THE TWILIGHT SERIES

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1 21/03/12 Phillippe O Zimet THE TWILIGHT SERIES Associate Professor in Endodontics School of Dentistry and Oral Health La Trobe University 77 Stud Rd Dandenong zimendo@c032.aone.net.au At the end of this lecture participants will be able to : 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " Treatment guidelines are from: 1. Guidelines for the evaluation and management of traumatic dental injuries. International Association of Dental Trauma Updated February 2012 Part 1 Anthony J. DiAngelis, Jens O. Andreasen, Kurt A. Ebeleseder, David J. Kenny, Martin Trope, Asgeir Sigurdsson, Lars Andersson, Cecilia Bourguignon, Marie Therese Flores, Morris Lamar Hicks, Antonio R. Lenzi, Barbro Malmgren, Alex J. Moule, Yango Pohl, Mitsuhiro Tsukiboshi 1

2 21/03/12 Definition and Diagnosis are from: 2. AAPD Trauma Guide AAPD Guideline on Pulp Therapy for Primary and Young Permanent Teeth The Dental trauma Guide 5. Traumatic Dental Injuries A Manual Highly recommended text Andreasen et al 2011 At the end of this lecture participants will be able to : AIM of Trauma Management: 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " Maintain, preserve or reinstate the original dentition Objective of Trauma Management: Preserve the pulp Preserve the periodontal ligament Maintain aesthetics of the dentition Maintain function of the dentition Ensure comfort of the dentition 2

3 21/03/12 Want to avoid treatable pathology that may result in loss of tooth (such as inflammatory resorption) or patient symptoms such as pulp necrosis or pulpitis. Pathology may not be evident early or provide confusing signs and symptoms. May get necrosis with infection late such as after calcification. How do we assess and manage? Sitra yusuf A parent s nightmare Nov 2010 Every effort is made to preserve the pulp of the immature permanent tooth, or induce revascularization or regeneration of pulp tissue. mccartney March 2007 June avulsed teeth 32, 31 and 42 some 5 days ago. Teeth placed in milk soon after for 2 hr note from the referring practitioner regarding an alveolar fracture Clinical examination revealed imbrucation of the lower anterior dentition with a lingual splint 43, 42, 41, 32 and 31 to be non responsive to pulp testing. Treatment?

4 21/03/12 At the end of this lecture participants will be able to : Gray The response of the teeth to trauma is variable 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " Remember dental trauma can happen any time and any place. The first course of treatment is prevention. EPIDEMIOLOGY - Relation to prevention Importance of mouthguard and face shields Use of seatbelts Use of safe toys eg swings Ref: Monash University Accident Research Centre, Newsome (mouthguards) IJPD 2001, Shahim ADJ 2006, Bastone ADJ 2000) 4

5 21/03/12 Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial C Finch, R Braham, A McIntosh, P McCrory and R Wolfe Injury Prevention 2005;11: This is the first randomized controlled trail of the effectiveness of protective equipment in community level Australian football, and one of a few worldwide in any sport. Players who were allocated to the custom fitted mouthguard study arm had a significantly lower rate of head and orofacial injuries than all other players. Mouthguards in sport activities : history, physical properties and injury prevention effectiveness. Knapik JJ, Marshall SW, Lee RB, Darakjy SS, Jones SB, Mitchener TA, delacruz GG, Jones BH. Sports Med. 2007;37(2): Studies that have examined injuries among mouthguard users and nonusers are of highly variable methodological quality. However, published research consistently shows that mouthguards offer significant protection against orofacial injuries. Meta-analysis indicates that the overall risk of an orofacial injury is times higher when a mouthguard is not worn, relative to wearing a mouthguard. Epidemiology of dental trauma; a review of the literature Bastone, Freer and McNamara ADJ 2000 Accidents within and around the home were the major sources of injury to the primary dentition Accidents at home and school accounted for most of the injuries to the permanent dentition. SO BE READY TO TREAT TRAUMA AT ANY TIME At the end of this lecture participants will be able to : 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " 5

6 21/03/12 WHO CLASSIFICATION (1992) -DENTAL INJURIES TREAT IN ASSOCIATION WITH HARD TISSUE/PULP 1. PERIODONTAL TISSUES 1.1. Concussion 1.2. Subluxation 1.3. Extrusive Luxation(peripheral dislocation,partial avulsion) 1.4. Lateral luxation 1.5. Intrusive luxation(central dislocation) 1.6. Avulsion (exarticulation) 2. INJURIES TO SUPPORTING BONE 2.1. Comminution (splintering) of the mandibular or maxillary alveolar socket 2.2. Fracture of the mandibular or maxillary socket wall 2.3. Fracture of the mandibular or maxillary alveolar process 2.4. Fracture of the mandible or maxilla 3. GINGIVAE OR ORAL MUCOSA 3.1. Laceration of gingivae or oral mucosa (includes tear and degloving) 3.2. Contusion of gingivae or oral mucosa (sub mucosal haemorrhage) 3.3. Abrasion of gingivae or oral mucosa (superficial) WHO CLASSIFICATION (1992) -DENTAL INJURIES 4. HARD DENTAL TISSUES AND PULP 1. Enamel infraction 2. Enamel fracture (uncomplicated crown fracture) 3. Enamel/dentine fracture (uncomplicated crown fracture) 4. Complicated crown fracture 5. Uncomplicated crown/root fracture 6. Complicated crown /root fracture 7. Root fracture At the end of this lecture participants will be able to : The common theme following trauma to the dentition is that following dental trauma there may injury to the: Pulp Tooth Separation or crushing of supporting tissues (gingivae, PDL, bone) 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " 6

7 21/03/12 RESULTS OF TRAUMA- MANY TISSUES AFFECTED BY TRAUMA " Pulp healing " " " Nothing/Physiologic surface resorption" Internal Resorption External Resorption (Infection " Induced / Inflammatory) External Resorption (Replacement)" Ankylosis" Pulpal Canal Obliteration" Invasive Cervical Resorption " Pulpal ischaemia - Necrosis or infection" Transient apical internal resorption" Transient apical breakdown" Transient/permanent marginal breakdow Following dental trauma there may injury to the: Pulp Tooth Separation or crushing of supporting tissues (gingivae, PDL, bone) Yusuf Consequences: What does this picture represent? haemolysis vital pulp haemolysis with ischaemia neuropraxia neurotmesis pulp necrosis pulp necrosis with infection Yusuf Consequences: At what point is treatment required?

8 21/03/12 Pulp necrosis and infection: Pulp necrosis and infection: Perera presurgical tigas Perera Pulp necrosis tooth fails to develop. Treat when signs or symptoms of infection occur: Prevalence of outcome following trauma to 899 injured teeth (Hecova Dent Trauma 2010): Battle open apex and pulp necrosis Follow up: In children, pulp necrosis was usually diagnosed within 6 months after the injury (91.9% of all injured teeth) and in virtually all teeth within one year. In patients older than 15 years, pulp necrosis was predominantly diagnosed later than 6 months (61.7% of all cases) or even later than 12 months (40%) after the trauma 8

9 21/03/12 Calcific Metamorphosis (Pulpal Calcific Obliteration) Aetiology Impact injury that did not result in necrosis Vital pulp Process of calcification- Temporary disruption in blood supply leads to deposition of tertiary dentine (irregular secondary) dentine. Can occur with all injury types. 70% of teeth with PCO discolour. The colour may be yellow or even grey Robertson A etal Incidence of pulp necrosis subsequent to pulpcanal obliteration from trauma of permanent incisors. J Endod 1996:22: Sandra Ennor 21 yellow from calcified pulp trzcinski Prognosis: Root development Crown fracture Pulp caclification can result in coronal discolouration which can occur some years later Adeleke O Oginni and Comfort A Adekoya-Sofowora 2007 siderus calcification and pap % annual risk of pulp necrosis and signs of infection

10 21/03/12 Prevalence of outcome following trauma to 899 injured teeth (Hecova Dent Trauma 2010): Pulp canal obliteration extrusive luxations, 62.5% with open apices and in 8.6% teeth with closed apices. lateral luxation, 34.8% in teeth with incomplete root formation and in 5.7% teeth with complete root development. Following dental there may injury to the: Pulp Tooth Separation or crushing of supporting tissues (gingivae, PDL, bone) Perera presurgical fracture Following dental trauma there may injury to the: Pulp Tooth Separation or crushing of supporting tissues (gingivae, PDL, bone) Separation cause collagen to cleave and some cell damage 10

11 21/03/12 Bony healing impaction stage (clot gelatinous coagulum) inflammation stage 7 days primary soft callus formation stage 2 weeks callus mineralisation stage 4 th week to 10 th week callus remodellation stage Following dental there may injury to the: Pulp Tooth Separation or crushing of supporting tissues (gingivae, PDL, bone) Crushing damages the cellular and intercellular systems. Damaged tissue is removed by macrophages and osteoclasts before traumatized tissue is repaired Soft Tissue Collagen at margins 3 days Granulation tissue fills defect 7 days Scarring with Collagen and decreasing Vascularity 2 weeks Connective tissue with Epidermis 1 month McCarthy Can I still reposition teeth at 5 days? PDL By 2 weeks 2/3 of the mechanical strength of the PDL is restored PULP If vascular supply is severed, ingrowth of new vessels begins at 4 days McCarthy Can I still reposition teeth at 5 days? Following dental there may injury to the: Pulp Tooth Separation or crushing of supporting tissues (gingivae, PDL, bone) In complicated luxation, intrusion or avulsion injuries the loss of protecting cementoblast layer and epithelial rests of Malassez allows osteoclasts and macrphages to remove damaged PDL and cementum on root surface. 11

12 21/03/12 1. Alveolar changes - Transient marginal breakdown Definition of resorption Loss of hard tissue by physiologic or pathologic means due to activation of clastic cells Following injury to the supporting bone, remodelling occurs with fabrication of granulation tissue. This is seen as a widened PDL space. After 2-3 months the periodontium usually reforms This can also be seen at the apex as transient apical breakdown (a transient apical radiolucency) cril ly Alveolar changes -Permanent marginal breakdown Following injury to the supporting bone, remodelling occurs with fabrication of granulation tissue. This is seen as a widened PDL space. In some instances the healing of the bone does not occur. This may be due to the degree of trauma, or presence of infection. Bony sequestrum may even occur. May be seen after lateral luxations, avulsion, intrusion, alveolar fracture or jaw fracture Tooth resorption: Andreasen s Classification of resorption: 1. Internal inflammatory 2. External: Surface Inflammatory Replacement 12

13 21/03/12 2. Tooth resorption Linsdkog/Heithersay s Classification: This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; (2) infection induced tooth resorption; (3) hyperplastic invasive tooth resorptions. Linsdkog/Heithersay s Classification (Heithersay ADJ 2007):" This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; Surface resorption Transient apical internal resorption Pressure resorption and orthodontic resorption Replacement resorption Ankylosis Linsdkog/Heithersay s Classification (Heithersay ADJ 2007):" This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; Surface resorption Transient apical internal resorption Pressure resorption and orthodontic resorption Replacement resorption Ankylosis Minimize surface resorption and maximize pulpal healing by ensuring teeth are repositioned correctly Maclean maclean not properly repositioned

14 21/03/12 Linsdkog/Heithersay s Classification (Heithersay ADJ 2007):" This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; Surface resorption Transient apical internal resorption Pressure resorption and orthodontic resorption Replacement resorption Ankylosis Transient apical internal resorption TAIR may be associated with colour change Problem is that resolution of colour change does not always occur and a more invasive approach (commencement of RCT) may still be warranted (Heithersay 2007). When I see colour change I am now less inclined to watch. Jacob peters Deege n Transient apical internal resorption may be associated with transient apical breakdown Linsdkog/Heithersay s Classification (Heithersay ADJ 2007):" This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; Surface resorption Transient apical internal resorption Pressure resorption and orthodontic resorption Replacement resorption Ankylosis 14

15 21/03/12 Compare Inflammatory Resoprtion to Replacement Resorption RR is affected by the status of the periodontal ligament. There is minimal impact from endodontic treatment. Most influence is from apical diameter for intrusion initial management in order to maintain vitality of the periodontal ligament fibers after avulsion Tooth survival improves with proper management. Either replace or store: 11 and 21 were placed in milk after 5 minutes for about 1 hour. 11 was passively managed. As 21 showed signs of resorption, active management. Is this inflammatory or replacement resorption? Prevalence of outcome following trauma to 899 injured teeth (Hecova Dent Trauma 2010): Root resorption: peppler prevalence of replacement resorption was 2.9% in laterally luxated teeth immature teeth and of mature teeth 42.9% of avulsed and replanted teeth (9 of 17 immature teeth and 12 of 32 mature teeth) is positive to EPT. Bizarre 15

16 21/03/12 Avulsed then in milk for half hour Bsmith avulse 2-3 min in about 2000 James Avulsed Milk half hour Avulsed 2-3 min in about Is this inflammatory or replacement resorption? Results of intrusion 04/02/04 Prognosis Intrusive Luxation -Resorption collis Sondos Al-Badri Dental Traumatology Volume 18 Issue 2 Page 73 - April 2002 Linsdkog/Heithersay s Classification (Heithersay ADJ 2007):" This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; Surface resorption Transient apical internal resorption Pressure resorption and orthodontic resorption Replacement resorption Ankylosis 16

17 21/03/12 Ankylosis Results in interface and fusion between bone and tooth Linsdkog/Heithersay s Classification:" This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; (2) infection induced tooth resorption; Associated with pulpal necrosis and infection which may or may not be of traumatic origin Linsdkog/Heithersay s Classification: This classification is clinically based subdividing resorptions into three broad groups: (2) infection induced tooth resorption; Internal inflammatory (infective) root resorption External inflammatory root resorption Linsdkog/Heithersay s Classification: This classification is clinically based subdividing resorptions into three broad groups: (2) infection induced tooth resorption; Internal inflammatory (infective) root resorption External inflammatory root resorption 17

18 21/03/ Jacob peterson Subluxation Linsdkog/Heithersay s Classification: This classification is clinically based subdividing resorptions into three broad groups: (2) infection induced tooth resorption; Internal inflammatory (infective) root resorption External inflammatory root resorption If you dont follow up correctly this can happen: Prevalence of outcome following trauma to 899 injured teeth (Hecova Dent Trauma 2010): Root resorption: inflammatory resorptions were observed in 33.3% of intruded teeth with immature teeth and 33.3% mature teeth. 18

19 21/03/12 Prevalence of outcome following trauma to 899 injured teeth (Hecova Dent Trauma 2010): Root resorption: external resorptions of the root substances in 16.2% of all teeth. inflammatory resorptions were observed in 4.5% of laterally luxated immature teeth and of 14.9% of mature teeth. Linsdkog/Heithersay s Classification: This classification is clinically based subdividing resorptions into three broad groups: (1) trauma induced tooth resorption; (2) infection induced tooth resorption; (3) hyperplastic invasive tooth resorptions. Internal replacement (invasive) resorption Invasive coronal resorption Invasive cervical resorption Invasive radicular resorption What do the statistics mean clinically: Tooth 32 was avulsed while the adjacent teeth were luxated. Patient replanted the tooth back into the socket himself within about 15-20min. tigas At the end of this lecture participants will be able to : 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " 19

20 21/03/12 Intra-oral examination for all trauma MATTHEW YOUSSEF 21 march 2012 Clinical Tooth colour Millimetre Loosening/moblity Dislocation (Vertical/Horizontal) Tenderness to palpation Tenderness to percussion Thermal sensibility test; CO2, EPT Thermal sensitivity test; hot, cold Mucosal laceration Locate missing segments Note craze lines (infractures), fracture Occlusal interference Radiographic (hard and soft tissue): May need to take multiple vertical and horizontal angles At the end of this lecture participants will be able to : 1.describe the aim and objective of trauma management. 2.discuss the aetiology of dental trauma. 3.classify dental injuries. 4.understand the effect of trauma on the pulp. 5.understand the effect of trauma on the periodontium. 6.examine a patient with dental trauma. 7.undertake acute management of traumatized teeth (including diagnosis and treatment planning). 8.Pursue " endodontic management of traumatized teeth. " Summary of Dental Trauma Triage Table 1. The Dental Trauma Algorithm for medics and corpsmen (translated from Hebrew) Yehuda Zadik Dental Traumatology 2008; 24: ; 20

21 21/03/12 1. Loss of consciousness or confusion? Nausea or vomiting? Facial or jaw deformation? Haematoma in the face or in the floor of the mouth? Yes. Immediately refer to Emergency Department 4. Tooth mobility (other than avulsion)? Yes More than 2 mm mobility? No 2. Avulsion ("knock-out) of a tooth? Yes. Find the tooth. Hold it by the crown and wash under gentle running saline or water (Do not scrub). Replant the tooth into the Socket. No Yes. Refer to a dentist within 24 h. Continue to # 5 No 3. Tooth displacement (other than avulsion)? No Yes. Refer to a dentist within 24 h. Continue to # 3 Success in replantation? Yes. Refer to a dentist within 24 h No. Place the tooth in milk, saline or inside the patients mouth. Refer immediately to a dentist or ED If cant see the tooth confirm is it intruded, avulsed or coronal fracture. Try to account for tooth or segments (?avulsion, embed in lip, inhaled) 5. Tooth fracture? Yes. Tooth fracture with pulp exposure, intra-coronal bleeding or pain? No Yes. Refer to a dentist within 24 h. Continue to # 6 Is restoration needed? No No Yes. Refer to a dentist within 48 h 5. Tooth fracture? Yes. Tooth fracture with pulp exposure, intra-coronal bleeding or pain? Prognosis Pulp healing: Root development No Yes. Refer to a dentist within 24 h. Continue to # 6 Is restoration needed? The tooth is fractured but no pulp exposure. 6. Soft tissue laceration? No Yes. Refer to a dentist within 48 h. Continue to #6 No Yes. Through-and-through laceration Yes. Superficial laceration A suspected foreign body embedded in the soft tissue and/or infection Yes. Refer to a dentist or Emergency Department within several hours 21

22 21/03/12 General Patient instructions Soft diet for up to two weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. FOLLOW UP 3 weeks 6 weeks 3 months 6 months (equals one year) 12 months (equals two years) 24 months (equals four years) Follow up as for all trauma: Any symptoms Clinical signs Sinus tract stoma or swelling Gingivitis Pocket depth Recession Tooth Colour Loosening Tenderness to palpation Tenderness to percussion Thermal test (sensibility, sensitivity) Radiograph-mm dislocation, pulp calcification, continued root development, marginal bone loss, periradicular radiolucency, resorption. In Summary when do I perform endodontic treatment? IADT 2011 suggest 2 signs and symptoms are required to suggest pulpal infection. When I think the pulp is infected (not just necrotic) 1.Radiographic: Periapical lesion not resolve or increasing Size of pulp chamber (internal resorption) Sign of external inflammatory resorption Pulp calcification is a sign of pulp vitality Continued root development 3. Tenderness to percussion Andreasen found that the only sign significantly related to pulp necrosis was tenderness to pecussion following tooth luxation. (Andreasen et al; Textbook and colour Atlas of Traumatic Injuries to the teeth 4 th Edition p 378 from Andreasen FM, Endod Dent Traumatol 1989;5:111-31) " 2Clinical: Response to pulp testing: calcification vs necrosis (but is it infected?) vs vascular intact Colour (calcification vs necrosis vs transient hyperaemia) Sinus tract stoma Prolonged TTP 22

23 21/03/12 4. Coronal discolouration Andreasen states that grey colour changes can be seen in the crown even 2 to 3 weeks after trauma. This may be accompanied by radiographic periapical radiolucency. (Andreasen et al; Textbook and colour Atlas of Traumatic Injuries to the teeth 4 th Edition p 378 from Andreasen FM, Endod Dent Traumatol 1989;5:111-31). But even colour changes may be transitory and as with apical radiolucency may resolve and reverse within 1 year. (Andreasen et al; Textbook and colour Atlas of Traumatic Injuries to the teeth 4 th Edition p 378 from Andreasen FM, Endod Dent Traumatol 1989;5:199 and 201). 4. Coronal discolouration Grey coronal colour change is often, not always, related to pulpal haemorrhage or pulp necrosis. Yellow coronal colour change is related to pulpal calcification. Clinically Heithersay feels that if discoloration begins it rarely reverses (ADJ 2007). If there is no change in 3 months I begin RCT. " " When do I Splint teeth?" " Reason for splinting:" 1. Aid repair" 2. Comfort-loose, TTP" The prognosis for the healing outcome is more dependent on the type of injury rather than the effect of the splinting. the use of cap splints and orthodontic bands were associated with a greater frequency of pulp necrosis (31, 38) and pulp canal obliteration (45) when compared with acid etch resin splints and no splinting. the majority of the selected studies suggested that an extended fixation period is not an indicator for a poor healing outcome. Review by Kahler and Heithersay. Dental Traumatology

24 21/03/12 James McCartney This is not correct position Original badly placed Corrected with orthodontics and associated resorption What does treatment delay mean? Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries a review article.dental Traumatology 18 (3), Fig. 18. Effect of treatment delay upon healing of 98 luxated teeth with dislocation. From Eklund et al., 1976 (22). Arnes Muhic fracture trauma palatal 12 24

25 21/03/12 Cayla Extrusive Luxation Kinga Wojciechowska Trauma displaced Intrusive Luxation patients archibald donahue intrusion 2 weeks

26 21/03/12 IADT 2011 Guidelines for intrusion: Incomplete root formation: Allow eruption without intervention If no movement in 3 weeks initiate orthodontic repositioning If tooth is intruded more than 7mm, reposition surgically or orthodontically. Teeth with complete root formation: Allow eruption without intervention if intruded less that 3mm. If no movement in 3 weeks initiate orthodontic or surgical repositioning to limit chance of ankylosis. If tooth is intruded more than 7mm, reposition surgically or orthodontically. Teeth with closed apices will require RCT commence 2 to 3 weeks after repositioning. Once an intruded tooth has been repositioned surgically or orthodontically stabilize for 4 to 6 weeks. Summary of the three methods are only partly evidence based. (From Spontaneous eruption This is the treatment of choice for deciduous/primary teeth and for permanent teeth with incomplete root formation. This treatment has been shown to lead to significantly fewer healing complications than orthodontic and surgical repositioning. If no movement is noted within 3 weeks, recommend rapid orthodontic repositioning. Orthodontic repositioning This treatment may be preferred for patients with delayed treatment. This allows repair of marginal bone in the socket along with the slow repositioning of the tooth. Surgical repositioning This treatment technique is preferable in acute phase. Intrusion with major dislocation of the tooth (approximately more than half a crown length) may be an indication for surgical repositioning. Root canal treatment should be considered in all cases with completed root formation where the chance of pulp revascularization is unlikely. Endodontic therapy should preferably be initiated within 3-4 weeks post-trauma. Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries a review article.dental Traumatology 18 (3), Fig. 6. Effect of treatment delay upon pulp healing of 38 complicated crown fractures treated by pulp capping. From Fuks et al.,

27 21/03/12 Andreasen, J.O., Andreasen, F.M., Skeie, A., Hjørting-Hansen, E. & Schwartz, O.Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries a review article.dental Traumatology 18 (3), Fig. 12. Effect of treatment delay upon pulp healing of 345 root fractures. From Cvek et al., 2002 (34) taliscott If pulp capping is not successful try revascularization rather than calcium hyrdoxide or MTA apexification. This is different to Follow-up procedures for avulsed permanent teeth: If root canal treatment is indicated (teeth with closed apex), the ideal time to begin treatment is 7-10 days postreplant. Calcium hydroxide is recommended for intra canal medication for up to one month followed by root canal filling with an acceptable material. An exception is a tooth that has been dry for more than 60 minutes before replantation in such cases the root canal treatment may be done prior to replantation. In teeth with open apices, that have been replanted immediately or kept in appropriate storage media, pulp revascularization is possible. Root canal treatment should be avoided unless there is clinical and radiographic evidence of pulp necrosis. 27

28 21/03/12 In cases of replanted teeth where endodontic treatment is not yet indicated teeth should be monitored by frequent controls during the first year (once a week during the first month, 3, 6, and 12 months) and then yearly thereafter. SUMMARY: My preference is to give teeth and pulps the be of the doubt and treat as necessary as we can induce periapical lesions to heal: Clinical and radiographic examination will provide information to determine outcome. What to do with this case? Arnes Muhic fracture trauma palatal 12 28