#D3/S2/W8
#Endo

Ellis classification

• class 1 - fracture little or no dentine
• class 2 - fracture dentine but no pulp exposure
• class 3 - extensive crown fracture with pulp exposure
• class 4 - tooth becomes non vital with/without loss of crown structure
• class 5 - tooth lost as result of trauma
• class 6 - roto fracture
• class 7 - tooth displacement with out crown or root fracture
• class 8 - fracture of crown en masse and its replacement
• class 9 - injury to primary dentition
  

Mechanism of injury

• energy of impact
• resilience of impacting object
• shape of impacting object
• direction of impacting force

Examination and diagnosis

• when where how did the injury occur
• previous injuries
• amnesia, unconsciousness, drowsiness, vomiting, headache
• spontaneous tooth pain
• teeth reactive to thermal changes, sweet sour foods
• teeth tender to touch or during eating
• any change in bite
• Check for extraoral wounds; palpate facial skeleton
• Record soft tissue injuries to oral mucosa and gingiva
• Check crowns of teeth for fractures, pulp exposures, colour changes
• Check displacement of teeth
• Occlusal disturbances
• Abnormal mobility of teeth or alveolar fragments
• Tenderness of teeth to percussion and changes in percussion note
• Pulp sensibility testing

Radiographic examination

• reveals the stage of root development
• discloses injuries affecting the root
• mandibular fracture
• maxillofacial injuries

Dental resorption

• resorptive process similar to bone
• differences between cells resorbing dentine and bone
• dentinoclasts
  • morphologically similar to osteoclasts
  • fewer nuclei
  • very small clear zones

Resorption types relating to trauma

• external
  • surface
  • inflammatory root
  • replacement (ankylosis)
  • cervical
• internal
  • internal inflammatory
  • internal surface and tunnelling (seen in root fractures)

Surface resorption

• pathogenesis
  • result of complex localised injury to PDL
  • mechanical injury/bacterial contamination
  • macrophages remove debris -> resorption cavity
  • repair with cementum
• diagnosis
  • more resorption lacunae superficial, cant be seen radiographically
  • deeper cavity result in altered root outline
• clinical management
  • none, self limiting
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Inflammatory root resorption

• 
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• pathogenesis
  • bacteria in pulp release toxins
  • toxin diffsue through tubule to PDL
  • stimulate osteoclasts on root surface
  • inflammatory root resorption
• resorption can be rapid
  • within few months
  • aggressive after avulsion injuries in 6-10yo (wider dentinal tubules and thin protective cementum)
  • resorption slower in older age groups
• diagnosis
  • radiographically
    • radiolucent bowl shaped cavitations along root surface
    • corresponding radiolucency in adjacent bone
    • can detect as early as 2 weeks after replantation
  • clinically
    • tender to percussion
    • dull tone (vs ankylosis)
• management
  • endo + endo medication

Replacement resorption (Ankylosis)

• histology
  • fusion of alveolar bone to root surface
• pathogenesis
  • extensive damage to PDL
  • bone repair dominates
  • replacement resorption
• 2 directions
  • progressive replacement resorption
    • tooth becomes part of continuous bone remodelling
  • transient replacement resorption
    • replacement resorption exposes dentinal tubules + infected root canal
    • replacement + inflammatory resorption
• diagnosis
  • percussion test - raised note
  • decreased tooth mobility - perio test
  • radiograph - disappearance of PDL space
• anderson et al 1984
  • <10%
  • 10 -20%

  • 20%

• clinical management
  • no treatment
  • young patients
    • disturb normal growth of alveolar process
  • exo
• 
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Cervical resorption

• pathogenesis
  • unknown
    • traumatic conditions ? suggested role of bacteria
  • cervical area
• diagnosis
  • radiographically
    • single lacuna in cervical area
    • alveolar bone
    • trace pulp chamber
  • pink spot
• clinical management
  • exposure resorption lacuna
    • orthodontic or surgical
  • removal of resorptive tissue
    • surgical curettage
    • trichloroacetic acid (90% solution)
• 

Internal inflammatory resorption

• pathogenesis
  • inflammatory signal
  • collateral blood supply?
  • cervical area
• diagnosis
  • radiolucency, oval shaped enlargement
  • root surface resorption
• management
  • removal of residual pulp tissue
  • chemo mechanical preparation
  • medication
  • root filling
    • thermoplastiticise GP technique
  • external communication
    • long term CH or surgical
  • 

Concussion/Subluxation

• concussion
  • minor damage to PDL, no gingival bleeding
  • tooth is TTpercussion, no loosening or displacement
  • no radiographic changes
• Subluxation
  • rupture PDL fibres, some mobility, may have gingival bleeding
  • TTpercussion
  • possible widened PDL on PA film
• management
  • relief of occlusal interference may be necessary
  • incase of severe loosening or multiple tooth injuries, teeth may be splinted (2 weeks)
  • soft diet 14 days otherwise
• CONCUSSION FOLLOW UP
  • 
• SUBLUX FOLLOW UP
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**Extrusive Luxation

Clinical and radiographic findings

• extruded teeth appear elongated often with lingual deviation
• always bleeding from PDL
• expanding PDL space apically on PA
  

Management
- gently reposition using finger pressure
- splint tooth for 2 weeks
- endo in cases where pulp necrosis anticipated/signs and symptoms indicate becoming necrotic

lateral luxation

Clinical and radiographic findings

• crowns displaced lingually associated with vestibular fractures of socket wall
• increased apical PDL space on an occlusal or eccentric exposure

Management
- gently reposition using finger pressure or forceps
- splint tooth 4 weeks
- monitor pulpal condition
- if pulp becomes necrotic, RCT indicated for prevention of root resorption

Intrusive luxation

Clinical and radiographic findings

• displaced axially into alveolar bone
• no mobility, high pitched (metallic sound) to percussion like ankylosis
• may be no PDL space on periapical film
• crowns displaced lingually associated with vestibular fractures of socket wall
• CEJ located more apically than non affected teeth

Treatment

• repositioning
  • spontaenous re eruption - treatment of choice for immature teeth (takes about 6 months for full eruption)
  • orthodontic eruption (Cases with completed root development)
  • surgical repositioning - where tooth is intruded more than 6mm or multiple intrusions
    
    

Crown Fractures

Enamel

Enamel Dentine

Rebonding crown fragment

Veneer to improve aesthetics after fragment reattachment

Complicated crown fractures

• immature teeth with pulpal involvement
  • pulp status
    • vital or necrotic
  • vital - assess exposure size
    • pulp cap
    • apexogenesis (Cvek pulpotomy)
  • necrotic
    • apexification
    • regeneration

cvek pulpotomy

• 96% success rate from 31mo follow up, pulpotomy completed ranging 1hour-90 days

Apexification

• must be resporable
• imaturature teeth with pulpal necrosis
• surgery not alternative
• **technique
  • isolation
  • access
  • pulp extirpation
  • working length
  • instrumentation
  • dry canal
  • calcium hydroxide
  • coronal seal
  • recall
  • hard tissue barrier
  • Obturation
  • modified lateral condensation
  • master GP cone -chemically softened
  • Thermoplasticised GP
  • Follow-up
• apical barrier
  • location
  • composition
    • bone
    • cementum
    • connective tissue
    • CaOH2
  • Hertwigs root sheath
    • apical barrier formation
    • remnants in PDL
  • role of calcium hydroxide
    • stimulate barrier formation
    • provide suitable environment
• 

Infraction

Enamel Fracture

Enamel Dentine Fracture

Root fractures

Treatment

• reduction of displaced coronal fragment
• immobilisation
• semi rigid fixation - acid etch / resin splint
• fixation for about one month

Crown root fracture

• fracture involving enamel, dentine, cementum
• 
  

perio surgery

ortho extrusion

Injuries to supporting bone

• comminution of alveolar socket
• fracture of socket wall
• fracture of alveolar process
• fracture of maxilla or mandible

Avulsion

Periodontal healing reactions

• healing with normal PDL
• healing wit hsurface resorption
• healing with replacement resorption (ankylosis)
• healing with inflammatory root resorption

PUlpal healing reactions

• revascularisaiton or necrosis
  • necrosis only diagnosed after 2-4 weeks
• predictors for revascularisation
  • width and length of RC
    • mature apices (<1mm apical foramen) only if immediate replantation otherwise necrosis
    • open apices - greater contact area for revascularisation
  • storage period and storage medio
    • dry storage / non physiologic storage
    • physiologic media - saline / milk - weak relationship with time

Autotransplantation