Trauma 101

In my practice, it is a fairly routine event to have a young child present secondary to a traumatic injury to upper or lower anterior teeth. Many of these children are referred to me because they have sustained an Ellis Class III injury, ie, a tooth fracture of some kind with a pulp exposure.

The kinetic energy in this type of trauma has been absorbed by tooth fracture as opposed to tooth movement and these teeth all have the potential to remain vital, even if the trauma (and resultant pulp exposure) was sustained several days to weeks before presentation.

Trauma and Immature Teeth

Particularly in immature teeth, it is an ideal goal to preserve this vitality to support continued/complete root development – apexogenesis. I consider it a serious error to devitalize these vital teeth with complete pulpal extirpation and traditional endodontic therapy.

I treat these teeth that experience this type of trauma using a modified version of a procedure attributed to Cvek.¹  I remove one to two millimeters of pulpal tissue from the remaining chamber space with a sharp small round end diamond under the microscope. Because the tissue is healthy, hemorrhage is easily and quickly controlled with gentle pressure with a sterile moist cotton pellet. I do not rinse with sodium hypochlorite or chlorhexidine.

Mineral trioxide aggregate is a modified Portland cement used for pulp capping, perforation repair and root end filling in apicoectomy procedures and is available through Dentsply. Although the manufacturer claims that white MTA does not stain like the original gray version, I have not found this to be true – as in my hands, both products have the potential to slightly discolor. Be sure to advise the parents of this possibility. I now use the gray MTA exclusively.

MTA mixed to the consistency of wet sand, is floated on to the pulpal tissue to form a one to two millimeter layer. After drying for several minutes with a gentle stream of warm dry air, composite resin, or more preferably, the tooth fragment, if available and intact, is bonded in place to complete the restoration. (Figures 1-8)

Case #1

Case #2

Properly treated, virtually all teeth treated in the manner described remain vital and complete root development.  There is no indication to ever complete conventional endodontic treatment and most of these teeth can be restored, not only to function, but also esthetically, with cosmetic additive procedures. (Figures 9-13)

Case #3

This trauma case was completed by my former partner, now retired, Dr. John Stropko, using the same techniques described.  The patient, now 22 years old, and a recent member of the US Air Force, was told by his military dentist at a screening appointment that this tooth requires endodontic treatment.  Since he is and has been asymptomatic for the past 14 years, he (accompanied by his mother) returned to my office for a second opinion.  Endodontic treatment here is not only not necessary, but would only make this patient worse.  Although this patient is completely satisfied with his appearance, any esthetic issues could easily be addressed with composite resin, or at most a veneer.

Reference:

1. Cvek M. Endodontic management and the use of calcium hydroxide in traumatized permanent teeth. In: Andreasen JO, Andreasen FM, Andersson L, eds. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Ames, Iowa: Blackwell Munksgaard; 2007:598-657.

Glen E. Doyon, DMD, Spear Contributing Author [ www.CMSEndo.com ]