It is estimated that 1 billion people have suffered a traumatic dental injury (TDI) at some point in their lives. One in five children in the UK have experienced a TDI to their permanent anterior teeth before leaving school.[i] Almost ninety percent of TDIs occur before the age of 20 and are rarely experienced after the age of 30.[ii]TDIs account for 5% of all traumatic injuries in people seeking first aid.[iii]
The most common causes of injuries to permanent teeth are falls (40%), traffic accidents (33%), and violent assault (21%).[iv] Global statistical studies suggest that males are between 34%-52% more likely to experience TDI than females.[v]
Most dental trauma affects the anterior teeth – particularly the maxillary central incisors.[vi] Crown fractures to the permanent incisors account for about 18%-22% of dental hard tissue injuries. 28%-44% are uncomplicated and 11%-15% are complex, usually requiring root canal treatment (RCT) combined with restorative techniques, such as composite or ceramic restorations and intra-radicular posts with crown placement.[vii]
Endodontic treatment considerations
The goal of conventional endodontic treatment is the prevention and/or elimination of apical periodontitis. The additional goal in the treatment of immature teeth is, wherever possible, to preserve pulp vitality. Complications associated with TDIs, as well as delays in treatment, can affect pulp health to an extent that treatment options are limited.[viii]
Because dental trauma is often accompanied with other serious injuries, treatment is frequently overlooked or delayed. Emergency care is focused on issues that pose a threat to life, and patients may be on medications to treat pain or inflammation caused by other trauma that initially mask symptoms of TDIs. Dental professionals may not be involved until several days after the trauma.[ix] However, swift and correct diagnosis is vital for managing complex TDIs, ensuring the correct management strategy is implemented quickly. The time between the moment of trauma and date of consultation is a decisive element in the therapeutic choice, and prognosis is affected.[x]
The tissues affected by TDIs are primarily the dental pulp, the periradicular tissues (periodontal ligament, alveolar bone) and the soft tissues of the mouth (gingivae, mucosa). Many factors such as the type of injury, the degree of displacement of a tooth, the stage of root development, the emergency management, the presence of caries and the presence of restorations determine the most appropriate clinical response. Some dental pulp reactions to TDI, especially pulp necrosis and infection, have an impact on reaction of the periradicular tissues.[xi]
Some injuries will require immediate RCT during their emergency management. Teeth with complicated crown fractures, complicated crown-root fractures and sub-crestal coronal third root fractures require immediate RCT to enable restoration of the tooth. Some luxation and avulsion injuries require RCT to prevent external inflammatory resorption. For most injuries, however, RCT should only be carried out when there are definite signs of pulp necrosis and infection of the root canal system.[xii]
Monitoring traumatised teeth is important to ensure early treatment of complications that can develop over time. Pulp necrosis can develop up to three months after trauma and calcific metamorphosis (CM), or pulp canal obliteration (PCO), can occur a year after the injury, discolouring the teeth or resulting in loss of pulp vitality.[xiii]
Electronic apex locators
When RCT treatment is advised, the removal of all pulp tissue, necrotic material and microorganisms from the root canal is essential for endodontic success. This can only be achieved if the length of the tooth and its canal shape is accurately measured.[xiv] Inaccurate determination of working length (WL) may result in retained necrotic tissues which will continue to drive infection within the canal if underextended. An overextended working length may result in irritation to the apical tissues.[xv]
Where sometimes multiple radiographs may have been used in complex cases, electronic apex locators (EALs) are now commonly used by endodontists to establish WL. Modern electronic apex locators can determine working length with accuracies of greater than 90%, and can reduce the number of radiographs required, minimising radiation exposure. EALs are now able to detect root perforations, root fractures, cracks and internal or external resorption, making them an excellent diagnostic tool in TDI treatment.[xvi]
Distinct tooth morphology, lack of patency, the accumulation of dentine debris and calcifications can affect accurate WL determination with some EALs. Those that incorporate constant recapitulation and irrigation produce a more accurate electronic length readings during instrumentation.[xvii]
COLTENE has developed a solution for canal preparation that takes the advantages of modern EALs to a new level. It’s a completely integrated, autonomous assistance system that guides mechanical and chemical preparation step by step. The innovative CanalProTM Jeni endomotor from COLTENE uses complex algorithms that enable the system to continuously adapt to the contours of the individual root canal anatomy. It enables continuous, precise measurement of working length, and controls variable file movements within millisecond intervals. The system gives automated acoustic signals when irrigation is required, and new integrated software detects the performance of files, recommending file changes when needed.
TDIs affect a vast number of people in the world, and the consequences can be devastating to patients, both in the short and long term. Early diagnosis and effective treatment planning with consistent follow-ups are all important factors for optimising outcomes after a TDI. Embracing innovative new technology can help dentists provide traumatised patients with more favourable results.
Email info.uk@coltene.com or call 0800 254 5115
COLTENE loyalty scheme https://rewards.coltene.com
Author: Mark Allen, General Manager at COLTENE
[i] Abbott PV. Indications for root canal treatment following traumatic dental injuries to permanent teeth. Australian Dental Journal. October 2023. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12989 Accessed March 2024.
[ii] Ramachandran A, Khan SIR, Al-Maslamani M, Baskaradoss JK. Pattern of Traumatic Dental Injuries Among Adults. Open Access Emerg Med. 2021 May 21;13:201-206. doi: 10.2147/OAEM.S311113. PMID: 34045907; PMCID: PMC8149273.
[iii] Antipovienė A, Narbutaitė J, Virtanen JI. Traumatic Dental Injuries, Treatment, and Complications in Children and Adolescents: A Register-Based Study. Eur J Dent. 2021 Jul;15(3):557-562. doi: 10.1055/s-0041-1723066. Epub 2021 Feb 3. PMID: 33535246; PMCID: PMC8382465.
[iv] Kallel I, Douki N, Amaidi S, Ben Amor F. The Incidence of Complications of Dental Trauma and Associated Factors: A Retrospective Study. Int J Dent. 2020 Mar 11;2020:2968174. doi: 10.1155/2020/2968174. PMID: 32256593; PMCID: PMC7086444.
[v][v] Antipovienė A, Narbutaitė J, Virtanen JI. Traumatic Dental Injuries, Treatment, and Complications in Children and Adolescents: A Register-Based Study. Eur J Dent. 2021 Jul;15(3):557-562. doi: 10.1055/s-0041-1723066. Epub 2021 Feb 3. PMID: 33535246; PMCID: PMC8382465.
[vi] Abbott PV. Indications for root canal treatment following traumatic dental injuries to permanent teeth. Australian Dental Journal. October 2023. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12989 Accessed March 2024.
[vii] Lakshmaiah D, Sr V, Ilango S, Sakthi N, Ps S. Management of Complex Crown Fractures: A Case Series. Cureus. 2023 Apr 20;15(4):e37907. doi: 10.7759/cureus.37907. PMID: 37220460; PMCID: PMC10200002.
[viii] Kallel I, Douki N, Amaidi S, Ben Amor F. The Incidence of Complications of Dental Trauma and Associated Factors: A Retrospective Study. Int J Dent. 2020 Mar 11;2020:2968174. doi: 10.1155/2020/2968174. PMID: 32256593; PMCID: PMC7086444.
[ix] Kallel I, Douki N, Amaidi S, Ben Amor F. The Incidence of Complications of Dental Trauma and Associated Factors: A Retrospective Study. Int J Dent. 2020 Mar 11;2020:2968174. doi: 10.1155/2020/2968174. PMID: 32256593; PMCID: PMC7086444.
[x] Krastl G, Weiger R, Filippi A, Van Waes H, Ebeleseder K, Ree M, Connert T, Widbiller M, Tjäderhane L, Dummer PMH, Galler K. Endodontic management of traumatized permanent teeth: a comprehensive review. 08 March 2021 https://doi.org/10.1111/iej.13508
[xi] Abbott PV. Indications for root canal treatment following traumatic dental injuries to permanent teeth. Australian Dental Journal. October 2023. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12989 Accessed March 2024.
[xii] Abbott PV. Indications for root canal treatment following traumatic dental injuries to permanent teeth. Australian Dental Journal. October 2023. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12989 Accessed March 2024.
[xiii] Vinagre A, Castanheira C, Messias A, Palma PJ, Ramos JC. Management of Pulp Canal Obliteration-Systematic Review of Case Reports. Medicina (Kaunas). 2021 Nov 12;57(11):1237. doi: 10.3390/medicina57111237. PMID: 34833455; PMCID: PMC8625069.
[xiv] Gordon MP, Chandler NP. Electronic apex locators. Int Endod J. 2004 Jul;37(7):425-37. doi: 10.1111/j.1365-2591.2004.00835.x. PMID: 15189431.
[xv] British Endodontic Society. A Guide To Good Endodontic Practice. September 2022. Available at: https://britishendodonticsociety.org.uk/_userfiles/pages/files/a4_bes_guidelines_2022_hyperlinked_final.pdf. Accessed March 2024
[xvi] Gordon MP, Chandler NP. Electronic apex locators. Int Endod J. 2004 Jul;37(7):425-37. doi: 10.1111/j.1365-2591.2004.00835.x. PMID: 15189431.
[xvii] Gordon MP, Chandler NP. Electronic apex locators. Int Endod J. 2004 Jul;37(7):425-37. doi: 10.1111/j.1365-2591.2004.00835.x. PMID: 15189431.
