CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 503
tissue healing of the root fracture and pulp healing.
teeth with incompletely formed root apices and positive pulp
sensitivity at the time of injury are also signicantly related to
pulp healing and hard tissue repair of the fracture.
Tooth splinting techniques are detailed later in this chapter;
however, current evidence indicates that teeth with roots fractured
in the apical and middle thirds heal better if splinted for only 3
A tooth with a fractured root is usually mobile, and its coronal
fragment is often displaced. Several baseline radiographs should
be taken from various angulations to verify the extent of the fracture.
Optimal results are obtained if the coronal fragment is repositioned
as soon as possible.
e tooth position should be veried radio-
graphically, and the pulp sensitivity should be tested. Accurate
repositioning of the tooth enhances the likelihood of both hard
A B C
• Figure 35.9 Regenerative endodontic technique. (A) Copious irrigation of pulp canal with sodium
hypochlorite. (B) Spinning triple antibiotic paste. (C) Stimulating bleeding by extending le 2 to 3 mm
beyond tooth apex. (D) Blood clot at cervix of tooth. (E) Mineral trioxide aggregate placed on blood clot.
• Figure 35.10 Successful revascularization of necrotic immature permanent left maxillary central incisor.
(A) Preoperative radiograph of immature incisor with complicated crown fracture, open apex, and apical
periodontitis. (B) Twenty-seven-month postoperative view. Note apical closure and root wall thickening.
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CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 503 tissue healing of the root fracture and pulp healing.38 Immature teeth with incompletely formed root apices and positive pulp sensitivity at the time of injury are also signicantly related to pulp healing and hard tissue repair of the fracture.Tooth splinting techniques are detailed later in this chapter; however, current evidence indicates that teeth with roots fractured in the apical and middle thirds heal better if splinted for only 3 A tooth with a fractured root is usually mobile, and its coronal fragment is often displaced. Several baseline radiographs should be taken from various angulations to verify the extent of the fracture. Optimal results are obtained if the coronal fragment is repositioned as soon as possible.13 e tooth position should be veried radio-graphically, and the pulp sensitivity should be tested. Accurate repositioning of the tooth enhances the likelihood of both hard A B CED• Figure 35.9 Regenerative endodontic technique. (A) Copious irrigation of pulp canal with sodium hypochlorite. (B) Spinning triple antibiotic paste. (C) Stimulating bleeding by extending le 2 to 3 mm beyond tooth apex. (D) Blood clot at cervix of tooth. (E) Mineral trioxide aggregate placed on blood clot. AB• Figure 35.10 Successful revascularization of necrotic immature permanent left maxillary central incisor. (A) Preoperative radiograph of immature incisor with complicated crown fracture, open apex, and apical periodontitis. (B) Twenty-seven-month postoperative view. Note apical closure and root wall thickening. 504 Part 4 The Transitional Years: Six to Twelve YearsPulp Canal ObliterationPCO is a degenerative pathologic process that ultimately leads to obliteration of the pulp canal (Figs. 35.12 and 35.13B). Andreasen showed that its occurrence depends on the type of luxation injury sustained and the stage of root development.40 us immature teeth with open apices suering moderate to severe injuries are likely to undergo PCO. It was noted previously that most primary teeth with PCO resorb normally, and thus treatment is usually not indicated. A conservative approach is also recommended for PCO in the permanent teeth. Current evidence indicates that pulp necrosis is an uncommon sequela of PCO, reportedly as low as 1%40 or as high as 33%.41 Crown discoloration may occur more frequently. Endodontic procedures can be successfully completed in a great majority of obliterated canals if necessary.7 e dentist is advised, then, to closely monitor PCO in permanent teeth and to initiate endodontic procedures only in response to periapical changes or for prevention of coronal discoloration in fully mature teeth.Rapidly Progressing (Inammatory) ResorptionRapidly progressing (inammatory) resorption can occur externally, internally, or both (see Fig. 35.13). It commonly arises following luxation injuries when the periodontal ligament (PDL) is inamed and the pulp is necrotic.42 Odontoclastic activity can occur so rapidly that the teeth are destroyed in a matter of weeks. Rapidly progressing resorption can be prevented by prompt extirpation (within 3 weeks) of the pulp in mature teeth that have suered luxation injuries. Luxated teeth with open apices should be observed closely, and their pulps should be extirpated at the rst sign of resorption. Regenerative endodontic or apical barrier techniques are then indicated to complete treatment.Immediate management of rapidly progressing resorption is essential. As soon as this process is detected radiographically, the pulp tissue in the tooth is thoroughly extirpated. Copious irrigation with sodium hypochlorite assists in the dissolution of organic debris in the canal. In permanent teeth, CaOH is placed in the to 4 weeks with a functional splint that allows for some mobility of the teeth.13,39 Teeth sustaining cervical third root fractures should be stabilized with a exible splint for 3 to 4 months.Root canal therapy should not be initiated until clinical and radiographic signs of necrosis or resorption are apparent. Even in those cases, treatment can often be limited to the coronal fragment, because in most instances the apical fragments maintain their vitality.Managing Sequelae to Dental TraumaIn Chapter 16, common reactions of the teeth to trauma are described. ree of the most challenging sequelae include pulp canal obliteration (PCO), rapidly progressing (inammatory) resorption (both external and internal), and replacement resorption. ese pathologic processes can occur following crown fractures or luxation injuries.• Figure 35.11 A vertical crown fracture of the distolingual cusp of this maxillary molar occurred secondary to a blow to the underside of this child’s chin. ABPCO• Figure 35.12 (A) Ten-day postoperative view of immature maxillary left central incisor in 7-year-old child that had been extruded and repositioned. (B) Sixteen-month postoperative view demonstrating pulp canal obliteration (PCO). CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 505 When radiographs conrm that the process has stopped, gutta-percha is placed as the nal lling material.Replacement Resorption (Ankylosis)Replacement resorption occurs most commonly following severe luxation injuries like avulsions or intrusions, in which PDL cells are destroyed. Alveolar bone directly contacts cementum on the involved tooth and fuses with it. en, as the bone undergoes its normal physiologic, osteoclastic, and osteoblastic activity, the root is resorbed or replaced with bone (Fig. 35.14). In young children canal with a technique identical to that used to induce apexication (see Chapter 34). Here the objective is not to induce apical closure but to create an environment unfavorable for the resorptive process. It is theorized that CaOH has antiseptic properties because of its extreme alkalinity. is medicament apparently percolates through the dentinal tubules to the areas of resorption at the PDL and halts its progress.CaOH should be retained in the tooth until radiographic signs of healing are apparent. is may take several months, and repeated applications of CaOH may be necessary if the resorption progresses. APCO IRB• Figure 35.13 (A) External rapidly progressing resorption (arrow). (B) Internal resorption (IR) of the lateral incisor; pulp canal obliteration (PCO) of the permanent central incisor. ([B] From McTigue DJ. Management of orofacial trauma in children. Pediatr Ann. 1985;14:125–129.)AB• Figure 35.14 (A) A permanent incisor that had been avulsed and stored dry for 3 hours was lled with gutta-percha before reimplantation. (B) Three years later, replacement resorption has completely destroyed the root. 506 Part 4 The Transitional Years: Six to Twelve Years• Figure 35.15 Orthodontic repositioning of intruded permanent incisor prevents replacement resorption (ankylosis) and alveolar bone loss. ExtrusionExtruded permanent teeth (Fig. 35.16A) should be repositioned as soon as possible and splinted for 2 to 3 weeks. It normally takes the PDL bers this period of time to reanastomose. Extruded permanent teeth with closed apices will undergo pulpal necrosis; therefore root canal therapy should be initiated after the teeth are splinted. Extruded teeth with open apices have a chance to revascularize and maintain their vitality, so the decision to initiate therapy should be delayed until clinical or radiographic signs indicate necrosis.Lateral LuxationAlveolar bone fractures frequently occur in lateral luxation injuries and can complicate their management (see Fig. 35.16B). In the most severe cases, PDL and marginal bone loss occur. Treatment is to reposition the teeth and alveolar fragments as soon as possible. A splint should then be applied for 3 to 6 weeks, depending on the degree of bone involvement. e author’s current protocol includes prescribing a 0.12% chlorhexidine mouthrinse. If the apices are closed, the pulps will likely become necrotic; therefore endodontic therapy should be instituted soon after the teeth are splinted. Again, teeth with open apices should be monitored until signs of necrosis are evident.Avulsione prognosis for long-term retention of an avulsed permanent tooth worsens the longer the tooth is out of its socket.44 e primary therapeutic concern is to maintain the vitality of PDL bers, and the longer they are out of the mouth, the worse the prognosis for their survival. It is thus imperative that the avulsed tooth be immediately reimplanted by the rst capable person, whether that person is a parent, teacher, or sibling (Fig. 35.17).Owing to a variety of circumstances, it is sometimes not possible to reimplant a tooth immediately. Research has shown that the best transport medium for avulsed teeth is cell culture media such as ViaSpan (DuPont Merck Pharmaceutical Company, Wilmington, DE) or Hanks balanced salt solution (HBSS; United Biochemicals, Sanborn, NY).45 ViaSpan is not readily available for clinical use, but HBSS is commercially available as EMT Tooth Saver (Biochrom AG, Berlin, Germany). Use of HBSS signicantly increases the likelihood of PDL cell survival for several hours.46e best alternative storage medium if culture media is not available is milk.47,48 It is readily available, relatively aseptic, and its osmolality is more favorable to maintaining the vitality of the PDL cells than is saline solution or tap water. Cool milk has with rapid bone turnover, roots are completely resorbed in 3 to 4 years. In adults, the process may take up to 10 years. Replacement resorption can be prevented by prompt and appropriate management of luxation injuries.Treating Luxation Injuries in the Permanent Dentitione reader is referred to Chapter 16 for the denition of the various types of luxation injuries. Luxation injuries damage the supporting structures of the teeth—that is, the PDL and alveolar bone. In addition, in mature teeth with closed apices, the pulp frequently becomes necrotic. Pulp necrosis occurs less frequently when immature teeth with open apices are luxated, but, as noted earlier, PCO is a common nding in these cases.Vitality of the PDL is far more important than pulp vitality in determining the prognosis of luxated teeth. e primary objective of treatment in these injuries is to maintain PDL vitality.ConcussionConcussion injuries in permanent teeth must be followed closely. Although the prognosis is normally good, pulp necrosis and root resorption have been reported. Involved teeth can be carefully taken out of occlusion if the child complains of pain.SubluxationPulp necrosis occurs far more commonly in subluxated permanent teeth than in primary teeth. ese teeth should be monitored closely with radiographs for at least 1 year, and root canal therapy should be instituted at the rst sign of pathologic change. Immature teeth with open apices are less likely to undergo pulpal necrosis. Splinting of subluxated teeth should be limited to a maximum of 2 weeks with a exible splint and then only when the patient requires it for comfort.13Intrusive Luxatione prognosis for intruded permanent teeth is not good. ese teeth frequently undergo pulpal necrosis, root resorption, and alveolar bone loss. Treatment for intruded teeth is controversial, owing to the lack of research in this area.43 Guidelines published by the International Association for Dental Traumatology recom-mend dierent strategies, depending on the apical development of the intruded tooth.13e treatment of choice for immature teeth intruded less than 7 mm is to allow them to reemerge spontaneously. If no movement is noted within 3 weeks, orthodontic repositioning using light forces should be employed (Fig. 35.15). Immature teeth intruded more than 7 mm should be orthodontically or surgically repositioned.Mature permanent teeth intruded less than 3 mm should be allowed to reemerge without intervention. If no movement is noted within 3 weeks, they should be repositioned surgically or orthodonti-cally before they ankylose. ose teeth intruded beyond 7 mm should be repositioned surgically. Evidence is not available to clearly indicate whether orthodontic or surgical repositioning is preferable for mature teeth intruded between 3 and 7 mm. e pulp in mature intruded teeth will likely become necrotic and lead to rapidly progressing resorption, so it should be extirpated within 3 weeks following the injury, and CaOH should be placed in the root canal using the same technique as described for apexication in Chapter 34. Radiographic monitoring of the tooth should occur for at least 1 year, and the CaOH in the canal should be replaced if signs of root resorption persist. CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 507 A B• Figure 35.16 (A) Extrusion injury of maxillary right central incisor and crown fracture of maxillary left central incisor. (B) Laterally luxated tooth. ACDB• Figure 35.17 (A) Both maxillary permanent central incisors avulsed. (B) Reimplanting avulsed teeth with nger pressure. (C) Aesthetic, exible splint fabricated using 50-pound test monolament shing line retained with composite resin. (D) Calcium hydroxide pulpectomies completed to prevent rapidly progress-ing resorption. (Courtesy Dr. Jeff Hays.)been shown to maintain the ability of PDL precursor cells to reproduce for twice as long as room temperature milk.49 ough some studies have indicated that storing the tooth in the patient’s mouth (saliva) may be favorable toward PDL survival, the danger of an alarmed child swallowing, aspirating, or chewing on the tooth eliminates this option in the author’s opinion. Water is not a good transport medium because it is a hypotonic solution and causes PDL cells to swell and rupture. us in these cases, with the tooth stored in cold milk, the patient should be taken to the dentist as soon as possible. 508 Part 4 The Transitional Years: Six to Twelve YearsPREVENTIVE/INTERCEPTIVE ORTHODONTIC TREATMENTHenry FieldsThere are relationships between malocclusion, orthodontics, and the dental trauma patient. Certain types of malocclusion are more prone to trauma, and following trauma, orthodontics can play a role in treatment. The data are clear that patients with protrusive teeth (excess overjet) and incompetent lips are most at risk for traumatic dental injuries (TDI)—as are children with previous primary dentition TDI or permanent dentition TDI prior to 9 years of age.1–3If this is the case, why not just provide early phase I orthodontic treatment for children with signicant class II malocclusion? Information from the two early treatment randomized prospective clinical trials combined with experience from Britain do not make the case based on an analysis of the benets of treatment.4 This is especially true if we recognize that most TDI are enamel and dentin fractures with moderate long-term sequelae compared with those with periodontal type injuries (intrusion, extrusion, avulsion, and luxation) that have signicant long-term consequences. It can be reasonably concluded that the benets of treatment for this latter group can have an impact, but predicting who is most at risk is not easy.Given this fact, early orthodontic treatment for those who have increased overjet, incompetent lips, and a history of permanent dentition TDI prior to 9 years old makes some sense if the treatment is limited to retraction of the incisors (not early class II growth modication) and then denitive orthodontics later. This, combined with a mouth guard that is worn consistently, can greatly reduce TDI.Because root resorption is so closely correlated with the extraoral period, the dentist should reimplant the tooth in its socket as soon as possible after the child arrives. Adequate evidence exists, however, to support the immediate placement of the avulsed tooth into HBSS while the patient is brought to the dental operatory and appropriate informed consent is being obtained from the parent.6 Soaking the tooth may reduce ankylosis and help debride necrotic cells, foreign bodies, and bacteria. e author’s current protocol is again to prescribe an oral mouthrinse of 0.12% chlorhexidine used empirically to reduce the likelihood of bacterial invasion of the PDL space. Controversy exists regarding the benet of systemic antibiotics for pulp or periodontal healing.50–52 Given the evidence that systemic antibiotics can prevent bacterial inva-sion of the necrotic pulp,53 Andreasen recommends a 1-week course of doxycycline for tooth avulsion patients.1 Doxycycline is preferred, owing to its antiresorptive properties54; however, tetracycline is known to stain developing teeth. erefore peni-cillin V is the antibiotic of choice for children age 8 years and younger.When immature teeth with open apices are avulsed, the ideal treatment objective is spontaneous revascularization of the pulp in addition to maintenance of PDL health. is would enable physiologic maturation of the immature root, including apexogenesis and root wall thickening. The tooth should be splinted for approximately 1 to 2 weeks. Success in these cases has been reported; therefore dentists should await clinical or radiographic signs of necrosis before initiating regenerative endodontic therapy. When the splint is removed, the dentist may note that the tooth is quite mobile. is mobility is preferable to long-term rigid splinting, because the latter has been correlated with an increased incidence of replacement resorption. e mobility of the tooth physiologically interrupts areas of incipient resorption/ankylosis on the PDL, allowing it to heal normally.In mature teeth with closed apices, a splint that aords the tooth functional mobility should be applied for 7 to 14 days. e necrotic pulp should be extirpated and replaced with CaOH after 1 week to prevent the initiation of rapidly progressing root resorption (see Fig. 35.17D). Importantly, root canal therapy should not be performed in the hand before reimplantation. is extends the extraoral period and places the PDL at greater risk to injury as a result of the additional manipulation of the tooth. e CaOH can be removed and a gutta-percha pulpectomy performed after 2 weeks. In those cases where the pulp was not removed within 2 to 3 weeks of the reimplantation, or when rapidly progressing resorption is evident radiographically, the CaOH should be maintained in the tooth until radiographic signs of healing are apparent.PDL cells on avulsed teeth that have been stored dry for more than 1 hour are necrotic, and these teeth will eventually ankylose and resorb. ere is some evidence that the pace of this resorption can be reduced if these teeth are soaked in uoride for approximately 20 minutes before reimplantation.55In summary, the procedure for reimplantation of a mature tooth is as follows:1. Hold the tooth by the crown to prevent damage to the PDL.2. Gently rinse the tooth with tap water. No attempt should be made to scrub or sterilize the tooth.3. Manually reimplant the tooth in the socket as soon as possible.4. Apply a light, functional splint for 1 to 2 weeks.5. Complete CaOH pulpectomy after 1 week and then remove splint.Splinting TechniqueVarious methods of splinting teeth have been advocated, but it is apparent that the ideal splint should possess the following characteristics:1. Be passive and not cause trauma2. Be exible and allow functional movement of the tooth3. Allow for vitality testing and endodontic access4. Be easy to apply and removeMany splints can meet these criteria, and several good commercial products are available. To allow for exibility, a light orthodontic arch wire or a 30- to 60-pound test monolament shing line can be used (see Fig. 35.17C).SummaryAdvances in dental research have greatly improved the ability of dentists to ensure long-term retention of traumatized teeth in children. It is the dentist’s responsibility to stay abreast of this new information and to be available to patients who need urgent treatment. As noted in the beginning of this chapter, www .dentaltraumaguide.org is an excellent resource for up-to-date information on the management of dental injuries. CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 509 Orthodontic Treatment for Immediate TraumaThere is a place for orthodontics, as mentioned in this chapter, following TDI for patients who have experienced intrusion, avulsion, and lateral luxation injuries. Contemporary thought is that both immature intruded less than 7 mm and mature teeth intruded less than 3 mm should have a chance to re-erupt for approximately 3 weeks.13 For those that do not actively or completely re-erupt following observation, and those with mature roots intruded 3 to 7 mm, orthodontic traction can be useful. Orthodontics as an alternative to surgical repositioning appears to have better supporting tissue outcomes,5 but may be impractical in terms of treatment time and appointments required as the intrusion approaches or exceeds 7 mm. Although there are many methods to extrude teeth, using a light exible overlay wire like .012 or .014 NiTi, supported by a heavier base wire (.016 or .018 steel), is relatively simple and effective (Fig. 35.18). Conversely, when avulsed teeth are not completely reimplanted or extruded teeth are encountered, achieving good positioning can be aided by using a light continuous archwire to intrude them (Fig. 35.19).Teeth that have been laterally luxated in any direction can be immediately repositioned and splinted. If this cannot be accomplished and they have consolidated in a new position without occlusal interference, ideally waiting for 3 months, as one would with a transplanted tooth before orthodontic movement is attempted, is recommended.6 In the case of lingually displaced maxillary teeth, they are often in traumatic occlusion, which prevents complete jaw closure. For these patients, immediate movement with light continuous orthodontic forces is best to better align the teeth and eliminate the occlusal interferences.Orthodontic Treatment for Patients With Traumatic Dental InjuriesThere is often a question of when to start orthodontic treatment for patients with TDI. Should treatment begin immediately, or should there be a period of healing before starting orthodontic tooth movement? Current recommendations suggest delaying orthodontic treatment for 3 months for minor dental trauma such as concussion, subluxation, and crown fractures. If the patient sustains major dental trauma (avulsion, root fracture, severe luxation), orthodontic treatment should possibly be delayed for up to 1 year to allow healing and determine the status of the injured teeth.7Patients who have experienced orthodontic treatment and trauma are more at risk for root resorption and pulpal necrosis of the injured teeth than those who have had either orthodontics or trauma alone.8–10 Those teeth with completed endodontic treatment are usually less prone to root resorption than normal teeth.11Orthodontics can also be helpful following traumatic injury when teeth are missing and spaces need to be closed or teeth repositioned for subsequent restorative treatment. The advent of temporary anchorage devices (TADS) has altered the possibilities for tooth movement dramatically in these cases.References1. Bauss O, Freitag S, Rohling J, et al. Inuence of overjet and lip coverage on the prevalence and severity of incisor trauma. J Orofac Orthop. 2008;69:402–410.2. Goettems ML, Brancher LC, da Coasta CT, et al. Does dental trauma in the primary dentition increases the likelihood of trauma in the permanent dentition? A longitudinal study. Clin Oral Investig. 2017;21:2415–2420.3. Glendor U, Koucheki B, Halling A. Risk evaluation and type of treatment of multiple dental trauma episodes to permanent teeth. Endod Dent Traumatol. 2000;16:205–210.4. Thiruvenkatachari B, Harrison JE, Worthington HV, et al. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children. Cochrane Database Syst Rev. 2013;(11):CD003452.5. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth: part 3—a clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dent Traumatol. 2006;22:99–111.6. Paulsen HU, Andreasen JO, Schwartz O. Pulp and peiodontgal healing, root development and root resortpiuon subsequent to transplantation and orthodontic rotation: a long-term study of autotransplanted premolars. Am J Orthod Dentofacial Orthop. 1995;108:630–640.7. Kindelan SA, Day PF, Kindelan JD, et al. Dental trauma: an overview of its inuence on the management of orthodontic treatment: part 1. J Orthod. 2008;35:68–78.8. Brin I, Ben-Bassat Y, Heling I, et al. The inuence of orthodontic treatment on previously traumatized permanent incisors. Eur J Orthod. 1991;13: 372–377.9. Bauss O, Scheafer W, Sadat-Khonsari R, et al. Inuence of orthodontic extrusion on pulpal vitality of traumatized maxillary incisors. J Endod. 2010;36:203–207.10. Bauss O, Reohling J, Sadat-Khonsari R, et al. Inuence of orthodontic intrusion on pulpal vitality of previously traumatized maxillary permanent incisors. Am J Orthod Dentofacial Orthop. 2008;134:12–17.11. Spurrier SW, Hall SH, Joondeph DR, et al. A comparison of apical root resorption during orthodontic treatment in endodontically treated vital teeth. Am J Orthod Dentofacial Orthop. 1990;97:130–134.PREVENTIVE/INTERCEPTIVE ORTHODONTIC TREATMENT—cont’d• Figure 35.19 Intrusion or alignment can sometimes be accomplished by a continuous exible wire, while monitoring any negative reactive side effects. • Figure 35.18 Extrusion using a base wire and a exible overlay wire. Remember that the method works by having the overlay wire slide through the brackets, so loose steel ties are recommended. Probably extending the overlay wire through one bracket on either side of the intruded tooth is adequate, since the more brackets, the more friction that is incurred and the slower the movement.