Endodontic clinical seminardentistry.tums.ac.ir/dentistry_content/media/image/2012/12/970... · •Dental history: •Avulsion of left maxillary lateral incisor(90/07/28). •3 hours

Endodontic clinical seminar 91/10/05

By: Dr. somayyeh dehghan

Case 1

• A 22 years-old female

Chief complaint:

• my tooth fell out due to trauma.

Medical history:

• Non-contributory

• Dental history:

• Avulsion of left maxillary lateral incisor(90/07/28).

• 3 hours dry time.

• Immersed in doxycycline for 15 min.

• Replanted and sutured.

• Referred after 10 days (90/08/08).

Pulpal tests:

Right Maxillary

central incisor

11

Left Maxillary

central incisor

21

Left Maxillary

lateral incisor

22

Left Maxillary

canine

23

cold + + - +

Heat + + - +

Tooth #22:

• Percussion: sensitive

• palpation: sensitive

• Mobility: Grade 1

Tooth #21:

• Percussion: sensitive

• palpation: normal

• Mobility: normal

1390/08/08: Radiographs with different angles

Treatment plan?

• Which factors determine the avulsed tooth prognosis?

1. Maturity of the tooth (mature/immature)

2. Dry time of the tooth (less than 60min/more than 60 min)

Favorable responses (new cementum)

Unfavorable responses

*osseous replacement resorption

*inflammatory resorption

Storage medium

HBSS(Hanks Balanced Salt Solution)

milk

saliva

Saline

Water(hypotonic)

Chamorro et al , Dental Traumatology 2008;24:11–16

• Overall, cells treated on ice showed significantly lower levels of apoptosis when compared with treatments at room temperature

• Milk and HBSS had a low percentage of apoptotic cells and no significant difference (P > 0.05)

*

Replantation

Closed apex Open apex Closed apex

Open apex

<60 min

>60 min

Replantation

* Rinse with saline & replant.


Open apex

<60 min

>60 min

Replantation

* Rinse with saline

* Topical antibiotics

Enhance revascularization

*Replant



Open apex

<60 min

>60 min

Replantation

*Place in acid

*Remove nonviable cells with gauze

*2% stannous fluoride

*Replant

* Rinse with saline



*Replant



Open apex

<60 min

>60 min

Replantation

*Not replant



*RCT & replant

*Place in acid



*Replant

* Rinse with saline



*Replant



Open apex

<60 min

>60 min

Splint and RCT


Open apex

<60 min

>60 min

Splint and RCT

*flexible splint for 2w.

*RCT 7-10 days later


Open apex

<60 min

>60 min

Splint and RCT


*follow up




Open apex

<60 min

>60 min

Splint and RCT




*follow up




Open apex

<60 min

>60 min

Splint and RCT


*RCT extraorally




*follow up




Open apex

<60 min

>60 min

How to manage the closed apex avulsed tooth with extra oral

dry time>60 minutes?

• Placing in acid for 5 minutes.

• Soaking in 2%stannous fluoride.

• splinting for 1-2 weeks(4week)

Is splinting duration important or not??

*

- 138 replanted avulsed permanent teeth - both short-term splinting (14 days or less) and long term-splinting (over 14 days) - successful periodontal healing after replantation is unaffected by splinting duration.

*

Petrovic et al.

low survival: •Delayed replantation •Unphysiological storage •Incisors with open apices •Required prolonged treatment with calcium hydroxide

flexible splints with physiologic movement of the tooth1

(TTS, suture2).

1. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology 2012; 28: 88–96. 2. Management of tooth avulsion, review and case report. Int journal of contemporary dentistry, 2011

what about traumatic occlusion?

Traumatic occlusion SP expression increases significantly in human dental pulp/PDL

inflammatory responses in pulpal and periapical tissues1.

1. Effect of Experimentally Induced Occlusal Trauma on Substance P Expression in Human Dental Pulp and Periodontal Ligament.

J Endod 2011;37:627–630.

What about antibiotic administration?

• systemic administration :

• clinical studies:

Not demonstrated.

• Experimental studies :

Limiting infection-related resorption:

Tetracycline

Penicillin V

amoxicillin

• Local administration :

Intracanal Ledermix

Topical application before replantation

Andreasen et al. The role of antibiotics in preventing healing complications after traumatic dental injuries: a literature review. Endodontic Topics 2006, 14, 80–92

1390/08/08 (first visit):

• Tooth #22 (lateral incisor) :

Suture was removed.

Root canal therapy was initiated for #22 (lateral) and treated with long-term calcium hydroxide therapy.

1390/09/26 (second visit):

• tooth #21:

Crown discoloration

Vitality: negative

Percussion: sensitive

Mobility: normal

1390/09/26 (second visit):

• tooth #21: Root canal therapy was initiated

Irrigated with NaOCl 5.25%

obturated with gutta-percha/AH26.

• Tooth #22: Ca(OH)2 was removed.

obturated with gutta-percha/AH26.

1391/03/30(6-month follow up):

• tooth #21:

No clinical and radiographic signs.

• Tooth #22:

Metallic-like percussion sound.

Possibly inflammatory and replacement resorption.

1391/04/10: 6-month follow up

1391/08/10 9-month follow up:

Diagnosis and treatment plan?

How to control root resorption?

MTA

Calcium hydroxide / MTA

Long- term calcium hydroxide

Andreasen et al.

fracture resistance: 1- MTA 2- CH(short-term,30 days)+ MTA (not significant) 3-saline 4- CH(long-term,100days) (significant) *

Witherspoon et al. *Clinical & RA evaluation 93.5% of teeth treated in 1 visit healed( MTA obturation) 90.5% of teeth treated in 2 visits healed. (3 weeks calcium hydroxide ) ( not significant)

*

Kafman et al. • teeth with root treatment

with MTA showed the highest fracture resistance at 1 year.

• MTA induced the expression of TIMP-2 in the dentin matrix and prevented destruction of the collagen matrix. *

Calcium hydroxide therapy

advantages: disadvantages:

High pH

No bacteria-tight seal*

Antimicrobial activity



High pH



detrimental effect on periodontal tissues when used as an intracanal medicament1.

1. Biocompatibility of dental materials used in contemporary endodontic therapy: a review. Part 1. Intracanal drugs and substances. IEJ,36, 75–85.



High pH



detrimental effect on periodontal tissues when used as an intracanal medicament1.

changes in the physical structure of dentin2.

1. Biocompatibility of dental materials used in contemporary endodontic therapy: a review. Part 1. Intracanal drugs and substances. IEJ,36, 75–85. 2. The effects of short-term calcium hydroxide application on the strength of dentine. Dental Traumatology 2010; 26: 43–46

MTA Advantages:


Sustained alkaline pH

bacterial-tight seal

Activates proliferation and differentiation of cells

Inhibits osteoclastic activity by high PH and inhibition of MMPs1.

1. Fracture resistance and histological findings of immature teeth treated with mineral trioxide aggregate. dental traumatol 2008.

Is chloroform contraindicated or not?

• Decreases Human Periodontal Ligament Fibroblasts growth1.

• Significantly reduces intracanal levels of E. faecalis2.

1.Chloroform Biocompatibility on Human Periodontal Ligament Fibroblasts.2010

2. The antimicrobial effect of chloroform on Enterococcus faecalis after gutta-percha removal. J Endod,2006

the use of chloroform during endodontic retreatment significantly reduced intracanal levels of cultivatable E. faecalis

*

What are Causes of central discoloration?

Causes of tooth

discoloration

Intrapulpal hemorrhage

Pulp necrosis

Is internal bleaching contraindicated in traumatized teeth or not?

Heat

bacteria

Previous trauma

external cervical

root resorption

Is internal bleaching contraindicated in traumatized

teeth or not?

1391/08/10:

• Tooth #22:

Retreatment and obturation with MTA.

• Tooth #21:

Internal bleaching with sodium perborate.

Thanks for your attention

Documents

Endodontic clinical seminardentistry.tums.ac.ir/dentistry_content/media/image/2012/12/970... · •Dental history: •Avulsion of left maxillary lateral incisor(90/07/28). •3 hours