Renata Pazera1, *Joanna Szczepańska2
Resorption as a sequela of dental trauma – diagnosis and management
Resorpcja jako powikłanie pourazowe – diagnostyka, leczenie
1Doctoral studies, Dentistry of Developing Dentition Department, Medical University of Łódź
Head of Department: Professor Joanna Szczepańska, MD, PhD
2Dentistry of Developing Dentition Department, Medical University of Łódź
Head of Department: Professor Joanna Szczepańska, MD, PhD
Mechaniczne uszkodzenie powierzchni tkanek przyzębia w trakcie m.in. intruzji lub zwichnięcia całkowitego staje się potencjalnym obszarem wystąpienia resorpcji. Celem pracy było przedstawienie na podstawie piśmiennictwa resorpcji patologicznej występującej w zębach stałych u dzieci, ze szczególnym uwzględnieniem diagnostyki, mechanizmu powstania oraz metod leczniczych. Zwrócono uwagę na jej związek przyczynowo-skutkowy po wystąpieniu urazu.
Często przyczyną zgłaszania się do gabinetu stomatologicznego w wieku rozwojowym jest uraz zębów stałych. Resorpcja jest jednym z możliwych poważnych powikłań, która może doprowadzić do utraty zęba. Na podstawie piśmiennictwa przytoczono metody zmniejszające ryzyko jej wystąpienia oraz skutki późnego wykrycia zmiany. Podkreślono istotę wizyt kontrolnych i wyszczególniono niepokojące zmiany kliniczno-radiologiczne mogące świadczyć o istnieniu resorpcji. Przedstawiono schematy leczenia endodontycznego oraz postępowanie w przypadku ankylozy.
Podsumowując, resorpcja jako powikłanie po urazie stanowi nieraz ryzyko utraty zęba pomimo prawidłowego zaopatrzenia zęba. Działanie czynnika uszkadzającego wraz z czynnikiem podtrzymującym, jakim jest m.in. infekcja, uniemożliwia samoistną regenerację tkanek przyzębia i skutkuje rozwojem resorpcji, nawet po długim czasie od wystąpienia urazu. Uświadomienie rodziców o istocie wizyt kontrolnych jest ważne dla możliwości wykrycia powikłań w odpowiednim czasie.
The area of mechanical damage rendered to the periodontal tissues upon intrusion or tooth avulsion becomes a potential site of resorption. The purpose of this study is to present the phenomenon of pathological resorption occurring in permanent teeth in children, with a particular emphasis on the course of diagnosis, the mechanism of occurrence, and the treatment options. Special attention has been paid to the cause-and-effect relationship between resorption and dental trauma.
Patients in developing age commonly seek the dentist’s help following dental trauma. Resorption is among the possible serious sequelae, potentially leading to loss of the tooth. Based on literature review, methods that reduce the risk of its occurrence, and the effects of a delayed diagnosis have been listed. The importance of follow-up appointments has been stressed, and the clinical and radiologic findings have been specified. Endodontic therapy protocols have also been presented, along with the indicated course of treatment for ankylosed teeth.
To recapitulate, resorption due to trauma frequently poses a risk of tooth loss in spite of adequate tooth treatment immediately following the trauma. The combined effect of the damaging factor and a stimulating factor such as an infection, may render the self-regeneration of the periodontal tissues impossible, and result in the development of resorption, even a long time after the trauma. The parents’ awareness concerning the importance of follow-up dental appointments is vital for a timely diagnosis of potential complications.
Resorption is a process leading to loss of the tissue of a tooth or the alveolar bone. In normal conditions it affects the roots of the primary teeth. Root resorption in permanent teeth is a pathological process. It is classified by its aetiology, advancement, and location. Dental trauma is among the initiating factors of external resorption, as it severs the periodontal ligament. Its progress depends on the presence of a stimulating factor such as an infection. Statistically, it is most common following tooth avulsion or intrusion (1, 2).
Adequate treatment of the traumatized tooth does not complete the therapy. The patient needs to be informed of the importance of the follow-up appointments. Early diagnosis of sequelae, including resorption, allows to arrest the pathological process, and facilitates longer survival of the tooth within the oral cavity. Management of resorption frequently fails, hence the significance of following strictly the current guidelines, including those by the International Association of Dental Traumatology, to reduce the risk of its occurrence (2, 3).
Management of internal resorption and external inflammatory resorption consists in endodontic therapy and temporary filling with calcium hydroxide. Chemo-mechanical preparation of the canal and introduction of an alkaline intracanal medicament improves the topical condition. The preferred method of canal obturation is the use of a liquid gutta-percha to seal sinus tracts, and prevent tension of the thinned and weakened root walls. The point where the sinus tract meets the periodontal ligament is treated with e.g. Mineral Trioxide Aggregate (MTA). Replacement resorption is not treated endodontically. An ankylosed tooth does not erupt, and in patients with developing dentition the growth of the alveolar ridge is arrested, resulting with an infra-position of the tooth. In such clinical conditions, the course of treatment is aimed at preserving a good quality alveolar ridge for further implantation and prosthetic treatment upon the completion of the patient’s growth. In such circumstances, coronectomy may be adopted as the treatment of choice (3, 4).
In this work on the basis of the literature was shown the mechanism of resorption, ways of avoid, diagnostic methods and treatment.
Ental trauma in children
Dental appointments due to teeth trauma in children have been on the rise. Among all injuries requiring treatment, dental traumas account for 5%. The analysis of all the of traumas treated at the Dentistry of Developing Dentition Department of the Medical University of Łódź in 2000-2003 revealed the most common reason for seeking dental help to be crown fractures involving a substantial part of the dentine without pulpal exposure, followed by subluxations (55 and 13% respectively of the total number of patients affected with dental traumas). Dental avulsion necessitating a replantation was found in 2.9% of the patients, and crown-root fracture in 2.5% of the treated children. Tooth avulsion is among the injuries with poor prognosis, leading to damaged pulp and periodontal tissues, i.e. the alveolar bone, the periodontal ligament, the root cementum, and the gingiva. The potential sequelae include pulpal necrosis, resorption, or ankylosis. Such complications, with lower prevalence, may also follow the intrusion of permanent teeth (5-7).
Sequelae of dental trauma
Adequate management of dental trauma, as early as immediately on the site of the accident, may have a major impact on the favourable outcome. Where there is enamel-dentine fracture involved, the management consists in crown reconstruction, typically with a composite material. Nonetheless, even such cases may entail complications, particularly when tissue breakage is substantial and the patient is young, i.e. the width of the dentinal tubules is large, and the mineralization degree of the intertubular dentine is low. Even prompt tooth reconstruction does not ensure treatment success. The most prevalent complications include chipped off reconstruction, pulpal necrosis with its sequelae (such as tooth discolouration, fissure, resorption, and ankylosis), tooth mobility, or tooth loss. Hence the importance of follow-up appointments, aimed at tooth assessment following the trauma, including such aspects as root development, and the condition of the pulp and of the tissues surrounding the root. Complications may follow the trauma as late as several years afterwards. The prevalence of resorption due to avulsion is estimated to range from 57.7-80%, and of resorption due to intrusion from 38-66%, these two entities being the injuries associated with the poorest prognosis (8-11).
The factors potentially reducing of the risk of resorption/its aggravation:
– early diagnosis and adequate management,
– replantation of the tooth within 20-30 minutes after the trauma increases favourable prognosis up to 85-97%,
– in the case of avulsion without an attempt at replanting the tooth on the site of the accident, storage of the tooth in a proper medium such as saliva, fresh cold milk, saline, HBSS (a balanced solution of potassium and sodium salts that preserves periodontal ligament’s viability up to 24 hrs, available as Sava-A-Tooth kit), ViaSpan solution used for organ storage in transplantology, that allows to limit cellular death within the periodontal ligament and the pulp,
– in the case of replantation of a tooth with an open apex (extra-oral dry time under 60 minutes, or in physiologic media), prior to replanting, soaking the tooth in a solution of doxycycline/minocycline 0.05 mg/ml for 5 minutes; additionally, prior 30-minute soak in HBSS is recommended to inhibit any bacterial infection and prevent complications,
– in the case of replantation of a tooth with an open apex (extra-oral dry time less than 60 minutes, or in wet, yet non-physiologic media), a 5-minute soak in citric acid, followed by a 20-minute soak in 2% sodium fluoride/2.5% zinc fluoride is recommended to prevent resorption,
– coverage of root surfaces with minocycline prior to replantation increases the chances for revascularization up to 91% (currently being tested),
– application of a flexible splint for 7-10 days or for 4 weeks, depending on the apex shape, with the use of materials designed for temporary bridges, orthodontic wire, glass fiber to prevent ankylosis and resorption,
– application of an antibiotic and steroid paste as an intracanal medicament following replantation and pulpal necrosis to inhibit the inflammation,
– following replantation, systemic administration of tetracycline in the dosage of 25 mg/kg of body weight/day; in children under 12 years of age, tetracycline is counter-indicated, owing to the risk of discolouration of the permanent teeth, with Phenoxymethyl Penicillin (Pen V) available as a possible alternative (an antibiotic from ß-lactam group, i.e. natural penicillins), e.g. Ospen, at a dosage appropriate for the child’s age and body weight, to facilitate the healing of the periodontal ligament, the pulp, and the soft tissues.
– radiographic control of the affected site after 2-3 weeks from the replantation to assess the periodontal ligament and the bone; in the case of inflammation, the endodontic therapy should be extended up to 6-24 months, with the medicament replaced every 3 months,
– adequate oral hygiene following the trauma to limit bacterial growth within the oral cavity and the gingival socket, particularly important where there is damage rendered to the tooth’s suspension apparatus, to prevent an infection of the periodontal ligament, including external inflammatory resorption,
– soft food to relieve the tooth’s functional load, thus facilitating improved healing of the pulp, the periodontal ligament, and the bone (1, 2, 10, 12-15).
The mechanism of resorption occurrence and progress
In normal circumstances, resorption affects only primary (deciduous) teeth before they are naturally replaced by permanent teeth. Both primary and permanent teeth may be affected by pathological resorption. The aetiology of this process is complex, and remains the subject of numerous studies. External resorption is initiated by mechanical or chemical damage to root surfaces. The protective layer of precementum and cementoblasts is then compromised, resulting in the exposure of the cellular cementum. For self-regeneration to occur, no infection or pressure in this area may take place (healing time is approximately 2-3 weeks when the damage is not extensive). This is referred to in literature as repair-related surface resorption.
The progress of resorption depends on the presence of clastic cells unable to adhere and act on an uncompromised root surface. Osteoclasts and odontoclasts demineralize the root surface. Ultimately, they also destroy the organic layer. The mechanism of action for odontoclasts and their origin remain unclear, even though their numerous similarities to osteoclasts have been identified, the presence of RANK (Receptor Activator of Nuclear Factor κβ) on their surface among them, instrumental in regulating the osteoclast and odontoclast activity. The activation takes place when RANKL (receptor activator of nuclear factor κβ ligand) is bound (1, 2, 4, 16, 17). There are many factors regulating the activity of clastic cells (tab. 1).
Tab. 1. The factors regulating the activity of clastic cells
|Kind of factor ||Action |
|M-CSF (monocyte macrophage colony stimulating factor)||inhibit cell activity by blocking RANK|
|TGF-β (transforming growth factor-β)||stimulates OPG production|
|TGF-β (transforming growth factor-β)||increase the activity of cells by upregulating RANKL|
|interferon gamma||inhibits the process of osteoclastogenesis|
|CSF-1 (colony stymulating factor)||contribute to the formation of osteoclast precursor cells|
The activated clastic cells acidify the environment through their presence in the cellular membranes of proton pumps. The dissolution of the apatites of dental tissue is facilitated by the decreased pH and the release of hydrolytic enzymes, and chloride and hydrogen ions. Moreover, MMP-9 and cathepsin k secreted by the clastic cells damage the organic portion of the dental tissue. The continuous activity of the damaging factor results in more profound destruction of the tissues (1, 11, 16).
Types of resorption
Depending on the place of its initiation, resorption is classified as internal or external. Two types of external resorption may be listed, namely inflammatory and replacement resorption. The first type results in loss of the dental tissue and its weakening, the second obliterates the canal. According to its location, external location is classified as type A located in the crown, type B located in the root canal, type C which ultimately leads to perforation of the root canal wall, and type D where the pulp chamber is perforated. External resorption is classified into surface resorption, replacement resorption, and ankylosis. On the root surface it may involve the cervical area, the central area, or the periapical area (1, 3, 11, 17).
According to Andreasen, the consequences of teeth damage due to trauma may include various forms of external resorption, i.e. surface (repair-related) resorption, resorption related to infection (inflammatory), or to ankylosis (replacement resorption, bone fusion), as well as transient destruction of the bone in the periapical area/the marginal region.
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