Current concepts inthemanagementofdentaltrauma

SALBADRIBD S , P HD , M FD S , M PA ED EN T, F D S ( PA E D D EN T ) , F H E S

R E AD E R / HONORA R Y CON SU LTAN T I N PA E D I AT R I C D EN T I S T R Y

Introduction

ØAroundoneintenchildrenhadsustaineddentaltraumatotheirincisors(12%atage12and10%atage15- ChildDentalHealthSurvey2013)

ØBoysat12aretwiceaslikelytosufferfromdentaltrauma

ØMinimalinformationwithregardtoadultpopulation

ØInGeneral:◦ Uncomplicatedcrownfracturemostcommoninpermanentteeth(50%)

◦ About5%pulpexposure◦ Luxationinjurieslesscommon

Predisposing factors for dental trauma

•Overjet, 3 – 6 mm OJ double incident of Dental Trauma than 0 – 3 mm, > 6mm OJ threefold.

•Lip competency

•Age peak 2-4 years, 8-10years

Managementofthevitalpulpinpermanentteeth

Treatment need for crown fracture •Subacute(within24hours)

•Delayed(>thefirst24hours)üAndreasen JOetal.Effectoftreatmentdelayuponpulpandperiodontalhealingoftraumaticdentalinjuries-- areviewarticle.Dent Traumatol.2002Jun;18(3):116-28.

üViduskalne I,CareR.Analysisofthecrownfracturesandfactorsaffectingpulpsurvivalduetodentaltrauma

• Goodseal– improveoutcomes

Direct Pulp Cap•Small exposure

• Recent, within 24 hours

• Tight seal against bacteria

•The reported prognosis for direct pulp capping is in the range of 80% when performed under ideal conditions.

üFuks AB, Bielak S, Chosak A. Clinical and radiographic assessment of direct pulp capping and pulpotomy in young permanent teeth. Pediatr Dent 1982: 4: 240– 244.üRavn JJ. Follow-up study of permanent incisors with complicated crown fractures after acute trauma. Scand J Dent Res 1982: 90: 363–372.

PulpotomyRemoval of exposed vital pulp to preserve the radicular vitality Any exposure sizeDelayed presentation (> 24 hours)üCvek M. A clinical report on partial pulpotomy

and capping with calcium hydroxide in permanent incisors with complicated crown fractures. J Endod 1978;4:232–7.

üFuks et al . Partial pulpotomy as a treatment alternative for exposed pulps in crown-fractured permanent incisors . Endod Dent Traumatol. 1987 Jun;3(3):100-2

üBimstein & Rotstien. Cvek pulpotomy: revisited. Dent Trauma 2016; 32: 438-442

Mineraltrioxideaggregate(MTA)• Firstintroducedin1993• tricalcium silicate,tricalcium oxideandsilicateoxide

• pH12.5• Hydrophilic• Biocompatible• Directboneapposition• Inductiveeffectoncementoblasts• Activelypromoteshardtissueformation• FacilitatestheregenerationofPDL• Marginalseal

MTA and the vital pulpØPulpcapping

ØPulpotomy

ØAdvantagesØSuperiorlong-termsealingabilityØStimulatesahigherqualityandgreateramountofreparativedentin

ØDisadvantagesØDiscolourationØCost

Evidence / Pulp cappingProspective studies comparing MTA to Ca[OH]2:

Initial healing is better with MTA; subsequent healing similar in MTA and Ca(OH)2PNair et al. Int Endod J. 2008 Feb;41(2):128-50 RCT (no long term outcome)PSawicki et al. Am J Dent. 2008 Aug;21(4):262-6

Observational study: PBogen et al. J Am Dent Assoc. 2008 Mar;139(3):305-15 . 97.6% of the

sample showed favourable outcomes; all immature teeth showed subsequent complete root formation (Caries)

Evidence/PulpotomyØRCT

ØProspectivestudiescomparingMTAtoCa(OH)2ØEl-Meligy andAvery.Pediatr Dent.2006Sep-Oct;28(5):399-404.Similarclinicalandradiographicoutcomes

BiodentineBioactiveDentineSubstitute

September2011

Calcium-silicatebasedformulation

mechanicalpropertiessimilartothesounddentine.

Tightseal

LimitedEvidence

Crown– RootFractureImmediatemanagement

Reattachfracturefragmentwithcompositeresin.

Definitivetreatmentoptions(usuallywithintwoweeksfromtheinitialinjury):1.Removefracturefragmentonly(pulpotomy ifexposedpulp)2.Removefragmentandgingivectomy3.Orthodonticextrusion4.Rootburial5.Extraction

Followup

Clinicalandradiographiccontrol6- 8weeksand1year

RootFractureClassification:

A- Directionoffractureline• Vertical• Horizontal

B- PositionoftheFractureLine:• Apical• Middle• Cervical:

◦ Poorerprognosis◦ Mayrequireextractionoftooth◦ Mayrequireextractionofcoronalfragmentandextrusionofroot◦ Splintingupto4months

Immediate Management• Immediaterepositioningifdisplaced• Splintupto4weeksoruntilstableifmobile• SoftdietandCHX• Reviewvitalityofcoronalfragment• Treatcomplications

AlveolarfractureManagement:◦ Reposition◦ Splintfor4weeks

Followup:◦ clinicalandradiographiccontrolafter6-8weeks,4months,6months,1yearandyearlyfor5years

Prognosis:- Pulpnecrosis- Resorption

Luxation Injuries•Concussion•Subluxation•Extrusion•Lateral Luxation•Intrusion•Avulsion

Management- Diagnosis

- Repositioning

- Splinting

-Followup

- Rootcanaltreatment

ManagementofNonVitalImmaturePermanentIncisor

Immature Permanent Incisors ◦Open apex◦Thin dentinal walls◦Root/crown ratio

Conventional Root End Closure (apexification)

Good success rate Straight forward techniqueNo known discoloration Calcium hydroxide has an antimicrobial effect, which achieves further disinfection.PMackie et al. BDJ 1988 and 1993PSheehy EC, Roberts GJ. Br Dent J. 1997 Oct 11;183(7):241-6.

ProblemswithapexificationMultiple visits over several monthsBarrier detection:PKinirons et al. 2001, 43.3 wks,PMackie et al. 1988, 5.1- 6.8 months

No qualitative increase in root dimensionsFinal filling difficult due to wide root canalRoot continues to be predisposed to fracture

Problems with apexification Risk of root fracture in immature teeth treated with apexification üCvek 1992. Endodontics and Dental Traumatology 8, 45–55.

885 luxated, non-vital immature incisors◦ Frequency of fractures dependant on

the stage of root development◦ Range 28-77%

ü Andreasen et al. 2002. Dental Traumatology 2002;18:134-7- Longterm calcium hydroxide as a root canal dressing may increase

risk of root fracture.- Proteolytic nature affects the circumpulpal dentine

MTA for Root End Closure

◦ Immediate barrier § One – two visits § Coronal seal üSaunders & Saunders EM. Endod Dent Traumatol 1994;10:105–8.

§ Improve compliance

RegenerativeEndodonticsBiologicallybasedproceduresdesignedtoreplacedamagedstructures,includingdentinandrootstructures,aswellascellsofthepulp-dentincomplex.

ObjectivesofRegenerativeEndodontics

◦Toregeneratepulp-liketissue,ideally,thepulp-dentincomplex.◦Regeneratedamagedcoronaldentin.E.g.followingacariousexposure◦Regenerateresorbedroot,cervicalorapicaldentin.

Whendidwestartthinkingaboutregenerativetechniques1952

üHermanBW.Onthereactionofthedentalpulptovitalamputationandcalxylcapping.DtschZahnarztlZ1952;7:1446-7.

Guidedtissueorboneregeneration(GTR,GBR)proceduresanddistractionosteogenesis

Theapplicationofplateletrichplasma(PRP)forboneaugmentation

Emdogainforperiodontaltissueregeneration

Researchintoregenerativeendodonticincludes:Stemcells

Growthfactors

Organ-tissueculture

Tissueengineeringmaterials

StemCellsandEndodontics◦ Dentalpulpstemcells(DPSC)◦ Stemcellsfromhuman-exfoliatedprimaryteeth(SHED)◦ Periodontalligamentstemcells(PDLSC).◦ StemCellsfromapicalpapilla(SCAP)

Scaffolds -Provideframeworkforcellgrowthdifferentiationandorganisationatalocalsite

-Natural(e.g.Collagen),Synthetic(polymerhydrogel)

-Porous

-Biocompatible

-Degradeslowlyandreplacedbyregenerativetissues

SuggestedTechnologiesforRegenerativeEndodontics

Rootcanalregenerationviabloodclotting

Scaffoldimplantation– GF,AB

Injectablescaffolddelivery(Hydrogel)

Stemcellimplantation

Pulpimplantation

GeneTherapy

Pulpregenerationviabloodclot1961

üNYGAARDOSTBY,B.:Theroleofthebloodclotinendodontictherapy.Anexperimentalhistologicstudy.Actaodont.scand.1961:19:323-353.

Consideredapossibilityafteravulsion

RequirementsDisinfectionofthecanal(non- infectedpulpnecrosisconditions)

Provideascaffold(bloodclot)

Coronalseal

DisinfectionoftherootcanalspaceIrrigation

Dressing◦ Ca(OH)2◦ Antibioticpaste

Tripleantibioticpaste• Ciprofloxacin200mg,Metronidazole500mg,Minocycline100mg

◦ Ciprofloxacin:Bactericidal,Gram–ve◦ Metronidazole:selectivelytoxic,Broadspectrumprotozoa&anaerobic

bacteria,bindtoDNA,disrupthelicalstructureleadingtorapidcelldeath

◦ Minocycline:Bacteriostatic,inhibitproteinsynthesis,Broadspectrum–ve &+ve.

Alternativeused•Bi- antibioticpaste

•TripleantibioticpasteReplaceMinocyclinewithcefaclor• Cefaclor:2nd generationcephalosporinantibiotic,broadspectrum

•Sealingdentinaltubules

HowdowegetcontinuedrootgrowthVitalpulpcellsremainattheapicalenddifferentiateintoodontoblastsguidedbyERSofHertwig

PDLSC

SCAP

Bloodclotisconsideredareservoirofgrowthfactors

Conventionaltreatmentvs.regenerativetechniquesReinforcementofdentinalwallsbydepositionofhardtissuethusstrengtheningtherootagainstfracture

Furtherpulpdisease

Differenttechniques

Emergingproblems

Furtherproofofconceptresearchandclinicaltrials

Traumatisedteethwithpoorprognosis

TheFutureØCoreoutcomesset:IADTØCarepathwaystoensureappropriateinitialmanagementandreducelongtermburdenØTransitionalcareØPROMs