Traumatic Injuries, Cracked Traumatic Injuries, Cracked Teeth and vertical root fractures Teeth and vertical root fractures

(VRF)(VRF)

FactFact

Most dental trauma occurs in 7_12 Most dental trauma occurs in 7_12 age rangeage range

And most trauma occurs in the And most trauma occurs in the anterior region of the mouth, anterior region of the mouth, maxilla>mandiblemaxilla>mandible

1. Crown FX without Pulp 1. Crown FX without Pulp exposureexposure

NO PROBLEM,RELAX AND RESTORE

Complicated Crown FX with Complicated Crown FX with Pulp ExposurePulp Exposure

Pulp Cap?

OR:EXTIRPATION if root is fully formed

Partial Pulpotomy@95%Full pulpotomy @75%

@80% IFw/in 24hrs

2. Crown-Root Fracture2. Crown-Root Fracturesometimes fractures at an sometimes fractures at an

angleangle

Angular Fracture: Is this restorable?

Remember, Remember,

In all trauma, the primary purpose of In all trauma, the primary purpose of our treatment is to keep the pulp our treatment is to keep the pulp vital, if at all possible, ESPECIALLY vital, if at all possible, ESPECIALLY if apex is openif apex is open

WHY?WHY?

Pulpotomy – Immature ApexPulpotomy – Immature ApexIf Vital = “Apexogenesis”*If Vital = “Apexogenesis”*

Apexogenesis vs Apexogenesis vs ApexificationApexification

Dealing with the immature rootDealing with the immature rootApexogenesisApexogenesis (Vital Pulp) best to treat w pulpotomy. The (Vital Pulp) best to treat w pulpotomy. The

idea is to allow the vital pulp to remain idea is to allow the vital pulp to remain vital and complete the development of vital and complete the development of the root apex the root apex

as well as as well as thickening of the RC wallsthickening of the RC wallsRCT maybe needed later BUT not if tooth RCT maybe needed later BUT not if tooth

remains asymptomatic AND vitalremains asymptomatic AND vital

ApexificationApexification (Necrotic Pulp) Hoping to get closure of (Necrotic Pulp) Hoping to get closure of

the apex the apex (&(& there is NO wall thickening)there is NO wall thickening) to be able to later do a proper RC seal via to be able to later do a proper RC seal via obturation. CaOH + time is proper tx over obturation. CaOH + time is proper tx over 3-18mo3-18mo

RCT ALWAYS NEEDED HERE* and is less RCT ALWAYS NEEDED HERE* and is less predictable due to thinner wallspredictable due to thinner walls

ObjectObject of of eithereither treatment is to allow for treatment is to allow for roofing over of apex and allow RCT to be roofing over of apex and allow RCT to be done at a later date. done at a later date.

And now, Regeneration?And now, Regeneration?

Revascularization of immature Revascularization of immature permanent teeth utilizing a mixture of permanent teeth utilizing a mixture of antibiotics(3 weeks), creating a blood antibiotics(3 weeks), creating a blood clot w/in the RCS which produces clot w/in the RCS which produces development of the tooth structuredevelopment of the tooth structure

3.Horizontal Root 3.Horizontal Root FractureFracture

Root FX (Horizontal)Root FX (Horizontal)

What do you do here? Try to reposition and splint 2-4 wks, check for vitality q 30 days

4. Luxation Injuries4. Luxation Injuries((MOST COMMON OF ALL DENTAL MOST COMMON OF ALL DENTAL

INJURIES)INJURIES)30-44% 30-44%

ConcussionConcussion SubluxationSubluxation ExtrusionExtrusion LateralLateral IntrusionIntrusion

WORST CASE SEQUELAE?

PULP NECROSIS

EXTERNAL/INTERNALROOT RESORPTION

Possible tooth lossAVULSION

Concussion Luxation InjuryConcussion Luxation Injury Least Least severe of severe of

Luxation injuriesLuxation injuries No displacement No displacement

of tooth nor of tooth nor excessive excessive mobilitymobility

Tooth tender to Tooth tender to touch touch “Bruised “Bruised PDL”PDL”

No radiographic No radiographic abnormalitiesabnormalities

Assess vitality Assess vitality in 4 wksin 4 wks

Subluxation Luxation InjurySubluxation Luxation Injury Tooth tender to touch Tooth tender to touch

& slightly mobile (1+) & slightly mobile (1+) but not displacedbut not displaced

Possible hemorrhage Possible hemorrhage from gingival crevicefrom gingival crevice

No radiographic No radiographic abnormalitiesabnormalities

Damage to supporting Damage to supporting structures?structures?

Assess vitality in 4 Assess vitality in 4 weeksweeks

Extrusion Luxation Extrusion Luxation InjuryInjury

Elongated mobile Elongated mobile toothtooth Cl. II mobility or Cl. II mobility or

greater greater Radiographs show Radiographs show

increased apical increased apical periodontal spaceperiodontal space

Manually repositionManually reposition Reposition tooth + Reposition tooth +

Flexible splintFlexible splint (2 (2 weeks)weeks)

Assess vitality in 4 Assess vitality in 4 weeksweeks

What is a flexible splint?What is a flexible splint?

-Allows physiologic movement of the -Allows physiologic movement of the teeth in order to minimize ankylosisteeth in order to minimize ankylosis

-In the past, .028 gauge ortho wire -In the past, .028 gauge ortho wire bonded to tooth for 7-10 days unless bonded to tooth for 7-10 days unless alveolar FX had occurred. Then 4-8 wksalveolar FX had occurred. Then 4-8 wks

OR: 4-6# fishing line bonded to teethOR: 4-6# fishing line bonded to teeth

--Currently, titanium trauma splint Currently, titanium trauma splint (TTS) is recommended(TTS) is recommended

Semi-rigid or flexible Semi-rigid or flexible splintingsplinting

Experimental studies in non-human Experimental studies in non-human primates have demonstrated that primates have demonstrated that rigid rigid splinting ,especially for prolonged splinting ,especially for prolonged periods, leads to ankylosis &/or external periods, leads to ankylosis &/or external resorption.resorption.

Maintaining a slight degree of tooth Maintaining a slight degree of tooth mobility appears to be beneficial to PDL mobility appears to be beneficial to PDL healinghealing

Titanium Trauma SplintMedaris AG, Basel Switzerland

TTS splintTTS splint

Insert picture of sameInsert picture of same Splinting of traumatized teeth with a Splinting of traumatized teeth with a

new device:TTS (Titanium Trauma new device:TTS (Titanium Trauma Splint)Splint)

Medartis AG, Basel, SwitzerlandMedartis AG, Basel, Switzerland Von arx T, etal Dent Traumatol, Von arx T, etal Dent Traumatol,

’01;17:180-84’01;17:180-84

Lateral Luxation InjuryLateral Luxation Injury Displaced laterally & Displaced laterally &

often locked in boneoften locked in bone Not tender to touch, Not tender to touch,

not mobilenot mobile Alveolus fracturedAlveolus fractured Percussion test: high Percussion test: high

metallic sound metallic sound (ankylosis)(ankylosis)

Increased PDL space Increased PDL space best seen on eccentric best seen on eccentric or occlusal radiographsor occlusal radiographs

Anesthetize & Anesthetize & repositionreposition

+ Flexible splint (4 + Flexible splint (4 weeks)weeks)

Assess vitality in 4 Assess vitality in 4 weeksweeks

Intrusion Luxation InjuryIntrusion Luxation InjuryExternal root resorption likelyExternal root resorption likely

Most severe of Most severe of luxations***luxations***

Tooth appears Tooth appears shortershorter: displaced : displaced into alveolar boneinto alveolar bone

PDL destruction/alveolar PDL destruction/alveolar crushing) Beware of crushing) Beware of ankylosis/resorption/ ankylosis/resorption/

pulp necrosis is all but pulp necrosis is all but certain in mature teeth***certain in mature teeth***

Not tender to touch, not mobileNot tender to touch, not mobile Percussion test: high metallic Percussion test: high metallic

soundsound Radiographs not always Radiographs not always

conclusiveconclusive

Slightly luxate with forceps or Slightly luxate with forceps or band and move orthodontically.band and move orthodontically.

Splinting is not usually necessary Splinting is not usually necessary (>4 weeks)(>4 weeks)

Tooth with open apex Tooth with open apex maymay spontaneously re-erupt.spontaneously re-erupt.

Treatment of intrusion Treatment of intrusion luxationluxation

Closed apex needs ortho. or surgical Closed apex needs ortho. or surgical repositioning and probable RCT in repositioning and probable RCT in 1-3 weeks 1-3 weeks

In all LUXATION and especially INTRUSION In all LUXATION and especially INTRUSION injuries, the apical neurovascular bundle injuries, the apical neurovascular bundle and attachment apparatus will and attachment apparatus will be be affected to some degree>>>loss of affected to some degree>>>loss of vitality & vitality & internal/external internal/external resorptionresorption

5. Avulsion5. Avulsion

Tooth is knocked completely out of mouthTooth is knocked completely out of mouth Viability of the PDL must be preserved for Viability of the PDL must be preserved for

successsuccess Extra-oral dry time is CRITICAL 30-60”***Extra-oral dry time is CRITICAL 30-60”*** Must be replaced in socket ASAP (15-20”) in Must be replaced in socket ASAP (15-20”) in

order to..order to.. Prevent ankylosisPrevent ankylosis Prevent external root resorptionPrevent external root resorption

To replant or not? should be “decent tooth”: No point in replanting THIS one

Replant?Replant?

TX is aimed at minimizing the TX is aimed at minimizing the inflammation from the inflammation from the two maintwo main consequences of avulsion, namely; consequences of avulsion, namely; attachment damage and pulpal infection attachment damage and pulpal infection that inevitably results that inevitably results

The SINGLE most VIP factor in achieving The SINGLE most VIP factor in achieving a favorable outcome is the SPEED at a favorable outcome is the SPEED at which a which a cleanclean tooth is tooth is properlyproperly replantedreplanted

Keeping the attached PDL moist is VIP!!*Keeping the attached PDL moist is VIP!!*

Replantation guidelinesReplantation guidelines

If tooth is out of the mouth less than 15-If tooth is out of the mouth less than 15-20”, replant according to guidelines20”, replant according to guidelines

If tooth was out and placed in cold milk or If tooth was out and placed in cold milk or other physiological solution w/in 15-20” & other physiological solution w/in 15-20” & available for replantation w/in 30”, available for replantation w/in 30”, replant and follow guidelinesreplant and follow guidelines

If tooth is out > 60” and not stored, there If tooth is out > 60” and not stored, there is usually one outcome: resorption and is usually one outcome: resorption and probable loss probable loss

If the pt is pre adolescent, the tooth may If the pt is pre adolescent, the tooth may become infraoccluded (ankylosed) as become infraoccluded (ankylosed) as he/she grows olderhe/she grows older

HOW FAST IS FAST? 5”, 30” 60”, TAKE YOUR PICK, it depends on whose book you read!

To replant or not To replant or not If the root of the avulsed tooth is not If the root of the avulsed tooth is not

completely formed, the prognosis for completely formed, the prognosis for survival and revascularization is possible survival and revascularization is possible if if not left out>60”not left out>60”

If root is incompletely formed and If root is incompletely formed and replantation is rapid, vitality may be replantation is rapid, vitality may be maintained but is not predictable maintained but is not predictable

First Aid InstructionsFirst Aid Instructions Handle by crown onlyHandle by crown only Pick off debris with tweezersPick off debris with tweezers Replant tooth if possible Replant tooth if possible __________________________________________________________________ If not, transport in appropriate If not, transport in appropriate

medium:medium: ““HBSS (Hank’s Balanced Salt solution)HBSS (Hank’s Balanced Salt solution) OR “Via Span” (if available)OR “Via Span” (if available) OR OR milk if above not availablemilk if above not available OR place in vestibule (saliva) & OR place in vestibule (saliva) &

Report to dental office ASAPReport to dental office ASAP

Once in Dental office:Once in Dental office:

Take films to make sure there is no Take films to make sure there is no alveolar FX & that adjacent teeth are alveolar FX & that adjacent teeth are OKOK ““Save-a-tooth” (Hank’s Balanced Salt Save-a-tooth” (Hank’s Balanced Salt

solution)solution) OR “Via Span”, milk, salineOR “Via Span”, milk, saline Gently clean socketGently clean socket Replant and check occlusionReplant and check occlusion Splint (7-10 days)Splint (7-10 days) RX antibioticsRX antibiotics

Avulsion InjuryAvulsion InjuryWhat What NOTNOT to do! to do!

Do NotDo Not Handle by rootHandle by root Scrub rootScrub root Allow tooth to dryAllow tooth to dry Submerge the tooth in waterSubmerge the tooth in water

(tap water is (tap water is hypotonic> hypotonic>

and will cause cell rupture)and will cause cell rupture)AAE has a Flow Chart Outlining Current Treatment Management Protocols of both Luxation and Avulsion cases ..www. aae.org.

If over 60” “dry time”If over 60” “dry time”

Remove remnants ofPDL by soaking in Remove remnants ofPDL by soaking in acid for 1” acid for 1”

Soak in Stannous Fl for 5”Soak in Stannous Fl for 5” No harm done to go ahead and complete No harm done to go ahead and complete

endo ASAPendo ASAP SplintSplint

Immature Tooth: Immature Tooth: Open Apex, Open Apex, revascularization revascularization is possible if out is possible if out

less than 30-60”less than 30-60” Replant as above EXCEPT differentReplant as above EXCEPT different Soak tooth in Doxycycline (1mg/20cc Soak tooth in Doxycycline (1mg/20cc

saline)<replantation for 5” saline)<replantation for 5” Monitor pulp vitality closely (q 30 d or Monitor pulp vitality closely (q 30 d or

until root development is confirmed)until root development is confirmed) Vital Open apex will NOT necessarily Vital Open apex will NOT necessarily

require RCT UNLESS pulp becomes require RCT UNLESS pulp becomes necrotic.necrotic.

What if it does? Do we do apexogenesis What if it does? Do we do apexogenesis then?then?

AnkylosisAnkylosis A problem following trauma A problem following trauma

and long termand long term rigidrigid splinting splinting

Tooth is solidly fixed and has Tooth is solidly fixed and has a high metallic ring when a high metallic ring when percussing. Does percussing. Does notnot erupt erupt with other teethwith other teeth

May lead to massive external May lead to massive external resorption & loss of toothresorption & loss of tooth

Internal= appearance of Internal= appearance of “aneurysm” w/in canal. “aneurysm” w/in canal.

Complications with Complications with Replanted avulsed teeth & Replanted avulsed teeth & Possibly with Rigid Long-Possibly with Rigid Long-

Term SplintingTerm Splinting Ankylosis (Replacement Ankylosis (Replacement Resorption)Resorption)

Vertical Root FractureVertical Root FractureLook for ‘J’-Shaped apical lesion

Look for Drop-off Pocket if . . . .

VRF difficult to confirm radiographically –UNLESS

separation of segments occurs

Transillumination Restoration Removal + Staining

Other methods of discovering VERTICAL ROOT FRACTURE

A surgical exploration is usually the only other way to confirm presence of VRF*

Flare-upsFlare-ups

Flare-upsFlare-ups

A flare-up is an acute exacerbation A flare-up is an acute exacerbation of an asymptomatic pulp/or of an asymptomatic pulp/or periapical pathosis after the periapical pathosis after the initiation or continuation of root initiation or continuation of root canal treatment.canal treatment.

Patient PresentationPatient Presentation

PainPain Pain and swelling Pain and swelling

FactorsFactors

MechanicalMechanical chemicalchemical Emotional Emotional

statestate GenderGender Microbial Microbial

• ImmunologicImmunologicalal

• PsychologicaPsychological statel state

• Regulation Regulation of periapical of periapical inflammationinflammation

IncidenceIncidence

1.4 to 19%1.4 to 19% 20 to 40%20 to 40%

Age of Patient?Age of Patient?

There is a lack of agreement There is a lack of agreement concerning the influence of age on concerning the influence of age on the incidence of flare-up.the incidence of flare-up.

40_59 year(most)40_59 year(most) Under the age of 20(least)Under the age of 20(least)

Gender and Flare-upsGender and Flare-ups

Women(most)Women(most)

Systemic conditionsSystemic conditions

Host resistanceHost resistance Allergy Allergy

Anatomic Location Anatomic Location

Mandibular teethMandibular teeth premolarspremolars

Anxiety Anxiety

Preoperative History of Preoperative History of the Tooththe Tooth

Number of Treatment Number of Treatment VisitsVisits

Causes of Inter-Causes of Inter-Appointment PainAppointment Pain

MechanicalMechanical ChemicalChemical Microbial injuryMicrobial injury

Re-Treatment CasesRe-Treatment Cases

13.6% flare-up13.6% flare-up

Strategies to Prevent Strategies to Prevent Flare-upsFlare-ups

Anxiety ReductionAnxiety Reduction Behavioral InterventionBehavioral Intervention Occlusal ReductionOcclusal Reduction

Pharmacologic Pharmacologic Strategies for Flare-upStrategies for Flare-up

Antibiotic Antibiotic NSAIDs and AcetaminophenNSAIDs and Acetaminophen Long-acting Local AnestheticsLong-acting Local Anesthetics

Patient InstructionsPatient Instructions

By the ClockBy the Clock NOTNOT PRNPRN

Systemic involvementSystemic involvement Compromised host Compromised host

resistanceresistance Fascial space involvementFascial space involvement

Indications for Antibiotic Therapy

Treatment of Treatment of Endodontic Flare-upsEndodontic Flare-ups

Diagnosis and Definitive TreatmentDiagnosis and Definitive Treatment Drainage Through the Coronal Drainage Through the Coronal

Access OpeningAccess Opening I&DI&D InstrumentationInstrumentation TrephinationTrephination( For severe pain ( For severe pain

without visible swelling)without visible swelling)