Management of Dental Injuries in Children

Management of Dental Injuries in Children

Dennis J. McTigue, DDS, MSAlabama Academy of Pediatric Dentistry

February 5, 2016

Dennis J. McTigue, DDS, MSAlabama Academy of Pediatric Dentistry

February 5, 2016

Limitations of trauma researchLimitations of trauma research Ethical - Patients can’t be randomized to “trauma”

and “no trauma” groups

Animal models – limited clinical applicability to humans

Retrospective case series studies Individual case reports

Randomized post-injury treatment interventions

Comparability of injuries studied

Andreasen, JO et al. Contradictions in the treatment of traumatic dental injuries and ways to proceed in dental trauma research. Dent Traumatol 2010; 26:16-22

Guidelines for TreatmentGuidelines for Treatment International Association of Dental Traumatology

Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012;28I. Fractures and luxations of permanent teeth II. Avulsion of permanent teethIII. Primary teeth

American Association of EndodontistsRecommended guidelines for the treatment of traumatic injuries. Chicago: AAE; 2013 www.AAE.org

HISTORY:HISTORY:

Patients name, Age, Sex, Address, and Phone Number

Medical History and Assessment of General Health

TETANUS PROTECTION PROTOCOLTETANUS PROTECTION PROTOCOL

Immunization completed plus booster within 5 years - no treatment

Greater than ten years since immunization -toxoid

Between 5 & 10 years since immunization and dirty wound - toxoid

No history of immunization and dirty wound - toxoid and antitoxin

http://www.health.state.mn.us/divs/idepc/diseases/tetanus/hcp/tetwdmgmt.htmlhttp://www.health.state.mn.us/divs/idepc/diseases/tetanus/hcp/tetwdmgmt.html

WHEN did the accident occur?

WHERE did the accident occur?

HOW did the accident occur?

RULE OUT:Child Abuse

CNS Injury

Child AbuseChild Abuse Annual US estimate – 1.5 million cases

Ratio of nonreported to reported = 100: 1

40-60% Abusers were abused as children

High rates with special needs patients

Most prevalent in age group 0-24 months

Diagnostic Evaluation for AbuseDiagnostic Evaluation for Abuse

Red Flags in the History:Injury incompatible with child’s developmental

abilities

Absent, changing, or evolving history

Delay in seeking medical care

Triggering event that precipitates loss of control in caregiver

Family crisis or stress

Prior history of abuse in caregiver

Bruising and LocationBruising and LocationNon‐Intentional Intentional

Forehead Ears

Vertex of chin Neck

Elbows Upper arms/legs

Knees/Shins

Child AbuseChild Abuse Bruising:

If bruising is seen in a non-ambulatory child or in non-prominent soft tissue locations on the body - consideration should be given to abuse or some other underlying condition

Bites:Patterns of bites vary in tooth shape, arch impression and

intercuspid distance depending on whether the bite was inflicted by a child (<30 mm) or an adult

Dentists are mandated reporters

CENTRAL NERVOUS SYSTEM INJURY

CENTRAL NERVOUS SYSTEM INJURY

Tecklenburg, F., and Wright, M.: Minor head trauma in the pediatric patient. Ped. Emer. Care Vol. 7, #1, pgs. 40-47, 1991.

AAP Clinical Practice Guidelines: The Management of Minor Head Injury in Children. Pediatrics Vol. 104, #6, pgs 1407-1415 , 1999;http://aappolicy.aappublications.org/cgi/content/full/pediatrics;104/6/1407

Signs of Increased Intracranial Pressure

Signs of Increased Intracranial Pressure

DIZZINESS

NAUSEA

VOMITING

HEADACHE

LETHARGY OR IRRITABILITY

LOSS OF MEMORY

PUPIL SIZE AND REACTION TO LIGHT

LOSS OF CONSCIOUSNESS

RECORD SYMPTOMS REPORTED BY PATIENTRECORD SYMPTOMS REPORTED BY PATIENT

Spontaneous Pain

Reaction to Thermal Change

Disturbances in Occlusion

CLINICAL EXAMCLINICAL EXAM

RECORD:

Extraoral Wounds and Palpation of Facial Skeleton

Injuries to intraoral soft tissues

Chin Trauma correlated with:Chin Trauma correlated with:

Posterior crown fractures

Mandibular condylar fractures

Cervical spine injury

Bertolami, C.N. and Kaban, L.B.: Chin trauma: a clue to associated mandibular and cervical spine injury, Oral Surg. Feb. 1982, pgs. 122-126.

Examine tooth crowns for fracture, pulp exposure, or color changeExamine tooth crowns for fracture, pulp exposure, or color change

Record displacement of teeth

RECORD:RECORD:

Mobility of Teeth or Alveolar Fragments

Sensitivity to Percussion

Abnormalities in Occlusion

Reaction to Vitality Tests

REACTION OF TEETH TO VITALITY TESTSREACTION OF TEETH TO VITALITY TESTS

A. Carbon Dioxide Snow B. Tetrafluoroethane (Endo

Ice) C. Electric Vitalometers

Weisleder, et al. The validity of pulp testing. JADA 140:1013-1017, 2009. Weisleder, et al. The validity of pulp testing. JADA 140:1013-1017, 2009.

ANDREASEN FM, ANDREASEN JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations.Endod Dent Traumatol 1985;5:160-169.

ANDREASEN FM, ANDREASEN JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations.Endod Dent Traumatol 1985;5:160-169.

ANDREASEN FM, ANDREASEN JO, TSUKIBOSHI M. Examination and Diagnosis of Dental Injuries.In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. pp. 255-279.

ANDREASEN FM, ANDREASEN JO, TSUKIBOSHI M. Examination and Diagnosis of Dental Injuries.In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. pp. 255-279.

RADIOGRAPHIC EVIDENCE OF PATHOLOGYRADIOGRAPHIC EVIDENCE OF PATHOLOGY

2 Weeks - Pulpal Necrosis

3 Weeks - Inflammatory Resorption (External and Internal)

6 Weeks - Replacement Resorption (Ankylosis)

COMMON REACTIONS OF TEETH TO TRAUMACOMMON REACTIONS OF TEETH TO TRAUMA PULPAL HYPEREMIA (PULPITIS)

INTERNAL HEMORRHAGE

PULP NECROSIS

PULP CANAL OBLITERATION

INFLAMMATORY RESORPTION . . . . a) Internal b) External

REPLACEMENT RESORPTION (Ankylosis)

PULPAL HYPEREMIA (PULPITIS)

INTERNAL HEMORRHAGE

PULPAL CANAL OBLITERATION (PCO) - RESULTSPULPAL CANAL OBLITERATION (PCO) - RESULTS

PCO dependent on type of injury PCO dependent on stage of root

development PN subsequent to PCO was uncommon

(1%) PCO occurs later than PN (12 mos. vs

3mos) PCO increased with bands / resin fixation

Oginni, et al. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol 25:620-625; 2009

Oginni, et al. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol 25:620-625; 2009

276 teeth with PCO

Measured color, EPT, mobility & percussion

Yellow discoloration in 67%

PA lesions and negative EPT in 33%

Normal PA and EPT in 31%

Small PA changes/high normal EPT in 36%

EtiologyEtiology

Inflammatory resorption Surface resorption of

cementum exposing dentinal tubules

Pulp necrosis

Toxic products from the pulp provoke an inflammatory response in the PDL

Replacement ResorptionReplacement Resorption

Direct union of bone and root

Resorption of root - Replacement with bone

Direct result of loss of vital PDL

Primary Pulp Exposure TX optionsPrimary Pulp Exposure TX options

Partial pulpotomy in immature incisor Ram D, Holan G. Partial pulpotomy in a traumatized primary

incisor with pulp exposure. Pediatr Dent 16:44-48, 1994

Pulpotomy when no resorption has begun Flores M. Traumatic injuries in the primary dentition. Dent

Traumatol 18:287-298, 2002

Pulpectomy with resorbable paste – 20% deflections of succeeding permanent incisorsColl et al. 1996, Flaitz et al. 1989

Extraction

Howley B, Seale N. et al. Pulpotomy versus pulpectomy for carious vital primary incisors: randomized controlled trial. Pediatr. Dent. 34:112E 2012

Howley B, Seale N. et al. Pulpotomy versus pulpectomy for carious vital primary incisors: randomized controlled trial. Pediatr. Dent. 34:112E 2012

Matched pairs carious vital primary incisors received either FC pulpotomy or CaOH RCT

74 teeth followed clinically and radiographically for up to 23 months

Success in 89% of FC pulpotomies and 73% in RCT. No significant difference between.

Subluxation (loosening)Subluxation (loosening)

An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth

Intrusive Luxation(central dislocation)Intrusive Luxation(central dislocation)

A displacement of the tooth into the alveolar bone.

This injury is accompanied by comminution or fracture of the alveolar socket.

Injuries to Developing TeethInjuries to Developing Teeth

Discoloration of the enamel

Enamel hypoplasia

Crown or rootdilaceration

Arrested Development

Sequestration of tooth germ

Disturbance in eruption

Injury to developing successorsInjury to developing successors

20% Assuncao, et al 2009

25% Sennhenn-Kirchner, et al 2006

Mild hypoplasia most common (~75%)

Most frequently following intrusions, then avulsions

Children aged 1 – 3 years at greatest risk

Limited diagnostic value of lateral anterior film? Holan G, et al. Pediatr Dent 2002Limited diagnostic value of lateral anterior film? Holan G, et al. Pediatr Dent 2002

Total spontaneous re-eruption: 40 – 60 % Partial re-eruption: 40%Pulp necrosis or root resorption: 50%PCO: 50%

Gondim et al. 2005, Borum et al. 1998, Holan et al. 1999

Total spontaneous re-eruption: 40 – 60 % Partial re-eruption: 40%Pulp necrosis or root resorption: 50%PCO: 50%

Gondim et al. 2005, Borum et al. 1998, Holan et al. 1999

Intrusive LuxationIntrusive Luxation

Allow to reerupt if apex is displaced toward or through labial plate

Extract if apex is displaced into developing tooth

International Association of Dental TraumatologyGuidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012:28;174-182

International Association of Dental TraumatologyGuidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2012:28;174-182

No evidence to support loss of space when primary anterior teeth are lost after primary canines erupt.

No evidence to support loss of space when primary anterior teeth are lost after primary canines erupt.

MANAGEMENT OF TRAUMATIC INJURIES TO YOUNG PERMANENT TEETH

MANAGEMENT OF TRAUMATIC INJURIES TO YOUNG PERMANENT TEETH

Capp, et al. Reattachment of rehydrated dental fragment using two techniques. Dent Traumatol 25:95-99, 2009

Capp, et al. Reattachment of rehydrated dental fragment using two techniques. Dent Traumatol 25:95-99, 2009

Remove dentin from coronal fragment before bonding

Rehydrate fragment in water for 30 minutes prior to bonding

Place chamfer on buccal and lingual surfaces after the fragment is bonded

Garoushi et al. Fracture resistance of fragmented incisal edges restored with fiber-reinforced composite. J Adhes Dent 8:91-95, 2006

Garoushi et al. Fracture resistance of fragmented incisal edges restored with fiber-reinforced composite. J Adhes Dent 8:91-95, 2006

Akgun et al. Ribbond for treatment of complicated crown fractures: Report of 3 cases. J Clin Ped Dent. 2012

TREATMENT ALTERNATIVES IN CLASS III FRACTURES OF PERMANENT TEETH

TREATMENT ALTERNATIVES IN CLASS III FRACTURES OF PERMANENT TEETH

DIRECT PULP CAP: small exposure, < 24 hours

PARTIAL PULPOTOMY (CaOH or MTA) preferred tx; larger exposures, > 24 hours

PULPECTOMY: closed apexAndreasen FM, Andreasen JO. Crown fractures. In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. 280-305.

International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2007:23

Andreasen FM, Andreasen JO. Crown fractures. In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. 280-305.

International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatol 2007:23

CALCIUM HYDROXIDE PARTIAL PULPOTOMYCALCIUM HYDROXIDE PARTIAL PULPOTOMY

96% SUCCESS WITH PULPS EXPOSED

1 HOUR TO 90 DAYS

Cvek, M.: A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture, J. Endo., Vol. 4, #8, Aug. 1978, pgs 232-237.

TECHNIQUETECHNIQUE 1) Gently Remove Dentin and Pulp to 1-2 mm

2) Use Copious Irrigation

3) Cover Pulp with CaOH

MTA PulpotomyMTA Pulpotomy

Witherspoon, D. Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth.J Endod. 2008 Jul;34

Witherspoon, D. Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth.J Endod. 2008 Jul;34

Zhu W, et al. Endodontic treatment with MTA of a mandibular first premolar with open apex: case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jul;106(1):e73-5

Zhu W, et al. Endodontic treatment with MTA of a mandibular first premolar with open apex: case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jul;106(1):e73-5

What does it contain?What does it contain?

Tricalcium silicate

Dicalcium silicate

Tricalcium aluminate

Tetracalcium aluminoferrite

Calcium sulfate

Bismuth oxide

So it is Portland CementSo it is Portland Cement

IndicationsIndications

Pulp cap

Pulpotomy

Open apices

Revascularization

Perforations

Resorptions

Root-end

Why MTA?Why MTA?

Biocompatible

Low cytotoxicity

No mutagenicity

Periodontal regeneration

Cemental regeneration

Pulpal regeneration

Excellent seal

PulpotomyPulpotomy

Clinical Procedures

• MTA

• moist pellet

• temp filling

• 1 week perm filling

• check vitality every 3 to 6 months

Clinical Procedures

• MTA

• moist pellet

• temp filling

• 1 week perm filling

• check vitality every 3 to 6 months

MTA partial pulpotomyMTA partial pulpotomy

AdvantageGood success rate

DisadvantagesCostRe-entryDiscolorationMaterial manipulation

Biodentine pulpotomyBiodentine pulpotomy

Martens L, et. al. Pulp management after traumatic injuries with a tricalcium silicate-based cement (BiodentineTM): a report of two cases, up to 48 months follow-up. Eur Arch Paediatr Dent. 2015

Martens L, et. al. Pulp management after traumatic injuries with a tricalcium silicate-based cement (BiodentineTM): a report of two cases, up to 48 months follow-up. Eur Arch Paediatr Dent. 2015

Clinical ApplicationsClinical Applications

1. DPC/IPC2. Temporary Restorations3. Liner/Base (Dentin

replacement)4. Pulpotomy and partial

(Cvek) pulpotomy5. Repair of root/pulpal floor

perforations6. Apexification7. Retrograde Root Filling8. Apexogenesis9. Root resorption repair:

internal/external

CRITERIA FOR SUCCESSCRITERIA FOR SUCCESS

1) No clinical signs or symptoms

2) No radiographic pathology

3) Continued development of immature roots

4) Formation of calcific barriers

5) Sensitivity to electrical stimulation

NECROTIC IMMATURE TEETH

NECROTIC IMMATURE TEETH

Apexification: CaOH

Apexification: MTA

Apexogenesis: Revascularization

Disadvantages: CaOH ApexificationDisadvantages: CaOH Apexification

Multiple visits over 8 – 16 months

Must achieve hard barrier at apex

Long term CaOH further weakens tooth

High incidence of subsequent root fracture

Calcium hydroxide weakens dentinCalcium hydroxide weakens dentin

Andreasen J. et al. Long term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 18:134-137, 2002

Rosenberg B. et al. The effect of calcium hydroxide root filling on dentin fracture strength. Dent Traumatol 23:26-29, 2007

Sahebi S. et al. The effects of short-term calcium hydroxide application on the strenth of dentine. Dent Traumatol 26:43-46, 2010

Mineral Trioxide Aggregate (MTA)Mineral Trioxide Aggregate (MTA)

High pH (similar to CaOH)

Exceptional sealing properties

Hardens within hours enabling canal obturation

Simon S, et al. Int. Endo J., 2007Simon S, et al. Int. Endo J., 2007

Thibodeau B, Trope M: Pulp revascularization of a necrotic infected immature permanent tooth: A case report and review of the literature. Pediatr Dent. Jan. 2007, 29:47-50

ciprofloxacin

metronidazole

cefaclor

REVASCULARIZATIONREVASCULARIZATION

Huang G. A paradigm shift in endodontic management of immature teeth: Conservation of stem cells for regeneration. J Dent 2008;36:379-86

Trope M. Regenerative potential of dental pulp. Pediatr Dent 2008;30:206-10

Hargreaves K, et al. Regeneration potential of young permanent tooth: What does the future hold? Pediatr Dent 2008;30:253-60

MANAGEMENT OF LUXATION INJURIES TO THE YOUNG PERMANENT DENTITION

MANAGEMENT OF LUXATION INJURIES TO THE YOUNG PERMANENT DENTITION

CONCUSSIONCONCUSSION

An injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth but with marked reaction to percussion.

Subluxation (loosening)Subluxation (loosening)

An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth

Concussion Treatment:Inform patient & parent about

potential sequelae;

Monitor

Subluxation Tx:Splint ?? F/U in 2 weeks;

Radiograph at 1 month

Concussion Treatment:Inform patient & parent about

potential sequelae;

Monitor

Subluxation Tx:Splint ?? F/U in 2 weeks;

Radiograph at 1 month

Primate studies have demonstrated that rigid and/or prolonged splinting may lead to extensive PDL healing complications, like ankylosis and replacement resorption.

Andreasen, J. A time-related study of PDL healing and root resorption activity after replantation of mature permanent incisors in monkeys. Swed Dent J 4:101-110, 1982

Andersson L, et al. Effect of masticatory stimulation on dentoalveolar ankyosis after experimental tooth replantation. Endod Dent Traumatol 1:13-16, 1985

Primate studies have demonstrated that rigid and/or prolonged splinting may lead to extensive PDL healing complications, like ankylosis and replacement resorption.

Andreasen, J. A time-related study of PDL healing and root resorption activity after replantation of mature permanent incisors in monkeys. Swed Dent J 4:101-110, 1982

Andersson L, et al. Effect of masticatory stimulation on dentoalveolar ankyosis after experimental tooth replantation. Endod Dent Traumatol 1:13-16, 1985

SPLINTS SHOULD:SPLINTS SHOULD:

1) Be passive and atraumatic

2) Be durable

3) Be flexible

4) Allow for vitality testing and endodontic access

5) Be easy to apply and remove

SplintingSplinting

Use fish line/acid-etch resin; soft arch wire/resin; ortho brackets with passive arch wire; suture as last resort.

Circumferential wire splints contraindicated

Splinting - Home CareSplinting - Home Care

No biting on splinted teeth

Soft diet

Maintenance of good oral hygiene

Intrusive Luxation(central dislocation)Intrusive Luxation(central dislocation)

A displacement of the tooth into the alveolar bone.

This injury is accompanied by comminution or fracture of the alveolar socket.

Intrusion Treatment ControversyIntrusion Treatment Controversy

Andreasen JO et al. : Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Endo. Dent. Traumatol. 22:99-111, 2006.

Wigen, et al. Intrusive luxation of permanent incisors in Norwegians aged 6-17 years: a retrospective study of treatment and outcome. Dent Traumatol 24:612-618, 2008

Ebelseder et al. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Endod Dent Traumatol 16:34-39, 2000

Kenny, et al. Avulsions and Intrusions: the controversial displacement injuries. JCDA 69:291-297, 2003.

Intrusive Luxation Tx:Intrusive Luxation Tx:OPEN APEX

If < 7 mm allow spontaneous repositioning; ortho extrusion if no movement within 2-4 weeksIf > 7 mm reposition surgically or orthodontically

CLOSED APEX< 3 mm allow spontaneous eruption; ortho extrusion or surgical reposition if no movement within 2-4 weeks 3 – 7 mm reposition orthodontically or surgically>7 mm reposition surgically & splint for 2 weeks

Chlorhexidine mouthrinse Remove pulp & fill with CaOH < 2-3 weeks Complete endo fill in 1 - 2 months if no resorption Antibiotics not helpful

EXTRUSIVE LUXATION(Peripheral dislocation, partial avulsion)EXTRUSIVE LUXATION(Peripheral dislocation, partial avulsion)

A partial displacement of the tooth out of its socket.

Andreasen J. et al. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1:207-220, 1985Andreasen J. et al. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1:207-220, 1985

Andreasen J. et al. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol 18:116-128, 2002Andreasen J. et al. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol 18:116-128, 2002

Andreasen J. et al. The relationship between pulpal dimensions and the development of pulp necrosis after luxation injuries in the permanent dentition. Endod Dent Traumatol 2:90-98, 1986

Andreasen J. et al. The relationship between pulpal dimensions and the development of pulp necrosis after luxation injuries in the permanent dentition. Endod Dent Traumatol 2:90-98, 1986

Extrusive Luxation Tx:Extrusive Luxation Tx:

Reposition tooth ASAP; best prognosis if completed within 2 hours

Light splint for 2 weeks Remove pulp & fill with CaOH within 7-14

days Chlorhexidine mouthrinse Complete endo fill in 1 - 2 months if no

inflammatory resorption

Lateral LuxationLateral Luxation

A displacement of the tooth in a direction other than axially.

This is accompaniedby comminution or fracture of the alveolar socket.

Andreasen, JO, et al. Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th ed. Pg. 418

Lateral Luxation Tx:Lateral Luxation Tx:

Reposition tooth ASAP; best prognosis if completed within 2 hours

Light splint for 3 - 4 weeks Remove pulp & fill with CaOH within 7-14

days Chlorhexidine mouthrinse Complete endo fill in 1 - 2 months if no

inflammatory resorption

Andreasen J. et al. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 11:51-58, 1995

Andreasen J. et al. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 11:51-58, 1995

Andersson L and Bodin I. Avulsed human teeth replanted within 15 minutes – a long-term clinical follow-up study. Endod Dent Traumatol 6:37-42, 1990

Andersson L and Bodin I. Avulsed human teeth replanted within 15 minutes – a long-term clinical follow-up study. Endod Dent Traumatol 6:37-42, 1990

Treatment of the Avulsed Permanent Tooth

Treatment of the Avulsed Permanent Tooth

I. Management at site of injury

II. Transport media

III. Management in dental office

IV. Adjunctive drug therapy considerations

V. Endodontic treatment

VI. Restoration of the avulsed tooth

Management at Site of InjuryManagement at Site of Injury

Replant immediately, if possible. If contaminated, rinse.

When cannot be replanted, place tooth in best transport medium available.

Recommended Storage MediaRecommended Storage Media1. Socket (immediate

replantation)

2. Cell culture medium

3. Milk

4. Physiologic saline

5. Saliva

Blomlof L. Milk and saliva as possbile storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J. 8:1-26, 1981Blomlof L. Milk and saliva as possbile storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J. 8:1-26, 1981

Wilson R. et al. Storage media for avulsed teeth: a literature review. Braz. Dent J 2013.Wilson R. et al. Storage media for avulsed teeth: a literature review. Braz. Dent J 2013.

Management of the Avulsed ToothManagement of the Avulsed Tooth What tissue should be

our primary concern? Pulp?

Socket?

PDL?

Management of the Avulsed ToothManagement of the Avulsed Tooth Ultimate goal

PDL healing without root resorption

Most critical factorMaintaining an intact

and viable PDL on the root surface

Managing Mature ToothExtraoral DRY Time < 1 Hour

Managing Mature ToothExtraoral DRY Time < 1 Hour

Objective is to maintain PDL cell vitality

Place in HBSS during history & exam

Handle by crown and gently replant

Splint 1 – 2 weeks

Remove pulp in 7-14 days

Place CaOH

Obturate canal in 2-4 weeks

Management of Root SurfaceManagement of Root Surface

Objective is to maintain PDL cell vitality

Keep moist in HBSS

Do not handle root surface

Gently remove persistent debris

Management of the SocketManagement of the Socket

Gently aspirate without entering socket

If clot present use saline irrigation

Do not curette socket

Do not vent socket

If alveolar bone collapsed, use blunt instrument to reposition

Manually compress bony plates after replantation

Management of Soft TissuesManagement of Soft Tissues

Tightly suture any soft tissue lacerations, particularly in the cervical region

SplintingSplinting

Use fish line/acid-etch resin; soft arch wire/resin; ortho brackets with passive arch wire; suture as last resort.

Circumferential wire splints contraindicated

Maintain splint 10-14 days; longer if tooth demonstrates excessive mobility

Splinting - Home CareSplinting - Home Care

No biting on splinted teeth

Soft diet

Maintenance of good oral hygiene

Antibiotics??Antibiotics??

Hammarstrom, L. et al., Endod Dent Traumatol 1986; parenteral antibiotics prior to extraction and immediately

following replantation resulted in less inflammatory resorption in monkeys. Prevents bacterial invasion of the necrotic pulp and inflammatory resorption; route & timing

Sae-Lim V. et al., Endod Dent Traumatol 1998; Tetracycline decreases root resorption by affecting the motility

of the osteoclasts and reduces effectiveness of collagenase

Cvek M. et al. Endod Dent Traumatol 1990; Soaking teeth in topical doxycycline prior to replantation

enhances revascularization

Adjunctive Drug Therapy Considerations

Adjunctive Drug Therapy Considerations

Systemic antibiotics: If < 12 y/o pen v (250 mg/kg/d in 4 divided doses x 7

days)

If ≥ 12 y/o doxycycline (100 mg q 12 h first day, then 50 mg q 12 h days 2 – 10)

Tetanus consultation within 24 hours

Chlorhexidine mouth rinses

NSAIDs to inhibit bone resorption & pain relief

Endodontic TreatmentMature Tooth < 1 Hour DRY Time

Endodontic TreatmentMature Tooth < 1 Hour DRY Time

Remove pulp in 7-14 days

Place CaOH

Obturate canal in 2-4 weeks

Endodontic TreatmentMature Tooth

Endodontic TreatmentMature Tooth

Remove pulp as soon as possible

Place Triamcinolone for at least 2 weeks

Obturate canal when no evidence of root resorption

Intracanal corticosteroids inhibit root resorption. Chen H, et al. Dent Traumatol 2008

Intracanal corticosteroids as anti-inflammatory, anticlastic meds: AAE Trauma Guidelines, 2013

PROGNOSIS IS BEST FOR REIMPLANTED TEETH IF :PROGNOSIS IS BEST FOR REIMPLANTED TEETH IF : Extra-Oral period is minimal

Periodontal ligament is not traumatized

If not replanted the transport and soaking solution is HBSS

Endo therapy is not done in the hand before reimplantation

An appropriate splint is applied for 1 week

CaOH pulpectomy is completed in 1 wk

Managing Avulsed Immature Tooth Open Apex < 1 Hour DRY Time

Managing Avulsed Immature Tooth Open Apex < 1 Hour DRY Time

Objective is to revitalize severed pulp

Managing Avulsed Immature Tooth

Open Apex < 1 Hour DRY Time

Managing Avulsed Immature Tooth

Open Apex < 1 Hour DRY Time

Best chance if replanted within 20 minutes - MUST be replanted within 60 minutes

Soak in doxycycline solution for 5 minutes ?

Replant and splint for two weeks

Recall every 3-4 weeks

If pathosis noted, extirpate pulp and do regenerative

procedure

Managing Mature ToothExtraoral DRY Time > 1 Hour

Managing Mature ToothExtraoral DRY Time > 1 Hour

Objective is to delay inevitable root resorption

Managing Mature ToothExtraoral DRY Time > 1 Hour

Managing Mature ToothExtraoral DRY Time > 1 Hour Objective is to delay inevitable root resorption

Remove all PDL fragments (manually, NaOH, Citric acid)

Soak in fluoride (Shulman, et al. JDR, 1973)

Complete endo now or later

Replant & splint

Anticipate replacement resorption

Consider decoronation

CLINICAL SIGNS OF ASPIRATION

CLINICAL SIGNS OF ASPIRATION

1) No symptoms

2) Initial choking and coughing

3) Irritating cough

4) Wheezing

5) Unilateral obstructive emphysema

6) Atelectasis

7) Pulmonary suppuration

Jarvinen S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 36:359-362, 1978

Jarvinen S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 36:359-362, 1978

Normal overjet 1 – 3 mm

Overjet 3 – 6 mm = 2 X injuries

Overjet 6 – 9 mm = 3 X injuries

Bauss O, et al. Influence of extrusion on pulpal vitality of traumatized maxillary incisors. JOE 36:203-207, 2010

Bauss O, et al. Influence of extrusion on pulpal vitality of traumatized maxillary incisors. JOE 36:203-207, 2010

Retrospective study comparing pulp vitality after ortho extrusion of traumatized vs. non-traumatized incisors

Traumatized teeth significantly more likely to become necrotic than non-traumatized

Necrosis occurred most frequently in early stages of extrusion.

Kindelan, et al. Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1. JO 35:68-78, 2008

Kindelan, et al. Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1. JO 35:68-78, 2008

“traumatized teeth that show signs of root resorption before orthodontic tx are at high risk of increased root resorption as a result of orthodontic forces” Levander et al. Eur J Orthod 10:30-38, 1988

“traumatized teeth that show signs of root resorption before orthodontic tx are at high risk of increased root resorption as a result of orthodontic forces” Levander et al. Eur J Orthod 10:30-38, 1988

ROOT FRACTURES FRACTURES INVOLVING:

DENTIN, CEMENTUM, and PULP

ROOT FRACTURES FRACTURES INVOLVING:

DENTIN, CEMENTUM, and PULPHealing Responses to Root

FractureHealing Responses to Root

Fracture Hard Tissue

Formation

Connective Tissue

Bone & Connective Tissue

Granulation Tissue

(non-healing)

Cvek M. et al. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7-17 years. Dent Traumatol 24:379-387, 2008

Cvek M. et al. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7-17 years. Dent Traumatol 24:379-387, 2008

78 % healed with hard tissue formation or interposition of soft tissue between the fragments

Highest frequency of tooth loss occurred in teeth with horizontal fractures in the cervix of the root

Principles of Root Fracture Treatment in Permanent Teeth

Andreasen, et al. Dent Traumatol, 2004

Principles of Root Fracture Treatment in Permanent Teeth

Andreasen, et al. Dent Traumatol, 2004

1) Treat ASAP 2) Reduce displaced fragments 3) Light splint for Middle & apical third 1 monthCoronal third 2 – 4 months

4) Monitor pulp vitality 5) Antibiotics NOT helpful

Bourguignon C. and Sigurdsson A. Preventive strategies for traumatic dental injuries. Dent Clin North Am 53:729-749, 2009.

Bourguignon C. and Sigurdsson A. Preventive strategies for traumatic dental injuries. Dent Clin North Am 53:729-749, 2009.

Mouthguards reported to reduce dental injuries up to 90% in contact sports

Laminated thermoplastic mouthguards are dimensionally most stable

No ethically feasible in vivo models to complete prospective studies

No evidence to support claims that mouthguards prevent neck or cerebral brain injuries

Dealing with “Lost-Cause” Injured TeethAn Introduction to Regenerative EndodonticsDealing with “Lost-Cause” Injured TeethAn Introduction to Regenerative Endodontics

Disadvantages: CaOH ApexificationDisadvantages: CaOH Apexification

Multiple visits over 8 – 16 months

Must achieve hard barrier at apex

Long term CaOH further weakens tooth (Doyon et al. 2005. Andreason J et al. 2002)

High incidence of subsequent root fracture (Cvek M. 1992)

Shabahang S, Torabinejad

M., 2000

Mineral Trioxide Aggregate (MTA)Mineral Trioxide Aggregate (MTA)

High pH (similar to CaOH) Exceptional sealing propertiesHardens within hours enabling canal

obturationNo root wall thickening

Simon S. et al. 2007.

Periapical tissue grows into pulp space of necrotic immature

permanent teeth.

Promotes maturogenesis.

Naturally or can be induced.

Revascularization

Banchs F, Trope M. 2004.

Thibodeau et al. 2007.

Regenerative EndodonticsRegenerative Endodontics Biologically based procedures to replace

damaged structures, including dentin and root structures and cells of the pulp-dentin complex, with live tissues that restore normal physiologic function.

Nygaard-Ostby B. 1961

Murray, et. al, 2007.

• 1950s-60s: Nygaard-Østby – role of blood clot in endo tx• 1950s: Ca(OH)2 used in a case report of vital pulp amputation• 1980-90s: Guided tissue or bone regeneration (GTR, GBR)• 1990s: Distraction osteogenesis • 1990s: Emdogain for periodontal tissue regeneration • 1990s: Recombinant human bone morphogenic protein

(rhBMP) • 2000: Platelet rich plasma (PRP) for bone augmentation • 2000: Fibroblast growth factor 2 (FGF2) for PDL

regeneration

History of Regenerative Dentistry

Tissue EngineeringTissue Engineering

Stem Cells

Signaling Molecules

Scaffolds

Hargreaves, et al. 2008

Murray et al. 2007

Cohen, S. et al.,2010.

Stem CellsStem Cells

Embryonic/fetal Postnatal/adult

Self renewal Proliferation Differentiation

Potency – potential to divide and express cells of different phenotypesPluripotent – embryonic - can differentiate into

endoderm, mesoderm or ectodermMultipotent - postnatal - can form other tissues;

umbilical cord blood, bone marrow, postnatal dental stem cells

Her own stem cells used to build tot a windpipeHer own stem cells used to build tot a windpipe

By Lindsey Tanner

Associated Press• Wednesday May 1, 2013 6:25 AM

CHICAGO — A 2-year-old girl born without a windpipe now has a new one grown from her own stem cells, the youngest patient in the world

to benefit from the experimental treatment.

Dental Stem CellsDental Stem Cells

Dental pulp stem cells (DPSC) differentiate into odontoblast-like cells involved in reparative dentin formation ~1% of pulp cells – decrease in number with age

Stem cells from exfoliated deciduous teeth (SHED) Periodontal ligament stem cells (PDLSC) Stem cells of the apical papilla (SCAP)

different than stem cells in mature tissues superior for hard tissue regeneration – possibly in

development of root dentin

Evoked bleeding triggers significant accumulation of undifferentiated stem cells into the canal space.

Friedlander, et al. 2009Huang, et al. 2008

Lovelace, et al. 2011

SCAPSCAP Essential for continued root development Undergo dentinogenic differentiation

when stimulated Differentiate into functional dentinogenic

cells in vivo, when implanted in animal models (Sonoyama, et al. 2006)

Adipogenic and neurogenic differentiation capabilities when treated with appropriate stimulation medium.

Potential to enable continued root development, pulpal healing and regeneration.

Sonoyama, et al. 2008

Growth FactorsGrowth Factors Proteins that bind to receptors on cells and induce cell proliferation and/or differentiation

Some cell specific - others versatile Many control stem cell activity, e.g. rate of proliferationdifferentiation into another tissue typesynthesis/secretion of mineralized matrix.

BMPs, PDGF, VEGF vascular endothelial growth factor (angiogenic factor), FGF-2

Demineralization of dental tissue can stimulate growth factor release.

Inflammation + and -Mullan, et al. 2008

Friedlander, et al. 2009

Smith, et al. 1995

ScaffoldsScaffolds

Tissues are 3 dimensional and need scaffold to promote cell growth and differentiation.

Bind and localize cells Contain growth factors Biodegrade over time healthy pulp.

Blood clot Platelet-rich plasma - PRP

Hargreaves K. et al. 2008

Biology of the root apexBiology of the root apex

Dental papilla evolves into dental pulp

Inner and outer enamel epithelia fuse to form HERS

As HERS migrates apically, the dental papilla is located apically to the developing pulp and is called the apical papilla.

Sonoyama, et al. 2008

Apical papilla – collateral circulation – maintains vitality

when tooth is necrotic

Removing papilla halts root formation…yet it continues if pulp is extirpated and papilla remains.

Soft, separable from tooth. Histologically, distinct from pulp,

less vascular and cellular.

DisinfectionDisinfection No tissue regeneration if infection. Better success with doxycycline soak. Bacterial biofilm on canal walls,

anatomical recesses, periapical area and dentinal tubules.

Higher level of disinfection needed for immature, infected teeth than mature teeth.

Root canal system infection is polymicrobial.

Combo antibiotics sterilize canal -minimize resistant bacteria

Metronidazole, ciprofloxacin and minocycline effective. Ritter, A. et al. 2004.

Hoshino, E. et al. 1996.Kling M. et al. 1986

Antibiotics (1:1:1)Metronidazole 500mg capCiprofloxacin 200mg capMinocycline 100mg cap

Carrier (1:1)Macrogol ointment Propylene glycol

Antibiotics: Carrier (1:5)

Triple Antibiotic Paste

Hoshino et al. 1996

High concentrations of antibiotics are toxic to SCAPHigh concentrations of antibiotics are toxic to SCAP Ruparel N. et al. Direct effect of intracanal

medicaments on survival of stem cells of the apical papilla. JOE 2012;58:1372-75

Trevino E. et al. Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. JOE 2011;37:1109-15

2 % chlorhexidine is toxic to stem cells2 % chlorhexidine is toxic to stem cells

Indications for RevascularizationIndications for Revascularization

No evidence-based guidelines for case selection

Necrotic immature teeth caused by trauma (caries?)

Apical opening > 1mm to allow ingress of regenerative tissue

Huang G. Journal of Dentistry 2008;36:379-386

Thibodeau B, Trope M. Pediatr Dent 2007;29:47-50.

McTigue D, Subramanian S, Kumar A. Management of immature permanent teeth with pulpal necrosis: a case series. Pediatr. Dent. 2013;35:55-60.

McTigue D, Subramanian S, Kumar A. Management of immature permanent teeth with pulpal necrosis: a case series. Pediatr. Dent. 2013;35:55-60.

32 regenerative endo cases in 28 children

10 teeth presented with sinus tracts

Apical healing occurred in 31 teeth

22 teeth (71%) achieved all root maturation parameters:

Apical closure

Root wall thickening

Root lengthening

Tooth DiscolorationTooth Discoloration

14 teeth discolored

7 discolored using both minocycline and grey MTA

7 teeth discolored with no minocycline and white MTA

11 teeth successfully bleached

Definition of successDefinition of success

Healing of sinus tract

Absence of signs and symptoms

Continued root development –“maturogenesis”

Platelet-rich plasma

Platelet-rich Plasma (PRP)Platelet-rich Plasma (PRP) Contains growth factors

Stimulates collagen production

Recruits other cells to site of injury

Produces anti-inflammatory agents

Initiates vascular growth

Induces cell differentiation

Controls local inflammatory response

Improves soft and hard tissue wound healing

Torabinejad M and Turman M. 2011

PRPPRP

PROEase of applicationShorter time to induce vital tissues within root

canal system.

CONDrawing blood on young patientSpecial equipment & meds to prepare PRPIncreased cost

Future Regenerative EndoFuture Regenerative Endo PRP Apical negative pressure irrigation Autologous post-natal stem cells

injected into teeth in a matrix Pulp implant – pulp tissue grown

in vitro in sheets and implanted surgically

Scaffold implant – pulp cells seeded to 3-D scaffold made of polymers and implanted surgically

Gene therapy – mineralizing genes introduced into vital pulp cells of necrotic and symptomatic teeth da Silva L. et al. 2010

Huang, et al. 2008 Murray, et. al, 2007.

Hargreaves, et al. 200

More Questions than Answers!More Questions than Answers!

“Revascularization” “ Revitalization” “Regeneration”??

Is it pulp…PDL…bone…cementum??? Antibiotics?? CaOH?? Biocompatible irrigants/disinfectants: NaOCl

…chlorhexidine..noni juice..Aquatine EC?? Stem cells?? Immunologic profile? Definition of “Success”?

Complications - ChallengesComplications - Challenges

Adequate Disinfection

Scaffold formation

Staining

Stimulating bleeding

Placing MTA

Bacteria-tight seal

Behavior!!