D435L09 Dental Trauma%2C Cracked teeth %26 Root Fracture.ppt

dentistry

1. Lecture 9, Lecture 9,
Traumatic Injuries, Cracked Teeth and Traumatic Injuries, Cracked Teeth and
vertical root fractures (VRF)vertical root fractures (VRF)
Ch1 (24-32), Ch16(610-646)

2. Abbreviation guideAbbreviation guide

FX=fractureFX=fracture

PN=pulp necrosisPN=pulp necrosis

B4=before or prior to..B4=before or prior to..

TX=treatmentTX=treatment

VPT=vital pulp therapyVPT=vital pulp therapy

VIP=very importantVIP=very important

3. Outline:Outline:
I. Crown FractureI. Crown Fracture
2. Crown-root fractures2. Crown-root fractures
3. Vertical/Horizontal Root Fracture3. Vertical/Horizontal Root Fracture
4. Luxation4. Luxation
5. Avulsion5. Avulsion
6. Resorption6. Resorption
7. Prevention7. Prevention

4. FactFact

Most dental trauma occurs in 7_10 age rangeMost dental trauma occurs in 7_10 age range

And most trauma occurs in the anterior region And most trauma occurs in the anterior region
of the mouth, maxilla>mandibleof the mouth, maxilla>mandible

5. 1. Crown FX without Pulp exposure1. Crown FX without Pulp exposure
NO PROBLEM,
RELAX AND RESTORE

6. Complicated Crown FX with Pulp Complicated Crown FX with Pulp
Exposure=VPTExposure=VPT
Pulp Cap?
OR:
EXTIRPATION if
root is fully formed
Partial Pulpotomy@95%
Full pulpotomy @75%
@80% IF
w/in 24hrs

7. 2. Crown-Root Fracture2. Crown-Root Fracture
sometimes fractures at an sometimes fractures at an angleangle
Angular Fracture:
Is this
restorable?

8. Remember, Remember,

In all trauma, the primary purpose of our In all trauma, the primary purpose of our
treatment is to keep the pulp vital, if at all treatment is to keep the pulp vital, if at all
possible, ESPECIALLY if apex is openpossible, ESPECIALLY if apex is open

WHY?WHY?

9. Pulpotomy – Immature ApexPulpotomy – Immature Apex
If Vital = “Apexogenesis”*If Vital = “Apexogenesis”*

10. 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 the allow the vital pulp to remain vital and complete the
development of the root apex development of the root apex
as well as as well as thickening of the RC wallsthickening of the RC walls
RCT maybe needed later BUT not if tooth remains RCT maybe needed later BUT not if tooth remains
symptomatic AND vitalsymptomatic 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 a to be able to later do a
proper RC seal via obturation. CaOH + time is proper RC seal via obturation. CaOH + time is
proper tx over 3-18moproper tx over 3-18mo
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 roofing over of treatment 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.

11. And now, Regeneration?And now, Regeneration?

Revascularization of immature permanent teeth Revascularization of immature permanent teeth
utilizing a mixture of antibiotics, creating a blood utilizing a mixture of antibiotics, creating a blood
clot w/in the RCS which produces development of clot w/in the RCS which produces development of
the tooth structurethe tooth structure

Banchs F, Trope MBanchs F, Trope M
“ “Revascularization of immature permanent Revascularization of immature permanent
teeth w PN & apical periodontitis….teeth w PN & apical periodontitis….
JOE, 196; 2004JOE, 196; 2004

12. Vertical FX of Crown>RootVertical FX of Crown>Root
@ 3% of all dental injuries@ 3% of all dental injuries
Generally if crack extends to the pulpal floor (molar), the tooth will be
lost
Most commonly cracked tooth – Distal of Mandibular second molar –
– May need to STAIN crown to see crack
WHY?
Look for
“Drop-Off”
Pocket at
base of
Crack site

13. Insert occlusal view of MMR/DMR Insert occlusal view of MMR/DMR
fracture to supplement previous slidefracture to supplement previous slide

Because, endo/perio lesion can mimic VRF Because, endo/perio lesion can mimic VRF
radiogragraphradiogragraph

14. If untreated, a crack will widen into a splitIf untreated, a crack will widen into a split

15. 3. Vertical Root Fracture3. Vertical Root Fracture
Look for ‘J’-Shaped apical lesion
Look for Drop-off Pocket if . . . .
VRF difficult to confirm
radiographically –UNLESS
separation of segments occurs

16. 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*

19. Horizontal Root FractureHorizontal Root Fracture
Tends to be Readily
apparent – especially
after separation
XS Mobility a good clue
Is this salvageable?
Prognosis is very poor

20. 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

21. 4. Luxation Injuries4. Luxation Injuries
((MOST COMMON OF ALL DENTAL INJURIES)MOST COMMON OF ALL DENTAL INJURIES)
30-44% text p630 30-44% text p630

ConcussionConcussion

SubluxationSubluxation

ExtrusionExtrusion

LateralLateral

IntrusiveIntrusive
WORST CASE SEQUELAE?
PULP NECROSIS
EXTERNAL/INTERNAL
ROOT RESORPTION
Possible tooth loss
AVULSION

22. Concussion Luxation InjuryConcussion Luxation Injury

Least Least severe of severe of
Luxation injuriesLuxation injuries

No displacement of No displacement of
tooth nor excessive tooth nor excessive
mobilitymobility

Tooth tender to Tooth tender to
touch touch “Bruised PDL”“Bruised PDL”

No radiographic No radiographic
abnormalitiesabnormalities

VIP!!! Assess vitality VIP!!! Assess vitality
in 4 wksin 4 wks

23. Subluxation Luxation InjurySubluxation Luxation Injury

Tooth tender to touch & Tooth tender to touch &
slightly mobile (1+) but not slightly mobile (1+) but not
displaceddisplaced

Possible hemorrhage from Possible hemorrhage from
gingival crevicegingival crevice

No radiographic No radiographic
abnormalitiesabnormalities

Damage to supporting Damage to supporting
structures?structures?

VIP!!! Assess vitality in 4 VIP!!! Assess vitality in 4
weeksweeks

24. Extrusion Luxation InjuryExtrusion Luxation Injury

Elongated mobile toothElongated mobile tooth

Cl. II mobility or greater Cl. II mobility or greater

Radiographs show Radiographs show
increased apical increased apical
periodontal spaceperiodontal space

Manually repositionManually reposition

Reposition tooth + Reposition tooth +
Flexible splintFlexible splint
MANDATORY 7-10 days ?MANDATORY 7-10 days ?

VIP!!! Assess vitality in 4 VIP!!! Assess vitality in 4
weeksweeks

25. 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 tooth -In the past, .028 gauge ortho wire bonded to tooth
for 7-10 days unless alveolar FX had occurred. for 7-10 days unless alveolar FX had occurred.
Then 4-8 wksThen 4-8 wks
OR: 4-6# fishing line bonded to teethOR: 4-6# fishing line bonded to teeth
--Currently, titanium trauma splint (TTS) is Currently, titanium trauma splint (TTS) is
recommended see p643, textrecommended see p643, text

26. Semi-rigid or flexible splintingSemi-rigid or flexible splinting

Experimental studies in non-human primates have Experimental studies in non-human primates have
demonstrated that demonstrated that rigid rigid splinting ,especially for splinting ,especially for
prolonged periods, leads to ankylosis &/or external prolonged periods, leads to ankylosis &/or external
resorption.resorption.

Maintaining a slight degree of tooth mobility appears to Maintaining a slight degree of tooth mobility appears to
be beneficial to PDL healingbe beneficial to PDL healing

Von Arx T, etal Splinting of Traumatized teeth Von Arx T, etal Splinting of Traumatized teeth
with a new device:TTS; Dent Traumatol with a new device:TTS; Dent Traumatol
2001;17:180-842001;17:180-84

27. Titanium Trauma Splint
Medaris AG, Basel Switzerland

29. TTS splintTTS splint

Insert picture of sameInsert picture of same

Splinting of traumatized teeth with a new Splinting 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

30. Lateral Luxation InjuryLateral Luxation Injury

Displaced laterally & often Displaced laterally & often
locked in bonelocked in bone

Not tender to touch, not Not tender to touch, not
mobilemobile

Alveolus fracturedAlveolus fractured

Percussion test: high metallic Percussion test: high metallic
sound (ankylosis)sound (ankylosis)

Increased PDL space best Increased PDL space best
seen on eccentric or occlusal seen on eccentric or occlusal
radiographsradiographs

Anesthetize & repositionAnesthetize & reposition
+ Flexible splint + Flexible splint
MANDATORY 4-8 weeksMANDATORY 4-8 weeks

VIP!!! Assess vitality in 4 VIP!!! Assess vitality in 4
weeksweeks

31. Intrusion Luxation InjuryIntrusion Luxation Injury
External root resorption likelyExternal root resorption likely

Most severe of Most severe of
luxations***luxations***

Tooth appears Tooth 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 in pulp 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 and Slightly luxate with forceps or band and
move orthodontically.move orthodontically.

Splinting is not usually necessarySplinting is not usually necessary

Tooth with open apex Tooth with open apex maymay
spontaneously re-erupt.spontaneously re-erupt.

32. Treatment of intrusion luxationTreatment of intrusion luxation

Closed apex needs ortho. or surgical Closed apex needs ortho. or surgical
repositioning and probable RCT in 1-3 weeks repositioning 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 attachment the apical neurovascular bundle and attachment
apparatus will apparatus will be affected to some degree>>>loss be affected to some degree>>>loss
of vitality & of vitality & internal/external resorptioninternal/external resorption

33. 5. Avulsion5. Avulsion

Tooth is knocked completely out of mouthTooth is knocked completely out of mouth

Viability of the PDL must be preserved for successViability of the PDL must be preserved for success

Extra-oral dry time is CRITICAL 30-60”***Extra-oral dry time is CRITICAL 30-60”***

Must be replaced in socket ASAP (15-20”) (text p641) in Must be replaced in socket ASAP (15-20”) (text p641) 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

34. Replant?Replant?

TX is aimed at minimizing the inflammation TX is aimed at minimizing the inflammation
from the from the two maintwo main consequences of avulsion, consequences of avulsion,
namely; attachment damage and pulpal infection namely; attachment damage and pulpal infection
that inevitably results that inevitably results

The SINGLE most VIP factor in achieving a The SINGLE most VIP factor in achieving a
favorable outcome is the SPEED at which a favorable outcome is the SPEED at which a
cleanclean tooth is tooth is properlyproperly replanted replanted

Keeping the attached PDL moist is VIP!!*Keeping the attached PDL moist is VIP!!*

35. 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 other If tooth was out and placed in cold milk or other
physiological solution w/in 15-20” & available for physiological solution w/in 15-20” & available for
replantation w/in 30”, replant and follow replantation w/in 30”, replant and follow
guidelinesguidelines

If tooth is out > 60” and not stored, there is usually If tooth is out > 60” and not stored, there is usually
one outcome: resorption and probable loss one outcome: resorption and probable loss

If the pt is pre adolescent, the tooth may become If 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!

36. To replant or not (cont)To replant or not (cont)

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 possible the 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 predictable vitality may be maintained but is not predictable

Kenny DH etal; Medicolegal aspects of replanting Kenny DH etal; Medicolegal aspects of replanting
permanent teeth. J Can Dent Assoc 71:245-48, 2005permanent teeth. J Can Dent Assoc 71:245-48, 2005

37. 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 medium:If not, transport in appropriate medium:

““Save-a-tooth” (Hank’s Balanced Salt solution)Save-a-tooth” (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) & Report to OR place in vestibule (saliva) & Report to
dental office ASAPdental office ASAP

38. Once in Dental office:Once in Dental office:

Take films to make sure there is no alveolar FX Take 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

SplintSplint

RX antibioticsRX antibiotics

39. Avulsion InjuryAvulsion Injury
What 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 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.

40. 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

PrayPray

41. Immature Tooth: Immature Tooth: Open Apex, Open Apex, revascularization revascularization
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/20cc Soak tooth in Doxycycline (1mg/20cc
saline)<replantation for 5” text,p642saline)<replantation for 5” text,p642

Monitor pulp vitality closely (q 30 d or until root Monitor pulp vitality closely (q 30 d or until root
development is confirmed)development is confirmed)

Vital Open apex will NOT necessarily require RCT Vital 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?

42. Case HistoryCase History

16 yr., African-American male presents 16 yr., African-American male presents
with avulsed teeth and deep puncture with avulsed teeth and deep puncture
wound or lipwound or lip

# 7 and # 8 intact # 7 and # 8 intact

30 minutes post assault (60 minutes=critical)30 minutes post assault (60 minutes=critical)

Patient is lucid, responsive, with no Patient is lucid, responsive, with no
apparent neurological impairmentapparent neurological impairment

Medical history non-contributoryMedical history non-contributory

43. AnkylosisAnkylosis

A problem following trauma and A problem following trauma and
long termlong term rigidrigid splinting splinting

Tooth is solidly fixed and has a high Tooth is solidly fixed and has a high
metallic ring when percussing. Does metallic ring when percussing. Does
notnot erupt with other teeth erupt with 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.

44. Complications with Replanted Complications with Replanted
avulsed teeth & Possibly with Rigid avulsed teeth & Possibly with Rigid
Long-Term SplintingLong-Term Splinting

Ankylosis (Replacement Resorption)Ankylosis (Replacement Resorption)

45. 7. Plug for Prevention7. Plug for Prevention

Mouth guards***Mouth guards***

Many of the injuries we discussed could be Many of the injuries we discussed could be
prevented through the aggressive promotion and prevented through the aggressive promotion and
use of mouth guards.use of mouth guards.

Every child should wear one for most active play. Every child should wear one for most active play.

Every adult involved in sports should wear one.Every adult involved in sports should wear one.

Become Involved in your Become Involved in your
Community! Begin the Service if Community! Begin the Service if
not available in your area.not available in your area.