7.3
Traumatic Dental Injuries
Elizabeth Shin Perry
Objectives
At the end of this case, the reader should appreciate the significance of traumatic dental injuries and understand the immediate management, long‐term treatment and follow‐up involved.
Introduction
A 14‐year‐old boy presented two days after a traumatic dental injury to his anterior teeth.
Chief Complaint
The patient was helping his father to build a fence on a hot summer day when he felt dizzy and fainted. When he regained consciousness, he saw that his face was bruised and bloody and his upper right central incisor (UR1) was missing, and his upper left central incisor (UL1) was out of the socket, hanging on his orthodontic wire by the bracket (Figure 7.3.1). The UR1 was found on the kitchen floor one hour after the accident and was then stored in milk. Three hours after the accident, the teeth were replanted and splinted in the local hospital emergency clinic (Figure 7.3.2). The patient reported to his general dentist, who referred him to the endodontic specialist for follow‐up treatment.
Medical History
Unremarkable.
Dental History
The patient was a regular dental attender and visited his dentist every six months for hygiene visits. He was undergoing orthodontic treatment.
Clinical Examination
The patient saw an endodontist two days after the traumatic injury. Clinical examination revealed a titanium splint previously placed apically to the orthodontic brackets extending from the upper right lateral incisor (UR2) to the upper left canine (UL3). The orthodontic bracket on the UR1 was missing and the orthodontic wire from the UR1 to the entire left side was previously removed. All maxillary and mandibular anterior teeth were examined for signs of injury. The UR1, UL1, UL2 and LL1 were tender to percussion and palpation, with no response to thermal (cold) or electric pulp sensibility testing, whereas the remaining anterior teeth were responsive within normal limits.
What did the periapical radiographs and limited‐view cone beam computed tomography images reveal?
The periapical radiographs of the upper and lower anterior teeth revealed widening of the periodontal ligament space at the apex of the UR1 and periapical radiolucencies associated with the UL1 and UL2 (Figure 7.3.3). Further imaging with a cone beam computed tomography (CBCT) scan confirmed the exact nature of the traumatic dental injury and also confirmed the position of the replanted teeth. The CBCT scan revealed:
- UR1: widening of the periodontal ligament at the apex. The tooth had been well approximated in the bony socket on replantation (Figure 7.3.4).
- UR2: periapical radiolucency and widening of the periodontal ligament on the buccal aspect of the root (Figure 7.3.5).
- UL1: periapical radiolucency with expansion of the cortical plate buccal to the root apex and widening of the periodontal ligament space on the palatal root surface, suggestive of the tooth being palatally displaced during the avulsion injury (Figure 7.3.6).
Diagnosis and Treatment Planning
What was the diagnosis?
The diagnosis for the UR1 and UL1 was pulpal necrosis and symptomatic apical periodontitis associated with prior avulsion and replantation. The diagnosis for the UL2 was subluxation with symptomatic apical periodontitis and for the LL1 was concussion with symptomatic apical periodontitis.
What was the treatment plan?
The initial treatment of replantation, repositioning and splinting of the avulsed teeth had already been performed by the emergency clinic on the day of the trauma two days previously. After assessment of the already managed traumatic dental injury, the treatment plan recommended for the UR1 and UL1 was to initiate root canal therapy within two weeks. Although the present splint that had been placed in the hospital emergency clinic was sufficient for temporary stabilisation of the replanted teeth, it was positioned apical to the orthodontic brackets and was not ideal for soft tissue management, thus removal and replacement of the splint were recommended.
The treatment recommended was:
- Remove the existing titanium splint and orthodontic brackets.
- Initiate endodontic treatment followed by intracanal medication of the root canal with calcium hydroxide.
- Place a new flexible splint, utilising orthodontic brackets and arch wire to splint/stabilise the traumatised teeth.
- Complete root canal treatment of the UR1 and UL1 in four weeks.
- Monitor the UL2 and LL1 on a periodic basis to evaluate pulp vitality and the onset of possible endodontic complications.
What is the role of calcium hydroxide in the treatment of traumatic dental injuries?
Calcium hydroxide is the intracanal medicament of choice for most traumatic dental injuries due to its ability to disinfect the canal space and dentine. It is antibacterial to most species within the root canal system, although some anaerobic bacteria such as Enterococcus faecalis may exhibit resistance. Calcium hydroxide has the ability to diffuse into the dentine and aids in the disinfection of infected dentinal tubules. The high pH of calcium hydroxide (between 12.5 and 12.8) permeates through the dentine to increase the pH of the outer root surface after several weeks, thereby preventing migration of the bacteria to the outer root surface, and may decrease the risk of root resorption.
Treatment
The titanium trauma splint was removed, and bracket and root canal treatment of the UR1 and UL1 was initiated. Root canal treatment was commenced under local anaesthetic and dental dam, the canals were instrumented and irrigated with sodium hypochlorite, and the canals were dressed with calcium hydroxide paste and sealed (Figure 7.3.7). The patient was seen that same day by his orthodontist to replace the missing bracket on the UR1 and maxillary arch wire (Figure 7.3.8). At the next visit, four weeks later, the calcium hydroxide was removed thoroughly with passive ultrasonic irrigation and the root canals were obturated with gutta percha and BC Sealer (Brasseler USA, Savannah, GA, USA). The access cavities were permanently sealed with a bonded composite restoration (Figure 7.3.9).
What about the continued negative response to pulp sensibility testing of the other teeth?
On completion of the root canal treatment of the UR1 and UL1 and at subsequent follow‐up four weeks later, the vitality of the UL2 and LL1 was reevaluated. In luxation traumatic dental injuries, pulp sensibility testing may initially exhibit no response due to transient pulpal damage. Thus, endodontic treatment should not be started solely on the basis of no response to pulp sensibility testing.
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