THE TWILIGHT SERIES trauma Dandenong 2012.pdf · Permanent Teeth 2004 4. ... Epidemiology of dental...

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THE TWILIGHT SERIES

www.zimendo.com.au

Phillippe O Zimet Associate Professor

in Endodontics School of Dentistry

and Oral Health La Trobe University

77 Stud Rd Dandenong

www.zimendo.com.au

[email protected]

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!At the end of this lecture participants will be able to : 1.!describe the aim and objective of trauma management. 2.!discuss the aetiology of dental trauma.

3.!classify dental injuries.

4.!understand the effect of trauma on the pulp.

5.!understand the effect of trauma on the periodontium.

6.!examine a patient with dental trauma.

7.!undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.!Pursue endodontic management of traumatized teeth.

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Treatment guidelines are from:

1. Guidelines for the evaluation and management of

traumatic dental injuries.

International Association of Dental Trauma

Updated February 2012 Part 1 Anthony J. DiAngelis,

Jens O. Andreasen, Kurt A. Ebeleseder, David J. Kenny, Martin Trope, Asgeir Sigurdsson, Lars Andersson, Cecilia

Bourguignon, Marie Therese Flores, Morris Lamar Hicks,

Antonio R. Lenzi, Barbro Malmgren, Alex J. Moule, Yango

Pohl, Mitsuhiro Tsukiboshi

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Definition and Diagnosis are from: 2. AAPD Trauma Guide 2007

3. AAPD Guideline on Pulp Therapy for Primary and Young

Permanent Teeth 2004

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

5. Traumatic Dental Injuries – A

Manual

Highly recommended text

Andreasen et al 2011

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AIM of Trauma Management:

•!Maintain, preserve or reinstate the

original dentition

Objective of Trauma Management:

•!Preserve the pulp

•!Preserve the periodontal ligament

•!Maintain aesthetics of the dentition

•!Maintain function of the dentition

•!Ensure comfort of the dentition

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Want to avoid treatable pathology that may result in loss of tooth (such as inflammatory resorption) or patient symptoms

such as pulp necrosis or pulpitis.

A parent’s nightmare

Pathology may not be evident early or provide confusing signs and symptoms. May get necrosis

with infection late such as after calcification.

How do we assess and manage?

Sitra yusuf!

18 09 08 Nov 2010

Every effort is made to preserve the pulp of the immature permanent tooth, or induce

revascularization or regeneration of pulp tissue.

March 2007! June 2009!

mccartney!

05 09 07!130807! 210808!

160710!

•!avulsed teeth 32, 31 and 42 some 5 days ago. Teeth placed in milk soon after for 2 hr

•!note from the referring practitioner

regarding an alveolar fracture

•!Clinical examination revealed imbrucation

of the lower anterior dentition with a lingual splint

•!43, 42, 41, 32 and 31 to be non responsive

to pulp testing.

•!Treatment?

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Gray 300610!

The response

of the teeth

to trauma

is variable







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Remember dental trauma can happen any time and any place. The first course of treatment is

prevention.!

EPIDEMIOLOGY - Relation to

prevention

•!Importance of mouthguard and face

shields

•!Use of seatbelts

•!Use of safe toys eg swings

Ref: Monash University Accident

Research Centre, Newsome

(mouthguards) IJPD 2001, Shahim

ADJ 2006, Bastone ADJ 2000) !

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Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial

C Finch, R Braham, A McIntosh, P McCrory and R Wolfe

Injury Prevention 2005;11:242-246

• This is the first randomized controlled trail of the

effectiveness of protective equipment in community level

Australian football, and one of a few worldwide in any sport.

• Players who were allocated to the

custom fitted mouthguard study arm had

a significantly lower rate of head and

orofacial injuries than all other players.

Mouthguards in sport activities : history, physical properties and injury prevention effectiveness. Knapik JJ, Marshall SW, Lee RB, Darakjy SS, Jones SB, Mitchener TA,

delaCruz GG, Jones BH. Sports Med. 2007;37(2):117-44

Studies that have examined injuries among mouthguard

users and nonusers are of highly variable methodological quality. However, published research consistently shows that

mouthguards offer significant protection against orofacial

injuries.

Meta-analysis indicates that the overall risk of an orofacial injury is 1.6–1.9 times higher when a mouthguard is not worn,

relative to wearing a mouthguard.

Epidemiology of dental trauma; a review of the literature

Bastone, Freer and McNamara

ADJ 2000

•!Accidents within and around the home were the major sources of injury to the primary dentition

•!Accidents at home and school accounted for most of the

injuries to the permanent dentition.

SO BE READY TO TREAT TRAUMA AT ANY TIME!!







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WHO CLASSIFICATION (1992) -DENTAL INJURIES!

TREAT IN ASSOCIATION WITH HARD! !TISSUE/PULP!

1. PERIODONTAL TISSUES!1.1. Concussion!1.2. Subluxation!1.3. Extrusive Luxation(peripheral dislocation,partial avulsion)!1.4. Lateral luxation!1.5. Intrusive luxation(Central dislocation)!1.6. Avulsion (exarticulation)!

2. INJURIES TO SUPPORTING BONE!2.1. Comminution (splintering) of the mandibular or maxillary alveolar socket!2.2. Fracture of the mandibular or maxillary socket wall!2.3. Fracture of the mandibular or maxillary alveolar process!2.4. Fracture of the mandible or maxilla!

3. GINGIVAE OR ORAL MUCOSA!3.1. Laceration of gingivae or oral mucosa (includes tear and degloving)!3.2. Contusion of gingivae or oral mucosa (sub mucosal haemorrhage)!3.3. Abrasion of gingivae or oral mucosa (superficial)!

WHO CLASSIFICATION (1992) -DENTAL INJURIES!

!4. HARD DENTAL TISSUES AND PULP!

1.! Enamel infraction!

2.! Enamel fracture (uncomplicated crown! !fracture)!

3.! Enamel/dentine fracture (uncomplicated! !crown ! fracture)!

4.! Complicated crown fracture!

5.! Uncomplicated crown/root fracture!

6.! Complicated crown /root fracture!

7.! Root fracture!

The common theme following trauma to the dentition is that following dental

trauma there may injury to the:

•! Pulp

•! Tooth

•! Separation or crushing of supporting tissues (gingivae, PDL, bone)







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RESULTS OF TRAUMA-MANY TISSUES

AFFECTED BY TRAUMA!

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Nothing/Physiologic surface resorption"Pulp healing

•!Internal Resorption!

•!External Resorption (Infection "Induced / Inflammatory)!

•!

External Resorption (Replacement)"Ankylosis"

!•!Pulpal Canal Obliteration"!•! Invasive Cervical Resorption "•! Pulpal ischaemia - Necrosis or infection"

•! Transient apical internal resorption"

•! Transient apical breakdown"

•! Transient/permanent marginal breakdown"

•!Following dental trauma there may injury to the:

•! Pulp

•! Tooth

•! Separation or crushing of supporting

tissues (gingivae, PDL, bone)

Yusuf 1711 08

Consequences:

What does this picture

represent?

•! haemolysis vital

pulp •! haemolysis with

ischaemia

•! neuropraxia

•! neurotmesis

•! pulp necrosis •! pulp necrosis with

infection!

Yusuf 1711 08

121109 220210 180908

Consequences:

At what point is

treatment required?

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tigas!

Pulp necrosis and infection:

19 01 10 19 07 10

Perera presurgical 220811!

Perera

220811!

Pulp necrosis and infection:

22 08 11

Battle open

apex and pulp

necrosis

280907!

Pulp necrosis – tooth fails to develop. Treat when signs or symptoms of infection occur:

280907

21 09 04 18 10 04

22 12 04 14 11 05

04 09 08

Prevalence of outcome following trauma

to 899 injured teeth (Hecova Dent Trauma 2010):

Follow up: In children, pulp necrosis was usually

diagnosed within 6 months after the injury

(91.9% of all injured teeth) and in virtually all

teeth within one year.

In patients older than 15 years, pulp necrosis

was predominantly diagnosed later than 6

months (61.7% of all cases) or even later than

12 months (40%) after the trauma

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trzcinski!

Calcific Metamorphosis (Pulpal Calcific Obliteration)

Aetiology

•!Impact injury that did not result in necrosis

•!Vital pulp

•!Process of calcification- Temporary disruption in blood supply leads to deposition of tertiary dentine (irregular

secondary) dentine. Can occur with all injury types.

19 07 07 29 04 08

16 07 11

Sandra Ennor 21 yellow from

calcified pulp 03 05 10!

70% of teeth with PCO discolour. The colour may be yellow or even grey!

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Robertson A etal Incidence of pulp necrosis subsequent

to pulpcanal obliteration from trauma of permanent

incisors. J Endod 1996:22:557-560

Root development

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Crown fracture

Prognosis: !

Adeleke O Oginni and Comfort A Adekoya-Sofowora

2007

Pulp caclification can result in coronal discolouration which can occur some years

later siderus calcification

and pap

170709

280808 021008 170709

•!1% annual risk of pulp necrosis and signs of infection

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Pulp canal obliteration

extrusive luxations, 62.5% with open apices

and in 8.6% teeth with closed apices.

lateral luxation, 34.8% in teeth with

incomplete root formation and in 5.7% teeth

with complete root development.

Following dental there may injury to the: •! Pulp

•! Tooth


tissues (gingivae, PDL, bone)

Perera presurgical

220811 fracture

130112

130112 290410

Following dental trauma there may injury to the:

•! Pulp

•! Tooth


tissues (gingivae, PDL, bone) •! Separation cause collagen to cleave

and some cell damage

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•! Tooth

•! Separation or crushing of supporting tissues

(gingivae, PDL, bone)

•! Crushing damages the cellular and intercellular systems.

•! Damaged tissue is removed by macrophages and

osteoclasts before traumatized tissue is repaired

McCarthy!

Bony healing!

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•!impaction stage (clot – gelatinous coagulum) •!inflammation stage 7 days

•!primary soft callus formation stage 2 weeks

•!callus mineralisation stage 4th week to 10th week

•!callus remodellation stage

Soft Tissue

Collagen at margins 3 days

Granulation tissue fills defect 7 days

Scarring with Collagen and decreasing Vascularity 2 weeks Connective tissue with Epidermis 1 month

!Can I still reposition teeth at 5 days? !

McCarthy!

PDL!

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•!By 2 weeks 2/3 of the mechanical strength of the PDL is restored

PULP

If vascular supply is severed, ingrowth of new vessels begins

at 4 days

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Can I still reposition teeth at 5 days? !


•! Tooth

•! Separation or crushing of supporting tissues (gingivae,

PDL, bone)

•! In complicated luxation, intrusion or avulsion injuries the loss of protecting cementoblast layer and epithelial rests

of Malassez allows osteoclasts and macrphages to

remove damaged PDL and cementum on root surface.

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Definition of resorption

•! Loss of hard tissue by

physiologic or pathologic means

due to activation of clastic cells

130807 300409

1. Alveolar changes - Transient marginal breakdown

Following injury to the supporting bone, remodelling

occurs with fabrication of granulation tissue.

This is seen as a widened PDL space. After 2-3 months the periodontium usually reforms

This can also be seen at the apex as transient apical

breakdown (a transient apical radiolucency)

cril

ly!

02 04 07! 28 05 07!

1. Alveolar changes -Permanent marginal breakdown

Following injury to the supporting bone,

remodelling occurs with fabrication of

granulation tissue.

This is seen as a widened PDL space.

In some instances the healing of the bone

does not occur.

This may be due to the degree of trauma,

or presence of infection.

Bony sequestrum may even occur.

May be seen after lateral luxations,

avulsion, intrusion, alveolar fracture or jaw

fracture

130807

300409

2. Tooth resorption:

Andreasen’s Classification of

resorption:

1.! Internal

inflammatory

2.! External:

•! Surface

•! Inflammatory

•! Replacement

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2. Tooth resorption

Linsdkog/Heithersay’s

Classification:

This classification is clinically

based subdividing resorptions into

three broad groups:

(1) trauma induced tooth

resorption;

(2) infection induced tooth

resorption;

(3) hyperplastic invasive tooth

resorptions.


Classification (Heithersay ADJ

2007): "

!This classification is clinically based

subdividing resorptions into three broad

groups:

(1) ! trauma induced tooth resorption;

•! Surface resorption

•! Transient apical internal resorption

•! Pressure resorption and orthodontic

resorption

•! Replacement resorption

•! Ankylosis



2007): "



groups:





resorption


•! Ankylosis

maclean not properly repositioned 161211!

Minimize surface resorption and

maximize pulpal healing

by ensuring teeth are

repositioned correctly

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Maclean!

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2007): "



groups:





resorption


•! Ankylosis

Jacob peters!

Transient apical internal

resorption

•!TAIR may be associated with colour change

•!Problem is that resolution of colour change

does not always occur and a more invasive

approach (commencement of RCT) may still be

warranted (Heithersay 2007).

•!When I see colour change I am now less

inclined to watch.!

Deege

n!

01 02 07! 22 03 07! 10 05 07

Transient apical internal resorption may be associated with transient

apical breakdown



2007): "



groups:





resorption


•! Ankylosis

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Compare Inflammatory Resoprtion to Replacement

Resorption

RR is affected by the status of

the periodontal ligament.

There is minimal impact from

endodontic treatment. Most

influence is from

•!apical diameter for intrusion

•!initial management in order to

maintain vitality of the periodontal ligament fibers

after avulsion!

Tooth survival improves with proper management. Either replace or store: 11 and 21 were placed in milk

after 5 minutes for about 1 hour. 11 was passively

managed.

As 21 showed signs of resorption, active management.

Is this inflammatory or replacement resorption?!

30.05.04!

peppler!

09 10 09 11 is positive to

EPT. Bizarre!



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Root resorption:

prevalence of replacement resorption was

2.9% in laterally luxated teeth immature teeth

and of mature teeth

42.9% of avulsed and replanted teeth (9 of 17

immature teeth and 12 of 32 mature teeth).

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Bsmith 100604avulse

2-3 min in

about 2000

100604 110910

110910

Avulsed 2-3 min in about 2000. Is this inflammatory or replacement resorption?

251102

James Avulsed Milk

half hour 280904!

280904 250903

Avulsed then in milk for half hour

collis!

Prognosis Intrusive Luxation -Resorption

Results of intrusion

04/02/04!

Sondos Al-Badri

Dental Traumatology

Volume 18 Issue 2 Page 73 - April 2002

120506!



2007): "



groups:





resorption


•! Ankylosis

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•!Results in interface and fusion between bone and

tooth

Ankylosis!


Classification:"



groups:

(1) trauma induced tooth resorption;

(2) infection induced tooth resorption;

Associated with pulpal necrosis and

infection which may or may not be of

traumatic origin


Classification:



three broad groups:


resorption;

•!Internal inflammatory (infective)

root resorption

•!External inflammatory root

resorption


Classification:



three broad groups:


resorption;


root resorption


resorption

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Jacob peterson!

071008!

09 02 09!09 12 08!

21 08 08!

23 06 08!

23 06 08!

Subluxation


Classification:



three broad groups:


resorption;


root resorption


resorption

If you don!t follow up correctly this can happen: Prevalence of outcome following trauma


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Root resorption:

inflammatory resorptions were observed in

33.3% of intruded teeth with immature teeth

and 33.3% mature teeth.

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Root resorption:

external resorptions of the root substances in

16.2% of all teeth.

inflammatory resorptions were observed in

4.5% of laterally luxated immature teeth and

of 14.9% of mature teeth.


Classification:

This classification is clinically based


groups:


(2) infection induced tooth resorption;

(3) hyperplastic invasive tooth

resorptions.

•!Internal replacement (invasive)

resorption

•!Invasive coronal resorption

•!Invasive cervical resorption

•!Invasive radicular resorption

tigas!

What do the statistics mean clinically:

Tooth 32 was avulsed while the adjacent teeth were

luxated. Patient replanted the tooth back into the

socket himself within about 15-20min.

10 03 11 19 01 10 19 07 10 21 11 11







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MATTHEW YOUSSEF email 21

march 2012!

Intra-oral examination for

all trauma

Clinical • Tooth colour

• Millimetre

Dislocation (Vertical/Horizontal) • Loosening/moblity

• Tenderness to palpation

• Tenderness to percussion • Thermal sensibility test; CO2, EPT Thermal sensitivity test; hot, cold

• Mucosal laceration • Locate missing segments Note craze lines (infractures), fracture

Occlusal interference Radiographic (hard and soft tissue): May need to take multiple vertical and

horizontal angles

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Summary of Dental Trauma Triage

Table 1. The Dental Trauma Algorithm for

medics and corpsmen (translated from

Hebrew)

Yehuda Zadik

Dental Traumatology 2008; 24: 698–701;

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1. Loss of consciousness or confusion?

Nausea or vomiting?

Facial or jaw deformation? Haematoma

in the face or in the floor of the mouth? Yes. Immediately refer to

Emergency Department

2. Avulsion ("knock-out!) of a tooth? Yes. Find the tooth. Hold it by the crown and

wash under gentle running saline or water

(Do not scrub!). Replant the tooth into the

Socket.

Success in replantation?

Yes. Refer to a

dentist within

24 h. Continue to #

3

No. Place the tooth in

milk, saline or inside

the patient!s mouth.

Refer immediately to a

dentist or ED

3. Tooth displacement (other than

avulsion)?

No

No

Yes. Refer to a dentist

within 24 h

No

If can!t see the tooth confirm is it intruded, avulsed

or coronal fracture. Try to account for tooth or

segments (?avulsion, embed in lip, inhaled)

4. Tooth mobility (other than

avulsion)?

Yes More than 2 mm

mobility?

Yes. Refer to a dentist within

24 h. Continue to # 5 No

5. Tooth fracture? Yes. Tooth fracture with pulp

exposure, intra-coronal

bleeding or pain?


within 24 h. Continue to # 6

No

Is restoration needed?


48 h

No

No

5. Tooth fracture? Yes. Tooth fracture with pulp

exposure, intra-coronal

bleeding or pain?


within 24 h. Continue to # 6

The tooth is

fractured but

no pulp

exposure. Is restoration needed?


48 h. Continue to #6

No

No

6. Soft tissue laceration?

No Yes. Through-and-through

laceration

Yes. Superficial

laceration

A suspected foreign body

embedded in the soft tissue and/or

infection


or Emergency Department

within several hours

Root development !!

Prognosis – Pulp healing: !

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FOLLOW UP

3 weeks

6 weeks

3 months

6 months (equals one year)

12 months (equals two years)

24 months (equals four years)!

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General Patient instructions •!Soft diet for up to two weeks.

•!Brush teeth with a soft toothbrush after

each meal.

•!Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

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Follow up as for all trauma:

Any symptoms

Clinical signs

•! Sinus tract stoma or swelling

•! Gingivitis

•! Pocket depth

•! Recession

•! Tooth Colour

•! Loosening

•! Tenderness to palpation

•! Tenderness to percussion

•! Thermal test (sensibility, sensitivity)

•!Radiograph-mm dislocation, pulp calcification, continued root

development, marginal bone loss, periradicular radiolucency, resorption.!

In Summary when do I perform endodontic treatment? IADT 2011 suggest 2 signs and symptoms are required to

suggest pulpal infection.

When I think the pulp is infected (not just necrotic)

1.!Radiographic: •!Periapical lesion not resolve or increasing

•!Size of pulp chamber (internal resorption)

•!Sign of external inflammatory resorption

•!Pulp calcification is a sign of pulp vitality

•!Continued root development

2 !Clinical:

•!Response to pulp testing: calcification vs necrosis (but is

it infected?) vs vascular intact •!Colour (calcification vs necrosis vs transient hyperaemia)

•!Sinus tract stoma

•!Prolonged TTP

3. Tenderness to percussion

Andreasen found that the only sign significantly

related to pulp necrosis was tenderness to

pecussion following tooth luxation. (Andreasen et al;

Textbook and colour Atlas of Traumatic Injuries to the teeth – 4th Edition p 378 from Andreasen FM,

Endod Dent Traumatol 1989;5:111-31)

"!

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4. Coronal discolouration

Andreasen states that grey colour changes can be

seen in the crown even 2 to 3 weeks after trauma.

This may be accompanied by radiographic periapical

radiolucency. (Andreasen et al; Textbook and colour Atlas of Traumatic Injuries to the teeth – 4th Edition p

378 from Andreasen FM, Endod Dent Traumatol

1989;5:111-31).

But even colour changes may be transitory and as with apical radiolucency may resolve and reverse

within 1 year. (Andreasen et al; Textbook and colour

Atlas of Traumatic Injuries to the teeth – 4th Edition p

378 from Andreasen FM, Endod Dent Traumatol 1989;5:199 and 201).

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4. Coronal discolouration

Grey coronal colour change is often, not always,

related to pulpal haemorrhage or pulp necrosis.

Yellow coronal colour change is related to pulpal calcification.

Clinically Heithersay feels that if discoloration begins

it rarely reverses (ADJ 2007). If there is no change in

3 months I begin RCT.

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When do I Splint teeth?""

Reason for splinting:"1.! Aid repair"

2.! Comfort-loose, TTP"

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•!The prognosis for the healing outcome is more dependent on the type of injury rather

than the effect of the splinting.

•!the use of cap splints and orthodontic

bands were associated with a greater frequency of pulp necrosis (31, 38) and pulp

canal obliteration (45) when compared with

acid etch resin splints and no splinting.

•!the majority of the selected studies suggested that an extended fixation period is

not an indicator for a poor healing outcome.

Review by Kahler and Heithersay. Dental Traumatology 2008

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This is not correct position

James

McCartney!

Original badly placed

Corrected with orthodontics and associated resorption

What does

treatment delay

mean?

Arnes Muhic 090909

fracture trauma palatal 12!

Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. &

Schwartz, O.Effect of treatment delay upon pulp and periodontal

healing of traumatic dental injuries – a review article.Dental

Traumatology 18 (3), 116-128.2002

Fig. 18. Effect of treatment delay upon healing of 98 luxated teeth with

dislocation. From Eklund et al., 1976 (22).

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Kinga Wojciechowska

Trauma displaced 11

041208!

1.3 Extrusive Luxation!

21 02 08.! 15 01 09.!

Cayla 190208!

21 02 08!

17 03 08!17 03 08!

24 06 09!

patients archibald

donahue

intrusion!

1.5 Intrusive Luxation

2 weeks!

21/03/12!

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IADT 2011 Guidelines for intrusion:

Incomplete root formation:

•! Allow eruption without intervention

•! If no movement in 3 weeks initiate orthodontic

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

orthodontically.

Teeth with complete root formation:

Allow eruption without intervention if intruded less that 3mm.

If no movement in 3 weeks initiate orthodontic or surgical repositioning to limit chance of ankylosis.

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

orthodontically.

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

Once an intruded tooth has been repositioned surgically or

orthodontically – stabilize for 4 to 6 weeks.

Summary of the three methods are only partly evidence based. (From www.dentaltraumaguide.org)

Spontaneous eruption

This is the treatment of choice for deciduous/primary teeth

and for permanent teeth with incomplete root formation.

This treatment has been shown to lead to significantly fewer healing complications than orthodontic and surgical

repositioning. If no movement is noted within 3 weeks,

recommend rapid orthodontic repositioning.

Orthodontic repositioning

This treatment may be preferred for patients with delayed treatment. This allows repair of marginal bone in the socket

along with the slow repositioning of the tooth.

Surgical repositioning

This treatment technique is preferable in acute phase. Intrusion with major dislocation of the tooth (approximately

more than half a crown length) may be an indication for

surgical repositioning.

!

Root canal treatment should be considered in all cases with completed root formation where the

chance of pulp revascularization is unlikely.

Endodontic therapy should preferably be initiated

within 3-4 weeks post-trauma.

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Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. &

Schwartz, O.Effect of treatment delay upon pulp and periodontal healing

of traumatic dental injuries – a review article.Dental

Traumatology 18 (3), 116-128.2002!

Fig. 6. Effect of treatment delay upon pulp

healing of 38 complicated crown fractures treated by pulp capping. From Fuks et al., 1982

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Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E.

& Schwartz, O.Effect of treatment delay upon pulp and

periodontal healing of traumatic dental injuries – a review

article.Dental Traumatology 18 (3), 116-128.2002

Fig. 12. Effect of treatment delay upon pulp

healing of 345 root fractures. From Cvek et al., 2002 (34).

taliscott!

12 11 08!180808! 22 06 09!

If pulp capping is not successful try

revascularization rather

than calcium hyrdoxide

or MTA apexification.

This is different to Follow-up procedures for avulsed permanent teeth:

•!If root canal treatment is indicated (teeth with closed apex),

the ideal time to begin treatment is 7- 10 days postreplant.

•!Calcium hydroxide is recommended for intra canal medication for up to one month followed by root canal filling

with an acceptable material.

•!An exception is a tooth that has been dry for more than 60

minutes before replantation – in such cases the root canal treatment may be done prior to replantation.

•!In teeth with open apices, that have been replanted

immediately or kept in appropriate storage media, pulp revascularization is possible. Root canal treatment should be

avoided unless there is clinical and radiographic evidence of

pulp necrosis.

21/03/12!

28!

•!In cases of replanted teeth where endodontic treatment is not yet indicated teeth should be

monitored by frequent controls during the first year

(once a week during the first month, 3, 6, and 12

months) and then yearly thereafter.

•!Clinical and radiographic examination will provide

information to determine outcome.

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

periapical lesions to heal:

Arnes Muhic 090909

fracture trauma palatal 12!

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THE TWILIGHT SERIES trauma Dandenong 2012.pdf · Permanent Teeth 2004 4. ... Epidemiology of dental...

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