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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 Crown-Root FracturesCrown-Root 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 2-3 Rigid splinting for 2-3
monthsmonths
Emergency ManagementEmergency Management
Previous Previous recommendationrecommendation– Rigid splinting for 2-3 Rigid splinting for 2-3
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 - 7 to 11Most common age - 7 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 theAvulsed 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, Hjorting-Hansen E.Andreasen JO, Hjorting-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;24:287-306.Acta Odontol Scand 1966;24:287-306.
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% resorption 10% resorption> 90 min > 90 min 90% resorption 90% resorption
Andreasen JO, Hjorting-Hansen E.Andreasen JO, Hjorting-Hansen E.Replantation of teeth I. Radiographic and clinical Replantation of teeth I. Radiographic and clinical
study study of 110 human teeth replanted after accidental loss.of 110 human teeth replanted after accidental loss.Acta Odontol Scand 1966;24:263-86.Acta Odontol Scand 1966;24:263-86.
Extraoral TimeExtraoral Time
Shorter time = Better prognosisShorter time = Better prognosis**< 30 min < 30 min 10% resorption 10% resorption> 90 min > 90 min 90% resorption 90% resorption
**depending on storage mediumdepending on storage medium
Andreasen JO, Hjorting-Hansen E.Andreasen JO, Hjorting-Hansen E.Replantation of teeth I. Radiographic and clinical Replantation of teeth I. Radiographic and clinical
study study of 110 human teeth replanted after accidental loss.of 110 human teeth replanted after accidental loss.Acta Odontol Scand 1966;24:263-86.Acta Odontol Scand 1966;24:263-86.
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 extra-alveolar period and storage media Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after upon periodontal and pulpal healing after
replantation replantation of mature permanent incisors in monkeys.of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43-53.Int J Oral Surg 1981;10:43-53.
Poor Poor resultsresults
Storage MediaStorage Media
Tap WaterTap Water DryDry Saliva Saliva SalineSaline
Andreasen JO.Andreasen JO.
Effect of extra-alveolar period and storage media Effect of extra-alveolar period and storage media upon 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;10:43-53.Int J Oral Surg 1981;10:43-53.
Good Good protection for protection for
2 hrs2 hrs
Poor Poor resultsresults
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 - Milk vs. SalivaStorage Media - Milk 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;62:912-6.J Dent Res 1983;62:912-6.
Storage Media - Milk vs. SalivaStorage Media - Milk 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 resorption extensive replacement resorption– Milk Milk healing almost as good as immediate replant healing almost as good as immediate replant
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;62:912-6.J Dent Res 1983;62:912-6.
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 hrs)Good for extended storage periods (72 and 96 hrs)
Trope M, Friedman S.Trope M, Friedman S.Periodontal healing of replanted dog teeth Periodontal healing of replanted dog teeth
stored stored in Viaspan, milk and Hank’s balanced salt in Viaspan, milk and Hank’s balanced salt solution.solution.
Endod Dent Traumatol 1992;8:183-8.Endod Dent Traumatol 1992;8:183-8.
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 hrs)Good for extended storage periods (72 and 96 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 Periodontal healing of replanted dog teeth
stored stored in Viaspan, milk and Hank’s balanced salt in Viaspan, milk and Hank’s balanced salt solution.solution.
Endod Dent Traumatol 1992;8:183-8.Endod Dent Traumatol 1992;8:183-8.
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;6:506-8.J Endodon 1980;6:506-8.
Root Surface ManipulationRoot Surface Manipulation
Extraoral dry timeExtraoral dry time determines handling determines handling
Root Surface ManipulationRoot Surface Manipulation
Extraoral Extraoral drydry time time << 1 hr 1 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 hr time > 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
1.0-2.4% topical 1.0-2.4% 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• Cross-sutureCross-suture
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– 20-30 lb 20-30 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 teeth.A functional splint for traumatized teeth.J Endodon 1982;8:328-31.J Endodon 1982;8:328-31.
Cross-Suture SplintCross-Suture Splint
IndicationsIndications– No adjacent teeth to No adjacent teeth to
splint tosplint to– Unmanageable Unmanageable
traumatized childrentraumatized children
Cross-Suture SplintCross-Suture 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 The effects of different splinting splinting times on times on replantation of teeth in replantation of teeth in monkeys.monkeys.
Oral Surg 1982;53:557-66.Oral Surg 1982;53:557-66.
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 The effects of different splinting splinting times on times on replantation of teeth in replantation of teeth in monkeys.monkeys.
Oral Surg 1982;53:557-66.Oral Surg 1982;53:557-66.
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 Kling M, et al. Endod Dent Traumatol 1986;2:83-9. 1986;2:83-9.
Andreasen JO, et al. Endod Dent Traumatol Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.1995;11:51-8.
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 18-34%Revascularization 18-34%
Kling M, et al. Endod Dent Traumatol Kling M, et al. Endod Dent Traumatol 1986;2:83-9. 1986;2:83-9.
Andreasen JO, et al. Endod Dent Traumatol Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.1995;11:51-8.
RevascularizationRevascularization
Loss of blood Loss of blood supply to pulpsupply to pulp
Revascularization – Day 4Revascularization – Day 4
Coronal pulpCoronal pulp– Extensive ischemic Extensive ischemic
injuryinjury
Revascularization – Day 4Revascularization – Day 4
Coronal pulpCoronal pulp– Extensive ischemic Extensive ischemic
injuryinjury
Apical pulpApical pulp– Initial revascularizationInitial revascularization
Revascularization – 4 WeeksRevascularization – 4 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;59-68.Endod Dent Traumatol 1995;11;59-68.
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;59-68.Endod Dent Traumatol 1995;11;59-68.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.Endod Dent Traumatol 1995;11;59-68.
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;59-68.Endod Dent Traumatol 1995;11;59-68.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.Endod Dent Traumatol 1995;11;59-68.
Pulpal Prognosis - AntibioticsPulpal Prognosis - Antibiotics
Systemic antibioticsSystemic antibiotics– Pulp Pulp
revascularization is revascularization is not increasednot increased
Cvek M, Cleaton-Jones P, Austin J, Lowni J, Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling M, Fatti P. Kling M, Fatti P.
Endod Dent Traumatol 1990;6:157-69.Endod Dent Traumatol 1990;6:157-69.
Cvek M, Cleaton-Jones P, Austin J, Lowni J, Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling M, Fatti P. Kling M, Fatti P.
Endod Dent Traumatol 1990;6:157-69.Endod Dent Traumatol 1990;6:157-69.
Pulpal Prognosis - AntibioticsPulpal Prognosis - Antibiotics
Systemic antibioticsSystemic antibiotics– Pulp Pulp
revascularization is revascularization is not increasednot increased
Topical antibioticsTopical antibiotics– Beneficial effectBeneficial effect
Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.Endod Dent Traumatol 1990;6:170-6.
Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.Endod Dent Traumatol 1990;6:170-6.
Pulpal Prognosis - AntibioticsPulpal Prognosis - Antibiotics
Topical DoxycyclineTopical Doxycycline– Decreased microorganisms in Decreased microorganisms in
pulpal lumenpulpal lumen– Increased pulp Increased pulp
revascularizationrevascularization
Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.Endod Dent Traumatol 1990;6:170-6.
Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.Endod Dent Traumatol 1990;6:170-6.
Pulpal Prognosis - AntibioticsPulpal Prognosis - Antibiotics
RecommendationRecommendation– Topical DoxycyclineTopical Doxycycline
» 1 mg in 20 ml physiologic saline1 mg in 20 ml physiologic saline» 5 minute soak5 minute soak
Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.Endod Dent Traumatol 1990;6:170-6.
Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.
Endod Dent Traumatol 1990;6:170-6.Endod Dent Traumatol 1990;6:170-6.
Endodontic RationaleEndodontic Rationale
Mature root - 4 weeksMature root - 4 weeks– Very limited Very limited
revascularizationrevascularization
Endodontic RationaleEndodontic Rationale
Mature root - 4 weeksMature root - 4 weeks– Very limited Very limited
revascularizationrevascularization– Ischemic coronal pulp with Ischemic coronal pulp with
great risk of infection !!!great risk of infection !!!
Endodontic Rationale – Mature Endodontic Rationale – Mature RootRoot
Pulpectomy Pulpectomy 7-14 days 7-14 days
Endodontic Rationale – Mature Endodontic Rationale – Mature RootRoot
Calcium hydroxideCalcium hydroxide placement placement
Endodontic Rationale – Mature Endodontic Rationale – 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 pH changes in dental tissues
after after root canal filling with calcium root canal filling with calcium hydroxide.hydroxide.
J Endodon 1981;7:17-21.J Endodon 1981;7:17-21.
Endodontic Rationale – Mature Endodontic Rationale – Mature RootRoot
Treatment recommendationTreatment recommendation– Ca(OH)Ca(OH)22 therapy for as long as therapy for as long as
practical, usually 6-12 monthspractical, usually 6-12 months
Treatment of the Avulsed Treatment of the Avulsed Permanent Tooth.Permanent Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Treatment of the Avulsed Treatment of the Avulsed Permanent Tooth.Permanent 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 Tooth.Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Recommended Guidelines of the American
Association of Endodontists, 1995.Association of Endodontists, 1995.
Specific Treatment RegimenSpecific Treatment Regimen
Root DevelopmentRoot Development Closed apexClosed apex Open apexOpen apex
Extraoral Extraoral DryDry Time Time One hour or lessOne hour or less More than one hourMore than one hour
Treatment of the Avulsed Treatment of the Avulsed Permanent Tooth.Permanent Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Treatment of the Avulsed Treatment of the Avulsed Permanent Tooth.Permanent Tooth.
Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.
Treatment FlowchartTreatment Flowchart
<< 1 hr 1 hr > 1 hr> 1 hr
ExtraoralExtraoral Dry Dry TimeTime
Apex MaturityApex MaturityClosedClosed OpenOpen Open or ClosedOpen or ClosedPulpectoPulpectomy7-14 my7-14
daysdays
ObservObservee
OptionOption: : Extraoral Extraoral
RCTRCT
PulpectoPulpectomy 7-14 my 7-14
daysdays
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 Tetanus: Prevention and
treatment.treatment.J Am Med Assoc 1978;240:675-J Am Med Assoc 1978;240:675-
6.6.
Rothstein RJ, Baker FJ.Rothstein RJ, Baker FJ.Tetanus: Prevention and Tetanus: Prevention and
treatment.treatment.J Am Med Assoc 1978;240:675-J Am Med Assoc 1978;240:675-
6.6.
Emergency TreatmentEmergency Treatment
Additional ConsiderationsAdditional Considerations– AnalgesicsAnalgesics– ChlorhexidineChlorhexidine– TetanusTetanus– AntibioticsAntibiotics
AntibioticsAntibiotics
PenicillinPenicillin– 500 mg qid for 4-7 days500 mg qid for 4-7 days
Andreasen JO.Andreasen JO.Atlas of replantation and Atlas of replantation and
transplantation of transplantation of teeth.teeth.Philadelphia: W.B. Saunders Co., Philadelphia: W.B. Saunders Co.,
1992;57-1992;57- 92.92.
AntibioticsAntibiotics
Tetracycline vs. amoxicillin Tetracycline vs. amoxicillin in a replacement resorption modelin a replacement resorption model
– Tetracycline had better anti-resorptive propertiesTetracycline had better anti-resorptive properties
Sae-Lim V, Wang CY, Choi GW, Trope M.Sae-Lim V, Wang CY, Choi GW, Trope M.
The effect of systemic tetracycline on The effect of systemic tetracycline on resorption of resorption of dried replanted dogs’ teeth.dried replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:127-32.Endod Dent Traumatol 1998;14:127-32.
AntibioticsAntibiotics
Tetracycline vs. amoxicillin Tetracycline vs. amoxicillin in an inflammatory root resorption modelin an inflammatory root resorption model
– Tetracycline had better anti-bacterial propertiesTetracycline had better anti-bacterial properties
Sae-Lim V, Wang CY, Trope M.Sae-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 inflammatory root resorption of replanted
dogs’ teeth.dogs’ teeth.
Endod Dent Traumatol 1998;14:216-20.Endod Dent Traumatol 1998;14:216-20.
AntibioticsAntibiotics
RecommendationRecommendation– ““Tetracycline could be considered as an alternative to Tetracycline could be considered as an alternative to
amoxicillin after avulsion injuries.”amoxicillin after avulsion injuries.”
Sae-Lim V, Wang CY, Trope M.Sae-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 inflammatory root resorption of replanted dogs
teeth.teeth.
Endod Dent Traumatol 1998;14:216-20.Endod Dent Traumatol 1998;14:216-20.
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 7-10 day prescriptionRemote possibility with 7-10 day prescription
Sae-Lim V, Wang CY, Trope M.Sae-Lim V, Wang CY, Trope M.Effect of systemic tetracycline and amoxicillin Effect of systemic tetracycline and amoxicillin
on on inflammatory root resorption of replanted dogs’ inflammatory root resorption of replanted dogs’ teeth.teeth.
Endod Dent Traumatol 1998;14:216-20.Endod Dent Traumatol 1998;14:216-20.
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 time time Follow AAE GuidelinesFollow AAE Guidelines
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