Follow up Schedule

1) Will depend on type of injuries present

a) Especially need for endodontic treatment

i) e.g. Immediate: Avulsion, Intrusion-mature teeth

b) And need to remove sutures &/or splint

i) Sutures: 5-6 days

ii) Flexible splint: 7-10 days

iii) Rigid splint: 6 wks - 3 months

2) If immediate endodontics not required:

• 2 weeks

• 1 month

• 2 months

• 3 months

• 6 months

• 9 months

• 1 year

• Annually for 5 years

• Then every 3 years

Tooth Response to Traumatic Injuries

The tooth will respond differently to different traumatic injuries. This depends on various factors viz. type of impact on tooth, vascularity of the canals, condition of periradicular structures, alignment of teeth etc.

•Pulpal Response

Favourable
Pulp response is favourable if it recovers & returns to it’s normal state. Pulp tissue could also fibrose or these may be pulp canal obliteration (PCO), which could be partial or complete.

Unfavourable

Pulp response to injury/trauma could lead to pulp necrosis or infection of the pulp space. It could lead to internal resorption of the tooth, which could be a surface resorption, inflamatory resorption or replacement resorption.

•Peri-radicular Responses to Trauma

Favourable

A favourable response would mean recovery and return to a normal state, fibrous healing or a transient apical breakdown.

Unfavourable

Unfavourable response would lead to cessation of root development, disturbances to root development or bone resorption which would be marginal (crestal), apical,lateral depending on the position with respect to the tooth surface.There could be gingival recession or external root resorption which can be categorized as surface, inflammatory and replacement resorption.

•Resorption as a Sequela to Traumatic Injuries

Resorption is the most frequent sequela to luxation injuries; three different types of resorption have been identified:

1) Surface,

2) Inflammatory, and

3) Replacement (ankylotic) resorption

Surface resorption: Small superficial cavities in cementum and outermost dentin. This type is not visible on radiographs and is usually repaired by new cementum. It may be transitory or progressive. The former leads to repair, the latter to further resorption

i) Inflammatory Resorption

Radiographically seen as a bowl-shaped resorptive area of the root and associated with adjacent bony radiolucencies. It involves both tooth structure and adjacent bone.Radiographically, there is apparent tooth loss along with adjacent bony destruction.Root canal therapy can be expected to arrest inflammatory resorption that involves replanted teeth; the resorption can be prevented by judicious timing of the root canal therapy.

ii) Replacement Resorption: External Replacement Resorption

Resorption of the root surface and its substitution by bone, resulting in ankylosis. This is a frequent sequela to replantation. As tooth structure is resorbed, it is replaced with bone that fuses to the tooth structure, thereby producing ankylosis.

iii) Invasive External Root Resorption Appears

• Usually many years after trauma

•Radiolucency — poorly defined margins

•Sub-gingival — external origin

•Resembles caries or internal resorption

•Very vascular — bleeds on probing

•Resorption is by invasive tissue and not inflammatory tissue

Factors Affecting Resorption
The following factors determine the rate of resorption

a) Extra-alveolar time — Greater the time greater the chances of resorption

b) Storage conditions — Storage in appropriate media delays resorption

c) Damage during avulsion — Loss of supporting periodontal fibers on the root or in the socket will lead to resorption. Mechanical damage can not be controlled.

d) Replant procedure — During replant procedure minimise trauma. An atraumatic procedure provides the best results.

e) Splinting- Physiologic splinting provides greatest chances for success.

f) Splinting

i) Flexible splint:

1) 7 - 10 days only

2) If NO root or bone fractures

3) Allows “functional” healing of periodontal ligament

4) Reduces ankylosis and replacement resorption

ii) Rigid splint - ONLY if:

1) Associated with bone fracture will take 6 weeks

2) Or if root fracture will take about 3 months

g) Endodontic treatment at the appropriate time with medicaments as required will delay resorption.

•Treatment of Resorption

In case of progressive resorption, any form of treatment does not help to arrest the resorption. Eventually the tooth has to be extracted so the treatment is directed to prevent or minimise the occurance of this type of resorption.In case of a transient resorption, treatment is not required and it stops by itself. It is difficult to access the difference between the progressive and transient type of resorption.

Avulsion

An avulsed tooth is completely displaced out of its socket; this trauma has also been referred to as an exarticulation. The length of extra-alveolar time determines both treatment procedures and prognosis. If the tooth has been left dry for less than 1 hour or kept in milk for no more than 4 to 6 hours, the protocol for treatment is described as “immediate” replantation; more than 1 hour of dry time is “delayed” replantation.

 

•Immediate Replantation

Replantation in the office must be preceded by a careful evaluation of the traumatized alveolus and the avulsed tooth.

1) Look for evidence, both clinically and radiographically, of alveolar fracture.

2) Inspect the alveolar socket for foreign bodies and debris, taking care not to scrape the bony walls.

3) The blood clot in the socket can be gently suctioned and the socket irrigated with saline.

4) Check the avulsed tooth for debris on the root; if such debris cannot be rinsed off with saline or water, gently pick it off with tweezers.

5) While inspecting the tooth, it can be held by the crown using gauze moistened in saline, which permits examination of the tooth without touching the root surface.

6) Gently insert the tooth into the socket.

7) The insertion should be slow and gentle so that pressure is minimized.

8) When the tooth is nearly in place, have the patient complete the process by biting on a piece of gauze.

9) Check occlusion. It is most important that it should not be in hyperocclusion. Such premature contact would delay or prevent recovery.

10) Need for splinting would depend on degree of mobility.

11) The physiologic splint should be left in place only long enough for the initial reattachment of periodontal ligament fibers; in most cases that can be expected to take place in 1 to 2 weeks, after which the splint should be removed.

12) Antibiotics should be administered for 5-7 days

13) Evaluate after 2 weeks and initiate endodontic therapy after 14 days. The exception to the rule of root canal therapy for avulsed teeth is when the tooth is still developing and has a wide open apical foramen. Such teeth have the potential for pulp revascularization.

•Delayed Replantation

The treatment for teeth with more than 1 hour of extra-alveolar time should include efforts to slow the inevitable replacement resorption.

1) Examine the avulsed tooth for debris. In contrast to avulsed teeth with less than 1-hour extra-alveolar time, those with more than 1 hour are not expected to retain the vitality of periodontal ligament cells and fibers.Therefore, it is best to remove pieces of soft tissue attached to the root surface.

2) Perform root canal therapy with the tooth in vitro. This can often be best accomplished by holding the tooth by the crown and proceeding with the endodontic treatment through an apical or coronal approach.

3) Apical approach involves resecting 2 – 3 mm of the root tip and completing extirpation, disinfection and obturtation procedures.

4) A coronal approach will involve greater destruction of tooth structure

5) Soak the tooth in a 2.4% fluoride solution acidulated at pH 5.5 for 20 minutes or more. The fluoride will slow the resorptive process.

6) The rest of the procedure mirrors the technique in immediate replantation.

7) Splint for 6 weeks.

• Protection of Root Surface

To reduce chance of replacement resorption you must ensure the following:

• Don’t allow the root to dry out since the periodontal ligament cells will necrose

• Storage media is important milk or tissue culture are the best media Saliva,Saline or Plastic Wrap are acceptable (avoid water)

• Replant/reposition immediately or as soon as possible.

• Physiologic splint to promote healing and prevent resorption due to disuse

To reduce chance of inflammatory resorption following two are required

a) Antibiotics are prescribed orally.

b) Endodontic treatment.