Wednesday, September 21, 2011

Crown Fractures: Permanent Dentition

Crown Fractures: Permanent Dentition

 Resident: Matthew Freitas


a) Def: crown fracture involving the enamel or the enamel and dentin without pulp exposure.

b) Tx objectives: maintain pulp vitality and restore normal esthetics and function; examine injured soft tissue for tooth fragments; small fractures with rough edges can be smoothed; larger fractures with can be restored.

c) Radiographic findings: loss of tooth structure confined only to the enamel of both the enamel and dentin.

d) Tx algorithm: see flow chart.

e) Prognosis: depends on the extent of injury to the PDL and secondarily on the extent of dentin exposed.



a) Def: crown fracture involving the enamel and dentin with pulp exposure.

b) Tx: maintain pulp vitality and restore normal esthetics and function; examine injured soft tissue for tooth fragments; pulpal tx options: direct pulp capping, partial pulpotomy, or pulpectomy.

c) Radiographic findings: loss of tooth structure with pulp exposure.

d) Tx algorithm: see flow chart.

e) Prognosis: depends on the extent of injury to the PDL and secondarily on age of pulp exposure, extent of dentin exposed, and stage of root development.


Kyung-Hong Cal Kim


: Partial displacement of the tooth axially from the socket; partial avulsion. Torn PDL.

-Primary tooth: reposition and allow for healing (except in cases when extraction is indicated) -Permanent tooth: reposition and and allow for healing (optimize healing of PDL and neurovascular supply while maintaining esthetic and functional integrity).

Radiographic findings
: Increased periodontal ligament space apically.

Treatment algorithm
-If aspiration risk -> extract.
-If tooth is causing occlusal interference -> extract or reposition and splint for 1-2 weeks. -Allow for spontaneous re-positioning or re-position and splint or consider extraction.
-Follow up in 2 weeks, explain to parents possibility of injury to permanent teeth.


-Re-position w/ digital manipulation if possible. Use slow and steady apical pressure to gradually displace coagulum formed b/w root apex and floor of the socket. Verify position with radiograph. -Physiologic splint using a fishing line or light SS wire for 1-2 weeks.
-Surgical or orthodontic re-positioning if digital manipulation is not possible.
-If apex is open -> CaOH pulpectomy within 2 weeks, followed by RCT.
-If apex is closed -> Rx chlorhexidine, analgesics, follow up in 2 weeks. Monitor for signs of pathology. Do not probe for 4 weeks.

-Clinical and radiographic follow up at 4 weeks, 6-8 weeks, 6 months, and 1 year.

General prognosis
Considerable risk for pulp necrosis and pulp canal obliteration for permanent teeth w/ closed apices. Revascularization of extruded tooth w/ an open apex can be confirmed radiographically by evidence of continued root formation. Look for periapical rarefaction, coronal discoloration as signs of pulpal necrosis in closed apex teeth, and continue to monitor pulpal response.

Avulsion-Permanent Tooth with Open Apex 1mm or Greater

Definition: Tooth is missing from socket.
Treatment Objectives: Put tooth back in socket.
Radiographic Findings: What was once in the socket is no longer there.
(Make sure to ask pt if they found the tooth when it fell out. I had a case at Hasbro where the tooth appeared to be avulsed but was actually 100% intruded).
Treatment Algorithm:
Tooth Immediately Replanted: Proceed with algorithm
Extraoral time <20 min and tooth transported in HBSS or milk for up to 6 hours:
-soak in 1% Doxycycline solution (1 mg Doxy/20 mL sterile solution) for 5 minutes and proceed with algorithm
Tooth brought in any other media (water, saliva, etc) or dry, up to one hour:
-Change solution to HBSS, or cold milk, soak in Doxycycline, proceed with algorithm
>60 Minutes extraoral dry time:
-Soak in Citric acid for 3 minutes then rinse well, OR debride PDL with scaler OR gauze.
-Place in NaF for 5 minutes OR cover with Emdogain for 5 minutes then proceed

For all immature avulsed teeth:
-PA to verify position
-Flexible splint 2 weeks, 4 weeks for dry time over 60 min
-Doxycycline or Amox for 7 days, Chlorhexidine for 7 days
-Tetanus vaccination verification (tooth in contact with soil)
-Post op instructions and follow up in 7-10 days.
-monitor q4w with pulp tests/radiographs

Ideal outcome: Revascularization/apexogenesis occurs over next 12-18 months
Alternative outcome:
-Apexification with MTA or CaOH; RCT
--if pathology presents, or tooth shows no signs of vitality/continued root formation after ~3 months.
-Decoronation if ankylosis suspected and infraposition appears.
-Follow up 1 week, 1 month, 3 months, 6 months, 12 months, every yr. for 5 years

-Necrosis 75%
-infection related resorption 25-40%
-ankylosis related resorption 30-45%
-tooth loss: steadily increases to 50% at 10 years

Tuesday, September 20, 2011

Crown Fracture (Complicated/Uncomplicated)

Crown fracture–complicated

Definition: an enamel-dentin fracture with pulp exposure.

Diagnosis: clinical and radiographic findings reveal a loss of tooth structure with pulp exposure.

Treatment objectives: to maintain pulp vitality and restore normal esthetics and function.

Primary teeth: Decisions often are based on life expectancy of the traumatized primary tooth and vitality of the pulpal tissue. Pulpal treatment alternatives are pulpotomy, pulpectomy, and extraction.

General prognosis: The prognosis of crown fractures appears to depend primarily upon the injury to the periodontal ligament. The age of the pulp exposure, extent of dentin exposed, and stage of root development at the time of injury secondarily affect the tooth’s prognosis. Optimal treatment results follow timely assessment and care.

Crown fracture–uncomplicated

Definition: an enamel fracture or an enamel-dentin fracture that does not involve the pulp.

Diagnosis: clinical and/or radiographic findings reveal a loss of tooth structure confined to the enamel or to both the enamel and dentin.

Treatment objectives: to maintain pulp vitality and restore normal esthetics and function. When looking for fragments in soft tissue lacerations, radiographs are recommended. For small fractures, rough margins and edges can be smoothed. For larger fractures, the lost tooth tooth structure can be restored.

General prognosis: The prognosis of uncomplicated crown fractures depends primarily upon the injury to the periodontal ligament and secondarily upon the extent of dentin exposed. Optimal treatment results follow timely assessment and care.

Root Fracture - Guideline on Management of Acute Dental Trauma

Resident Name: Elliot Chiu

Trauma Session – Root Fracture


-A dentin and cementum fracture involving the pulp

-Coronal fragment may be mobile and attached to the gingiva

-1 or more radiolucent horizontal lines; may require different angulations to diagnose

Tx objective:

-To optimize healing of the PDL and pulp

Primary Dentition - Tx:

Either extract or leave it.

1. Fracture is located in coronal 1/3 of root? Segment is an aspiration risk?

- EXT coronal segment, leave apical segment if not easily removed.

2. Fracture is located in middle or apical 1/3?

- Leave it and follow-up in 4 weeks to monitor signs of pathology

Permanent Dentition – Tx:

Either splint or leave it.

In each scenario, give chlorhexidine, analgesics, follow up in 4 weeks to monitor signs of pathology

1. Coronal segment is NOT mobile?

- Leave it

2. Coronal segment is mobile? Fracture in coronal 1/3 of root?

- Splint for 2-3 mons

3. Coronal segment is mobile? Fracture in middle to apical 1/3?

- Splint for 4 weeks

General prognosis:

-In permanent teeth, location of root fracture has NOT been shown to affect pulp survival after injury

-Things that increase the chances of hard tissue repair and pulpal healing: Young age, immature roots, positive pulp sensitivity at time of injury, approximating the dislocated segments w/in 1mm


Trauma Session
by Meg

definition: Apical displacement of tooth into alveolar bone. Tooth compresses PDL and commonly crushes alveolar socket.

treatment objective: Perserve alveolar bone, PDL. Prevent periodontal infection/necrosis. Limit damage to adult dentition.

radiographic finding: Radiographs necessary to determine displacement of apex with relationship to permanent tooth.
If apical tip can be seen, appears shorter than contralateral= apex displaced labially
If apical tip displaced palatal, apex cannot be seen and tooth appears elongated.
extraoral lateral radiograph used to detect displacement of apex toward or through labial bone.

TX algorithm:
PRIMARY... Root tip towards or through buccal plate -yes - 6 mos spontaneous re-eruption - follow-up 4 weeks, talk to parents if no - EXT
PERMANENT...Open apex -yes - slight surgical luxation and spontaneous re-eruption or ortho reposition with RX CHX, analgesics and follow-up if closed apex - intrusion greater than 6mm - surgical reposition, soft splint 1-2 weeks, CaOH pulpectomy within two weeks and RX CHX plus analgesics. If less than 6mm intrusion - surgical or orthodontic reposition plus CaOH pulpectomy within 3 weeks.

Monday, September 19, 2011

Guideline on Management of Acute Dental Trauma (Avulsion Closed Apex)

Resident: Cho

Author(s): Clinical Affairs Committee

Journal: AAPD Reference Manual

Year. Volume (number). Page #’s: Revised 2007. 31(6). 187-193.

Avulsion: Permanent Tooth (Closed Apex less than 1mm)

Definition: Complete displacement of tooth out of socket. PDL is severed and fracture of the alveolus may occur.

Treatment objectives: To replant ASAP and stabilize the replanted tooth. Possible contraindications include immunocompromise, severe cardiac/seizure/mental disability/uncontrolled diabetes, lack of alveolar integrity.

Radiographic findings: Tooth missing from socket.

Treatment algorithm: Replant, obtain PA to verify position, flexible splinting for 2 weeks (4 weeks if extraoral dry time >60 minutes), antibiotics for 1 week, chlorhexidine rinse for 1 week, assess tetanus vaccination, post-op instructions, follow up 7-10 days, initiate pulpectomy within 7-10 days, complete RCT within 1 month, appropriate follow up times.

General prognosis: Prognosis depends on time of replantation. If tooth cannot be replanted within 5 minutes, it should be stored in a medium that will help maintain vitality of the PDL fibers. Risk of pulp necrosis, root resorption, ankylosis, and infraocclusion. An extraoral dry time of 60 minutes is considered the point where survival of the PDL cells is unlikely.

Guideline on Management of Acute Dental Trauma (Primary Concussion, Subluxation, Lateral Luxation)

Resident’s Name: Jessica Wilson

Article title: Guideline on Management of Acute Dental Trauma.
Author(s): Clinical Affairs Committee.
Journal: AAPD Reference Manual.
Year. Volume (number). Page #’s: Revised 2007. 31(6). 187-193.

Primary Concussion:
Definition: Injury to the tooth-supporting structures without abnormal loosening or displacement.
Clinical Findings: No mobility, displacement or sulcular bleeding. Percussion and palpation sensitivity.
Radiographic Findings: No abnormalities expected.
Tx Objectives: Optimize healing of PDL and maintain pulp vitality.
Treatment: Monitor pulpal condition of tooth.
General Prognosis: In absence of associated infection, no pulpal therapy indicated.

Primary Subluxation:
Definition: Injury to the tooth-supporting structures with abnormal loosening, but without displacement.
Clinical Findings: Mobility without displacement that may/may not have sulcular bleeding.
Radiographic Findings: No abnormalities expected.
Tx Objectives: Optimize healing of PDL and neurovascular supply.
Treatment: Tooth should be followed for pathology.
General Prognosis: Usually favorable with tooth returning to normal within 2 weeks.

Primary Luxation:
Definition: Displacement of tooth in a direction other than axially; the PDL is torn and contusion or fracture of alveolar bone occurs.
Clinical Findings: Lateral displacement with crown usually in a palatal or lingual direction and may be locked into this new position. The tooth is usually not mobile or tender to the touch.
Radiographic Findings: Increase in PDL space and root apex usually through the labial bone plate.
Tx Objectives: To allow passive repositioning or actively reposition and splint for 1-2 weeks to allow healing, except when the injury is severe or the tooth is nearing exfoliation.
1. If tooth is aspiration risk or it is determined that the displaced tooth has encroached upon the developing permanent tooth germ: extract.
2. If tooth is not causing occlusal interference: Allow for spontaneous repositioning or reposition and splint or consider extraction.
3. If tooth is causing occlusal interference: Extract or reposition and splint.
General Prognosis: Those requiring repositioning have a higher risk of developing necrosis than those that are left to spontaneously reposition. Always advise parents of possible damage to developing permanent teeth (enamel hypoplasia, hypocalcification, crown/root dilacerations or disruptions in eruption).

Wednesday, September 14, 2011

Management of Avulsed Permanent Incisors: A Comprehensive Update

Resident: Swan
Article Title: Management of Avulsed Permanent Incisors: A Comprehensive Update
Authors: McIntyre, et al.
Journal: Pediatric Dentistry V29 No 1, Jan/Feb 07
Main Purpose: update the 2001 avulsion flow charts with current concepts, recent literature, and new philosophies.
Main Points:
This article preceded Meg,'s which provides an even more recent update, but some of the more salient points I took from this article are the following:

1) Resorption is the primary reason for loss of replanted teeth (68% of teeth may develop resorptions)
2)Plug the sink when you rinse an avulsed tooth!
3) If replanted quickly, DON'T scrape off all debris from tooth. It's better to leave minor debris on surface than to remove all viable PDL cells.
4)soaking tooth left dry for more than an hour in Alendronate (Foxamax) or HBSS helps root healing, resulting in less resorption.
5) in mature teeth, pulpectomy in all teeth within 7-10 days (wait ~3 weeks to obturate to ensure PDL responds well.)
6) based on several studies, authors recommend immature teeth be soaked in a 1% doxycycline solution for 5 minutes before replanting. (1 mg doxycycline/20 ML sterile liquid). Idea is that this reduces contamination and aids revascularization.
7) Have HBSS available at your office. If someone brings in a tooth in something non-physiologic
8)saliva is non-physiologic? Several sources stated that it is worse than tap water

Assessment: Good article. For our population, it's all about maintaining alveolar bone until growth is complete, so decoronation is an intriguing treatment. I'd like to see this done and then followed up on. Clear instructions given to parents are very important, because if a tooth, especially an immature tooth, is immediately replanted, it has a great chance at survival and revascularization.

Permanent Tooth Replantation Following Avulsion: Using a Decision Tree to Achieve the Best Outcome

Permanent Tooth Replantation Following Avulsion: Using a Decision Tree to Achieve the Best Outcome

By Judy D. McIntyre, DMD, MS; Jessica Y Lee, MPH, PhD; Martin Trope, DMD; William F. Vann Jr. DMD, PhD

Pediatric Dentistry V31/ No2 MAR/APR 2009

Resident Meg

Purpose: Discussion and update of tooth replantation flowcharts published in 2001 and 2007 with current concepts, philosophies, literature based findings and consensus from the 2008 AAPD Dental Trauma Symposium

Methods: Using Lee and Colleagues published flowcharts following an avulsion, updates were made to these concepts with recent literature, new philosophies and a 2008 AAPD symposium on dental trauma.


Main complications and discussion included:
***Minimizing Attachment Damage and Reducing the Chances of Pulpal Infection

Points to remember
*Immediate replantation!!!
*Dry time less than 20 min is ideal
*A tooth with at least 1mm opening at the apex may revasculaize while teeth with closed apices will need endo
*Gentle rinsing with saline or tap water is okay should there be visual contaminates.
*Alveolar socket may be rinsed with saline to remove contaminates and blood clot.
*Splinting time for avulsion is approximately 2 weeks
*Revascularization success for reimplanted teeth ranges from 8-34 percent in immature teeth
*PDL healing range from 24-57 percent.
*Avulsions are most common in growing children therefore consideration of maintaining the tooth or alveolar socket until approximately 18 years of age is important when tx planning.
* Antibiotic tx has shown some success in studies (dogs) for an open apices only.
*Arestin, commonly used for perio pockets, has shown some success in revascularization in immature teeth.
*Transport mediums are HBSS, milk, Cold Gatorade and Cold Saline???
*For teeth out of the mouth for 60 minutes and no chance of revascularization the tooth can be used to maintain crestal bone. PDL should be removed by soaking the tooth in citric acid, soaking in fluoride, then replanted. Decoronation of the tooth at a later date.
* Recent literature shows success with tetracyline soaking and Emdogain for complete revascularization.
*Systemic antibiotics is recommended by the IADT. First on list is tetracyclin then PenVK.


I enjoyed reading about the new ideas and particularly recent literature in the decoronation practice. After last year's emergency experiences I'm still in a mental debate about replantation considering that most of this occurs well after the 60 min limit? I'd love to see the followup for patients with decoration practices used. I worry about our patients who get a tooth reimplanted Check Spellingat Hasbro and then bony necrosis, but I'm always open to new thoughts!

Flexible Wire Composite Slinting for Root Fracture of Immature Permanent Incisors: A Case Report

Resident: Matthew Freitas
Author: Deshpande, A. et al

Pediatric Dentistry 2011; 33:1 63-66

Case Report: 7 year-old female presented to a pediatric clinic in India, with trauma to the maxillary anterior region, following a fall from a bicycle 15 mins earlier. Teeth 8 and 9 were traumatized with immature apices. Radiographs were taken.
Tooth 8: mobility on palpation and sensitive to touch, oblique root fractures at apical 1/3 and middle 1/3, displacement of fracture segment.
Tooth 9: mobility on palpation and sensitive to touch, oblique root fracture of apical 1/3, displacement of fractured segment.
Tx: clean injured area, LA, reposition and splint 3 months with 0.3mm soft, round stainless steel, flexible wire bonded with resin. Antibiotics given (Clamox: 250mg Amox + 125mg Clavulanic acid) 3x day, chlorhexidine, anti-inflammatory and soft diet.
1 week: central incisors were still tender
3 mo: no pain or tenderness, no mobility, good root healing and additional apical formation evident on radiograph
2 years: complete root development

Key Points: Root fractures of permanent teeth with immature, open apices and wide root canals have more favorable pulp survival. In addition, fractured segments that are not displaced will also have increased survival. Repositioning is an important factor for proper healing. Some studies show 80% survival with open apices and 30% with complete root development after a root fracture. The author favored a more flexible splint to encourage healing with normal physiological mobility. Fractured teeth should be splinted for at least 3 months. Early tx is most important.

Essentials of Rebonding Tooth Fragments for the Best Functional and Estetic Outcomes

Author: Macedo Et al.

Pediatric Dentistry Vo. 31 No.2 Mar/Apr 2009

Purpose: Discussion of Rebonding fractured segments of teeth following trauma.

Methods: Controlled clinical research is difficult but several studies have been examined to come up with some generalized guidelines which will help to achieve most desirable outcomes.

The tooth fragments must be retrieved, be relatively intact, and be easily adaptable to the remaining tooth. If pulpal involvement has occured it must be managed appropriately. Fragment and tooth should be beveled, etched and bonded in place with a resin based composite if the the fragment needs to be repositioned (not flowable or GI). If the segment adapts well and can be replaced easily, bonding agent and flowable can be used and should be cured together. Liners should be kept to absolute minimum as they decrease bond strength. Finishing of the bevels should take place in future appointments to match any color change in the fractured segment and to hide the margin. The fragment should also be hydrated as soon as possible for the best outcome. Finally, if multiple fragments are present, it is best not but them back together like a puzzle.

Discussion: Very interesting collection of studies about fractures. I was impressed that strength can be around 80-90% of normal. I would love to try to rebond a segment if someone can find it and bring it in.

Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies

Kyung-Hong Cal Kim

Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies

Author: McIntyre JD, Vann Jr WF

Pediatric Dentistry, MAR/APR 2009

Cvek pulpotomy according to Dr. Miomir Cvek
-Recommended for CCF, complicated fracture involving enamel, dentin, and pulp.
-Size of pulpal exposure, treatment time after the exposure up to 30 hours are NOT critical for success of treatment.
-Pulpectomy/RCT are not always necessary following Cvek pulpotomy.
-Appropriate healing criteria should include
-An absence of symptoms and periapical radiolucency
-Presence of radiographic hard tissue barrier at dentin-pulp interface
-Continued root development of immature roots
-Recommended armamentarium
-Sterile diamond round bur
-Sterile saline
-Rubber dam
-Chlorhexidine antiseptic
-Calcium hydroxide (stimulates formation of a hard tissue barrier)
-ZOE + final resin bonded restoration (quality of seal is a key factor)

Case Report 1
-10 yr, 9mo old boy from a pool accident.
-Presented < 30 minutes after the accident w/ crown fragments in milk.
-CCF extending below gingival margin on the facial aspect of the teeth #8,9.
-Non-hemorrhagic pulp exposures, WNL mobility, no hemorrhage around the PDL, no root fracture.
-Final Dx: concussion w/ CCF.

-2 weeks: Asymptomatic, (+) cold sensitivity.
-3 weeks: re-bonded fragments using a dentin bonding agent and a filled composite resin, custom fitted mouth guard delivered 4 days later.
-12 months: began 24month ortho tx during which time #8,9 were under biomechanical stress - no adverse outcomes.
-2 uneventful debonds of the fragments.
-42 months: no periapical pathology, vital, asymptomatic.

Case Report 2
-7 yr, 2mo old girl who fell while climbing over a large boulder in archeological dig
-Cleared for dental care at the hospital nearby 6.5 hours after the fall.
-50% eruption of both #8,9
-More than physiologic mobility, vertical distal oblique fracture line, tapering off to coronal to the root surface. Incomplete coronal fracture (distal segment is not mobile)
-Blood oozing from the fracture line, but no periodontal hemorrhage.
-4mm open apex
-Tx: CRI, Cvek pulpotomy, composite placed as far gingivally as possible on facial aspect, recognizing that the fracture line remained exposed deeper subgingivally.
-Recommended 1 wk soft diet, meticulous oral hygiene, 1 wk 2% chlorhexidine bid rinse.

-11 days after: No color change, (+) cold test, probing depths WNL.
-Monthly follow-up up to 3 months: continued root formation, no periapical pathology, vitality WNL.
-14 weeks: formation of calcific bridge apical to the Cvek pulpotomy.
-Once teeth began erupting further, increments of composite added to the facial aspect as more of the fracture line is exposed.
-12 months: Intermediate restoration was removed down to calcific bridge, then restored w/ bonded composite as far subgingival as possible to ensure deeper subgingival bonding and sealing the facial-lingual gap b/w tooth & distal segment.
-24 month ortho tx 2 yrs after trauma.
-Pulp Canal Obliteration first noted 3 years after trauma.
-At 60 months, delayed cold response noted while electric pulp test remains WNL.
-With increased PCO, discoloring progressed over “several years,” while the tooth continued to test vital until 10 years after trauma.
-External bleaching at 11 years after trauma before she went on to college.

Assessment of the Article:
Interesting case reports supporting effectiveness of Cvek pulpotomy. It would be interesting to see how progression of PCO would affect the vitality of the tooth AFTER 11 years in the second case report. I guess monitoring the tooth without placing a definitive (unless that composite restoration they placed at the gap is considered definitive) restoration can be justified by continued positive pulp testing, but if that justification for some reason no longer exists after a few more years, due to complete obliteration of canal, endo therapy would no longer be a possible treatment option. If a long term monitoring after Cvek pulpotomy led to a complete obliteration of canal, can you still consider this case a successful case?

Tuesday, September 13, 2011

A Novel Multidisciplinary Approach for the Treatment of an intruded Immature Permanent Incisor

Article title: A Novel Multidisciplinary Approach for the Treatment of an intruded Immature Permanent IncisorAuthor(s): Sapir et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2004. 26:5.
Major topic: Intrusion Management

Intrusion only comprises 3% of dental injuries in the permanent dentition.
Observation for spontaneous eruption is only recommended in very mild intrusions.

Case Report:
A 7 ½ year old female presented 3 days after falling with a completely intruded #9. EOE: enlarged bilateral submandibular glands and incompetent lips. IOE: 8mm overjet, #9 presented with swollen, red gingiva, uncomplicated crown fracture, mild mobility and incisal edge 6mm intruded in comparison to the incisal edge of #8. Radiographs revealed no alveolar fracture and no root penetration into the nasal cavity.

After a chlorhexadine rinse, the tooth was monitored for 2 weeks, but no spontaneous re-eruption occurred. At this time, orthodontic extrusion with a modified Hawley appliance was initiated. One week later, the tooth became symptomatic, mobile, grey in color and a widened PDL was radiographically evident. Pulpal necrosis was confirmed with a test cavity. A pulpectomy was performed and CaOH was placed in the canal. 2 weeks later, radiographs showed severe external root resorption and marginal bone breakdown. After 5 weeks of ortho extrusion, the tooth was restored with composite and a celluloid crown.

Six months following, a radiograph suggested apexification had completed, this was confirmed with an endo file and the canal was obturated with gutta percha. The crown was restored with a clear Luminex post and composite.

After one year of uneventful follow-up, ortho treatment was initiated to create a more ideal overjet and at 5 years follow-up the tooth remained functional and asymptomatic.

Assessment of Article:
I was impressed by the results of this case report. I would have preferred that they included a picture/description of the modified Hawley and earlier initiation of pulpectomy may have prevented such significant external root resorption, but overall a very interesting case.

Essentials of Rebonding Tooth Fragments for the Best Functional and Esthetic Outcomes

Resident Name: Elliot Chiu

Title: Essentials of Rebonding Tooth Fragments for the Best Functional and Esthetic Outcomes

Author: Georgia V. Macedo

Journal: Pediatric Dentistry 2009

Main Purpose

To summarize the current knowledge of tooth fragment reattachment.

Key Points


-Simple, fast, conservative, affordable treatment

-No errors in shade matching or contours

-Most patients will accept a guarded prognosis and prefer to have the original fragment rebonded


-Avoid dehydrating tooth fragment, it can compromise esthetics

-Liners/bases should be minimized

-If the pulp is exposed for a short duration and pulp is not bleeding, direct pulp cap before rebonding fragment. Fragment might need adjustment to fit.

-If the pulp is exposed and bleeding, partial pulpotomy should be performed, then rebond.

-If the pulp is irreversibly compromised, RCT should be completed, then rebond.

-Avoid rebonding when there are multiple crown fragments or when the fragment adapts poorly.

-Patients who play sports should get a mouth guard


-Etch and bond both the fragment and tooth. If the fragment adapts well, place flowable in between and cure. If the fragment adapts, but has a void, use packable composite instead of flowable.

-Prepare a shallow double chamfer along the bonded line on the facial, then restore with composite. This will add strength to the rebonding.


Good guidelines on how to rebond fractured teeth. The author did mention that the studies on the subject are limited and some have contradictory results. Studies on the longevity of these restorations and actual restoration technique are limited. How much of her advice is actually evidence based or anecdotal?

Monday, September 12, 2011

Transplantation of Premolars as an Approach for Replacing Avulsed Teeth

Resident: Cho

Author: Andreasen et al.

Journal: Pediatric Dentistry, March/April 2009

Type: Conference Paper

Main Purpose: Discuss transplantation of premolars as a treatment option for tooth loss in the anterior maxilla

Key Points:
- 7-8% of injuries involving teeth of the anterior maxilla results in tooth loss.
- Apart from orthodontic gap closure, autotransplantation of teeth appears to be the most biologic approach – shown to have 90% long term success.
Currently not recommended in patients that have ideal occlusion.

- Requirements for successful tooth transplantation:
¾ root development of donor tooth
min. trauma to cellular components + Hertwig’s epithelial root sheath to donor tooth

- Ideal tooth for missing max CI:
mand 2nd premolars, maxillary 2nd premolars, diminutive maxillary 3rd molars
- Ideal tooth for missing max LI:
mand 1st premolars
*Maxillary 1st premolars are excluded due to their double-rooted nature.
- Recommend giving pre- and post-transplant antibiotics.
- Possible complications: pulp necrosis, resorption, ankylosis (these complications are rare when donor tooth has wide-open apex)
- Tooth transplantation should only be performed by professionals who are familiar with this technique and perform with sufficient frequency to maintain the skill level needed to achieve success.

Assessment of Article: Great article – has some nice pictures at the end that show esthetic results using this method. Would have liked more detailed explanation about technique of autotransplantation.

Wednesday, September 7, 2011

The Prevalence of Traumatic Dental Injuries: A 24-month Survey

Resident’s Name: Matthew Freitas

Author(s): A. Shayegan et al

Journal: Journal of Dentistry for Children

Year. Volume (number). Page #’s: 2007. 74:3. 194-199.

Major topic: Trauma


-Assess the prevalence of traumatic dental injuries in children.


-214 children with orofacial trauma (457 traumatized teeth) treated by maxillofacial surgery and pediatric dentistry at the Queen Fabiola Children’s Hospital in Brussels, Belgium (between 2003-2005).


-More permanent (62%) teeth traumatized vs. primary (38%).

-2 Teeth traumatized (51%), 1 tooth (20%), 3 teeth, (13%).

-Highest freq. of trauma occurred between 2 and 4 years of age (more boys).

-Most arrived for tx between 30mins-2days (79%); only 42% on same day.

-Injuries usually occurred at school (40%) and at home (36%).

-All anterior, most maxillary (90%) and central incisors (89%).

-Most common injury =  falls (71%) and commonly subluxation.

-Most common soft tissue = gingival/mucosal laceration.

-Treatment: primary = exam alone vs. permanent = restorations.


-Good statistical study. The author stressed the importance of early dental visits in order to provide an opportunity for parents and care givers to receive preventive instructions and counseling for their child’s oral health and prevention of trauma.