Injuries or Trauma in permanent dentition .pptx

Injuries to permanent dentition.
Avulsion

1. INJURIES TO PERMANENT DENTITION DR SHUJA ASLAM MEMON BDS.FCPS.MFD Assistant Professor operative dentistry I ncharge peadododontics department

2. 1. Emergency: (a) retain vitality of fractured or displaced tooth (b) treat exposed pulp tissue (c) immobilization of displaced teeth (d) antiseptic mouthwash ± antibiotics and tetanus prophylaxis. 2. Intermediate: (a) pulp therapy (b) minimally invasive crown restoration. 3. Permanent: (a) apexogenesis / apexification /regeneration for teeth that have lost vitality (b) root canal filling + root extrusion ( c ) semi-permanent or permanent restoration .

3. Enamel infraction Monitoring is necessary. Enamel fracture smoothing of any rough edges. No restoration is needed unless there are aesthetic concerns

4. ENAMEL-DENTINE FRACTURE: Emergency protection of the exposed dentine can be achieved by the following. 1. A bonded composite resin or compomer . 2. Glass ionomer cement within an orthodontic band Final restoration of most enamel–dentine fractures can be achieved by the following. Resin-bonded composite applied either freehand or utilizing a celluloid crown-former 2. Reattachment of crown fragment If the fracture line is not very close to the pulp, the fragment can be reattached immediately. However, if it is close to the pulp, it is advisable to place calcium hydroxide or calcium silicate cement dressing over the exposed dentine for a month while storing the fragment in saline

5. Technique for fragment attachment 1. Check the fit of the fragment and the vitality of the tooth 2. Clean the fragment and tooth with pumice–water slurry. 3. Isolate the tooth with rubber dam. 4. Attach the fragment to a piece of sticky wax to facilitate handling. 5. Etch enamel for 30 seconds on both fracture surfaces and extend for 2mm from the fracture line on tooth and fragment. Wash for 15 seconds and dry for 15 seconds. 6. Apply bonding agent ± dentine primer according to the manufacturer’s instructions and light cure for 10 seconds. 7. Place the appropriate shade of composite resin over both surfaces and position the fragment. Remove gross excess and cure for 60 seconds labially and palatally . 8. Remove any excess composite resin with sandpaper discs.

6. Complicated crown fracture Newly erupted teeth have short roots, their apices are wide and often diverging, and the dentine walls of the entire tooth are thin and relatively weak. Provided that the pulp remains healthy, dentine deposition and normal root development will continue for 3-5 years after eruption in permanent teeth.

7. Vital pulp therapy 1.Direct Pulp capping 2. pulpotomy : partial or complete Non vital therapy: 1.Root canal treatment 2.Apexification(either by MTA or CAOH) 3.Regenerative endodontics

8. Within 24 hrs: direct pulp capping 24-48 hrs: partial pulpotomy 48-72 hrs: complete pulpotomy If large exposure involving pulp: Root canal treatment

9. DIRECT PULP CAPPING: isolate with rubber dam. Preparation if needed Any bleeding should be controlled with sterile cotton wool, which may be moistened with saline or sodium hypochlorite Then layer of setting calcium hydroxide or calcium silicate cement(MTA or Biodentine ) is gently flowed onto the exposed pulp and surrounding dentine and quickly overlaid with a ‘bandage’ of adhesive material (e.g. composite). Success is determined on the radiograph by the following: • root is growing in length • root canal is maturing (narrowing )

10. PULPOTOMY: Under local anaesthesia and rubber dam, pulp tissue is excised with a diamond bur via high speed handpiece under constant water cooling. Gently rinse the wound with sterile saline or sodium hypochlorite (1–2%) to stop bleeding. Apply a calcium hydroxide or calcium silicate cement dressing to the pulp. For partial pulpotomy , a setting calcium hydroxide cement may be gently flowed onto the pulp surface, but for complete pulpotomy,stiff mixture of calcium hydroxide powder in sterile saline which is carried to the canal in an amalgam carrier and gently packed into place with pluggers . Then composite

11. Calcific barrier formation Root formation is complete Composite resin Hard setting cement Non-setting calcium hydroxide cement

12. Non-vital pulp therapy: pulpectomy or root canal treatment

13. Challenges in pulpectomy if apex is open: the root has thin dentine walls liable to fracture a wide open apex there is no natural apical constriction or stop against which a suitable root filling material can be placed

14. local anaesthesia and rubber dam isolation determine a provisional working length by estimating from an undistorted preoperative radiograph. Little canal shaping is usually needed. Instead, the canal should be thoroughly cleaned with sodium hypochlorite marked to stay 2–3mm short of working length. MTA is then mixed to a clay-like consistency. It is carried to the canal in small increments with a dedicated MTA gun, or with an amalgam carrier, and is carefully walked up the canal with pluggers set 2mm short of working length to prevent over-extension. take a radiograph to confirm its position. If you are happy, continue to build increments until an apical plug of 4mm thickness has been achieved seal moist cotton wool in the canal for at least 24 hours before bringing the patient back Then obturation . Apexification

15. APEXIFICATION WITH CAOH Only difference is that CaOH is placed for 3 months and then changed. Barrier forms in approximately 18 months Advantages of MTA apexification : Single visit Less patient compliance needed More cost effective than multiple visit procedures of caoh

16. Disadvantages of Caoh Brittle barrier formed It takes 18 months for barrier to form expensive

17. Manual obturation backfill with thermoplastic gp Obturation

18. Regenerative endodontic treatment First treatment visit • Isolate the tooth using rubber dam. • Access the tooth and extirpate the pulp using barbed broaches. • Negotiate the canal with minimal or no filing to prevent further weakening of the existing dentinal walls. • Irrigate the root canal system with: – copious amounts of 1.5% sodium hypochlorite ( NaOCl ) – 5mL sterile saline. • Dry the canal using paper points. • Mix metronidazole (100mg) and ciprofloxacin (100mg) with distilled water. • Inject the mixture of the two antibiotics into the root canal system. • Place a cotton pellet to cover the root canal orifice and seal the access with a glass ionomer cement

19. Second treatment visit If clinical signs or symptoms persist, the procedures performed in the first appointment should be repeated. Administer plain local anaesthetic solution (no vasoconstrictor, e.g. 3% mepivicaine ), isolate the tooth, and re-access as described above. Flush the antibiotic mixture out of the root canal by irrigation with copious amounts of normal saline. Irrigate the root with 10mL 17% EDTA. Dry the root canal thoroughly with paper points. Insert a sterile sharp instrument (25 mm k file or finger spreader) with a length of 2mm beyond the working length to intentionally induce bleeding into the root canal. Allow the bleeding to fill the root canal. Once the root canal is filled with blood, place a sterile cotton-wool pledget in the pulp chamber and allow a clot to form in the root canal. Hermetically seal the access cavity with these material to prevent coronal leakage and contamination: collagen,MTA then glass ionomer , and then composite resin.

20. Uncomplicated crown–root fracture After removal of the fractured piece of tooth these vertical fractures are commonly a few millimetres incisal to the gingival margin on the labial surface but down to the cemento -enamel junction palatally . Prior to placement of a restoration the fracture margin has to be brought supra-gingival by either gingivoplasty or extrusion ( orthodontically or surgically) of the root portion.

21. Complicated crown–root fracture Same as above plus endodontic treatment

22. Complicated crown root fracture

23. Root fracture It is divided into coronal,middle and apical fracture. Coronal fracture: If displacement has occurred, the coronal fragment should be repositioned as soon as possible by gentle digital manipulation .Splint for 4 months. Fractures in the cervical third of the root will repair as long as no communication exists between the fracture line and the gingival crevice. If there is communication, splinting is not recommended and an early decision must be made to extract the coronal fragment and retain the remaining root, internally splint the root fracture with H files to nickel–chromium points , or extract the two fragments Extraction of coronal fragment and root retention The remaining radicular pulp should be removed and the canal temporarily dressed prior to obturating with gutta percha . Three options are now available 1. Post, core, and crown restoration if access is adequate. 2. Extrusion of the root either surgically or orthodontically if the fracture extends too subgingivally for adequate access. 3. Cover the root with a mucoperiosteal flap. This will maintain the height and width of the arch and facilitate later placement of a single tooth implant .

24. Middle and apical third root fracture: In apical and middle third fractures any endodontic treatment is usually confined to the coronal fragment only. A barrier is achieved on the coronal aspect of the fracture line by preparation of a stop with MTA, and the coronal canal is obturated with gutta percha . The apical fragment almost always contains viable pulp tissue After completion of endodontic treatment, repair and union between the two fragments with connective tissue is a consistent finding. Splint for 4 weeks.

25. Three main categories of repair are recognized. 1. Repair with calcified tissue: invisible fracture line 2. Repair with connective tissue: narrow radiolucent fracture line 3.Repair with bone and connective tissue: the two fragments are separated by a bony bridge

26. Middle third root fracture

27. Middle third root fracture of both permanent central incisors with bony repair and sclerosis of the apical fragments

28. Initial presentation of a high coronal root fracture which extended palatally below alveolar bone. (b), (c) Post, core, and diaphragm after root extrusion. (d) Final ceramic crown

29. A functional splint involves one, and a rigid splint two, abutment teeth on either side of the injured tooth Splinting Dento -alveolar fractures These require 3–4 weeks of rigid splinting For Root fractures ,functional splint is done

30. Types and methods of constructing splints Composite/acrylic resin and wire splint Bend a flexible orthodontic wire to fit the middle third of the labial surface of the injured tooth and one abutment tooth either side. Stabilize the injured tooth in the correct position palatally with soft red wax. Clean the labial surfaces. Isolate, dry, and etch the middle of the crown of the teeth with 37% phosphoric acid for 30 seconds, wash, and dry. Apply a 3mm diameter circle of either flowable or filled composite resin or acrylic resin to the centre of the crowns. Position the wire into the filling material and then apply more composite or acrylic resin. Mould and smooth the composite. Acrylic resin is more difficult to handle, and smoothing and excess removal can be done with a flat plastic instrument. Cure the composite for 60 seconds. Wait for the acrylic resin to cure. Smooth any sharp edges with sandpaper discs.

31. Composite resin and wire splint for a luxation injury.

32. Prefabricated titanium trauma splint This splint has a number of advantages, including ease of adaptation owing to its flexibility. It is also easy to apply with composite resin, easy to remove, and allows the tooth to retain the physiological mobility which is essential for healing the PDL

33. Titanium trauma splint

34. Orthodontic brackets and wire Foil–cement splint A temporary splint made of soft metal (cooking foil) and cemented with quick-setting zinc oxide– eugenol cement is an effective temporary measure either during the night when it is difficult to fit a composite wire splint as a single-handed operator or while awaiting construction of a laboratory-made splint

35. Laboratory splints INDICATIONS:traumatized maxillary incisors, unerupted lateral incisors, and either carious or absent primary canines. Both methods require alginate impressions Acrylic splint: There is full palatal coverage and the acrylic is extended over the incisal edges for 2–3mm of the labial surfaces of the anterior teeth. The splint should be removed for cleaning after meals and at bedtime. Thermoplastic splint The splint is constructed from polyvinylacetate – polyethylene (PVAC–PE) copolymer Like the acrylic splint, it should be removed after meals and at bedtime.

36. Concussion T he tooth is tender to percussion (TTP). Subluxation In addition to the above there is rupture of some PDL fibres and the tooth is mobile in the socket, although not displaced. The treatment for both concussion and subluxation is as follows: occlusal relief soft diet for 7 days immobilization with a functional splint for 2 weeks chlorhexidine 0.2% mouthwash twice daily

37. Extrusive Luxation : There is a rupture of PDL and pulp. Treatment is a functional splint for 2 weeks. Lateral luxation There is a rupture of PDL, pulp, and the alveolar plate The treatment for both extrusive and lateral luxation is as follows: atraumatic repositioning with gentle but firm digital pressure non-rigid functional splint for 4 weeks antibiotics, e.g. amoxicillin 250mg three times daily (<10 years old, 125mg three times daily) for 5 days chlorhexidine 0.2% mouthwash twice daily while splint is in position soft diet for 2–3 weeks

38. the prognosis is significantly better for open apex teeth

39. Five-year pulpal survival after injuries involving the periodontal ligament Type of injury Open apex (%) Closed apex Concussion 100 96 Subluxation 100 85 Extrusive luxation 95 45 Lateral luxation 95 25 Intrusive luxation 40 0

40. INTRUSIVE LUXATION : There is extensive damage to the PDL, pulp, and alveolar plate(s). There are two distinct treatment categories: the open apex and the closed apex. Both categories can be discussed depending on whether the intrusive injury is <7mm or >7mm. Open apex <7mm: There is eruptive potential which may be improved by disimpaction with forceps. If no movement in 2–4 weeks, move orthodontically >7mm : surgical repositioning under local anaesthetic , local anaesthetic /sedation, or general anaesthetic is appropriate. Functional splint for 4–8 weeks.

41. Closed apex <7mm: Orthodontic extrusion is probably indicated straight away. The danger of a tooth ankylosing in an intruded position should always be borne in mind >7mm Surgical repositioning and functional splint for 4–8 weeks

42. Monitor pulpal status clinically and radiographically and start endodontics if necessary. Elective pulp extirpation will be necessary for all significant intrusive luxation injuries in closed apex teeth at about 10 days. The risk of pulpal necrosis in these injuries is high, especially in the closed apex. The incidence of resorption and ankylosis sequelae is also high Also prescribe antibiotics, chlorhexidine mouthwash, and soft diet.

43. Avulsion and replantation Successful healing after replantation can only occur if there is minimal damage to the pulp and PDL. The extra-alveolar dry time (EADT), the type of extra-alveolar storage medium, and the total extra-alveolar time (EAT), i.e. the time that the tooth has been out of the mouth, open or close apex,minimal damage to PDL,condition of socket,necrosed pulp,splinting time are critical factors

44. Advice on phone (to teacher, parent, etc.) 1. Don’t touch the root—hold by the crown. 2. If the tooth is dirty, wash briefly (10 seconds) under cold running water. 3. Replace in the socket or transport in milk to the surgery. 4. If replaced, bite gently on a handkerchief to retain it and come to the surgery. The best transport medium is the tooth’s own socket. Milk, saliva, the patient’s buccal sulcus , or normal saline are alternatives

45. Replantation of teeth with a dry storage time less than 1 hour Immediate surgery treatment 1. Do not handle the root. If replanted, remove tooth from socket. 2. Rinse the tooth with normal saline. Note the state of root development. Store in saline. 3. Local analgesia. 4. Irrigate the socket with saline. Remove clot and any foreign material. 5. Push the tooth gently but firmly into the socket. 6. Non-rigid functional splint for 14 days. 7. Check occlusion. 8. Baseline radiographs: periapical or anterior occlusal . Any other teeth injured? 9 Systemic antibiotics, chlorhexidine mouthwash, soft diet as previously. 10. Check tetanus immunization status.

46. Antibiotics Tetracycline is first choice for age >12 years for 1 week post replantation . Phenoxymethylpenicillin (Pen V) or amoxicillin are suitable for children <12 years. Review 1. Radiograph prior to splint removal at 14 days. 2. Remove splint at 14 days. 3. Endodontics —commence prior to splint removal for categories (b) and (c). (a) Open apex, EAT <30–45 minutes. Observe. (b) Open apex, EAT >30–45 minutes. Endodontics : ( i ) subsequent intracanal dressings: non-setting calcium hydroxide paste (ii) replace calcium hydroxide every 3 months until apical barrier or place MTA plug (iii) obturate canal with gutta percha and sealer.

47. c) Closed apex. Endodontics : ( i ) subsequent intracanal dressing: non-setting calcium hydroxide paste ( ii) obturate with gutta percha and sealer as soon as possible as long as there is no progressive resorption . 2.Radiographic review: 1 month; 3 months; every 6 months for 2 years; then annually. 3. If resorption is progressing unhalted, keep non-setting calcium hydroxide in the tooth until exfoliation, changing it every 6 months. The immature tooth with an EAT <30–45 minutes may undergo pulp revascularization. However, these teeth require regular clinical and radiographic review because once EIR occurs it progresses rapidly.

48. Replantation of teeth with a dry storage time longer than 1 hour Teeth with very immature apices should not be replanted. The incidence of resorption , ankylosis , and subsequent loss is high because of the high rate of bone remodelling in this age group. Mature teeth with a dry storage time of more than 1 hour will have a non-vital PDL. The necrotic PDL and pulp should be removed at chairside with pumice and water on a bristle brush prior to rinsing with normal saline. The root canal is then obturated with gutta percha and sealer, and the tooth is replanted and splinted for 4 weeks. The aim of this treatment is to produce ankylosis , allowing the tooth to be retained as a natural space maintainer, perhaps for a limited period only.