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Traumatic injuries srikanth

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Page 1: Traumatic injuries srikanth
Page 2: Traumatic injuries srikanth
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CONTENTS Introduction Classification Etiology and causes Clinical examination Enamel fractures Uncomplicated crown fracture complicated crown fracture Crown root fracture Root fracture Luxation injuries Avulsion conclusion

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Introduction

Traumatic dental injuries are everyday occurrences and their prevalence has been continuously rising. Trauma has been one of the main etiological factor for numerous restorative and endodontic procedures. A thorough knowledge of various types of traumatic injuries is mandatory to treat these cases successfully.

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• Ellis classification

class 1

class 2

class 3

class 4

class 5

Class 6

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Ellis And Daveys Classification

• Class I – simple crown fracture with plain enamel involvement

• Class II – extended crown fracture with noticeable dentinal involvement, without pulp

exposure• Class III - extended crown fracture with noticeable dentinal

involvement, with pulp exposure• Class IV – teeth that lost vitality, with or without loss of

crown • Class V – traumatically avulsed teeth• Class VI – crown fracture with or without loss of crown

• Class VII - tooth luxation without crown or root fracture• Class VIII – cervical crown fracture• Class IX - traumatic injuries on primary teeth

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• WHO classification (1978)873.60 – crown fracture involving only enamel873.61 – crown fracture involving enamel and

dentin without pulp exposure873.62 – crown fracture involving enamel and

dentin with pulp exposure873.63 – root fracture873.64 – crown root fracture873.66 – tooth luxation873.67 – tooth intrusion or extrusion873.68 – tooth avulsion873.69 – other injuries ( soft tissue injuries )

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• Andreasen modification of WHO classification

873.64 – complicated and uncomplicated crown root fracture

873.66 – concussion

Subluxation

Luxation injuries with alveolar fractures

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• WHO classification (1995)

S.02.5 - Fracture Of ToothS.02.50 - Fracture of enamel only + enamel infractionS.02.51 - Fracture of crown of tooth without

pulpal involvementS.02.52 - Fracture of crown of tooth with

pulpal involvementS.02.53 - fracture of root of toothS.02.54 - Fracture of crown with root of tooth,

with or without pulpal involvementS.02.57 - multiple fractures of tooth

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• Andreasen classification Injuries to teeth

Crown infraction and uncomplicated fracture without involvement of dentinUncomplicated crown fracture with involvement of dentinComplicated crown fractureUncomplicated crown root fracture Complicated crown root fractureRoot fracture

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• Injuries to periodontal tissues

Concussion

Subluxation

Intrusive luxation

Extrusive luxation

lateral luxation

Exarticulation

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• Garcia Godoys classification

Class 0 – enamel crackClass 1 – enamel fracture Class 2 – enamel- dentin fracture without pulp exposure Class 3 – enamel-dentin fracture with pulp exposure Class 4 – enamel-dentin-cementum fracture without pulp

exposureClass 5 – enamel-dentin-cementum fracture with pulp

exposureClass 6 – root fractureClass 7 – concussion

Class 8 – luxation ( loosening )

Class 9 – lateral displacementClass 10 – intrusionClass 11 – extrusionClass 12 – avulsion

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• Pulver classificationClass I

Division I – no external fracture, no displacementDivision II – displacement but no fractureDivision III – fracture of enamel only, no

displacementDivision IV – displacement and fracture of

enamel onlyClass II

Division I – fracture of enamel and dentin only, no displacement

Division II - displacement and fracture of enamel and dentin only

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Class III

Division I – fracture (with exposure of pulp), no displacement

Division II – displacement and fracture (with exposure of pulp)

Class IV

Division I – fracture of root

Class V

Division I – intrusion

Division II – partial avulsion

Division III –complete avulsion

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Heithersay and Morile classification (sub gingival fractures)

Class 1 – fracture line does not extend below the level of attached gingiva

Class 2 – fracture line extends below the level of attached gingiva but above the crest of alveolar bone

Class 3 – fracture line extend below the level of crest of alveolar bone

Class 4 – fracture line is within the coronal third of root but below the level of crest of alveolar bone

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Ingle classification

Soft tissuesLacerationsContusionsAbrasions

Tooth fracturesEnamel fractureCrown fracture – uncomplicatedCrown fracture – complicatedCrown root fractureRoot fracture

Luxation injuriesTooth concussionSubluxationIntrusive luxationLateral luxationExtrusive luxationAvulsion

Facial skeletal injuriesAlveolar processBody of mandibleTMJ

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Causes and incidence

1. Accidental falls

2. Traffic accidents

3. Acts of violence

4. Sports

7 to 10 years – most accident prone

Maxillary cental incisors, lateral incisors and

then mandibular incisors

Most common dental trauma – enamel fracture or

uncomplicated crown fracture

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Clinical examination

Soft tissues- adjacent to fractured teeth should be carefully examined and palpated

Facial bones

Teeth1. Fracture2. Mobility3. Displacement4. Injury to periodontal tissues

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5. PULPAL TRAUMAevaluated both initially and at various

times following the trauma

Pulp stunning

Pulp test unpredictable in trauma – why???(Pillegi et al,EDT’96)

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LDF – promising practical problems

PULSE OXIMETRYmeasuring vascular health by evaluating

oxygen saturation

highly effective – recently traumatised teeth(Velayutham et al’07)

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Prognosis of pulp after different levels of fracture

LEVEL OF FRACTURE PROGNOSIS OF PULP

Enamel infractionEnamel infraction 97 – 100% survival97 – 100% survival

Enamel fractureEnamel fracture 99-100% survival99-100% survival

Enamel – dentin fractureEnamel – dentin fracture

uncomplicateduncomplicated

75-98% survival75-98% survival

0.2%-0.5% obliteration0.2%-0.5% obliteration

Enamel – dentin fractureEnamel – dentin fracture

complicatedcomplicated

Direct pulp capping:72-81%Direct pulp capping:72-81%

Vital amputation 94 -100%Vital amputation 94 -100%

All crown root fracturesAll crown root fractures Worse than crown fractures, no Worse than crown fractures, no reports availablereports available

(Olsburg et al’01)

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Prognosis of pulp after luxation injuries

Type of luxation injury Type of luxation injury Pulp deathPulp death

concussionconcussion 4%4%

sub-luxationsub-luxation 12%12%

lateral luxationlateral luxation 77%77%

extrusive luxationextrusive luxation 55 – 98%55 – 98%

intrusive luxationintrusive luxation 100%100%

Barnett et al ‘02

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Radiographic examination

- embedded fragments in soft tissues

- dislocations

- root and jaw fractures

- resorptive and calcific changes

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Soft tissue injuries

control bleeding, repositioning displaced tissues and suturing

LacerationLaceration

ContusionContusion

AbrasionAbrasion

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Enamel fracture

• Chips and cracks confined to enamel

• Enamel infractions – transillumination, indirect light or disclosing dyes

• Cracks – no treatment

• Follow up

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Crown fractures (uncomplicated)

• Outcome – formation of irritation dentin or pulp necrosis

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Composite Build Up Restores About 100% Strength Recovery

Reattachment of fractured fragment – restores around 50% to 60% of original strength

(worthington et al ’99)

GO IN FOR REATTACHMENT WHENEVER POSSIBLE !!!

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Methods of reattachmentA. using circumferential bevel before reattaching

B. using a V shaped notch

C. placing a internal groove

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D. placing a chamfer at the fracture line after reattaching

E. superficial over contour over the fracture line

F. simple reattachment

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Fracture strength of different reattachment techniquesSuperficial over contour, placing a internal groove provided fracture strength as high as sound teeth (Reis & others ‘01)

Influence of materials used in reattachment on Influence of materials used in reattachment on fracture strength fracture strength

Different material combinations used to bond tooth fragments to remaining crown were found to have no influence on fracture strength after bonding

(Reis, Kraul et al ’02)

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Crown fracture (complicated)

0.9 to 13% - all dental injuries Consequence First 24 hrs – proliferative response with inflammation not

extending more than 2mm into pulp

Treatment1. Vital pulp therapy

2. Pulpectomy

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Factors affecting treatment selectionFactors affecting treatment selectiona.a. TimeTimeb.b. Attachment damageAttachment damagec.c. Restorative treatment planRestorative treatment pland.d. Level of developmentLevel of development

VITAL PULP THERAPYVITAL PULP THERAPY PULP CAPPINGPULP CAPPING - no absolute indications- no absolute indications

- a bacteria tight coronal seal more difficult- a bacteria tight coronal seal more difficult- 80% success rate- 80% success rate

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PARTIAL PULPOTOMY Shallow or CVEK pulpotomy Advantage over deep pulpotomy

Procedure

Prognosis – 94 to 96%

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Material of choiceMaterial of choice

CaOH or MTACaOH or MTA

The reparative dentin is consistently more uniform and thicker under MTA compared with CaOH

Heide And Cvek – Safe to proceed with shallow pulpotomies upto 1 week post fracture

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FULL PULPOTOMY

Traumatic exposures after 72 hours Technique Prognosis – 75%

Contraindicated – mature teethpulpectomy has a success rate 95%, whereas if apical

periodontitis develops, the prognosis of RCT drops to 80%.

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Other treatmentsOther treatments

a.a. PulpectomyPulpectomy

b.b. Apexification proceduresApexification procedures

CaOH apexificationCaOH apexification MTA apexificationMTA apexification

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CROWN – ROOT FRACTURE

Complicated and uncomplicatedComplicated and uncomplicated

Treatment modalitiesTreatment modalities

ReattachmentReattachment

Restorative TreatmentRestorative Treatment

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Crown root fracture and biological width

Biological width – Biological width – connective tissue attachment + connective tissue attachment + junctional epitheliumjunctional epithelium

Andersean et al – 4mm tooth structure above crest of alveolar bone

Methods Methods a.a. Periodontal surgeryPeriodontal surgery

b.b. Surgical extrusionSurgical extrusion

c.c. Orthodontic extrusionOrthodontic extrusion

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Periodontal surgery

Apically repositioned flap surgeryApically repositioned flap surgeryesthetics??esthetics??

When to go for gingivectomy???When to go for gingivectomy???

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Surgical extrusion (intra-alveolar transplantation)

ProcedureProcedure

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AdvantagesAdvantages

DisadvantagesDisadvantages

surgical extrusion of average 4.25mm ( 3 – 7mm) can be performed without any complication and good

long term success (caliskan et al ’99 )

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Healing after surgical extrusion

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Orthodontic extrusion

Slow or forced extrusionSlow or forced extrusion

ProcedureProcedure

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Time of treatment – 2 to 3 weeksTime of treatment – 2 to 3 weeks

Stabilisation – 2-3 monthsStabilisation – 2-3 months

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Orthodontic extrusion with supracrestal fibrotomy ( Ami Smidt et ’05 )

Force required –25 to 30 g ( Reitan and Vanarsdall ’94 )

50 to 75 g ( Profitt and Fields ’93 )

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Root fracture

• Types – Types – transverse or obliquetransverse or obliquesingle or multiplesingle or multiplecomplete or incompletecomplete or incomplete

• Radiographs – angled within 4 degrees of fracture lineRadiographs – angled within 4 degrees of fracture line• Additional radiograph at 45 degrees ( INGLE )Additional radiograph at 45 degrees ( INGLE )• At least 3 angled radiographs – 45, 90 , 110 degrees At least 3 angled radiographs – 45, 90 , 110 degrees

( COHEN( COHEN ) )

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• Displacement - none to severeDisplacement - none to severe• Biological consequenceBiological consequence

pulp necrosis of coronal part – 25%pulp necrosis of coronal part – 25%pulp necrosis of apical part – rare

Emergency treatmentEmergency treatment

a. Repositioning – finger pressure or a. Repositioning – finger pressure or orthodontic interventionorthodontic intervention

b. Splinting - 2 to 4 weeksb. Splinting - 2 to 4 weeks

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• Healing pattern of root fracturesHealing pattern of root fractures(Andresean and Hjorting-Hansen)

1. Healing With Calcified Tissue

2. Healing with interproximal connective tissue

3. Healing with interproximal bone and connective tissue

4. Interproximal inflammatory tissue without healing

First 3 types - success

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• TREATMENT OPTIONSTREATMENT OPTIONS

a.a. Root canal therapy of both segmentsRoot canal therapy of both segments

b.b. Root canal treatment of coronal segment Root canal treatment of coronal segment alonealone

c.c. Use of intraradicular splintUse of intraradicular splint

d.d. Root extrusionRoot extrusion

Cvek modification of root canal therapy of coronal segment alone

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• PrognosisPrognosis- amount of dislocation, stage of root development - amount of dislocation, stage of root development and quality of treatment.and quality of treatment.

• Fracture location on prognosisFracture location on prognosisMore apical the fracture, better the prognosis More apical the fracture, better the prognosis

MISCONCEPTIONMISCONCEPTION

- location did not influence outcome ( Zachrisson and

Jacobsen )

- fracture location matters less as long as it is not too close to the alveolar crest

( Jacobsen )

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• ComplicationsComplications

a.a. Pulp necrosisPulp necrosis

b.b. Pulp canal obliterationPulp canal obliteration

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Deep root fracture without pulp necrosis

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Deep root fracture with pulp necrosis

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Autotransplantation for shallow root fracture

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Deep root fracture with coronal and apical pulp necrosis

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Luxation injuries

Largest group – 30 to 44%

Includes1. Concussion2. Subluxation3. Extrusive luxation4. Lateral luxation5. Intrusive luxation6. Avulsion

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concussion

No displacement Normal mobility Sensitivity to percussion

Management

symptomatic

D. Diagnosis

root fracture, subluxation

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subluxation

Sensitivity to percussion Increased mobility No displacement

Mangement

optional splinting for 2 to 3 weeks

D. Diagnosis

root fracture

Pulp death in 12 to 20%

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Lateral luxation

Displacement labially, mesially, distally or palataly

Management

repositioning

splinting (2 – 3 months)

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Extrusive luxation

Displacement in coronal direction

Differential Diagnosis

root fracture

Management

1. Repositioning

2. Splint – 1 - 3 weeks

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Intrusive luxation

Displacement in apical direction

into alveolus Poorprognosis

Management

1. No treatment in immature teeth

2. Repositioned – surgical or

orthodontic or combination

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Sequalae to luxation injury

Yellow discoloration Grey discoloration Resorption – 5 to 15% Incomplete root formation

Primary teeth – pulp space obliteration by calcification

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Healing events2 weeks afterreplantation Most

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Healing with minorinjury to the periodontal ligament

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Healing with moderate injury to theperiodontal ligament and associated infection in the pulp and/or dentinal tubules

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Healing afterextensive injury to theperiodontal ligament

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Hank’s Balanced Salt Solution (HBSS),

Viaspan® ,Euro-Collins® , Custodiol

Minimum Essential Medium (MEM)

Saline , Water, Saliva, Milk, Propolis ,

Red mulberry, Egg white, Coconut water,

Gatorade ,Ricetral,,Green tea , Conditioned medium

Contact lens solution , Salvia extract,

Tooth rescue box (Dentosafe)

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Storage medium

Desired – PDL viability

Saliva, saline and tap water

Hanks balanced salt solution (HBSS) standard saline solution

non toxic, pH balanced and contains essential nutrients

‘Save-A-Tooth’

– no longer recommended

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Milk

PDL cell viability – physiological osmolality

Milk with a lower fat content more useful at maintaining cell viability than milk with higher fat content

(Sigalas et al ’04)

longer shelf life milk with lower fat content – tested (Ozan et al’07)

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Propolis

Multifunctional material

anti inflammatory, antibacterial, antioxidant, antifungal, antiviral and tissue regenerative

properties

10% Propolis better than milk, HBSS

(Ozan et al’07)

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Order of preference

By literaturePropolisPropolis

HBSSHBSS

Long shelf life Milk with low Long shelf life Milk with low fat contentfat content

Milk with high fat contentMilk with high fat content

SalineSaline

SalivaSaliva

By availabilityLong shelf life milk with low Long shelf life milk with low

fat contentfat content

Milk with high fat contentMilk with high fat content

SalineSaline

SalivaSaliva

Contact lens solution – alternative (Sigalas et al’04)

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Treatment objectives

Avoid or minimize – inflammation

1. attachment damage

2. pulpal infection

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PREPARARTION OF SOCKET

Left undisturbedLeft undisturbed

Light aspiration – remove blood clotLight aspiration – remove blood clot

Alveolar bone collapse – reposition using blunt Alveolar bone collapse – reposition using blunt instrumentsinstruments

Rinse of emdogainRinse of emdogain

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Clinical Management of avulsed teeth

Preparation of rootPreparation of root

Extra oral time

Less than 60 minutesLess than 60 minutes Greater than 60 minutesGreater than 60 minutes

Closed apexClosed apex Open apexOpen apex

Root development

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Replantation of a tooth with completed root formation

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Replanting a tooth withincomplete root formation

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Extra oral time more than 60 minutes

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‘EXARTICULATION’

Attachment damage and pulp necrosis

Why osseous replacement or replacement

resorption occurs???

External inflammatory resorption after avulsion???

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Development of inflammatory root resorption and pulp necrosis

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Development of ankylosis

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EMDOGAIN EMDOGAIN - Increase resistance to root resorption- Stimulate PDL regeneration

(Fillipi et al’01)- inhibits epithelial cell growthinhibits epithelial cell growth

How does it act ??How does it act ??

Emdogain – does not prevent progressive root resorption.

(Schjott at al’05)

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Splinting

Splinting – technique and durationSplinting – technique and duration

Splinting technique – physiological tooth Splinting technique – physiological tooth movementmovement

Duration – minimalDuration – minimal

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Splinting techniques

a. Rigid

b. Semi rigid

TypesBracket splint

Composite Resin splint

Acrylic or gold cap splints

Orthodontic bands + arch bar splints

Composite – wire splint / bonded metal wire splint

Titanium trauma splint (TTS)

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TTS required reduced chair side time – application and removal

(VonArx et al’01)

TTS and composite wire splint – less gingival irritation, well tolerated

(Fillipi et al’02)

TTS and composite wire splint – allowed physiological mobility

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Duration of splinting

Root fracture – 2 to 4 weeks (2 – 4 months)

Avulsion – 7 to 10 days

Avulsion with alveolar fracture – 4 to 8 weeks

Lateral luxation – 3 to 4 weeks

Extrusive luxation – 4 to 8 weeks

Sub luxation – 2 to 3 weeks (optional)

concussion – 1 to 2 weeks (optional)

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Adjunctive therapy Systemic and topical antibiotic application

Tetracycline – affects osteoclast motility + reduction of collagenase effectiveness

(Sae-Lim et al’98)

Systemic pencillin

Chlorhexidine rinses

Tetanus booster – within 48 hours

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Various factors influence the outcome of teeth that

had undergone trauma. Correct diagnosis, quality and

timeliness of initial and long term treatment can improve

the prognosis of the traumatized teeth.

Conclusion

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REFERENCES

- Essentials of traumatic injuries to the teeth J.O.Anderasen and F.M. Anderasen

-Treatment planning for traumatized teeth - Mitsuhiro tsukiboshi

-cohen’s pathways of the pulp tenth edition

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- Ingle’s –Endodontics 6th edition

- Storage Media For AvulsedTeeth: A Literature Review Brazilian Dental Journal (2013) 24(5): 437-445

- Transport media for avulsed teeth: A review Aust Endod J 2012; 38: 129–136

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- A proposal for classification of tooth fractures based on treatment needJournal of Oral Science, Vol. 52, No. 4, 517-529, 2010

Assessment of pulp vitality: a reviewInternational Journal of Paediatric Dentistry 2009; 19: 3–15

STUDY OF STORAGE MEDIA FOR AVULSED TEETH Brazilian Journal of Dental Traumatology (2009) 1(2): 69-76

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Fracture resistance of tooth fragment reattachment: effects of different preparation techniques and adhesive materials Dental Traumatology 2010; 26: 9–15;

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