Spring 2016 SOUTH CALGARY ENDODONTICS ISSUE 1 FALL 2014 www.southcalgaryendo.ca 403-474-1893 Drs. Staniloff, Kolosowski and Smorang are pleased to announce: Mission Endodontics and South Calgary Endodontics are now working together to provide you and your patients professional endodontic care. www.missionendo.ca 403-228-7122
Avulsed Teeth Treatment Options for Luxation and Avulsion Injuries Education Issue #: of [Date] patients is of paramount importance for the proper protocol for treatment when tooth Dolor avulsion Sit Amet occurs. If the tooth is not replanted at the time of the injury, it should be placed promptly in milk, saline or another type of physiologic solution. A visit to the dentist is required as soon as possible. If the tooth has been avulsed yet replanted within 30 minutes followed by splinting for 2 weeks; a good prognosis is expected. A tooth with an open apex can be replanted with in 60 minutes with a good chance of spontaneous pulp regeneration/revascularization taking place. Root canal therapy or regeneration should be performed only at subsequent follow up visits should the vitality tests yield negative results or the tooth exhibits resorption. Figure 1. An avulsed tooth that was replanted after 2 hours Figure 2. RCT had been performed subsequent to replantation, yet complete root resorption had occurred An avulsed tooth that that has been out of the socket for more than one hour and allowed to become dessicated will eventually become ankylosed after replantation. External resorption will inevitably follow. There is a suggestion to soak the tooth with 2% sodium fluroride and to perform a root canal procedure prior to replantation. A decoronation procedure to preserve the bone for future implant placement may be performed. This involves the removal of the crown protion of the tooth the the level of the bone, removal of the pulp tissue followed by covering the remaining tooth structure with the existing gingiva. Figure 3. Observed resorption on a recall radiograph of tooth 11 previously replanted Figure 4. Tooth 11 has now been decoronated to preserve the bone for future implant placement All avulsion cases need to be monitored on a recall schedule of 4 weeks, 3 months, 6 months and one year, followed by yearly recall s over the next five years. Any complications such as ankylosis, or resorption or infection need to be noted. Patients should be informed as to what or how these potential complications may affect the long-term prognosis of these teeth. With any avulsion patients, they are advised to be on a soft diet and avoid contact sports. Home care consists of rinsing twice daily with 0.12% chlorhexidine for 2 weeks. As always the use of mouth guards is strongly encouraged. 2
Issue #: [Date] Intrusion Injuries Dolor Sit Amet Intrusion injuries are slightly more complex in treatment planning and have an inherent likelihood of ankylosis and/or resorption risk due to trauma to the PDL. In addition, there is very close to a 100 percent chance of pulp necrosis in cases with a closed apex. Mature teeth with more than 3mm and immature teeth with more than 7mm intrusion, should be repositioned surgically or extruded orthodontically within 3 weeks Figure 5. Surgical repositioning of intruded 22. Figure 6. Flexible splint placed in the patient from figure 5 prevents ankylosis. Anything larger than 0.016 or 0.4mm wire is too rigid for a normal PDL to attach and regenerate properly. Mature teeth with less than 3mm intrusion and immature tooth with intrusion less than 7mm can be observed for 3 weeks for the spontaneous eruption, and in case of non-movement, orthodontic repositioning can be initiated. A mature tooth with more than 3mm intrusion can also be extracted and replanted in a correct position. Staying within the 3-week observation period is important to prevent the tooth from ankylosing in an intruded position. Intruded teeth should be splinted for 4 weeks and followed up at the same intervals as other luxation injuries. Due to high risk of pulp necrosis and root resorption, a prompt referral to an Endodontist is important. Placement of calcium hydroxide or steroid intracanal medicaments to lower the risk of resorption is most often necessary for mature teeth. Pulp regeneration or apexification are the choices for treatment in teeth with open apexes. With any luxation injuries, the patients are advised to stay on a soft diet for 1 week and rinse with 0.12% chlorhexidine twice daily for 2 weeks. 3
Concussion or Subluxation In Issue concussion #: [Date] or subluxation, the tooth has not been displaced but may exhibit increased mobility Dolor and Sit pain Amet on pressure or biting. No treatment is indicated for those injuries, but follow up to assess pulp vitality and possible subsequent treatment is necessary. Figure 7. Subluxated tooth with discoloration and necrosis upon recall examination. In any other luxation injury, it is essential to attempt to reposition the tooth to its normal position and, with an exception of intrusive luxation, place a flexible splint for 2 weeks. Follow up clinical and radiographic exam needs to be done in the intervals of 2 weeks (also to remove the splint), 4 weeks, 8 weeks, 6 months, 1 year and once a year thereafter for 5 years. Figure 8. Firm finger pressure is needed to reposition this extruded incisor after anesthesia. Note the fractured 22. Pulp vitality testing utilizing cold is one of the most standard of tests in determining the health of the dental pulp. Ice test using frozen water are diagnostic but can give a false positive test as melting ice can evoke a positive response from the melting of the ice on the gingiva, ultimately affecting our diagnosis. Aerosol refrigerant spray used on a cotton swab can also be used as a cold test. It tends to be expensive, and must be reapplied to the cotton swab repeatedly for accurate testing. Frozen CO 2 or CO 2 snow is the most reliable and inexpensive way to test for vitality of the dental pulp. As the frozen CO 2 warms it sublimes and does not melt, eliminating the false positive inaccuracies described with frozen water. In our office we use frozen CO2 as the cold test of choice. Unfortunately the Ice formers are not readily available in North America any longer. We at South Calgary Endodontics have sourced a producer in Europe, and will be accepting orders in the coming month for these ice formers. Please call our office if you are interested in placing an order, or have any questions regarding the use of Ice Formers. 4
Issue #: [Date] Dolor Sit Amet