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Dental Tribune Middle East & Africa No. 3, 2017

Dental Tribune Middle East & Africa Edition | 3/2017 ◊Page 10 mCME Fig. 3a: Schematic drawing of a com- mon situation after root fracture: The crown portion is displaced inward toward the palate and the fractured piece is stuck to the facial cortical plate. Figs. 3b, c: It is impossible to move the coronal portion back to its original loca- tion without releasing it from the cortical plate. This is accomplished by pulling the coronal portion down and then repositioning it. Fig. 3d: A periapical radiograph of a root fracture a few hours after the injury. It was established that both fragments were in good approximation of each other. Splinting was done for two weeks. Fig. 3e: At the nine-month recall, internal root resorption was noted, but no defect in the PDL or adjacent bone, indicating a ‘normal’ healing process. Fig. 3f: Five-year recall, no endodontic treatment was needed. Fig. 4a: In lateral luxation injuries of maxillary teeth, the apex is frequently pushed through the cortical plate fa- cially. Figs. 4b, c: To reposition the tooth, it has to be released prior to moving the crown forward. 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 en- sure 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. Additionally, sensibility tests should be conducted on all teeth involved as well as opposing teeth. Cold testing is recommended over electric pulp testing in young individuals.6 Both testing methods should be consid- ered, however, especially when there is no response to one of the two. The pulp might be non-responsive for several weeks after a traumatic in- jury, so a pulp test should be done at every follow-up appointment until a normal response is obtained.7 Once the diagnosis is confirmed and more serious complications such as CNS and jaw or other facial bone frac- tures have been ruled out, the emer- gency phase of the treatment needs to be initiated. The aim of treating dental trauma should be to either maintain or regain pulpal vitality in traumatized teeth. This is because dental trauma most frequently oc- curs in preteens or young teens in whom the teeth have not yet fully developed, and root development will cease without a vital pulp. Clinical examples Dental trauma can be roughly di- vided into two groups: fractures and luxation injuries. The fractures are then further divided by type: crown, crown-root and root fractures. If the pulp is exposed to the oral environ- ment, it is called a complicated frac- ture; if not exposed, it is called an uncomplicated fracture. Crown fractures: The first thing to do in any crown or crown-root fracture is to look for the broken-off tooth fragment. With modern bonding technology it is possible to rebond the fragment to the tooth, which is esthetically the best solution. Prior to reattaching the tooth fragment, the remaining den- tal thickness immediately covering the pulp needs to be assessed radio- graphically and clinically. If there is at least 0.5 mm of the dentin remain- ing, there is no need to cover it with a protective liner. If it is estimated that the remaining dentin is less than 0.5 mm, it is advisable to cover the deepest part, closest to the pulp, with a cavity liner, and then dimple the fragment accordingly.8,9 If the tooth fragment was kept dry, it should be rehydrated in distilled water or sa- line for 30 minutes prior to reattach- ment. This process will increase its bonding strength10 (Figs. 1a–c). In a complicated fracture, the goal is to create a bacteria-tight seal to protect the pulp, after ensuring that the pulpal wound is clean and all inflamed tissue removed.11,12 The two best capping materials available today are calcium hydroxide and mineral trioxide aggregate (MTA),13,14 but newer bioceramic materials are showing promise for this applica- tion. It is advisable to create a 1-2 mm reservoir into the pulp with a high- speed diamond bur and copious wa- ter cooling, place the capping materi- al, and then either reattach the tooth fragment or restore the crown with a composite resin material (Figs. 2a–c). Crown-root fractures One of the more challenging types of fracture to treat is the crown-root fracture because the fracture margin has to be exposed around the tooth/ crown to properly restore the tooth. This can be accomplished by gingi- vectomy if the fracture line is in the sulcus. In more extreme cases, the tooth will have to be extruded with orthodontic forces or surgically re- positioned. In the emergency ses- sion, if the pulp is exposed, it needs to be protected in the same fashion as complicated crown fractures. If the pulp is not exposed, all acces- sible exposed dentin areas should be covered for the patient’s comfort. Pulpal survival for all these fracture types is generally good; however, en- dodontic treatment may be indicat- ed later.15,16 Therefore, it is of utmost importance that a recall schedule is followed and that the teeth involved in the trauma are tested every time. Tables 1 & 2 outline the recommend- ed recall rates for most common dental injuries. It is not uncommon for there to be no response to vitality tests for up to three months, and a lack of response to vitality tests does not always indicate that root canal treatment is needed—especially in young and immature teeth. Rather, it is advisable to look for at least one other sign of pulpal necrosis, such as vestibule swelling, periapical lesions and/or dramatic color change of the crown. If no signs exist, continue to monitor the patient at regular ap- pointments every three months, for up to one year. Root fractures The pulp is affected in all root frac- tures. However, if the fragments are approximated soon after the frac- ture, there is a good chance that no endodontic treatment is necessary, just observation. With good approxi- mation, it is likely that the pulp will revascularize across the fracture re- gardless of the age of the patient17, 18 (Figs. 3a–f). A recent retrospective study included assessment of splint- ing type and time of root fracture. The study determined that, if the cervical portion of the tooth is stable once the two pieces have been ap- proximated, no splint or a flexible splint for two weeks produces the best treatment outcome.2,18 Longer splinting time is recommended only when the fracture is close to the cer- vical 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 damage to the PDL and allow for the best possible healing. As with all dental injuries, follow- up is essential. Late complications, such as internal or external root resorptions, are relatively frequent and require endodontic treatment, especially in more severe injuries. In many of these cases, referral to an endodontist is advisable. Luxation injuries are divided into subcategories, mainly by degree of severity. The two mildest are termed “concussion” and “subluxation.” In those cases, the tooth is still in its original location, but is tender to percussion and/or, in the case of sub-luxation, has increased mobil- ity. While no immediate treatment is needed for these injuries, follow-up is critical because the pulp may be- come necrotic, making endodontic intervention paramount. When trauma has moved the tooth out of its normal position, it needs to be replaced gently as soon as pos- sible. The only exceptions are cases of intrusion when it might not be pos- sible or advisable to manipulate the tooth immediately. When an imma- ture tooth is intruded 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 or- thodontic repositioning. For intru- sion of more than 7 mm, surgical or orthodontic repositioning should be performed with in three weeks. In the case of an intruded tooth with a closed apex, there is a possibility of re-eruption if the tooth is slightly 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, orthodon- tic extrusion or extraction and re- implantation is recommended. If a tooth with a closed apex is intruded more than 3 mm, orthodontic or surgical repositioning should be performed within three weeks. The risk with all intrusions is that the intruded tooth may ankylose in the infraposition. Once that begins, the tooth may not be movable except possibly surgi- 11 cally. 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 eventually be lost due to ankylo- sis.19-21 Splinting of a luxated tooth is rec- ommended only for teeth that are still mobile after repositioning. In all types of trauma cases, a splint must allow for physiological move- ment.22,23 (See Figs. 4a–c & 5, and Table 3, regarding splinting time.) When assessing luxation trauma, it is important to consider the maturi- ty of the apex. If it is still open, there is a chance that the pulp will survive the trauma 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 ad- visable to follow the patient closely (Table 1) or refer him or her to an en- dodontist for further evaluation. Be- cause of the injury to the PDL, 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, placing calcium hydroxide for two to four weeks pri- or to obturation is recommended; however, one should allow the PDL to heal for two weeks before place- ment (see treatment for avulsion, be- low). Apexification or revasculariza- tion is recommended for teeth with open apices.24,25 It is important to remember that dental injuries do not always fall into one group or category, but often a combination of several categories. Injuries in multiple categories will impact the outcome. For example, it was recently demonstrated that the existence of a concurrent luxation injury with an uncomplicated crown fracture and complete root develop- ment are significant risk factors of pulp necrosis.26 Avulsion The time outside of the socket for an avulsed tooth is the most critical of its survival. If the tooth is replanted within 30 minutes, or alternatively kept in a physiological solution of specialized media or milk for a few hours, it has a fairly good progno- sis.27,28 If the tooth has been dry for more than one hour, the periodontal ligament cannot be expected to sur- vive and the tooth will likely become ankylosed (Fig. 7). Once reimplanted, most teeth need to be stabilized with a physiological splint for two weeks.29 If the avulsed tooth has an open apex and was reimplanted within the hour, there is a possibility that the pulp will revascularize. In this case, delaying endodontic treatment at the emergency stage is recom- mended. Endodontic treatment should be performed later only if signs of pul- ÿPage 13 Table 2. Follow-Up Procedures for Luxated Permanent Teeth Table 3. Splinting Time for Various Types of Injuries TIME Concussion/Subluxation Extrusion Lateral Luxation Intrusion 2 Weeks Splint removal (if applied for subluxation) Clinical and radiographic examination Splint removal Clinical and radiographic examination 4 Weeks Clinical and radiographic Clinical and radiographic examination examination Clinical and radiographic Clinical and radiographic examination examination Splint removal Splint removal Clinical and radiographic Clinical and radiographic examination examination 6-8 Weeks 6 Months 1 Year Clinical and radiographic Clinical and radiographic Clinical and radiographic Clinical and radiographic examination examination examination control Clinical and radiographic Clinical and radiographic Clinical and radiographic Clinical and radiographic examination examination examination examination Clinical and radiographic Clinical and radiographic Clinical and radiographic Clinical and radiographic examination examination examination examination Type of Injury Subluxation Extrusive luxation Avulsion Lateral luxation Intrusion Root fracture (middle 1/3) Alveolar fracture Splinting Time 2 weeks 2 weeks 2 weeks 2 weeks 4 weeks 4 weeks 4 weeks 2-5 Years Yearly up to 5 years Yearly up to 5 years Yearly up to 5 years Yearly up to 5 years Root fracture (cervical 1/3) 4 months

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