Dental Extrusion.pptx

Dental Extrusion

1. DENTAL EXTRUSION

2. INTRODUCTION Trauma to the oral cavity comprises of 5% injuries in people that look for treatment. Among all facial damages, dental injuries are the most common. Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults affecting 10.5–17.3% of the population . Crown fractures and luxations are the most commonly of all dental injuries . World Prevalence 22.7% affecting primary teeth Commonly occur between 2-6 years old Proper diagnosis, treatment planning, and follow up are important for achieving a favorable outcome. Guidelines should assist dentists and patients in decision making and in providing the best care possible, both effectively and efficiently. DEFINITION OF EXTRUSION: Displacement of the tooth out of its socket in an incisal/axial direction, tear of the periodontal ligament along with injury to the apical vessels 2

3. 3 Extrusive luxation injuries make up nearly 2.6% of all traumatic injuries to the dentition, with subsequent pulp canal obliteration 24% and pulpal necrosis 64%, as the most common consequence Humphreys classified extrusive luxation to three categories: smaller than or equal to 3mm : MILD between 3 and 5mm : MODERATE larger than 6mm : SEVERE He demonstrated that for severely extruded teeth and for those with closed apices, the risk of pulpal necrosis was greatest

4. 4 In extrusive luxation, the apical development stage is a key factor in pulp healing In a patient with open apices , the pulp has the potential to heal , usually following pulp canal obliteration. In teeth with closed apices , the probability of pulp revascularization is low, which leads to pulp necrosi s, and can often be detected within the first eight weeks Study investigated pulp necrosis after extrusion in 52 teeth with closed apices and observed that 51 teeth were necrotized. They concluded that teeth with fully mature root development were forcefully separated from their blood supply and were not expected to recover when reinserted in their previous position

5. Extrusive luxation in primary dentition

6. Partial displacement of the tooth out of its socket The tooth appears elongated and can be excessively mobile. Occlusal interference may be present 7 Clinical findings

7. RECOMMENDATIONS Periapical film –paralleling technique O cclusal R adiograph should be taken at the time of initial presentation for : -diagnostic purposes -to establish a baseline FINDINGS Widened periodontal ligament space apically Please used thyroid collar if needed 8 Radiographic

8. 9 Treatment decisions are based on: D egree of displacement Excessively displaced : extract Mobility I f excessively mobile or extruded > 3mm : extract under LA I nterference with the occlusion If not interfering, allow spontaneous reposition R oot formation A bility of the child to tolerate the emergency situation Pulp tests are not reliable in primary dentition treatment Treatment should be performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries. Extractions have the potential to cause long-term dental anxiety

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10. Parent and patient education Extra care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible Soft diet Avoid using the tooth in mastication To encourage gingival healing and prevent plaque accumulation, parents should: C lean the affected area with a soft brush or Oral toilet using cotton swab combined with an alcohol-free 0.1%- 0.2% chlorhexidine gluconate mouth rinse twice a day for 1 wk 11

11. 12 Clinical examination after 1 week 6-8 week 1 year C ontinue clinical follow up each year until eruption of the permanent teeth i f unfavourable outcome is likely Radiographic on follow up: only indicated if clinical findings are suggestive of pathosis ( eg , an unfavourable outcome) Parents should be informed to watch for any unfavorable outcomes and the need to return to the clinic as soon as possible . If unfavourable outcomes are identified, treatment is often required Follow up The follow-up treatment, which frequently requires the expertise of a child-oriented team, is outside the scope of these guidelines

12. outcomes Favorable outcome Unfavorable outcome • Asymptomatic • Pulp healing with: - Normal color of the crown or transient red/ gray or yellow discoloration - Pulp canal obliteration - No signs of pulp necrosis and infection • Continued root development in immature teeth • Realignment of the extruded tooth • No interference with the occlusion • No disturbance to the development and/or eruption of the permanent successor • Symptomatic • Signs of pulp necrosis and infection—such as: - Sinus tract, gingival swelling , abscess, or increased mobility - Persistent dark gray discoloration plus one or more signs of root canal infection • Radiographic signs of pulp necrosis and infection –PA lesion • No further root development of immature teeth • No improvement in the position of the extruded tooth • Negative impact on the development and/or eruption of the permanent successor 13

13. Extrusive luxation in permanent dentition

14. Partial displacement of the tooth out of its socket The tooth appears elongated Has increased mobility Occlusal interference may be present Likely to have no response to pulp sensibility test 16 Clinical findings

15. RECOMMENDATIONS Periapical film – 1 x paralleling technique, 2 x vertical/ horizontal angulations Occlusal R adiograph should be taken at the time of initial presentation for: diagnostic purposes to establish a baseline FINDINGS Increased periodontal ligament space apically and laterally Tooth not seated in its socket Appear elongated incisally 17 Radiographic

16. 18 • Reposition the tooth by gently pushing It back into the tooth socket under local anaesthesia • Stabilize the tooth for 2 week using a passive and flexible splint . If alveolar bone fracture, splint for an additional 4- 8 weeks Used up to 0.4mm diameter wire to obtain physiological stabilization Maintain repositioned tooth in correct position, favour initial healing, provide comfort and function Keep composite and bonding agent away from gingiva to avoid plaque retention and secondary infection • Monitor the pulp condition with pulp sensibility tests cold test and EPT test not reliable in young permanent teeth due to underdeveloped nerve fibres not conclusive for pulp necrosis in traumatized teeth because temporary loss of sensibility is common during post traumatic pulp healing • If the pulp becomes necrotic and infected , endodontic treatment appropriate to the tooth's stage of root development is indicated to eliminate any infection, to facilitate healing and retention of the tooth treatment

17. 19 • Teeth with incomplete root formation : May survive and heal, therefor RCT should be avoided unless there is clinical and radiographical evidence of pulp necrosis or PA lesion on follow up. Pulp exposed – conservative pulp therapy such as pulp capping, partial pulpotomy , cervical pulpotomy . (aim to maintain pulp and allow continue root dev) If the pulp becomes necrotic and there are signs of inflammatory (infection-related) external resorption, root canal treatment should be started as soon as possible. As such infection is very rapid in children. Endodontic procedures suitable for immature teeth should be used ( apexification or revascularization) Teeth with complete root formation: Early endo tx advisable if severely extruded Root canal treatment should be started , using intracanal medicaments: Corticosteroid/antibiotic paste can be used as anti inflammatory and anti resorptive to prevent external resorption. Left in situ for 6 weeks calcium hydroxide is recommended intracanal medicaments and placed at least 2 weeks up to 1 month followed by root canal filling • teeth with external infection related root resorption Start rct immediately Used calcium hydroxide as intracanal medicament and placed for 3 weeks and replaced every 3 months until radiolucencies of resorption lesion disappear. Final obturation can be done once bone repair visible radiographically Endodontic treatment

18. 20 Limited evidence for the use of systemic abx in emergency mx of luxation injuries U se by clinicians if TDI accompanied by soft tissue and other associated injuries Patient medical status may warrant antibiotic coverage Used of tetanus booster may be required if injury contaminated –if doubt refer medical Use of Antibiotics

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22. Parent and patient education Extra care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible Soft diet Avoid using the tooth in mastication Enforced oral hygiene care Avoid participate in contact sports To encourage gingival healing and prevent plaque accumulation, parents should: C lean the affected area with a soft brush or Oral toilet using cotton swab combined with an alcohol-free 0.1%- 0.2% chlorhexidine gluconate mouth rinse twice a day for 1 wk 24

23. 25 Clinical and radiographic examinations both are necessary after: 2 weeks after splint removal 4 weeks 8 weeks 12 weeks 6 months 1 year Yearly for at least 5 years Parents and patient should be informed to watch for any unfavorable outcomes and the need to return to the clinic as soon as possible . If unfavourable outcomes are identified, treatment is often required Follow up

24. outcomes Favorable outcome Unfavorable outcome • Asymptomatic • C linical and radiographic signs of normal or healed periodontium . • Positive response to pulp sensibility testing; however , a false negative response is possible for several months. • Endodontic treatment should not be started solely on the basis of no response to pulp sensibility testing • No marginal bone loss • Continued root development in immature teeth • Symptomatic • Pulp necrosis and infection such as: - Sinus tract, gingival swelling, abscess, or increased mobility, persistent dark gray discoloration • Apical periodontitis • Breakdown of marginal bone • External inflammatory (infection-related) resorption – if this type of resorption develops , root canal treatment should be initiated immediately, with the use of calcium hydroxide as an intracanal medicament . • Alternatively, corticosteroid/ antibiotic medicament can be used initially, which is then followed by calcium hydroxide for at least 2-3 weeks and change after 3months 26

25. CASE REPORT

26. 78% of traumatized primary teeth maintained pulpal vitality. At the clinical evaluation, the frequency of the developmental disorders observed in permanent successors was 10.5%, with enamel hypocalcification being the most common sequela.

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28. 30 History: 9 year old female referred to the trauma center of Shiraz school of dentistry, two days after an injury to her face and jaws, due to a bicycle accident. No previous trauma was reported. C/o : spontaneous pain over maxilla and mandibular incisors area Examination C ontusion of chin, lips, and nose Torn and bleeding gums were observed 11, 21- avulsed 31, 41, 42- severely extruded – tender to percussion, non-responsive to cold and electric pulp testing Alveolar bone fracture on lower incisors area

29. 31 Radiograph: the roots of 11, 21, 31,41, 42 were fully formed, and the apices were completely closed. The periodontal ligament space had widened by more than 5mm

30. 32 Management: LA given, the avulsed 11, 21 were replanted in their appropriate place and splinted using a flexible 0.5 mm wire 31,41, 42 were first positioned in their correct place, then splinted using a flexible 0.5 mm wire R adiography was taken to ensure correct positioning of the teeth Occlusal adjustment was made to prevent occlusal traumatic interference. Hygiene instructions were provided. RX: Systemic penicillin for seven days and daily mouthwash with 0.12% chlorhexidine digluconate was prescribed. Endodontic treatment of avulsed 11,21 was started seven days after replantation canals were filled with calcium hydroxide. Final filling of the canals took place 30 days later. S ince it was not possible to obtain a good tugback with gutta-percha, the root canals were sealed using MTA. The rest of the canals were backfilled using gutta-percha and AH26 sealer Teeth were restored with composite resin the splints were removed after six weeks

31. 33 A , B, Clinical appearance of wire-composite splinting of maxillary and mandibular incisors; C , D, Radiography was taken to ensure correct positioning of the teeth, The splint was extended to the primary canines .

32. 34 Follow up: Initially 31,42, 42 did not respond to the sensitivity tests; however, since there were no signs indicating necrosis, the researchers did not find endodontic intervention necessary. In clinical and radiographic follow-ups, three, six, nine and twelve months following the procedure, 31,41,42 showed no signs of necrosis and were not sensitive to percussion and palpation tests. There were no mobility, probing defects or discoloration. Radiographically, there was no apical pathosis , root resorption, ankylosis or marginal bone loss. The teeth still did not show any sign of necrosis after the 18-month follow-up 31, 41 responded to the cold and electric tests after 12 months follow up 42 showed no response to any of the tests. Due to lack of signs indicating necrosis, an endodontic intervention was not performed. The patient is still undergoing follow-up.

33. 35 Radiographic (A, B) and Clinical (C) appearance at 18 months follow-up; Normal color of the crowns and normal position of the teeth is seen. A , B, Endodontic treatment of the maxillary central incisors; C , The splints were removed after 6 weeks .

34. 36 It is possible that young patients (aged 7 to 15) may have open or partially open apices, even though the apices appear closed , radiographically it may take as long as nine months for normal blood flow to return to the coronal pulp of a traumatized fully formed tooth. As circulation is restored, the responsiveness to pulp tests might return The 31, 41 responded to the cold and electric tests after the 12-month follow-up Some authors suggested endodontic treatment for extruded teeth with complete root formation, due to high incidence of pulp necrosis in traumatic teeth with complete root formation. In contrast, immature teeth should be managed by pulpal monitoring and radiographs, and for cases where pulpal necrosis occurs, endodontic treatment should be performed. Other authors stated that all traumatically extruded teeth with open or closed apices should be monitored regularly, and in cases where signs of pulp necrosis appear, endodontic treatment should be initiated. In this patient, the sensitivity tests did not provide reliable responses in the recall visits ; yet endodontic intervention was not performed as the teeth showed no signs of necrosis. There were also no signs of crown discoloration, periapical lesions or gingival recession . discussions

35. 37 Results of this case report showed that in young patients, with closed apices, the dental pulps might be alive following trauma. In such cases, short-interval clinical and radiographic follow-ups are necessary E ndodontic treatment must be avoided until the appearance of signs indicating necrosis conclusion

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37. 39 13 teeth with extrusive luxation but no other injury to dental hard tissue Result: 1 healed completely 9 showed pulp canal obliterations 3 develop pulp necrosis No tooth with PCO developed pulp necrosis Treatment used: Manual repositioning Orthodontic repositioning Stabilization splinting

38. 40 There are three ways of treating extrusive luxation injuries, namely through manual, orthodontic or surgical repositioning . In 2002, Andreasen et al . argued that the choice of treatment should also depend on its timing in relation to the injury. Accordingly , they distinguished between acute (within the first 3 h), subacute (within 24 h) and delayed (after more than 24 h) treatment . Extrusive luxation is normally treated under local anesthesia. After radiographic assessment, the luxated tooth is repositioned manually and stabilized using a flexible splint. Three teeth were treated using manual repositioning and all these teeth developed PCO. This approach was used for moderate–mild extrusions with a maximum dislocation of 3 mm . When manual repositioning is not possible, surgical and orthodontic repositioning are alternative approaches . This is a slow, gradual process that can help to safeguard dental pulp vitality, prevent ankylosis and promote periodontal healing, especially in healthy young subjects Surgical repositioning, or intentional replantation : involves the extraction of the extruded tooth followed by irrigation and gentle cleaning of the socket. The tooth is then reinserted into the socket as quickly as possible. Appropriate endodontic treatment needs to be performed within 15 days of the dental trauma to prevent the onset of IRR orthodontic repositioning technique : was performed using NiTi orthodontic arch wires ( 0.14/0.16) inserted in preadjusted edgewise orthodontic brackets. The wire, generating light forces of up to 40gr, produced a gentle and gradual movement of the extruded tooth in the socket In the present study, the treatment was chosen on the basis of the time that had elapsed since the trauma, the severity of the extrusion and the need to quickly eliminate the dental interference (i.e ., occlusal trauma or OT) in order to restore a correct occlusal relationship. Dental interference, if maintained, causes serious hypofunction . Accordingly , orthodontic repositioning, which very often consists of a vestibular intrusion movement to reposition palatally extruded teeth, was chosen for seven luxated teeth.

39. Thank you!

40. References 42 International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and Luxations (Cecilia Bourguignon et al) may 2020 International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition (Peter F. Day) may 2020 Pulp Revascularization Following Severe Extrusive Luxation Injury in Mature Permanent Mandibular Incisors: A Case Report ( Fariborz Moazzami1 and Elham Karami ) August 2018