Clinical Continued »
Resorption Dental resorption involves the removal of mineralised dental tissues and according to Fuss et al. (2003) involves two distinct phases, injury and stimulation. In dental trauma cases, there are a number of categories of resorption which concern us and these are specifically related to certain injury types. In essence, resorption involves the loss of hard tissue while the unmineralised predentine and precementum remain protected. This protection of the predentine layer has been attributed to an unknown ‘protection factor’ (Wedenberg ı987). While a detailed description of resorption is beyond the remit of this article, an outline of the types is given below. Internal inflammatory resorption
(IIR) may arise following a traumatic injury in the presence of a partially necrotic pulp. Bacterial contamination in the root canal system may act to stimulate an inflammatory response in the remaining pulpal tissues, with the subsequent loss of dental hard tissues. This presents as a ballooning radiolucency of the anatomy from the internal aspect of the root canal. Infection may also act as a stimulus
for external inflammatory resorption (EIR), with the dentinal tubules acting as a pathway for exit of bacteria and their associated byproducts to the periodontium. These lesions present as radiolucencies at the lateral aspects of the root or in the apical region (Fig 7). Radiographically, the radiolucency is often superimposed over the root canal, with the lines of the root canal anatomy visible. As the aetiology suggests, our
management of these cases should focus on the removal of the infective stimulus which will halt the resorptive process. It is critical that we do not mis-diagnose such cases or delay commencement of root canal treatment in traumatised teeth for too long as the effects of the process can lead to devastating loss of hard tissues. Often, our dilemma as clinicians is
between allowing an injured pulp every chance to exhibit signs of recovery while not delaying our treatment for too long. Importantly, not all types of resorption are as damaging and this often depends on the extent of the initial injury. In some trauma cases we
may see subtle signs of an EIR process which seems to self limit and cease over time. Replacement resorption arises due
to damage to the external surface of the root and is common after avulsion injuries, especially those teeth with a long extra-alveolar dry time or those that are mis-handled (both in terms of manual handling and storage medium). This process essentially involves loss of dental hard tissue and subsequent replacement with bone. With injured teeth losing their aforementioned protective layer, bone resorbing osteoclasts begin this process of replacement resorption. Unfortunately, our knowledge of this disease process is limited and it may continue gradually until an entire root has been resorbed. Various figures have been proposed
to define the extent of replacement resorption needed to cause ankylosis of an injured tooth, with 20 per cent being suggested. Such teeth will of course lose their physiological mobility and have a high or metallic percussive tone. It is best to continue to monitor these cases and inform the patient of the likely complications which may arise in the future.
Conclusion Management of injuries to the dento- alveolar complex involves strict adherence to biological principles and a common-sense approach to the technical aspects of the treatment. Our approach at all times should be targeted at facilitating efficient healing of the tissues and allowing adequate time for this to occur. A regular and structured review protocol should be implemented with strict attention being paid to the possible healing complications, their appearance and the effect on prognosis.
Readers are directed to the following websites:
www.dentaltraumaguide.org www.dentaltrauma.co.uk
ABOUT THE AUTHOR
Dr Robert Philpott, BDS MFDS MClinDent MRD (RCSEd), qualified from Cork Dental School in 2003 and completed his endodontic training at Eastman in London in 2009. He has worked as a specialist in endodontics in Ireland, London and Australia. He currently divides his time working as a consultant in endodontics at Edinburgh Dental Institute and in private practice at Edinburgh Dental Specialists.
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