انت هنا الان : شبكة جامعة بابل > موقع الكلية > نظام التعليم الالكتروني > مشاهدة المحاضرة

Management of Injuries to Permanent Dentition:

الكلية كلية طب الاسنان     القسم التقويم والاطفال وطب الاسنان الوقائي     المرحلة 5
أستاذ المادة حسن فليح فرحان السلطاني       6/5/2011 4:18:46 AM

Lec. 14                                             pediatric dentistry                                          د. حسن الوطيفي  

Management of Injuries to Permanent Dentition:

1-Crown infraction: No treatment need.2- Simple Enamel Fracture:
No restoration is needed and the treatment is limited to smoothing of any rough edges. The child should be reexamined at 2 weeks and again at one month after the injury to check the vitality.

2- Enamel and dentine fracture without Pulp Exposure:
1. Require pulp protection against thermal, chemical and osmotic irritation and from bacteria via the dentinal tubules and restoration of crown morphology to prevent drifting of tooth.
2. Occasionally the dentist may have the opportunity to reattach the fragment of fracture tooth using resin and bonding technique. If little or no dentine exposed, reattachment of the crown fragment is an alternative that can be considered. For cases in which considerable dentine is exposed, an indirect pulp cap is indicate if the patient come immediately after trauma but if the patient come later on, the probability of being  non vital increase.
3. If enough part is missing to compromise the entire tooth structure, but the pulp is not permanently damaged and no tooth fragment is present, the tooth will require immediate temporary restoration:
1- Orthodontic band.
2- Acrylic crown.
3- Celluloid crown and stainless steel crown.
4- Composite resin restoration.
Some time permanent treatment is indicated such as protective coverage with a gold or porcelain crown.
4. Pulp vitality should be cheeked for 4-6 weeks.

3- Enamel and Dentine Fracture with Pulp Exposure:
1. These fractures exposing the pulp are often painful, and patients with this condition require timely referral to a dentist.
2.  If the patient is seen with in an hour or two after injury and the vital exposure is small, and if sufficient crown remains to retain temporary restoration to support the capping material and prevent the ingress of oral fluids, a direct pulp capping is indicated.
3. If the pulp exposure large and the child did not seek treatment until several hours or days after the injury or if insufficient crown remains to retain temporary restoration to support the capping material as well as if the tooth immature (open apex) the tooth will require pulp care (vital pulpotomy or apexogenesis). The successful pulpotomy allows the pulp in the root canal to maintain its vitality and also allows the apical portion to continue.
4. Yet another indication to the vital palpotomy is trauma to a mature   permanent (closed apex) tooth that has caused both a pulp exposure and a root fracture.

Type of vital pulpotomy:
A- Shallow pulpotomy:
A shallow or partial pulpotomy is preferable if coronal pulp inflammation is not widespread and if a deeper access opening is not needed to help retain the coronal restoration.
B- Conventional pulpotomy: This treatment is indicated for immature permanent teeth if necrotic pulp tissue is evident at the exposure site with inflammation of the underlying coronal tissue.
5. Occasionally a patient has an acute periapical abscess associated with a traumatized tooth. The trauma may have caused a very small pulp exposure that was overlooked, or the pulp may have been devitalized as a result of injury or actual severing of the apical vessels, so RCT. is indicated if the apex is closed.

THERAPY TO STIMULATE ROOT GROWTH AND APICAL REPAIR SUBSEQUENT TO PULPAL NECROSIS IN ANTERIOR PERMANENT TEETH (APEXIFICATION)
One of the most challenging endodontic procedures is the treatment and subsequent filling of the root canal of a tooth with an open or funnel-shaped apex. The lumen of the root canal of such an immature tooth is largest at the apex and smallest in the cervical area and is often referred to as a blunderbuss canal. However, a less traumatic endodontic therapy called apexification has been found to be highly effective in the management of immature, necrotic permanent teeth. The apexification procedure should precede conventional root canal therapy in the management of teeth with irreversibly diseased pulps and open apices.
The following steps are included in the technique:
1. The affected tooth is isolated with a rubber dam, and an access opening is made into the pulp chamber.
2. A file is placed in the root canal, and a radiograph is made to establish the root length accurately. It is important to avoid placing the instrument through the apex, which might injure the epithelial diaphragm.
3. After the remnants of the pulp are removed using barbed broaches and files, the canal is flooded with hydrogen peroxide to aid in the removal of debris. The canal is then irrigated with sodium hypochlorite and saline.
4. The canal is dried with large paper points and loose cotton.
5. A thick paste of calcium hydroxide and camphorated mono-parachlorophenol (CMCP) or calcium hydroxide in a methylcellulose paste is transferred to the canal with the aid of an amalgam carrier. An endodontic plugger may be used to push the material to the apical end, but an excess of material should not be forced beyond the apex of the tooth.
6. A cotton pledget is placed over the calcium hydroxide, and the seal is completed with a layer of reinforced zinc oxide–eugenol cement for 1 to 2 weeks.
Placing a calcium hydroxide dressing in the canal is optional at the first appointment. Whether the tooth is filled in one or two appointments (or more) should be determined to a large extent by the clinical signs and symptoms present and to a lesser extent by operator convenience. The signs and symptoms of active infection should be eliminated before the canal is filled with the treatment paste. Absence of tenderness to percussion is an especially good sign before filling the canal. If the canal continues to weep but other signs of infection seem to be controlled after two or three appointments, the dentist may elect to proceed with the calcium hydroxide paste treatment.
8. As a general rule the treatment paste is allowed to remain 6 months. The root canal is then reopened to determine if the tooth is ready for a conventional gutta-percha filling as determined by the presence of a "positive stop" when the apical area is probed with a file. Often there is also radiographic evidence of apical closure.

Frank has described four successful results of apexification treatment:
    1) Continued closure of the canal and apex to a normal appearance.
    2) A dome shaped apical closure with the canal retaining a blunderbuss appearance.
    3) No apparent radiographic change but a positive stop in the apical area.
    4) A positive stop and radiographic evidence of a barrier coronal to the anatomic apex of the tooth.
9. If apical closure has not occurred in 6 months, the root canal is retreated with the calcium hydroxide paste.
10. If weeping in the canal was not controlled before filling, re-treatment is recommended 2 or 3 months after the first treatment.
11. Ideally the postoperative radiographs should demonstrate continued apical growth and closure as in a normal tooth.
12. When closure has been achieved, the canal is obliterated in the conventional manner with gutta-percha.

Mineral trioxide aggregate (MTA): As alternative to calcium hydroxide in the apexification procedure. 
1- The root canals were rinsed with 5% sodium hypochloride.
2- Calcium hydroxide was then placed in the canals for 1 week.
3- Following this, the apical portion of the canal (4 mm) was filled with MTA, and the remaining portion of the root canals was closed with thermoplastic gutta-percha.
4- Follow-up At 6-month and 1-year clinically and radiographically.
4- Enamel, Dentine and Cementum Fracture:
A tooth that is vertically fractured or fractured below the gum line will require root canal treatment when there is closed apex, or apexification and root canal treatment when there is open apex before protective restoration. Some time the eventual restoration may require a post in the root canal. The tooth will then be reevaluated in 2-4 weeks. A tooth that no longer has enough remaining structure to retain restoration may have to be extracted.

5- Concussion: Require long term follow up and/ or root canal therapy.
6- Luxation of Permanent Teeth:
1. Require repositioning, splinting along with long term follow-up.
2.  If repositioned teeth do not respond to the pulp test within 2-3 weeks, endodontic treatment is indicated before theirs evidence of root resorption, which occure mostly after sever injuries of this type.
3.  If the tooth not mobile just reduce little bite of the incisal edge.

7- Intrusive Luxation:
Teeth subject to intrusive luxation have been intruded into the alveolar bone, which may occur to the point that the teeth are not visible. Intruded teeth were successfully treated by multidisciplinary approach. It can be treated by:
    1- Immediate surgical correction.
    2- Intruded immature permanent teeth may be left to re-erupt spontaneously with in 1-2 weeks.
3- If the tooth does not show early spontaneous re-eruption or if intrusion is severe, orthodontic repositioning over a period of 2-3 weeks should be initiated.
     4- Rather than repositioning the tooth to gain endodontic access, a palatal gingivectomy and endodontic treatment 10 days after the injury should be considered.

8- Extrusive Luxation: Management includes:
1. Careful repositioning and stabilizing of the tooth for 2-3 weeks.
2.  If mature repositioned tooth do not response to vitality tests with in 2-3 weeks after reposition, endodontic treatment is indicated.
3.  With extruded immature tooth, the clinician should monitor the situation and be prepared to intervene with endodontic therapy if condition warranted.

9- Avulsions: Avulsion of permanent teeth is the most serious of all dental injuries and replantation is the treatment of choice.
Replantation is the technique in which a tooth, usually one in the anterior region, is reinserted into the alveolus after its loss or displacement by accidental means.
The prognosis depends on:
1. The measures taken at the place of accident (contamination) and extra oral dry time.
2. Stage of root development (closed or open apex). If the apex is open, there is greater chance of regaining pulp vitality after replantation. If the apex closed, RCT is indicated after few days after replantation. 
3. The condition of tooth and the condition of PDL remaining on the root surface.
Treatment:
1. The tooth should be immediately reimplanted with simple finger pressure or some time under local anesthesia and then secured in place by a splint.
2. If rinsing is required, normal saline should be used, and any clot present in the socket should be flushed out before reimplantation.
3.  If the tooth cannot be replanted within 5 minutes, it should be stored in a medium that will help maintain vitality of the periodontal ligament fibers.  
4.  If a dentist can see the child within 30 minutes and the tooth has been preserved correctly, there is a possibility that it may be successfully re-implanted.
5.  If the tooth is visibly contaminated, it should be gently rinsed in cold running tap water and then reimplanted.
6. Care should be taken not to touch, rub, or clean the root, which could remove periodontal ligament fibers and reduce the chance of successful reimplantation.
7. The socket should not scrap with an instrument.
8. Emdogain has been shown to increase the incidence of healed periodontal ligament when this gel is applied to root surface of the avulsed tooth prior to implantation.
9.  Antibiotic prophylaxis with penicillin should be prescribed.
10.  Tetanus vaccine should be administered.
Transportation media for avulsed teeth include:
1. Child mother milk.
2. Milk (skim or low-fat milk or pasteurized bovine milk if available, is preferred).
3.  Isotonic saline.
4.  Emergency medical treatment tooth saver (EMT- tooth saver).
5.  Hank s buffered saline.
6.  Human saliva and perhaps blood and tape water. 


المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .