1

Trauma – Update from Clinical Examples

Paul D. Eleazer

University of Alabama at Birmingham

DDS 1947

Waycross

1

2

4

35

6

78

9

2

Guidelines Guidelines are not guarantees

Guidelines change

Most trauma guidelines are based on anecdotes / “Expert Opinion”

Very few good research projects exist

Background Andreason, Danish oral surgeon - schools

AAE Guidelines – 20032004

Pedo’s are different

Recent lit.

Dentaltraumaguide.org

Exhaustive databaseThousandsSince 1962Great example of EBD

Many categories have few examples

Jens Andreasen, et al.

3

Risk / Prevention Girls fall / Boys fight (sports)

Primary tooth injuries peak @ age 2-3

Permanent tooth injuries peak @ 9-10

Trauma to the oral cavity is a Hugepublic health problem worldwide

Risks

Young

Male

Previous trauma

Crown fracture is most common

Procumbent Anteriors

4

Prevention Helmet with FacemaskMotorcycle trauma

Football

MouthguardDistributes force

May transmit force to spine, brain

Outline AssessmentPhysical Exam

History

Radiography

Head and Neck Exam

Cases

Prognosis / Follow-up visits

MD / Emergency Room Referral

Tetanus – wi/ 5y=OK

C-spine

Swallowed / Aspirated matter

Soft tissue suturing ?

5

Smooth Muscle in Artery will stop bleeding, IF CLEAN CUT

artery

Capillaries and veins continue to bleed

Middle Meningeal ArteryPasses into cranial vault in central base of brain Ragged Tear

6

Brain Movement = Easy to break MMA

Hematoma from ruptured MMA

Brain protein between microtubules ruptures with force

Microtubules inside neurons are paths for chemical transport, protein (tau) between tubules breaks when the brain moves too much and stops suddenly. Neurons lose function(die)

Shenoy, U Penn, Biophys J, 2013

7

MD / Emergency Room Referral

Tetanus – wi/ 5y=OK C-spine Fx Swallowed /

Aspirated matter Soft tissue suturing ? Occipital Artery tear? CSF leak Basilar Skull Fx

Bleeding from ear canal = really bad

Assessment - History

Force- direction and magnitude

Did tooth move? Bleed?

Consider fulcrum for fx.

Soft tissue Tear ?

PDL Compression ?

Root / Bone Fracture ?

8

Assessment – Dental X-rays

Different horizontal and vertical angles

See fx / resorption

Cervical spine views for vertebral fx.

Vertical angle radiographs

Is this a fx?

What about this?

Change vertical angle

9

Assessment – Clinical Exam

Mobility / Percussion (Auscultation) Indicates PDL tear

DisplacementConfirm that root is repositioned

Splint

Pulp tests (negative not reliable)

Discoloration = Intrapulpal Bleed

Foreign material embedded in soft tissue

Validity of Pulp Tests, All Cases

Linda Levin, JEndo 12-09 and Andreasen text 3rded. pp. 196-215

EPT-sensitivity=.71-.93, specificity=.92-.96

Cold – .68-.92 .70-.93

Heat – .68-.86 .41-.81

Laser Doppler 1.0 1.0

May need to wait 6 w. for accurate test (longer?)

+ test early = very good sign

Concussion

Fracture – enamel only; enamel + dentin; crown only; w/ or wo/ pulp exposure

Discolorations

Subluxation and Luxation Intrusion – surgical reposition or orthodontic extrusion

Extrusion – Lateral

Avulsions – Replanted in field, in mouth, in Medium, dry time

Resorptions / Ankylosis

Fractures

Pulpal Regeneration

The Trauma Continuum

10

Cases: Concussion Fractures – crown – root Intrusion Subluxation Luxation Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

Concussion

Check for foreign body in lip / tongue / lung / stomach

Watch for symptoms

Microfracture of enamel ?

Case Study

Courtesy Dr. Jim Tinnin

Love, Endod Dent Traumatol 1996

Concussion can allow bacteria into pulp

16 Intact teeth received impact injury

No visible fracture or luxation

7 had bacteria in pulpConclusion: Micro enamel/dentin infractions

May be wise to seal enamel

11

Concussionsusually heal

BUT, can result in pulp necrosis

Cases: Concussion Fractures – crown – root Intrusion Subluxation Luxation Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

Pulp cap

Pulpotomy

Pulpectomy ______

Soft tissue

Crown Fractureenamel or enamel + dentin,w/ or wo/ pulp exposure

Bonded restoration / Bond piece back on

Pulp Cap (Frank or near exposure)

Pulpotomy

Pulpectomy (Apexification/Apexogenesis)

Pulp prognosis degrades w/

larger exposure, time open, pt’s healing, pulp blood flow

12

Enamel Only Fractures

Dr. Jim Tinnin

BUT #8 Discoloration = Previous Trauma

Enamel and Dentin, Pulp Intact

Dr. Jim Tinnin

Where did the Incisal Edges go? Lip ?

Bacterial ingress into pulp minimal for few days, (extreme thermal pain)

Dr. Jim Tinnin

13

Crown Fx

= energy dissipated

= usually heals

Rule Breaker

Accident history may have disclosed a bodily blow

in addition to enamel fracture

Why Endo ?

Two (+) Blows

Tooth Loose ?

14

Two Blows -#7 and 8 needed endo –#9 healed OK

Get a Good history

Required Endo #7 & 8

Concussion in addition to dentin-enamel fx

Pulp Cap Excellent prognosis

Inflammation at 48 h is 2 mm into pulp

Bacteria invade pulp (superficial)Why wait? Treat ASAP

Calcium hydroxide

MTA

Cvek, JOE 1982

Harran-Ponce,

Dent Tramatol 2002

15

Closed Apex Prognosis (Statistics mean nothing if you are the one)

Pulp cap = 99%

Pulp Prognosis (open apex =10% better)

Pulp OK

Let’s Build a Chart

Pulpotomy Cut to level where bleeding stops by itself

(No vasodilation = no inflammation)

Best wound with water-cooled large round diamond Granath & Hagman

Deep pulpotomy w/ open apex

MTA ?

Max. Time before pulpectomy:

11 days (Andreasen)

External resorption visible microscopically

Apexification vs. apexogenesis (pulp vital)

Conclusion: Pulp tests not reliable

Sooner is better !

11

Pulpectomy

16

Always, Always, Always Use aRubber Dam

File Appendix

Pulp Exposed 4-98, MTA Pulpotomy

Dr. Jim Tinnin

Pulp Still OK @ 40 m.

Dr. Jim TinninAPRIL ‘98AUGUST ‘01

17

Soft Tissue Laceration (multiple small sutures)

Abrasion

Contusion (bruise)

Debride well

Heals better if moist (Neosporin Ointment)

Peridex for intraoral wounds

Neosporin has 3 antibiotics,Ointment stays moist

Neosporin + pain relief swaps bacitracin for local anesthetic

“N” Drugs

Neosporin (Neomycin, Polymyxin B, analgesic)External topical, not absorbed thru skin

Neomycin – absorbed thru m. memb. Nystatin (N.Y.State lab) disrupts fungal

cell walls, topical, oral (not absorbed) Nizoral (ketaconazole) inhibits fungal

sterols, our corticosteroids, oral dosing systemic absorption

antibacterial antifungal

18

Gray Discoloration Acute – Bleeding, may heal (rare)

Chronic – Old bleed, pulp necrosis (likely)

The gray primary tooth of longstandingbleeding intrapulpally

may be necrotic, and thus a risk to succedaneous tooth

What about old trauma ?

Pulp necrosis

Possible damage to 2° t.

Endo ZOE fill absorbs

Stay wi/ canal

Bumped & Discolored = Intrapulpal Bleed

19

Yellow Discoloration

From Andreasen text

Calcific metamorphosis

May take many years for pulp necrosisF. Andreason Eur. DJ 1987 and Jacobsen

JDR 1977 say 1% per year chance of pulp necrosis after calcific metamorphosis

But a serious clinical problem to treat non-surgically

I say: Follow for 1 year, & do endo if canal closing

Yellow Discoloration

Calcific Metamorphosis -typically occurs during 1st year

Why did it abscess ?

Dr. Jason Sayer

20

Calcific Metamorphosis patient- dead stop - note lateral

position of radiolucency

Dr. Jason Sayer

Calcific Metamorphosis patient- note lateral

canal

Dr. Jason Sayer

#8 high school football trauma -Now age 74 and painful74-17 = 57 !

3-4 mm shorter

21

65 y o female #7 painCalcific metamorphosis or deep restoration calcified canal ?

Status of #8?

Bleaching

30% H2O2 is too strong Cases of external

resorption Need to make a seal

at cervical

Sodium perborate Slower Less potential damage

Slightly over bleached, probably will return OK

From Google Images

22

External vs. Internal Bleaching

H2O2 reaches pulp wi. 15 min. (Cooper, JOE, 92) Apparently pulp neutralizes chemical wo/ permanent damage

Sensitivity often increases dramatically (weeks)

Carbamide peroxide = 1/3 of [H2O2]

Heat degrades proteins (not for vital bleach)

Healing = Sometimes a surprise

49 years ago the patient received a trauma to #9, with subsequent pain then drainage. The patient, then a 16 year old girl, refused to allow extraction. The dentist attempted endo, but the drainage persisted for several years (with the patient still refusing extraction).

Eventually the drainage stopped – WHY ?

What killed intracanal bacteria ?

Asymptomatic w/ good bone, but crown fx at age 65, endo thru crown

3 year recall, new crownFirst file size = size at pulpal death

Resorption @ root end

23

Fell and Bumped Chin Traumato Mandibular Anteriors

How Many Need Endo ?

Test Max. too

7 Month Result –

Asymptomatic, Lateral still tests vital

Bone fill beginning

Cases: Concussion

Fractures – crown – root Intrusion Subluxation Luxation Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

24

Crown–Root FractureAuto Wreck

Extract small piece and evaluate

Crown usually prevents this

iatrogenic ?This is very rare

Horizontal position = fx. after crown

25

Root FractureAngle and Force of Blow Level of Fracture ?Mobility ? Splint 3-4 weeks or more Hope for cementum “callus” Post that lutes two pieces ?

avoid cement into bone

Some Possible Fractures

Cusp Fx. Incomplete Fx. Hopeless Do these exist ?

Fractured from apex:Natural or Spreader ?

26

Mobility Issue

Dr. Chris Fleming

Apical segment did not move, and is likely vital

When to debride pulp ?

Do MTA to fracture ?

Move broken part in and splint

Horizontal Root Fx.Usually apical segment is vitalAvoid cement in fracture line

Severe Inflammation

Old Trauma, Failed Pulp Cap

Dr. Jim TinninCa(OH)2 x 6 m

G-P Fill @ 6 m

External Resorption

27

Cut threads is apical segment and draw coronal part tight

Minimal threads needed

Seal canal w. MTA slurry ?

Treatment for Crestal Level Fx.or Intrusion of whole tooth

Surgical extrusion

Orthodontic extrusion

Implant

28

Bone Crest is least favorable root fracture

Kerbl & Eleazer

Root FractureTraumatic decoronation #22

Kerbl & Eleazer

Cases: Concussion Fractures – crown – root

Intrusion Subluxation Luxation Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

29

Intrusion Very poor pulpal prognosis

High risk to succedaneous tooth

Surgical extrusion

Orthodontic Extrusion

Antibiotic(s) in canal may decrease ext. root resorption

Prognosis Pulp Prognosis is Based on:Time of compression of vessels (1-2 hours ?)

Root Prognosis is Based on:Damage to cementum / PDL and infection

Intrusion Controversy Andreasen says pulpal necrosis almost

100% External resorption highly likely.

My dental school: Let it re-erupt

Saroglu (OOO2006 – 102(4):e60-5.

5 cases of permanent teeth w/ open apexes that spontaneously re-erupted

30

Let it Re-erupt ?Wigen (Dent Traumatol 2008)

35 of 37 primary teeth re-erupted in 3-12 months

7 forcefully erupted w/ surg and 7 w/ ortho

43% remained vital @ 4 y. (range 1-12y)

Cunha (Endodont Dent Traumatol 1995)

Severe blow in dog deep intrusion

All re-erupted wi/2 months

O.R. Case - Intrusion, Surgical Access to Linguals Dr. Brad Alley 9-04 8 w post trauma, Mixed Dentition = no ortho extrusion

Open Apexes

MTA Fills

Bradley Alley 9-04

31

O.R. Case Bradley Alley 9-04MTA Fills

Orthodontic Extrusion

Endo

Post w/ hook

(cut trans-septal fibers)

Elastic traction to ortho wire (1 week)

Stabilize (1 month)

Ortho wire allows direct extrusive force from hook cemented in canal

32

Elastic in position

Ortho Extrusion - 5 mm in 1 m.

Dr. Mark Essner

Ortho Extrusion

Gingivectomy to allow pulpectomy

Courtesy Dr. Frank Kerbl

33

Cases: Concussion Fractures – crown – root Intrusion

Subluxation – Luxation Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

Moved, but back in place by itself

= PDL tear

Subluxation (PDL tear, moves back into position)

Check occlusion

Splint (none / light for 7-10 days)

Pain pills (NSAIDs)

Soft diet

CHX rinse bid

Case Study

Sub-Luxationor

Luxation

Note Wide PDL

Is Occl. OK?

34

Closed Apex Prognosis (Statistics mean nothing if you are the one)

Pulp cap = 99%

Concussion = 90%

Subluxation = 75% -Calcif. Meta.10% 20%

Pulp Prognosis (open apex =10% better)

Pulp OK

Resorption / PDL

Cases: Concussion Fractures – crown – root Intrusion Subluxation

Luxation - Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

Still out of place,

? Blood supply

Lateral, Extrusion,

Intrusion

Luxation(Moved but still in socket)

Check occlusion

Splint (none / light for 7-10 days)

Pain pills (NSAIDs)

Soft diet

CHX rinse bid

35

Luxations Lateral luxation Intrusive luxation Extrusive luxation

Splint lightly for 1-2 w.Some mobility prevents ankylosis

Bone fracture needs more stability x 6-8 w.

Splint Maybe no splint

Light, brief = reduce ankylosis w/ movementBond wire or heavy fishing line

Titanium mesh

Attach to firm teeth first, traumatized one last

Splint 3-4 weeks (longer)(more rigid) for alveolar fx or mid-root fx (avoid cement in fx.)

If you MUST

Not like this !

36

Attach wire to sides, then lute avulsed teeth

Debride canals ASAP, Splint for 10 days, Ca(OH)2 for ___

TTS Titanium mesh splintAdatia & Kenny J Cal Dent Assoc 2006

Von Arx et al Dent Traumatol 2001

Patterson Dental $47.00

Medartis

37

Estimate Force, DirectionFacial plate fractured & root trapped

Pressure may result in resorption, or fracture

Must pull down to reposition

How far will pulpal vessels stretch before rupturing?

About 2 mm

Can vessels ends rejoin ?Maybe, but rare

Plan on Endo if moved >2 mm, dying pulp has NO BENEFIT,

remove ASAP

38

Closed Apex Prognosis (Statistics mean nothing if you are the one)

Pulp cap = 99%

Concussion = 90%

Subluxation = 75% - Calcif. Meta. 10% 20%

Extrusion = 15% - Calcif. Meta. 60% 20%

Lateral lux. = 10% - Calcif.Meta. 60% 30%

Alveolar fx. = 10% 100%

Intrusion = 0%??? 100%

Root Fx. = varies – PDL/resorption 60%

Pulp Prognosis (open apex =10% better)

Pulp OK

Resorption / PDL

Cases: Concussion Fractures – crown – root Intrusion Subluxation Luxation

Avulsion Resorption Ankylosis Bone fracture Pulp Regeneration

Avulsion = out of socket

Replanted in field

In milkSaliva

Saline

Gatorade

Out , 30 min. (AAE: 1 hour)

Dry > 30 min. (AAE: 1 hour)

39

Replant Permanent Teeth

If not out too long

If not mistreated (Kleenex)

Tetanus

Antibiotics

Splint briefly50% PDL strength @ 2 w

100% PDL strength @ 8 w.

Avulsions: Clot in socketRemove gently or Not (do not damage PDL)

Open apexDry > 1 h. = generally not rec. to replant

Closed apexEndo for sure

Pulpectomy ASAPAntibiotics + corticosteroid in canal

Avulsed Primary teeth

Do not replant due to damage to succedaneous t.

Tooth may already be damaged

Infection may aid / cause resorption

40

Primary tooth injury can impact tooth bud Study force

Treat before infected

Generally, extract damaged primary tooth

Primary Tooth Luxated / Avulsed = Leave It Out

Dr. Jim Tinnin

This is a Problem !Permanent Teeth Avulsed in Mixed Dentition

Dr. Jim Tinnin

41

Best Case Avulsion Replanted in fieldHold by crown, rinse, replant (even backward)

Light splint x 7-10 days (No splint)

Endo ASAP

Antibiotic / Tetanus (TIG / booster after 5 y. / q 10 y for all)

50% PDL strength @ 2 w (100%@8w) Mandell

Avulsed Tooth “high”

Compress clot, maintain pressureMay need splint

Occlusal adjustment

2nd best In mouth

Saliva is good

Hold in mouth (Do not swallow)

Antibiotic

Tetanus

42

In transport medium Via-Span

Hank’s Balanced Salts solution

Milk

Physiologic saline

Antibiotic

Tetanus

Cases: Concussion Fractures – crown – root Intrusion Subluxation Luxation Avulsion

Resorption - Ankylosis Bone fracture Pulp Regeneration

Internal – External

Replacement – Inflamm.

Long time Out, Dry Case of long dry time (Kleenex)(1/2 to 1 h)Strip PDL to minimize foreign body rejectionSoak in fluoride to retard resorption

Bisphosphonate ? Emdogain, GEM 21, other growth enhancer(s) Load canal w/ calcium hydroxide / iodoform

AntibioticTetanus

43

Straumann Emdogain

Made from pig tooth buds in Sweden

Works nicely in perio

Again available in USUS FDA banned in 2007 until factory passed

inspection

Chemically remove smear layer and apply to root

1-800-448-8168

Growth- Factor Enhanced Matrix 21s

GEM 21s Osteohealth – 631-924-4000

Recombinant Platelet-Derived Growth Factor (rhPDGF-BB), and a synthetic bone matrix, Beta-tricalcium phosphate (ß-TCP)

FDA approved (2006) for perio regeneration

TraumaticExtrusion time

Extruded 1 month ago

Pulp #8 test vital to cold and EPT

Splint ? Occlusion ?

Case Study

44

Oblique Fracture

X-Trac Device1. Drill canal to size

2. Thread in self tapping screw

3. Place plate over tap-screw

4. Apply pressure w/ jack screw

A-Titan Instruments $2500.00

877-284-8261 Hamburg, NY

Implant

Bone Graft at 6 w.

45

Resorption – need break in pre-dentin / pre-cementum

Internal External

Inflammatory Replacement (ankylosis)

Osteoclasts activated by inflammation

Problem: Damage from trauma or forceps to reposition tooth

Replacement Resorption(Ankylosis)

Poor Prognosis

Body “sees” dentin as bone

Rapid External Resorption

Ca(OH)2 in canals failed on #7. Note crestal bone loss.

Inflammation 2 weeks after Ca(OH)2

Concussion from Horse Kick

46

Note Irregular Outline of Pulp w/ External Resorption

Internal Resorption – Excellent Prognosis – Did not Perforate to PDL Blood Supply

Internal resorption May have begun externally

True internal resorption has excellent prognosis if treated before perf. into PDL

? Prognosis

47

Perforated facial of root = must do surgery, perio defect

Geristore is best bet

Geristore

Dual Cure

Hybrid Ionomer-Composite

Very biocompatible

DenMat

Also need Etchant, Primer, Clear Matrix Strips, Finishing Instruments (#12 Blade, Burs, Sanding Strips)

Geristore for external resorption

48

External ResorptionMay need a Cone Beam

External Resorption at Epithelial Attachment, Extr. by Dr. Geurs

Extensive weakening of tooth

49

Clinical Crown Esthetically bonded in Position - Dr. Liu

Not like ortho resorption

Almost always limited to apex

Stops when force stops

# 9 at 2 weeks after avulsion

External Resorption

(Inflammatory)

Note #9 shorter than #8, perhaps a prior trauma ?

50

Reduce Resorption Calcium hydroxide

Penicillin (Hammarstrom, Endo. Dent. Traumatol 1986;2:51-3)

Tetracycline (Selvig, Scand JDR 1992;100(4):200-3)

Stannous Flouride (ibid.)

Corticosteroid (Trope,J Endo 2009;35:663-7)

Calcium Hydroxide Decreases resorptionCounteracts osteoclast’s HCl

Coagulation necrosis = stimulates osteoid

Ca45 shows new calcium not from Ca(OH)2

Antibacterial

But it Weakens dentin (White JOE 2002)

& Kills bone and nerve

Calcium Hydroxide Needs a second germicide

Sigma-Aldrich

800-558-9160

#10,945-2 $10.40/5g

50-50 Iodoform & Ca(OH)2

51

We have grown E. faecalisin Calcium hydroxide

2004 UAB Study Chris McHugh: E. faecalisgrows in pH 11

Commercial preparations pH 10 USP Ca(OH)2 pH 12 2012 UAB Study Jason Latham: E. faecalis

grows in Calasept (pH 12+)First growth after 4 m, now adapted and grows

faster

Dangers-

Ca(OH)2

Ahlgren OOO 2003

Other Calcium Hydroxide Overfill Accidents

Sharma, OOO, May ‘08

52

Calcium hydroxide is dangerous

Lindgren, J Oral Maxillofac Surg ‘02

Clorox accident

JADA 2000

External Resorption

53

Stannous Fluoride + Doxycycline

Selvig Scand J Dent Res 1992;100:200-3.

Hx: 1% SnF2 chron. inflam. resorption/ankylos

Exp: dog teeth extracted, dry for 45 min.,

0.1% SnF2 x 5 min, then 1% doxy. X 5 min.,

85% root surface OK @ 4 w.

(control 33%)

Dilute Stannous Fluoride caused less cell damage, while enhancing healing

Corticosteroid in canal

Kirakozova…Trope JOE 2009;35:663-7.

Dog teeth 60 min. dry

outcome measure: pdl healing

0.05% clobetasol intracanal 56% healed OK

0.05% fluocinonide 32%OK

control 14% OK

No systemic c/s

My Thought Bacteria wi/ tubules may be cause of

resorption

Calcium hydroxide does not kill all bacteria (E. faecalis)

Need second germicide to boost Ca(OH)2

I favor 50:50 w. IodoformVitapex has 22% silicone oil

54

Cases: Concussion Fractures – crown – root Intrusion Subluxation Luxation Avulsion Resorption

Ankylosis Bone fracture Pulp Regeneration

Ankylosis Sound (Auscultation)

Only part of PDL may ankylose

Block repositioning may work

Endodontic Endosseous Stabilizer Tri-Lock™ Endodontic Titanium ImplantsPark Dental Research, NYC

Al Frank (Dent Clin N AM – 1967)

Courtesy: Dr. Robert Barfield – healing @ 2-3 y, failed at 6 y –angled out buccal

55

Cases: Concussion Fractures – crown – root Intrusion Subluxation Luxation Avulsion Resorption Ankylosis

Bone fracture Pulp Regeneration

Fractured alveolus Several teeth move

Obvious on x-ray

More rigid splint x 3-4 weeks or more

Intermaxillary fixation (vomiting danger)

Displaced apex (to labial)

Case Study

Easily Diagnosed – Two teeth in alveolus, held by soft tissue

Courtesy Dr. Cody Nelson

56

Bridal wire applied from #’s 9 – 11 to re-approximate bone

Courtesy Dr. Cody Nelson

2008 Trampoline, 3 teeth pushed back w. alveolar fx. & splinting

2010 2 pulps died, why not 3?

Frequency of Mandibular Fractures

Deviation TO side of fx when opening

57

Alveolar Fx. – mixed-dentitionremovable/compos. splint

4-01

CourtesyDr. Steve Clark

4 teeth Move Together

6 m post, good color, EPT?

CourtesyDr. Steve Clark

1 1/3 y post = AOK

Note: Calcif. #26 canal

CourtesyDr. Steve

Clark

58

3 year post-trauma

Still asympt.Good color#26 calcif.

Courtesy Dr. Steve Clark

Cases: Concussion

Fractures – crown – root

Intrusion

Subluxation

Luxation

Avulsion

Resorption

Ankylosis

Bone fracture

Pulp/PDL Regeneration

Pulp Regeneration- need 1.1 mm open apex

1. Chemically debride necrotic pulp cells

2. Place antibiotic mixture in canal

3. Observe for signs of troubleMetronidazole

Clindamycin

Minocycline

Case Study

Thibodeau…Trope JOE 2007;33:680-9.

Wang…Trope…Huang JOE 2010;36-56-63.

59

Current Thinking for Pulp Regen.

ASAP: NaOCl debridement, instrumentation to min.110 file Dry Triple antibiotic paste (consider omitting tetracycline)

2 w. later: Saline irrigation of canal (Essner- 0.04% NaOCl = highest concentration wo/ cell

death) Induce bleeding from pulp stump (STEM CELLS) Preserve CLOT at mid root level Gently apply MTA over clot

George T-J. Huang

SCID Mice

Human roots – 6 mm long – implanted SQcanals reamed to 2 mm

1 mm of an end plugged w/ MTA

5 mm wide, open canal space

Human stem cells planted in pulp turned into pulp, with working odontoblasts on dentin

Huang et al. Tissue Eng Part A 2010 Feb;16:605-15.

Tissue Engineering:Place PDL cells on Dry Tooth

Dog: tooth extracted, PDL cells stripped and into culture medium (pulp extirpated), pulp left in dry isolation

PDL cells grow and reproduce x 30 days

PDL cells painted on root and replanted

PDL reformed (control = ankylosis & resorption)

Wang, JOE Feb. 2010

60

Cryopreservation

Magnetic cryopreservationSLOW FREEZING IN A WEAK MAG. FIELD

73% preservation of cells (5 generations of normal reproduction after thawing)

Lee JOE Aug 2010

Prognosis – Follow-ups

Ins. Co. attorney wants legal release

Test adjacent teeth Pulp cap is best bet

Closed Apex Prognosis (Statistics mean nothing if you are the one)

Pulp cap = 99% Concussion = 90%

Subluxation = 75% - Calcif. Meta. 10% 20%

Extrusion = 15% - Calcif. Meta. 60% 20%

Lateral lux. = 10% - Calcif.Meta. 60% 30% Alveolar fx. = 10% 100% Intrusion = 0%??? 100% Root Fx. = varies – 60%

Pulp Prognosis (open apex =10% better)

Pulp OK Resorption / PDL

61

Follow-ups, AAE 2013 Guidelines

Luxated permanent teeth

2 w

4 w

6-8 w

6 m

12m

yearly x 5 y

Avulsed perm. teeth

Endo @ 7-10 d

2 w

4 w

3 m

6 m

yearly x 5 y

Fx permanent teeth, bony fx.• 4 w• 6-8 w• 4 m• 6 m• 12 m• Yearly x 5 y

Splint (light)only if mobile, remove at 10 d-2 wBony Fx and high root fx, splint (rigid)4 m.

Gather Your Armamentarium Now

Splint: material, bonding

Suture

Root therapy: 2.4% sodium fluoride, Emdo-Gain, GEM21

Canal therapy: Ca(OH)2, other disinfectant, c/s, bisphosphonate

Triple Antibiotic PasteMetronidazole, Clindamycin, Minocycline (?)

Summary

Determine direction/ amount of force

C-spine x-rays, etc.

Tetanus

Antibiotic

X-ray/palpate lip/cheek/tongueWhere is the broken piece ? Lung x-ray

Multiple x-rays of roots

Wiggle one tooth / Do others move ?

Occlusion

Soft diet

Follow-up

Don’t Forget the Whole Body !

62

SummaryWhat was the direction and concentration of force?Did a fracture dissipate some force?

Think at the microscope levelWhat are the cells doing?Can the cementum reform?

What is the healing timeline?PDL mends in 6-8w.

What is the blood supply like?

Disclaimer

These are current guidelines Not guarantees

Guidelines are NOT Absolutes