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ePaper created 2016-11-22, 09:52:12 | version 1.38.0
| CE article traumatic dental injuries 20 roots 4 2016 cal portion of the tooth is stable once the two pieces have been approximated, no splint or a flexible splint for two weeks produces the best treatment out- come.2, 18 Longer splinting time is recommended only when the fracture is close to the cervical area. Luxation injuries All luxation injuries will cause some damage to the periodontal ligament and, in some cases, the pulp as well. The immediate treatment is to limit further dam- age to the PDL and allow for the best possible healing. As with all dental injuries, follow-up is essential. Late complications,suchasinternalorexternalrootresorp- tions, are relatively frequent and require endodontic treatment, especially in more severe injuries. In many ofthesecases,referraltoanendodontistisadvisable. Luxation injuries are divided into subcategories, mainly by degree of severity. The two mildest are termed“concussion”and“subluxation.”Inthosecases, the tooth is still in its original location, but is tender to percussion and/or, in the case of sub-luxation, has in- creased mobility. While no immediate treatment is neededfortheseinjuries,follow-upiscriticalbecause thepulpmaybecomenecrotic,makingendodonticin- tervention paramount. Whentraumahasmovedthetoothoutofitsnormal position,itneedstobereplacedgentlyassoonaspos- sible.Theonlyexceptionsarecasesofintrusionwhenit might not be possible or advisable to manipulate the tooth immediately. When an immature tooth is in- truded up to 7 mm, it is recommended to wait three weeks and watch for signs of re-eruption. If no signs exist, one can initiate orthodontic repositioning. For intrusion of more than 7 mm, surgical or orthodontic repositioningshouldbeperformedwithinthreeweeks. In the case of an intruded tooth with a closed apex, thereisapossibilityofre-eruptionifthetoothisslightly intruded (less than 3 mm) and the patient is younger than 17 years old. If the tooth is not moving after two to three weeks, however, orthodontic extrusion or ex- tractionandreimplantationisrecommended.Ifatooth withaclosedapexisintrudedmorethan3 mm,ortho- dontic or surgical repositioning should be performed within three weeks. The risk with all intrusions is that the intruded tooth may ankylose in the infraposition. Oncethatbegins,thetoothmaynotbemovableexcept possibly surgically. It is well to advise the patient and the parents/guardians that the long-term prognosis of an intruded tooth is unpredictable, as it is likely to eventuallybelostduetoankylosis.19-21 Splinting of a luxated tooth is recommended only forteeththatarestillmobileafterrepositioning.Inall types of trauma cases, a splint must allow for physio- logicalmovement.22, 23 (SeeFigs.4a–c&5,andTable3, regarding splinting time.) When assessing luxation trauma, it is important to consider the maturity of the apex. If it is still open, thereisachancethatthepulpwillsurvivethetrauma or revascularize, allowing the growth of the tooth to continue (Figs. 6a–c). If the apex is closed, endodontic treatment is likely needed. It is advisable to follow the patient closely (Table 1) or refer him or her to an endodontist for fur- therevaluation.BecauseoftheinjurytothePDL,rapid inflammatory root resorption can occur (within days or a few weeks) if the necrotic pulpal tissue becomes infected. For mature teeth diagnosed with necrotic pulps,placingcalciumhydroxidefortwotofourweeks Splinting Time for Various Types of Injuries Type of Injury SplintingTime Subluxation Extrusive luxation Avulsion Lateral luxation Intrusion Root fracture (middle 1/3) Alveolar fracture Root fracture (cervical 1/3) 2 weeks 2 weeks 2 weeks 2 weeks 4 weeks 4 weeks 4 weeks 4 months Fig.5: Once the tooth has been repositioned,the patient bites into a softened pink wax plate that had been previously rolled one or two times.This will ensure that the luxated (or avulsed) tooth stays in place while being splinted.In this case,a 16-pound fishing line was used as the splint on the luxated tooth. Fig.6a:An immature tooth that was laterally luxated,as can be seen by the empty socket space around the apex on the radiograph. Fig.6b:The tooth was repositioned and splinted for two weeks. Fig.6c:At the six-month recall there is good evidence that the apex is maturing and the pulp responds normally to cold.At the three-year recall the pulp chamber is completely calcified; however,the tooth responds normally to EPT and there is no apical pathology. Fig.6a Fig.5 Fig.6b Fig.6c Table 3 42016