JC TRAUMA ppt of trauma management and factors article

study

1. Mateusz Radwanski 1,† , Corrado Caporossi 2,†, Monika Lukomska-Szymanska 3,* ,† , Arlinda Luzi 4 and Salvatore Sauro 4,5,* Complicated Crown Fracture of Permanent Incisors: A Conservative Treatment Case Report and a Narrative Review Presenter- S Lipi prakash

2. INTRODUCTION Trauma of the oral and maxillofacial region occurs frequently and comprises 5%of all injuries for which people seek dental treatment Trauma to the facial area represents a public health problem involving children and adolescents; it generally involves the teeth and their supporting structures. The most frequent causes are falls, traffic accidents, domestic violence, fights, and sports. Most dental injuries occur during the first 2 decades of life, especially between 2 and 3 years and between 8 and 12 years of age, occurring more often in boys than in girls [1–3]. Management and Followup of Complicated Crown Fractures in Young Patients Treated with Partial Pulpotomy

3. Due to their position, the teeth most frequently affected by dental traumatism are the maxillary incisors: 80% centrals and 16% laterals . Several diagnostic criteria have been used to classify traumatic dental injuries The currently accepted system is based on the World health organisation’s application of International classification of diseases to dentistry and stomatology , and modified by Andreasen Andreasen’s modified classification of traumatic injuries to teeth Enamel infraction- An incomplete fracture of enamel without loss of tooth substance Enamel fracture( uncomplicated crown fracture)- A fracture with loss of enamel only Enamel-dentin fracture- A fracture with loss of enamel and dentin, but not involving the pulp Grossman’s endodontic practice 13 th edition

4. Complicated crown fracture- A fracture involving enamel and dentin , and exposing the pulp Uncomplicated crown-root fracture- A fracture involving enamel, coronal and radicular dentin, and cementum , but not exposing pulp Complicated crown-root fracture- A fracture involving enamel, coronal and radicular dentin, and cementum with exposure of the pulp Root fracture- A fracture involving radicular dentin, cementum , and pulp Luxation injuries- Concussion: An injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth, but with increased reaction to percussion Grossman’s endodontic practice 13 th edition

5. Subluxation : An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth Extrusive luxation : Partial displacement of the tooth out of its socket Lateral luxation : Displacement of the tooth in a direction other than axially. Intrusive luxation : Displacement of the tooth into the alveolar bone. Avulsion : Complete displacement of the tooth out of its socket Treatment of crown fractures with exposed pulp in permanent young teeth depends on the degree of pulp exposure, time between accident and examination, effect of the traumatism, and the stage of root development. Treatment options of crown fractures with pulpal exposure are direct pulp capping, partial pulpotomy , pulpectomy , or extraction. Grossman’s endodontic practice 13 th edition

6. Vital pulp therapy is the treatment initiated on an exposed pulp to repair and maintain pulp vitality. The aim of vital pulp therapy is to treat reversible pulpal injuries in order to maintain pulp vitality in both primary and permanent teeth Direct pulp capping is defined as a procedure in which the exposed vital pulp is covered with a protective dressing or base placed directly over the site of exposure in an attempt to preserve pulpal vitality. Pulpotomy is defined as a procedure in which a portion of exposed coronal vital pulp is surgically removed as a means of preserving the vitality and function of the remaining radicular portion The pulpotomy procedure can be classified on the basis of amount of pulpal tissue removed- Grossman’s endodontic practice 13 th edition

7. Partial pulpotomy ( Cvek’s pulpotomy )- A kind of pulpotomy in which only a portion of coronal pulp is removed until normal tissue that is free of inflammation is reached before placing a medicament Complete pulpotomy ( cervical pulpotomy )- It involves the complete removal of coronal portion of the dental pulp , followed by placement of medicament that will promote healing and preserve the vitality of tooth Type of medicament employed – Calcium hydroxide pulpotomy MTA pulpotomy Formocresol pulpotomy Grossman’s endodontic practice 13 th edition

8. Complicated Crown Fracture of Permanent Incisors: A Conservative Treatment Case Report and a Narrative Review Mateusz Radwanski 1,† , Corrado Caporossi 2,†, Monika Lukomska-Szymanska 3,* ,† , Arlinda Luzi 4 and Salvatore Sauro 4,5,*

9. INTRODUCTION Traumatic dental injuries (TDIs) concern mostly children and young adults .The occurrence of complicated crown fracture ranges between 2% and 13%, The treatment of complicated crown fractures according to the International Association of Dental Traumatology (IADT, 2020) includes conservative treatment of the pulp, such as partial pulpotomy , in both mature and immature roots. Determining the condition of the pulp before starting treatment is crucial. False negative results in pulp vitality tests can occur due to temporary loss of nervous response after trauma. Pulp vitality testing should be performed after the injury and during follow-up visits to monitor changes over time.

10. Pulp Vitality Testing - Tests such as the cold test and electric pulp test are used. Laser Doppler flowmetry (LDF) is recommended for evaluating blood flow in the pulp Radiographic Examination :- A parallel periapical radiograph is recommended during diagnosis. Additional radiographs are needed if there are signs or symptoms of other potential injuries. For soft tissue injuries, X-rays of the lip and/or cheek may be necessary to check for tooth fragments or external debris. Cone beam computerized tomography (CBCT) is considered for suspected root fractures, crown-root fractures, or lateral luxations to determine the location, extent, and direction of the injury.

11. Management of tooth fragment : - If a tooth fragment is available, it should be reattached. - If the fragment is not available, covering the dentin with a glass- ionomer or a bonding agent and composite resin is recommended The favorable outcomes include asymptomatic teeth with positive response to pulp sensibility testing, good quality restoration, and continued root development in immature teeth. Factors Influencing Treatment Outcomes:- Severity of the injury. - Quality and timeliness of initial care. - Adherence to a recall protocol (14 days, 6-8 weeks, 3 and 6 months, and one year after the injury). - Follow-up includes radiographic assessment and cold/hot vitality tests.7 This case report mainly Emphasis on possible conservative treatment for complicated tooth fracture involves partial pulpotomy followed by adhesive reattachment of the tooth fragment

12. CASE PRESENTATION A 15 year old male patient (case #1) experienced a blunt trauma during basketball game. The patient suffered from a complicated fracture of the crowns of 11 and 21 . The fragments were recovered and kept immersed in milk until the appointment two days after the trauma

13. CASE PRESENTATION In case #2, a 21 year old male patient reported to dental office immediately after a complicated crown fracture of the crowns of 11 during a tennis game . The dental fragment was immediately stored in Hank’s balanced saline solution

14. In both cases, teeth were vital with thermal and electrical stimulus; no mobility and symptoms of other trauma were detected during clinical and X-ray examination (Figure 2A,B). The tooth fragments were not damaged, fit the tooth crowns, and did not interfere with the occlusion The preoperative X-rays

15. Fragments of teeth(A) 11 and 21 (B) 11

16. Pulp Treatment Option- In case of complicated crown fractures, vital pulp therapy (VPT) interventions include direct pulp capping (DPC) partial pulpotomy (PP), and complete pulpotomy (CP) Clinical factors such as the vitality of the pulp, the time from exposure to intervention, age of the patient, other coexisting injuries, the cause of exposure, and the extent of exposure may influence the favorable outcome of VPT

17. Vital Pulp Therapy (VPT) Intervention Description of the Method Indication Direct pulp capping (DPC) (1) Placement of protective pulp capping material directly over the exposure A recent and pinpoint-sized exposed vital pulp Partial pulpotomy (PP) (1) Partial removal of the coronal pulp; (2) Hemostasis ; (3) Placement of a pulp capping material Pulp exposure treated within 14 days after trauma, caries-free, open apex or thin dentinal walls, and vital and asymptomatic pulp Full (complete) pulpotomy (CP) (1) Removal of the entire coronal pulp to the level of canal orifices; (2) Hemostasis ; (3) Placement of a pulp capping material. More than 2 week lapsse between trauma and treatment, extensive pulp exposure

18. Based on the analysis of the clinical conditions and additional tests, it was decided to perform PP with adhesive/composite reattachment in both the cases, maintaining the vitality of the treated teeth. PP has the advantage of preserving the cell-rich coronal pulp, which may provide greater healing potential, and so maintain the possibility of having physiological dentin deposition The increasing time between injury and intervention contributes to lower treatment success It is important to consider that the success of VPT is influenced by factors such as proper infection control (rubber dam isolation), bleeding control, selection of the capping material providing a tight seal, and a final restoration.

19. Preparation of Operatory Field In the present cases, administered the anesthesia of 2% lidocaine with 1: 80,000 adrenalines , and performed a total rubber dam isolation to avoid cross-contamination, the partial pulpotomy was executed through high-speed bur under continuous saline irrigation. For bleeding control, the hemostatic agents are recommended. According to the guidelines (2021) of the American Association of Endodontists (AAE), the use of sodium hypochlorite is recommended, due to its bactericidal properties, and the ability to remove fibrin, clot, biofilm , and discolorations Thereby, to control bleeding, cotton pellets soaked with 1% sodium hypochlorite were applied and the hemostasis was obtained after 2 min in both cases.

20. Choice of Materials An ideal pulpotomy material should be biocompatible, non-toxic, induce hard tissue formation, and exhibit a disinfecting properties. The materials used in pulpotomy are calcium hydroxide (CH) and calcium silicate materials (CSMs) Most CSMs, such as mineral trioxide aggregate (MTA), consist mainly of dicalcium or tricalcium silicates, and are mixed with water MTA stimulates the pulp cells to produce a dentine deposition (e.g., dentin bridge). During setting, calcium hydroxide is released, providing the antimicrobial properties. The disadvantages of MTA include the difficulty of application, long setting time, and teeth discoloration [35].

21. The powder of MTA is mixed with distilled water (3:1 ratio) to obtain a wet, gel-like consistency [45]. For mixing, a metal or plastic spatula and a glass plate or paper can be used. The working time with the material is about 5 min, and the setting time is long, from 3 to 4 h The excavator, a retrograde amalgam that carries, can be used for the delivery of the prepared MTA, and paper points, pluggers , or ultrasounds for the condensation. Condensation with excessive force can reduce the strength and surface hardness

22. Apply MTA excessively to cover pulp and all walls without creating voids Use a cotton pellet moistened with sterile water for final condensation and to initiate the setting reaction Remove excess material with a cotton pellet or mechanically with burs Appropiate thickness for pulpotomy :3-4 mm Assess thickness and compaction with an X-ray In the present cases, MTA (ENDOPASS, DEI -Italia, Varese, Italy) was mixed with bi-distilled water using a plastic spatula on a glass pad, And condensed with paper points and moist cotton pellet and the excess of material was removed with cotton pellet. Superiority of MTA-based materials due to lower solubility when compared with CH, greater biocompatibility, and the quicker formation of thicker and more homogenous dentin bridge, which may be a greater barrier to bacterial leakage . Therefore, in the present cases, MTA was applied.

23. Restorative Procedure Compared to conventional restorative techniques, the reattachment of tooth fragments exhibits several advantages: -the original shape, color, brightness, and texture of the enamel surface . The incisal edges of reattached fragments tend to wear at a similar rate to adjacent natural teeth. This technique is less time-consuming, minimally invasive, and simple to perform . In both cases, the selective enamel etching both on the tooth and the fragment was performed using a 36% phosphoric acid gel ( DeTrey Conditioner 36, Dentsply Sirona GmbH, Bensheim , Germany) under rubber dam isolation.

24. Then, a self-etching two-component adhesive system ( Clearfil ™ Se Bond, Kuraray Noritake Dental Inc., Tokyo, Japan, CSE) was applied as per manufacturer’s instruction, and air-dried with a strong stream of air for 5 s to completely remove the excess adhesive. This was finally light-cured for 20 s (Radii Xpert , Voco GmbH, Cuxhaven, Germany). Subsequently, a thin layer of enamel (Shade A2) mass composite ( Asteria Tokuyama NE, Tokuyama Dental Corporation, Taitouku Tokyo, Japan) was applied directly on the tooth as an intermediate material to reattach the fragment to the tooth. The composite was heated up to 54 ◦C in a warming device ( AdDent Calset ™ Composite Warmer, AdDent Inc., Danbury, CT, USA) to increase the degree of polymerization, a better adaptation of the fragment on the tooth and to provide easier management of the excess removal [77]. Next, photopolymerization was carried out for 10 s.

25. Occlusion Adjustment Occlusal adjustment involves the development of an acceptable central relation contact position for the patient, ensuring acceptable lateral and protrusion guidance. Therefore, the presented cases were performed using a diamond bur (#3118F—KG Sorensen, Cotia , SP, Brazil). Due to the perfect fit of tooth fragments and prior excess removal, minimal occlusion adjustment was needed.

26. Finishing and Polishing Polishing provides smoothness of the surface, hence reduces the accumulation of dental plaque As polishing removes flourine rich enamel layer and therefore should be carried out selectively The restored teeth were first finished using fine and extra-fine diamond burs (2135F and 2135FF, respectively (KG, Sorensen, Cotia , SP, Brazil)), and finally polished using either a Soflex discs coarse, medium, fine, and super-fine grit Sof-Lex disk (3M ESPE, St. Paul, MN, USA) in a slow-speed hand piece for 30 s each

27. Follow-Up Visits and Prognosis The follow-up visits after trauma injury are of paramount importance and, therefore, mandatory. The most common post-traumatic problems include pulp infection and necrosis, pulp canal obliteration (PCO) or root resorptions . In the case of the complicated crown fractures, the recommended follow-up visits are as follows: after 14 days, 6–8 weeks, 3 and 6 months, and one year after the injury. In the present cases, the check-ups were carried out in accordance with the recommended scheme, and the positive results obtained after one year by interview, radiological examination, and pulp sensitivity cold/hot test indicate the success of the treatment.

28. DISCUSSION Importance of Biological Treatment for Exposed Pulp Essential for patients with open apices to ensure further physiological root formation. Direct Pulp Capping with Calcium Hydroxide (CH) - Success rate: 54-90%. Partial Pulpotomy with Calcium Hydroxide- Success rate: 86-100%. Hydraulic Calcium-Silicate-Based Cements (CSMs) - May contribute to better prognosis of Vital Pulp Therapy (VPT) compared to CH. - Success rate of total pulpotomy : 74-100% after 1 to 5 years follow-up.

29. Success Rate of Partial Pulpotomy in Permanent Dentition with Complicated Crown Fractures - Ranges from 87.5% to 100%. Key factors: initial condition of the pulp, absence of damage, and no trauma affecting blood supply. Adhesive Techniques for Reattachment Procedure Increases success rate to 84-93%. - Long-term success reported after 5 or even 9 years.8. Impact of Pulp Treatment on Reattachment Stability - Pulp treatment does not impair stability. - Success depends on micromechanical retention between composite resin and etched enamel, and hybrid layer.

30. Applicability of Reattachment Technique Suitable for both uncomplicated and complicated crown fractures. Adhesive reattachment combined with vital pulp therapy is a good first-choice treatment option. Home Management with Biomimetic Hydroxyapatite Toothpaste - Reduces discoloration and hypersensitivity more effectively than conventional fluoride toothpaste after reconstruction

31. CRITICAL APPRAISAL PROS Relevance and Timeliness: The study is relevant as it tackles common dental traumas, providing updated guidelines and treatment options in line with the International Association of Dental Traumatology (IADT) 2020 guidelines.2. Conservative Approach- Emphasizing conservative treatment is a strength, promoting less invasive procedures which align with current trends in dental treatment aimed at preserving natural tooth structure and vitality. Comprehensive Review- The narrative review section is thorough, covering various aspects of traumatic dental injuries, diagnostic techniques, and treatment options. It offers a well-rounded understanding of the subject, beneficial for both clinical and academic purposes. Case Presentation- The inclusion of detailed case reports provides practical insights into the application of the discussed techniques. Visual aids such as intraoral photographs and radiographs enhance the understanding of the cases presented. Scientific Rigor- The article adheres to scientific rigor, supported by a robust reference list, including recent and relevant studies. This strengthens the credibility and reliability of the information presented

32. CONS- Limited Sample Size- The study presents only two case reports. While detailed, the small sample size limits the generalizability of the findings. Larger studies with more diverse populations are necessary to validate the efficacy and applicability of the treatment methods discussed. Follow-Up Duration-The follow-up periods mentioned (ranging from 14 days to one year) are relatively short. Long-term outcomes of the conservative treatments, especially concerning the longevity and durability of the adhesive reattachment, are not covered. Bias and Subjectivity- The narrative review nature of the article may introduce bias, as the authors’ interpretations and opinions can influence the conclusions drawn. A systematic review or meta-analysis could provide a more objective evaluation of the available evidence. Lack of Control Cases-The absence of control cases or comparisons with alternative treatment methods limits the ability to assess the relative effectiveness of the conservative approaches highlighted. Technical Details-Some technical details, such as the exact materials and techniques used for the adhesive reattachment and pulpotomy , are not thoroughly described. Including this information would enhance the reproducibility of the procedures by other practitioners.

33. CONCLUSION The article provides valuable insights into conservative treatment methods for complicated crown fractures in permanent incisors, emphasizing the importance of preserving tooth vitality and function. While the study has notable strengths, including its relevance, comprehensive review, and practical case reports, it also has limitations such as a small sample size, short follow-up duration, and potential biases. Future research with larger sample sizes, longer follow-up periods, and more detailed technical descriptions would be beneficial to validate and expand upon these findings.