The document discusses traumatic injuries to the permanent dentition, specifically crown fractures. It provides an overview of the etiology, incidence, classification, and management of dental injuries. Key points include that the incidence of dental trauma from accidents and sports has increased in recent decades, commonly affecting the front teeth of children and teenagers. Proper initial treatment is important to promote healing. Classification systems help describe the specific injury and guide clinical decision making.
Traumatic Dental Injuries to Permanent TeethDrSusmita Shah
A comprehensive presentation of traumatic injuries to permanent teeth; this includes multiple classifications, risk factors, prevalence and management according to International Association of Dental Traumatology and Adreasen J O.
This document discusses the treatment of dental injuries, including fractured enamel, uncomplicated crown fractures, and complicated crown fractures with minimal pulp exposure. It describes options for treating the fractures such as leaving them, rounding sharp edges, reattaching fragments, or restoring with a crown. For complicated fractures, it outlines diagnostic signs and radiographic appearances. Treatment may include direct pulp capping, partial pulpotomy, apexification, root canal treatment, or extraction. Reattachment of fragments is described as providing good esthetics, function, and psychology benefits when possible.
The document provides information on traumatic injuries to teeth, including concussions, luxations, and fractures. It describes the clinical signs, radiographic findings, and treatment approaches for each type of injury. Concussions involve inflammation of the periodontal ligament without tooth displacement. Luxations occur when a tooth is displaced from its socket, sometimes with alveolar bone fractures. Fractures are classified as enamel fractures, enamel-dentin fractures, enamel-dentin-pulp fractures, or root fractures. Treatment depends on the specific injury but may include repositioning displaced teeth, pulpotomies, root canals, extractions, or orthodontic/surgical repositioning.
An overview of the diagnostic process in endodontics, including information about the pain system, referred pain, non-odontogenic pain, the diagnostic process, tests and treatment planning in endodontics.
Ferrule refers to a band of metal that encircles the external surface of a tooth. It strengthens root-filled teeth by resisting various stresses. A minimum ferrule height of 1.5-2mm is recommended. Factors like ferrule height, width, location, tooth type, post type, and core material affect its functionality. Ferrule promotes better fracture resistance and allows for repairable fractures versus non-repairable fractures without it. When ferrule cannot be created, crown lengthening or forced eruption can help generate tooth structure for ferruling.
The document discusses various methods for endodontic diagnosis including obtaining a thorough medical and dental history, examining subjective symptoms, performing clinical observations and tests, and interpreting radiographs. A key part of diagnosis involves determining the cause of pain or pathology through differential diagnosis and comparing current symptoms to other potential conditions. The diagnostic process aims to identify both diseased and healthy teeth through indirect evaluation of a patient's response to various stimuli and tests.
This document provides an overview of root fractures, including their definition, classification, causes, diagnosis and management. It discusses the different types of root fractures - horizontal/transverse and vertical. For horizontal fractures, it describes their sub-classification based on location and extent. Diagnosis involves dental and medical history, clinical examination including mobility and radiographs. Management depends on the location of the fracture and includes repositioning and splinting, disinfection and obturation, or surgical removal of the apical fragment. Prognosis depends on maintaining the fragments in proper alignment during healing.
Diagnosis and treatment planing in EndodonticsSalem Rekab
This document provides an overview of endodontic diagnosis and treatment planning. It discusses the importance of gathering a chief complaint, health history, dental history, and conducting a subjective and objective examination of the patient. The subjective examination involves questioning the patient about their symptoms such as the intensity, spontaneity, and persistence of any pain. The objective examination includes extraoral and intraoral soft tissue exams, examining the dentition, and performing clinical tests like percussion, palpation, and pulp vitality tests using heat, cold, or electricity. Together, the subjective and objective exams allow the clinician to make a tentative diagnosis which is then confirmed through further examination and testing.
Traumatic Dental Injuries to Permanent TeethDrSusmita Shah
A comprehensive presentation of traumatic injuries to permanent teeth; this includes multiple classifications, risk factors, prevalence and management according to International Association of Dental Traumatology and Adreasen J O.
This document discusses the treatment of dental injuries, including fractured enamel, uncomplicated crown fractures, and complicated crown fractures with minimal pulp exposure. It describes options for treating the fractures such as leaving them, rounding sharp edges, reattaching fragments, or restoring with a crown. For complicated fractures, it outlines diagnostic signs and radiographic appearances. Treatment may include direct pulp capping, partial pulpotomy, apexification, root canal treatment, or extraction. Reattachment of fragments is described as providing good esthetics, function, and psychology benefits when possible.
The document provides information on traumatic injuries to teeth, including concussions, luxations, and fractures. It describes the clinical signs, radiographic findings, and treatment approaches for each type of injury. Concussions involve inflammation of the periodontal ligament without tooth displacement. Luxations occur when a tooth is displaced from its socket, sometimes with alveolar bone fractures. Fractures are classified as enamel fractures, enamel-dentin fractures, enamel-dentin-pulp fractures, or root fractures. Treatment depends on the specific injury but may include repositioning displaced teeth, pulpotomies, root canals, extractions, or orthodontic/surgical repositioning.
An overview of the diagnostic process in endodontics, including information about the pain system, referred pain, non-odontogenic pain, the diagnostic process, tests and treatment planning in endodontics.
Ferrule refers to a band of metal that encircles the external surface of a tooth. It strengthens root-filled teeth by resisting various stresses. A minimum ferrule height of 1.5-2mm is recommended. Factors like ferrule height, width, location, tooth type, post type, and core material affect its functionality. Ferrule promotes better fracture resistance and allows for repairable fractures versus non-repairable fractures without it. When ferrule cannot be created, crown lengthening or forced eruption can help generate tooth structure for ferruling.
The document discusses various methods for endodontic diagnosis including obtaining a thorough medical and dental history, examining subjective symptoms, performing clinical observations and tests, and interpreting radiographs. A key part of diagnosis involves determining the cause of pain or pathology through differential diagnosis and comparing current symptoms to other potential conditions. The diagnostic process aims to identify both diseased and healthy teeth through indirect evaluation of a patient's response to various stimuli and tests.
This document provides an overview of root fractures, including their definition, classification, causes, diagnosis and management. It discusses the different types of root fractures - horizontal/transverse and vertical. For horizontal fractures, it describes their sub-classification based on location and extent. Diagnosis involves dental and medical history, clinical examination including mobility and radiographs. Management depends on the location of the fracture and includes repositioning and splinting, disinfection and obturation, or surgical removal of the apical fragment. Prognosis depends on maintaining the fragments in proper alignment during healing.
Diagnosis and treatment planing in EndodonticsSalem Rekab
This document provides an overview of endodontic diagnosis and treatment planning. It discusses the importance of gathering a chief complaint, health history, dental history, and conducting a subjective and objective examination of the patient. The subjective examination involves questioning the patient about their symptoms such as the intensity, spontaneity, and persistence of any pain. The objective examination includes extraoral and intraoral soft tissue exams, examining the dentition, and performing clinical tests like percussion, palpation, and pulp vitality tests using heat, cold, or electricity. Together, the subjective and objective exams allow the clinician to make a tentative diagnosis which is then confirmed through further examination and testing.
This presentation is all about restoration of endodontically treated teeth, prefabricated post and core, cast post and core, direct and indirect technique.
Abutment & Its Selection In Fixed Partial DentureSelf employed
This document discusses factors to consider when selecting abutment teeth for fixed partial dentures (FPDs). It defines an abutment tooth and outlines how to assess potential abutments, including taking radiographs and evaluating crown morphology, root configuration, crown-to-root ratio, and other anatomical features. Good abutment teeth are vital with adequate bone and root support and crown structure to withstand forces from the FPD. Location, occlusion, tooth structure and root health must be optimized for successful force distribution from the prosthesis.
This document discusses periodontal response to external forces on teeth. It defines trauma from occlusion as injury to tissues from forces exceeding their adaptive capacity. Trauma can be acute or chronic, and primary (normal support) or secondary (reduced support). It discusses classifications and concepts around how gingival inflammation spreads to bone. Glickman's concept describes zones of irritation and co-destruction that are differentially affected. Waerhaug's concept is that bone loss is due exclusively to plaque inflammation. The stages of tissue response to increased forces are injury, repair, and adaptive remodeling.
This document discusses dentoalveolar injuries, which are injuries limited to the teeth and supporting structures of the alveolus. It defines various types of dentoalveolar injuries including concussions, subluxations, luxations, and avulsions. For each type of injury, it describes the diagnosis, classification, and treatment recommendations. Treatment depends on factors like the stage of root development, presence of fractures, and degree of tooth displacement. In general, immediate repositioning and splinting is recommended for displaced teeth, while avulsed teeth should be cleaned and stored in milk before replantation with splinting and antibiotics.
This document discusses space maintainers, which are appliances used to maintain space after premature loss of primary teeth. It defines space maintainers and describes their important functions. The main causes of premature primary tooth loss are caries, trauma, ectopic eruption, and systemic disorders. Premature loss can lead to undesirable tooth movement and malocclusion. The document discusses factors that influence space closure rate and direction, as well as treatment considerations for timely space maintenance. It also outlines types of space maintainers, including fixed and removable, and their advantages and disadvantages.
This document contains information about several dental devices and procedures:
1. It provides specifications for the BONART ART-E1 dental laser, including its power output, power supply requirements, and included electrode tip sets.
2. It lists contact information for Dr. Nikhil Srivastava, a professor of pedodontics.
3. It provides specifications for the Sunny gold dental laser, including its laser source, output power, wavelength, timing functions, dimensions, weight, and electrical input.
4. The remainder of the document discusses various endodontic procedures for primary and young permanent teeth such as indirect pulp therapy, pulp capping, pulpotomy, pulpectomy, and
This document provides an overview of endodontic diagnosis, including the importance of history taking, clinical examination findings, sensitivity testing, radiographic interpretation, and developing a diagnostic scheme. It discusses diagnoses related to the pulp and periapical tissues, including normal pulps and tissues, reversible and irreversible pulpitis, pulp necrosis, apical periodontitis, abscesses, and other conditions. The document emphasizes gathering all available clinical information to form a diagnosis and treatment plan.
This lecture, which oriented to the level of mind of undergraduate students, discuss the topic of pulpectomy, its indications, contraindications, and procedural steps.
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This document discusses furcation involvement in multi-rooted teeth. It begins with definitions of anatomical terms related to furcations. It then discusses various classifications of furcation involvement, ranging from initial/incipient involvement to more advanced through-and-through defects. Epidemiology, etiology, diagnosis and factors affecting treatment outcomes are also covered. The document concludes with an overview of management approaches, which include maintaining the furcation, increasing access, removing the furcation, or closing it with new attachment.
This document discusses apexification and apexogenesis procedures for immature teeth with open apices. It defines open apices as teeth with arrested root development resulting in a large apical opening. For teeth with vital pulp but pulp exposure, the goal is apexogenesis to allow continued root development through calcium hydroxide pulpotomy. For teeth with non-vital pulp, apexification is used to induce apical closure with materials like calcium hydroxide or MTA to create an apical plug for filling. Successful outcomes depend on follow up over 1-2 years to monitor continued root development or closure of the apex.
This document provides an overview of enamel hypoplasia, including its definition, classification, etiology, clinical features, radiographic features, and management. Enamel hypoplasia is defined as an incomplete or defective formation of the enamel matrix of teeth. It can be hereditary or environmental in origin. Common causes include nutritional deficiencies, infections like syphilis, and dental fluorosis from excess fluoride intake. Clinical features range from mild pitting to severe absence of enamel. Treatment depends on severity and location, and may include desensitizing agents, composite restoration, crowns, or extractions for severely malformed teeth.
Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation, and maintenance of patients with missing or deficient teeth using substitutes. It includes fixed and removable prostheses. A fixed partial denture is a partial denture that is securely attached to abutment teeth, roots, or implants to replace one or more missing teeth. Successful treatment requires attention to patient assessment, diagnosis, treatment planning, operative skills, and follow-up care.
1. Osseous surgery involves modifying the alveolar bone support of teeth and includes techniques like osteoplasty and ostectomy. It aims to eliminate pockets and correct unphysiological bone architecture.
2. Factors in selecting a technique include the amount and location of bone loss, root trunk length, and anatomical limitations. Techniques range from non-resective procedures like osteoplasty to resective procedures like ostectomy.
3. Outcomes of osseous surgery generally include pocket elimination and establishment of physiological bone contours and architecture, though some bone loss from remodeling is expected in the range of 0.06mm to 1.2mm.
This document provides information on band and loop space maintainers. It begins by introducing space maintainers and their objectives in maintaining arch integrity and guiding eruption of permanent teeth. It then discusses different types of space maintainers, including removable, fixed, functional and non-functional varieties. Specific appliances like band and loop, lingual arch, and distal shoe are explained. The document outlines the indications, contraindications, advantages and disadvantages of band and loop space maintainers. It provides details on the materials and instrumentation used in fabricating band and loop space maintainers. Overall, the document serves as an overview of band and loop space maintainers, their classification, objectives, considerations and fabrication.
The document summarizes traumatic dental injuries and their management. It discusses the classification, clinical features, treatment, and stabilization periods for various types of dentoalveolar injuries including enamel fractures, crown fractures, root fractures, luxations, and avulsions. Splinting is described as the best method for immobilizing mobile teeth or displaced teeth, with different splinting techniques and materials discussed. Prompt treatment of dental trauma is emphasized to save injured teeth.
This document provides information on post and core procedures for restoring endodontically treated teeth. It discusses various post types and materials, as well as factors to consider for post selection and tooth preparation. The key points covered include the importance of ferrule effect for reinforcement, minimizing tooth structure removal, and using post designs and materials that distribute stresses evenly to reduce risk of root fracture. Both prefabricated and custom cast post and core fabrication techniques are described.
The document discusses attached gingiva, defining it as the portion of gingiva that extends from the base of the gingival crevice to the mucogingival junction. It describes the width and thickness of attached gingiva, noting it varies between 1-9mm wide and has an average thickness of 1.25mm. Microscopically, attached gingiva has a keratinized, cellular epithelium and dense connective tissue. It functions to act as a buffer zone, bear trauma and forces from occlusion, and prevent attachment loss and recession.
This document provides an overview of early childhood caries (ECC), including definitions, classifications, prevalence, risk factors, management, and prevention. ECC is defined as the presence of one or more decayed, missing, or filled tooth surfaces in any primary tooth in a child under 6 years old. Key risk factors include dental plaque, mutans streptococci bacteria, frequent sugar consumption, and improper feeding practices like prolonged bottle use. Prevention strategies focus on educating parents and caregivers on promoting proper oral hygiene, healthy diets, and reducing transmission of cariogenic bacteria from mother to child.
This document provides an overview of the management of dental traumatic injuries in paediatric patients. It discusses the classification, aetiology, epidemiology, clinical evaluation and treatment protocols for various injuries. Key points include:
- Dental trauma is common in children aged 2-4 and 7-10 years old, often due to falls or collisions.
- Injuries range from enamel fractures to luxations and avulsions and are classified systems like Andreasen.
- Clinical evaluation involves medical history, extraoral/intraoral exams, sensitivity tests, and radiographs to diagnose the injury.
- Treatment depends on the injury but may include allowing re-eruption, extraction, or restoration with composite for fractures.
A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.
This seminar consists of introduction, incidence, etiology, various classifications, history, clinical examination,sequelae of trauma of primary teeth followed by management
The document discusses various classifications and terminology related to traumatic dental injuries in children. It describes different types of injuries like enamel fractures, enamel-dentin fractures with and without pulp exposure, crown-root fractures, and provides details on clinical signs, radiographic findings, and treatment guidelines for each. Traumatic dental injuries are common in primary and permanent dentition of children, with the greatest incidence between ages 2-4. Proper classification and management is important to prevent long-term complications.
This presentation is all about restoration of endodontically treated teeth, prefabricated post and core, cast post and core, direct and indirect technique.
Abutment & Its Selection In Fixed Partial DentureSelf employed
This document discusses factors to consider when selecting abutment teeth for fixed partial dentures (FPDs). It defines an abutment tooth and outlines how to assess potential abutments, including taking radiographs and evaluating crown morphology, root configuration, crown-to-root ratio, and other anatomical features. Good abutment teeth are vital with adequate bone and root support and crown structure to withstand forces from the FPD. Location, occlusion, tooth structure and root health must be optimized for successful force distribution from the prosthesis.
This document discusses periodontal response to external forces on teeth. It defines trauma from occlusion as injury to tissues from forces exceeding their adaptive capacity. Trauma can be acute or chronic, and primary (normal support) or secondary (reduced support). It discusses classifications and concepts around how gingival inflammation spreads to bone. Glickman's concept describes zones of irritation and co-destruction that are differentially affected. Waerhaug's concept is that bone loss is due exclusively to plaque inflammation. The stages of tissue response to increased forces are injury, repair, and adaptive remodeling.
This document discusses dentoalveolar injuries, which are injuries limited to the teeth and supporting structures of the alveolus. It defines various types of dentoalveolar injuries including concussions, subluxations, luxations, and avulsions. For each type of injury, it describes the diagnosis, classification, and treatment recommendations. Treatment depends on factors like the stage of root development, presence of fractures, and degree of tooth displacement. In general, immediate repositioning and splinting is recommended for displaced teeth, while avulsed teeth should be cleaned and stored in milk before replantation with splinting and antibiotics.
This document discusses space maintainers, which are appliances used to maintain space after premature loss of primary teeth. It defines space maintainers and describes their important functions. The main causes of premature primary tooth loss are caries, trauma, ectopic eruption, and systemic disorders. Premature loss can lead to undesirable tooth movement and malocclusion. The document discusses factors that influence space closure rate and direction, as well as treatment considerations for timely space maintenance. It also outlines types of space maintainers, including fixed and removable, and their advantages and disadvantages.
This document contains information about several dental devices and procedures:
1. It provides specifications for the BONART ART-E1 dental laser, including its power output, power supply requirements, and included electrode tip sets.
2. It lists contact information for Dr. Nikhil Srivastava, a professor of pedodontics.
3. It provides specifications for the Sunny gold dental laser, including its laser source, output power, wavelength, timing functions, dimensions, weight, and electrical input.
4. The remainder of the document discusses various endodontic procedures for primary and young permanent teeth such as indirect pulp therapy, pulp capping, pulpotomy, pulpectomy, and
This document provides an overview of endodontic diagnosis, including the importance of history taking, clinical examination findings, sensitivity testing, radiographic interpretation, and developing a diagnostic scheme. It discusses diagnoses related to the pulp and periapical tissues, including normal pulps and tissues, reversible and irreversible pulpitis, pulp necrosis, apical periodontitis, abscesses, and other conditions. The document emphasizes gathering all available clinical information to form a diagnosis and treatment plan.
This lecture, which oriented to the level of mind of undergraduate students, discuss the topic of pulpectomy, its indications, contraindications, and procedural steps.
Visit us on Facebook:
https://www.facebook.com/iraqi.Dental.Academy
This document discusses furcation involvement in multi-rooted teeth. It begins with definitions of anatomical terms related to furcations. It then discusses various classifications of furcation involvement, ranging from initial/incipient involvement to more advanced through-and-through defects. Epidemiology, etiology, diagnosis and factors affecting treatment outcomes are also covered. The document concludes with an overview of management approaches, which include maintaining the furcation, increasing access, removing the furcation, or closing it with new attachment.
This document discusses apexification and apexogenesis procedures for immature teeth with open apices. It defines open apices as teeth with arrested root development resulting in a large apical opening. For teeth with vital pulp but pulp exposure, the goal is apexogenesis to allow continued root development through calcium hydroxide pulpotomy. For teeth with non-vital pulp, apexification is used to induce apical closure with materials like calcium hydroxide or MTA to create an apical plug for filling. Successful outcomes depend on follow up over 1-2 years to monitor continued root development or closure of the apex.
This document provides an overview of enamel hypoplasia, including its definition, classification, etiology, clinical features, radiographic features, and management. Enamel hypoplasia is defined as an incomplete or defective formation of the enamel matrix of teeth. It can be hereditary or environmental in origin. Common causes include nutritional deficiencies, infections like syphilis, and dental fluorosis from excess fluoride intake. Clinical features range from mild pitting to severe absence of enamel. Treatment depends on severity and location, and may include desensitizing agents, composite restoration, crowns, or extractions for severely malformed teeth.
Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation, and maintenance of patients with missing or deficient teeth using substitutes. It includes fixed and removable prostheses. A fixed partial denture is a partial denture that is securely attached to abutment teeth, roots, or implants to replace one or more missing teeth. Successful treatment requires attention to patient assessment, diagnosis, treatment planning, operative skills, and follow-up care.
1. Osseous surgery involves modifying the alveolar bone support of teeth and includes techniques like osteoplasty and ostectomy. It aims to eliminate pockets and correct unphysiological bone architecture.
2. Factors in selecting a technique include the amount and location of bone loss, root trunk length, and anatomical limitations. Techniques range from non-resective procedures like osteoplasty to resective procedures like ostectomy.
3. Outcomes of osseous surgery generally include pocket elimination and establishment of physiological bone contours and architecture, though some bone loss from remodeling is expected in the range of 0.06mm to 1.2mm.
This document provides information on band and loop space maintainers. It begins by introducing space maintainers and their objectives in maintaining arch integrity and guiding eruption of permanent teeth. It then discusses different types of space maintainers, including removable, fixed, functional and non-functional varieties. Specific appliances like band and loop, lingual arch, and distal shoe are explained. The document outlines the indications, contraindications, advantages and disadvantages of band and loop space maintainers. It provides details on the materials and instrumentation used in fabricating band and loop space maintainers. Overall, the document serves as an overview of band and loop space maintainers, their classification, objectives, considerations and fabrication.
The document summarizes traumatic dental injuries and their management. It discusses the classification, clinical features, treatment, and stabilization periods for various types of dentoalveolar injuries including enamel fractures, crown fractures, root fractures, luxations, and avulsions. Splinting is described as the best method for immobilizing mobile teeth or displaced teeth, with different splinting techniques and materials discussed. Prompt treatment of dental trauma is emphasized to save injured teeth.
This document provides information on post and core procedures for restoring endodontically treated teeth. It discusses various post types and materials, as well as factors to consider for post selection and tooth preparation. The key points covered include the importance of ferrule effect for reinforcement, minimizing tooth structure removal, and using post designs and materials that distribute stresses evenly to reduce risk of root fracture. Both prefabricated and custom cast post and core fabrication techniques are described.
The document discusses attached gingiva, defining it as the portion of gingiva that extends from the base of the gingival crevice to the mucogingival junction. It describes the width and thickness of attached gingiva, noting it varies between 1-9mm wide and has an average thickness of 1.25mm. Microscopically, attached gingiva has a keratinized, cellular epithelium and dense connective tissue. It functions to act as a buffer zone, bear trauma and forces from occlusion, and prevent attachment loss and recession.
This document provides an overview of early childhood caries (ECC), including definitions, classifications, prevalence, risk factors, management, and prevention. ECC is defined as the presence of one or more decayed, missing, or filled tooth surfaces in any primary tooth in a child under 6 years old. Key risk factors include dental plaque, mutans streptococci bacteria, frequent sugar consumption, and improper feeding practices like prolonged bottle use. Prevention strategies focus on educating parents and caregivers on promoting proper oral hygiene, healthy diets, and reducing transmission of cariogenic bacteria from mother to child.
This document provides an overview of the management of dental traumatic injuries in paediatric patients. It discusses the classification, aetiology, epidemiology, clinical evaluation and treatment protocols for various injuries. Key points include:
- Dental trauma is common in children aged 2-4 and 7-10 years old, often due to falls or collisions.
- Injuries range from enamel fractures to luxations and avulsions and are classified systems like Andreasen.
- Clinical evaluation involves medical history, extraoral/intraoral exams, sensitivity tests, and radiographs to diagnose the injury.
- Treatment depends on the injury but may include allowing re-eruption, extraction, or restoration with composite for fractures.
A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.
This seminar consists of introduction, incidence, etiology, various classifications, history, clinical examination,sequelae of trauma of primary teeth followed by management
The document discusses various classifications and terminology related to traumatic dental injuries in children. It describes different types of injuries like enamel fractures, enamel-dentin fractures with and without pulp exposure, crown-root fractures, and provides details on clinical signs, radiographic findings, and treatment guidelines for each. Traumatic dental injuries are common in primary and permanent dentition of children, with the greatest incidence between ages 2-4. Proper classification and management is important to prevent long-term complications.
The document discusses the surgical anatomy of the mandibular third molar region. It describes the thick lateral bone and convex alveolar process medially. The mylohyoid ridge continues posteriorly towards the third molar. Behind the third molar is the retromolar triangle, bounded by lingual and buccal crests. Lateral to this is the retromolar fossa. The retromolar canal and foramen, present in around 25% of individuals, transmits neurovascular branches through this region. The inferior alveolar canal contains the inferior alveolar nerve and vessels below the third molar area.
This document describes Andreasen's classification system for traumatic dental injuries. It presents the four main categories of this classification system: injuries to the hard dental tissues and pulp, injuries to the periodontal tissues, injuries to the supporting bone, and injuries to the gingiva or oral mucosa. For each category, it then lists and describes the specific types of injuries that fall under that category. The classification system provides detailed terminology for classifying different types of traumatic dental injuries.
The document discusses classification systems and types of dental injuries. It describes soft tissue injuries, tooth fractures including enamel fractures and uncomplicated crown fractures without pulp exposure. For uncomplicated crown fractures, the goals of emergency treatment are to protect the pulp by placing a protective material over exposed dentin, reduce discomfort, preserve pulp vitality, and restore the fractured crown area.
This document discusses the classification, assessment, and management of dental injuries involving traumatic injuries to teeth. It begins with an overview of various classification systems for dental injuries. It then discusses the general assessment of traumatic dental injuries, including patient history, clinical examination, and radiographic evaluation. The document focuses on specific injury types like crown fractures, root fractures, and luxation injuries. It provides details on pulp testing and the endodontic and restorative treatment of traumatized teeth. Classification systems help categorize injuries to determine appropriate treatment and prognosis. A thorough clinical and radiographic examination is important for assessing traumatic dental injuries. Management depends on the specific type and severity of injury.
The document discusses different types of luxation injuries to permanent teeth, including concussion, subluxation, extrusive luxation, lateral luxation, and intrusive luxation. It describes the clinical presentation, diagnosis, treatment, and prognosis of each type of injury. Luxation injuries involve trauma to the supporting tissues of the tooth and can damage the periodontal ligament and pulp. The document emphasizes the importance of promptly repositioning displaced teeth and splinting them to allow for proper healing.
Management of traumatic lesions to primary dentitionSaeed Bajafar
This document discusses the management of traumatic injuries to primary teeth. It covers the etiology, epidemiology, classification systems, examination process, and various types of injuries including their treatment and potential sequelae. The types of injuries discussed include enamel fractures, crown fractures, root fractures, luxation injuries, alveolar fractures, and avulsion. Treatment depends on factors such as the child's age, tooth development, and severity of injury. The goal is often to preserve the primary tooth and its function until exfoliation when possible.
This document discusses dentoalveolar trauma, including diagnosis, clinical examination, radiographic examination, classification, and treatment. It covers obtaining a thorough history of the trauma and examining the soft tissues, teeth, and bone clinically and radiographically. Ellis' classification of dental injuries is described. Treatment depends on the class of injury and may include splinting, stabilization, root canal treatment, or referral for surgery. Low-level laser therapy can aid in healing. Management aims to reduce complications and promote healing of injured tissues.
The document describes classifications of dental injuries including fractures and luxations of permanent and primary teeth. It discusses classifications for different types of fractures of permanent teeth such as enamel fractures, crown-root fractures with or without pulp exposure, and root fractures. It also provides classifications for luxation injuries of permanent teeth including concussion, subluxation, extrusive luxation, lateral luxation, and intrusive luxation. Finally, it summarizes classifications for luxation injuries that can occur in the primary dentition.
This document provides information about dento-alveolar trauma. It begins with the speaker's credentials and declarations of no conflicts of interest. The learning objectives are listed as diagnosis, first aid treatment, in-office treatment, maxillofacial trauma signs, biostimulation use, and complications of improper management. Diagnosis involves history, clinical examination including vitality tests, and radiographic examination. Treatment depends on factors like stage of root formation and presence of fractures. Splinting may be used for alveolar fractures or displaced teeth. Laser biostimulation is discussed as a potential alternative or addition to endodontic treatment. References are provided.
This document discusses various types of traumatic injuries to teeth. It begins by introducing the topic and defining some key terms. It then provides a detailed classification system for dental injuries developed by the International Association of Dental Traumatology, which categorizes injuries based on their effects on hard dental tissues, periodontal tissues, supporting bone, and soft tissues. The document also discusses several other classification systems. It provides descriptions, clinical findings, radiographic findings, and treatment approaches for different injury types including enamel fractures, uncomplicated crown fractures, crown-root fractures, and luxation injuries.
- Traumatic injuries to primary and permanent teeth are common, with maxillary central incisors most frequently affected. Injuries range from enamel fractures to luxations and avulsions.
- Epidemiological studies show that approximately 1/3 of children experience dental trauma to primary teeth and 1/5 experience trauma to permanent teeth. Injuries most often occur from falls at home for young children and from sports for adolescents.
- Proper classification and diagnosis of dental injuries is important to determine appropriate treatment and management. Conditions range from concussion with no displacement to intrusive luxation with tooth displacement into bone.
Principles, indications and contraindications of removal ofijazkhan2222
This document discusses the principles, indications, and contraindications of removing impacted teeth. It defines an impacted tooth as one that fails to erupt into the dental arch within the expected time. Common causes of impacted teeth and which teeth are most likely to become impacted are described. Indications for removing impacted teeth include preventing periodontal disease, dental caries, pericoronitis, root resorption, issues under dental prosthetics, cysts/tumors, jaw fractures, facilitating orthodontic treatment, and obstruction of normal tooth eruption or unexplained pain. Classification systems for impacted teeth include describing the angulation, relationship to the ramus, and relationship to the occlusal plane.
Traumatized Teeth
Copyright by Dr. Khin Swe Aye
Department of Conservative Dentistry
University of Dental Medicine, Yangon
Feel free to request to take it down this slide if you are copyright owner.
This document discusses the management of various types of traumatic dental injuries. It begins by classifying injuries based on Andreasen's modified classification system, including enamel infractions, fractures, luxation injuries, and root fractures. For each type of injury, the document describes characteristics, diagnosis, and treatment recommendations. It emphasizes the importance of promptly repositioning displaced or avulsed teeth and splinting when needed to allow for periodontal ligament healing. The document also stresses the need for follow-up evaluations and root canal treatment in mature teeth to prevent complications like pulp necrosis and resorption.
Restorative management of worn dentition (PART 1)- AETIOLOGYAshish Choudhary
This document provides an overview of tooth wear and its various etiological factors including abrasion, abfraction, attrition, bruxism, and erosion. It discusses the characteristics and mechanisms of each factor in detail. The document emphasizes that tooth wear is usually caused by multiple overlapping factors. It also outlines the steps in evaluating tooth wear, including determining the severity, making a diagnosis, and developing a treatment plan. Treatment options discussed include both preventive measures and various restorative techniques.
This document provides an overview of oral and maxillofacial injuries in children. It discusses the prevalence, etiology, and predisposing conditions of such injuries. It also covers history taking and examination procedures, as well as treatment approaches for different types of injuries including soft tissue injuries, facial fractures, and traumatic dental injuries. Key points include that falls are a common cause of injuries in young children, while sports and accidents are more common causes in older children. Treatment depends on the specific type and severity of injury, and may involve procedures like debridement, closure, splinting, root canals, or extraction in some cases. The goal is to restore function and reduce risks of further complications.
This document discusses impacted teeth, including definitions, causes, classifications, and surgical management. It notes that the most commonly impacted teeth are the mandibular and maxillary third molars. Factors that can cause impaction include inadequate jaw size, heredity, and dietary habits. Impacted teeth are classified based on their angle, depth, and position relative to other teeth and structures. Complications from impacted teeth include infection and cysts. Indications for removal include preventing complications and facilitating treatment. Surgical removal involves raising flaps, removing bone using chisels, and sometimes dividing the tooth. Proper technique and suturing help reduce risks of damage or injury.
This document discusses various types of tooth cracks and fractures, including craze lines, fractured cusps, cracked tooth syndrome, and split teeth. It begins with an introduction to how common cracks and fractures are for dentists to encounter. It then provides background on the history and classification of different crack types. The majority of the document discusses each specific crack type in detail, covering definitions, etiology, clinical features, diagnosis, and treatment options. It aims to provide an overview and review of longitudinal tooth cracks and fractures.
This document discusses the management of children with special health care needs. It begins by defining key terms like disability, handicap, and dentally handicapped. It then discusses factors that can influence disabilities, various classification systems for disabilities, and the prevalence of different disabilities in India. It also covers the Americans with Disabilities Act of 1990. The document outlines how family/parental attitudes, patient attitudes, and dentist attitudes can all impact care for children with special needs. It discusses the impacts of disabilities on oral and general health as well as barriers to care. The document concludes by discussing tools that can help in treating children with special health care needs, including concrete tools like office layout and equipment as well as conceptual tools like behavioral techniques
This document discusses the dental management of children with genetic disorders. It covers several genetic disorders including Down syndrome, Crouzon syndrome, Marfan syndrome, and ectodermal dysplasia. For each disorder, it discusses the characteristics, prevalence, dental concerns, and recommended dental management approaches. Common dental problems for children with genetic disorders include increased risk of periodontal disease, malocclusion, missing teeth, and enamel defects. The document emphasizes the importance of preventive oral care, modified dental treatment approaches, and maintaining a supportive rapport with these patients.
This document discusses the dental management of patients with hematological disorders. It covers the basics of blood physiology, hemostasis and coagulation factors. Specific disorders discussed in detail include hemophilia A/B which are sex-linked bleeding disorders caused by a deficiency of coagulation factors VIII and IX respectively. The clinical features, investigations, classifications and treatments are outlined for these conditions. Modified dental protocols are recommended to minimize bleeding risks in affected patients, including local hemostatic measures and factor replacement therapies.
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This document discusses myofunctional appliances and the basic principles of myofunctional therapy. It covers topics like normal growth and development of bones, TMJ, muscles and hormones. It describes principles of functional appliances and their role in correcting malocclusion. Different types of functional appliances are listed along with bonding procedures in orthodontics. The document also discusses theories of growth, development of cranial and facial bones, muscles of mastication, TMJ and the effect of muscular force.
The document provides guidelines for the management of avulsed permanent teeth, dividing it into two main stages: emergency treatment and definitive treatment. For emergency treatment, it outlines steps like keeping the patient calm, finding and cleaning the tooth if dirty, and seeking immediate dental treatment. Definitive treatment involves clinical and radiographic examination, sensibility testing, and treatment based on the apex status and extraoral dry time of the tooth. It details protocols for teeth with open or closed apices that were replanted immediately, stored in media, or dry for over 60 minutes. The guidelines emphasize the importance of this area in pediatric dentistry.
Guidelines for the management of traumatic dental injuries.ii.avulsion of per...Dr.Tinet Mary Augustine
- The document provides guidelines for the management of avulsed permanent teeth, dividing treatment into emergency and definitive care stages.
- Emergency treatment includes finding the tooth, cleaning it, and replanting or storing it in appropriate media like saline or coconut water until replantation. Definitive care involves examination, root canal treatment, antibiotics, and follow-up based on whether the tooth's root is open or closed.
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This document discusses traumatic injuries to primary teeth. It covers the examination, treatment, and potential complications of various types of dental injuries in primary teeth. The types of injuries discussed include concussions, subluxations, extrusion, lateral luxation, intrusion, and avulsion. Treatment options are provided for different severities of injuries from smoothing enamel fractures to pulpectomies or extractions. Complications like pulp necrosis, root resorption, and effects on the permanent successor teeth are also outlined.
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1. Dr.Tinet Mary Augustine. BDS,MDS
Pediatric Dentist
Dr.Tinet’s Pedorayz, Pediatric And Early Age Orthodontic
Dental Clinic
TRAUMATIC INJURIES TO
THE PERMANENT DENTITION
-CROWN FRACTURE
DR.TINET MARY AUGUSTINE.BDS.MDS 1
3. CONTENTS
Introduction
Etiology
Incidence
Predisposing factors
Mechanism of dental injury
Wound healing and treatment principles
History and clinical examination
Classification of TDI
DR.TINET MARY AUGUSTINE.BDS.MDS 3
4. •Traumatic injuries of the primary dentition
•Traumatic injuries of the permanent dentition
•Crown fractures
•Crown Root fractures
•Root Fractures
•Luxation injuries
•Avulsion
•Soft Tissue Injuries
•Injuries to the Supporting Bone
•Prevention Of Dental Injuries
•Summary and ConclusionDR.TINET MARY AUGUSTINE.BDS.MDS 4
5. Incidence of dental trauma due to automobile accidents and violent sports
has increased significantly during the last decade causing anterior teeth of
children and teenagers to be commonly affected.
Mean prevalence of dental and oral injuries is between 14% and 27%.
Quality and timeliness of initial care contribute to a desirable
outcome by promoting healing.
DR.TINET MARY AUGUSTINE.BDS.MDS 5
6. Incidence of dental trauma will overtake the incidence of caries and
periodontal disease in children and teenagers. (Andreasen 1993)
DR.TINET MARY AUGUSTINE.BDS.MDS 6
7. Etiology
Unintentional TDI
Intentional TDI (self harm and violence)
Iatrogenic injuries
DR.TINET MARY AUGUSTINE.BDS.MDS 7
12. HALLETS FACTORS
INFLUENCING
TRAUMA:
Energy of Impact
Resilience of impacting object
Shape of impacting object
Direction of Impacting force.
DR.TINET MARY AUGUSTINE.BDS.MDS 12
13. PREVALENCE IN PRIMARY DENTITION (at 5
years )
Boys (31-40%)
Girls (16-30%)
Andreasen 1972DR.TINET MARY AUGUSTINE.BDS.MDS 13
14. PREVALENCE IN PERMANENT DENTITION
( 12 Years)
Boys (12-33%)
Girls (4-19%)
Andreasen 1972DR.TINET MARY AUGUSTINE.BDS.MDS 14
15. WOUND HEALING SUBSEQUENT TO INJURY
Wound healing is a reaction of any multicellular organism
on tisssue damage in order to restore the continuity and
function of the tissue or organ.
DR.TINET MARY AUGUSTINE.BDS.MDS 15
16. The sequence of events after wounding is:
Control of bleeding
Establishing a line of defense against infection
Cleansing the wound site of necrotic tissue elements, bacteria
or foreign bodies
Closing the wound gap with newly formed connective tissue
and epithelium
Modifying the primary wound tissue to a more functionally
suitable tissue.
DR.TINET MARY AUGUSTINE.BDS.MDS 16
17. Traumatic dental injury represents acute transmission of
energy to the tooth and supporting structures
Tooth Supporting tissue
Fracture Displacement Separation Crushing
DR.TINET MARY AUGUSTINE.BDS.MDS 17
18. Separation Crushing
-extrusive luxation
-Cleavage of intercellular structures
-Limited damage to cells
-Wound healing by the existing
cellular system with minimum delay.
-Intrusive luxation
-extensive damage to cellular & intercellular
system
-wound healing by removal of damaged tissue
by macrophages & osteoclasts before
restoration of traumatized tissue
-delayed healing (splinting period)
DR.TINET MARY AUGUSTINE.BDS.MDS 18
19. Possible Consequences of Dental Trauma
Pulpal hyperemia
May lead to infarction and necrosis
DR.TINET MARY AUGUSTINE.BDS.MDS 19
23. Peripheral Root Resorption
Due to damage of peridontal structures
Usually in severe injuries with displacement of the tooth
DR.TINET MARY AUGUSTINE.BDS.MDS 23
24. Ankylosis
PDL injury > inflammation > osteoclastic activity > fusion
between bone and root surface
DR.TINET MARY AUGUSTINE.BDS.MDS 24
25. Examination of the traumatized patients
How did the injury occur?
Where did the injury occur?
When did the injury occur?
Has there been previous injury to the teeth?
Has there been any treatment before?
Is there any reaction in the teeth to cold and/or heat?
Is there any disturbance in the bite?
DR.TINET MARY AUGUSTINE.BDS.MDS 25
26. Clinical examination
Chief complaint
External examination
Intraoral soft tissue examination
Examination of hard tissue
Mobility testing
Percussion testing
Thermal and Electrometric testing
DR.TINET MARY AUGUSTINE.BDS.MDS 26
27. Soft Tissue Injuries
Examine lacerations and contusions of the face, lips, and
gingivae
Remove any tooth fragments or debris embedded in the
tissue
Gently cleanse the area to aid in visual examination
(topical anesthetic, soaked gauze sponges)
Develop treatment plan
DR.TINET MARY AUGUSTINE.BDS.MDS 27
28. Hard Tissue Injuries
Examine teeth and alveolar process
Note extent of crown fracture, if any
Check for displaced or avulsed teeth
Note amount of mobility
Check for pulp exposures
Examine adjacent/opposing teeth for injury
DR.TINET MARY AUGUSTINE.BDS.MDS 28
29. Radiographic Examination
Radiographs of the injured tooth, adjacent teeth, and
opposing teeth
Evaluate proximity of fracture to pulp
Estimate root development
Look for root and alveolar fractures
Note any periapical pathology
DR.TINET MARY AUGUSTINE.BDS.MDS 29
31. Other Diagnostic Tests
Wait at least 2 weeks
Electrical and thermal tests may be unreliable in primary
teeth
DR.TINET MARY AUGUSTINE.BDS.MDS 31
32. Classification
Classification of Anterior teeth trauma by Sweets (1955)
Ellis & Davey’s classification (1970)
Modified Ellis classification
Andreasen classification( 1981)
Heithersay and Morile (1982)
Garcia Godoys classification (1984)
WHO International Classification of Diseases (1992)
WHO classification (1993)
DR.TINET MARY AUGUSTINE.BDS.MDS 32
33. CLASS 1 FRACTURE OF CROWN EXPOSING NO DENTIN
CLASS 2 FRACTURE OF CROWN EXPOSING LITTLE DENTIN
CLASS 3 EXTENSIVE FRACTURE OF CROWN INVOLVING MORE DENTIN BUT NO PULP
EXPOSURE
CLASS 4 EXTENSIVE FRACTURE OF CROWN EXPOSING PULP
CLASS 5 COMPLETE FRACTURE OF CROWN EXPOSING PULP
CLASSS 6 FRACTURE OF ROOT WITH OR WITHOUT LOSS OF CROWN STRUCTURE
CLASSS 7 TOOTH LOSS AS A RESULT OF TRAUMA
Classification of Anterior teeth trauma by
Sweets (1955)
DR.TINET MARY AUGUSTINE.BDS.MDS 33
34. DISADVANTAGE:
No stress on injuries to supporting structures soft tissues and
bone.
Indicates more towards permanent teeth than primary
teeth
DR.TINET MARY AUGUSTINE.BDS.MDS 34
35. Ellis and Davey’s classification (1960)
Class I -Fracture involving enamel
Class II -Fracture involving enamel & dentin
Class III -Fracture involving enamel,dentin & pulp
Class IV -Teeth that lost their vitality with or without
loss of crown
Class V -Traumatically avulsed tooth
Class VI -Fracture of the root with or without crown fracture
Class VII -Displacement of the tooth without crown/root fracture
Class VIII -Cervical crown fracture
Class IX -Fracture of deciduous teeth
DR.TINET MARY AUGUSTINE.BDS.MDS 35
37. Modified Ellis classification
[By McDonald, Avery and Lynch(1983)]
Class I - Simple fracture of crown , involving little or no dentin
Class II - Extensive fracture of the crown involving considerable dentin but
not the dental pulp
Class III - - Extensive fracture of the crown involving considerable dentin and
exposing the pulp
Class IV - loss of the entire crown
DR.TINET MARY AUGUSTINE.BDS.MDS 37
38. Andreasen classification( 1981)
Injuries to teeth
Crown infraction and uncomplicated fracture without
involvement of dentin
Uncomplicated crown fracture with involvement of
dentin
Complicated crown fracture
Uncomplicated crown root fracture
Complicated crown root fracture
Root fracture
DR.TINET MARY AUGUSTINE.BDS.MDS 38
39. Injuries to periodontal tissues
Concussion
Subluxation
Intrusive luxation
Extrusive luxation
lateral luxation
Exarticulation
DR.TINET MARY AUGUSTINE.BDS.MDS 39
40. Injuries To Supporting Bone
Comminution of mandibular or maxillary alveolar socket.
Fracture of maxillary or mandibular socket wall.
Fracture of maxillary or mandibular alveolar process
DR.TINET MARY AUGUSTINE.BDS.MDS 40
41. Injury to gingiva or oral mucosa
Laceration of gingiva or oral mucosa
Contusion
Abrasion
DR.TINET MARY AUGUSTINE.BDS.MDS 41
42. Heithersay and Morile (1982)
Classification of subgingival fractures based on level of teeth fracture in relation to various horizontal planes
of the periodontium
Class I : fracture line does not extend below the level of
attatched gingiva
Class II : fracture line extends below the level of attatched
gingiva but not below the level of the alveolar crest
Class III : fracture line extends below the level of alveolar crest
Class IV : fracture line is within the coronal
third of the root but below the level of
alveolar crest
DR.TINET MARY AUGUSTINE.BDS.MDS 42
43. Garcia Godoys classification (1984)
Class 0 – enamel crack
Class 1 – enamel fracture
Class 2 – enamel- dentin fracture without pulp exposure
Class 3 – enamel-dentin fracture with pulp exposure
Class 4 – enamel-dentin-cementum fracture without pulp
exposure
Class 5 – enamel-dentin-cementum fracture with pulp
exposure
Class 6 – root fracture
Class 7 – concussion
Class 8 – luxation ( loosening )
Class 9 – lateral displacement
Class 10 – intrusion
Class 11 – extrusion
Class 12 – avulsion
DR.TINET MARY AUGUSTINE.BDS.MDS 43
44. Type of injuries Code
Enamel infarction N 502.50
Enamel fracture N 502.50
Enamel- dentin fracture
(uncomplicated crown fracture)
N 502.51
Complicated crown fracture N 502.52
Root fracture N 502.53
Uncomplicated Crown- root fracture N 502.54
Complicated Crown- root fracture N 502.54
WHO International Classification of Diseases (1992)
A. INJURIES TO HARD DENTAL TISSUES AND PULP
DR.TINET MARY AUGUSTINE.BDS.MDS 44
45. Concussion
Subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation
Avulsion
N 503.20
N 503.20
N 503.20
N 503.20
N 503.21
N 503.22
B. INJURIES TO THE PERIODONTAL TISSUES
DR.TINET MARY AUGUSTINE.BDS.MDS 45
46. Communition of mandibular alveolar
socket
Communition of maxillary alveolar
socket
Fracture of mandibular alveolar socket
wall
Fracture of maxillary alveolar socket
wall
Fracture of mandible
Fracture of maxilla
N 502.60
N 502.40
N 502.60
N 502.40
N 502.61
N 502.42
C. INJURIES TO THE SUPPORTING BONE
DR.TINET MARY AUGUSTINE.BDS.MDS 46
47. Laceration
Contusion
Abrasion
S 01.50
S 00.50
S 00.50
D. INJURIES TO THE GINGIVA OR ORAL MUCOSA
DR.TINET MARY AUGUSTINE.BDS.MDS 47
48. WHO (1993)
873.60 873.61 873.62 873.63
873.64 873.66 873.67 873.68DR.TINET MARY AUGUSTINE.BDS.MDS 48
49. 873.69 – soft tissue injuries
WHO
DR.TINET MARY AUGUSTINE.BDS.MDS 49
50. Andreasen modification of WHO classification
873.64 – complicated and uncomplicated
crown root fracture
873.66 – concussion
Subluxation
Luxation injuries with alveolar
fractures
DR.TINET MARY AUGUSTINE.BDS.MDS 50
51. History
Diagnosis
Treatment protocol
EXAMINATION AND DIAGNOSIS
DR.TINET MARY AUGUSTINE.BDS.MDS 51
52. Patient’s name,age,sex,address and telephone number:
When did the injury occur
Where did the injury occur:
How did injury occur:
Treatment elsewhere:
History of previous dental injuries:
General health:
Did the trauma cause drowsiness, vomiting or headache:
Is there spontaneous pain from the teeth:
History
DR.TINET MARY AUGUSTINE.BDS.MDS 52
53. Are the teeth tender to touch or during eating:
Is there any disturbance in the bite:
Recording of extraoral wounds and palpation of the facial
skeleton:
Recording of injuries to oral mucosa or gingival injuries:
Examination of crowns ofteeth:
Recording of displacement of teeth:
Disturbances in occlusion:
Tenderness of teeth to percussion and change in percussion
tone:
Reaction of teeth to pulpal testing:
DR.TINET MARY AUGUSTINE.BDS.MDS 53
54. Overview of the
management of the
traumatized teeth
(Anderson Classification)
DR.TINET MARY AUGUSTINE.BDS.MDS 54
74. LUNDY AND STANLEY (1969):Speed of bacterial
penetration into prepared dentin left exposed to saliva
and plaque formation in vivo was found to be 0.03–
0.36mm 6–11 days after preparation and 0.52mm after
approximately 84 days.
INVOLVING DENTIN
DR.TINET MARY AUGUSTINE.BDS.MDS 74
85. Incidence
Complicated crown fractures occur in 0.9% to 13% of all dental injuries.
DR.TINET MARY AUGUSTINE.BDS.MDS 85
86. Clinical Examination
Inspection and exploration of the tooth.
Inspection - show the size of the pulp exposure, the presence or absence of
hemorrhage, and the amount of crown structure remaining.
The degree of pulp involvement varies from a pinpoint exposure to a total
unroofing of the coronal pulp
Experience of pain
DR.TINET MARY AUGUSTINE.BDS.MDS 86
87. Radiographic examination
A. The state of apical development
B. The state of the apical and periapical zones.
C. Presence of radicular fracture
DR.TINET MARY AUGUSTINE.BDS.MDS 87
88. Biologic Consequences
• If left untreated - results in pulp necrosis.
• First reaction after the injury is hemorrhage and local inflammation .
• In the first 24 hours after the injury, a proliferative response with
inflammation extending not more than 2 mm into the pulp will be present
• In time, the bacterial challenge results in local pulpal necrosis and a slow
apical progression of the pulpal inflammation
DR.TINET MARY AUGUSTINE.BDS.MDS 88
91. MANAGEMENT
The patient’s clinical history brings out factors that influence the treatment plan.
• Time elapsed between the time of injury and the time the patient is seen in the operatory.
• Size of the pulp exposure.
• Size of the remaining crown
• Stage of development of the tooth - maturity of the tooth,
• Concomitant luxation injury,
• Age of the patient as well as the effect of surgical procedures and choice of wound dressing
DR.TINET MARY AUGUSTINE.BDS.MDS 91
92. Time Between Trauma and Treatment
• For 48 hours after a traumatic injury, the initial reaction of the pulp is proliferative, with no
more than a 2-mm depth of pulpal inflammation.
• After 48 hours, chances of direct bacterial contamination of the pulp increase,
DR.TINET MARY AUGUSTINE.BDS.MDS 92
93. Stage of Development of the Tooth
• Loss of vitality in an immature tooth can have catastrophic consequences
• Pulpectomy in a mature tooth has an extremely high success rate
DR.TINET MARY AUGUSTINE.BDS.MDS 93
94. Concomitant Attachment Damage
• A concomitant luxation injury compromises the nutritional supply to the pulp &
contraindicates conservative treatment.
• In immature luxated teeth the chance of pulp survival is considerable and conservative
treatment may allow further root development.
DR.TINET MARY AUGUSTINE.BDS.MDS 94
95. • Vital pulp therapy - pulp capping, partial pulpotomy, or full pulpotomy
• Non vital pulp therapy- Pulpectomy.
• The choice of treatment depends on the stage of development of the tooth,
the time between trauma and treatment, concomitant periodontal injury,
and the restorative treatment plan.
TREATMENT
DR.TINET MARY AUGUSTINE.BDS.MDS 95
96. Vital Pulp Therapy: Requirements for Success
• Treatment of a non inflamed pulp.
Vital pulp therapy of the inflamed pulp yields an inferior success rate, so
the optimal time for treatment is in the first 24 hours when pulp inflammation is
superficial.
DR.TINET MARY AUGUSTINE.BDS.MDS 96
97. Bacteria-tight seal
If the exposed pulp is effectively sealed from bacterial leakage, successful healing of
the pulp with a hard tissue barrier will occur independent of the dressing placed on
the pulp and after more extended time periods between accident and treatment.
DR.TINET MARY AUGUSTINE.BDS.MDS 97
98. The effect of age is controversial as degenerative changes in the pulp increase with
age.
Capping or pulpotomy, should not be performed if degenerative or inflammatory
changes are anticipated, such as in teeth with reduced pulpal lumen due to trauma. So
removal of the pulp could be a more successful procedure
Surgical procedures invariably cause further injury to the remaining pulp and should
be kept to a minimum.
DR.TINET MARY AUGUSTINE.BDS.MDS 98
99. Pulp Capping
• Pulp capping implies placing the dressing directly on the pulp
exposure without any removal of the soft tissue
TREATMENT METHODS
DR.TINET MARY AUGUSTINE.BDS.MDS 99
100. • When a small exposure can be treated shortly after injury within 24 hours..
INDICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 100
101. • The fracture surface and pulpal wound are washed with saline.
• When bleeding has ceased, the exposed pulp is covered with a soft-or a hard-setting
calcium hydroxide compound.
• The exposed dentin - protected with glass ionomer cement
• If the definitive restoration of the crown must be postponed, a temporary crown
restoration should be placed
PROCEDURE
DR.TINET MARY AUGUSTINE.BDS.MDS 101
102. Various instruments have been recommended for pulpal amputation, such as spoon
excavators, slowly rotating round burs and high-speed abrasive diamonds.
Spoon excavator, successfully used in molars, has proven unsuitable in young incisors.
Slowly rotating instruments are known to inflict significant injury to the remaining pulp,
limiting the chance of survival
Injury to the underlying tissue is minimal when abrasive diamond is used at high speed to
remove part of the pulp, provided that the bur and tissues are adequately cooled
PULPAL AMPUTATION
DR.TINET MARY AUGUSTINE.BDS.MDS 102
103. • Camp (2002) asserted that almost all young, endodontically
involved teeth have a good blood supply and there is always vital
tissue in the apical third of the canal, which cannot be removed
• Pulp capping and Pulpotomy - remains valuable techniques
DR.TINET MARY AUGUSTINE.BDS.MDS 103
105. • Calcium hydroxide has traditionally been used for vital pulp therapy
• Advantage - antibacterial and disinfects the superficial pulp.
CALCIUM HYDROXIDE
DR.TINET MARY AUGUSTINE.BDS.MDS 105
106. • Liquefaction necrosis - in the most superficial layers
• Deeper layers of pulp - a coagulative necrosis at the junction of the necrotic and
vital pulp, resulting in mild irritation.
• Mild irritation initiates an inflammatory response, and in the absence of bacteria
the pulp will heal with a hard tissue barrier
Hard-setting calcium hydroxide does not cause necrosis of the superficial layers
of pulp, it has also been shown to initiate healing with a hard tissue barrier.
HISTOLOGIC PICTURE
DR.TINET MARY AUGUSTINE.BDS.MDS 106
109. Tunnel defects through dentinal bridges under it and poor sealing properties
(Schuurs et al. 2000).
• Many materials, such as zinc oxide eugenol, tricalcium phosphate, and
composite resin, have been proposed as medicaments for vital pulp therapy.
•
DISADVANTAGE
DR.TINET MARY AUGUSTINE.BDS.MDS 109
110. MTA reveals very good sealing properties in dry and blood
contaminated environments [Maturo et al., 2009].
MTA
DR.TINET MARY AUGUSTINE.BDS.MDS 110
111. BIODENTIN
• Biocompatabile
• Good antimicrobial activity
• Stimulate tertiary dentin formation
• Stronger mechanically,less soluble and produce tighter seals compared with
calcium hydroxide
• Less setting time,
• Good handling characteristic than MTA
DR.TINET MARY AUGUSTINE.BDS.MDS 111
112. • More recent studies suggest that with the bioceramic as the pulp cap, the inflamed pulp is
not the impediment as previously thought, but rather that the seal seems to be the major
factor for success.
DR.TINET MARY AUGUSTINE.BDS.MDS 112
113. It is defined as the treatment of a vital pulp by capping or pulpotomy
in order to permit continued growth of the root and closure of the open
apex.
APEXOGENESIS
DR.TINET MARY AUGUSTINE.BDS.MDS 113
114. • Root end development occurs in a tooth with a normal pulp and minimal inflammation
• Pulp of immature teeth has significant reparative potential
• Pulp revascularisation and repair occurs more efficiently in tooth with an open apex
• Poor long term prognosis of an endodontically treated immature teeth
• Relatively thin dentine in obturated canals of immature roots and open apex are prone
to fracture
RATIONALE
DR.TINET MARY AUGUSTINE.BDS.MDS 114
115. Sustaining a viable Hertwig’s sheath to stimulate continues development of root
To attain favourable crown:root ratio
To attain root end closure
To preserve pulp vitality to secure further root development and maturation
Generating dentinal bridge at the site of pulpotomy
GOAL
DR.TINET MARY AUGUSTINE.BDS.MDS 115
116. • Traumatized or pulpally involved vital permanent tooth when root apex is
incompletely formed.
• No history of spontaneous pain
• No sensitivity on percussion
• No hemorrhage.
• Normal radiographic appearance.
INDICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 116
117. Evidence that radicular pulp has undergone degenerative changes
Purulent drainage
History of prolonged pain
Necrotic debris in canal
Periapical radiolucency
CONTRAINDICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 117
118. Proposed by Mejare and Cvek in 1978.
Indicated in young permanent teeth where the pulp is exposed by
mechanical or bacterial means and the remaining radicular tissue is
judged vital by clinical and radiographic criteria whereas the root
closure is not complete.
PARTIAL PULPOTOMY - CVEK PULPOTOMY.
DR.TINET MARY AUGUSTINE.BDS.MDS 118
119. Administration of an anesthetic (possibly without a vasoconstrictor), rubber dam
placement, and superficial disinfection
1- to 2-mm deep cavity is prepared into the pulp, using a high-speed handpiece
with a sterile diamond bur of appropriate size and copious water coolant
bleeding is excessive, the pulp is amputated deeper until only moderate
hemorrhage is seen.
Excess blood is carefully removed by rinsing with sterile saline, and the area is
dried with a sterile cotton pellet.
Use of 5% sodium hypochlorite ( bleach)
TECHNIQUE
DR.TINET MARY AUGUSTINE.BDS.MDS 119
120. A thin layer of pure calcium hydroxide is mixed with sterile saline or anesthetic
solution to a thick mix and carefully placed on the pulp stump.
The prepared cavity is filled with a material with the best chance of a bacteria-
tight seal to a level flush with the fractured surface.
DR.TINET MARY AUGUSTINE.BDS.MDS 120
128. Minor injury to the pulp
Undisturbed physiologic apposition of dentin, especially in the critical cervical area of the tooth.
Coronal pulp remains, which allows sensitivity testing to be carried out at the follow-up visits.
Prognosis is extremely good (94% to 96%).
Compared with pulp capping, it implies better wound control and, by sealing off the cavity with
a material which does not allow microleakage, provides effective protection for the pulp.
ADVANTAGE
DR.TINET MARY AUGUSTINE.BDS.MDS 128
129. Cvek, (1978) reported 96% success rate with partial pulpotomy technique
regardless of the stage of the root development, contamination by the oral fluids
(up to 7 days), or size of the original exposure (up to 4mm).
Fuks et al (1987) reported 94% success with partial pulpotomy or shallow
pulpotomy technique when employed in complicated crown fractures.
SUCCESS RATE
DR.TINET MARY AUGUSTINE.BDS.MDS 129
130. Blanco, (1996) concluded that, the partial pulpotomy technique is a successful and
permanent treatment of crown fractures with pulpal exposure regardless of the size of
exposure, the maturity of the root, or the interval between accident and dental treatment.
Blanco and Cohen (2002) evaluated the Cveks pulpotomy in the management of immature
and mature teeth and found that treatment is successful and concluded that partial
pulpotomy remains the prudent treatment choice with proper case selection.
DR.TINET MARY AUGUSTINE.BDS.MDS 130
131. Full pulpotomy involves removal of the entire coronal pulp to a level
of the root orifices.
FULL PULPOTOMY/CERVICAL PULPOTOMY
DR.TINET MARY AUGUSTINE.BDS.MDS 131
132. Traumatic exposures after more than 72 hour
Carious exposure of a young tooth with a partially developed apex
Contraindicated in mature teeth.
INDICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 132
133. Administration of an anesthetic,
Rubber dam placement,
Superficial disinfection,
The coronal pulp is removed to the level of the root orifices calcium
hydroxide dressing, a bacteria-tight seal, and coronal restoration.
TECHNIQUE
DR.TINET MARY AUGUSTINE.BDS.MDS 133
134. Sensitivity testing not possible, owing to the loss of coronal pulp
CONSIDERATION
DR.TINET MARY AUGUSTINE.BDS.MDS 134
135. Radiographic Evaluation- to assess for signs of apical periodontitis
and to ensure the continuation of root formation
Clinical evaluation
FOLLOW UP
DR.TINET MARY AUGUSTINE.BDS.MDS 135
136. Range of 75%, is poorer than for partial pulpotomy.
Because of the inability to evaluate pulp status after full pulpotomy,
some authors have recommended radicular procedure having a success
rate in the range of 95%, whereas if apical periodontitis develops, the
prognosis of root canal treatment drops significantly to about 80%
PROGNOSIS
DR.TINET MARY AUGUSTINE.BDS.MDS 136
137. • Obliteration of the pulp chamber,
• High solubility in oral fluids,
• Lack of adhesion to the dentin.
• Multiple visits are required
• Hard tissue formed under calcium hydroxide has tunnel defects.
DISADVANTAGE(when using CaOH)
Accorinte Mde L, Holland R, Reis A, Bortoluzzi MC, Murata SS, Dezan E, Jr, et al. Evaluation of mineral trioxide
aggregate and calcium hydroxide cement as pulp-capping agents in human teeth. J Endod. 2008;34:1–6.DR.TINET MARY AUGUSTINE.BDS.MDS 137
141. • No clinical symptoms
• No radiographically demonstrable intraradicular or periradicular pathological changes
• Continued root development in immature teeth
• Radiographically observed (and eventually clinically verified) continuous hard tissue
barrier
• Positive sensitivity to electrical stimulation
• Follow-up for at least 3 years.
EVALUATION
DR.TINET MARY AUGUSTINE.BDS.MDS 141
145. • It is defined as a method to induce development of the root apex of an immature
pulpless tooth by formation of osteocementum/bone like tissue (Cohen).
Apexification is a method of inducing apical closure through the formation of
mineralized tissue in the apical pulp region of a nonvital tooth with an
incompletely formed root and an open apex (Morse et al. 1990).
APEXIFICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 145
146. For nonvital permanent teeth with open apex (Blunderbuss canals).
To induce either closure of open apical third of root canal or the
formation of an apical calcific barrier against which obturation can be
achieved.
INDICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 146
147. • Moller et al. (981) have shown that infected necrotic pulp tissue induces strong inflammatory
reactions in the periapical tissues. Therefore removal of the infected pulp tissue should create an
environment conducive to apical closure without use of a medication.
• McCormick et al. (1983) have hypothesized that debridement of the root canal and removal of
the necrotic pulp tissue and microorganisms along with a decrease in pulp space are the critical
factors in apexification.
• Chawla HS et al , England MC et al, Whittle M et al - have described apical closure without the
use of a medicament.
DIFFERENT VIEWS
DR.TINET MARY AUGUSTINE.BDS.MDS 147
148. • Das S et al instrumentation may in fact hamper root development and that preparation of
these canals should be done cautiously, if at all
.
• Cooke and Robotham hypothesize that the remnants of Hertwig’s epithelial root sheath,
under favorable conditions, may organize the apical mesodermal tissue into root
components. They advise avoidance of trauma to the tissue around the apex.
DR.TINET MARY AUGUSTINE.BDS.MDS 148
149. Zinc oxide eugenol
Tricalcium phosphate+β-tricalcium phosphate
Resorbable tricalcium phosphate
Collagen–calcium phosphate gel
Calcium hydroxide
Mineral trioxide aggregate.
MEDICAMENTS USED
DR.TINET MARY AUGUSTINE.BDS.MDS 149
150. • Calcium hydroxide was first introduced by Kaiser in 1964 who
proposed that this material mixed with camphorated parachlorophenol
(CMCP) would induce the formation of a calcified barrier across the
apex
• Popularized by Frank
CALCIUM HYDROXIDE
DR.TINET MARY AUGUSTINE.BDS.MDS 150
151. Hard Tissue Apical Barrier
• Pure calcium hydroxide powder is mixed with sterile saline (or anesthetic solution) to a
thick (powdery) consistency The calcium hydroxide is packed against the apical soft
tissue with a plugger or thick point to initiate hard tissue formation.
• This step is followed by backfilling with calcium hydroxide to completely fill the canal
Traditional Method - calcium hydroxide
apexification
DR.TINET MARY AUGUSTINE.BDS.MDS 151
152. Calcium hydroxide washout is evaluated by its relative radiodensity in the canal,
it is prudent to use a calcium hydroxide mixture without the addition of a
radiopaquer, such as barium sulfate..
At 3-month intervals, a radiograph is exposed to evaluate whether a hard tissue
barrier has formed and if the calcium hydroxide has washed out of the canal.
Excessive calcium hydroxide dressing changes should be avoided - because the
initial toxicity of the material is thought to delay healing.
DR.TINET MARY AUGUSTINE.BDS.MDS 152
153. • When completion of a hard tissue barrier is suspected, the calcium hydroxide
washed out of the canal with NaOCl
• A file of a size that can easily reach the apex can be used to gently probe for a stop at
the apex.
• When a hard tissue barrier is indicated radiographically and can be probed with an
instrument, the canal is ready for filling.
DR.TINET MARY AUGUSTINE.BDS.MDS 153
154. Periapical healing and the formation of a hard tissue barrier occur
predictably with long-term calcium hydroxide treatment (79% to 96%).
There are several associated problems :
1. The time required for formation of the calcified barrier (3-24 months)
2. Multiple appointments needed for reapplication of calcium hydroxide
3. The effect of long-term (several months or more) calcium hydroxide on
the mechanical properties of dentin.
PROGNOSIS
DR.TINET MARY AUGUSTINE.BDS.MDS 154
156. Care must be taken to avoid excessive lateral force during filling, owing to the thin walls of the
root.
Hard tissue barrier consists of irregularly arranged layers of coagulated soft tissue, calcified tissue,
and cementum like tissue, islands of soft connective tissue, giving the barrier a “Swiss cheese”
consistency.
Formation of the hard tissue barrier might be some distance short of the radiographic apex
Filling should be completed to the level of the hard tissue barrier and not forced toward the
radiographic apex.
Filling the Root Canal
DR.TINET MARY AUGUSTINE.BDS.MDS 156
157. CONSIDERATION
Exposure to calcium hydroxide denatures the carboxylate and phosphate groups in dentin .
Highest frequency of fracture occurred in teeth with the least developed roots
. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal
dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7
DR.TINET MARY AUGUSTINE.BDS.MDS 157
158. • Chawla (1980) suggests that that it suffices to place the paste only once and wait for
radiographic evidence of barrier formation
• Chosack et al. (1997) found that after the initial root filling with calcium hydroxide
there was nothing to be gained by repeated root filling either monthly or after 3 months.
• Proponents of a single application claim that the calcium hydroxide is only required to
initiate the healing reaction and therefore repeated applications are not warranted
How often the calcium hydroxide dressing
should be changed??
DR.TINET MARY AUGUSTINE.BDS.MDS 158
159. • Calcium hydroxide should be replaced only when symptoms develop or the
material appears to have washed out of the canal when viewed radiographically.
Cvek M. Treatment of non-vital permanent incisors with calcium hydroxide. I. Follow-up of periapical repair
and apical closure of immature roots. Odonotol Revy 1972;23:27–44.
Feiglin B. Differences in apex formation during apexification with calcium hydroxide paste. Endod Dent
Traumatol 1985;1:195–9.
DR.TINET MARY AUGUSTINE.BDS.MDS 159
160. • Radiographs cannot be relied upon to determine the amount of calcium hydroxide remaining in
the canal or to demonstrate whether or not the barrier is complete.
• It allows clinical assessment of barrier formation and may increase the speed of bridge formation
• Ideal time to replace a dressing depends on the stage of treatment and the size of the foramen
opening.
• removal of the pulp could be a more successful procedure, although no age limit can be set for
either pulp preservation or removal. However, conservative treatment
Abbot P. Apexification with calcium hydroxide – when should the dressing be changed? The case for
regular dressing changes. Aust Endod J 1998;24:27–32DR.TINET MARY AUGUSTINE.BDS.MDS 160
161. • Sheehy and Roberts - 5 to 20 months.
• Finucane and kinirons - mean time to barrier formation was 34.2 weeks (range
13–67 weeks).
• Age may be inversely related to the time required for apical barrier formation.
Time required for apical barrier formation in
apexification using calcium hydroxide
DR.TINET MARY AUGUSTINE.BDS.MDS 161
162. • Cvek has reported that infection and/or the presence of a periapical radiolucency at
the start of treatment increases the time required for barrier formation
• Kleier and Barr found that in the presence of symptoms the time required for
apical closure was extended by approximately 5 months to an average of 15.9
months
DR.TINET MARY AUGUSTINE.BDS.MDS 162
163. • Morse et al. - as the non-surgical condensation of a biocompatible
material into the apical end of the root canal.
• The rationale is to establish an apical stop that would enable the root
canal to be filled immediately.
ONE VISIT APEXIFICATION
DR.TINET MARY AUGUSTINE.BDS.MDS 163
165. • MTA has good physical characteristics and is biocompatible.
• Provides a very good seal
• Has excellent marginal adaptation
• Maintains a high pH for a long period of time.
MTA
DR.TINET MARY AUGUSTINE.BDS.MDS 165
166. MTA or One Visit Apexification
DR.TINET MARY AUGUSTINE.BDS.MDS 166
168. • Within six months, a 0.43 mm thick dentin bridge is evident when MTA is used compared to 0.15
mm with no odontoblastic layer in the case of calcium hydroxide.
• Accorinte et al., have reported that pulp healing with calcium hydroxide is slower than that with
MTA, when used as a pulp capping agent in human teeth.
• Sarkar et al. have proved that MTA can bond chemically to the dentin by a diffusion-controlled
reaction between the apatite layer of MTA and the dentin.
• Chen et al. have shown that MTA is biocompatible and appears to have osetoconduction effects
on the bone cells
COMPARITIVE STUDIES
DR.TINET MARY AUGUSTINE.BDS.MDS 168
169. • Witherspoon and Ham - MTA provides scaffolding for the formation of hard tissue
and the potential of a better biological seal.
• Regan and Gutmann - consider that the importance of this technique lies in the
expedient cleaning and shaping of the root canal system, followed by its apical seal
with a material that favors regeneration. Fractures of immature teeth with thin roots
is reduced - a bonded core can be placed immediately within the root canal.
DR.TINET MARY AUGUSTINE.BDS.MDS 169
172. “Biologically based procedures designed to replace damaged
structures, including dentin and root structures, as well as cells of the
pulp-dentin complex.
Regeneration of functional pulpal tissue - utilizing protocols referred
to as regenerative endodontic procedures (REPs).
REGENERATIVE ENDODONTICS
Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a
review of current status and a call for action. J Endod 2007;33:377-90
DR.TINET MARY AUGUSTINE.BDS.MDS 172
173. Complete restoration of pulpal function
Healing of apical periodontitis
Continued development of the root apex
Increased thickness of the root canal wall of immature teeth with
pulpal necrosis.
Regenerative endodontic therapy - an alternative treatment approach
builds on the principles of Regenerative medicine and Tissue
engineering.
GOALS
DR.TINET MARY AUGUSTINE.BDS.MDS 173
174. Tissue engineering is an interdisciplinary field that integrates the
principles of biology and engineering to develop biological substitutes
that replace or regenerate human cells, tissue or organs in order to
restore or establish normal function
TISSUE ENGINEERING
DR.TINET MARY AUGUSTINE.BDS.MDS 174
175. KEY ELEMENTS OF TISSUE ENGINEERING
DR.TINET MARY AUGUSTINE.BDS.MDS 175
176. Stem cells are defined as a distinct subpopulation of undifferentiated cells
with self-renewal and differentiation potential.
There are two main types:
Embryonic, and adult or postnatal.
STEM CELLS
DR.TINET MARY AUGUSTINE.BDS.MDS 176
177. • Tooth germ progenitor cells (TGPCS);
• Dental follicle stem cells (DFSCS);
• Salivary gland stem cells - SGSCS);
• Stem cells of the apical papilla (SCAP);
• Dental pulp stem cells (DPSCS);
• Inflamed periapical progenitor cells (IPAPCS);
• Stem cells from human exfoliated deciduous teeth(shed);
• Periodontal ligament stem cells (PDLSCS),
• Bone marrow stem cells (BMSCS)
• oral epithelial stem cells (OESCS);
• Gingival-derived mesenchymal stem cells (GMSCS);
• Periosteal stem cells (PSCS).
Sources of postnatal stem cells in the oral
environment
Hargreaves KM, Diogenes A, Teixeira FB:
Treatment options: biologic basis of
regenerative endodontic procedures, J
Endod 39:s30, 2013DR.TINET MARY AUGUSTINE.BDS.MDS 177
178. The apical papilla and its residing stem cells (SCAP) were first characterized in 2006.
The apical papilla is a dense reservoir of undifferentiated MSCs with great proliferative
and odontogenic differentiation capacity.
SCAP are regulated by Hertwig’s epithelial root sheath
DR.TINET MARY AUGUSTINE.BDS.MDS 178
179. Growth Factors
Growth factors are proteins that bind to receptors on the cell and act as signals to
induce cellular proliferation and/or differentiation
Key growth factors in pulp and dentin formation - bone morphogenetic protein,
transforming growth factor–beta and fibroblastic growth factor .
Current REPs - utilize growth factors found in platelets and dentin .
DR.TINET MARY AUGUSTINE.BDS.MDS 179
180. Dentin contains a number of bioactive molecules that, when released, play
an important role in regenerative procedures
Dentine phosphoprotein (DPP) and dentine sialoprotein (DSP) -
noncollagenous proteins of organic matrix.
Dentin-derived growth factors are thought to play a key role to be
deciphered into the regulation of progenitor cell recruitment, cell
proliferation, and differentiation of new dentine-secreting cells
Smith AJ, Scheven BA, Takahashi Y, et al. Dentine as a bioactive extracellular matrix. Arch Oral Biol
2012;57:109-21. 26. Sun HH, Jin T, Yu Q, et al. Biological approaches toward dental pulp regeneration by tissue
engineering. J Tissue Eng Regen Med 2011;5:e1-16.DR.TINET MARY AUGUSTINE.BDS.MDS 180
182. Scaffolds
Scaffolds provide support for cell organization, proliferation, differentiation and vascularization
Provide a spatially correct position of cell location
Nutrient and gaseous exchanges
Galler KM, Hartgerink JD, Cavender AC, et al. A customized self-assembling peptide
hydrogel for dental pulp tissue engineering. Tissue Eng Part A 2012;18:176-84.
DR.TINET MARY AUGUSTINE.BDS.MDS 182
183. • Dentin , the blood clot, platelet-rich plasma ,platelet rich fibrin.
• Biodegradable or permanent scaffolds made of natural (collagen, hyaluronic acid,
chitosan and chitin)
• Synthetic - polylactic acid, polyglycolic acid, tricalcium phosphate, polyepsilon
caprolactone,hydroxyapatite materials
• Peptide hydrogel nanofibers and various fibrin gels
SCAFFOLDS
DR.TINET MARY AUGUSTINE.BDS.MDS 183
184. What are the Considerations for Clinical Regenerative
Endodontic Procedures?
1. Young patient
2. Necrotic pulp and immature apex
3. Minimal or no instrumentation of the dentinal walls
4. Placement of an intracanal medicament
5. Creation of a blood clot or protein scaffold in canal
6. Effective coronal seal .
Law A. Considerations for regeneration procedures. J Endod 2013;39(3 Suppl):S44-56.
DR.TINET MARY AUGUSTINE.BDS.MDS 184
185. Procedure
Two- or multi-step procedure
The first appointment-proper access and disinfection of the pulp space.
The second appointment focuses on removing the antimicrobial medicament
Releasing growth factors from the dentin (e.G., By irrigating EDTA)
DR.TINET MARY AUGUSTINE.BDS.MDS 185
186. PROTOCOLS TO BE FOLLOWED
FIRST APPOINTMENT-DISINFECTION
ANESTHESIA, RUBBER DAM ISOLATION
REMOVAL OF CARIES IF ANY,DEROOFING OF PULPCHAMBER,REMOVAL OF CORONAL PULP ,GET A
STRAIGHT LINE ACCESS
COPIOUS IRRIGATION
1.5% NaOCl (20ml/canal ,5min) ; Saline/EDTA (20ml/canal ,5min)
DRY CANAL WITH PAPER POINTS
PLACE INTRACANAL MEDICAMENT
Triple antibiotic paste/calcium hydroxide
CORONAL SEAL TO PREVENT MICROLEAKAGE
DR.TINET MARY AUGUSTINE.BDS.MDS 186
187. SECOND APPOINTMENT(2-4 WEEKS)
ASSESS THE RESPONSE OF INITIAL TREATMENT
ANESTHESIA,3%MEPIVACAINE WITHOUT VASOCONSTRICTOR
ISOLATION
COPIOUS GENTLE IRRIGATION WITH 20ML OF 17% EDTA
DRY WITH PAPER POINT.
CORONAL SEAL -PLACE 3-4MM RMGIC
PLACE A RESORBABLE MATRIX OVER THE BLOOD IF NECESSARY AND WHITE MTA/BIODENTIN AS
CAPPING MATERIAL
INDUCE BLEEDING PASSING 2MM PAST APICAL FORAMEN TO THE LEVEL OF CEJ
COMPLETE SEAL USING PREFORMED CROWNS/CONVENTIONAL CROWNS
DR.TINET MARY AUGUSTINE.BDS.MDS 187
188. A) Root canal revascularization via blood clotting
First Treatment Visit for Regenerative Endodontics
DR.TINET MARY AUGUSTINE.BDS.MDS 188
189. • Typically 2 to 4 Weeks after the First Visit
• Clinical exam to ensure that that there is no moderate to severe sensitivity to
palpation & percussion.
• Local anesthesia (no epinephrine), rubber dam isolation is obtained.
• Intracanal medicament is removed by irrigating with 17% EDTA (30 mL/canal, 5
min) & then a final flush with saline (5 mL/canal, 1 min).
• Canals - dried with paper points.
Final (Second) Treatment Visit for
Regenerative Endodontics
DR.TINET MARY AUGUSTINE.BDS.MDS 189
190. • Bleeding is induced by rotating a precurved K-file size #25 at 2 mm past the apical foramen -
whole canal filled with blood to the level of the cementoenamel junction.
• Premeasured piece of collaplug is carefully placed on top of the blood clot to serve as an
internal matrix for the placement of approximately 3 mm of white MTA (Dentsply, Tulsa,
OK) or Biodentin (Septodont).
• 3- to 4-mm layer of glass ionomer layer is flowed gently over the bioactive coronal barrier &
light cured for 40 secs.
• A bonded reinforced composite resin restoration is placed over the glass ionomer.
• Followed-up at 3 months, 6 months, and yearly after that for a total of 4 years.
DR.TINET MARY AUGUSTINE.BDS.MDS 190
193. Advantage
Easy delivery, adequate mechanical properties, controllable biodegradation &
incorporation of growth factors.
Disadvantage
The blood clot contains a great number of hematopoietic cells that eventually undergo cell
death, releasing their toxic intracellular enzymes into the microenvironment, which may
be detrimental to stem cell survival.
DR.TINET MARY AUGUSTINE.BDS.MDS 193
194. Medicaments to disinfect the canal space
Triple antibiotic paste ( 1 : 1 : 1 mixture of ciprofloxacin/metronidazole/minocycline)
Ca(OH)2
An in vitro study has shown that a TAP concentration of 39 μg/mL would be best for
application in disinfection root canal
Chuensombat S., Khemaleelakul S., Chattipakorn S., Srisuwan T. Cytotoxic effects and
antibacterial efficacy of a 3-antibiotic combination: an in vitro study. Journal of
Endodontics. 2013;39(6):813–819. doi: 10.1016/j.joen.2012.11.041.DR.TINET MARY AUGUSTINE.BDS.MDS 194
195. Tooth is asymptomatic and functional
Radiographic evaluation:
6-12 months
Resolution of periapical radiolucency
May see increased dentinal wall thickness
12-24 months
Increased dentinal wall thickness
Increased root length
Guidelines for clinical and radiographic follow-
up evaluation
DR.TINET MARY AUGUSTINE.BDS.MDS 195
196. Discoloration of the tooth after revascularisation- due to minocycline in TAP or
MTA ( grey/white) -cervical barrier
Patient compliance
Nature of the hard tissue formed – cementum like, bone like or PDL like tissues
Poor root devolopment
Increased dentin wall thickness occurs in the apical third and middle third and not
in cervical third
Drawbacks or limitations
DR.TINET MARY AUGUSTINE.BDS.MDS 196
197. Revascularisation depends on the presence of stem cells and growth factors
Calcification of the canal space after the procedure
Chances for failure after revascularization- high in long standing chronic infections
DR.TINET MARY AUGUSTINE.BDS.MDS 197
200. Drawbacks to their clinical use:
• The process requires collection of intravenous blood that can be challenging in
children,
• The diversity and concentration of growth factors within PRP and PRF
preparations are not controllable,
• They lack temporal degradation control and the mechanical strength to support
a coronal restoration..
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201. Contemp Clin Dent. 2015 Jan-Mar; 6(1): 63–68
• PRF has huge potential to accelerate the growth characteristics in immature
necrotic permanent teeth as compared to PRP and blood clot.
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204. Whether the procedure should be considered a permanent treatment???.
• These teeth will develop obliteration of the canal lumen and should have clinic-
radiological follow-up
• Nygaard-Ostby - several degrees of internal root canal resorption after 10 months,
• Obliteration of the root canal following the REP procedure, might lead to endodontic and
prosthetic future complication
Wigler R, Kaufman AY, Lin S, et al. Revascularization: a treatment for permanent teeth
with necrotic pulp and incomplete root development. J Endod 39: 319-326, 201
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205. • failure is coronal microleakage of saliva -an obliterated root canal also
obstructs the adequate orthograde treatments which commonly leads to technical
complications such as root perforation or instrument breakage.
Hugo Plascencia , Álvaro Cruz ,Mariana Díaz, Ana Laura Jiménez Root Canal Filling after
Revascularization/Revitalization
The Journal of Clinical Pediatric Dentistry Volume 40, Number 6/2016
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207. OVERALL OF THE CLINICAL PROCEDURES
Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, Iwaku M. In-vitro antibacterial susceptibility of bacteria
taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J. 1996;29:125
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