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Endo Pt. 2 (Dental Trauma (Trauma Hx (Previous Trauma WHEN – did the…
Endo Pt. 2
Dental Trauma
Eitiology of Trauma:
Falls, Bicycle Accidents, Violence, Sports
Trauma Hx
Previous Trauma
WHEN – did the accident occur
WHERE – did the accident occur, sports field vs. operating theatre
HOW – did the accident occur
RULE OUT – CNS injury & Child abuse
Mechanism of action
May suggest other injuries
"Blow to the chin" = condylar fracture?, VRF?, soft tissue injuries?
Symptoms
spontaneous pain
reaction to thermal
occlusal disturbances?
Dental Injuries
Reactions to Tooth Trauma
Pulpitis Internal
Hemorrhage Tooth
(turns grey/black)
Pulp Infection / Necrosis
Pulp Canal Obliteration
(Often discolour and don’t respond well to bleaching)
Inflammatory Resorption
(Internal - rare External – after an avulsion injury)
Replacement Resorption
(Ankylosis)
Increased chance of pulpal revascularization in teeth with open(developing) root apices
Classification of Trauma (ANDREASEN)
A: Injuries to the hard dental tissues and pulp
Enamel Infarction
An incomplete fracture (crack) of the enamel without loss of the tooth substance
Uncomplicated Crown Fracture
A fracture contained to the enamel or involving enamel and dentin, but not exposing the pulp
Complicated Crown-Root Fracture
A fracture involving enamel, dentin and cementum and exposing pulp.
Root Fracture
A fracture involving dentin, cementum and the pulp.
Complicated Crown Fracture
A fracture involving enamel and dentin and exposing the pulp
Uncomplicated Crown-Root Fracture
A fracture involving enamel, dentin and cementum but not involving the pulp.
B: Injuries to the periodontal tissues
Concussion
An injury to the tooth supporting structures without abnormal loosening or displacement of the tooth, but with marked reaction to percussion.
Subluxation
An injury to the tooth supporting structures with abnormal loosening but without displacement of the teeth.
Intrusive Luxation
Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.
Extrusive Luxation
Partial displacement of the tooth out of its socket.
Lateral Luxation
Displacement of the tooth in a direction other than axially. This is accompanied by comminution or fracture of the alveolar socket.
Avulsion
Complete displacement of the tooth out of the socket
C: Injuries to Supporting Bone
D: Injuries to gingiva or oral mucosa
Follow-up Examinations
1 week - 3 weeks - 6 weeks - 3 months - 6 months - 1 year
Soft tissues:
Swelling, sinuses, inflammation, LOA
Teeth:
Colour/transillumination, Mobility, Percussion, Vitality testing
Radiographic:
Healing or disease
Endodontic Assessment
Differential Diagnosis
Normal Pulp
Symptom Free
Reversible Pulpitis
Mild or transient pulpal infl, may result in sharp pains that do not linger. Usually due to caries and coronal leakage. Perio appears normal
Irreversible Pulpitis
A severe insult resulting in irreversible inflammation. Symptoms may include throbbing pain to various stimuli that may linger. It can be exacerbated and relieved by different actions. - woken up at night?
Pulp Necrosis
Partial or complete necrosis of the pulp, until the periodontium(apical) or involved it will be symptom-free. Single-rooted teeth usually do not respond to sensibility testing, whereas multi-rooted may have a partially vital pulp.
Acute/Chronic Periapical Periodontitis
Radiographically widening of the PDL space, may be TTP or tender to chewing. Otherwise symptom free.
Acute/Chronic Periapical Abscess
Acute will present with an intense throbbing pain, TTP, mobility, no response to tests, may be swelling and a fever
Chronic will present symptom free, with no sensitivity, a large apical area, and assoc. with sinus tract
Facial Cellulitis
localized infection of the soft tissues; begins as a PA, however infection can spread through facial planes/spaces
Goals of Tx: Elimination of bacteria and endotoxins from the root canal system
Examination:
Special Tests: sensibility = EPT(84%)/Cold(90%), Fracfinder, LA pain block, GP tracer
Radiography = PAs, PBWs, Occlusal
(bone level, root fractures, assoc. structures ect)
E/O - facial swellings?
I/O- soft tissue swelling, occlusion, perio (mobility, pocketing, coronal restorability, TTP/palpation)
HPC – recent dentistry work, trauma, pain/discomfort that has been around a while and been ignored?? (
Important
)
Tx Plan:
Is the tooth restorable?
Is endo re-Tx best Option - Exo? - Surgery?
Long-term prognosis? Success or failure
Needs good coronal seal
Is the management achievable (biofilms + accessory canals)
--> Re-treatment is Primary treatment of choice
Greater chance of eliminating bacteria
Less postoperative discomfort
Less chance of damaging anatomical structures
Endo Tx teeth as abutments:
Success w/ = single crowns > bridge > RPDs
Restoration of Endo Tx Teeth
Tooth Fracture
Endo Access
Access cavity needs to reflect internal anatomy, however usually removes most of the central dentine
= RCT have the same fracture resistance as vital teeth w/ MODs
MUST removal of restorations and caries
(also allows the clinician to assess restorability of the tooth and address potential leakage caused by crown/restoration)
Ideal Access
reduce cusps
straight line access
ID of all canal orifice
Maxilla
47% premolars > 1 canal 60%
1st molars have MB2
Mandible
30% incisors have 2 canals
1st/2nd molars have 3-5 canals, some may be C shaped
Which teeth fracture?
Max Anterior 7% + Max Posterior 42%
Mand Anterior 3% + Mand Posterior 48%
Restoration
Aims
Conserve remaining structure
=
reduce cusps and presence of ferrule
1-2 mm ferrule, ideally with four walls
Directly restore early
cuspal coverage x6 times greater survival rates
eg. Fuji IX orofice barrier w/ Com Overlay
Indirect considerations
quality of root filling
quality of existing restoration
position in the mouth (ie anterior seldom need crowns)
Patient factors (medical, age, hx, financial)
Position in the mouth
Anterior teeth
Coronal restoration doesnt significantly improve outcomes
Remaining tooth structure (dentine) is the most important to prevent failure
A post may be placed (small pulp chamber, limited RDT)
Premolar Teeth
subject to strong lateral forces, therefore benefit from crowning
Onlay suitable if sufficient RDT is avaliable
Post and Core if minimal RDT present
Molar teeth
Frequently fracture, must have cuspal protection and/ or ferrule[1-2 mm]
Coronal-Radicular core
= most favourable
(w/ comp, Am, or indirect)
Crowned RCT molars have greater survival rate than uncrowned RCT molars
Posts and Cores
Posts
purpose is to retain the core
DO NOT STRENGTHEN ROOTS
Reduce fracture resistance
Retention related to length, shape and diameter
Risks
Procedural accidents (strip or apical perforation)
Root fracture (cracks)
Tx Failure
(fracture of root/post, loss of retention, 2° caries)
Ideal =
1:1 CR ratio, extend beyond alveolar bone
Parallel sided
Serrated w/ Passive fit
Min 4-5mm GP apically
Procedure:
Direct (prefabricated) - Ex. Parapost system
Indirect (fabricated) - Ex. Cast metal
Causes of Endo Failure?
Bacteria in the canal
Coronal leakage – remove/replace crown
Fractures – cracked teeth
Missed canals
– ie 3rd canals
Post preparation errors
Short root fillings
Iatrogenic – transportations, zips, ledges