Perawatan Endodontik Pada Gigi yang Terkena Trauma
- Trauma pada gigi akan melibatkan pulpa secara langsung maupun tidak langsung, karena itu perlu pertimbangan perawatan endodonsia pd gigi tsb.
- Trauma gigi paling sering terjadi pd usia 8-12, kemudian usia 2-3 thn.
- Boys tend to injure their teeth more frequently than girls, by ratios varying from 2:1 to 3:1.
- Maxillary central incisors, followed by maxillary lateral incisors and then the mandibular incisors, are the teeth most frequently involved.
- The most commonly observed dental trauma involves fracture of enamel, or enamel and dentin, but without pulp involvement.
Klasifikasi
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WHO Classification of diseases and modified by Andreasen
- Dentofacial Injuries
- Soft Tissue
- Laceration
- Contrusion
- Abrasion
- Tooth fracture
- Enamel fracture
- Crown fracture
- uncomplicated (no pulp exposure)
- uncomplicated (with pulp exposure)
- Crown- root fracture
- Root fracture
- Luxation injuries
- Tooth concussion
- Subluxation
- Extrusive luxation
- Lateral luxation
- Intrusive luxation
- Avulsion
- Facial skeletal injuries
- Alveolar process- maxilla/mandible
- Body of maxillary/ mandibular bone
- Temporomandibular joint
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WALTON (based on Andreasen's modification)
- Enamel Fracture
- Crown fracture
- without pulp involvement
- pulp involvement
- Crown-root fracture
- Root fracture
- Luxation
- Avulsion
- Fracture of the alveolar process (mandible of maxilla)
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Klasifikasi Ellis
- Klas 1: Fraktur email
- Klas 2: Fraktur dentin tanpa terbukanya pulpa
- Klas 3: Fraktur mahkota dgn terbukanya pulpa
- Klas 4: Fraktur akar
- Klas 5: Luksasi gigi
- Klas 6: Intrusi gigi
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Pemeriksaan cedera dental
- keluhan utama
- riwayat penyakit sedang diderita
- riwayat medis dan pemeriksaan klinis (jar. lunak, tulang muka juga gigi dan jaringan penyangga)
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Cedera Jaringan Lunak
- Injuries to oral soft tissues can be lacerations, contusions, or abrasions of the epithelial layer or a combination of injuries.
- If treatment is indicated, it consists of controlling bleeding, repositioning displaced tissues, and suturing.
- Oral soft tissues heal rather quickly
Fraktur Gigi
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FRAKTUR EMAIL
- Tidak berbahaya utk pulpa, prognosis baik.
- Hanya perlu grinding n smoothing pd tepi yg tajam atau merestorasi struktur yg hilang.
- Pulp vitality tests should be performed both immediately after the injury and again in 6 to 8 weeks.
- It must be kept in mind that, even with minor traumatic injuries, such as enamel fractures, damage to the apical neurovascular bundle may have occurred.
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FRAKTUR MAHKOTA DGN PULPA BELUM TERBUKA (uncomplicated)
- Biasanya tidak tdpt nyeri parah, umumnya tidak memerlukan perawatan segera.
- Noted: proximity of the fracture to the pulp, surface area of dentin exposed, age of the patient, concomitant injury to the pulp’s blood supply, length of time between trauma and treatment, and possibly the type of initial treatment performed.Kedekatan fraktur ke pulpa, luas permukaan dentin yang terpapar, usia pasien, bersamaan dengan pasokan darah pulpa, lamanya waktu antara trauma dan perawatan, dan mungkin jenis perawatan awal yang dilakukan.
- Prognosis baik, kec disertai luksasi.
Restored crown fracture that does not involve the pulp directly. Exposed dentin is covered with a hard-setting liner followed by restoration of the missing tooth structure using acid-etched bonded resin.
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FRAKTUR MAHKOTA DGN PULPA TERBUKA (Complicated)
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Melibatkan email, dentin dan pulpa.
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The extent of fracture, the stage of root development, and the length of time since injury are noted.
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Terapi:
Pulp capping is a time-honored procedure that is sometimes quite successful. Pulpotomi atau RCT sebelum merestorasi bagian gigi yg hilang.
- Sesegera mungkin setelah terjadinya cedera.
Shallow pulpotomy. A, Preparation of the pulp wound area with a round diamond stone cooled by a constant water spray. B, Protective dressing (arrow) of hard-setting calcium hydroxide covered with sealing cement (zinc oxide-eugenol, zinc phosphate, or glass ionomer). C, Missing tooth structure restored with acid-etched composite resin bonded to enamel.
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TREATMENT EVALUATION AFTER 6 MONTHS AND THEN YEARLY.
Criteria for a successful shallow pulpotomy
- The tooth is asymptomatic and functions properly
- There is no radiographic evidence of periradicular periodontitis
- There is no indication of foot resorption
- The tooth responds to pulp testing (if pulp testing is possible)
- Continued root development and dentin formation are evident radiographically, if the root was immature at the time of treatment. If the pulp ebcomes nectoric or formation is arrested, apexification is then necessary.
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FRAKTUR MAHKOTA-AKAR
- Enamel, dentin, and cementum are involved. If the pulp is also involved, the case is considered more complicated.
- Pd gigi anterior: chisel-type fracture, dgn garis fraktur diagonal meluas ke subgingiva s/d ke permukaan akar.
- Another variation is the fracture that shatters the crown.
- Crownroot fractures often include the molars and premolars. Cusp fractures that extend subgingivally are common.
Crown-root fracture with pulp exposure.
A, Note loose mesial crown fragments, which are attached by periodontal ligament fibers.
B, After anesthesia, loose fragments are removed and rubber dam applied. Note exposure of radicular pulp (arrow). C,The remainder of coronal pulp tissue is amputated and the surface of pulp allowed to coagulate. Cotton pellet (CP) aids by controlling initial bleeding. D, After surface coagulation, the area is irrigated and calcium hydroxide placed directly over pulp tissue. It helps to prepare a shelf around the pulp orifice to support the base and prevent the cement from being pushed into the underlying pulp tissue (arrows point to shelf in dentin).
E, After placement of base, acid-etched composite will be used for final restoration.
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FRAKTUR AKAR
Disebut juga: fraktur akar intraalveolus, fraktur akar horisontal, fraktur akar transversal. Jarang terjadi (3%) dan sukar dideteksi.
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Stabilization of root fractures with a mobile coronal segment.
A, Orthodontic wire is adapted to labial surfaces of anterior teeth and attached using the acid-etched resin technique. If possible, all six anterior teeth are included for better stabilization.
B, At future evaluation, root formation has responded to treatment (stabilization). Internal calcification adjacent to the fracture (arrows) indicates repair.
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Successful treatment of pulp necrosis in a root-fractured incisor with root canal filling of coronal fragment.
A, Condition after the injury.
B, Segment is repositioned, stabilized, and treated.
C, Five months after obturation; the segment is stable.
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Root fracture treated by root canal therapy of both apical and coronal fragments.
A, Note the fistulous tract.
B, Tract traced with a gutta-percha point to the root fracture (white arrow). Periodontal lesion associated with fracture is evident (dark arrows).
C, Segments aligned properly so that instrumentation is possible.
D, Sealer extruded into the interproximal area (arrows).
E, Follow-up at 11 months shows resolution of the lesion with a small remaining area expected to heal.
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CEDERA LUKSASI
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Causa:
sudden impact atau terbentur benda keras ketika terjatuh.
● Paling sering terjadi diantara dental trauma yg lain (30-44%)
● Dpt menimbulkan trauma pd jar penyangga gigi dan mempengaruhi pasokan darah, saraf ke pulpa.
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Concussion
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Klinis
- Luksasi paling ringan,
- hanya sensitif pd perkusi,
- tidak ada mobilitas,
- tidak ada perubahan letak.
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Terapi:
symptomatic, allow the tooth to rest (avoid biting).
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Monitor pulpal status by EPT and watch clinically for tooth color changes and radiographically for evidence of resorption.
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Prognosis: good
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Subluxation
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Gigi sensitif thdp perkusi dan goyang. Tidak berubah letak. EPT (-)/(+).
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Terapi:
Tidak ada, kecuali mobilitas sedang;
- jika mobilitas grade 2 mungkin perlu untuk menstabilkan gigi untuk waktu yang singkat (2 sampai 3 minggu) untuk meningkatkan pemulihan ligamen periodontal dan pengurangan mobilitas.
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Extrusive Luxation
- Sebagian gigi telah berubah letak di soketnya, namun masih di sumbu panjangnya. Mobilitas meningkat, pd Rӧ terlihat, EPT (-).
- Terapi:
- immediate repositioning n stabilizing with splint for 4-8 weeks.
- Jika giginya nekrosis/pulpitis irreversible → RCT.
- Note: perubahan warna mahkota, EPT, lesi peradikuler pd Rӧ.
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Lateral Luxation
- Gigi berubah letak ke labial, lingual,mesial, atau distal dari sumbu panjang.
- Often very painful. Perkusi (-)/(+). Jika gigi tidak goyang → gigi terdorong ke tulang alveolus, bila di perkusi akan terdengar suara metal.
- Terapi = terapi luksasi ekstrusi.
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Intrusive Luxation
- Gigi terdorong masuk kedalam soketnya dalam arah aksial (apeks). Mobilitas menurun dan menyerupai ankilosis.
- Terapi: tergantung pd maturitas akar. Little or no treatment for very immature teeth, aggressive initial treatment for more mature teeth (ortodonsia).
- Pd kasus intrusi ekstrem → bedah reposisi, orto.
- If necessary → endodontics therapy.
A, Intruded immature tooth (arrow).
B, Six weeks later. Note re-eruption of the left central incisor, almost catching up with its contralateral mate.
Luxation injuries. A, Subluxation: the tooth is loosened but not displaced. B, Extrusive luxation: the tooth is partially extruded from its socket. Occasionally this is accompanied by an alveolar fracture. C, Lateral luxation: the crown is displaced palatally and the root apex labially. D, Intrusive luxation: the tooth is displaced apically.
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Tooth Avulsion
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Gigi yg telah keluar seluruhnya dari soket.
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misc
Angka kejadian 3%.
- Tooth avulsion is a true dental emergency since timely attention to replantation could save many teeth.
- Prognosa baik (immediate replantation).
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Medium Menyimpan
- Lama gigi keluar dari soket, media penyimpanan yg lembab agar sel2 ligamen periodontal dan serabut2 pd permukaan akar tetap hidup dan minimizing handling of the root.
- susu
- saliva
The best transport medium is a commercially available storage-transport medium or physiologic saline (usually neither is available); milk, however, is an excellent alter native.12 Saliva is acceptable, whereas water is not good for maintaining root-surface cell vitality
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First Aid for Avulsed Teeth
- Rinse the tooth in cold, running tap water (10-seconds)
- Do not scrub the toothh
- Replace the tooth in the socket using gentle finger pressure
- Hold (or have the patient hold) the tooth in position
- Seek dental care immediately
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Replantation
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Replantation within 1 Hour of Avulsion—Tooth with a Closed Apex
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Place the tooth in a cup of physiologic saline while preparing for replantation.
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Take radiographs of the area of injury to look for evidence of alveolar fracture.
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Examine the avulsion site carefully for any loose bone fragments that may be removed. If the alveo lus is collapsed, spread it open gently with an instrument.
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Irrigate the socket gently with saline to remove contaminated coagulum.
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Grasp with extraction forceps the crown of the tooth to avoid handling the root.
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Examine the tooth for debris and if present, gently remove it with saline solution from a syringe.
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Using the forceps, partially insert the tooth into the socket. Gentle finger pressure can be used for complete seating of the tooth, or the patient can bite on a piece of gauze to accomplish the seating.
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Check for proper alignment and correct any hyper occlusion. Soft tissue lacerations should be tightly sutured, particularly cervically.
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Stabilize the tooth for 2 weeks with a flexible splint.
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Antibiotics are recommended for patients with
replanted avulsed teeth.41 In patients 12 years of
age and older, doxycycline 100 mg, 2 times per
day for 7 days, is the current recommendation.
Alternatively, penicillin V 500 mg, 4 times per day
for 7 days, can be prescribed. For children under
the age of 12, penicillin V 25 to 50 mg/kg of body
weight in divided doses every 6 hours for 7 days
can be prescribed.12 A tetanus booster injection is
recommended if the last one was administered
more than 5 years previously.5
- Supportive care is important. Instruct the patient
(and parents) to use a soft diet for up to 2 weeks,
to brush with a soft toothbrush after every meal,
and to use a chlorhexidine mouth rinse (0.12%)
twice a day for a week.
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Replantation within 1 Hour of Avulsion—Tooth with Open Apex (Figure 10-19)
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Place the tooth in a cup of physiologic saline while preparing for replantation.
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Administer local anesthetic.
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Examine the alveolar socket, looking for fracture of the socket wall.
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If available, cover the root surface with minocycline hydrochloride microspheres (Arestin, OroPharma Inc., Warminster, PA) before replanting the tooth.
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Replant the tooth with slight digital pressure.
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Suture gingival laceration, especially in the cervical area.
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Verify normal position of the replanted tooth.
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Apply a flexible splint for two weeks.
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For children younger than nine years, penicillin V 25 to 50 mg/kg in divided doses every 6 hours for 7 days can be prescribed. A tetanus booster injec tion is recommended if the last one was adminis tered more than 5 years previously.
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Replantation More Than 1 Hour After Avulsion— Tooth with Closed Apex
If a tooth has been out of the alveolar socket for more than 1 hour (and not kept moist in a suitable medium),
periodontal ligament cells and fibers will not survive, regardless of the stage of root development. Replacement resorption (ankylosis) will probably be the eventual sequela after replantation. Therefore, treatment efforts before replantation include treating the root surface with fluoride to slow the resorptive process
- Examine the area of tooth avulsion and the radio
graphs for evidence of alveolar fractures.
- Remove debris and pieces of soft tissue adhering to
the root surface using a dry piece of gauze.
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Soak the tooth in a 2.4% solution of sodium fluo ride (acidulated to pH 5.5) for 5 to 20 minutes.
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Perform root canal treatment on the tooth while it is held in a flfl uoride-soaked piece of gauze. Often the procedure can be accomplished from an apical direction if the root is immature.
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Administer local anesthesia.
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Suction the alveolar socket carefully to remove the blood clot and irrigate the socket with saline.
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Replant the tooth gently into the socket, checking for proper alignment and occlusal contact.
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Splint the tooth for 4 weeks
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Guidelines for Replantation
Ideally, if an avulsed tooth can be replanted at the site of injury, the prognosis is better than waiting until the patient is transported to a treatment facility. The following advice can be given over the telephone to someone able to assist the victim:
- Rinse the tooth in cold running water. The purpose is to rinse off any obvious debris that may have collected on the root surfaces.
- Do not scrub the tooth. The less the root surface is touched, the less damage to fibers and cells. Suggest that the person applying these first-aid measures handle the tooth by holding on to the crown of the tooth and not the root.
- Replace the tooth in the socket.Many individuals, even parents, may be squeamish about this step. A relatively easy way out is for the first-aid person to place the tooth, root tip first, partly into the socket, then let the patient bite down gently on a piece of cloth such as a handkerchief to move the tooth back into its normal, or nearly normal, position.
- Bring the patient to the dental office right away to complete the treatment of replantation.
ONE VISIT ENDODONTIC
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INDIKASI
● Gigi vital uncomplicated
● Uncomplicated non vital teeth with sinus tract (fistula)
● Pasien yang sibuk dan mempunyai waktu terbatas untuk datang ke klinik gigi
● Tidak dibawah pengaruh obat seperti antibiotik prophylaxis
● Fraktur anterior yang membutuhkan estetik segera
● Pasien yang kooperatif
● Tidak dalam keadaan sakit atau akut
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KONTRA INDIKASI
● Abses alveolar akut dengan pus
● Saluran akar yang rumit
● Periodontitis apikalis dengan nyeri severe pada perkusi
● Gigi non vital nyeri tanpa sinus tract
● Kasus dengan kesulitan prosedur seperti kanal yang terkalsifikasi, curvature, ekstrakanal, dll
● Pasien dengan gangguan TMJ dan sulit membuka mulut
● Gigi dengan akses terbatas
● Kasus retreatment non surgical
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KEUNTUNGAN
● Dokter gigi mempunyai kewaspadaan yang tinggi terhadap anatomi saluran akar secara langsung setelah instrumentasi
● Tidak ada resiko kehilangan tanda-tanda(landmark)
● Saluran akar tidak pernah lebih bersih selain setelah instrumentasi yang sesuai
● Tidak ada resiko flare-up karena kebocoran tumpatan sementara
● Gigi lebih cepat untuk restorasi final sehingga mengurangi resiko pencabutan karena fraktur
● Kegelisahan/ketidaknyamanan sebelum dan setelahperawatan terbatas hanya satu kunjungan
● Waktu hemat untuk pasien dan dokter gigi
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KERUGIAN
● Ketidakmampuan untuk mengeringkan saluran akar sepenuhnya
● Waktu yang tidak cukup untuk menyelesaikan prosedur
● Kemungkinan peningkatan tekanan otot TMJ atau tekanan psikis pasien atau dokter gigi
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Evaluasi keberhasilan perawatan
● Tidak ada rasa nyeri
● Hilangnya fistel
● Fungsi tetap baik
● Tidak ada tanda kerusakan jaringan
- *respon pulpa: 2-3 minggu
Tambahan dari Miw
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An open apex is in the developing root of immature teeth until apical closure occurs, which is approximately 3 years after eruption. In
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Apexogenesis
—apexogenesis (vital pulp therapy)
is defifi ned as a vital pulp therapy procedure
performed to encourage continued physiologic develop
ment and formation of the root end. The objective is to
maintain the vitality of the radicular pulp. Therefore the
pulp must be vital and capable of repair, which is often
the case when an immature tooth sustains a small coronal
exposure after trauma. A small exposure can be treated
by pulp capping. The steps involved in pulp capping and
apexogenesis with MTA
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apeksifikasi-apexification (root-end closure).
Apexififi cation is the induction of a calcififi c barrier (or the
creation of an artififi cial barrier) across an open apex.
Apexififi cation involves removal of the necrotic pulp fol
lowed by debridement of the canal and placement of
an antimicrobial medicament (Figure 2-15). In the past,
much emphasis has been placed on the type and proper
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obat
Calcium hydroxide has been the most widely accepted
material for induction of an apical barrier. The mecha
nism of action of calcium hydroxide remains controver
sial in spite of much research on its effect on pulp tissue.
It has, however, been demonstrated that the reaction of
the periapical tissues to calcium hydroxide is similar
to that of pulp tissue. Calcium hydroxide produces a
multilayered, sterile necrosis permitting subjacent
mineralization.103
Recently, interest has centered on the use of MTA for
apexififi cation.99,104 This material has demonstrated good
biocompatibility and ability to seal, and its high pH may
impart some antimicrobial properties.
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