A Road to Managing Dental Trauma with Predictable Results

a road map to managing dental trauma!with predictable outcomes

h. ryan kazemi, dmd!oral and maxillofacial surgeon!

bethesda, MD

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common causesfalls playground accident abuse bicycle mva assaults altercations athletic injuries

predisposing factorsabnormal occlusions overjet > 4 mm labially inclined incisors lip in competence short upper lip mouth breathing

mechanism of injury

timing

bleeding?

loc?

history

account for all teeth

tissue

teeth position

lacerations

examination

teeth!mobilities

extent of!injury

alveolar bone

embedded FB

submandibular!duct

parotid duct

examination

FOMteeth!fractures

tonguenerves

vessels

facial!wounds

facial!fractures

vitality test!- short term!- long term

examination- teethpercussion!- pain ! —> injury to periodontal ligament!- sound —> dull (subluxated) or hard metallic (locked)

teeth!color

day 0 day 28 2 months 3 months

0 29.4% 82.35% 94.11%

positive responsiveness in pulp tests

panorexradiographs

periapical

CBCT root fractures degree of extrusion or intrusion periodontal disease root development size of pulp chamber & canal jaw fractures tooth fragments caries

oral!surgeon

team communication

endodontist

restorative!dentist

hard dental tissue & pulp

periodontal!tissue

supporting!bone

gingiva or oral mucosa


periodontal!tissue

supporting!bone


crown infraction!uncomplicated crown fracture!complicated crown fracture!uncomplicated crown-root fracture!complicated crown-root fracture!root fracture


impact to only enamel!transillumination for dx!upper incisor labial aspect!—> no treatment!vitality check & f/u!if non vital at time of exam, observe

crown infraction


enameloplasty!composite restoration

crown fractureuncomplicated- enamel only


seal dentin tubules!promote secondary dentin deposition!calcium hydroxide liner over dentin and composite restoration!monitor vitality

crown fractureuncomplicated- enamel & dentin

glass ionomer

CaOH2 solubility in water —> dissolution


enamel & dentin with exposure of pulp!

!

treatment options:!pulp capping!partial pulpotomy!endodontic treatment

crown fracturecomplicated- enamel & dentin with exposure of pulp


tooth is sound & small exposure!!

!

pulp capping!(CH or MTA)


MTA- mineral trioxide aggregate!•forms CH that releases ca ions for cell attachment and proliferation!•creates an antibacterial environment with its alkaline PH!•modulated cytokine production!•encourages differentiation and migration of hard tissue producing cells!•forms hydroxyapatite on MTA surface and provides a biological seal

Pitt-Ford and Patel: Most pulps capped with MTA were free of

inflammation and showed calcified bridge after 5 months


!

immature teeth with open apex!!

!

cervical pulpotomy!(MTA / CH)


2-4 mm

most require pulpectomy after root development is completed

pulpotomy & capping

MTA or Biodentine courtesy: Dr. Pirooz Zia

Biodentine™: a dentin substitute indicated for use in:!!

crown for temporary enamel restorations!permanent dentin restorations!deep or large carious lesions!deep cervical or radicular lesions!pulp capping or pulpotomy!used in the root for root and furcation perforations!internal and external resorptions!apexification!retrograde surgical filling.

biodentine!bioactive dentin substitute

sets in 10 - 12 minutes!!natural micro mechanical anchorage

for excellent sealing properties without surface preparation.!!similar mechanical properties and

mechanical behavior as human dentin.!!3.5mm aluminum radiopacity for

easy short and long term follow-up.

biodentine!bioactive dentin substitute


!

mature teeth with closed apex!!

!

pulpectomy & endodontic tx



treatment depending on amount of root remaining!primary teeth —> extract!permanent teeth —>!

> extract: too apical / vertical!> rct / ortho eruption!> rct and submerge root!> extraction / site graft!> extraction / immed. implant

crown-root fracturesuncomplicated (no pulp exposure)

uncomplicated!crown fracture

uncomplicated!crown root fracture

restored extracted

extraction with no grafting per patient

3 months

loss of buccal plate

1!!

graft

6 months

2!!

implant

3!!

provisional!for 3 m

4!!

final

hard dental tissue & pulp crown-root fractures

complicated (pulp exposure)

treatment depending on amount of root remaining!primary teeth —> extract!permanent teeth —>!

> extract: too apical / vertical!> rct / ortho eruption!> rct and submerge root!> extraction / site graft!> extraction / immed. implant

no boneno implant


75% involve centrals!40% with alveolar bone fx!primary teeth —> if no mobility, may preserve and allow normal exfoliation. If mobile, then extract

root fractures


permanent teeth!apical third level!

!

no mobility- prognosis good with minimal treatment.!coronal aspect may remain vital and no endo treatment may be necessary.

root fractures

hard dental tissue & pulp root fractures

permanent teeth!mid-root level!

!

may have fair prognosis!needs splinting: 2-3 month!check vitality continually!resorption in 60% within 1y!!

>> immediate implant / graft!>> site graft / delayed implant

hard dental tissue & pulp root fractures

permanent teeth!high-root level!

!

poor prognosis!atraumatic extraction!

!

>> immediate implant / graft!>> site graft / delayed implant

healing by ‘calcific callus’

courtesy: Dr. Pirooz Zia

is buccal!bone intact?

buccal bone intact

tooth fracture!(adult)

above bone at bone below bone

no pulp exposure

pulp exposure

minor!fracture

sig!fracture

buccal bone

no buccal bone

restore pulpectomy

restore

crown length or

ortho eruption

treat same as below bone

fracture extract!graft

implant

extract!implant!

graft


periodontal!tissue

supporting!bone


concussion!subluxation (loosening)!intrusive luxation (central dislocation)!extrusive luxation (partial avulsion)!lateral luxation!retained root fracture!exarticulation (complete avulsion)

periodontal!tissue

tooth is tender to touch!no mobility!percussion sensitive!no treatment!check vitality later as necrosis can develop in several weeks to months

concussion

periodontal!tissue

bleeding is common!percussion sensitive!positive mobility!treatment: non-rigid splint for 7-10 days!monitor for pulp complications

subluxation

periodontal!tissue

compression into socket!impaction to complete disappearance in alveolus!significant damage to pdl!high incidence of external resorption, pulp necrosis, marginal bone loss!percussion- dull metallic

intrusive luxation

periodontal!tissue

treatment options!!

re-erupt if immature tooth!immediate repositioning (high resorption / bone loss)!low-force ortho reposition!extraction!primary teeth —> extract

intrusive luxation

periodontal!tissue

apex displaced out of socket with NV rupture!pdl space is widened!dull percussion sound!primary tooth —> extract

extrusive luxation

periodontal!tissue

treatment- permanent teeth!manipulate into socket!nonrigid splint 1-2 weeks!

!

>> within few hours of injury!>> after 33 hours- increased rate of pulp necrosis

extrusive luxation

periodontal!tissue

often with bone fracture!reposition & compress!splint 2-8 weeks!endo tx

lateral luxation

incomplete root formation!

!

endo treatment may not be necessary

endodontic consult

periodontal!tissue

fracture of root at cervical or deeper!

treatments:!>> extract / implant / graft!>> extract / graft!>> endo / submerge!>> endo / ortho eruption

retained root fracture

periodontal!tissue

extract, implant, graft!if!

buccal bone intact!gingival margin is ideal!can achieve primary implant stability!tissue not traumatized / infected


periodontal!tissue

extract & graft!if!

buccal bone is not intact!bone loss has occurred!primary implant stability can not be achieved!tissue is traumatized


periodontal!tissue

rct & submerge!(preserve tissue)!

if!no bone fracture!patient growth incomplete!adult patient with soft tissue loss (goal is to regenerate soft tissue)


periodontal!tissue

rct & ortho eruption!(to augment tissue)!

if !no bone fracture!soft tissue is apical to adjacent gingival margin!vertical bone loss (good bone level on adjacent tooth)


best tissue preservation!!

immediate implant!bone graft in gap!immediate provisional to support soft tissue

periodontal!tissue

15% of permanent teeth!7-13% of primary teeth!maxillary incisors!most common age 7-10!treatment goal: maintain vitality of cells (pulp & pdl)

avulsion (exarticulation)

periodontal!tissue

timeavulsion (exarticulation)

within!30 minutes

periodontal!tissue

other factors for success!!

width & length of root canal!stage of root development!type of storage medium!degree of oral trauma


periodontal!tissue

treatment options!!

re-implantation!immediate implant / graft!site graft / delayed implant


periodontal!tissue

Andreasen & Hjorting-Hansen!!

after 2 years or more, 90% of teeth re-implanted within 30 minutes exhibit no discernible resorption of roots!95% resorption if > 2 hours

avulsion (exarticulation)re-implantation

resorption in avulsion cases

courtesy: Dr. Pirooz Zia

periodontal!tissue

early re-implantation is key!instructions if at site of injury!

1. inspect tooth for debris!2. hold only by crown!3. cleanse with milk or saliva!4. put tooth into socket!5. hold with light pressure!6. come to office


periodontal!tissue

storage!!

buccal vestibule!under tongue!milk!hanks balanced salt solution!NO TAP WATER


periodontal!tissue avulsion (exarticulation)

medium ph osmolarity

saline 7.0 295

tap water 7.5 12

salive 6.3 110-120

viaspan 7.4 320

gatorade 3.0 280-360

milk 6.75 275

coconut water 6.2 288

blood plasma 7.2-7.4 290

hank’s bss 7.0 270-290

hypotonic

periodontal!tissue

assessment!!

history!type of injury!how long ago?!‘dry time’!exam site!accountability of teeth!type of storage medium


periodontal!tissue

primary teeth!!

do not!re-implant


periodontal!tissue

conditions before!re-implantation!

!

tooth without perio disease!socket intact!no ortho issues- crowding!less than 30 minutes!stage of root development (incomplete >> within 2 h)


periodontal!tissue

treatment- closed apex!(dry time < 30 min; tooth in medium 20 min to 6 h)!

!

irrigate tooth if with debris!clean coagulum with saline!re-implant and press!splint while patient in occlusion!nonrigid splint for 1-2 wk!if bone fx —> splint 3-4 wk!suture lacerations


periodontal!tissue

treatment- closed apex!(dry time > 60 min)!

!

irrigate tooth if with debris!clean coagulum with saline!immerse tooth in sodium fluoride solution- 5 minutes!re-implant and press!keep patient in occlusion!nonrigid splint for 4-6 wks


periodontal!tissue

Post treatment- closed apex!!

doxycycline or penicillin vk for 7 days!chlorhexidine rinse for 1 week!assess tetanus vaccination!soft diet 2 weeks!initiate pulpectomy within 7-14 days


periodontal!tissue

treatment- open apex!(dry time < 30 min; tooth in medium 20 min to 6 h)!

!

irrigate tooth if with debris!tooth in doxycycline (100 mg / 20 cc saline) for 5 minutes!clean coagulum with saline!re-implant and press!keep patient in occlusion!nonrigid splint for 1-2 wk


periodontal!tissue

treatment- open apex!(dry time > 60 min)!

!

reimplantation usually not indicated (per american association of endodontics)!may follow same protocol as closed apex (McIntyre, Lee, Trope- permanent tooth replantation following avulsion- pediatric dent 31:137, 2009)


periodontal!tissue

post treatment- open apex!!

doxycycline or penicillin vk for 7 days!chlorhexidine rinse for 1 week!assess tetanus vaccination!soft diet 2 weeks!monitor every 4 weeks + pulp test + X-rays!apexogenesis over next 12-18 months?


periodontal!tissue

follow-up procedures


time closed apex open apex

1-2 weeks initiate endo treatment endo or monitor for vascularity

2-3 weeks clinical & x-ray eval clinical & x-ray eval



6 months clinical & x-ray eval clinical & x-ray eval

1 year clinical & x-ray eval clinical & x-ray eval

yearly for 5 years clinical & x-ray eval clinical & x-ray eval


periodontal!tissue

supporting!bone


comminution of the alveolar socket!fracture of the alveolar socket wall!fracture of the alveolar process!fractures of the mandible or maxilla

supporting!bone

reduce with digital manipulation!if tooth can not be preserved, extract and graft site to preserve tissue

comminution- alveolar bone

supporting!bone

reduce!rigid splint for 4 weeks!primary teeth- may not need any treatment

fracture of socket wall

supporting!bone

closed reduction!open reduction if segment is notably displaced!stabilization for 4 weeks!check teeth vitality and monitor

fracture- alveolar process


periodontal!tissue

supporting!bone


laceration of gingiva or oral mucosa!contusion of gingiva or oral mucosa!abrasion of gingiva or oral mucosa


management!!

debridement!irrigate NS!re-approximate!primary closure

lacerations

splinting!techniques

splinting- acid etch resin splint

light cured preferred to allow time!bridge: resin or wire (28g)

splinting- semirigid splint

resin with waxed dental floss, suture, flexible braided ortho wire or monofilament nylon line!kevlar!fiber splints (fiber force)- use with protemp material for more movement!flexible wire composite splints!titanium splints


fiber splints


periodontal!tissue

supporting!bone


multi-system injuries

• tooth avulsion!• fracture alveolar bone!• extrusive luxation!• lacerations!• crown fractures

surgical order!!

inside-out!downward-up

1. extract fractured teeth!2. debridement of avulsion site!3. reduce dentoalveolar fracture segment!4. splint teeth / alveolar segment!5. graft extraction / avulsion site!6. closure of lacerations

thank you

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A Road to Managing Dental Trauma with Predictable Results

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Transcript of A Road to Managing Dental Trauma with Predictable Results