pediatric pediatric dental trauma: the old and the new

PediatricPediatric Dental Trauma: The Dental Trauma: The Old and The NewOld and The New

Dr. Dr. DuyDuy--DatDat VuVud.m.dd.m.d., ., m.scm.sc., ., f.r.c.d.(cf.r.c.d.(c))

A little review of dental traumaA little review of dental trauma

•• Tooth displacements (Tooth displacements (luxationsluxations))–– Primary teethPrimary teeth–– Permanent teethPermanent teeth

•• Tooth fracturesTooth fractures–– Primary teethPrimary teeth–– Permanent teethPermanent teeth

•• Alveolar bone fracturesAlveolar bone fractures•• Soft tissues lacerationsSoft tissues lacerations•• Complex dental and Complex dental and maxillomaxillo--facial traumafacial trauma

Tooth displacements (Tooth displacements (luxationsluxations))

•• Reduce the Reduce the luxationluxation and splint and splint mobile teeth for mobile teeth for ~7 to 10 days~7 to 10 days

Tooth displacements (Tooth displacements (luxationsluxations))

•• Exception: intruded Exception: intruded tooth = let the tooth tooth = let the tooth rere--erupt on its own erupt on its own (within 4(within 4--6 weeks)6 weeks)

Tooth fracturesTooth fractures

•• Repair the fracture with Repair the fracture with estheticesthetic dental materialsdental materials

•• ProctectProctect the pulp/the pulp/””nervenerve”” if exposedif exposed

Alveolar bone fracturesAlveolar bone fractures

•• Reduce bone Reduce bone fracture and splint fracture and splint the teeth for ~4 the teeth for ~4 weeksweeks

Soft tissue lacerationsSoft tissue lacerations

•• CleanClean--up the up the lacerationslacerations

•• Remove all foreign Remove all foreign bodiesbodies

•• suturessutures

Complex dental and Complex dental and maxillomaxillo-- facial traumafacial trauma•• Team work approach (with Team work approach (with

OMFS and/or plastic and/or OMFS and/or plastic and/or ENT)ENT)

•• Extractions of any teeth in the Extractions of any teeth in the line of fractures of the jawsline of fractures of the jaws

Consequences of dental traumaConsequences of dental trauma

•• Pulp becomes Pulp becomes necrotic = necrotic = ““tooth tooth diesdies””

•• Treatment: root canal Treatment: root canal treatmenttreatment

Typical root canal treatmentTypical root canal treatment

In the past, we do root canal treatment but In the past, we do root canal treatment but in a young patient the long term results are in a young patient the long term results are somewhat disastroussomewhat disastrous……

The “old”...

So what is new?So what is new?

•• If the traumatized tooth is vital, we try to keep If the traumatized tooth is vital, we try to keep the teeth as vital as long as possible to avoid the teeth as vital as long as possible to avoid early root canal treatment in young growing early root canal treatment in young growing pediatricpediatric patientspatients

•• The sooner we take care of that tooth, the The sooner we take care of that tooth, the better the prognosisbetter the prognosis

•• Root canal treatment is still the gold standard to Root canal treatment is still the gold standard to treat treat ““dead toothdead tooth”” in older adults!in older adults!

Pulp treatment traumatized immature teeth

•• ““The special concern for The special concern for maintaining maintaining pulpalpulpal health health during tooth development during tooth development becomes an important goal in becomes an important goal in managing traumatic injuries in managing traumatic injuries in the immature dentitionthe immature dentition””

•• Risk of fracture of the weak Risk of fracture of the weak underdeveloped rootunderdeveloped root

•• Potential orthodontic/Potential orthodontic/estheticesthetic complicationscomplications

•• GROWTH and DEVELOPMENTGROWTH and DEVELOPMENT

MTA

• “Mineral trioxide aggregate”...

• vs CaOH:– Higher level of

biocompatibility– Does not

deteriorate/disintegrate with time

– Not an irritant to the pulp– Does not cause pulpal

calcification

Pulp treatment traumatized immature teeth

What else is new from the past 5 years…• Avulsion protocol• Splints• Temporary fillings• Fragment re-attachment• Pulp treatment:

– Calcium hydroxide– MTA– Revascularization

• De-coronation (for ankylosis)

Avulsion protocol

Avulsion protocol

• Primary teeth:– No scientific evidence for replantation

• Permanent teeth:– On-site replantion ASAP for maximum

prognosis– Keep in Hank’s physiologic solution or cold

milk and visit to dentist immediately for replantation... DO NOT DELAY

Avulsion protocol•• ReplantationReplantation and splint (for 7and splint (for 7--10 days)10 days)•• Closed apex:Closed apex:

–– Calcium hydroxide is recommended for intraCalcium hydroxide is recommended for intra-- canal medication for up to one canal medication for up to one month (ideal time to begin treatment is 7month (ideal time to begin treatment is 7--10 days post10 days post--replantationreplantation))

–– Root canal treatmentRoot canal treatment

•• Open apex:Open apex:–– pulp revascularization is possiblepulp revascularization is possible–– Root canal treatment should be avoided unless there is clinical Root canal treatment should be avoided unless there is clinical and radiographic and radiographic

evidence of pulp necrosisevidence of pulp necrosis–– In case of pulp necrosis:In case of pulp necrosis:

•• calcium hydroxide is recommended for intracalcium hydroxide is recommended for intra-- canal medication for up to one monthcanal medication for up to one month•• MTA for apical seal + root canal treatmentMTA for apical seal + root canal treatment•• ... Revascularization...... Revascularization...

•• Clinical control:Clinical control:–– Replanted teeth should be Replanted teeth should be monitored by frequent controlsmonitored by frequent controls (like any other (like any other

trauma) during the first year (one week, 1, 3, 6, and 12 months)trauma) during the first year (one week, 1, 3, 6, and 12 months) and then yearly and then yearly thereafterthereafter

–– What we are afraid of is What we are afraid of is resorptionresorption (inflammatory and (inflammatory and ankylosisankylosis))

SplintsSplints

•• The The ““oldold””......

Splints nowSplints now……•• SemiSemi--rigid/flexiblerigid/flexible

–– ““twistotwisto”” orthodontic wire (0.15 or 0.175)orthodontic wire (0.15 or 0.175)–– ““homehome--mademade”” with orthodontic ligatureswith orthodontic ligatures–– TofflemireTofflemire matrixmatrix–– InterproximalInterproximal compositecomposite→→to permit physiologic tooth movementto permit physiologic tooth movement

•• All splints have to be passiveAll splints have to be passive•• Most splints should be kept for 7Most splints should be kept for 7--10 days, except for 10 days, except for

root and/or alveolar bone fractures and/or severe lateral root and/or alveolar bone fractures and/or severe lateral luxationsluxations –– up to 4 weeksup to 4 weeks

•• To avoid:To avoid:–– NiNi--titi wires, paper clipswires, paper clips

from Andreasen

Tooth fractures treatmentTooth fractures treatment

•• The The ““oldold””

Tooth fractures treatmentTooth fractures treatment

•• The The ““newnew””–– Temporary fillingTemporary filling–– ReRe--attachment of attachment of

fragmentsfragments

Temporary fillings for tooth Temporary fillings for tooth fracturesfractures

•• To relieve pain in the fastest way possibleTo relieve pain in the fastest way possible•• Fast to apply and to setFast to apply and to set•• Easily removable for the dentist but not Easily removable for the dentist but not

for the patientfor the patient•• Ideal material = light cure glass Ideal material = light cure glass ionomerionomer

Tooth fragment re-attachment

Fractured tooth with fragment

But what if a young tooth is But what if a young tooth is dead no matter what?dead no matter what?•• The The ““oldold””: root canal : root canal

treatment with its treatment with its known problemsknown problems

The “new”: Revascularization

Revascularization

•• Documented since 2004Documented since 2004•• The ideal treatment for an immature The ideal treatment for an immature necrosednecrosed

tooth is to regenerate a healthy pulptooth is to regenerate a healthy pulp--dentin dentin complex that would allow the continued complex that would allow the continued maturation of the rootmaturation of the root

•• Resolution of the Resolution of the periapicalperiapical lesion, significant lesion, significant lengthening of the root, thickening of the lengthening of the root, thickening of the dentinal walls, and closure of the apexdentinal walls, and closure of the apex

Revascularization techniqueRevascularization technique

•• Access cavityAccess cavity•• PulpectomyPulpectomy (necrotic pulp) (necrotic pulp) –– length determinationlength determination•• Copious irrigation with hypochlorite sodiumCopious irrigation with hypochlorite sodium•• Rinse with normal salineRinse with normal saline•• Insertion of triInsertion of tri--antibiotic paste (homeantibiotic paste (home--made) in the canalmade) in the canal•• Temporary seal for ~2 to 6 weeksTemporary seal for ~2 to 6 weeks•• Then verify for resolution of infection (signs/symptoms, radiogrThen verify for resolution of infection (signs/symptoms, radiographs)aphs)•• ReRe--open canal, reopen canal, re--irrigation with hypochlorite sodium and salineirrigation with hypochlorite sodium and saline•• Dry coronal half of canal with sterile paper pointsDry coronal half of canal with sterile paper points•• Induce a blood clot in the canal by creating a bleeding from apeInduce a blood clot in the canal by creating a bleeding from apex with sterile file in x with sterile file in

the canalthe canal•• Wait ~15 minutes, blood clot at the enamelWait ~15 minutes, blood clot at the enamel--cementumcementum junctionjunction•• Seal with 3mm of MTA, Seal with 3mm of MTA, cotoncoton pellet, temporary filling (48 hours to set)pellet, temporary filling (48 hours to set)•• GI, compositeGI, composite•• F/U (1, 2, 4, 6 months postF/U (1, 2, 4, 6 months post--op; then every 6 months)op; then every 6 months)

Revascularization techniqueRevascularization technique

•• Original triOriginal tri--antibiotic paste:antibiotic paste:–– 100 mg of 100 mg of minocyclineminocycline powderpowder–– 500 mg of 500 mg of ciprofloxacineciprofloxacine

powderpowder–– 500 mg of 500 mg of metronidazolemetronidazole

powderpowder–– mixed with a base of mixed with a base of

propylene glycol and propylene glycol and macrogolmacrogol–– The powder and base were The powder and base were

mixed at the time of the mixed at the time of the appointment to prevent appointment to prevent moisture contaminationmoisture contamination

Problems encountered...Problems encountered...

•• bluish discoloration of the bluish discoloration of the crowncrown

•• Caused by the presence Caused by the presence minocyclineminocycline above the above the cementocemento--enamel junctionenamel junction

•• For this protocol, For this protocol, minocyclineminocycline was replaced by was replaced by cefaclorcefaclor 500 500 mg, a second generation mg, a second generation cephalosporinecephalosporine

•• This change resolved the This change resolved the staining for the cases that staining for the cases that followedfollowed

Problems encountered...Problems encountered...

•• Fail to produce a Fail to produce a blood clot that would blood clot that would reach the reach the cementocemento-- enamel junctionenamel junction

•• It was formed, but It was formed, but remained under the remained under the CEJ...CEJ...

Problems encountered...Problems encountered...

•• Technically difficult to Technically difficult to control the placement control the placement of the MTAof the MTA

•• Once placed over the Once placed over the blood clot, the MTA blood clot, the MTA material would material would collapse in the canalcollapse in the canal

Problems encountered...Problems encountered...

•• Visible root elongation Visible root elongation was not noticed at was not noticed at the one month followthe one month follow-- upsups

•• Most of the cases Most of the cases demonstrated demonstrated significant significant lengthening of the lengthening of the root but only after a root but only after a six months periodsix months period

Revascularization, also...Revascularization, also...

•• New evidences show that it might not be New evidences show that it might not be dentine forming in the canal...dentine forming in the canal...

•• We are still very far from We are still very far from ““regenerationregeneration””......

Importance of a nice smile

• Nothing equals a nice smile

• « a smile is the shortest distance between two persons » (Victor Borge)

Lost of a permanent young tooth

• Alveolar bone exists only when there is a tooth present

• Supporting bone resobs when a tooth is lost

• The younger the patient, the faster and the more severe the bone loss process will be

“it doesn’t matter, we can always place an implant…” - ?!?

• There might be not enough bone to place an implant

• Bone and gingival grafts are expensive and not enjoyable experiences

• Success is never guarantied…

“it doesn’t matter, we can always place an implant…” - ?!?

Ankylosis

De-coronation (cases of ankylosis)

• “In children below the age of 15, if ankylosis occurs, and when the infraposition of the tooth crown is more than 1mm, it is recommended to perform decoronation to preserve the contour of the alveolar ridge.”

But letBut let’’s not forget the old but s not forget the old but proven basicsproven basics•• The importance of The importance of

followfollow--up... Even up... Even for minor trauma!!!for minor trauma!!!

In resume:

• Try to keep any/all teeth and/or teeth fragments (exception for avulsed primary teeth)

• Try to keep to traumatized teeth vital as long as possible

• Time is a major factor, the sooner the treatment, the better the prognosis!!!

• Our mission of the MCH: best care for life

Thank you!