dr. sathish abraham

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silicate-based cement Biodentine™: a report of two cases, up to 48 months follow-up. Eur Arch. Paediatr Dent. 2015 May 31. 33. Bakland L. Traumatic injuries.
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DR. SATHISH ABRAHAM

INTRODUCTION CLASSIFICATIONS WHO Classification Andreasen Classification Garcia- Godoy Classification Ellis Classification Sanders Classification Basrani Classification Ulfohn Classification Heithersay-Morile Classification

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 INCIDENCE / PREVALANCE ETIOLOGY & PREDISPOSING FACTORS HISTORY, CLINICAL EXAMINATION & DIAGNOSIS MANAGEMENT WOUND HEALING AND COMPLICATIONS FUTURE CONSIDERATIONS

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REFERENCING/REVIEWING

Dental trauma is one of the most unfortunate occurrence from a patient's perspective and the most challenging situation from an endodontist's viewpoint.

There is an urgent need to close the gap between the research activities and the practice management in order to improve the quality of health care provided to the patients; especially when it is about dental trauma.

When it comes to managing a patient with dental trauma; multi-factorial

The field of management of dental trauma is too deep and complex for

considerations have to be put into perspective. These factors are decisions

relying just upon evidence based dentistry. However; certain guidelines

based on best available scientific evidence, clinician's experience and

have been put forth internationally by different associations for improving the oral health care and overall quality of life for the needy.

judgment,

values,

patient's

preference

and

his/her

circumstances.

Unfortunately, evidence based dental plan cannot always be formulated

Newer

towards managing emergency situations; one such being dental trauma.

researched upon and we have a professional obligation to remain updated

approaches like revascularization are continuously being

about the developments in the field.

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TYPE OF DENTAL TRAUMA  DIRECT TRAUMA

 INDIRECT TRAUMA

ENERGY OF THE IMPACT

TRAUMA TO THE TEETH/DENTITION PERIODONTAL LESIONS.

CAUSE

PULPAL

THEY ARE OF GREAT RELEVANCE TO PRESENT DAY DENTISTRY, BECAUSE OF THEIR FREQUENCY, THE FUNCTIONAL AND ESTHETIC DISTURBANCES THAT ACCOMPANY THEM, AND THE RAPIDITY WITH WHICH THESE PROBLEMS MUST BE TREATED.

RESILIENCE OF THE IMPACTING OBJECT

SHAPE OF THE IMPACTING OBJECT DIRECTION OF THE IMPACTING FORCE Andersson L. Trauma in a global health perspective. Dent Traumatol 2008; 24(3): 267.

AN EPIDEMIOLOGICAL STANDPOINT IDENTIFIED A TOTAL OF 54 CLASSIFICATION SYSTEMS. SOME WERE MENTIONED OR USED ONLY ONCE (BY THE ORIGINAL AUTHOR) WHILE THE MAJORITY OF THE ARTICLES USED OR MENTIONED ANDREASEN’S CLASSIFICATION (32%), FOLLOWED BY ELLIS’ (14%) AND GARCIA-GODOY’S (6%) WHO HAS GIVEN A CLASSIFICATION IN 1978 WHICH WAS AGAIN MODIFIED IN 1995. THESE ARE BASED ON CERTAIN CODING DEPENDING ON THE SITE & TYPE OF INJURY.

Feliciano KMPC, de Franca Caldas Jr. A. A systematic review of the diagnostic classifications of traumatic dental injuries. Dent Traumatol 2006; 22(2): 71–76.

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AND

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CLINICAL SCENARIO

1978

1995

ANDREASEN

GARCIA GODOY

ENAMEL CRACKS

N873.60

ENAMEL FRACTURE

N873.60

S02.50

ENAMEL INFARCTION

-

S02.50

UNCOMPLICATED CROWN FRACTURE

CLASS I

ENAMEL -DENTIN

N873.61

S02.51

UNCOMPLICATED CROWN FRACTURE

CLASS II

ENAMEL – DENTIN - PULP

N873.62

S02.52

COMPLICATED CROWN FRACTURE

CLASS III

ROOT FRACTURE

N873.63

S02.53

ROOT FRACTURE

CLASS V

CROWN – ROOT FRACTURE N873.64 WITHOUT INVOLVING PULP

S02.54

UNCOMPLICATED CROWN – ROOT FRACTURE

CLASS IV

CROWN – ROOT FRACTURE WITH INVOLVEMENT OF PULP

S02.54

COMPLICATED CROWN – ROOT FRACTURE

CLASS IV

WHO

N873.64

WHO CLINICAL CLINICAL WHO 1978 1995 SCENARIO SCENARIO ROOT FRACTURE LUXATION (ALL TYPES)

ANDREASEN ANDREASEN

ELLIS

GARCIAGAODOY

N873.63

N873.66

LUXATION EXTRUSIVE LUXATION

CONCUSSION -CLASS VI ALL LUXATIONS – CLASS VII

INTRUSION/EXTRUSION N873.67

INTRUSIVE LUXATION

CLASS – VIII CLASS - IX

AVULSION

AVULSION/EXARTICULATION

CLASS -X

N873.68

LARGEST PROPORTION OF INJURIES AFFECTING THE PERMANENT DENTITION IS REPRESENTED BY CROWN FRACTURES. ORAL INJURIES ACCOUNT FOR AS MUCH AS 5% OF ALL BODY INJURIES WITH AN EVEN HIGHER PROPORTION OF ORAL INJURIES AMONG CHILDREN. TEETH ARE INJURED IN MORE THAN NINE OF TEN PATIENTS PRESENTING WITH ORAL INJURIES.

UNCOMPLICATED CROWN FRACTURES: MAJORITY COMPLICATED CROWN FRACTURES: 2-3%.

VIOLENCE, TRAFFIC ACCIDENTS AND SPORTS ACTIVITIES, HAVE BEEN IDENTIFIED AS SOME OF THE MAJOR CAUSES THAT CONTRIBUTE TO DENTAL TRAUMA.

INTRA-ALVEOLAR ROOT FRACTURES: LESS THAN 3%. TOOTH LUXATION: 30 TO 44%. AVULSION: LESS THAN 3%.

Andersson L. Trauma in a global health perspective. Dent Traumatol 2008; 24(3): 267.

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Bakland L. Endodontic considerations in dental trauma. In: Ingle J, Bakland L. Endodontics. 5th ed. Hamilton London. BC Decker Inc. 2002: 795- 843.

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LOCATION OF DENTAL INJURIES MAJORITY : ANTERIOR TEETH (MAXILLARY CENTRAL INCISORS) LESS FREQUENT: MANDIBULAR CENTRAL INCISORS AND MAXILLARY LATERAL INCISORS.

SEX AND AGE DISTRIBUTION PRIMARY DENTITION: 31 TO 40% IN BOYS AND 16 TO 30% IN GIRLS. PERMANENT DENTITION: 12 TO 33% IN BOYS AND 4 TO 19% IN GIRLS. A STUDY OF THE AGE WISE DISTRIBUTION OF DENTAL TRAUMA SHOWS THAT MOST DENTAL INJURIES OCCUR DURING THE FIRST TWO DECADES OF LIFE.

Andreasen J, Andreasen F. Textbook and color atlas of traumatic injuries to the teeth. 3rd ed. Munksgaard. Mosby 1994.

INJURIES CAN BE CATEGORIZED AS: INTENTIONAL (VIOLENCE) UNINTENTIONAL (SPORTS INJURY) IATROGENIC INJURIES IN NEWBORNS

CHILD PHYSICAL ABUSE FALLS AND COLLISIONS SPORTS

AUTOMOBILE/MOTORCYCLE INJURIES

Hovland E, Gutmann J, Dumsha T. Traumatic Injuries To Teeth. Dent Clin North Am 1995; 39(1):1-231.

ASSAULTS DRUG-RELATED INJURIES MENTAL RETARDATION AND EPILEPSY DENTINOGENESIS IMPERFECTA

THE TRAUMATOLOGY LITERATURE IS LIMITED TO FACTORS THAT MAY PREDISPOSE TO TRAUMATIC TOOTH INJURIES WHICH SIGNIFICANTLY INCREASE SUSCEPTIBILITY TO DENTAL INJURY : •MALOCCLUSION •OVERJET - 4 MM (MORE) •SHORT UPPER LIP •INCOMPETENT LIPS •MOUTH BREATHING Forsberg CM, Tedestam G. Etiological and predisposing factors related to traumatic injuries to permanent teeth. Swed Dent J. 1993;17:183–90.

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CLINICAL DENTAL HISTORY: SUBJECTIVE STATEMENT

•CHIEF COMPLAINT

•HISTORY OF PRESENT ILLNESS •WHEN AND WHERE DID THE INJURY HAPPEN? •HOW DID THE INJURY HAPPEN?

•HAVE YOU HAD TREATMENT ELSEWHERE BEFORE COMING HERE? •HAVE YOU HAD SIMILAR INJURIES BEFORE? •HAVE YOU NOTICED ANY OTHER SYMPTOMS SINCE THE INJURY? •WHAT SPECIFIC PROBLEMS HAVE YOU HAD WITH THE TRAUMATIZED

TOOTH/TEETH?

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MEDICAL HISTORY ALLERGIC REACTIONS TO MEDICATIONS BLEEDING DISORDERS

DIABETES EPILEPSY CURRENT MEDICATIONS

CLINICAL EXAMINATION EXTRA-ORAL EXAMINATION: SOFT TISSUES FACIAL BONES INTRA-ORAL EXAMINATION SOFT TISSUE, TEETH: FRACTURE, DISPLACEMENT, MOBILITY INJURY TO PERIODONTAL LIGAMENT AND ALVEOLUS PULPAL TRAUMA In case of luxated/mobile teeth, it is important to reposition/immobilize them prior to testing. Strict isolation is a must

TETANUS IMMUNIZATION STATUS Croll T, Brooks E, Schut L, Laurent J. Rapid neurologic assessment and initial management for the patient With traumatic dental injuries. Journal of the American Dental Association;100(4): 530-534.

 INJURIES TO THE ROOT AND THE PERIODONTAL STRUCTURES.  SIZE OF THE PULP CHAMBER, RESORPTIVE AND CALCIFIC CHANGES

 PROXIMITY OF THE FRACTURE LINE TO THE PULP.  STAGE OF ROOT FORMATION.

NEWER DIAGNOSTIC AIDS  MICRO - CT IMAGING  CBCT

CROWN FRACTURES 26 TO 76 % OF INJURIES TO THE PERMANENT DENTITION. THEY INCLUDE: ENAMEL INFARCTION ENAMEL FRACTURE ENAMEL-DENTIN FRACTURE UNCOMPLICATED FRACTURE COMPLICATED FRACTURE

UNCOMPLICATED FRACTURE NO SPONTANEOUS PAIN, EXPOSED DENTIN MAY RESPOND TO THERMAL CHANGES AND MASTICATION.

Croll T, Brooks E, Schut L, Laurent J. Rapid neurologic assessment and initial management for the patient With traumatic dental injuries. Journal of the American Dental Association;100(4): 530-534.

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PINKISH TINGE: IN SUCH CASES, IT IS IMPORTANT NOT TO PERFORATE THE DENTIN

WITH A PROBE WHILE SEARCHING FOR PULP EXPOSURES.

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PRIMARY AIM : MAINTAIN PULP VITALITY

1.PROVISIONAL PREFABRICATED CROWNS COMPOSITE RESTORATION USING CELLULOID CROWNS SPLINTING 2.DEFINITIVE REATTACHMENT OF THE CROWN FRAGMENT COMPOSITE RESTORATION VENEERS FULL CROWN COVERAGE

TREATMENT OPTIONS INCLUDE: VITAL PULP THERAPY COMPRISING PULP CAPPING, PARTIAL PULPOTOMY OR FULL

PULPOTOMY MATURE TOOTH: PULPECTOMY IMMATURE TOOTH: APEXIFICATION

NEW APPROACH TO TREATMENT OF NONVITAL PULPS: PULP REVASCULARIZATION

Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis Endodontic Topics 2006; 14(1): 51–59.

UNCOMPLICATED FRACTURES COMPLICATED FRACTURES

CLINICAL FINDINGS: •THE FRACTURE LINE BEGINS A FEW MILLIMETERS INCISAL TO THE

MARGINAL GINGIVA ON THE FACIAL ASPECT OF THE CROWN, FOLLOWING AN OBLIQUE COURSE BELOW THE GINGIVAL CREVICE ORALLY. •THE FRAGMENTS ARE USUALLY ONLY SLIGHTLY DISPLACED, THE CORONAL FRAGMENT BEING KEPT IN POSITION BY FIBERS OF THE PERIODONTAL LIGAMENT ON THE ORAL ASPECT.

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FRACTURE LINE: SINGLE/MULTIPLE VERTICAL FULLY ERUPTED PERMANENT TEETH: COMPLICATED, ERUPTING PERMANENT TEETH: UNCOMPLICATED. SYMPTOMS: PULP EXPOSURE, SLIGHT PAIN MOBILITY OF THE CROWN FRAGMENT

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COMPLICATED CROWN-ROOT FRACTURES EMERGENCY TREATMENT: STABILIZING CORONAL FRAGMENT WITH A COMPOSITE RESIN SPLINT TO ADJACENT TEETH. THE TOOTH WILL GENERALLY REMAIN SYMPTOM FREE DEFINITIVE TREATMENT: WITHIN A FEW DAYS AFTER INJURY.

1.VITAL PULP THERAPY - PULP CAPPING, PARTIAL PULPOTOMY, OR FULL

PULPOTOMY 2.MATURE TOOTH: PULPECTOMY 3.IMMATURE TOOTH: APEXIFICATION

UNCOMPLICATED CROWN-ROOT FRACTURES 1.REATTACHMENT OF FRACTURED SEGMENT 2.REMOVAL OF FRAGMENT AND COMPOSITE RESTORATION. 3.FULL CROWN.

Trope M, Blanco L, Chivian N, Sigurdsson A. The role of endodontics after dental traumatic injuries. In: Cohen S, Hargreaves K. Pathways of the Pulp. 9th ed. Mosby 2006: 610-649.

CLINICAL SCENARIO FRACTURE LINE EXTENDING AT THE LEVEL OF GINGIVAL SULCUS FRACTURE LINE EXTENDING SUB GINGIVAL SUPRA-CRESTAL LEVEL FRACTURE LINE EXTENDING SUB GINGIVAL AND ALSO AT SUB-CRESTAL LEVEL. Andreasen J, Andreasen F. Textbook and color atlas of traumatic injuries to the teeth. 3rd ed. Munksgaard. Mosby 1994. Chung MP, Wang SS, Chen CP, Shieh YS. Management of crown-root fracture tooth by intra-alveolar transplantation with 180-degree rotation and suture fixation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Feb;109(2):e126-30.

HORIZONTAL FRACTURES RELATIVELY UNCOMMON ROOT FRACTURES MAY BE DIVIDED INTO: 1.HORIZONTAL FRACTURES 1. 2. 3.

APICAL THIRD MIDDLE THIRD CERVICAL THIRD

CLINICAL FINDINGS SLIGHTLY EXTRUDED TOOTH, FREQUENTLY DISPLACED IN A LINGUAL DIRECTION. BLEEDING FROM THE GINGIVAL SULCUS MAY BE SEEN. DIAGNOSIS IS ENTIRELY DEPENDENT ON RADIOGRAPHIC EXAMINATION.

MIDDLE THIRD FRACTURES ARE THE MOST FREQUENT, WHILE FRACTURES OF THE APICAL AND CERVICAL THIRDS OCCUR WITH EQUAL FREQUENCY. 1.SINGLE TRANSVERSE FRACTURE 2.OBLIQUE OR MULTIPLE FRACTURES

2.VERTICAL FRACTURES WHILE THE TYPICAL APICAL OR MID-ROOT FRACTURE FOLLOWS A STEEP COURSE FACIO-ORALLY IN AN INCISAL DIRECTION, CERVICAL THIRD FRACTURES TEND TO BE MORE HORIZONTAL.

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RADIOGRAPHIC EXAMINATION A root fracture will normally be visible : 15-200 of the fracture plane.

Radiographic appearance: fracture lines are oblique, if an ellipsoid radiolucent line is seen on the radiograph Two additional peri - apical radiographs should be taken; with vertical angulations +150 and –150 of the original. Steep occlusal exposure: fractures of the apical third of the root. It is important to remember that as long as it is undisturbed, the apical segment remains vital in 99% of cases. The coronal segment may or may not be vital.

THE PRINCIPLES OF TREATING ROOT-FRACTURED PERMANENT TEETH ARE REDUCTION OF DISPLACED CORONAL FRAGMENT AND FIRM IMMOBILIZATION. IMPORTANT CONSIDERATIONS 1. POSITION OF TOOTH AFTER IT HAS FRACTURED 2. MOBILITY OF CORONAL FRAGMENT 3. STATUS OF PULP 4. POSITION OF FRACTURE LINE

TREATMENT OPTIONS ROOT CANAL THERAPY OF BOTH THE SEGMENTS ROOT CANAL TREATMENT OF THE CORONAL SEGMENT USE OF AN INTRA-RADICULAR SPLINT.

ROOT EXTRUSION Hovland E, Gutmann J, Dumsha T. Traumatic Injuries To Teeth. Dent Clin North Am 1995; 39(1):1231

Sibel Kocak, Guvan Kayaoglu. Intraradicular splinting with endodontic instrument of horizontal root fracture-case report. Dental Traumatology 2008; 24:578-580.

DIAGNOSIS OF VERTICAL ROOT FRACTURE VITAL TOOTH: PATIENT IS UNABLE TO LOCATE THE SOURCE OF PAIN AND CAN BE OTHERWISE ASYMPTOMATIC. CAREFUL CLINICAL EXAMINATION MAY SHOW A TOOTH, TYPICALLY MANDIBULAR MOLAR, WITH A LARGE RESTORATION. ASSOCIATED WITH THE TOOTH MAY BE AN ISOLATED FINDING SUCH AS DEEP POCKET, IN AN OTHERWISE PERIODONTALLY HEALTHY MOUTH. PULP TESTING IS USUALLY NOT HELPFUL.

HAIR-LIKE FRACTURE LINE. ROOT SEGMENT SEPARATION: LARGE BONE LOSS  ‘HALO’ SURROUNDING THE ROOT OF AFFECTED TOOTH MAY BE SEEN. CONE-BEAM COMPUTED TOMOGRAPHY (CBCT) APPEARS TO BE MORE

ACCURATE ENDODONTICALLY TREATED TOOTH CLINICAL EXAMINATION MAY REVEAL A SYMPTOMATIC (MILD PAIN AND PRESSURE ON

MASTICATION) TOOTH WITH NONSURGICAL ENDODONTIC TREATMENT WITH OR WITHOUT DOWEL PLACEMENT AND, PERHAPS SURGICAL ROOT CANAL TREATMENT MULTIPLE TIMES. ALSO ASSOCIATED WITH THE TOOTH MAY BE AN OSSEOUS DEFECT OR A SINUS. A DEFINITIVE DIAGNOSIS MAY BE ATTAINED ONLY BY AN EXPLORATORY FLAP REVEALING DEHISCENCE, FENESTRATION, AND/OR A CLEAR FRACTURE.

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Trope M, Chivian N, Sigurdsson A, Vann W. Traumatic injuries. In: Cohen S, Burns R. Pathways of the Pulp. 8th ed. Mosby 2002: 603-650. Wang P, Yan XB, Lui DG, Zhang WL, Zhang Y, Ma XC. Detection of dental root fractures by using conebeam computed tomography. Dentomaxillofac Radiol. 2011 Jul;40(5):290-8

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VERTICAL CROWN ROOT FRACTURES

CONCUSSION AN UNFAVORABLE PROGNOSIS AND EXTRACTION IS USUALLY THE ONLY

TREATMENT OPTION. IN POSTERIOR TEETH WITH MULTIPLE ROOTS, HEMISECTION OR ROOT AMPUTATION OF THE FRACTURED ROOT MAY BE THE TREATMENT OF CHOICE, FOLLOWED BY A NEW RESTORATION OF THE TOOTH.

SUBLUXATION

EXTRUSIVE LUXATION LATERAL LUXATION INTRUSIVE LUXATION

Tamse A. Vertical root fractures in endodontically treated teeth: diagnostic signs and clinical

management. Endodontic Topics 2006; 13(1): 84–94.

 CONCUSSION: TENDER TO TOUCH AND MARKED REACTION TO PERCUSSION IN HORIZONTAL AND/OR VERTICAL DIRECTION.

 SUBLUXATED TEETH: MOBILITY IN A HORIZONTAL DIRECTION AND SENSITIVITY TO PERCUSSION. HEMORRHAGE FROM THE GINGIVAL CREVICE IS USUALLY PRESENT.

WIDTH OF THE PERIODONTAL LIGAMENT SPACE PULP CANAL OBLITERATION: TEETH WITH OPEN APICES

INDICATES ONGOING PULPAL VITALITY.

 EXTRUDED TEETH: ELONGATED AND MOST OFTEN WITH LINGUAL DEVIATION OF THE CROWN. BLEEDING IS ALWAYS PRESENT FROM THE PERIODONTAL LIGAMENT. PERCUSSION SOUND IS DULL.

 LATERAL LUXATION: CROWNS DISPLACED LINGUALLY.

 INTRUTION: MARKED DISPLACEMENT. TEETH ARE LOCKED IN THEIR POSITION IN THE BONE NOT SENSITIVE TO PERCUSSION AND ARE FIRM.

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 PULP TESTING

SHOULD BE CARRIED OUT AND RECORDED IN CASES OF LUXATION, IN SPITE OF THE FACT THAT AN INITIAL “NO RESPONSE” IS COMMON. THE RESULTS PROVIDE THE BASIS FOR LATER EVALUATION.

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LUXATION INJURIES WITH DISPLACEMENT:

TOOTH TO REST

REPOSITIONING IF REPORTED EARLY.

EXTRUDED TEETH: TO PROMOTE RECOVERY OF TRAUMA TO PERIODONTAL LIGAMENT AND APICAL VESSELS. OCCLUSAL GRINDING OF THE OPPOSING TEETH,  REPEATED PULP TESTS DURING THE FOLLOW-UP PERIOD.  FLEXIBLE SPLINT : UP TO 2 WEEKS.

PUSHED BACK TO POSITION

LATERALLY LUXATED TEETH: FORCEFUL AND HENCE TRAUMATIC.

DELAYED TREATMENT: ACCOMPLISHED ORTHODONTICALLY.

Flores Mt, Malmgren B, Andersson L, Andreasen Jo, Bakland Lk, Barnett F, Bourguignon C, Diangelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, Von Arx T. Guidelines For The Management Of Traumatic Dental Injuries. I.Fractures And Luxations Of Permanent Teeth. Dent Traumatol 2007; 23(2): 66–71.

THE PERIODONTAL LIGAMENT, ALVEOLAR BONE, CEMENTUM, GINGIVA, AND DENTAL PULP ARE ALL DAMAGED WHEN A TOOTH IS AVULSED.

TRUE DENTAL EMERGENCY SINGLE TOOTH AVULSION : MOST FREQUENT. MULTIPLE AVULSIONS : OCCASIONAL. THE PATIENT PRESENTS WITH BLEEDING FROM EMPTY ALVEOLAR SOCKET.

INTRUDED TEETH: SURGICAL REPOSITIONING OF THE TOOTH.

 FLEXIBLE SPLINT SHOULD BE APPLIED FOR 2-3 WEEKS.

AT THE ACCIDENT SITE (IMMEDIATE) REPLANT IF POSSIBLE/ PLACE IN AN APPROPRIATE STORAGE MEDIUM. EVERY EFFORT SHOULD BE MADE TO REPLANT THE TOOTH WITHIN THE FIRST 15–20MIN.

STORAGE MEDIA MILK/SALIVA/PHYSIOLOGIC SALINE/ CELL CULTURE MEDIA IN SPECIALIZED TRANSPORT CONTAINERS NEWER ALTERNATIVES CASEIN PHOSPHOPEPTIDE-AMORPHOUS CALCIUM PHOSPHATE

 Tuna EB, Yaman D, Yamamato S. What is the best root surface treatment for avulsed teeth? Open Dent J. 2014 Sep 29;8:175-9.

 Andersson L. IADT guidelines for treatment of traumatic dental injuries. Dent Traumatol. 2012 Feb;28(1):1-1.

PROPOLIS COCONUT WATER Poi WR, Sonoda CK, Martins CM, Melo ME, Pellizzer EP, Mendonca MR, Panzarini SR. Storage media for avulsed teeth: a literature review. Braz Dent J. 2013 Sep-Oct;24(5):437-45.

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WHEN THE PATIENT ARRIVES AT YOUR OFFICE, PUT THE TOOTH IN A GLASS OF SALINE/ consider surface treatment 1. TAKE A HEALTH HISTORY 2. EXAMINE THE AREA 3. TAKE RADIOGRAPHS 4. REPLANT/RE-IMPLANT (AFTER CAREFUL CONSIDERATIONS) 5. SPLINTING (IMMOBILIZATION)

IF THE TOOTH HAS BEEN REPLACED; AND SEEMS IN AN ACCEPTABLE POSITION, SPLINT/IMMOBILIZE. Hiremath H, Kulkarni S, Sharma R, Hiremath V, Motiwala T. Use of Platelet-rich fibrin as an autologous biologic rejuvenating media for avulsed teeth - an in vitro study. Dental Traumatol. 2014 Dec;30(6):442-446.

LESS THAN AN HOUR WITH OPEN APEX  REPLANT & SPLINT/STABILIZE 1 WEEK RECALL – CHECK PULPAL RESPONSE OBSERVATION FOR PULP STATUS & ROOT DEVELOPMENT  1, 2, 3 ,4 WEEKS 3, 6, 9 & 12 MONTHS  YEARLY ONCE FOR 5 YEARS APEXOGENESIS/ REVASCULARISATION/ ENDODONTIC TREATMENT AFTER APEXIFICATION  

LESS THAN AN HOUR WITH FULLY FORMED APEX



REPLANT & SPLINT/STABILIZE

1 WEEK RECALL – CHECK PULPAL RESPONSE  OBSERVATION FOR PULP STATUS.  1, 2, 3 ,4 WEEKS 3, 6, 9 & 12 MONTHS  YEARLY ONCE FOR 5 YEARS ENDODONTIC TREATMENT WITH INTRACANAL MEDICATION 

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IMPORTANT FACTORS CONTAMINATION OF THE TOOTH TIME ELAPSED ROOT DEVELOPMENT CONTAMINATED TOOTH CAREFUL HANDLING OF THE TOOTH WITH A WET SPONGE PIECE IS ADVISABLE TO CLEAN THE DEBRIS

ENDODONTIC CARE – PHASE 3 1. TIME LESS THAN 1 HOUR MORE THAN AN HOUR EXTENDED EXTRA-ORAL TIME 2. ROOT DEVELOPMENT OPEN APEX CLOSED APEX

MORE THAN AN HOUR WITH OPEN APEX    

REPLANT & SPLINT/STABILIZE 1 WEEK RECALL – CHECK PULPAL RESPONSE OBSERVATION FOR PULP STATUS & ROOT DEVELOPMENT 1, 2, 3 ,4 WEEKS 3, 6, 9 & 12 MONTHS

REVASCULARISATION/ ENDODONTIC TREATMENT AFTER APEXIFICATION

MORE THAN AN HOUR WITH FULLY FORMED APEX    

REPLANT & SPLINT/STABILIZE 1 WEEK RECALL – CHECK PULPAL RESPONSE OBSERVATION FOR PULP STATUS. 1, 2, 3 ,4 WEEKS 3, 6, 9 & 12 MONTHS

ENDODONTIC TREATMENT AFTER INTRA CANAL MEDICATION

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DELAYED REPLANTATION WITH OPEN APEX REPLANT & SPLINT/STABILIZE  1 WEEK RECALL ENDODONTIC TREATMENT AFTER INTRA CANAL MEDICATION  OBSERVATION OF TOOTH  1, 2, 3 ,4 WEEKS 3, 6, 9 & 12 MONTHS  YEARLY ONCE FOR 5 YEARS CAN CONSIDER REVASCULARISATION

DELAYED REPLANTATION WITH FULLY FORMED APEX REPLANT & SPLINT/STABILIZE  1 WEEK RECALL ENDODONTIC TREATMENT AFTER INTRA CANAL MEDICATION  OBSERVATION OF TOOTH  1, 2, 3 ,4 WEEKS 3, 6, 9 & 12 MONTHS  YEARLY ONCE FOR 5 YEARS CAN CONSIDER EXTRA ORAL ENDODONTIC TREATMENT

SUTURE SPLINTS WIRE SPLINTS ARCHBAR SPLINTS GUNNING SPLINTS MINI PLATES & LAG SCREWS ACRYLIC CAP SPLINTS ORTHODONTIC SPLINTS COMPOSITE SPLINTS COMPOSITE WIRE SPLINTS RIBBOND SPLINTS TITANIUM TRAUMA SPLINTS

HEALING WITH CALCIFIED TISSUE. HEALING WITH INTER-PROXIMAL CONNECTIVE TISSUE HEALING WITH INTER-PROXIMAL BONE AND CONNECTIVE TISSUE INTERPROXIMAL INFLAMMATORY TISSUE WITHOUT HEALING.

COMPLICATIONS 



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ANKYLOSIS RESORPTION

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SEQUALE TO TRAUMA BLOOD VESSELS: MARGINATION, DIAPEDESIS, TRANSMIGRATION CELLULAR: RELEASE OF CYTOKINES AND CHEMOKINES There are both pro-inflammatory & anti-inflammatory activities. CYTOKINES PRO-INFLAMMATORY IL-1, IL-6, IL-11, IL-18, TNF- : stimulates inflammatory process, differentiates osteoblasts, osteoclasts, promotes angiogenesis, stimulates osteo-progenitor cells to release BMP’s to induce bone formation. ANTI-INFLAMMATORY IL-6, TGF- : regulates healing process. CHEMOKINES Small proteins, directs the movements of circulating cells to site of injury.

PULP NECROSIS SIZE OF THE PULP LENGTH OF THE APICAL PULP COMPRESSION OF THE PULP (INTRUSION) AGE EXTERNAL CONTAMINANTS (AVULSION) DENTIN EXPOSURE PULP EXPOSURE EXACTNESS OF REPOSITIONING

Yadav A, Saini V, Arora S. MCP-1: chemoattractant with a role beyond immunity: a review Clin Chim Acta 2010: 411(21-22):1570-9.

PREDICTORS FOR MARGINAL BONE LOSS

DISTURBED ROOT DEVELOPMENT LUXATION WITH DISPLACEMENT

COMPRESSION OF BONE

(INTRUSION & LATERAL LUXATION) AVULSION AND REIMPLANTATION EXPOSURE OF BONE

INCOMPLETE REPOSITIONING ALVEOLAR FRACTURES

(ALVEOLAR & JAW FRACTURES) ADJACENT TOOTH OR BONE INJURY

(MULTIPLE INTRUSIONS) INTRUSION OF PRIMARY TEETH AGE JAW FRACTURES

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 CONDITIONING THE PDL : STORAGE IN TISSUE CULTURE MEDIA

ENAMEL MATRIX PROTEIN  TOPICAL TREATMENT OF ROOT SURFACE: WITH FLUORIDE/TETRACYCLINE/PRF  REVASCULARIZATION OF PULP SPACE

SPLIT POSTERIOR TEETH

 OPTIMAL SPLINT TYPES WITH REGARDS TO PERIODONTAL AND PULPAL

(VERTICAL CROWN ROOT FRACTURES IN POSTERIORS)

HEALING  EFFECT ON ADRENALINE CONTENT OF LOCAL ANESTHESIA ON HEALING  REDUCING THE INFLAMMATION WITH CORTICOSTEROIDS  USE OF TITANIUM POSTS/ENDO-IMPLANTS FOR ROOT ELONGATION AND AS

ALTERNATIVES TO CONVENTIONAL ROOT CANAL TREATMENT  LONG TERM DEVELOPMENT OF ALVEOLAR CREST FOLLOWING

REPLANTATION AND DECORONATION

International Association of Dental Traumatology. DENTAL TRAUMA GUIDELINES: Revised 2012

Abraham S and Chacko LN. Split Posterior Tooth: Conservative Clinical Reattachment. 2014;2014:bcr2013-202695

Schematic representation.

Sathish Abraham and Lisa Neelathil Chacko BMJ Case Reports 2014;2014:bcr-2013-202695 ©2014 by BMJ Publishing Group Ltd

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Clinical photographs

Sathish Abraham, and Lisa Neelathil Chacko BMJ Case Reports 2014;2014:bcr-2013-202695 ©2014 by BMJ Publishing Group Ltd

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