Introduction
Trauma to the teeth is usually follows multiple patterns, where proper diagnosis is very important in terms.1 The time that has elapsed between injury and treatment is of prime importance, as it will affect the prognosis 2 Traumatic injuries affect enamel, dentin, pulp, periodontium, alveolar bone or gingiva. Assessing the status of an injured pulp holds importance in order to establish a reference for follow-up. 3 These limitations of conventional pulp testing make diagnosis following trauma challenging, as temporary loss of sensibility occurs frequently due to pulpal oedema after injuries resulting in the displacement of teeth. In such cases, it may take several weeks before a response to sensibility testing returns or if the injury is severe, it can lead to severing of pulpal vessels due to the luxation followed by necrosis of the pulp.4 The factors most important for pulp necrosis are the severity of trauma (concussion least, intrusion most) and the stage of root formation (mature apex > immature apex). 5 Pulp necrosis can lead to infection of the root canal system, with external inflammatory root resorption. In mature teeth, pulp regeneration cannot occur, and the necrotic pulp gets infected approximately after 3 weeks. 6
Cementum covering the root is also affected, resulting in the loss of its protection provided by the same. 7 Now microbial toxins can pass through the dentinal tubules and initiate an inflammatory response in the corresponding periodontal ligament resulting in the resorption of the root and alveolar bone 8 with the formation of granulation tissue containing lymphocytes, plasma cells, and PMNL`s. Multinucleated giant cells resorb the denuded root surface, and this continues until the stimulus (microorganisms in the pulp space) is removed. 9 Radiographically, the resorption is observed as progressive radiolucent areas of the root and adjacent bone.
Case Summary
A female healthy child, 13 years old, presented with the parents to paediatric dental clinic to “check swollen gum inside the mouth and repair broken front tooth”. Clinical dental examination revealed an upper left central incisor 21 with enamel-dentin-pulp fracture accompanied with a they had not sought any dental treatment thereafter because the child was very apprehensive and fearful; recently, there was an increasing swelling in the hard palate discharging yellow secretions through the gingival sulcus of the upper left revealed that the teeth 11, 22, 23, 24, 25 were vital, while the tooth 21 was negative. Radiographic examination using orthopantomography and periapical radiographs showed a complicated crown fracture of the tooth 21 accompanied with arrested root development and open apex, in addition to a huge oval bone radiolucency measuring around 25mm extended from 21 to the area of upper left second premolar A female healthy child, 13 years old, presented with the parents to paediatric dental clinic to “check swollen gum inside the mouth and repair broken front tooth”. Clinical dental examination revealed an upper left central incisor 21 with enamel-dentin-pulp fracture accompanied with a they had not sought any dental treatment thereafter because the child was very apprehensive and fearful; recently, there was an increasing swelling in the hard palate discharging yellow secretions through the gingival sulcus of the upper left revealed that the teeth 11, 22, 23, 24, 25 were vital, while the tooth 21 was negative. Radiographic examination using orthopantomography and periapical radiographs showed a complicated crown fracture of the tooth 21 accompanied with arrested root development and open apex, in addition to a huge oval bone radiolucency measuring around 25mm extended from 21 to the area of upper left second premolar A female healthy child, 13 years old, presented with the parents to paediatric dental clinic to “check swollen gum inside the mouth and repair broken front tooth”. Clinical dental examination revealed an upper left central incisor 21 with enamel-dentin-pulp fracture accompanied with a
A 19 years old young male patient reported to the department of Conservative dentistry & Endodontics, Iggdc jammu with the chief complaint of pain & swelling in the left upper back region of jaw with a history of trauma to the left zygomatic area due to interpersonal violence 4 years back. Clinical examination revealed tenderness on percussion & fluctuant palatal abscess i.r.t to 21, 22, 23, 24, 25. Radiographic examination using OPG and IOPAR revealed large periapical radiolucency measuring 25mm × 23mm with sclerotic border suggested to be an infected periapical cyst extending from distal aspect of root of 21 to the mesial aspect of root of 25 (Figure 1).
The pulp sensibility test, utilising Endo Ice (-50°) showed that 21 & 25 were vital, while the tooth 22, 23, & 24 showed no response. Patient was assured that the pathology could be managed and the treatment steps were discussed meticulously. In the emergency phase of treatment, accumulated pus was evacuated by incision & drainage of palatal abscess & the access to the root canal was achieved (to allow for free discharge of the secretions through the pulp chamber) and pulp was extirpated. Subsequently, recall appointments were scheduled, root canals were debrided chemomechanically followed by intracanal medicament dressing (Triple Antibiotic Dressing, 2 weeks & biweekly Ca(OH)2 twice). Calcium Hydroxide (Powder) mixed with o.9% normal saline was inserted using gutta percha cone, size 35# and packed inside the canal using wet cotton pellets. Coronal seal was obtained with temporary filling(Cavit). After one month, CH dressing was reinserted again for 2 weeks. 6 weeks later, once the exudates coming through the access cavity completely disappeared and the palatal swelling started to decrease in size, teeth were obturated using cold lateral condensation followed by composite resin restoration. Patient was regularly followed over a period of 9 months (Figure 3a) & 12 months (Figure 3b). Radiographically a successful healing of periapical bone could be clearly seen on IOPAR after 3 month (Figure 2) & 9 month follow up. (Figure 3).
Discussion
Dental trauma is a serious health problem affecting the person’s life physically & psychologically as well. This case report presented the consequences of a trauma to the teeth left untreated for four years resulting in large periapical osteolytic lesion with well defined sclerotic borders, suggestive of an infected radicular cyst. 10
This provisional diagnosis was not confirmed by a histopathological examination as the treatment was carried out without any surgical intervention. The decompression in this case report was achieved through incision & drainage, and also to some extent through the root canal orifice of maxillary left canine. There are many limitations in this case report; including the only use of only conventional IOPAR without confirming with cone beam computed tomography CBCT through which a comprehensive radiographic detail can be obtained.
