Nature of Injury. Consequences of Trauma. Repair versus Regeneration. Repair versus Regeneration. Repair versus Regeneration

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1 Consequences of Trauma Nature of trauma Separation injury Crushing injury Early wound healing Late wound healing Nature of Injury Wound healing Control of hemmorage Establish line of defense against infection Cleanse wound Necrotic tissue Bacteria Close wound gap New connective tissue, epithelium Repair versus Regeneration Dynamics of Wound Repair Hemostasis phase Inflammatory phase Proliferative phase Remodeling phase Repair versus Regeneration Dynamics of Wound Repair Hemostasis phase Rupture of vasculature Vasoconstriction Platelet aggregation and activation Clotting and chemotaxis Endothelial cells, mast cells, lymphocytes, macrophages, fibroblasts, etc.. Repair versus Regeneration Dynamics of Wound Repair Inflammatory phase PMNs, lymphocytes, and Macrophages Prevent D Fence Cleanse wound no infection Growth factors Repair versus Regeneration Dynamics of Wound Repair Proliferative phase Fibroblasts, endothelial cells capillary network Epithelial cells divide to close wound 1

2 Repair versus Regeneration Dynamics of Wound Repair Remodeling phase Vascularity decreases Reorganization of collage Contraction of wound Scar/scab Classification of Dental Injuries Injury to the gingiva or oral mucosa Injury to the periodontal tissue Injury to the hard dental tissue and pulp Injury to hard dental tissue pulp and bone Classification of Dental Injuries Injury to the gingiva or oral mucosa Antibiotic coverage? Wound debridement Reposition and suturing Foreign bodies Classification of Dental Injuries Injury to the gingiva or oral mucosa Antibiotic coverage? Wound is heavily contaminated wound debridement no optimal Wound cleansing delayed more than 24 hours Open reduction of jaw fractures Host defense compromised Diabetes HIV Prosthetic heart valves Bite wounds Human or Animal Classification of Dental Injuries Injury to the gingiva or oral mucosa Wound Debridement All oral wounds CONATMINATED Remove and neutralize microorganism Physiologic saline Chlorhexidine Note: even clean wounds not lower chance for infections Classification of Dental Injuries Injury to the gingiva or oral mucosa Reposition and suturing Approximate wound edges Increase healing phase Sutures attraction of plaque and ultimately infection????? Small sutures Minimal excess 2

3 Classification of Dental Injuries Injury to the gingiva or oral mucosa Foreign bodies Increases chance of infection Retards healing Importance of cleansing wound Prevents scarring and disfigurement Classification of Dental Injuries Injury to the gingiva or oral mucosa Injury to the periodontal tissue Response of Oral Tissues to Trauma PDL Injury Receptors for pain Touch Pressure Proprioception Response of Oral Tissues to Trauma PDL Injury Severe dental trauma Hemorrhage and edema rupture and contusion of blood vessels in PDL apparatus 2 weeks for PDL fibers to heal and 50-60% healed with mechanical properties Mandel Viidik 1989 Response of Oral Tissues to Trauma PDL Injury Wound healing through Macrophage Osteoclast Cementoclast Necrotic PDL removed as well as bone and cementum Response of Oral Tissues to Trauma PDL Injury Wound healing through Macrophage Ankylosis Competitive would healing between bone and PDL fibers Break down of PDL and bone Apical lesions and widen PDL 3

4 Classification of Dental Injuries Injury to the gingiva or oral mucosa Injury to the periodontal tissue Injury to the hard dental tissue and pulp Response of Oral Tissues to Trauma Pulp Injury al wound healing response Damage pulp tissue replaced and differentiated with new tissue Dentin exposure Defense response Neutralize and control bacteria Pulp exposure Classification of Dental Injuries Injury to the gingiva or oral mucosa Injury to the periodontal tissue Injury to the hard dental tissue and pulp Injury to hard dental tissue pulp and bone Response of Oral Tissues to Trauma Bone Injury Wound healing phases Stage I: coagulum Hemostasis erythrocytes and leukocytes in Fibrin Stage II : Granulation tissue 2-3 days post replaced entire coag in 7 days Stage III: Connective tissue Starts 20 days and replaceds granulation tisue Stage IV: Bone development Started with in 7 days post operatively 38 days immature bone Crown Fracture without Pulp Exposure Crown Fracture without Pulp Exposure Exposed dentinal tubules Bacterial communication vitality Protect Pulp Composite restoration MTA or glass ionomer liner 4

5 Crown Fracture without Pulp Exposure Monitor for 2 months post trauma Risk of pulp complications ie necrosis or calcification minimal 0.5% Complications extremely rare 0% Crown Fracture with Pulp Exposure Crown Fracture with Pulp Exposure Indirect and direct insult to the pulp Granulation tissue al vascularity???? cap with MTA Partial pulpotomy MTA Glass ionomer liner base Composite restoration Monitor Crown Fracture with Pulp Exposure high success rate with pulp capping Monitor radiographically and vitality testing Intact with normal pulp Necrotic pulp Crown-Root Fracture Crown-Root Fracture Dependent on location of fracture Inflammatory process in PDL at area of fracture due to plaque 5

6 Crown-Root Fracture above gingival crest Seal tubules protect pulp Restore to function below gingival crest Remove coronal segment allow long junctional epithelial attatchment Remove coronal segment surgical exposure of subgingival fragment Fragment removal and extrusion EXT Crown-Root Fracture high success rate with pulp capping Monitor radiographically and vitality testing Intact with normal pulp Necrotic pulp Root Fracture Root Fracture Complex injury to PDL and Pulp coronal to fracture line Apical extent relatively intact Reposition as needed Splint rigid Root Fracture Hard tissue healing and mobility WNL no treatment Connective tissue healing Increase mobility pulp WNL Calcification of coronal pulp Granulation tissue healing Increased excessive mobility necrotic Movement of segment Root Fracture root development, extent of displacement Immature apex healing 85% mature apex healing 20% Resorption 33% 6

7 Alveolar Fracture Alveolar Fracture Boney fracture may disrupt blood supply Root resorption???? Reposition Immobilization splint 3-4 weeks Alveolar Fracture Necrosis 91% Monitor over the next year Root resorption 12 % Resorption A response from the pulp, periodontal ligament, or bone, usually dealing with low grade irritations that are sufficient to cause inflammation. Walton and Toribinejad Resorption a condition associated with either a physiologic or a pathologic process resulting in a loss of dentin, cementum or bone of any combination of the above Glossary AAE Resorption Surface/ Transient Usually not detectable by a radiograph Microscopic exam reveals former resorptive defects with new deposition of cementum Can represent healing No treatment necessary 7

8 Resorption Inflammatory Resorption Surface/ Transient Inflammatory Initiated by minimal inflammation in the pulp Will usually subside with removal of pulp. Internal resorption Internal Resorption Internal Resorption Internal resorption is initiated within pulp chamber or root canal of the tooth The key diagnostic tool: A good radiograph 8

9 Indications of the 3d accuimtomo/ I-CAT CBCT INVALUABLE Dento Maxillo-Facial- Surgery Impacted, displaced teeth (wisdom teeth, canines, supernumerary teeth) Apical periodontitis, cysts of the jaw Pre- and postoperative for imaging of important anatomical landmarks and structures Implant-planning and recall Cleft-palate patients Internal Resorption Internal Resorption Internal root resorption must be differentiated from external resorption or root surface caries Radiographic Features: Margins are smooth and clearly defined Distribution over the root is symmetrical Pulp chamber or canal can not be followed through lesion Internal Resorption Resorption Clinical Features Asymptomatic Responds to vitality tests Surface/ Transient Inflammatory Initiated by minimal inflammation in the pulp Will usually subside with removal of pulp. Due to additional stimulation of the resorbing cells, the destruction becomes progressive and may lead to total resorption of the root Pink tooth appearance 9

10 Internal Resorption DETECTION the pink spot describes the condition in which highly vascular soft tissue can be seen after the dentine has been resorbed Mummery 1920 DETECTION DETECTION Inflammatory Resorption External Resorption Internal resorption External resorption External resorption is initiated in the periodontium, and often results in significant loss of hard tooth structure External Resorption Radiographic Features: Irregular borders, moth-eaten appearance Asymmetric distribution over the root Pulp chamber or canal can be followed through lesion Relationship of the defect to the canal on different angle films External Resorption Treatment Modalities Long term calcium hydroxide 10

11 Intracanal Medicaments Phenolics - Antimicrobial Camphorated Monoparachlorophenol (CMCP) Metacresylacetate (Cresatin) Aldehydes - Fixatives Formocresol Steroids Anti-inflammatory Dexamethasone Calcium Hydroxide Sterilant and tissue dissolution Combination (Vitapex) Concussion Injury Concussion Injury Injury to PDL Edema and bleeding Impact on neurovascular bundle Occlusal adjustment Soft diet 2 weeks Splint? PRN ie. multiple teeth Concussion Injury Monitor vitality Immature apex 97% survival Mature apex 90% survival External root resorption Immature apex 3% Mature apex 8% Subluxation Injury Subluxation Injury Injury to PDL Bleed and tear of fibers Total or partial rupture of neurovascular bundle Occlusal adjustment Splint PRN 11

12 Subluxation Injury Immature apex pulp survival 87% Mature apex pulp survival 75% Immature apex 100% WNL Mature apex 95% WNL 2% inflammatory root resorption 2% surface resorption Extrusive Luxation Extrusive Luxation disruption of PDL and nuerovascular bundle Reorganization of PDL and..pulp? Reposition Splinting non rigid splint 2-3 weeks Follow up radiographically PULP Open apex Calcification 57% Necrosis 7% Survival 32% PDL 88% WNL 10% root resorption Extrusive Luxation Closed apex Calcification 17% Necrosis 67 % Survival 17% 87% WNL 20% root resorption Lateral Luxation Lateral Luxation Similar to Extrusive but with complicatoin of bone fracture and compression of apical tissue Reposition Splint minimum 3-4 weeks May be up to 8 weeks if mobile 12

13 PULP Open apex Calcification 70% Necrosis 10% Survival 18% PDL 91% WNL 9% root resorption Lateral Luxation Closed apex Calcification 8% Necrosis 80 % Survival 12% 67% WNL 32% root resorption Intrusive Luxation Intrusive Luxation Disruption of PDL, neurovascular bundle, compression of the alveolar bone Reposition with forceps or ortho Splint therapy 3 weeks Intrusive Luxation Open apex necrosis 62% Pulp survival 12% Closed apex necrosis 97% Open apex PDL WNL 32% Both open and close inflam root resorption 33% Avulsion Avulsion Biologic considerations Both PDL and pulp ischemia Bacterial invasion Length of time extraorally <1 hour try to replant >1hour decision to replant or leave alone due to high incidence of external root resorption 13

14 Treatment of the Avulsed Permanent Tooth I. Management at the site of Injury A. Replant immediately, if contaminated, rinse before replanting. B. If immediate replantation impossible, place tooth in the best transport medium available. Hank s Balanced Salt Solution (H.B.S.S.) Culture media Compatible ph and osmolarity Reconstitute PDL cells Avulsed Tooth Endodontic Therapy Avulsed Tooth Endodontic Therapy Open Apex < 60 mins. Replant and recall every 3-4 weeks Open Apex > 60 mins. Instrument and Ca(OH) 2 Closed Apex < 60 mins. Instrument canal 7-14 days after reimplantation. Ca(OH) 2 for 6-12 months Obturation Avulsed Tooth Endodontic Therapy Avulsed Tooth < 20 mins with Open Apex Closed Apex > 60 mins. Soak tooth in 2.4% sodium fluoride for 20 mins. Emdogain. Perform root canal treatment either extraorally or intraorally Soak tooth in doxycycline (1mg/20mg saline) for 5 mins.. 14

15 Avulsed Tooth > 20 mins and < 60mins Soak tooth in H.B.S.S. for 30 mins. and 5 mins. in a Doxycycline solution.???? Avulsed Tooth > 60mins Soak tooth in Citric Acid for 5mins, Fluoride for 5 mins., than a Doxycycline solution for 5 mins. Avulsed Tooth Medication If endodontic treatment has been initiated in 7-10 days following trauma, Ca(OH) 2 treatment for 7-14 days is adequate. Avulsed Tooth Medication Adjunctive Drug Therapy A. Systemic antibiotics -Doxycycline 100mg BID for 7 days Pen VK 500 QID for 7 days B. Tetanus consultation within 48 hrs C. Chlorhexidine rinses D. Analgesics Treatment of the Avulsed Permanent Tooth B. Open apex, > 1 hr. extraoral dry time NO REPLANTATION Treatment Open Apex Systemic Antibiotics no matter time interval of reimplantation Doxycycline 100mg BID for 7 days Pen VK 500 QID for 7 days Refer for Tetanus booster with contact of soil Physiologic splint 7-10 days<60min >60min no reimplantation 15

16 Injury to Primary Dentition Principles 16

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