report of two cases, up to 48 months follow-up. Eur Arch Paediatr Dent. 2015
Martens L, et. al. Pulp management after traumatic injuries with a tricalcium silicate-based cement (BiodentineTM): a report of two cases, up to 48 months follow-up. Eur Arch Paediatr Dent. 2015
Clinical ApplicationsClinical Applications
1. DPC/IPC2. Temporary Restorations3. Liner/Base (Dentin
replacement)4. Pulpotomy and partial
(Cvek) pulpotomy5. Repair of root/pulpal floor
perforations6. Apexification7. Retrograde Root Filling8. Apexogenesis9. Root resorption repair:
internal/external
CRITERIA FOR SUCCESSCRITERIA FOR SUCCESS
1) No clinical signs or symptoms
2) No radiographic pathology
3) Continued development of immature roots
4) Formation of calcific barriers
5) Sensitivity to electrical stimulation
NECROTIC IMMATURE TEETH
NECROTIC IMMATURE TEETH
Apexification: CaOH
Apexification: MTA
Apexogenesis: Revascularization
Disadvantages: CaOH ApexificationDisadvantages: CaOH Apexification
Multiple visits over 8 – 16 months
Must achieve hard barrier at apex
Long term CaOH further weakens tooth
High incidence of subsequent root fracture
Calcium hydroxide weakens dentinCalcium hydroxide weakens dentin
Andreasen J. et al. Long term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 18:134-137, 2002
Rosenberg B. et al. The effect of calcium hydroxide root filling on dentin fracture strength. Dent Traumatol 23:26-29, 2007
Sahebi S. et al. The effects of short-term calcium hydroxide application on the strenth of dentine. Dent Traumatol 26:43-46, 2010
Mineral Trioxide Aggregate (MTA)Mineral Trioxide Aggregate (MTA)
High pH (similar to CaOH)
Exceptional sealing properties
Hardens within hours enabling canal obturation
Simon S, et al. Int. Endo J., 2007Simon S, et al. Int. Endo J., 2007
Thibodeau B, Trope M: Pulp revascularization of a necrotic infected immature permanent tooth: A case report and review of the literature. Pediatr Dent. Jan. 2007, 29:47-50
ciprofloxacin
metronidazole
cefaclor
REVASCULARIZATIONREVASCULARIZATION
Huang G. A paradigm shift in endodontic management of immature teeth: Conservation of stem cells for regeneration. J Dent 2008;36:379-86
Trope M. Regenerative potential of dental pulp. Pediatr Dent 2008;30:206-10
Hargreaves K, et al. Regeneration potential of young permanent tooth: What does the future hold? Pediatr Dent 2008;30:253-60
MANAGEMENT OF LUXATION INJURIES TO THE YOUNG PERMANENT DENTITION
MANAGEMENT OF LUXATION INJURIES TO THE YOUNG PERMANENT DENTITION
CONCUSSIONCONCUSSION
An injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth but with marked reaction to percussion.
Subluxation (loosening)Subluxation (loosening)
An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth
Concussion Treatment:Inform patient & parent about
potential sequelae;
Monitor
Subluxation Tx:Splint ?? F/U in 2 weeks;
Radiograph at 1 month
Concussion Treatment:Inform patient & parent about
potential sequelae;
Monitor
Subluxation Tx:Splint ?? F/U in 2 weeks;
Radiograph at 1 month
Primate studies have demonstrated that rigid and/or prolonged splinting may lead to extensive PDL healing complications, like ankylosis and replacement resorption.
Andreasen, J. A time-related study of PDL healing and root resorption activity after replantation of mature permanent incisors in monkeys. Swed Dent J 4:101-110, 1982
Andersson L, et al. Effect of masticatory stimulation on dentoalveolar ankyosis after experimental tooth replantation. Endod Dent Traumatol 1:13-16, 1985
Primate studies have demonstrated that rigid and/or prolonged splinting may lead to extensive PDL healing complications, like ankylosis and replacement resorption.
Andreasen, J. A time-related study of PDL healing and root resorption activity after replantation of mature permanent incisors in monkeys. Swed Dent J 4:101-110, 1982
Andersson L, et al. Effect of masticatory stimulation on dentoalveolar ankyosis after experimental tooth replantation. Endod Dent Traumatol 1:13-16, 1985
SPLINTS SHOULD:SPLINTS SHOULD:
1) Be passive and atraumatic
2) Be durable
3) Be flexible
4) Allow for vitality testing and endodontic access
5) Be easy to apply and remove
SplintingSplinting
Use fish line/acid-etch resin; soft arch wire/resin; ortho brackets with passive arch wire; suture as last resort.
Circumferential wire splints contraindicated
Splinting - Home CareSplinting - Home Care
No biting on splinted teeth
Soft diet
Maintenance of good oral hygiene
Intrusive Luxation(central dislocation)Intrusive Luxation(central dislocation)
A displacement of the tooth into the alveolar bone.
This injury is accompanied by comminution or fracture of the alveolar socket.
Intrusion Treatment ControversyIntrusion Treatment Controversy
Andreasen JO et al. : Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Endo. Dent. Traumatol. 22:99-111, 2006.
Wigen, et al. Intrusive luxation of permanent incisors in Norwegians aged 6-17 years: a retrospective study of treatment and outcome. Dent Traumatol 24:612-618, 2008
Ebelseder et al. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Endod Dent Traumatol 16:34-39, 2000
Kenny, et al. Avulsions and Intrusions: the controversial displacement injuries. JCDA 69:291-297, 2003.
Intrusive Luxation Tx:Intrusive Luxation Tx:OPEN APEX
If < 7 mm allow spontaneous repositioning; ortho extrusion if no movement within 2-4 weeksIf > 7 mm reposition surgically or orthodontically
CLOSED APEX< 3 mm allow spontaneous eruption; ortho extrusion or surgical reposition if no movement within 2-4 weeks 3 – 7 mm reposition orthodontically or surgically>7 mm reposition surgically & splint for 2 weeks
Chlorhexidine mouthrinse Remove pulp & fill with CaOH < 2-3 weeks Complete endo fill in 1 - 2 months if no resorption Antibiotics not helpful
EXTRUSIVE LUXATION(Peripheral dislocation, partial avulsion)EXTRUSIVE LUXATION(Peripheral dislocation, partial avulsion)
A partial displacement of the tooth out of its socket.
Andreasen J. et al. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1:207-220, 1985Andreasen J. et al. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1:207-220, 1985
Andreasen J. et al. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol 18:116-128, 2002Andreasen J. et al. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol 18:116-128, 2002
Andreasen J. et al. The relationship between pulpal dimensions and the development of pulp necrosis after luxation injuries in the permanent dentition. Endod Dent Traumatol 2:90-98, 1986
Andreasen J. et al. The relationship between pulpal dimensions and the development of pulp necrosis after luxation injuries in the permanent dentition. Endod Dent Traumatol 2:90-98, 1986
Extrusive Luxation Tx:Extrusive Luxation Tx:
Reposition tooth ASAP; best prognosis if completed within 2 hours
Light splint for 2 weeks Remove pulp & fill with CaOH within 7-14
days Chlorhexidine mouthrinse Complete endo fill in 1 - 2 months if no
inflammatory resorption
Lateral LuxationLateral Luxation
A displacement of the tooth in a direction other than axially.
This is accompaniedby comminution or fracture of the alveolar socket.
Andreasen, JO, et al. Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th ed. Pg. 418
Lateral Luxation Tx:Lateral Luxation Tx:
Reposition tooth ASAP; best prognosis if completed within 2 hours
Light splint for 3 - 4 weeks Remove pulp & fill with CaOH within 7-14
days Chlorhexidine mouthrinse Complete endo fill in 1 - 2 months if no
inflammatory resorption
Andreasen J. et al. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 11:51-58, 1995
Andreasen J. et al. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 11:51-58, 1995
Andersson L and Bodin I. Avulsed human teeth replanted within 15 minutes – a long-term clinical follow-up study. Endod Dent Traumatol 6:37-42, 1990
Andersson L and Bodin I. Avulsed human teeth replanted within 15 minutes – a long-term clinical follow-up study. Endod Dent Traumatol 6:37-42, 1990
Treatment of the Avulsed Permanent Tooth
Treatment of the Avulsed Permanent Tooth
I. Management at site of injury
II. Transport media
III. Management in dental office
IV. Adjunctive drug therapy considerations
V. Endodontic treatment
VI. Restoration of the avulsed tooth
Management at Site of InjuryManagement at Site of Injury
Replant immediately, if possible. If contaminated, rinse.
When cannot be replanted, place tooth in best transport medium available.
Recommended Storage MediaRecommended Storage Media1. Socket (immediate
replantation)
2. Cell culture medium
3. Milk
4. Physiologic saline
5. Saliva
Blomlof L. Milk and saliva as possbile storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J. 8:1-26, 1981Blomlof L. Milk and saliva as possbile storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J. 8:1-26, 1981
Wilson R. et al. Storage media for avulsed teeth: a literature review. Braz. Dent J 2013.Wilson R. et al. Storage media for avulsed teeth: a literature review. Braz. Dent J 2013.
Management of the Avulsed ToothManagement of the Avulsed Tooth What tissue should be
our primary concern? Pulp?
Socket?
PDL?
Management of the Avulsed ToothManagement of the Avulsed Tooth Ultimate goal
PDL healing without root resorption
Most critical factorMaintaining an intact
and viable PDL on the root surface
Managing Mature ToothExtraoral DRY Time < 1 Hour
Managing Mature ToothExtraoral DRY Time < 1 Hour
Objective is to maintain PDL cell vitality
Place in HBSS during history & exam
Handle by crown and gently replant
Splint 1 – 2 weeks
Remove pulp in 7-14 days
Place CaOH
Obturate canal in 2-4 weeks
Management of Root SurfaceManagement of Root Surface
Objective is to maintain PDL cell vitality
Keep moist in HBSS
Do not handle root surface
Gently remove persistent debris
Management of the SocketManagement of the Socket
Gently aspirate without entering socket
If clot present use saline irrigation
Do not curette socket
Do not vent socket
If alveolar bone collapsed, use blunt instrument to reposition
Manually compress bony plates after replantation
Management of Soft TissuesManagement of Soft Tissues
Tightly suture any soft tissue lacerations, particularly in the cervical region
SplintingSplinting
Use fish line/acid-etch resin; soft arch wire/resin; ortho brackets with passive arch wire; suture as last resort.
Circumferential wire splints contraindicated
Maintain splint 10-14 days; longer if tooth demonstrates excessive mobility
Splinting - Home CareSplinting - Home Care
No biting on splinted teeth
Soft diet
Maintenance of good oral hygiene
Antibiotics??Antibiotics??
Hammarstrom, L. et al., Endod Dent Traumatol 1986; parenteral antibiotics prior to extraction and immediately
following replantation resulted in less inflammatory resorption in monkeys. Prevents bacterial invasion of the necrotic pulp and inflammatory resorption; route & timing
Sae-Lim V. et al., Endod Dent Traumatol 1998; Tetracycline decreases root resorption by affecting the motility
of the osteoclasts and reduces effectiveness of collagenase
Cvek M. et al. Endod Dent Traumatol 1990; Soaking teeth in topical doxycycline prior to replantation
enhances revascularization
Adjunctive Drug Therapy Considerations
Adjunctive Drug Therapy Considerations
Systemic antibiotics: If < 12 y/o pen v (250 mg/kg/d in 4 divided doses x 7
days)
If ≥ 12 y/o doxycycline (100 mg q 12 h first day, then 50 mg q 12 h days 2 – 10)
Tetanus consultation within 24 hours
Chlorhexidine mouth rinses
NSAIDs to inhibit bone resorption & pain relief
Endodontic TreatmentMature Tooth < 1 Hour DRY Time
Endodontic TreatmentMature Tooth < 1 Hour DRY Time
Remove pulp in 7-14 days
Place CaOH
Obturate canal in 2-4 weeks
Endodontic TreatmentMature Tooth
Endodontic TreatmentMature Tooth
Remove pulp as soon as possible
Place Triamcinolone for at least 2 weeks
Obturate canal when no evidence of root resorption
Intracanal corticosteroids inhibit root resorption. Chen H, et al. Dent Traumatol 2008
Intracanal corticosteroids as anti-inflammatory, anticlastic meds: AAE Trauma Guidelines, 2013
PROGNOSIS IS BEST FOR REIMPLANTED TEETH IF :PROGNOSIS IS BEST FOR REIMPLANTED TEETH IF : Extra-Oral period is minimal
Periodontal ligament is not traumatized
If not replanted the transport and soaking solution is HBSS
Endo therapy is not done in the hand before reimplantation
An appropriate splint is applied for 1 week
CaOH pulpectomy is completed in 1 wk
Managing Avulsed Immature Tooth Open Apex < 1 Hour DRY Time
Managing Avulsed Immature Tooth Open Apex < 1 Hour DRY Time
Objective is to revitalize severed pulp
Managing Avulsed Immature Tooth
Open Apex < 1 Hour DRY Time
Managing Avulsed Immature Tooth
Open Apex < 1 Hour DRY Time
Best chance if replanted within 20 minutes - MUST be replanted within 60 minutes
Soak in doxycycline solution for 5 minutes ?
Replant and splint for two weeks
Recall every 3-4 weeks
If pathosis noted, extirpate pulp and do regenerative
procedure
Managing Mature ToothExtraoral DRY Time > 1 Hour
Managing Mature ToothExtraoral DRY Time > 1 Hour
Objective is to delay inevitable root resorption
Managing Mature ToothExtraoral DRY Time > 1 Hour
Managing Mature ToothExtraoral DRY Time > 1 Hour Objective is to delay inevitable root resorption
Remove all PDL fragments (manually, NaOH, Citric acid)
Soak in fluoride (Shulman, et al. JDR, 1973)
Complete endo now or later
Replant & splint
Anticipate replacement resorption
Consider decoronation
CLINICAL SIGNS OF ASPIRATION
CLINICAL SIGNS OF ASPIRATION
1) No symptoms
2) Initial choking and coughing
3) Irritating cough
4) Wheezing
5) Unilateral obstructive emphysema
6) Atelectasis
7) Pulmonary suppuration
Jarvinen S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 36:359-362, 1978
Jarvinen S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 36:359-362, 1978
Normal overjet 1 – 3 mm
Overjet 3 – 6 mm = 2 X injuries
Overjet 6 – 9 mm = 3 X injuries
Bauss O, et al. Influence of extrusion on pulpal vitality of traumatized maxillary incisors. JOE 36:203-207, 2010
Bauss O, et al. Influence of extrusion on pulpal vitality of traumatized maxillary incisors. JOE 36:203-207, 2010
Retrospective study comparing pulp vitality after ortho extrusion of traumatized vs. non-traumatized incisors
Traumatized teeth significantly more likely to become necrotic than non-traumatized
Necrosis occurred most frequently in early stages of extrusion.
Kindelan, et al. Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1. JO 35:68-78, 2008
Kindelan, et al. Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1. JO 35:68-78, 2008
“traumatized teeth that show signs of root resorption before orthodontic tx are at high risk of increased root resorption as a result of orthodontic forces” Levander et al. Eur J Orthod 10:30-38, 1988
“traumatized teeth that show signs of root resorption before orthodontic tx are at high risk of increased root resorption as a result of orthodontic forces” Levander et al. Eur J Orthod 10:30-38, 1988
ROOT FRACTURES FRACTURES INVOLVING:
DENTIN, CEMENTUM, and PULP
ROOT FRACTURES FRACTURES INVOLVING:
DENTIN, CEMENTUM, and PULPHealing Responses to Root
FractureHealing Responses to Root
Fracture Hard Tissue
Formation
Connective Tissue
Bone & Connective Tissue
Granulation Tissue
(non-healing)
Cvek M. et al. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7-17 years. Dent Traumatol 24:379-387, 2008
Cvek M. et al. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7-17 years. Dent Traumatol 24:379-387, 2008
78 % healed with hard tissue formation or interposition of soft tissue between the fragments
Highest frequency of tooth loss occurred in teeth with horizontal fractures in the cervix of the root
Principles of Root Fracture Treatment in Permanent Teeth
Andreasen, et al. Dent Traumatol, 2004
Principles of Root Fracture Treatment in Permanent Teeth
Andreasen, et al. Dent Traumatol, 2004
1) Treat ASAP 2) Reduce displaced fragments 3) Light splint for Middle & apical third 1 monthCoronal third 2 – 4 months
4) Monitor pulp vitality 5) Antibiotics NOT helpful
Bourguignon C. and Sigurdsson A. Preventive strategies for traumatic dental injuries. Dent Clin North Am 53:729-749, 2009.
Bourguignon C. and Sigurdsson A. Preventive strategies for traumatic dental injuries. Dent Clin North Am 53:729-749, 2009.
Mouthguards reported to reduce dental injuries up to 90% in contact sports
Laminated thermoplastic mouthguards are dimensionally most stable
No ethically feasible in vivo models to complete prospective studies
No evidence to support claims that mouthguards prevent neck or cerebral brain injuries
Dealing with “Lost-Cause” Injured TeethAn Introduction to Regenerative EndodonticsDealing with “Lost-Cause” Injured TeethAn Introduction to Regenerative Endodontics
Disadvantages: CaOH ApexificationDisadvantages: CaOH Apexification
Multiple visits over 8 – 16 months
Must achieve hard barrier at apex
Long term CaOH further weakens tooth (Doyon et al. 2005. Andreason J et al. 2002)
High incidence of subsequent root fracture (Cvek M. 1992)
Shabahang S, Torabinejad
M., 2000
Mineral Trioxide Aggregate (MTA)Mineral Trioxide Aggregate (MTA)
High pH (similar to CaOH) Exceptional sealing propertiesHardens within hours enabling canal
obturationNo root wall thickening
Simon S. et al. 2007.
Periapical tissue grows into pulp space of necrotic immature
permanent teeth.
Promotes maturogenesis.
Naturally or can be induced.
Revascularization
Banchs F, Trope M. 2004.
Thibodeau et al. 2007.
Regenerative EndodonticsRegenerative Endodontics Biologically based procedures to replace
damaged structures, including dentin and root structures and cells of the pulp-dentin complex, with live tissues that restore normal physiologic function.
Nygaard-Ostby B. 1961
Murray, et. al, 2007.
• 1950s-60s: Nygaard-Østby – role of blood clot in endo tx• 1950s: Ca(OH)2 used in a case report of vital pulp amputation• 1980-90s: Guided tissue or bone regeneration (GTR, GBR)• 1990s: Distraction osteogenesis • 1990s: Emdogain for periodontal tissue regeneration • 1990s: Recombinant human bone morphogenic protein
(rhBMP) • 2000: Platelet rich plasma (PRP) for bone augmentation • 2000: Fibroblast growth factor 2 (FGF2) for PDL
regeneration
History of Regenerative Dentistry
Tissue EngineeringTissue Engineering
Stem Cells
Signaling Molecules
Scaffolds
Hargreaves, et al. 2008
Murray et al. 2007
Cohen, S. et al.,2010.
Stem CellsStem Cells
Embryonic/fetal Postnatal/adult
Self renewal Proliferation Differentiation
Potency – potential to divide and express cells of different phenotypesPluripotent – embryonic - can differentiate into
endoderm, mesoderm or ectodermMultipotent - postnatal - can form other tissues;
umbilical cord blood, bone marrow, postnatal dental stem cells
Her own stem cells used to build tot a windpipeHer own stem cells used to build tot a windpipe
By Lindsey Tanner
Associated Press• Wednesday May 1, 2013 6:25 AM
CHICAGO — A 2-year-old girl born without a windpipe now has a new one grown from her own stem cells, the youngest patient in the world
to benefit from the experimental treatment.
Dental Stem CellsDental Stem Cells
Dental pulp stem cells (DPSC) differentiate into odontoblast-like cells involved in reparative dentin formation ~1% of pulp cells – decrease in number with age
Stem cells from exfoliated deciduous teeth (SHED) Periodontal ligament stem cells (PDLSC) Stem cells of the apical papilla (SCAP)
different than stem cells in mature tissues superior for hard tissue regeneration – possibly in
development of root dentin
Evoked bleeding triggers significant accumulation of undifferentiated stem cells into the canal space.
Friedlander, et al. 2009Huang, et al. 2008
Lovelace, et al. 2011
SCAPSCAP Essential for continued root development Undergo dentinogenic differentiation
when stimulated Differentiate into functional dentinogenic
cells in vivo, when implanted in animal models (Sonoyama, et al. 2006)
Adipogenic and neurogenic differentiation capabilities when treated with appropriate stimulation medium.
Potential to enable continued root development, pulpal healing and regeneration.
Sonoyama, et al. 2008
Growth FactorsGrowth Factors Proteins that bind to receptors on cells and induce cell proliferation and/or differentiation
Some cell specific - others versatile Many control stem cell activity, e.g. rate of proliferationdifferentiation into another tissue typesynthesis/secretion of mineralized matrix.
BMPs, PDGF, VEGF vascular endothelial growth factor (angiogenic factor), FGF-2
Demineralization of dental tissue can stimulate growth factor release.
Inflammation + and -Mullan, et al. 2008
Friedlander, et al. 2009
Smith, et al. 1995
ScaffoldsScaffolds
Tissues are 3 dimensional and need scaffold to promote cell growth and differentiation.
Bind and localize cells Contain growth factors Biodegrade over time healthy pulp.
Blood clot Platelet-rich plasma - PRP
Hargreaves K. et al. 2008
Biology of the root apexBiology of the root apex
Dental papilla evolves into dental pulp
Inner and outer enamel epithelia fuse to form HERS
As HERS migrates apically, the dental papilla is located apically to the developing pulp and is called the apical papilla.
Sonoyama, et al. 2008
Apical papilla – collateral circulation – maintains vitality
when tooth is necrotic
Removing papilla halts root formation…yet it continues if pulp is extirpated and papilla remains.
Soft, separable from tooth. Histologically, distinct from pulp,
less vascular and cellular.
DisinfectionDisinfection No tissue regeneration if infection. Better success with doxycycline soak. Bacterial biofilm on canal walls,
anatomical recesses, periapical area and dentinal tubules.
Higher level of disinfection needed for immature, infected teeth than mature teeth.
Root canal system infection is polymicrobial.
Combo antibiotics sterilize canal -minimize resistant bacteria
Metronidazole, ciprofloxacin and minocycline effective. Ritter, A. et al. 2004.
Hoshino, E. et al. 1996.Kling M. et al. 1986
Antibiotics (1:1:1)Metronidazole 500mg capCiprofloxacin 200mg capMinocycline 100mg cap
Carrier (1:1)Macrogol ointment Propylene glycol
Antibiotics: Carrier (1:5)
Triple Antibiotic Paste
Hoshino et al. 1996
High concentrations of antibiotics are toxic to SCAPHigh concentrations of antibiotics are toxic to SCAP Ruparel N. et al. Direct effect of intracanal
medicaments on survival of stem cells of the apical papilla. JOE 2012;58:1372-75
Trevino E. et al. Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. JOE 2011;37:1109-15
2 % chlorhexidine is toxic to stem cells2 % chlorhexidine is toxic to stem cells
Indications for RevascularizationIndications for Revascularization
No evidence-based guidelines for case selection
Necrotic immature teeth caused by trauma (caries?)
Apical opening > 1mm to allow ingress of regenerative tissue
Huang G. Journal of Dentistry 2008;36:379-386
Thibodeau B, Trope M. Pediatr Dent 2007;29:47-50.
McTigue D, Subramanian S, Kumar A. Management of immature permanent teeth with pulpal necrosis: a case series. Pediatr. Dent. 2013;35:55-60.
McTigue D, Subramanian S, Kumar A. Management of immature permanent teeth with pulpal necrosis: a case series. Pediatr. Dent. 2013;35:55-60.
32 regenerative endo cases in 28 children
10 teeth presented with sinus tracts
Apical healing occurred in 31 teeth
22 teeth (71%) achieved all root maturation parameters:
Apical closure
Root wall thickening
Root lengthening
Tooth DiscolorationTooth Discoloration
14 teeth discolored
7 discolored using both minocycline and grey MTA
7 teeth discolored with no minocycline and white MTA
11 teeth successfully bleached
Definition of successDefinition of success
Healing of sinus tract
Absence of signs and symptoms
Continued root development –“maturogenesis”
Platelet-rich plasma
Platelet-rich Plasma (PRP)Platelet-rich Plasma (PRP) Contains growth factors
Stimulates collagen production
Recruits other cells to site of injury
Produces anti-inflammatory agents
Initiates vascular growth
Induces cell differentiation
Controls local inflammatory response
Improves soft and hard tissue wound healing
Torabinejad M and Turman M. 2011
PRPPRP
PROEase of applicationShorter time to induce vital tissues within root
canal system.
CONDrawing blood on young patientSpecial equipment & meds to prepare PRPIncreased cost
Future Regenerative EndoFuture Regenerative Endo PRP Apical negative pressure irrigation Autologous post-natal stem cells
injected into teeth in a matrix Pulp implant – pulp tissue grown
in vitro in sheets and implanted surgically
Scaffold implant – pulp cells seeded to 3-D scaffold made of polymers and implanted surgically
Gene therapy – mineralizing genes introduced into vital pulp cells of necrotic and symptomatic teeth da Silva L. et al. 2010
Huang, et al. 2008 Murray, et. al, 2007.
Hargreaves, et al. 200
More Questions than Answers!More Questions than Answers!
“Revascularization” “ Revitalization” “Regeneration”??
Is it pulp…PDL…bone…cementum??? Antibiotics?? CaOH?? Biocompatible irrigants/disinfectants: NaOCl
…chlorhexidine..noni juice..Aquatine EC?? Stem cells?? Immunologic profile? Definition of “Success”?
Complications - ChallengesComplications - Challenges
Adequate Disinfection
Scaffold formation
Staining
Stimulating bleeding
Placing MTA
Bacteria-tight seal
Behavior!!
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