3. FactFact
Most dental trauma occurs in 7_12 age rangeMost dental trauma occurs in 7_12 age range
And most trauma occurs in the anterior regionAnd most trauma occurs in the anterior region
of the mouth, maxilla>mandibleof the mouth, maxilla>mandible
4. 1. Crown FX without Pulp exposure1. Crown FX without Pulp exposure
NO PROBLEM,
RELAX AND RESTORE
5. Complicated Crown FX with PulpComplicated Crown FX with Pulp
ExposureExposure
Pulp Cap?
OR:
EXTIRPATION if
root is fully formed
Partial Pulpotomy@95%
Full pulpotomy @75%
@80% IF
w/in 24hrs
6. 2. Crown-Root Fracture2. Crown-Root Fracture
sometimes fractures at ansometimes fractures at an angleangle
Angular Fracture:
Is this
restorable?
7. Remember,Remember,
In all trauma, the primary purpose of ourIn all trauma, the primary purpose of our
treatment is to keep the pulp vital, if at alltreatment is to keep the pulp vital, if at all
possible, ESPECIALLY if apex is openpossible, ESPECIALLY if apex is open
WHY?WHY?
9. Apexogenesis vs ApexificationApexogenesis vs Apexification
Dealing with the immature rootDealing with the immature root
ApexogenesisApexogenesis
(Vital Pulp) best to treat w pulpotomy. The idea is to(Vital Pulp) best to treat w pulpotomy. The idea is to
allow the vital pulp to remain vital and complete theallow the vital pulp to remain vital and complete the
development of the root apexdevelopment of the root apex
as well asas well as thickening of the RC wallsthickening of the RC walls
RCT maybe needed later BUT not if tooth remainsRCT maybe needed later BUT not if tooth remains
asymptomatic AND vitalasymptomatic AND vital
ApexificationApexification
(Necrotic Pulp) Hoping to get closure of the apex(Necrotic Pulp) Hoping to get closure of the apex (&(&
there is NO wall thickening)there is NO wall thickening) to be able to later do ato be able to later do a
proper RC seal via obturation. CaOH + time isproper RC seal via obturation. CaOH + time is
proper tx over 3-18moproper tx over 3-18mo
RCT ALWAYS NEEDED HERE* and is lessRCT ALWAYS NEEDED HERE* and is less
predictable due to thinner wallspredictable due to thinner walls
ObjectObject ofof eithereither treatment is to allow for roofing over oftreatment is to allow for roofing over of
apex and allow RCT to be done at a later date.apex and allow RCT to be done at a later date.
10. And now, Regeneration?And now, Regeneration?
Revascularization of immature permanent teethRevascularization of immature permanent teeth
utilizing a mixture of antibiotics(3 weeks), creatingutilizing a mixture of antibiotics(3 weeks), creating
a blood clot w/in the RCS which producesa blood clot w/in the RCS which produces
development of the tooth structuredevelopment of the tooth structure
12. 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
13. 4. Luxation Injuries4. Luxation Injuries
((MOST COMMON OF ALL DENTAL INJURIES)MOST COMMON OF ALL DENTAL INJURIES)
30-44%30-44%
ConcussionConcussion
SubluxationSubluxation
ExtrusionExtrusion
LateralLateral
IntrusionIntrusion
WORST CASE SEQUELAE?
PULP NECROSIS
EXTERNAL/INTERNAL
ROOT RESORPTION
Possible tooth loss
AVULSION
14. Concussion Luxation InjuryConcussion Luxation Injury
LeastLeast severe ofsevere of
Luxation injuriesLuxation injuries
No displacement ofNo displacement of
tooth nor excessivetooth nor excessive
mobilitymobility
Tooth tender toTooth tender to
touchtouch “Bruised PDL”“Bruised PDL”
No radiographicNo radiographic
abnormalitiesabnormalities
Assess vitality in 4Assess vitality in 4
wkswks
15. Subluxation Luxation InjurySubluxation Luxation Injury
Tooth tender to touch &Tooth tender to touch &
slightly mobile (1+) but notslightly mobile (1+) but not
displaceddisplaced
Possible hemorrhage fromPossible hemorrhage from
gingival crevicegingival crevice
No radiographicNo radiographic
abnormalitiesabnormalities
Damage to supportingDamage to supporting
structures?structures?
Assess vitality in 4 weeksAssess vitality in 4 weeks
16. Extrusion Luxation InjuryExtrusion Luxation Injury
Elongated mobile toothElongated mobile tooth
Cl. II mobility or greaterCl. II mobility or greater
Radiographs showRadiographs show
increased apicalincreased apical
periodontal spaceperiodontal space
Manually repositionManually reposition
Reposition tooth +Reposition tooth +
Flexible splintFlexible splint (2 weeks)(2 weeks)
Assess vitality in 4 weeksAssess vitality in 4 weeks
17. What is a flexible splint?What is a flexible splint?
-Allows physiologic movement of the teeth in-Allows physiologic movement of the teeth in
order to minimize ankylosisorder to minimize ankylosis
-In the past, .028 gauge ortho wire bonded to-In the past, .028 gauge ortho wire bonded to
tooth for 7-10 days unless alveolar FX hadtooth for 7-10 days unless alveolar FX had
occurred. Then 4-8 wksoccurred. Then 4-8 wks
OR: 4-6# fishing line bonded to teethOR: 4-6# fishing line bonded to teeth
--Currently, titanium trauma splint (TTS) isCurrently, titanium trauma splint (TTS) is
recommendedrecommended
18. Semi-rigid or flexible splintingSemi-rigid or flexible splinting
Experimental studies in non-human primates haveExperimental studies in non-human primates have
demonstrated thatdemonstrated that rigidrigid splinting ,especially forsplinting ,especially for
prolonged periods, leads to ankylosis &/or externalprolonged periods, leads to ankylosis &/or external
resorption.resorption.
Maintaining a slight degree of tooth mobility appears toMaintaining a slight degree of tooth mobility appears to
be beneficial to PDL healingbe beneficial to PDL healing
21. TTS splintTTS splint
Insert picture of sameInsert picture of same
Splinting of traumatized teeth with a newSplinting of traumatized teeth with a new
device:TTS (Titanium Trauma Splint)device:TTS (Titanium Trauma Splint)
Medartis AG, Basel, SwitzerlandMedartis AG, Basel, Switzerland
Von arx T, etal Dent Traumatol, ’01;17:180-84Von arx T, etal Dent Traumatol, ’01;17:180-84
22. Lateral Luxation InjuryLateral Luxation Injury
Displaced laterally & oftenDisplaced laterally & often
locked in bonelocked in bone
Not tender to touch, notNot tender to touch, not
mobilemobile
Alveolus fracturedAlveolus fractured
Percussion test: high metallicPercussion test: high metallic
sound (ankylosis)sound (ankylosis)
Increased PDL space bestIncreased PDL space best
seen on eccentric or occlusalseen on eccentric or occlusal
radiographsradiographs
Anesthetize & repositionAnesthetize & reposition
+ Flexible splint (4 weeks)+ Flexible splint (4 weeks)
Assess vitality in 4 weeksAssess vitality in 4 weeks
23. Intrusion Luxation InjuryIntrusion Luxation Injury
External root resorption likelyExternal root resorption likely
Most severe ofMost severe of
luxations***luxations***
Tooth appearsTooth appears shortershorter: displaced into: displaced into
alveolar bonealveolar bone
PDL destruction/alveolar crushing)PDL destruction/alveolar crushing)
Beware of ankylosis/resorption/Beware of ankylosis/resorption/
pulp necrosis is all but certain inpulp necrosis is all but certain in
mature teeth***mature teeth***
Not tender to touch, not mobileNot tender to touch, not mobile
Percussion test: high metallic soundPercussion test: high metallic sound
Radiographs not always conclusiveRadiographs not always conclusive
Slightly luxate with forceps or band andSlightly luxate with forceps or band and
move orthodontically.move orthodontically.
Splinting is not usually necessary (>4Splinting is not usually necessary (>4
weeks)weeks)
Tooth with open apexTooth with open apex maymay
spontaneously re-erupt.spontaneously re-erupt.
24. Treatment of intrusion luxationTreatment of intrusion luxation
Closed apex needs ortho. or surgicalClosed apex needs ortho. or surgical
repositioning and probable RCT in 1-3 weeksrepositioning and probable RCT in 1-3 weeks
In all LUXATION and especially INTRUSION injuries,In all LUXATION and especially INTRUSION injuries,
the apical neurovascular bundle and attachmentthe apical neurovascular bundle and attachment
apparatus willapparatus will be affected to some degree>>>lossbe affected to some degree>>>loss
of vitality &of vitality & internal/external resorptioninternal/external resorption
25. 5. Avulsion5. Avulsion
Tooth is knocked completely out ofTooth is knocked completely out of
mouthmouth
Viability of the PDL must beViability of the PDL must be
preserved for successpreserved for success
Extra-oral dry time is CRITICAL 30-Extra-oral dry time is CRITICAL 30-
60”***60”***
Must be replaced in socket ASAPMust be replaced in socket ASAP
(15-20”) in order to..(15-20”) in 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
26. Replant?Replant?
TX is aimed at minimizing the inflammationTX is aimed at minimizing the inflammation
from thefrom the two maintwo main consequences of avulsion,consequences of avulsion,
namely; attachment damage and pulpal infectionnamely; attachment damage and pulpal infection
that inevitably resultsthat inevitably results
The SINGLE most VIP factor in achieving aThe SINGLE most VIP factor in achieving a
favorable outcome is the SPEED at which afavorable outcome is the SPEED at which a
cleanclean tooth istooth is properlyproperly replantedreplanted
Keeping the attached PDL moist is VIP!!*Keeping the attached PDL moist is VIP!!*
27. Replantation guidelinesReplantation guidelines
If tooth is out of the mouth less than 15-20”,If tooth is out of the mouth less than 15-20”,
replant according to guidelinesreplant according to guidelines
If tooth was out and placed in cold milk or otherIf tooth was out and placed in cold milk or other
physiological solution w/in 15-20” & available forphysiological solution w/in 15-20” & available for
replantation w/in 30”, replant and followreplantation w/in 30”, replant and follow
guidelinesguidelines
If tooth is out > 60” and not stored, there is usuallyIf tooth is out > 60” and not stored, there is usually
one outcome: resorption and probable lossone outcome: resorption and probable loss
If the pt is pre adolescent, the tooth may becomeIf the pt is pre adolescent, the tooth may become
infraoccluded (ankylosed) as he/she grows olderinfraoccluded (ankylosed) as he/she grows older
HOW FAST IS FAST? 5”, 30” 60”, TAKE YOUR PICK, it depends on whose book you read!
28. To replant or notTo replant or not
If the root of the avulsed tooth is not completely formed,If the root of the avulsed tooth is not completely formed,
the prognosis for survival and revascularization is possiblethe prognosis for survival and revascularization is possible
if not left out>60”if not left out>60”
If root is incompletely formed and replantation is rapid,If root is incompletely formed and replantation is rapid,
vitality may be maintained but is not predictablevitality may be maintained but is not predictable
29. First Aid InstructionsFirst Aid Instructions
Handle by crown onlyHandle by crown only
Pick off debris with tweezersPick off debris with tweezers
Replant tooth if possibleReplant tooth if possible
__________________________________________________________________
If not, transport in appropriate medium:If not, transport in appropriate medium:
““HBSS (Hank’s Balanced Salt solution)HBSS (Hank’s Balanced Salt solution)
OR “Via Span” (if available)OR “Via Span” (if available)
OROR milk if above not availablemilk if above not available
OR place in vestibule (saliva) & Report toOR place in vestibule (saliva) & Report to
dental office ASAPdental office ASAP
30. Once in Dental office:Once in Dental office:
Take films to make sure there is no alveolar FXTake films to make sure there is no alveolar FX
& that adjacent teeth are OK& that adjacent teeth are OK
““Save-a-tooth” (Hank’s Balanced Salt solution)Save-a-tooth” (Hank’s Balanced Salt 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
31. Avulsion InjuryAvulsion Injury
WhatWhat 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 hypotonic>(tap water is 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.
32. If over 60” “dry time”If over 60” “dry time”
Remove remnants ofPDL by soaking in acid for 1”Remove remnants ofPDL by soaking in acid for 1”
Soak in Stannous Fl for 5”Soak in Stannous Fl for 5”
No harm done to go ahead and complete endo ASAPNo harm done to go ahead and complete endo ASAP
SplintSplint
33. Immature Tooth:Immature Tooth: Open Apex,Open Apex, revascularizationrevascularization
is possible if out less than 30-60”is possible if out less than 30-60”
Replant as above EXCEPT differentReplant as above EXCEPT different
Soak tooth in Doxycycline (1mg/20ccSoak tooth in Doxycycline (1mg/20cc
saline)<replantation for 5”saline)<replantation for 5”
Monitor pulp vitality closely (q 30 d or until rootMonitor pulp vitality closely (q 30 d or until root
development is confirmed)development is confirmed)
Vital Open apex will NOT necessarily require RCTVital Open apex will NOT necessarily require RCT
UNLESS pulp becomes necrotic.UNLESS pulp becomes necrotic.
What if it does? Do we do apexogenesis then?What if it does? Do we do apexogenesis then?
34. AnkylosisAnkylosis
A problem following trauma andA problem following trauma and
long termlong term rigidrigid splintingsplinting
Tooth is solidly fixed and has a highTooth is solidly fixed and has a high
metallic ring when percussing. Doesmetallic ring when percussing. Does
notnot erupt with other teetherupt with other teeth
May lead to massive externalMay lead to massive external
resorption & loss of toothresorption & loss of tooth
Internal= appearance ofInternal= appearance of
“aneurysm” w/in canal.“aneurysm” w/in canal.
35. Complications with ReplantedComplications with Replanted
avulsed teeth & Possibly with Rigidavulsed teeth & Possibly with Rigid
Long-Term SplintingLong-Term Splinting
Ankylosis (Replacement Resorption)Ankylosis (Replacement Resorption)
36. Vertical Root FractureVertical Root Fracture
Look for ‘J’-Shaped apical lesion
Look for Drop-off Pocket if . . . .
VRF difficult to confirm
radiographically –UNLESS
separation of segments occurs
37. 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*
41. Flare-upsFlare-ups
A flare-up is an acute exacerbation of anA flare-up is an acute exacerbation of an
asymptomatic pulp/or periapical pathosis afterasymptomatic pulp/or periapical pathosis after
the initiation or continuation of root canalthe initiation or continuation of root canal
treatment.treatment.
45. Age of Patient?Age of Patient?
There is a lack of agreement concerning theThere is a lack of agreement concerning the
influence of age on the incidence of flare-up.influence of age on 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)
54. Strategies to Prevent Flare-upsStrategies to Prevent Flare-ups
Anxiety ReductionAnxiety Reduction
Behavioral InterventionBehavioral Intervention
Occlusal ReductionOcclusal Reduction
55. Pharmacologic Strategies forPharmacologic Strategies for
Flare-upFlare-up
AntibioticAntibiotic
NSAIDs and AcetaminophenNSAIDs and Acetaminophen
Long-acting Local AnestheticsLong-acting Local Anesthetics
57. Systemic involvementSystemic involvement
Compromised host resistanceCompromised host resistance
Fascial space involvementFascial space involvement
Indications for
Antibiotic Therapy
58. Treatment of Endodontic Flare-Treatment of Endodontic Flare-
upsups
Diagnosis and Definitive TreatmentDiagnosis and Definitive Treatment
Drainage Through the Coronal Access OpeningDrainage Through the Coronal Access Opening
I&DI&D
InstrumentationInstrumentation
TrephinationTrephination( For severe pain without visible( For severe pain without visible
swelling)swelling)
