Dental trauma can range from minor enamel injuries to significant loss of teeth and hard and soft tissues. When faced with such emergencies, the clinician must consider
surgical, restorative, endodontic, and periodontal implications and make quick decisions on a treatment that can lead to the best long term result. In this presentation,
Dr. H. Ryan Kazemi will review various types of dental injuries and a simplified map to choosing the most appropriate treatment quickly and easily. In addition, he will discuss complicating factors and treatment concepts.
10. vitality test!
- short term!
- long term
examination- teeth
percussion!
- pain ! —> injury to periodontal ligament!
- sound —> dull (subluxated) or hard metallic (locked)
teeth!
color
day 0 day 28 2 months 3 months
0 29.4% 82.35% 94.11%
positive responsiveness in pulp tests
13. hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
14. hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
crown infraction!
uncomplicated crown fracture!
complicated crown fracture!
uncomplicated crown-root fracture!
complicated crown-root fracture!
root fracture
15. hard dental
tissue & pulp
impact to only enamel!
transillumination for dx!
upper incisor labial aspect!
—> no treatment!
vitality check & f/u!
if non vital at time of exam,
observe
crown infraction
16. hard dental
tissue & pulp
enameloplasty!
composite restoration
crown fracture
uncomplicated- enamel only
17. hard dental
tissue & pulp
seal dentin tubules!
promote secondary dentin
deposition!
calcium hydroxide liner
over dentin and composite
restoration!
monitor vitality
crown fracture
uncomplicated- enamel & dentin
glass ionomer
CaOH2 solubility in water —> dissolution
18. hard dental
tissue & pulp
enamel & dentin with
exposure of pulp!
!
treatment options:!
pulp capping!
partial pulpotomy!
endodontic treatment
crown fracture
complicated- enamel &
dentin with exposure of pulp
19. hard dental
tissue & pulp
tooth is sound & small exposure!
!
!
pulp capping!
(CH or MTA)
crown fracture
complicated- enamel &
dentin with exposure of pulp
20. MTA- mineral trioxide aggregate!
•forms CH that releases ca ions for cell
attachment and proliferation!
•creates an antibacterial environment
with its alkaline PH!
•modulated cytokine production!
•encourages differentiation and migration
of hard tissue producing cells!
•forms hydroxyapatite on MTA surface
and provides a biological seal
Pitt-Ford and Patel: Most pulps
capped with MTA were free of
inflammation and showed
calcified bridge after 5 months
21. hard dental
tissue & pulp
!
immature teeth with open apex!
!
!
cervical pulpotomy!
(MTA / CH)
crown fracture
complicated- enamel &
dentin with exposure of pulp
2-4 mm
most require pulpectomy after root development is completed
23. Biodentine™: a dentin substitute indicated for use in:!
!
crown for temporary enamel restorations!
permanent dentin restorations!
deep or large carious lesions!
deep cervical or radicular lesions!
pulp capping or pulpotomy!
used in the root for root and furcation perforations!
internal and external resorptions!
apexification!
retrograde surgical filling.
biodentine!
bioactive dentin substitute
24. sets in 10 - 12 minutes!
!
natural micro mechanical anchorage
for excellent sealing properties
without surface preparation.!
!
similar mechanical properties and
mechanical behavior as human
dentin.!
!
3.5mm aluminum radiopacity for
easy short and long term follow-up.
biodentine!
bioactive dentin substitute
25. hard dental
tissue & pulp
!
mature teeth with closed apex!
!
!
pulpectomy &
endodontic tx
crown fracture
complicated- enamel &
dentin with exposure of pulp
26. hard dental
tissue & pulp
treatment depending on
amount of root remaining!
primary teeth —> extract!
permanent teeth —>!
> extract: too apical / vertical!
> rct / ortho eruption!
> rct and submerge root!
> extraction / site graft!
> extraction / immed. implant
crown-root fractures
uncomplicated (no pulp exposure)
44. hard dental
tissue & pulp
75% involve centrals!
40% with alveolar bone fx!
primary teeth —> if no
mobility, may preserve and
allow normal exfoliation. If
mobile, then extract
root fractures
45. hard dental
tissue & pulp
permanent teeth!
apical third level!
!
no mobility- prognosis
good with minimal
treatment.!
coronal aspect may remain
vital and no endo treatment
may be necessary.
root fractures
46. hard dental
tissue & pulp root fractures
permanent teeth!
mid-root level!
!
may have fair prognosis!
needs splinting: 2-3 month!
check vitality continually!
resorption in 60% within 1y!
!
>> immediate implant / graft!
>> site graft / delayed implant
66. tooth fracture!
(adult)
above bone at bone below bone
no pulp
exposure
pulp
exposure
minor!
fracture
sig!
fracture
buccal
bone
no buccal
bone
restore pulpectomy
restore
crown
length or
ortho
eruption
treat same as
below bone
fracture
extract!
graft
implant
extract!
implant!
graft
68. periodontal!
tissue
tooth is tender to touch!
no mobility!
percussion sensitive!
no treatment!
check vitality later as
necrosis can develop in
several weeks to months
concussion
73. periodontal!
tissue
compression into socket!
impaction to complete
disappearance in alveolus!
significant damage to pdl!
high incidence of external
resorption, pulp necrosis,
marginal bone loss!
percussion- dull metallic
intrusive luxation
75. periodontal!
tissue
apex displaced out of
socket with NV rupture!
pdl space is widened!
dull percussion sound!
primary tooth —> extract
extrusive luxation
85. periodontal!
tissue
rct & submerge!
(preserve tissue)!
if!
no bone fracture!
patient growth incomplete!
adult patient with soft
tissue loss (goal is to
regenerate soft tissue)
retained root fracture
86. periodontal!
tissue
rct & ortho eruption!
(to augment tissue)!
if !
no bone fracture!
soft tissue is apical to
adjacent gingival margin!
vertical bone loss (good
bone level on adjacent
tooth)
retained root fracture
91. periodontal!
tissue
15% of permanent teeth!
7-13% of primary teeth!
maxillary incisors!
most common age 7-10!
treatment goal: maintain
vitality of cells (pulp & pdl)
avulsion (exarticulation)
93. periodontal!
tissue
other factors for success!
!
width & length of root canal!
stage of root development!
type of storage medium!
degree of oral trauma
avulsion (exarticulation)
95. periodontal!
tissue
Andreasen & Hjorting-Hansen!
!
after 2 years or more, 90%
of teeth re-implanted within
30 minutes exhibit no
discernible resorption of
roots!
95% resorption if > 2 hours
avulsion (exarticulation)
re-implantation
97. periodontal!
tissue
early re-implantation is key!
instructions if at site of injury!
1. inspect tooth for debris!
2. hold only by crown!
3. cleanse with milk or saliva!
4. put tooth into socket!
5. hold with light pressure!
6. come to office
avulsion (exarticulation)
103. periodontal!
tissue
treatment- closed apex!
(dry time < 30 min; tooth in medium 20 min to 6 h)!
!
irrigate tooth if with debris!
clean coagulum with saline!
re-implant and press!
splint while patient in occlusion!
nonrigid splint for 1-2 wk!
if bone fx —> splint 3-4 wk!
suture lacerations
avulsion (exarticulation)
re-implantation
104. periodontal!
tissue
treatment- closed apex!
(dry time > 60 min)!
!
irrigate tooth if with debris!
clean coagulum with saline!
immerse tooth in sodium fluoride
solution- 5 minutes!
re-implant and press!
keep patient in occlusion!
nonrigid splint for 4-6 wks
avulsion (exarticulation)
re-implantation
105. periodontal!
tissue
Post treatment- closed apex!
!
doxycycline or penicillin vk for 7 days!
chlorhexidine rinse for 1 week!
assess tetanus vaccination!
soft diet 2 weeks!
initiate pulpectomy within 7-14 days
avulsion (exarticulation)
re-implantation
106. periodontal!
tissue
treatment- open apex!
(dry time < 30 min; tooth in medium 20 min to 6 h)!
!
irrigate tooth if with debris!
tooth in doxycycline (100 mg / 20 cc
saline) for 5 minutes!
clean coagulum with saline!
re-implant and press!
keep patient in occlusion!
nonrigid splint for 1-2 wk
avulsion (exarticulation)
re-implantation
107. periodontal!
tissue
treatment- open apex!
(dry time > 60 min)!
!
reimplantation usually not indicated (per
american association of endodontics)!
may follow same protocol as closed apex
(McIntyre, Lee, Trope- permanent tooth
replantation following avulsion- pediatric dent
31:137, 2009)
avulsion (exarticulation)
re-implantation
108. periodontal!
tissue
post treatment- open apex!
!
doxycycline or penicillin vk for 7 days!
chlorhexidine rinse for 1 week!
assess tetanus vaccination!
soft diet 2 weeks!
monitor every 4 weeks + pulp test + X-rays!
apexogenesis over next 12-18 months?
avulsion (exarticulation)
re-implantation
112. hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
comminution of the alveolar socket!
fracture of the alveolar socket wall!
fracture of the alveolar process!
fractures of the mandible or maxilla
116. hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
laceration of gingiva or oral mucosa!
contusion of gingiva or oral mucosa!
abrasion of gingiva or oral mucosa