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Classifications
Enamel
Infraction
Clinical
Radiograph
Cannot be
detected
Lines in en
-vertical
-horizontal
-diverging
Take to exclude
any concomitant
luxation
Short-term
Management
Soft diet
Sensitivity to cold
will disappear
OHI
Restoration
1. No txn
2. Seal the cracks
-prevent bacterial
invasion
-prevent stains
Enamel #
Long-term Management
Prognosis
Follow-up after
-1 week
-1,2,6,12 mths
-every year
Very good
RG + vitality control
To disclose pulp & PDL
damage
If necrosis
occurred, possible
luxation may
have been
overlooked
If no symptoms appear
on follow-up then
regular 6/12 recall
-mobility
-discoloration
-TTP
-signs of infection
Reassurance
Reassurance
Very good
No damage to
pulp & PDL
Small #
Smoothening the
roughened en edges
Prevent laceration of
tongue & lips
Good cosmetic result
Large #
Restore with AECR
Esthetic
Prevent space loss
If necrosis
occurred, possible
luxation may
have been
overlooked
Enamel-dentin
#
Mx acclusal
PA
Single tooth
Can be associated with
luxation
Exclude
-root #
-luxation
Mx central incisor
-mesial
-distal
BIOLOGY
Sensitivity proportional
to area of exposed dn
& maturity of tooth
Search for minor pulp
exposures
Thin dn layer covering
pulp (pinkish)
-dont probing the area
-pulp perforation may
occur
Exposed dn
tubules permit
invasion of
bacteria to pulp
cause pulp
inflammation
Severity depends
on pulpal
vascularity
presence/absenc
e of luxation
injury
Objectives
1. Protect pulp from external environment
-chemical
-thermal
-bacteria
2. Prevent pain
3. Prevent tilting of adjacent teeth
4. Restore function & esthetics
Principles
1. If no luxation, restore tooth immediately
with AECR
2. In case of luxation (mobility & bleeding)
-temporary restoration (GIC, Vitrebond)
-difficulty in maintaining isolation control
Large # + retained
Reattached with DBA
AECR
Not retained
GIC liner / Vitrebond
AECR
No luxation
Follow-up after 2 mths
Vitality + RG
If normal vitality
-regular 6/12 recall
-at least 5 years
With luxation
Follow-up after
-1 week
-1,2,6 mths
-every year
-at least 5 years
RG + vitality control
If no symptoms
appear on follow-up
then regular 6/12
recall
Enameldentine # with
pulp exposure
(complicated
crown #)
Depending of
presence/absence of
luxation
Pulp
Bright red
Cyanotic
Ischemic appearance
Spontaneous bleeding
(may be)
5% of all trauma
Proliferation of pulp
tissue can occur
-when txn is delayed
for long time
Pulp exposure followed
by sensitivity
-thermal changes
-mastication
Lost tooth
substance
PDL changes
(luxation case)
BIOLOGY
Exposed dentinal
tubules & pulp
-direct & indirect
access to pulp
-inflammatory
response
-granulation
tissue formation
Pulpal response
(first few days)
1. Proliferative
Pulpal
hyperplasia
More common
Irrespective of
exposure size
Abscess
formation if
untreated
2. Destructive
Abscess
formation in
subsurface layer
Superficial tissue
necrosis
FOLLOW-UP
To ensure no
problems to the
developing
permanent tooth.
Assess
Mobility
Vitality
TTP
Ankylosis
Discoloration
Sign of infections
-clinical
-RG
If tooth is mobile
-evaluate
hyperocclusion
-need of splinting
If hyperocclusion
-relieve it
-soft diet
If mobility to
zero
-suspect ankylosis
If spontaneous
pain /
Pain associated
with hot/cold
-pulp
degeneration
Discoloration
-yellow (PCO)
-pink (hyperemia)
-grey/black (pulp
death)
RG
Root development
PA infection
Pulp calcification
Ankylosis
Root resorption
-internal
-external
Interference with
development of
permanent tooth
bud
-if so, exo the
primary
Aim
Preservation of pulp
-vital
-inflammation-free
-biologically walled
off by a continuous
hard tissue barrier
Indications/Success
factors
Very small exposure
(1-1.5mm)
Shortly after injury
(few hours)
Sufficient crown
remaining
-to hold capping
material
-efficient seal
Healthy pulp before
trauma
Technique
Success
1. Rubber dam
SR 72-88%
2. Hemorrhage
controlled with
normal saline
RG
Hard tissue healing 3
mths after txn
Prognosis depends on
Sterile technique
-RD
-disinfection with NS
Biocompatible
capping agent
Efficient seal
4. Dn covered with
GIC liner
5. AECR
No luxation
Mature vs immature
teeth
Partial Pulpotomy
Part of the coronal
pulp is removed to
eliminate inflamed &
contaminated tissue
that has been
exposed to oral
cavity
Preservation of pulp
-vital
-inflammation-free
-biologically walled
off by a continuous
hard tissue barrier
Leave only healthy
tissue
-enhance physiologic
Immature/mature
teeth
Irrespective of
exposure size & time
before txn
(up to 72 hours)
Pulp free from
inflammation
1. LA, RD(cuff
technique)
2. Cavity preparation
-diamond bur
-2-3mm deep
3. irrigation with NS
-until bleeding stop
-dry the cavity
4. Place Ca(OH)2 on
pulp & dentin
SR 96%
maturation of root
-maintain tooth
vitality
-trauma
-caries
No luxation
Formation of dentinal
bridge under
Ca(OH)2
Cervical Pulpotomy
(Apexogenesis)
Complete coronal
pulp is removed up to
the constriction of
the root canal
Preservation of pulp
-vital
-inflammation-free
-biologically walled
off by a continuous
hard tissue barrier
Apical closure in
immature teeth
Root development
Later apply to
carious, immature
perm. 1st M
Immature teeth
where necrotic tissue
is seen at exposure
site (deeper than
2mm)
Immature teeth, vital
pulp but large
exposure
Immature teeth, vital
pulp, small exposure
but pt didnt seek txn
(>72hours)
Immature teeth, vital
pulp but insufficient
crown structure (nonrestorable tooth)
-no coagulum
between them
5. AECR
6. Review after
-3,6,12 months
-for 5 years
1. LA, RD(cuff
technique)
2. Pulp amputation to
cervical level
-diamond bur
3. Irrigation with NS
-until bleeding stop
-dry cavity
4. Place Ca(OH)2 on
pulp & dentin
-no coagulum
between them
5. Seal with GIC/ZOE
cement
6. AECR
No luxation
7. Review after
-3,6,12 months
-for 5 years
SR 72%
6 weeks early ca
barrier
1 year ca barrier +
root development
10 years mature
root
Pulpectomy
Complete removal of
pulp
Removal of necrotic
tissue
Immature teeth
-apexification
-stimulate root
development (apical
closure by ca barrier)
-for routine endo
later on
Mature teeth
-RCT
-place root canal
filling
-prevent further
pathosis
Apexification
-immature tooth
-necrotic pulp or
-irreversible pulpitis
RCT
-mature tooth
-necrotic pulp or
-irreversible pulpitis
-damage to blood
vessels (luxation)
1. LA, RD (cuff
technique)
2. Pulp chamber
amputated
-tapered diamond bur
3. Place non-setting
Ca(OH)2
-within 1-2mm apex
4. seal cavity with GP
& GIC
5. Repeat above
every
-3/12 for 12-18
months
-take PA to verify
apical barrier
-check clinically with
small paper point
6. When apical
closure achieved, fill
root
-thermoplastic/
conventional GP
-lateral condensation
Successful result
1. Closure of apex to
normal appearance
2. Dome-shaped
apical closure
3. Positive stop RG
evidence of barrier
coronal to apex
4. No RG change but
positive stop in apical
area
Apexification occur in
6-18 months
SR 74-100%
Long-term success
depends on
1. Quality apical seal
2. Amount root
structure present
-length
-thickness
3. Type of restoration
-coronal seal
Largest long-term
risks
Vertical root # of
immature tooth
during function