Management of Permanent Tooth Dental Trauma in Children and Young Adolescents Jessica Y. Lee DDS, MPH, PhD Chair and Distinguished Professor Department of Pediatric Dentistry University of North Carolina at Chapel Hill
Disclosure I, nor my immediate family have any financial interests that would create a conflict of interest or restrict their independent judgment with regard to the content of this session.
Objectives Part I- 1) Up-to-date fundamentals for the diagnosis permanent tooth dental children and adolescents. 2) Current concepts of splinting luxated and avulsed permanent teeth. 3) Management of traumatic exposures by reliance on evidencebased concepts. Part II- 1) Treatment strategies for avulsed teeth using a clinicianfriendly flow-chart based on best evidence. 2) How to perform new concepts of pulp regeneration and decoronation
Review of Avulsion Management
Prognosis Tooth survival 21-89 % Pulp healing 9-50 % PDL healing 4-27 % Gingival healing 93-95 % Andreasen (Textbook and Color Atlas of Traumatic Injuries to the teeth 4 th edition) If tooth is immediately replanted: PDL healing: 85-97% Pulp revascularization (immature roots): 41-93% Andreasen et al (Endodont Dental Traumatol 1995)
Immediate replantation = BEST prognosis
Severed attachment http://www.dentaltraumaguide.org/permanent_avulsion_etiology.aspx
Avulsions
Severe Attachment Damage
HBSS- 1 st option Milk- 2 nd option other storage media
E/O dry time <20min and tooth was transported in HBSS or milk for 20min 6hrs Soak in 1% Doxycycline for 5 min for open apex only Replant Replant tooth Obtain PA to verify position Place flexible splint for ~14 d Rx: Doxycycline/Pen VK for 7d; Chlohexidine rinse for 1 wk Assess tetanus vaccination Provide post-op instructions; inform of prognosis Follow-up in 7-10d Permanent tooth replantation following avulsion: using a decision tree to achieve the best outcome (McIntyre et al ;Ped Dent 2009)
Revascularization
Advantages of Maintaining Tooth Vitality Following Dental Trauma Continued Root Development Thicker dentinal walls.
Pulpal Necrosis Dry time < 60 min Open apex Soak the tooth for 5 min in doxycycline (1mg/20ml saline)
Triple Antibiotic Paste Hoshino et al. 1996 Studied the antibacterial effect of a mixture of: ciprofloxacin, metronidazole minocycline,
Does it work? Iwaya et al. theorized that in root open (immature) teeth with periapical abscess there might be some vital pulp tissue or progenitor cells present in the apical area of the tooth. If this was the case, successful removal the necrotic infected coronal pulp tissue and disinfection of the pulpal space, those cells had the potential to proliferate and form a new pulp. (Iwaya et al. 2001)
Pre - op 24 month recall (Banchs and Trope 2004)
Calcium Hydroxide Calcium hydroxide increased recruitment, migration, proliferation, and mineralization of the DPSCs (Pulp Stem Cells) Tissue Eng Part A. 2010 Jun;16(6):1823-33. doi: 10.1089/ten.TEA.2009.0054. Dental stem cell therapy with calcium hydroxide in dental pulp capping. Ji YM 1, Jeon SH, Park JY, Chung JH, Choung YH, Choung PH.
Revascularization Dental pulp regeneration is aided by blood and blood substitutes after experimental removal of the pulpal tissue in immature teeth. (Nygaard-Ostby 1961, Myers and Fountain 1974)
Disinfection Scaffold Pre - op SCAP Stem Cells 24 month recall (Banchs and Trope 2004)
Scaffolds AAE Considerations for a Regenerative Endodontics Procedure
Post Treatment
10 Day Post-op Visit
3 Week Post-op Visit ity Tests #7-10 Percussion: WNL Palpation: WNL Endo Ice: + Mobility #7,8,10: WNL #9: Class I
Poll Question What is your treatment recommendation at this time? 1) Monitor and bring child back in three months for trauma follow up 2) Monitor and bring child back in one month for trauma follow up 3) Access tooth and begin RCT
7 Week Post-op Visit Vitality Tests #7-10 Percussion: WNL Palpation: WNL Mobility: WNL Endo Ice: + EPT: + Radiographic appearance of inflammatory root resorption (IRR). Now what?
#9-View through Microscope Necrotic Tissue visible upon access. In microscope view, vital tissue present in apical 1/3.
12/5/07 8 Week Post-op Visit Tx options to disinfect canal: Ledermix, CaOH, 3-mix-MP Chose 3-mix-MP. Mother understands risk of discoloration. Ciprofloxacin, Metronidazole, and Minocycline. Macrogol and Propylene Glycol for paste consistency. Triple antibiotic placed. Cotton pellet and Pink Fuji Triage placed. RTC: 6 weeks Revascularization/ MTA / composite. Alternative treatment options discussed. Long Term CaOH apexification. MTA apexification.
6 weeks later
3MP appt. and 8 mo Post-Revascularization Comparison
6/30/08 Internal Bleaching Appt. with Endo. Removal of Lingual restoration. Sodium Perborate and IRM placed. RTC: 1 week. 7/7/08 Parent and child satisfied with color. Removal of IRM and Sodium Perborate. Restored lingual access with packable composite, shade A1.
E/O dry time > 60 minutes Remove PDL cells: use 3% Citric Acid for 3 minutes, Scaler, soft pumice Soak in Sodium Fluoride for 5 minutes Replant tooth Obtain PA to verify position Place flexible splint for ~14 d Rx: Doxycycline/Pen VK for 7d; Chlohexidine rinse for 1 wk Assess tetanus vaccination Provide post-op instructions; inform of prognosis Follow-up in 7-10d Permanent tooth replantation following avulsion: using a decision tree to achieve the best outcome (McIntyre et al ;Ped Dent 2009)
The Condemned PDL: Dry Time > 60 minutes If tooth has been extraoral and/or dry for 60 mins+, the PDL has NO chance for survival. If a tooth like this is replanted, it WILL undergo resorption (likely ORR) & ultimately, be lost. The AAE does not recommend replanting these teeth.
PDL Removal Gentle scaling and root planning OR Soaking the tooth in citric acid (3 mins)
PDL Removal Followed by fluoride treatment (5 20 mins) F - soak will delay but not prevent ankylosis. F - soak has been shown to significantly reduce the rate of resorption (in a FU of 5y). Nevertheless, these teeth will not survive long-term.
Poll question What treatment options would you consider? 1) Build up tooth #9 2) Extract tooth #9 3) De-coronate tooth #9
Decoronation
Decoronation Malmgren, B and Malmgren, O. 2002 An excellent tx option for an ankylosed tooth:
Decoronation
Decoronation Preserves the vertical and horizontal volume of the alveolar process until maxillary growth is completed These few years may have provided sufficient time needed for valuable 3D alveolar growth or bone maintenance This aids in future restorative planning, maximizes esthetics and treatment options Extraction, however, contributes to further loss of this essential bone
Resources AAPD Trauma Guidelines http://www.aapd.org/policies/ IADT Guidelines http://www.iadt-dentaltrauma.org/ Dental Trauma Guide Online http://www.dentaltraumaguide.org/
Questions
Thank you