Traumatic injuries to anterior teeth in children

ENDODONTICS The American Captain

Association

Warren

.

TRAUMATIC

J. He&nun,

.

.

.

INJURIES

of Endodontists Editor

.

.

.

.

.

.

TO ANTERIOR

.

.

TEETH

.

.

.

.

.

IN CHILDREN

l’c~rltaps ttte 1110sl (list t*cxsiltK l)tY1l)l(~ttl 10 tII(L ~Il’tliill OfYiCc~is ill211 Of it’itllmatic injury to young ~wt~~ttitneitt ;tttt(~t~ior 1(~~1 It. I’t~olwi~ tliagrtosis and wictttific~ c~valnation ot’ th proyttosis it t’e ncwssa~~y lwt’otv cw~wc~t 1Iicmpc~ntic~ ~~roceclul~c~s citlt he deeded 1lpolt. r1 taorttiitc \nttc’tt-alttl-\~;rit I)olie>. is I’l~itll~lll lvitli inltt~wttl dwrigyr. IZoutinc co\ci~ayc~ or tllc‘ vtvwtt witlt zittc ositl~~-c~t~(~iloI ~~l’c~p;Ll’ilti0tt~ tltit~ %‘I’\-( littlv ~)lll’[XW’ 0ihcY tttitlt Itt;tsliill~ s~lll!)lc!lIlS. .I aIll~‘S. ScltOll~, iIll< I Spt’rwt~,’ in tltvir iitvcstigat iott 01’ t lt(l hiolog). 01’ t Itc lttll]). c~stal~lisltc~tl 1ttat ;tlttlonglt inflatttittation \vits IttiniIttUI rlltclvl~ xittv ositlc-c~ll~~~11ol, OllOllt~~‘r~lilSti~~ activity tlccdcd

\\-a~ at it statttlst ill. 7’ttcl tls(’ 01’ c~ttgc~nol \vItvt*(~ is to ltc il~Oi(l~Yl I)cYJaltsc~ or tlto i~~tt~l~~lt~~~ 0I’ this

wp;ttxti\~i~

(Iotttitw

i<

to SlO\\ tlo\Vn slwh activity. (il:tss ittld %alttlcV” poinlctl l.ttis ollt iii 1!4-C!4 iIll< lll’~(~d tlt(t c~tlt~~l0~Illc~1tt 0l’ c~alvinttt It~~dt~ositlv 10 stiittulalc~ \\h;tt S(~llXC1t’iltltl K(‘tldCt” llil\-C ittjliric3 Illit~ ittvol\~o tilt, (‘t’o\vtt. tIt(, c;tllctl wpatxti\~~ d~,fttiltoF”ttc’sis, ‘I’t~;ti~tttittic~

root, 01’ ltotlt.

1’11~

irijnty~ ttt;r)’ rc3ttll

jtt I~isitliott,

ttlC~li~ilttl~‘ltt

c~vt~lsiott, or l’t2vt 11w. ‘rlt(’

[)lLll? ItlZlJ- 01’ Itlit>. 1lOt l)C’ ]~~‘t~tlliltl~~tttl~~ ~littlt~~~.(‘(l 1))’ I’t*?l(dllIt’C: ihc tt~‘llt’c~v~s~‘Lllilt~ suppl.v. Tlrck thisiott lo wtailt tlt(L l)nlp

01’

t)j-

S~‘V(‘l’il~l~‘(’

is dvlwndent

(II’

no1

TRATJMATTC

vo1irme 15

N,lml,el1

INJTJRIER

TO ANTERTOR

TEETB

335

only on its prognosis but also on the restorative procedure which is to follow ( for example, the need for dowel rrtention) Ll careful c~sairliriation of t hr paticrit ~l~oultl inclmlc t hc following consid crations : 1. Investigation of the nature of the accident 2. Inspection of the soft tissues (a) Fistula (1)) I~aceration 3. Visual inspection of coronal danlag? (a) I)iscoloration (1,)

I’LIlP

c’xposLwc

(c) Extent of dentine loss (d) Crazing of enamel (c) Kature of fractnrc ( f) J>isplaccment 1. Roentgcnograms (a) Accurate as regards apico-incisal length (b) IXagnostic quality (c) Tangential views to eliminate overshadowing marks 5.

Pulp

of anatomic land-

tests

(a) Electrical tests (recorded for future comparison) (b) Thermal tests, recording degree and duration of response 6. Tactile tests (a j Dcgrec of mobility (1)) I’ain response to percussive forces (c ) Pain response to scratching drntinc (d) Palpation for alveolar damage 7. CYicck of occlusi\-e cscursions An investigation of the nature of the accident can often girt thr doctoi valuable diagnostic hints. A soft or padded blow is more likely to cause a fracture of the root (Fig. 1). A sharp or hard, direct tooth-contact injury is more likely to cause coronal fract,urc (Fig. 2). It is well to remember that pulpal vitalit,y is more prevalent in teeth that have varying degrees of fracture than in t,eeth where no fracture exists. Anderson:: attributes this to a decompression Actually, there is considerably less and development of collateral circulation. apical destruction of nutrient vessels when the force results in fracture coronal to that arca and it becomes a matter of st,ress distribution. l
Fix.

2.-TIrnv.ing

illustrating

Iran1

tooth-rontact

injury

for either a protective procedure, pulpotomy, or pulpectomy, depending upon the exigencies of the situation. In the age group with which this article is concerned, the amount of dentinal barrier t,o the pulp is slight and it would be wise to consider any injury to the dentine as being, in effect, an injury to the pulp. This is particularly true when we consider the odontoblastic processes which can be affected by the stimulation imposed. Physiologic repair can be stimulated via exposed drntine as well as via the exposed pulp. Zander and Law* demonstrated &is in 1912. The nature of the coronal fracture can influence the decision to tlr>at or On the lingual surface there may bc a vertical splinter, often not to treat. The level of the concealed, which would prohibit treatment or restoration. fracture, either horizontal or diagonal, may be such as to make the eventual restoration impossible. Thus, it is important to consider the nature of the’fracture. Coronal fracture at the subgingival or gingival level may not be a deterrent if gingivectom>T and alveoloplasty can yield sufficient tooth structure for dowel rctmtion. I
Fig.

3-Apexiflcation

on fractured

anterior

tooth.

‘I.

TRAUMATIC

YLNJURIEH

TO ANTERIOR

TEETH

339

too far from normal limits, the possibility of pulp recovery exists and the tooth should be kept under observation for some time; the pulp responses should be compared with past recorded readings. The classic indications of pulpal hyperemia should, of course, be rega,rded as a reversible phenomenon, and rccovcry is likely when normal precautionary measures arc taken to ensure further trauma. Mobilit,y of the tooth should be investigated carefully. Holding t,he ball of the index finger somewhat firmly against the labial alveolar mucosa while Demoving the crown slight,ly may give cvidcnce of alveolar or root fracture. pression of the t,ooth might indiratc a degree of luxation or root fracture with displacement. Traumatic injury to the anterior tooth where no fracture results (root or crown) most often results in tearing of periodontal ligaments. The aecompanying hemorrhage and edema in the narrow confines of the periodontal space The pain occasionally confuses the result in the severe pain of periccmentit,is. dentist because of the fact. that, the pulp tests vital. In the control of surh the antihist,amines to bc a most helpful chemotherapeutic pain, I have fonrlcl aid, with or without the usual analgcsivs. If t,he inflamma.toq- process does not proceed to such an extent that apical nutrient vessels arc adversely afYrctcd. Nesolution and rccovcry are often dethe recovery is generally complctc. pendent upon relief from occlusive trauma and ma?- be facilitated by immobilization. Coronal fracture is the most common problem. The patient usually has little pain other than that resultin, 0’ from stimulat,ion of exposed dcntinr or pulp. rf such pain pcrsist,s or is present withct further stimulus, then wc may suspect intrapulpal pressure from edema accompanying pulp inflammafoltion. Hcrc the prognosis for the pulp is not good, and pulp extirpation lowed by the biochemical procedures of endodontic thcrnpy is indicated. If. however, it is ncccssary to provide stimulation in order to indace the pain response, the prognosis for the pulp is probabl> good and stimulation of odontoblast,ic activity hy application of calcium hydroxide is in ordrr. The tooth is isolated by a rubber-darn, washctl thol~onghl~~ with normal saline solution, and dried, and the calcium hydroxide paste is applied oven the entire surfacr of the exposed dentine (Fig. ,5). Xftcr grntlc drying with warm air, a J)rOtcctivc crown of quick-cure acrylic or metal is ccm(mtcd to place with zinc oxyphosphate cement (Fig. 6). The attc>mpt hcrc is to stimulate reparative dentine formation and to prevent driftin g and malpositioninp of the antcrio~ t,eeth. Sinccl these injuries occur so frcqucntly at an agsc when root apices arc’ still incomplete, every effort should be made to maintain yitalitp and to stimulate apexification. For this purpose, calcium hydroxitlc is ideal. The clc>position of rcparativc drntinc and thcl complc+ion of al)esification proceeds rathe rapidly, and pc~rrnancnt restoration nertl noi 1~ unduly- ~lc~layccl. Tf’ the> pull) is vital and is so cxposc4 as to necc3sitatcl pulpotom~. similar satisfactory resuits may bo espcctctl. Pulpcctomy is :I last i~~soi~l ai1~1is tlrlayc~l ev(ln W~PYC cl-c>ntnal dowel rctentioii is plariricd, sinrcl ol~in~~atio~~is c+onsidcl*ably less tlifficult whtTc the root has a ron~pletecl apex. Ali opf~niiig in thcx pi*otec+ivc crown ran be filled with ccmCnt, which ran 1~ lmno\-et1 for* pulp tcst,ing with tooth

shultl IN: startcrt without delay. ‘I‘0 (l\lOt,(’ Sl.‘liZcl’ illl(l .Bcllder” : “JllIjammation is not confined to the I)UII1ilI tissues bllt is delc7+ablo in tllr pcAdenta1 membrane and marrow spaces of ttu: surreundi trg boric. Osteoctastic activity of the alveolar bono nlw!~ be SW11within a I’ew (lil\-S of t Ilo odontoblastic injury. Thns a grannlon~a is initiated long before it is clinically- tlctectable.” Since it is possihlc that root fracture which is not demonstrable rocntaenographicallr h Y n-ray csist and that occlusive Eorccs may aggravate such a capillary fracture, 1 frcqucntly employ a splinting procedure fol* irnmobilization, just as if a fracture wcrc in cvidcnce. t 1wap.v

k!SZ ‘CT

Fig.

‘I.--Pulp-tester’

electrode

contactinp

tooth

paste

in lingual

area

of opening

of

protective

If, in the case of a fractured root, the fragments are in close apposition or can be placed in such position, the cementum can generally bridge the gap and restore continuity of the root. The hemorrhage that takes place where there is displacement of parts is evcntnall!- resorbed and organized bp fihrohlastic activity. This takes place very soon after injury, so that a fibrous bridge is formed between the fragments. The crmentoblasts from healthy adjoining cementum eventually invade the area from all directions on both fragments, and the result is eomplcte covering on both terminal surfaces of typical periodontal tissues (Fig. 8). These teeth generally respond positively to all pulp testing, and the pulp canals are almost always obliterated by calcific infiltration. Such calcific infiltration, it might be mentioned her-c. vcq- often ensues after traumat’ic injury with no fractnrc and, of course, is not. immune to subsequent periapical pathosis.

The prognosis for a tooth with a i’ractured root is inr-crsely proportional to the proximity of the break to t,he cervix of the tooth. The location of the fulcrum and the amount of supporting alveolus and periodontal attachment arc important factors. The prognosis is considerably- enhanced where the fragments are so calose together as to permit new cementum to bridge the gap or rest,orc continuity to the root and where calcification within the canal extends into both fragments (Fig. 9). There must, of course, be no infection either in the pulp canal or at the fracture site. If pulpal vitality is lost, the eventual obturation can possibl: assist in keeping the parts together and aid in stabilization (Fig. 10). For this purpose (+rossrnan” suggests the use of a platinized gold cone. Perhaps the simplest, method of immobilization is to mold a puttylike mix of quick-cure acrylic to previously lubricated teeth and gingival tissues, permitting the patient to bite through completely and comfortably. The splint is removed just before the full heat of polymerization sets in. It is trimmed and polished and cemented to place with zinc oxyphosphate cement (Fig. 11). This is kept in position for about six weeks, at which time the cement has dissolved sufficiently to allow easy removal.

Fig. Il.-Acrylic

splint

cemented

to anterior

teeth.

Such an acrylic splint can be modified to include as many teeth as necessary. The splint can serve a multiple purpose. It can immobilize, hold calcium hydroxide against exposed dentine or pulp, support a luxated tooth, and insulate against both t,hermal and occlusal shock. Its use for retention of evulsed teeth is without parallel. It is my opinion that wiring or orthodontic methods of immobilization are potentially harmful in that they involve considerable manipulation. In the age group with which this article is concerned the situation does not allow for wire ligation, because of poor and changing contacts which preclude a good ligation technique. The acrylic splint minimizes manipulation possibilities and allows little of the reciprocal movement effect so prevalent in other techniques.