management of permanent tooth dental trauma in children ...€¦ · part i-1) up-to-date...
TRANSCRIPT
Management of Permanent Tooth Dental Trauma in Children
and Young Adolescents
Jessica Y Lee DDS MPH PhDChair and Distinguished ProfessorDepartment of Pediatric Dentistry
University of North Carolina at Chapel Hill
Disclosure
I nor my immediate family have any
financial interests that would create a conflict
of interest or restrict their independent
judgment with regard to the content of this
session
Part I-
1) Up-to-date fundamentals for the diagnosis permanent tooth dental children and adolescents
2) Current concepts of splinting luxated and avulsed permanent teeth
3) Management of traumatic exposures by reliance on evidence-based concepts
Part II-
1) Treatment strategies for avulsed teeth using a clinician-friendly flow-chart based on best evidence
2) How to perform new concepts of pulp regeneration and decoronation
Objectives
Review of Avulsion Management
Prognosis
Tooth survival 21-89
Pulp healing 9-50
PDL healing 4-27
Gingival healing 93-95 Andreasen (Textbook and Color Atlas of Traumatic Injuries to the teeth 4th edition)
If tooth is immediately replantedPDL healing 85-97
Pulp revascularization (immature roots) 41-93
Andreasen et al (Endodont Dental Traumatol 1995)
Immediate replantation =
BEST prognosis
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Disclosure
I nor my immediate family have any
financial interests that would create a conflict
of interest or restrict their independent
judgment with regard to the content of this
session
Part I-
1) Up-to-date fundamentals for the diagnosis permanent tooth dental children and adolescents
2) Current concepts of splinting luxated and avulsed permanent teeth
3) Management of traumatic exposures by reliance on evidence-based concepts
Part II-
1) Treatment strategies for avulsed teeth using a clinician-friendly flow-chart based on best evidence
2) How to perform new concepts of pulp regeneration and decoronation
Objectives
Review of Avulsion Management
Prognosis
Tooth survival 21-89
Pulp healing 9-50
PDL healing 4-27
Gingival healing 93-95 Andreasen (Textbook and Color Atlas of Traumatic Injuries to the teeth 4th edition)
If tooth is immediately replantedPDL healing 85-97
Pulp revascularization (immature roots) 41-93
Andreasen et al (Endodont Dental Traumatol 1995)
Immediate replantation =
BEST prognosis
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Part I-
1) Up-to-date fundamentals for the diagnosis permanent tooth dental children and adolescents
2) Current concepts of splinting luxated and avulsed permanent teeth
3) Management of traumatic exposures by reliance on evidence-based concepts
Part II-
1) Treatment strategies for avulsed teeth using a clinician-friendly flow-chart based on best evidence
2) How to perform new concepts of pulp regeneration and decoronation
Objectives
Review of Avulsion Management
Prognosis
Tooth survival 21-89
Pulp healing 9-50
PDL healing 4-27
Gingival healing 93-95 Andreasen (Textbook and Color Atlas of Traumatic Injuries to the teeth 4th edition)
If tooth is immediately replantedPDL healing 85-97
Pulp revascularization (immature roots) 41-93
Andreasen et al (Endodont Dental Traumatol 1995)
Immediate replantation =
BEST prognosis
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Review of Avulsion Management
Prognosis
Tooth survival 21-89
Pulp healing 9-50
PDL healing 4-27
Gingival healing 93-95 Andreasen (Textbook and Color Atlas of Traumatic Injuries to the teeth 4th edition)
If tooth is immediately replantedPDL healing 85-97
Pulp revascularization (immature roots) 41-93
Andreasen et al (Endodont Dental Traumatol 1995)
Immediate replantation =
BEST prognosis
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Prognosis
Tooth survival 21-89
Pulp healing 9-50
PDL healing 4-27
Gingival healing 93-95 Andreasen (Textbook and Color Atlas of Traumatic Injuries to the teeth 4th edition)
If tooth is immediately replantedPDL healing 85-97
Pulp revascularization (immature roots) 41-93
Andreasen et al (Endodont Dental Traumatol 1995)
Immediate replantation =
BEST prognosis
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Immediate replantation =
BEST prognosis
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
httpwwwdentaltraumaguideorgPermanent_Avulsion_Etiologyaspx
Severed attachment
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Avulsions
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Severe Attachment Damage
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
HBSS- 1st option Milk- 2nd option other storage media
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Replant
EO dry time lt20min and tooth was transported in HBSS or
milk for 20min6hrs
Soak in 1 Doxycycline for 5 min for open
apex only
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Advantages of Maintaining Tooth Vitality Following Dental Trauma
Continued Root
Development
Thicker
dentinal walls
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Pulpal Necrosis
Dry time lt 60 minOpen apex
Soak the tooth for 5 min in doxycycline
(1mg20ml saline)
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Triple Antibiotic Paste Hoshino et al 1996
Studied the antibacterial effect of a mixture of
ndash ciprofloxacin
ndash metronidazole
ndash minocycline
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Iwaya et al theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth
If this was the case successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space those cells had the potential to proliferate and form a new pulp
(Iwaya et al 2001)
Does it work
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
24 month recallPre - op(Banchs and Trope 2004)
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Calcium Hydroxide
Calcium hydroxide increased recruitment migration proliferation and mineralization of the DPSCs (Pulp Stem Cells)
Tissue Eng Part A 2010 Jun16(6)1823-33 doi 101089tenTEA20090054
Dental stem cell therapy with calcium hydroxide in dental pulp capping
Ji YM1 Jeon SH Park JY Chung JH Choung YH Choung PH
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth
(Nygaard-Ostby 1961 Myers and Fountain 1974)
Revascularization
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
24 month recallPre - op
(Banchs and Trope 2004)
SCAP Stem Cells
Disinfection
Scaffold
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Scaffolds
AAE Considerations for a Regenerative Endodontics Procedure
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
PostTreatment
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
10 Day Post-op Visit
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
3 Week Post-op Visit
ity Tests 7-10
Percussion WNL
Palpation WNL
Endo Ice +
Mobility
ndash7810 WNL
ndash9 Class I
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Poll Question
What is your treatment recommendation
at this time
1) Monitor and bring child back in three months for trauma follow up
2) Monitor and bring child back in one month for trauma follow up
3) Access tooth and begin RCT
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
7 Week Post-op Visit
Vitality Tests 7-10
Percussion WNL
Palpation WNL
Mobility WNL
Endo Ice +
EPT +
Radiographic appearance of inflammatory root resorption (IRR)
Now what
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
9-View through Microscope
Necrotic Tissue visible upon
access
In microscope view vital tissue
present in apical 13
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
8 Week Post-op Visit
Tx options to disinfect canal ndash Ledermix CaOH 3-mix-MP
Chose 3-mix-MP Mother understands risk of discoloration ndash Ciprofloxacin Metronidazole and Minocycline
ndash Macrogol and Propylene Glycol for paste consistency
Triple antibiotic placed
Cotton pellet and Pink Fuji Triage placed
RTC 6 weeks ndash Revascularization MTA composite
Alternative treatment options discussedndash Long Term CaOH apexification
ndash MTA apexification
12507
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
6 weeks later
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
3MP appt and 8 mo Post-Revascularization Comparison
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
63008
bullInternal Bleaching Appt with Endo
bullRemoval of Lingual restoration
bullSodium Perborate and IRM placed
bullRTC 1 week
7708
bull Parent and child satisfied with color
bull Removal of IRM and Sodium Perborate
bull Restored lingual access with packable
composite shade A1
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
EO dry time gt 60 minutes
Remove PDL cells use 3 Citric Acid for 3 minutes Scaler
soft pumice
Soak in Sodium Fluoride for 5 minutes
Replant tooth
Obtain PA to verify position
Place flexible splint for ~14 d
Rx DoxycyclinePen VK for 7d
Chlohexidine rinse for 1 wk
Assess tetanus vaccination
Provide post-op instructions inform of prognosis
Follow-up in 7-10d
Permanent tooth replantation following avulsion using a decision
tree to achieve the best outcome (McIntyre et al Ped Dent 2009)
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
The Condemned PDL Dry Time gt 60 minutes If tooth has been extraoral andor dry for 60 mins+ the PDL has NO chance for
survival
ndash If a tooth like this is replanted it WILL undergo resorption (likely ORR) amp ultimately be lost
ndash The AAE does not recommend replanting these teeth
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
PDL Removal
Gentle scaling and root planning OR
Soaking the tooth in citric acid (3 mins)
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
PDL Removalbull Followed by fluoride treatment (5 ndash 20 mins)
bull F- soak will delay but not prevent ankylosis
bull F- soak has been shown to significantly reduce the rate of resorption (in a FU of 5y)
bull Nevertheless these teeth will not survive long-term
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Poll question
What treatment options would you consider
1) Build up tooth 92) Extract tooth 93) De-coronate tooth 9
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Decoronation
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Decoronation
Malmgren B and Malmgren O 2002
An excellent tx option for an ankylosed tooth
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Decoronation
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Decoronation
Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed
These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance
This aids in future restorative planning maximizes esthetics and treatment options
ndash Extraction however contributes to further loss of this essential bone
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Resources
AAPD Trauma Guidelines
httpwwwaapdorgpolicies
IADT Guidelines
httpwwwiadt-dentaltraumaorg
Dental Trauma Guide Online
httpwwwdentaltraumaguideorg
Questions
Thank you
Questions
Thank you
Thank you