lecture trauma border study club aug 2015 - next meeting · at the end of this seminar participants...

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www.zimendo.com.au

Sam Sophie Thomas Simran

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DENTOALVEOLAR TRAUMA UPDATE:HAVE OUR TREATMENTS RECENTLY CHANGED?

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Phillippe O Zimet Associate Professor in Endodontics School of Dentistry and Oral Health La Trobe University 77 Stud Rd Dandenong www.zimendo.com.au [email protected]

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Programme: 9.30 – 10.00: The aims and objectives of trauma management – A/Prof Phillippe O Zimet 10.00 – 10.45: Initial and emergency triage – Dr Averil Tse 10.45 – 11.30: When/how long is splinting required – Dr Kim Dang 11.30 – 12.15 lunch 12.15 – 1.00: Pulpal changes following trauma. When is it necessary to undertake RCT? - Dr Sara Firouzabadi 1.00– 1.45: Managing the fractured crown – Dr Daniel Felman 1.45 – 2.15: Afternoon Tea 2.15– 3.00: Managing the open apex – Dr Artika Soma 3.00 – 3.45: For How long should patients be followed up following/after dental trauma? A/Prof Phillippe O Zimet 3.45 – 4.15 Panel discussion and question time !!!!!!

Programme: 9.30 – 10.00: The aims and objectives of trauma management – A/Prof Phillippe O Zimet 10.00 – 10.45: Initial and emergency triage – Dr Averil Tse 10.45 – 11.30: When/how long is splinting required – Dr Kim Dang 11.30 – 12.15 lunch 12.15 – 1.15: Pulpal changes following trauma. When is it necessary to undertake RCT? - Dr Sara Firouzabadi 1.15 – 1.45: Afternoon Tea 1.45– 2.30: Managing the open apex – Dr Artika Soma 2.30 – 3.45: Managing the fractured crown For How long should patients be followed up following/after dental trauma? A/Prof Phillippe O Zimet 3.45 – 4.15 Panel discussion and question time !!!!!!

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At the end of this seminar participants will: 1.  be able to identify those factors which require management at the initial and emergency triage. Dr Averil Tse 2.  be aware when and how long splinting is required. Dr Kim Dang 3.  understand the effect of trauma on the pulp. Dr Sara Firouzabadi 4.  be aware of management of the fractured crown following trauma. Dr Daniel Felman 5.  apply knowledge on current thoughts on pulp capping and pulp preservation. Dr Artika Soma 6. be able to implement a post trauma follow-up protocol. A/Prof Phillippe Zimet!

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Introduction: A guide for the perplexed 1. describe the aim and objective of trauma management. 2. classify dental injuries. 3. Be aware of the variability of response of the dento-alveolar tissues to dental trauma.

yusop fracture 12 and cvek pulpotomy heal 280613.jpg!

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Introduction: 1.  Describe the aim and objective of trauma management. 2.  Classify dental injuries. 3.  Be aware of the variability of response of the dento-alveolar tissues to dental trauma.

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The issues: 1.  Occurs unscheduled, inconvenient and inopportune

time. 2.  Families are in distress expecting immediate

decisions. 3.  How to manage the unpredictability of presentation

and outcome? 4.  May affect patient self image – fix patient ASAP 5.  Avoid extensive and expensive future treatment 6.  Avoid treatable pathology

AIM of Trauma Management: • Maintain, preserve or reinstate the original dentition Objective of Trauma Management: • Preserve the pulp • Preserve the periodontal ligament • Maintain aesthetics of the dentition • Maintain function of the dentition • Ensure comfort of the dentition

lachlan Carstein from Jemima roberts 110511 traumati pulp exposure!

What to do? Immediate: •  to manage presenting complaint •  to prevent future problems (pulp, tooth,

periodontium) Long term: maintain management in the most conservative means possible to maintain the pulp and periodontium !

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lachlan Carstein from Jemima roberts 110511 traumati pulp exposure!

Problem is: •  Immediate presentation after trauma is variable and

unpredictable •  Long term response of tissues is variable and

unpredictable Understand the variability to create an ordered response to management of the patient following dento-alveolar trauma.!

How to use Guides and Guidelines – theory versus application: •  EVIDENCE BASED or BEST

AVAILABLE EVIDENCE •  As evidence increases and

reinterpreted the Guidelines are modified

•  Guidelines act as a guide and not absolute criteria and allow for clinical judgement as necessary.

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Treatment guidelines are from

www.iadt-dentaltrauma.org:

1. Guidelines for the evaluation and management of traumatic dental injuries – Part 1 Fractures and Luxations of Permanent Teeth. International Association of Dental Trauma Updated February 2012 Part 1: Fractures and luxations of permanent teeth Anthony J. DiAngelis, Jens O. Andreasen, Kurt A. Ebeleseder, David J. Kenny, Martin Trope, Asgeir Sigurdsson, Lars Andersson, Cecilia Bourguignon, Marie Therese Flores, Morris Lamar Hicks, Antonio R. Lenzi, Barbro Malmgren, Alex J. Moule, Yango Pohl, Mitsuhiro Tsukiboshi

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2. Guidelines for the evaluation and management of traumatic dental injuries – Part 2 Avulsion of Permanent Teeth . International Association of Dental Trauma Updated February 2012 Part 2: Avulsion of permanent teeth Lars Andersson, Jens O. Andreasen, Peter Day, Geoffrey Heithersay, Martin Trope, Anthony J. DiAngelis, David J. Kenny, Asgeir Sigurdsson, Cecilia Bourguignon, Marie Therese Flores, Morris Lamar Hicks, Antonio R. Lenzi, BarbroMalmgren, Alex J. Moule, Mitsuhiro Tsukiboshi.



3. Guidelines for the evaluation and management of traumatic dental injuries – Part 3 Injuries in the Primary Teeth. International Association of Dental Trauma Updated February 2012 Part 3: Trauma to primary teeth Barbro Malmgren, Jens O. Andreasen, Marie Therese Flores, Agneta Robertson, Anthony J. DiAngelis, Lars Andersson Giacomo Cavalleri, Nestor Cohenca Peter Day, Morris Lamar Hicks, Olle Malmgren, Alex J. Moule, Juan Onetto, Mitsuhiro Tsukiboshi.

4. The Dental trauma Guide http://www.dentaltraumaguide.org !

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6. Dental Trauma Application for iPhone

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lucy 25 11 10 concussion subluxation trauma enamel chip!

Examination for all trauma: Following PMH and presenting complaint

(when, where, what happened)

Clinical signs in descending order •  Note/locate missing teeth and segments of teeth

•  Soft tissue lacerations and swelling

•  Dislocation vertical/horizontal– mm

•  Occlusal interference

•  Loosening

•  Thermal test (sensibility, sensitivity)

•  Gingivitis and Pocket depth and Recession

•  Tooth Colour and craze lines

•  Tenderness to palpation

•  Tenderness to percussion

• Radiograph-mm dislocation, pulp calcification, continued root development, marginal bone loss, periradicular radiolucency, tooth resorption.!

• .!

Why do we classify dental injuries? To provide guidance as to the possible effects the trauma had on the tooth and periodontium. If you know what to expect; you know how to treat.

1.Gingival margin

Fig 2.16 Andreasen et al Textbook and Colour Atlas of Traumatic Injuries to the teeth 4th ed

Tissues that may be damaged?

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2. PDL Rupture of fibres between root surface and alveolar bone although can occur where fibres insert into bone or cementum Andreasen et al Textbook and Colour Atlas of Traumatic Injuries to the teeth 4th ed Chap 17

Distinguish between injury to PDL and damage to cemenetum Grzesik and Narayanan Crit Rev Oral Biol Med 13(6):474-484 (2002)

Fig 2.18 Andreasen et al Textbook and Colour Atlas of Traumatic Injuries to the teeth 4th ed


3. Pulp neurovascular bundle is severed

4. Alveolar bone may fracture

Andreasen et al Textbook and Colour Atlas of Traumatic Injuries to the teeth 4th ed Fig 17.2

5. Cementum surface is damaged

6. Cementum, Dentine and enamel Fracture of dental hard tissues


From Andreasen Dental Traumatology 2012; 28: 142–147; Fig 3

Dental Trauma Entities – each has a different treatment. !Injuries to the dental hard tissues and the pulp

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From Andreasen Dental Traumatology 2012; 28: 142–147; Fig 3

Dental Trauma Entities – each has a different treatment. Injuries to the periodontal tissues

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Problem: Outcome after traumatic dental injury is not predictable Pathology may not be evident early. Pathology may provide confusing signs and symptoms.

Sitra yusuf!

18 09 08

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RESULTS OF TRAUMA-MANY TISSUES AFFECTED BY TRAUMA!"""!

• •

Nothing/Physiologic surface resorption Pulp healing

• Internal Resorption (apic/intraradicular) • External Resorption (Infection

Induced / Inflammatory)

• External Resorption (Replacement) Ankylosis • Pulpal Canal Obliteration •  Invasive Cervical Resorption

•  Pulpal ischaemia – Necrosis +/- infection •  Transient apical internal resorption •  Transient apical breakdown •  Transient/permanent marginal breakdown

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Which of these can treatment influence:!"""!

• •

Nothing/Physiologic surface resorption Pulp healing – reposition tooth

• Internal Resorption (apic/intraradicular) - protect pulp • External Resorption (Infection Induced / Inflammatory) – protect pulp

• External Resorption (Replacement) Ankylosis – replace tooth ASAP or maintain cementum vitality • Pulpal Canal Obliteration •  Invasive Cervical Resorption

•  Pulpal ischaemia – Necrosis +/- infection •  Transient apical internal resorption •  Transient apical breakdown •  Transient/permanent marginal breakdown

•

Stubs!

Open apex Every effort is made to preserve the pulp of the immature permanent tooth, Consideration is given to induce revascularization or regeneration of pulp tissue.

March 2007

What to do?

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2 year recall

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Theory versus clinical reality

Tali friede 060513 11 avulsed 15 y ago replaced in 3 min CO2 pos!

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Theory versus clinical reality

11 avulsed 15 y ago. 11 years old Replaced in 3 min CO2 +ve

At the end of this seminar participants will: 1.  be able to identify those factors which require management at the initial and emergency triage. Dr Averil Tse 2.  be aware when and how long splinting is required. Dr Kim Dang 3.  understand the effect of trauma on the pulp. Dr Sara Firouzabadi 4.  be aware of management of the fractured crown following trauma. Dr Daniel Felman 5.  apply knowledge on current thoughts on pulp capping and pulp preservation. Dr Artika Soma 6.  be able to implement a post trauma follow-up protocol. A/Prof Phillippe Zimet!

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MATTHEW YOUSSEF email 21 march 2012!

What to do at the first phone call:

Urgency or Emergency

The four R’s REASSURANCE!! REPLACE avulsed teeth REPOSITION displaced teeth REVIEW teeth

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Summary of Dental Trauma Triage Table 1. The Dental Trauma Algorithm for medics and corpsmen (translated from Hebrew) Yehuda Zadik Dental Traumatology 2008; 24: 698–701;

The initial telephone call for the receptionist

1. Loss of consciousness or confusion? Nausea or vomiting? Facial or jaw deformation? Haematoma in the face or in the floor of the mouth?

Yes. Immediately refer to Emergency Department

2. Avulsion (�knock-out�) of a tooth? Yes. Find the tooth. Hold it by the crown and wash under gentle running saline or water for less 10 sec (Do not scrub!). Replant the tooth into the socket.

Success in replantation?

Yes. Refer to a dentist within 24 h. Continue to # 3. Need antibiotics?

No. Place the tooth in isosmotic solution e.g. milk, saline or inside the patient�s mouth. Refer immediately to a dentist or ED. Antibiotics?

3. Tooth displacement (other than avulsion)?

No

No

Yes. Refer to a dentist within 24 h

No

If can�t see the tooth confirm is it intruded, avulsed or coronal fracture. Try to account for tooth or segments (?avulsion, embed in lip, inhaled)

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Debris in the lip Dental Trauma Guide

4. Tooth mobility (other than avulsion)?

Yes More than 2 mm mobility?

Yes. Refer to a dentist within 24 h. Continue to # 5 No

5. Tooth fracture? Yes. Tooth fracture with pulp exposure, intra-coronal bleeding or pain?

Yes. Refer to a dentist within 24 h. Continue to # 6

No

Is restoration needed?

Yes. Refer to a dentist within 48 h

No

No

5. Tooth fracture? Yes. Tooth fracture with pulp exposure, intra-coronal bleeding or pain?

Yes. Refer to a dentist within 24 h. Continue to # 6

The tooth is fractured but no pulp exposure.

Is restoration needed?

Yes. Refer to a dentist within 48 h. Continue to #6

No

No

6. Soft tissue laceration?

No Yes. Through-and-through laceration. Antibiotis? Tetanus protection

Yes. Superficial laceration. Antibiotis? Tetanus protection?

A suspected foreign body embedded in the soft tissue and/or infection

Yes. Refer to a dentist or Emergency Department within several hours

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Wash for 10 secs under running water!

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www.ase.org.au

5 year follow up avulsion and in milk for 1.5 hours

mikayla navakis ortho after avulsion milk 1.5 hours 5 y review!


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McCarthy!

Bony healing!

!• impaction stage (clot – gelatinous coagulum) • inflammation stage 7 days • primary soft callus formation stage 2 weeks • callus mineralisation stage 4th week to 10th week • callus remodeling stage Soft Tissue Collagen at margins 3 days Granulation tissue fills defect 7 days Scarring with Collagen and decreasing Vascularity 2 weeks Connective tissue with Epidermis 1 month

! Can I still reposition teeth at 5 days? !

McCarthy!

PDL!

!• By 2 weeks 2/3 of the mechanical strength of the PDL is restored. Mandel et al Arch Oral Biol 19819 from Shinohara Dent Trauma 2011 PULP If vascular supply is severed, ingrowth of new vessels begins at 4 days. Depends on apical foramen diameter. Andreasen Traumatic Dental Injuries – A manual

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Can I still reposition teeth at 5 days? !

When does too much time elapse between trauma and management? Except for avulsion, healing allows management to occur even a short time after of a few days.

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1. When do I Splint teeth?""Reason for splinting:"1.  Aid repair"2.  Comfort-loose, TTP"

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2. How long do I Splint teeth?""1.  Displacement/Luxation: 4 - 6 weeks"2.  Avulsion: 2 – 4 weeks"

• The prognosis for the healing outcome is more dependent on the type of injury rather than the effect of the splinting.

• the majority of the selected studies suggested that an extended fixation period is not an indicator for a poor healing outcome. Review by Kahler and Heithersay. Dental Traumatology 2008

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James McCartney

• Ensure teeth are splinted following correct repositioning:

If can’t splint tooth correctly use GIC so endodontist or paedodontist can remove splint and reposition tooth.

brodie nemet borough place splint 031014 for lecture!

290410

What to do? Understand what happens

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Park!

19 07 06!27 04 06!

May not see fracture for a number of weeks, so splinting was not initiated !

14 10 09

May need to take radiographs from multiple angles

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de vos fracture at gingival margin120412!

What to do?

020212 21 CO2 +ve

de vos fracture at gingival margin120412!

What to do?

020212 No splint

260712

Basil Yusop Pulp exposue, trauma 201212!

20 12 12

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yusop fracture 12 and cvek pulpotomy heal 280613!

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No splint

27 03 15

lapiz fracture and pulp calcification obliteration metamorphosis 130112

130112 290410 11, 21 CO2 neg - not surprised

dordic fracture midroot heal 070512

dordic 15 06 10!

dordic 20 10 10

15 06 10 20 10 10

070512

Splinted

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Brad Robinson!

06 08 88

What to do?

Brad Robinson!

06 08 88 08 08 91


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!!Prognosis – Pulp healing: !

Distinguish between pulp showing: •  obvious signs of vitality •  uncertain pulp status / pulp necrosis •  obvious pulp necrosis with infection.

From Text book and color Atlas of Traumatic Injuries to the Teeth Andraesen et al 2007

!!Prognosis – Pulp healing: !

Depends on: •  Type of injury •  Degree of trauma •  Age of patient and development of tooth

Pulpal Response after Acute Dental Injury in the Permanent Dentition: Clinical Implications—A Review Frances M. Andreasen, DDS, Dr Odont,*† and Bill Kahler, DClinDent, PhD (J Endod 2015;41:299–308)

What is the difference between pulp necrosis with infection and pulp necrosis?

Sitra yusuf!

18 09 08

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46 subluxated teeth with incomplete root formation!

Pulp sensibility testing? May be difficult due to a response to the trauma.

Koelewyn neg CO2 developing 240313.jpg!

24 03 13

31 06 12 11 -ve CO2

46 subluxated teeth with incomplete root formation!

Pulp sensibility testing? Initially consider neuropraxia, pulp necrosis, pulp necrosis with infection.

Later consider pulp canal obliteration!

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13 08 12 21 -ve CO2

lydia Gart neg co2 burt PCO 060613!

06 06 13

Confirmed Bastos et al Dental traumatology 2014 •  38% teeth that had an initial negative response were

classified as non-vital in the final visit).

•  82.4% teeth that showed a positive initial response •  to pulp sensibility tests were vital at the final

appointment

•  Necrosis was confirmed significantly earlier •  than pulp vitality

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Battle open apex and pulp necrosis 280907!

Pulp necrosis –Treat only when signs or symptoms of infection including pulpitis occur:

280907

21 09 04 18 10 04

22 12 04 14 11 05

04 09 08

Use a local history of trauma. Assess adjacent teeth also.!

Prevalence of outcome following trauma to 899 injured teeth (Hecova Dent Trauma 2010):

Follow up: In children, pulp necrosis was usually diagnosed within 6 months after the injury (91.9% of all injured teeth) and in virtually all teeth within one year. In patients older than 15 years, pulp necrosis was predominantly diagnosed later than 6 months (61.7% of all cases) or even later than 12 months (40%) after the trauma

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Yusuf 1711 08

Consequences: What does this picture represent? •  haemolysis vital

pulp •  haemolysis with

ischaemia (pulp necrosis)

•  pulp necrosis with infection!

Yusuf 1711 08

121109 220210 180908

Concussion Consequences: At what point is treatment required? No response to CO2

02 04 07 28 05 07 18 09 07

Care with signs and symptoms Transient Apical Breakdown

TAB heals within about 6 months

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My preference is to give teeth and pulps the benefit of the doubt and treat as necessary as we can induce periapical lesions to heal:

krishan Maheepala 241108 post trauma develop radiolucency

24 11 08

krishan Maheepala 240209 post trauma develop radiolucency

24 02 09

krishan Maheepala 110609 post trauma develop radiolucency healed

11 06 09


singh!

04 02 04!30 07 03!


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lucinda miller good heal fracture horizontal 290515

30 07 13 19 09 13 29 05 15

calcification Macpherson 100510!

Pulp Canal Obliteration – PCO Calcific metamorphosis

A sign of a vital but irritated pulp

daniel cohen luxation., neg CO2 always, checked EPT +ve on 100815!

23 03 13 21 07 14 10 08 15

CO2 –ve always, EPT +ve on 100815

trzcinski!

Pulp Canal Obliteration – PCO Calcific metamorphosis

Aetiology • Impact injury that did not result in necrosis • Vital pulp • Process of calcification- Temporary disruption in blood supply leads to deposition of tertiary dentine (irregular secondary) dentine. Can occur with all injury types.

19 07 07 29 04 08 16 07 11

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!!Prognosis of PCO: !

Adeleke O Oginni and Comfort A Adekoya-Sofowora 2007

Pulp calcification can result in coronal discolouration which can occur some years later

Fig. 65 – Dark tooth with a fully mineralized canal ( t o o t h h a s n o t h a d endodontic therapy)

Fig. 66 – Dark tooth with a fully mineralized canal after KöR Whitening Deep Bleaching Max Ultra From Kor company 051012

siderus calcification and pap 170709

280808 021008 170709

1% annual risk of pulp necrosis and signs of infection Andreasen F and Kahler W J Endod 2014

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Transient discolouration - Immediately after trauma: •  Discoloration may be evident in teeth with closed apex. •  Discoloration can disappear within 4 weeks to 6 months. •  Sensibility, which was lost at the injury, followed the

changes in discoloration. •  All teeth had regained normal sensibility when the

discoloration had disappeared. Malmgren Dental Traumatology 2012; 28: 200–204; •  Heathersay says he feels only 50% of discolouration

resolves Heithersay ADJ 2007 Conclusion: Transient discoloration in intra-alveolar fractures is relatively common and is indicative of a good prognosis for healing. Usually comes and goes early. Malmgren Dental Traumatology 2012; 28: 200–204;

Kinga Wojciechowska Trauma displaced 11 041208!

Extrusive Luxation and Fracture 11, sublux 21; 12,11,21 CO2 pos

21 02 08! 15 01 09!

Cayla 190208!

21 02 08 21, 22 CO2 neg

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17 03 08 17 03 08

24 06 09 051010

From Andreasen et al Textbook and Colour Atlas of Traumatic Injuries to the teeth 4th ed

What happens to existing pulpal blood vessels? The process of anastomosis of the blood vessels is known as inoscultation Converse et al British Journal of Plastic Surgery (Ig75), 28, 274-282 !

Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article.Dental Traumatology 18 (3), 116-128.2002 Fig. 15. Effect of treatment delay upon healing of 209 subluxated teeth with major mobility. From Eklund et al., 1976 (22)

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Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article.Dental Traumatology 18 (3), 116-128.2002

Fig. 18. Effect of treatment delay upon healing of 98 luxated teeth with dislocation. From Eklund et al., 1976 (22).

James McCartney

Original avulsed 32, 31, 42. Badly placed 13 08 07

Corrected with orthodontics and associated resorption 15 09 07

16 07 10

• External inflammatory root resorption - PERIRADICULAR


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The fractured crown:

•  Rebond fragment •  Keep fragment moist •  Try to avoid RCT unless sign of

pulpal infection

stubs!

Note the continued root development

March 2007

June 2009

March 2012

kumar trauma review 020312!

02 03 12 22 12 92

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Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article.Dental Traumatology 18 (3), 116-128.2002 Fig. 3. Effect of no treatment upon pulp healing of 654 large uncomplicated angular crown fractures. From Ravn, 1981 (9)

Riley Webster!

What happened to the pulp? Complicated crown fracture 18 months ago

190315 031014

Management of Crown

1. Locate missing segment

2. Temp crown

3.Replace missing fragment

4. Composite buildup.

5. May need endo for retention

From Visual Endodontics!

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From Andreasen - Textbook and Color Atlas of Traumatic Injuries to the Teeth 2007 Do the bevel/chamfer after initial reattachment. Use a wax template. 1. Bevel improves reattachment strength. Chazine Dent Trauma 2011 2. Initially use dual cure flowable composite. Use light cure composite over bevel as more colour stable than dual cure

From Andreasen Textbook and Color Atlas of Traumatic Injuries to the Teeth 2007

Retention can be improved with labial veneer

2 year recall

Check for signs of pulpal and PDL change.!

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Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article.Dental Traumatology 18 (3), 116-128.2002!

Fig. 3. Effect of no treatment upon pulp healing of 654 large uncomplicated angular crown fractures. From Ravn, 1981 (9)

Arnes Muhic 090909 fracture trauma palatal 12!

What to do with this case?

240909

090909

090909

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Treatment recommendations are the same as for complicated and uncomplicated crown fractures (See previous). Especially try to preserve pulp in immature teeth. In addition, attempts at stabilizing loose segments of the tooth by bonding may be advantageous, at least as a temporary measure, until a definitive treatment plan can be formulated. Definitive options include: 1.  Fragment removal only with supragingival restoration – long junctional epitheleum. 2. Fragment removal and gingivectomy (sometimes ostectomy) with supragingival restoration. 3. Fragment removal and gingivectomy (sometimes ostectomy) with RCT and supragingival restoration with possible coronal post retention. 3. Orthodontic extrusion of apical fragment. Usually requires RCT and supragingival restoration with possible coronal post retention. 4. Surgical extrusion. . Usually requires RCT and supragingival restoration with possible coronal post retention. 5. Decoronation. 6. Extraction.# # #

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3. Orthodontic extrusion of apical fragment.

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Atkins ortho extrusion trauma 10 y recall!

Radiographically root appears short 10 y recall

Matthew lee fractured crown Nov 08!

Matthew lee fractured crown Nov 08!

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Surgical extrusion.!


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taliscott

12 11 08 180808 22 06 09

For immature roots if pulp capping is not successful consider revitalization.

28 09 12

Management of the open apex

•  Traditionally, multiple Ca(OH)2 dressing was used to encourage apexification. There is a potential for root fractures.

•  The outcome for regeneration is good if the procedure proceeds. But the process is very unpredictable.

•  The long term outcome for immediate MTA apexification is also good.

Jeeruphan Tet al. Mahidol study 1: Comparison of radiographic and survival outcomes of immature teeth treated with either regenerative endodontic or apexification methods: a retrospective study. J Endod 2012: 38: 1330–1336.

the survival rate after at least 6 months •  revascularization-treated teeth (100%) •  MTA apexification−treated teeth (95%) •  calcium hydroxide (77.2%).

Mahidol Study 1: Journal of Endodontics Volume 38, Issue 10 , Pages 1330-1336, October 201

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milone discolour 21 mta steps of applying MTA in Sopix milone140113!

Management of the open apex

•  A concern during apexification is discolouration due to intracanal medication or MTA

•  Predictability of regenerative procedures is a concern

Diogenes et al Endo Topics 2012


Stainer effect of prim trauma 270206

PRIMARY TEETH & TRAUMA!

Dilaceration

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Be aware of the possibility of reversible/irreversible changes. Need to make a initial diagnosis first

The diagnosis in preparation for the treatment plan following trauma should include:

1. Type of trauma: Periodontal tissues injury Injuries to supporting bone Gingivae or oral mucosa Hard Dental Tissues and Pulp

2. Pulpal Diagnosis: Relatively normal (includes pulp canal obliteration), uncertain (includes neuropraxia), reversible pulpitis, irreversible pulpitis, necrotic, necrotic infected. 3. Alveolar and periodontal diagnosis: •  Marginal: normal, transient alveolar breakdown, alveolar breakdown,

uncertain. •  Peripapical: normal, transient apical breakdown, apical periodontitis,

uncertain. 4. Hard dental tissues injury (acute damage) – resulting in a tooth that has a good prognosis (conserve), fair prognosis (conserve), questionable – borderline, questionable – poorer If practical/possible delay borderline until patient out of pain. End-stage - extract. 5. Hard dental tissues resorptive diagnosis – external, internal, transient.

koelewyn2 splint 310512!

Alveolar changes - Transient marginal breakdown This is seen as a widened PDL space or granulation tissue. After 2-3 months the periodontium usually reforms

310512

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What to do?

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Alveolar changes -Permanent marginal breakdown

130807 300409

Herman Dental Traumatology 2012; 28: 394–402;

Deegen!

01 02 07

11 CO2 neg

21 CO2 pos!

22 03 07

11 CO2 neg

21 CO2 pos!

!

10 05 07

11 CO2 pos

21 CO2 pos

Transient apical internal resorption may be associated with transient apical breakdown

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Resorption Linsdkog/Heithersay’s

Classification (Heithersay ADJ 2007):#!This classification is clinically based

subdividing resorptions into three broad groups: (1)  trauma induced tooth resorption; •  External surface resorption •  Transient apical internal resorption •  External pressure resorption and

orthodontic resorption •  External replacement resorption •  Ankylosis

Josephine Sullivan resorption avulsion out of mouth dry 1/2 hour !

Compare:

Infection related External Inflammatory Resorption

Trauma Induced External Replacement Resorption

Out of mouth for 30 min

6month follow up.

Bsmith 100604avulse 2-3 min in about 2000

100604 110910 110910

Avulsed 2-3 min in about 2002.

Is this: Infection Induced External Inflammatory Root Resorption -Periradicular?

Trauma Induced External Replacement Resorption?

Trauma Induced External Surface Resorption?

251102

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Bsmith 100604avulse 2-3 min in about 2000

220812

220812 010414 300914

270415

collis

Prognosis Intrusive Luxation

Results of intrusion 04/02/04! 120506

patients archibald donahue intrusion!

What to do?

2 weeks!

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Karpoh lee intrusion 010909!

250609!

What to do?

Karpoh lee intrusion 010909!

250609! 300709! 010909!

250609! 300709!From Dr Luke Borgula

Karpoh lee intrusion 270812.jpg!

2012!

From Dr Luke Borgula

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IADT 2011 Guidelines for intrusion: Incomplete root formation: •  Allow eruption without intervention •  If no movement in 3 weeks initiate orthodontic

repositioning •  If tooth is intruded more than 7mm, reposition surgically or

orthodontically. Teeth with complete root formation: •  Allow eruption without intervention if intruded less that

3mm. •  If no movement in 3 weeks initiate orthodontic or surgical

repositioning to limit chance of ankylosis (prefer ortho after 3 weeks).

•  If tooth is intruded more than 7mm, reposition surgically or orthodontically.

•  Teeth with closed apices will require RCT – commence 2 to 3 weeks after repositioning.

Once an intruded tooth has been repositioned surgically or orthodontically – stabilize for 4 to 6 weeks.

risely arrested resorption 120907!

risely arrested resorption 110308!

120907 110308

Intrusion: Once changes arise perform treatment

RESORPTION Linsdkog/Heithersay’s

Classification: This classification is clinically

based subdividing resorptions into three broad groups: (2) infection induced tooth resorption; • lnternal inflammatory (infective) root resorption • External inflammatory (infective) root resorption

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tim shaw displaced teeth extra see radiographs earlier!

Note increasing apical internal resorption. May be difficult to distinguish Infection induced AIR from trauma induced TAIR. May also be associated with External inflammatory (infective) root resorption – apical.!Fill to level of resorption with MTA – check with EAL. May use long term calcium hydroxide.

02 09 11 19 01 12

• Internal inflammatory (infective) root resorption - APICAL

tim shaw displaced teeth extra see radiographs earlier!

Fill to level of resorption with MTA – check with EAL. May use long term calcium hydroxide.

02 07 12 19 01 12

• Internal inflammatory (infective) root resorption - APICAL

Jacob peterson!

23 06 08

Subluxation

What to do?

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Jacob peterson

071008

09 02 09 09 12 08

21 08 08

23 06 08

Subluxation • Internal inflammatory (infective) root resorption - INTRARADICULAR

23 06 08

Jacob peterson Feb 09 prebleach internal resorption!

Post bleach – colour changes are reversible Two week review

Linsdkog/Heithersay’s Classification:

This classification is clinically based subdividing resorptions into three broad groups: (2) infection induced tooth resorption; • Internal inflammatory (infective) root resorption • External inflammatory root resorption

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If you don�t follow up correctly this can happen:

• External inflammatory root resorption - PERIRADICULAR

Following avulsion tooth survival improves with proper management. Either replace or store: 11 and 21 were placed in milk after 5 minutes for about 1 hour. 11 was passively managed.

As 21 showed signs of external resorption, active management.

But look at tooth 11!

30.05.04!

peppler!

09 10 09 11 is positive to EPT. Bizarre!

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James Avulsed Milk half hour 280904!

280904 250903

Avulsed then in milk for half hour

Tali friede 060513 11 avulsed 15 y ago replaced in 3 min CO2 pos!

Pulp: Following avulsion Generally teeth with closed apices do not revascularize. It occurs only if the tooth is replanted immediately. The process of revascularization in mature teeth is debatable. Andreasen reports apparent re-establishment of vascularization in four mature teeth; three teeth with obliteration of the pulp chamber; two of the four teeth responded positive on a vitality test. From REPLANTATION OF TEETH 1. RADIOGRAPHIC AND CLINICAL STUDY OF 110 HUMAN TEETH REPLANTED AFTER ACCIDENTAL LOSS .I. 0. ANDREASEN E. HJORNG HANSEN ad-teaching.informatik.uni-freiburg.de/...00016356609028222.pdf

11 avulsed age 12 replaced in 3 min CO2 +ve

Ingrowth of bone may be associated with ankylosis

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alinejad 181212 resorption avulsed 1hr. Decoronate in 8 months time!

Following avulsion no significant difference between medicaments was found in the proportion of teeth or patients showing periodontal healing for Ultracal or Ledermix. Day Dent Traumat 2012

If you can�t replant the tooth milk is a good storage medium. The storage medium affects the PDL, cementum and possibly the pulp. • Milk has physiological osmolality (230-270 mOsm/kg as is extracellular fluid). • pH of milk is in physiological range (6.5-6.9). • Can provide some nutrients to cells. • Pasteurized milk has very low bacterial count. • Milk must be fresh and refrigerated. Sour milk is destructive. • Fresh Milk should be refrigerated and when the tooth is placed in fresh milk. Keep the container chilled by surrounding with ice (Layug 1998). • Chilled milk is effective for about 1 - 2 hours (Lekic 1998). • Skim milk is felt to be better than whole milk (Harkacz 1997). • Long life milk is OK and does not need refrigeration (Marino 2000). • If no milk – use saliva until can get milk. After saliva – out in milk

If you can�t replant the tooth milk is a good storage medium. The storage medium affects the PDL, cementum and possibly the pulp (continued). • Baby formulas are also OK (Pearson 2003). • Some reconstituted powdered milk is OK (Pearson 2003, Blomlof 1981). • Yogurt usually has additives such as sweeteners which may affect the pdl/cementum – use as a last resort (no reference). • Gatorade and contact lens solution are hypertonic and not good (Chamorro Dent Trauma 2007) • Soy milk is OK (Maozami Dent Trauma 2012) • Water has osmolality of 30 mOsm/kg so is used only for brief wash • Egg white can be used but is probably impractical (Udoye AEJ 2013) • Saliva is OK for 30 minutes (Lekic 1998) • Normal saline can be used but results are variable (Udoye AEJ 2013) • Coconut water has too low pH. (Udoye AEJ 2013) • Others suggest coconut milk is better than milk (Thomas J Conserv Dent. 2008 Jan-Mar; 11(1): 22–29) • Temperature – cold or room temp of milk – is not an influence

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Effect of time on avulsion: •  Replantation of a tooth within 5 min maintain of the

cementum and PDL cells in normal function

•  After more than 15 min of dry storage the cementum tissue is necrotic initiating TIERRR. Also after more than 15 min of dry storage, the precursor, progenitor or stem cells are no longer able to differentiate into fibroblasts and initiate the regenerative process.

•  After 30 min of dry storage, virtually all of the cementum and PDL cells on the tooth root are likely to have become necrotic

From Udoye AEJ 2013

Systemic antibiotics for avulsion: •  no evidence from human case series of

beneficial periodontal outcomes between the use of a systemic penicillin or tetracycline.

•  Ensure a tetanus booster and prompt referral to the child’s general medical practitioner if environmental contamination of the tooth.

From Day UK National Clinical Guidelines in Paediatric Dentistry Treatment of Avulsed Teeth. Revised 2012

Malmgren J Endod 2014

What if TIERRR occurs?

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Ankylosis – interdental fibres of PDL are still attached causing tipping of adjacent teeth


After decoronation: 1.  Coronal blood clot is organized

from the surrounding tissues 2.  The blood clot becomes

organized and new bone is created.

3.  A new periosteum is formed on top of the alveolar crest

4.  The transeptal fibres are no longer attached to the adjacent ankylosed tooth

5.  As the adjacent teeth erupt the newly formed and reorganized transeptal periodontal ligament fibres induces bone apposition through traction in the periosteum from the reorganized fibers

Alveolar bone width decreases by 50% following extraction Schropp Int J Prosth and Rest Dent 2003 Following decoronation a loss of about 10% may be expected in alveolar bone width after 1 year Lim J Endod 2014 ! !

Some labial bone loss even with decoronation Tsukiboshi Dent Tramatol 2014

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Summary of post trauma review process

FOLLOW UP 3 weeks

6 weeks

3 months

6 months (equals one year)

12 months (equals two years)

24 months (equals four years)!

!

General Patient instructions • Need Tetanus • Soft diet for up to two weeks. • Brush teeth with a soft toothbrush after each meal. • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. • Antibiotics if avulsion !

Follow up as for all trauma: Any symptoms

Clinical signs •  Sinus tract stoma or swelling

•  Gingivitis

•  Pocket depth

•  Recession

•  Tooth Colour

•  Loosening

•  Tenderness to palpation

•  Tenderness to percussion

•  Thermal test (sensibility, sensitivity)

• Radiograph-mm dislocation, pulp calcification, continued root development, marginal bone loss, periradicular radiolucency, tooth resorption, horizontal root fracture that has developed, bone resorption!

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In Summary when do I perform endodontic treatment? IADT 2011 suggest 2 signs and symptoms are required to suggest pulpal infection. When I think the pulp is infected (not just necrotic) 1. Radiographic: 1.1 Periapical lesion not resolve or increasing 1.2 Size of pulp chamber (internal resorption) 1.3 Sign of external or internal inflammatory resorption 1.4 Is there pulp canal obliteration? A sign of pulp vitality 1.5 Is there continued root development? A sign of pulp vitality. 1.6 Is there internal resorption; intraradicular or apical?

2  .Clinical : 2.1 Response to pulp testing: calcification , necrosis/infected, necrosis/uninfected, neuropraxia/vascular intact. 2.2 Colour (calcification, necrosis, transient hyperaemia – wait up to 1 year to resolve?) 2.3 Sinus tract stoma 2.4 Prolonged TTP. 2.5 check teeth on either side of obvious trauma in case of coincident trauma.

Tenderness to percussion Andreasen found that the only sign significantly related to pulp necrosis was tenderness to percussion following tooth luxation. (Andreasen et al; Textbook and colour Atlas of Traumatic Injuries to the teeth – 4th Edition p 378 from Andreasen FM, Endod Dent Traumatol 1989;5:111-31) Andreasen FM. Histological and bacteriological study of pulps extirpated after luxation injuries. Ended Dent Traumatology 1988;4:170-81. Andreasen and Kahler (J Endod 2015;41:299–308) !

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Thank you and questions?

lecture trauma border study club aug 2015 - next meeting · at the end of this seminar participants...

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