Trauma – Update from Clinical Examples

Trauma – Update
from Clinical
Examples
Paul D. Eleazer
University of Alabama at
Birmingham
DDS
1947
Waycross
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7
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9
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4
1
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 – 20032004
 Pedo’s are different
 Recent lit.


Dentaltraumaguide.org

Exhaustive database
 Thousands
 Since
 Great
1962
example of EBD
Many categories have few
examples
 Jens Andreasen, et al.

2
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 Huge
public health problem worldwide
Risks
Young
 Male
 Previous trauma
 Crown fracture is most
common
 Procumbent Anteriors

3
Prevention

Helmet with Facemask
 Motorcycle
trauma
 Football

Mouthguard
 Distributes
 May
force
transmit force to spine, brain
Outline

Assessment
 Physical
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 ?

4
Smooth Muscle in Artery will
stop bleeding, IF CLEAN CUT

artery
Capillaries and veins continue
to bleed
Middle Meningeal Artery
Passes into cranial vault in central
base of brain
Ragged Tear
5
Brain Movement = Easy to break
MMA
Hematoma from ruptured MMA
Brain protein between
microtubules ruptures with force
Shenoy, U Penn,
Biophys J, 2013
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)
6
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 ?
7
Assessment
– Dental X-rays

Different horizontal
and vertical angles

Cervical spine
views for vertebral
fx.

See fx / resorption
Vertical angle
radiographs
Is this a fx?
What about this?
Change
vertical angle
8
Assessment – Clinical Exam

Mobility / Percussion (Auscultation)

Displacement
 Indicates
 Confirm
PDL tear
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
The Trauma Continuum
 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
/ Ankylosis
 Resorptions
 Fractures
 Pulpal
Regeneration
9
Cases:
 Concussion
Fractures – crown – root
 Intrusion
 Subluxation
 Luxation
 Avulsion
 Resorption
 Ankylosis
 Bone fracture
 Pulp Regeneration

Case Study
Concussion
Courtesy Dr. Jim Tinnin
Check for foreign
body in lip / tongue /
lung / stomach
 Watch for symptoms
 Microfracture of
enamel ?

Concussion can allow
bacteria into pulp
Love, Endod Dent Traumatol 1996
16 Intact teeth received impact injury
No visible fracture or luxation
7 had bacteria in pulp
Conclusion: Micro enamel/dentin infractions
May be wise to seal enamel
10
Concussions
usually heal
BUT, can
result in pulp
necrosis
Cases:
Concussion
Fractures – crown – root
 Intrusion
Pulp cap
 Subluxation
Pulpotomy
 Luxation
Pulpectomy
 Avulsion
______
 Resorption
Soft tissue
 Ankylosis
 Bone fracture
 Pulp Regeneration


Crown Fracture
enamel 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
11
Enamel Only Fractures
BUT #8 Discoloration = Previous Trauma
Dr. Jim Tinnin
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
12
Crown Fx
= energy
dissipated
= usually
heals
Rule Breaker
Why Endo ?
Accident history
may have
disclosed a
bodily blow
in addition to
enamel fracture
Two (+)
Blows
Tooth
Loose ?
13
Two Blows #7 and 8
needed endo
–
#9 healed OK
Get a Good history
Concussion in
addition to
dentin-enamel fx
Required
Endo #7 & 8
Pulp Cap
Excellent prognosis
Inflammation at 48 h is 2 mm into pulp Cvek, JOE 1982
Harran-Ponce,
 Bacteria invade pulp (superficial) Dent Tramatol 2002


 Why
wait? Treat ASAP
Calcium hydroxide
 MTA

14
Let’s Build a Chart
Closed Apex Prognosis (Statistics
mean nothing if you are the one)
Pulp OK

Pulp cap = 99%
Pulp Prognosis (open apex =10% better)
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 ?

Pulpectomy
Max. Time before pulpectomy:
11 days
11
(Andreasen)
Sooner is better !
External resorption visible microscopically
Apexification vs. apexogenesis (pulp vital)
 Conclusion: Pulp tests not reliable


15
Always,
Always,
Always
Use a
Rubber
Dam
File
Appendix
Pulp Exposed 4-98, MTA Pulpotomy
Dr. Jim Tinnin
Pulp Still OK @ 40 m.
APRIL ‘98
Dr. Jim Tinnin
AUGUST ‘01
16
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
antibacterial

antifungal
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

17
Gray Discoloration


Acute – Bleeding, may heal (rare)
Chronic – Old bleed, pulp necrosis (likely)
The gray primary tooth of longstanding
bleeding intrapulpally
may be necrotic, and thus a risk to succedaneous tooth
What about old trauma ?
Pulp necrosis
Possible
damage to 2° t.
 Endo


 ZOE
 Stay
fill absorbs
wi/ canal
Bumped & Discolored =
Intrapulpal Bleed
18
Yellow Discoloration
From Andreasen text
Calcific metamorphosis

May take many years for pulp necrosis
 F.
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 nonsurgically
 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
19
Calcific
Metamorphosis
patient
- dead stop
- note lateral
position of
radiolucency
Dr. Jason Sayer
Calcific
Metamorphosis
patient
- note lateral
canal
Dr. Jason Sayer
3-4 mm shorter
#8 high
school
football
trauma Now age
74 and
painful
74-17 = 57 !
20
65 y o female #7 pain
Calcific 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
21
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
What killed
49 years ago the patient received intracanal bacteria ?
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 ?
Asymptomatic w/ good bone, but
crown fx at age 65, endo thru crown
Resorption
@ root
end
First file size = size at pulpal death
3 year recall, new crown
22
Fell and Bumped
Chin  Trauma
to 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

23
Crown–Root Fracture
Auto Wreck
Extract
small piece
and
evaluate
Horizontal
position = fx.
after crown
Crown usually
prevents this
iatrogenic ?
This is very rare
24
Root Fracture
 Angle
and Force of Blow
of Fracture ?
 Mobility ?
 Level



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 ?
25
Mobility Issue
Apical segment did not move,
and is likely vital
When to debride pulp ?
Do MTA to fracture ?
Move broken part in and splint
Dr. Chris Fleming
Horizontal Root Fx.
Usually apical segment is vital
Avoid cement in fracture line
Severe Inflammation
Old Trauma, Failed Pulp Cap
G-P Fill @ 6 m
External Resorption
Dr. Jim Tinnin
Ca(OH)2 x 6 m
26
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


27
Bone Crest is
least
favorable root
fracture
Kerbl & Eleazer
Root Fracture
Traumatic decoronation #22
Kerbl & Eleazer
Cases:


Concussion
Fractures – crown – root
 Intrusion
Subluxation
Luxation
 Avulsion
 Resorption
 Ankylosis
 Bone fracture
 Pulp Regeneration


28
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:

Root Prognosis is Based on:
 Time
of compression of vessels (1-2 hours ?)
 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
29
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)
blow in dog  deep intrusion
re-erupted wi/2 months
 Severe
 All
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
30
O.R. Case
Bradley Alley 9-04
MTA 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
31
Elastic in position
Ortho Extrusion - 5 mm in 1 m.
Dr. Mark Essner
Ortho Extrusion
Courtesy Dr. Frank Kerbl
Gingivectomy to allow
pulpectomy
32
Cases:
Concussion
Fractures – crown – root
 Intrusion
 Subluxation – Moved, but back
in place by itself
 Luxation
= PDL tear
 Avulsion
 Resorption
 Ankylosis
 Bone fracture
 Pulp Regeneration


Case Study
Subluxation (PDL tear, moves
back into position)
Check occlusion
 Splint (none / light for 7-10 days)
 Pain pills (NSAIDs)
 Soft diet
 CHX rinse bid

Sub-Luxation
or
Luxation
Note Wide
PDL
Is Occl. OK?
33
Closed Apex Prognosis (Statistics
mean nothing if you are the one)
Pulp OK
Pulp cap = 99%
Resorption / PDL
 Concussion = 90%
 Subluxation = 75% -Calcif. Meta.10% 20%

Pulp Prognosis (open apex =10% better)
Cases:
Lateral,
Extrusion,
Intrusion
Concussion
Fractures – crown – root
 Intrusion
 Subluxation
 Luxation - Still out of place,
? Blood supply
 Avulsion
 Resorption
 Ankylosis
 Bone fracture
 Pulp Regeneration


Luxation
(Moved but still in socket)
Check occlusion
 Splint (none / light for 7-10 days)
 Pain pills (NSAIDs)
 Soft diet
 CHX rinse bid

34
Luxations
Lateral luxation
 Intrusive luxation
 Extrusive luxation


Splint lightly for 1-2 w.

Bone fracture needs more stability x 6-8 w.
 Some
mobility prevents ankylosis
Splint
If you MUST
Maybe no splint
 Light, brief = reduce ankylosis w/ movement

 Bond
wire or heavy fishing line
mesh
 Attach to firm teeth first, traumatized one last
 Titanium

Splint 3-4 weeks (longer)(more rigid) for
alveolar fx or mid-root fx (avoid cement in fx.)
Not like this !
35
Attach wire
to sides,
then lute
avulsed
teeth
Debride canals ASAP, Splint for 10 days,
Ca(OH)2 for ___
TTS Titanium mesh splint
Adatia & Kenny J Cal Dent Assoc 2006
Patterson Dental $47.00
Von Arx et al Dent Traumatol 2001
Medartis
36
Estimate Force, Direction
Facial 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
Plan on Endo if moved >2 mm,
dying pulp has NO BENEFIT,
remove ASAP
 Can
vessels ends rejoin ?
Maybe, but rare
37
Closed Apex Prognosis (Statistics
mean nothing if you are the one)
Pulp OK








Pulp cap = 99%
Resorption / PDL
Concussion = 90%
Subluxation = 75% - Calcif. Meta. 10%
20%
Extrusion = 15% - Calcif. Meta. 60%
20%
Lateral lux. = 10% - Calcif.Meta. 60%
Alveolar fx. = 10%
Intrusion = 0%???
Root Fx. = varies – PDL/resorption 60%
30%
100%
100%
Pulp Prognosis (open apex =10% better)
Cases:
Concussion
Fractures – crown – root
 Intrusion
 Subluxation
 Luxation


 Avulsion
Resorption
Ankylosis
 Bone fracture
 Pulp Regeneration


Avulsion = out of socket
Replanted in field
 In milk

 Saliva
 Saline
 Gatorade


Out , 30 min. (AAE: 1 hour)
Dry > 30 min. (AAE: 1 hour)
38
Replant Permanent Teeth
If not out too long
If not mistreated (Kleenex)
 Tetanus
 Antibiotics
 Splint briefly


 50%
PDL strength @ 2 w
PDL strength @ 8 w.
 100%
Avulsions:

Clot in socket

Open apex
 Remove
gently or Not (do not damage PDL)
Dry > 1 h. = generally not rec. to replant

Closed apex
 Endo

for sure
Pulpectomy ASAP
 Antibiotics
+ 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

39
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
40
Best Case Avulsion

Replanted in field
 Hold
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 pressure

Occlusal adjustment
 May
need splint
2nd best
In mouth
Saliva is good
 Hold in mouth (Do not swallow)
 Antibiotic
 Tetanus

41
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
-
Internal – External
Replacement – Inflamm.
Ankylosis
 Bone fracture
 Pulp Regeneration

Long time Out, Dry

Case of long dry time (Kleenex)(1/2 to 1 h)
 Strip
 Soak
PDL to minimize foreign body rejection
in fluoride to retard resorption
Bisphosphonate ?
Emdogain, GEM 21, other growth enhancer(s)
 Load canal w/ calcium hydroxide / iodoform


 Antibiotic
 Tetanus
42
Straumann Emdogain
1-800-448-8168
Made from pig tooth buds in Sweden
Works nicely in perio
 Again available in US


 US
FDA banned in 2007 until factory passed
inspection

Chemically remove smear layer and apply
to root
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

Case Study
Traumatic
Extrusion

time
Extruded 1 month ago
Pulp #8 test vital to cold and EPT
Splint ? Occlusion ?
43
Oblique Fracture
1. Drill canal to size
X-Trac Device
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.
44
Resorption
– need break in pre-dentin / pre-cementum
Problem: Damage from
trauma or forceps to
reposition tooth
Internal
 External

Inflammatory
 Replacement (ankylosis)


Osteoclasts activated by inflammation
Replacement
Resorption
(Ankylosis)
Poor Prognosis
Body “sees”
dentin as bone
Rapid External Resorption
Inflammation 2 weeks after Ca(OH)2
Concussion from Horse Kick
Ca(OH)2 in canals failed on #7. Note crestal bone loss.
45
Note
Irregular
Outline of
Pulp w/
External
Resorption
Internal Resorption – Excellent
Prognosis – Did not Perforate to
PDL Blood Supply

Internal resorption
? Prognosis
May have begun externally
 True internal resorption has excellent
prognosis if treated before perf. into PDL

46
Perforated facial of root =
must do surgery,  perio
defect
Geristore
is best bet
Geristore
DenMat
Dual Cure
Hybrid Ionomer-Composite
 Very biocompatible


Also need Etchant, Primer, Clear Matrix Strips,
Finishing Instruments (#12 Blade, Burs,
Sanding Strips)
Geristore for
external
resorption
47
External Resorption
May need a Cone Beam
External Resorption at
Epithelial Attachment,
Extr. by Dr. Geurs
Extensive weakening of tooth
48
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 ?
49
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 resorption
 Counteracts
osteoclast’s HCl
necrosis = stimulates osteoid
 Ca45 shows new calcium not from Ca(OH)2
 Coagulation

Antibacterial
dentin (White JOE 2002)
 & Kills bone and nerve

But it Weakens
Sigma-Aldrich
800-558-9160
Calcium
Hydroxide
Needs a
second
germicide
#10,945-2 $10.40/5g
50-50 Iodoform & Ca(OH)2
50
We have grown E. faecalis
in Calcium hydroxide
2004 UAB Study Chris McHugh: E. faecalis
grows 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
51
Calcium hydroxide is
dangerous
Lindgren, J Oral Maxillofac Surg ‘02
Clorox
accident
JADA 2000
External
Resorption
52
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%
OK
No healed
systemic c/s
0.05% fluocinonide  32%OK
control  14% OK
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. Iodoform

 Vitapex
has 22% silicone oil
53
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 Implants

Al Frank (Dent Clin N AM – 1967)
 Park
Dental Research, NYC
Courtesy: Dr. Robert Barfield – healing @ 2-3 y, failed at 6 y –angled out buccal
54
Cases:
Concussion
Fractures – crown – root
 Intrusion
 Subluxation
 Luxation
 Avulsion
 Resorption
 Ankylosis


 Bone

fracture
Pulp Regeneration
Case Study
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)

Easily Diagnosed – Two teeth in alveolus, held by soft tissue
Courtesy Dr. Cody Nelson
55
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
56
4-01
4 teeth Move
Together
Courtesy
Dr. Steve Clark
Alveolar Fx. – mixed-dentition
removable/compos. splint
6 m post, good color,
EPT?
Courtesy
Dr. Steve Clark
1 1/3 y post = AOK
Note:
Calcif. #26
canal
Courtesy
Dr. Steve
Clark
57
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








Case Study
Pulp Regeneration
- need
1.
2.
3.
1.1 mm open apex
Chemically debride necrotic pulp cells
Place antibiotic mixture in canal
Observe for signs of trouble
Metronidazole
Clindamycin
Thibodeau…Trope JOE 2007;33:680-9.
Minocycline
Wang…Trope…Huang JOE 2010;36-56-63.
58
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
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
 (Essner-
George T-J. Huang
SCID Mice
 Human roots – 6 mm long – implanted SQ

 canals
reamed to 2 mm
mm of an end plugged w/ MTA
 5 mm wide, open canal space
1

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
59
Cryopreservation

Magnetic cryopreservation

73% preservation of cells (5 generations of
normal reproduction after thawing)
 SLOW
FREEZING IN A WEAK MAG. FIELD
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 OK
Pulp cap = 99%
Concussion = 90%

Subluxation = 75% - Calcif. Meta. 10%
20%

Extrusion = 15% - Calcif. Meta. 60%
20%

Lateral lux. = 10% - Calcif.Meta. 60%
Alveolar fx. = 10%
Intrusion = 0%???
Root Fx. = varies –
30%
100%
100%
60%




Resorption / PDL
Pulp Prognosis (open apex =10% better)
60
Follow-ups, AAE 2013 Guidelines
Fx permanent Luxated
teeth, bony fx. permanent teeth
• 4w
 2w
• 6-8 w
 4w
• 4m
 6-8 w
• 6m
 6m
• 12 m
 12m
• Yearly x 5 y
 yearly x 5 y
Avulsed perm.
teeth






Endo @ 7-10 d
2w
4w
3m
6m
yearly x 5 y
Splint (light)only if mobile, remove at 10 d-2 w
Bony 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 Paste
 Metronidazole,
S
u
m
m
a
r
y
Clindamycin, Minocycline (?)
Determine direction/ amount of force
 C-spine x-rays, etc.
 Tetanus
 Antibiotic
 X-ray/palpate lip/cheek/tongue

 Where
is the broken piece ? Lung x-ray
x-rays of roots
 Multiple
Wiggle one tooth / Do others move ?
 Occlusion
Don’t Forget the
 Soft diet
Whole Body !
 Follow-up

61
Summary
What was the direction and
concentration of force?
Did a fracture dissipate some
force?
Think at the microscope level
What 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

Not guarantees
guidelines
Guidelines
are NOT
Absolutes
62