Clinical Continued »
for traumatised teeth with Ledermix showing promising results in the case of avulsed teeth (Bryson et al. 2002). This may not now be readily available in the UK and Odontopaste is proving to be a reliable alternative. In the case of other traumatic injuries, non-setting calcium hydroxide is advised. Prior to the advent of MTA for the
apexification (physical apical barrier formation) of immature teeth, long term dressing with calcium hydroxide was common. This proved to be a time consuming and unreliable method of barrier formation and potentially pre-disposed teeth to cervical fracture (Andreasen et al. 2002). MTA placement in these cases is best achieved using an apical placement system such as a Dovgan carrier or Dentsply’s Micro Apical Placement System. Such devices simplify the technique
and ensure placement of an adequate thickness of the material, while avoiding extrusion (Fig 6). The remaining canal is often best obturated using a thermoplasticised technique thereby minimising voids in the root filling. More recently, case reports have
emerged of revascularisation of teeth with open apices using combinations of antibiotics (Banchs & Trope 2004), combinations of irrigants (Shin et al. 2009) or simply sodium hypochlorite and EDTA, along with MTA. Results of these are promising although doubts remain regarding the structure and origin of such regenerated tissue as it
appears to be more similar to bone than pulpal tissue. Discolouration of traumatised teeth
may also pose problems in management. As aforementioned, care must be exercised to remove remnants of pulpal tissue from the pulp horns in access cavity design and the root filling material should always be compacted to a level ımm below the cervical level of the tooth. This avoids subsequent discolouration from residues of root canal sealer and allows for correct placement of composite. The current protocol for non-vital bleaching of root filled teeth dictates that bleaching agents containing a maximum of 6 per cent hydrogen peroxide are allowed. The ‘walking bleach’ technique often results in acceptable aesthetic results for patients and clinicians alike.
Complications and prognosis The biological complications following a traumatic injury to the dento-alveolar complex most frequently involve the pulp and the periodontal ligament (PDL). These healing complications are primarily a result of the extent of the injury (often the physical displacement of the tooth/teeth) and the efficiency with which we manage the injury.
Pulpal necrosis While the severity of the initial injury is a prognostic factor for pulpal survival following trauma, the stage of development of the tooth is also important. Intuitively, we would assume that teeth with immature apices have
a greater repair capability and this is borne out in the literature. Reports on pulpal revascularisation appeared in the literature as early as ı978 (Skoglund et al. ı978) and more recently, various protocols have been proposed in order to potentially regenerate injured and even partially necrotic pulps. Literature suggests that the incidence
of pulpal necrosis in permanent incisors is high in teeth suffering severe lateral luxation, intrusive and obviously avulsion
“Often our dilemma is between allowing injured pulp every chance to exhibit signs of recovery while not delaying treatment too long”
injuries. In the case of horizontal root fractures, the degree of separation between the coronal and apical fragments often dictates whether the coronal pulp survives. In the case of an avulsed tooth,
necrosis is almost certainly inevitable and endodontic treatment should be initiated within ı0 days to limit the potential for associated complications.
Continued »
Fig 7a
Fig 7b
Fig 7c
Series of radiographs showing suboptimal root fillings in traumatised maxillary anterior teeth. Note signs of replacement and external inflammatory resorption
30 Ireland’s Dental magazine
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