traumatic injuries to the teeth
TRANSCRIPT
Traumatic Injuries Traumatic Injuries
to the Teethto the Teeth
Scott A. Schwartz, Colonel, USAF, DCScott A. Schwartz, Colonel, USAF, DC
Traumatic Injuries to the TeethTraumatic Injuries to the Teeth
Crown FracturesCrown Fractures
CrownCrown--Root FracturesRoot Fractures
Root FracturesRoot Fractures
Luxation InjuriesLuxation Injuries
AvulsionAvulsion
Traumatic Injuries to the TeethTraumatic Injuries to the Teeth
Root Fracture UpdateRoot Fracture Update
Traumatic Injuries to the TeethTraumatic Injuries to the Teeth
Root Fracture UpdateRoot Fracture Update
Management of the Management of the
Avulsed ToothAvulsed Tooth
Root Fracture UpdateRoot Fracture Update
Clinical examinationClinical examination
–– Tooth usually slightly extrudedTooth usually slightly extruded
–– Tooth frequently displaced Tooth frequently displaced
linguallylingually
Root Fracture UpdateRoot Fracture Update
Clinical examinationClinical examination
–– Tooth usually slightly extrudedTooth usually slightly extruded
–– Tooth frequently displaced Tooth frequently displaced
linguallylingually
Root Fracture UpdateRoot Fracture Update
Clinical examinationClinical examination
–– Diagnosis entirely Diagnosis entirely
dependent upon dependent upon
radiographic radiographic
examinationexamination
Emergency ManagementEmergency Management
Periapical radiographsPeriapical radiographs
–– Standard XCP radiographStandard XCP radiograph
–– Increased vertical angulationIncreased vertical angulation
Emergency ManagementEmergency Management
Periapical radiographsPeriapical radiographs
–– Standard XCP radiographStandard XCP radiograph
–– Increased vertical angulationIncreased vertical angulation
Emergency ManagementEmergency Management
Reposition coronal Reposition coronal
fragmentfragment
Emergency ManagementEmergency Management
Previous Previous
recommendationrecommendation
–– Rigid splinting for 2Rigid splinting for 2--3 3
monthsmonths
Emergency ManagementEmergency Management
Previous Previous
recommendationrecommendation
–– Rigid splinting for 2Rigid splinting for 2--3 3
monthsmonths
New recommendationNew recommendation
–– Splinting for 3 weeksSplinting for 3 weeks
Root Fracture HealingRoot Fracture Healing
Root Fracture ComplicationsRoot Fracture Complications
Pulp necrosisPulp necrosis
–– Coronal segment Coronal segment 20 to 20 to
44%44%
Root Fracture ComplicationsRoot Fracture Complications
Pulp necrosisPulp necrosis
–– Coronal segment Coronal segment 20 to 20 to
44%44%
–– Apical segment Apical segment 0%0%
Root Fracture ComplicationsRoot Fracture Complications
Pulp necrosisPulp necrosis
–– Coronal segment Coronal segment 20 to 20 to
44%44%
–– Apical segment Apical segment 0%0%
Root Fracture ComplicationsRoot Fracture Complications
Pulp necrosisPulp necrosis
–– Coronal segment Coronal segment 20 to 20 to
44%44%
–– Apical segment Apical segment 0%0%
Pulp canal obliteration Pulp canal obliteration
69%69%
Root Fracture ComplicationsRoot Fracture Complications
Pulp necrosisPulp necrosis
–– Coronal segment Coronal segment 20 to 20 to
44%44%
–– Apical segment Apical segment 0%0%
Pulp canal obliteration Pulp canal obliteration
69%69%
Root resorption Root resorption 60%60%
Root Fracture TreatmentRoot Fracture Treatment
SummarySummary
–– Reposition and splint for Reposition and splint for 3 weeks3 weeks !!!!
Root Fracture TreatmentRoot Fracture Treatment
SummarySummary
–– Reposition and splint for Reposition and splint for 3 weeks3 weeks !!!!
–– Monitor with pulp tests and Monitor with pulp tests and
radiographsradiographs
Root Fracture TreatmentRoot Fracture Treatment
SummarySummary
–– Reposition and splint for Reposition and splint for 3 weeks3 weeks !!!!
–– Monitor with pulp tests and Monitor with pulp tests and
radiographsradiographs
–– Do not initiate endodontic treatment Do not initiate endodontic treatment
unless there are signs of pulp unless there are signs of pulp
necrosisnecrosis
Management of the Avulsed Management of the Avulsed
ToothTooth
Management of the Management of the
Avulsed ToothAvulsed Tooth
OverviewOverview
Periodontal Ligament Responses Periodontal Ligament Responses
Treatment ConsiderationsTreatment Considerations
Pulpal Prognosis/ Endodontic RationalePulpal Prognosis/ Endodontic Rationale
Treatment RegimenTreatment Regimen
Avulsed Permanent TeethAvulsed Permanent Teeth
Incidence Incidence
–– 0.5% to 16% of 0.5% to 16% of
traumatic injuriestraumatic injuries
Main etiologic Main etiologic
factorsfactors
–– FightsFights
–– Sports injuriesSports injuries
–– Automobile Automobile
accidentsaccidents
Avulsed Permanent TeethAvulsed Permanent Teeth
Maxillary central incisor Maxillary central incisor
–– Most commonly avulsed Most commonly avulsed
toothtooth
Mandibular teethMandibular teeth
–– Seldom affectedSeldom affected
Most frequently involves a Most frequently involves a
single toothsingle tooth
Avulsed Permanent TeethAvulsed Permanent Teeth
Most common age Most common age -- 7 to 117 to 11
–– Permanent incisors eruptingPermanent incisors erupting
–– Loosely structured PDLLoosely structured PDL
Avulsed Permanent TeethAvulsed Permanent Teeth
Associated injuriesAssociated injuries
–– Fracture of alveolar Fracture of alveolar
socket wallsocket wall
Avulsed Permanent TeethAvulsed Permanent Teeth
Associated injuriesAssociated injuries
–– Fracture of alveolar Fracture of alveolar
socket wallsocket wall
–– Injuries to the lips Injuries to the lips
and gingivaand gingiva
Management of theManagement of the
Avulsed ToothAvulsed Tooth
What tissue should What tissue should
be our primary be our primary
concern?concern?
–– Pulp?Pulp?
Management of the Management of the
Avulsed ToothAvulsed Tooth
What tissue should What tissue should
be our primary be our primary
concern?concern?
–– Pulp?Pulp?
–– Socket?Socket?
Management of the Management of the
Avulsed ToothAvulsed Tooth
What tissue should What tissue should
be our primary be our primary
concern?concern?
–– Pulp?Pulp?
–– Socket?Socket?
–– PDL?PDL?
Management of the Management of the
Avulsed ToothAvulsed Tooth
Ultimate goalUltimate goal
–– PDL healing without PDL healing without
root resorptionroot resorption
Management of the Management of the
Avulsed ToothAvulsed Tooth
Ultimate goalUltimate goal
–– PDL healing without PDL healing without
root resorptionroot resorption
Most critical factorMost critical factor
–– Maintaining an intact Maintaining an intact
and viable PDL on and viable PDL on
the root surfacethe root surface
Periodontal Ligament Periodontal Ligament
ResponsesResponses
Surface ResorptionSurface Resorption
Replacement Resorption (Ankylosis)Replacement Resorption (Ankylosis)
Inflammatory ResorptionInflammatory Resorption
Andreasen JO, HjortingAndreasen JO, Hjorting--Hansen E.Hansen E.
Replantation of teeth II. Histological study Replantation of teeth II. Histological study of 22 replanted anterior teeth in humans.of 22 replanted anterior teeth in humans.
Acta Odontol Scand 1966;24:287Acta Odontol Scand 1966;24:287--306.306.
Periodontal Ligament Periodontal Ligament
ResponsesResponses
Surface resorptionSurface resorption
–– Superficial resorption Superficial resorption
cavitiescavities
–– Mainly in cementumMainly in cementum
–– Complete repair of Complete repair of
PDLPDL
Periodontal Ligament Periodontal Ligament
ResponsesResponses
Replacement Replacement resorption resorption
(Ankylosis)(Ankylosis)–– Direct union of bone Direct union of bone
and rootand root
–– Resorption of root Resorption of root --Replacement with Replacement with bonebone
–– Direct result of loss of Direct result of loss of vital PDLvital PDL
Periodontal Ligament Periodontal Ligament
ResponsesResponses
Inflammatory resorptionInflammatory resorption
–– Resorption of cementum Resorption of cementum
and dentinand dentin
–– Inflammatory reaction in Inflammatory reaction in
the periodontal ligamentthe periodontal ligament
EtiologyEtiology
Inflammatory Inflammatory
resorptionresorption
–– Surface resorption of Surface resorption of
cementum exposing cementum exposing
dentinal tubulesdentinal tubules
EtiologyEtiology
Inflammatory Inflammatory
resorptionresorption
–– Surface resorption of Surface resorption of
cementum exposing cementum exposing
dentinal tubulesdentinal tubules
–– Pulp necrosisPulp necrosis
EtiologyEtiology
Inflammatory Inflammatory
resorptionresorption
–– Surface resorption of Surface resorption of
cementum exposing cementum exposing
dentinal tubulesdentinal tubules
–– Pulp necrosisPulp necrosis
–– Toxic products from Toxic products from
the pulp provoke an the pulp provoke an
inflammatory inflammatory
response in the PDLresponse in the PDL
Periodontal Ligament ResponsesPeriodontal Ligament Responses
Surface resorptionSurface resorption
Periodontal Ligament ResponsesPeriodontal Ligament Responses
Surface resorptionSurface resorption
Replacement resorption (Ankylosis)Replacement resorption (Ankylosis)
Periodontal Ligament ResponsesPeriodontal Ligament Responses
Surface resorptionSurface resorption
Replacement resorption (Ankylosis)Replacement resorption (Ankylosis)
Inflammatory resorptionInflammatory resorption
Treatment ConsiderationsTreatment Considerations
Extraoral timeExtraoral time
Extraoral environmentExtraoral environment
Root surface manipulationRoot surface manipulation
Management of the socketManagement of the socket
StabilizationStabilization
Extraoral TimeExtraoral Time
Shorter time = Better prognosisShorter time = Better prognosis**< 30 min < 30 min 10% resorption10% resorption
> 90 min > 90 min 90% resorption90% resorption
Andreasen JO, HjortingAndreasen JO, Hjorting--Hansen E.Hansen E.
Replantation of teeth I. Radiographic and clinical study Replantation of teeth I. Radiographic and clinical study of 110 human teeth replanted after accidental loss.of 110 human teeth replanted after accidental loss.
Acta Odontol Scand 1966;24:263Acta Odontol Scand 1966;24:263--86.86.
Extraoral TimeExtraoral Time
Shorter time = Better prognosisShorter time = Better prognosis**< 30 min < 30 min 10% resorption10% resorption
> 90 min > 90 min 90% resorption90% resorption
**depending on storage mediumdepending on storage medium
Andreasen JO, HjortingAndreasen JO, Hjorting--Hansen E.Hansen E.
Replantation of teeth I. Radiographic and clinical study Replantation of teeth I. Radiographic and clinical study of 110 human teeth replanted after accidental loss.of 110 human teeth replanted after accidental loss.
Acta Odontol Scand 1966;24:263Acta Odontol Scand 1966;24:263--86.86.
Extraoral EnvironmentExtraoral Environment
Viability of PDL cells is Viability of PDL cells is
criticalcritical
Storage MediaStorage Media
Tap WaterTap Water
DryDry
Saliva Saliva
SalineSaline
Andreasen JO.Andreasen JO.
Effect of extraEffect of extra--alveolar period and storage media alveolar period and storage media
upon periodontal and pulpal healing after replantation upon periodontal and pulpal healing after replantation
of mature permanent incisors in monkeys.of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43Int J Oral Surg 1981;10:43--53.53.
Poor Poor resultsresults
Storage MediaStorage Media
Tap WaterTap Water
DryDry
Saliva Saliva
SalineSaline
Andreasen JO.Andreasen JO.
Effect of extraEffect of extra--alveolar period and storage media upon alveolar period and storage media upon
periodontal and pulpal healing after replantation periodontal and pulpal healing after replantation
of mature permanent incisors in monkeys.of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43Int J Oral Surg 1981;10:43--53.53.
GoodGood protection protection for 2 hrsfor 2 hrs
Poor resultsPoor results
Milk As A Storage MediumMilk As A Storage Medium
Physiologic Physiologic
osmolalityosmolality
Markedly fewer Markedly fewer
bacteria than salivabacteria than saliva
Readily availableReadily available
Storage Media Storage Media -- Milk vs. SalivaMilk vs. Saliva
Storage for 2 hrsStorage for 2 hrs–– Periodontal healing almost as good as immediate Periodontal healing almost as good as immediate
replantationreplantation
Blomlof L, et al.Blomlof L, et al.
Storage of experimentally avulsed teeth in milk Storage of experimentally avulsed teeth in milk prior to replantation.prior to replantation.
J Dent Res 1983;62:912J Dent Res 1983;62:912--6.6.
Storage Media Storage Media -- Milk vs. SalivaMilk vs. Saliva
Storage for 2 hrsStorage for 2 hrs–– Periodontal healing almost as good as immediate Periodontal healing almost as good as immediate
replantationreplantation
Storage for 6 hrsStorage for 6 hrs–– Saliva Saliva extensive replacement resorptionextensive replacement resorption
–– Milk Milk healing almost as good as immediate healing almost as good as immediate replantreplant
Blomlof L, et al.Blomlof L, et al.
Storage of experimentally avulsed teeth in milk Storage of experimentally avulsed teeth in milk prior to replantation.prior to replantation.
J Dent Res 1983;62:912J Dent Res 1983;62:912--6.6.
Cell Culture MediaCell Culture Media
Eagle’s MediumEagle’s Medium
Hank’s Balanced Salt Solution Hank’s Balanced Salt Solution
Hank’s Balanced Salt SolutionHank’s Balanced Salt Solution
Proper pH and osmolalityProper pH and osmolality
Reconstitutes depleted cellular metabolitesReconstitutes depleted cellular metabolites
Washes toxic breakdown products from the Washes toxic breakdown products from the
root surfaceroot surface
Organ Transplant Storage MediaOrgan Transplant Storage Media
ViaspanViaspan
–– Dramatically prolongs the storage of human Dramatically prolongs the storage of human
organsorgans
–– ExpensiveExpensive
–– Not readily availableNot readily available
Storage Media ComparisonStorage Media Comparison
ViaspanViaspan–– Complete healing after 6 and 12 hrsComplete healing after 6 and 12 hrs
–– Good for extended storage periods (72 and 96 Good for extended storage periods (72 and 96 hrs)hrs)
Trope M, Friedman S.Trope M, Friedman S.
Periodontal healing of replanted dog teeth stored Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank’s balanced salt solution.in Viaspan, milk and Hank’s balanced salt solution.
Endod Dent Traumatol 1992;8:183Endod Dent Traumatol 1992;8:183--8.8.
Storage Media ComparisonStorage Media Comparison
ViaspanViaspan–– Complete healing after 6 and 12 hrsComplete healing after 6 and 12 hrs
–– Good for extended storage periods (72 and 96 Good for extended storage periods (72 and 96 hrs)hrs)
Hank’s balanced salt solutionHank’s balanced salt solution–– Healing results similar to ViaspanHealing results similar to Viaspan
Trope M, Friedman S.Trope M, Friedman S.
Periodontal healing of replanted dog teeth stored Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank’s balanced salt solution.in Viaspan, milk and Hank’s balanced salt solution.
Endod Dent Traumatol 1992;8:183Endod Dent Traumatol 1992;8:183--8.8.
Recommended Storage MediaRecommended Storage Media
1. Socket (immediate 1. Socket (immediate
replantation)replantation)
2. Cell culture 2. Cell culture
mediummedium
3. Milk3. Milk
4. Physiologic saline4. Physiologic saline
5. Saliva5. Saliva
Root Surface ManipulationRoot Surface Manipulation
Attempt to retain PDL cell viabilityAttempt to retain PDL cell viability–– Do not curette root surfaceDo not curette root surface
–– Avoid caustic chemicalsAvoid caustic chemicals
Van Hassel HJ, Oswald RJ, Harrington GW.Van Hassel HJ, Oswald RJ, Harrington GW.
Replantation 2. The role of the periodontal Replantation 2. The role of the periodontal ligament.ligament.
J Endodon 1980;6:506J Endodon 1980;6:506--8.8.
Root Surface ManipulationRoot Surface Manipulation
Extraoral dry timeExtraoral dry time determines handlingdetermines handling
Root Surface ManipulationRoot Surface Manipulation
Extraoral Extraoral drydry time time << 1 hr1 hr
–– PDL healing is still possiblePDL healing is still possible
–– Handling recommendationsHandling recommendations
»» Keep root moistKeep root moist
»» Do not handle root surfaceDo not handle root surface
»» Gentle debridementGentle debridement
Root Surface ManipulationRoot Surface Manipulation
Extraoral Extraoral drydry time > 1 hrtime > 1 hr
–– Loss of PDL cell viability Loss of PDL cell viability
inevitable inevitable
–– Treatment recommendationsTreatment recommendations
»» Remove tissue tagsRemove tissue tags
»» Soak in accepted dental Soak in accepted dental
fluoride solution for 20 minfluoride solution for 20 min
Fluoride TreatmentFluoride Treatment
1.01.0--2.4% topical 2.4% topical
fluoride solutionfluoride solution
–– Sodium fluoride Sodium fluoride
(Andreasen)(Andreasen)
–– Stannous fluoride Stannous fluoride
(Krasner)(Krasner)
20 minute soak20 minute soak
Management of the SocketManagement of the Socket
Remove contaminated coagulum in Remove contaminated coagulum in
socketsocket
–– Irrigate with sterile saline Irrigate with sterile saline
Management of the SocketManagement of the Socket
Examine socket Examine socket If fracture is evidentIf fracture is evident
–– Reposition fractured bone with a blunt Reposition fractured bone with a blunt
instrumentinstrument
Management of the SocketManagement of the Socket
Replant using light digital pressureReplant using light digital pressure
StabilizationStabilization
Splint Splint
–– Definition Definition a a rigidrigid or or flexibleflexible device used to device used to
support, protect, or immobilize teeth, preventing support, protect, or immobilize teeth, preventing
further injuryfurther injury
–– TypesTypes
•• Acid etch compositeAcid etch composite
•• CrossCross--suturesuture
Acid Etch Composite SplintsAcid Etch Composite Splints
Interproximal compositeInterproximal composite
Acid Etch Composite SplintsAcid Etch Composite Splints
Composite with arch wireComposite with arch wire
Acid Etch Composite SplintsAcid Etch Composite Splints
Composite with monofilament nylonComposite with monofilament nylon
Acid Etch Composite SplintsAcid Etch Composite Splints
Functional SplintFunctional Splint–– 2020--30 lb 30 lb
monofilament nylonmonofilament nylon
–– Bonded with Bonded with compositecomposite
–– Allows physiologic Allows physiologic movementmovement
Antrim DD, Ostrowski JS.Antrim DD, Ostrowski JS.
A functional splint for traumatized A functional splint for traumatized teeth.teeth.
J Endodon 1982;8:328J Endodon 1982;8:328--31.31.
CrossCross--Suture SplintSuture Splint
IndicationsIndications
–– No adjacent teeth to No adjacent teeth to
splint tosplint to
–– Unmanageable Unmanageable
traumatized childrentraumatized children
CrossCross--Suture SplintSuture Splint
Splinting TimeSplinting Time
Effect of splinting timeEffect of splinting time–– 7 days7 days
–– 30 days30 days
Nasjleti CE, Castelli WA, Nasjleti CE, Castelli WA, Caffesse RG.Caffesse RG.
The effects of different splinting The effects of different splinting times on replantation of teeth in times on replantation of teeth in monkeys.monkeys.
Oral Surg 1982;53:557Oral Surg 1982;53:557--66.66.
Splinting TimeSplinting Time
Recommended timeRecommended time–– 7 to 10 days7 to 10 days
Nasjleti CE, Castelli WA, Nasjleti CE, Castelli WA, Caffesse RG.Caffesse RG.
The effects of different splinting The effects of different splinting times on replantation of teeth in times on replantation of teeth in monkeys.monkeys.
Oral Surg 1982;53:557Oral Surg 1982;53:557--66.66.
Pulpal PrognosisPulpal Prognosis
Stage of root developmentStage of root development
Dry storage timeDry storage time
Storage mediaStorage media
AntibioticsAntibiotics
Stage of Root DevelopmentStage of Root Development
Mature roots (Mature roots (<< 1.0 mm) 1.0 mm) –– Revascularization 0%Revascularization 0%
Kling M, et al. Endod Dent Traumatol 1986;2:83Kling M, et al. Endod Dent Traumatol 1986;2:83--9. 9.
Andreasen JO, et al. Endod Dent Traumatol Andreasen JO, et al. Endod Dent Traumatol 1995;11:511995;11:51--8.8.
Stage of Root DevelopmentStage of Root Development
Mature roots (Mature roots (<< 1.0 mm) 1.0 mm) –– Revascularization 0%Revascularization 0%
Immature roots (> 1.0 mm)Immature roots (> 1.0 mm)–– Revascularization 18Revascularization 18--34%34%
Kling M, et al. Endod Dent Traumatol 1986;2:83Kling M, et al. Endod Dent Traumatol 1986;2:83--9. 9.
Andreasen JO, et al. Endod Dent Traumatol Andreasen JO, et al. Endod Dent Traumatol 1995;11:511995;11:51--8.8.
RevascularizationRevascularization
Loss of blood Loss of blood
supply to pulpsupply to pulp
Revascularization Revascularization –– Day 4Day 4
Coronal pulpCoronal pulp
–– Extensive ischemic Extensive ischemic
injuryinjury
Revascularization Revascularization –– Day 4Day 4
Coronal pulpCoronal pulp
–– Extensive ischemic Extensive ischemic
injuryinjury
Apical pulpApical pulp
–– Initial revascularizationInitial revascularization
Revascularization Revascularization –– 4 Weeks4 Weeks
Pulp statusPulp status
–– RevascularizationRevascularization
–– ReinnervationReinnervation
–– New odontoblastic layerNew odontoblastic layer
RevascularizationRevascularization
Typical sequelaTypical sequela
–– Pulp canal obliterationPulp canal obliteration
Dry Storage TimeDry Storage Time
As dry storage time increasesAs dry storage time increases
Pulp survival decreasesPulp survival decreases
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59Endod Dent Traumatol 1995;11;59--68.68.
Storage MediaStorage Media
Nonphysiologic storageNonphysiologic storage–– Minimal chance of pulp Minimal chance of pulp
revascularizationrevascularization
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59Endod Dent Traumatol 1995;11;59--68.68.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59Endod Dent Traumatol 1995;11;59--68.68.
Storage MediaStorage Media
Nonphysiologic storageNonphysiologic storage–– Minimal chance of pulp Minimal chance of pulp
revascularizationrevascularization
Physiologic storagePhysiologic storage–– HBSS, milk, saline, salivaHBSS, milk, saline, saliva
–– Improved chance of pulp Improved chance of pulp revascularizationrevascularization
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59Endod Dent Traumatol 1995;11;59--68.68.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59Endod Dent Traumatol 1995;11;59--68.68.
Pulpal Prognosis Pulpal Prognosis -- AntibioticsAntibiotics
Systemic antibioticsSystemic antibiotics
–– Pulp Pulp
revascularization is revascularization is
not increasednot increased
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Lowni J, Kling Jones P, Austin J, Lowni J, Kling M, Fatti P. M, Fatti P.
Endod Dent Traumatol 1990;6:157Endod Dent Traumatol 1990;6:157--69.69.
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Lowni J, Kling Jones P, Austin J, Lowni J, Kling M, Fatti P. M, Fatti P.
Endod Dent Traumatol 1990;6:157Endod Dent Traumatol 1990;6:157--69.69.
Pulpal Prognosis Pulpal Prognosis -- AntibioticsAntibiotics
Systemic antibioticsSystemic antibiotics
–– Pulp Pulp
revascularization is revascularization is
not increasednot increased
Topical antibioticsTopical antibiotics
–– Beneficial effectBeneficial effect
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Kling M, Lowni J, Jones P, Austin J, Kling M, Lowni J, Fatti P. Fatti P.
Endod Dent Traumatol 1990;6:170Endod Dent Traumatol 1990;6:170--6.6.
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Kling M, Lowni J, Jones P, Austin J, Kling M, Lowni J, Fatti P. Fatti P.
Endod Dent Traumatol 1990;6:170Endod Dent Traumatol 1990;6:170--6.6.
Pulpal Prognosis Pulpal Prognosis -- AntibioticsAntibiotics
Topical DoxycyclineTopical Doxycycline
–– Decreased microorganisms in Decreased microorganisms in
pulpal lumenpulpal lumen
–– Increased pulp Increased pulp
revascularizationrevascularization
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Kling M, Lowni J, Jones P, Austin J, Kling M, Lowni J, Fatti P. Fatti P.
Endod Dent Traumatol 1990;6:170Endod Dent Traumatol 1990;6:170--6.6.
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Kling M, Lowni J, Jones P, Austin J, Kling M, Lowni J, Fatti P. Fatti P.
Endod Dent Traumatol 1990;6:170Endod Dent Traumatol 1990;6:170--6.6.
Pulpal Prognosis Pulpal Prognosis -- AntibioticsAntibiotics
RecommendationRecommendation
–– Topical DoxycyclineTopical Doxycycline
»» 1 mg in 20 ml physiologic saline1 mg in 20 ml physiologic saline
»» 5 minute soak5 minute soak
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Kling M, Lowni J, Jones P, Austin J, Kling M, Lowni J, Fatti P. Fatti P.
Endod Dent Traumatol 1990;6:170Endod Dent Traumatol 1990;6:170--6.6.
Cvek M, CleatonCvek M, Cleaton--Jones P, Austin J, Kling M, Lowni J, Jones P, Austin J, Kling M, Lowni J, Fatti P. Fatti P.
Endod Dent Traumatol 1990;6:170Endod Dent Traumatol 1990;6:170--6.6.
Endodontic RationaleEndodontic Rationale
Mature root Mature root -- 4 weeks4 weeks
–– Very limited Very limited
revascularizationrevascularization
Endodontic RationaleEndodontic Rationale
Mature root Mature root -- 4 weeks4 weeks
–– Very limited Very limited
revascularizationrevascularization
–– Ischemic coronal pulp with Ischemic coronal pulp with
great risk of infection !!!great risk of infection !!!
Endodontic Rationale Endodontic Rationale –– Mature Mature
RootRoot
Pulpectomy Pulpectomy 77--14 days14 days
Endodontic Rationale Endodontic Rationale –– Mature Mature
RootRoot
Calcium hydroxideCalcium hydroxide
placementplacement
Endodontic Rationale Endodontic Rationale –– Mature Mature
RootRoot
Calcium hydroxideCalcium hydroxide–– AntibacterialAntibacterial
–– Increases pH in dentinIncreases pH in dentin
–– Favors mineralization over resorptionFavors mineralization over resorption
Tronstad L, Andreasen JO, et al.Tronstad L, Andreasen JO, et al.
pH changes in dental tissues after pH changes in dental tissues after root canal filling with calcium root canal filling with calcium hydroxide.hydroxide.
J Endodon 1981;7:17J Endodon 1981;7:17--21.21.
Endodontic Rationale Endodontic Rationale –– Mature Mature
RootRoot Treatment recommendationTreatment recommendation
–– Ca(OH)Ca(OH)22 therapy for as long as therapy for as long as
practical, usually 6practical, usually 6--12 months12 months
Treatment of the Avulsed Permanent Treatment of the Avulsed Permanent Tooth.Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Treatment of the Avulsed Permanent Treatment of the Avulsed Permanent Tooth.Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Specific Treatment RegimenSpecific Treatment Regimen
Treatment of the Avulsed Permanent Treatment of the Avulsed Permanent Tooth.Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Specific Treatment RegimenSpecific Treatment Regimen
Root DevelopmentRoot Development
Closed apexClosed apex
Open apexOpen apex
Extraoral Extraoral DryDry TimeTime
One hour or lessOne hour or less
More than one hourMore than one hour
Treatment of the Avulsed Permanent Treatment of the Avulsed Permanent Tooth.Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Treatment of the Avulsed Permanent Treatment of the Avulsed Permanent Tooth.Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Treatment FlowchartTreatment Flowchart
<< 1 hr1 hr > 1 hr> 1 hr
ExtraoralExtraoral Dry Dry TimeTime
Apex MaturityApex MaturityClosedClosed OpenOpen Open or ClosedOpen or Closed
PulpectomyPulpectomy77--14 days14 days
ObserveObserve
OptionOption: :
Extraoral Extraoral RCTRCT
Pulpectomy Pulpectomy 77--14 days14 days
Emergency TreatmentEmergency Treatment
Replantation Replantation
techniquetechnique
–– Local anesthetic, if Local anesthetic, if
necessarynecessary
–– Radiograph to verify Radiograph to verify
positionposition
–– Check occlusionCheck occlusion
–– Physiologic splintPhysiologic splint
Emergency TreatmentEmergency Treatment
Additional Additional
ConsiderationsConsiderations
–– AnalgesicsAnalgesics
Emergency TreatmentEmergency Treatment
Additional Additional
ConsiderationsConsiderations
–– AnalgesicsAnalgesics
–– ChlorhexidineChlorhexidine
Emergency TreatmentEmergency Treatment
Additional ConsiderationsAdditional Considerations
–– AnalgesicsAnalgesics
–– ChlorhexidineChlorhexidine
–– TetanusTetanus
»» Refer to physician for tetanus prophylaxis prnRefer to physician for tetanus prophylaxis prn
Rothstein RJ, Baker FJ.Rothstein RJ, Baker FJ.
Tetanus: Prevention and treatment.Tetanus: Prevention and treatment.
J Am Med Assoc 1978;240:675J Am Med Assoc 1978;240:675--6.6.
Rothstein RJ, Baker FJ.Rothstein RJ, Baker FJ.
Tetanus: Prevention and treatment.Tetanus: Prevention and treatment.
J Am Med Assoc 1978;240:675J Am Med Assoc 1978;240:675--6.6.
Emergency TreatmentEmergency Treatment
Additional ConsiderationsAdditional Considerations
–– AnalgesicsAnalgesics
–– ChlorhexidineChlorhexidine
–– TetanusTetanus
–– AntibioticsAntibiotics
AntibioticsAntibiotics
PenicillinPenicillin–– 500 mg qid for 4500 mg qid for 4--7 days7 days
Andreasen JO.Andreasen JO.
Atlas of replantation and transplantation of Atlas of replantation and transplantation of teeth.teeth.
Philadelphia: W.B. Saunders Co., 1992;57Philadelphia: W.B. Saunders Co., 1992;57--92.92.
AntibioticsAntibiotics
Tetracycline vs. amoxicillin Tetracycline vs. amoxicillin
in a replacement resorption modelin a replacement resorption model
–– Tetracycline had better antiTetracycline had better anti--resorptive propertiesresorptive properties
SaeSae--Lim V, Wang CY, Choi GW, Trope M.Lim V, Wang CY, Choi GW, Trope M.
The effect of systemic tetracycline on resorption of The effect of systemic tetracycline on resorption of
dried replanted dogs’ teeth.dried replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:127Endod Dent Traumatol 1998;14:127--32.32.
AntibioticsAntibiotics
Tetracycline vs. amoxicillin Tetracycline vs. amoxicillin
in an inflammatory root resorption modelin an inflammatory root resorption model
–– Tetracycline had better antiTetracycline had better anti--bacterial propertiesbacterial properties
SaeSae--Lim V, Wang CY, Trope M.Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs’ teeth.inflammatory root resorption of replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:216Endod Dent Traumatol 1998;14:216--20.20.
AntibioticsAntibiotics
RecommendationRecommendation
–– “Tetracycline could be considered as an alternative “Tetracycline could be considered as an alternative
to amoxicillin after avulsion injuries.”to amoxicillin after avulsion injuries.”
SaeSae--Lim V, Wang CY, Trope M.Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs teeth.inflammatory root resorption of replanted dogs teeth.
Endod Dent Traumatol 1998;14:216Endod Dent Traumatol 1998;14:216--20.20.
Tetracycline Use In Young Tetracycline Use In Young
ChildrenChildren
Tetracycline stainingTetracycline staining–– Not a problem since avulsed maxillary anteriors Not a problem since avulsed maxillary anteriors
have already erupted and are not susceptible to have already erupted and are not susceptible to stainingstaining
–– At worst, posterior teeth might be stainedAt worst, posterior teeth might be stained»» Remote possibility with 7Remote possibility with 7--10 day prescription10 day prescription
SaeSae--Lim V, Wang CY, Trope M.Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs’ teeth.inflammatory root resorption of replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:216Endod Dent Traumatol 1998;14:216--20.20.
Avulsion SequelaeAvulsion Sequelae
Closed ApexClosed Apex
Extraoral dry time Extraoral dry time
1 hour or less1 hour or less
Avulsion SequelaeAvulsion Sequelae
Closed ApexClosed Apex
Extraoral dry time Extraoral dry time
more than 1 hourmore than 1 hour
Avulsion SequelaeAvulsion Sequelae
Open ApexOpen Apex
Extraoral dry time Extraoral dry time
1 hour or less1 hour or less
Avulsion SequelaeAvulsion Sequelae
Open ApexOpen Apex
Extraoral dry time Extraoral dry time
more than 1 hourmore than 1 hour
Avulsion ManagementAvulsion Management
Be prepared Be prepared --
Dental Trauma KitDental Trauma Kit
Immerse tooth in a Immerse tooth in a
physiologic storage medium physiologic storage medium
to “buy time”to “buy time”
Determine extraoral Determine extraoral drydry timetime
Follow AAE GuidelinesFollow AAE Guidelines