Dental Traumatology 2001; 17: 145148 Printed in Denmark .

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Copyright C Munksgaard 2001

DENTAL TRAUMATOLOGY
ISSN 1600-4469

Editors note

The International Association of Dental Traumatology (IADT) has developed guidelines for the treatment of traumatic dental injuries. The guidelines presented in this issue of Dental Traumatology are part of the series that has been published in the previous issues and will be continued over the next few issues of the journal. In addition, selected cases are shown to illustrate these treatment guidelines. This issue will present guidelines for the treatment of luxation injuries. Avulsions will be dealt with separately in the next issue. These guidelines are intended as an aid to the dentist in the management and treatment of traumatized teeth. Practitioners must always use their own professional judgement. The IADT cannot guarantee any positive results associated with the application of the guidelines, although it is felt that timely and proper treatment will maximize the chances of success.

Guidelines for the evaluation and Management of traumatic dental injuries

Committee: M. T. Flores, J. O. Andreasen, L. K. Bakland Contributors: B. Feiglin, J. L. Gutmann, K. Oikarinen, T. R. Pitt Ford, A. Sigurdsson, M. Trope, William F. Vann Jr., F. M. Andreasen I. Introduction

Epidemiological studies reveal that one out of two children sustained a dental injury, most often between ages 8 and 12. Crown fracture is the most frequent type of trauma, generally resulting from accidents, sport activities, or violence. In most dental trauma, a rapid and appropriate treatment can lessen its impact from both an oral health and an aesthetic standpoint. New technology and an improved understanding of the inammatory process have led to a more conservative approach in managing dental trauma. The International Association of Dental Traumatology (IADT), conscious of the variation in the treatment of dental trauma has developed these guidelines as a type of consensus statements. These guidelines reect much thoughtful discussion among members of the IADT as well as a detailed review of international dental literature. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. Guidelines are needed to assist dentists as well as other health care professionals in delivering the best care possible in the most efcient manner. It is very important to promote public awareness and to educate the population at greatest risk for dental injury. Therefore, this report includes basic information on both prevention and rst aid. The correct application of these techniques immediately following the trauma should improve short and long-term outcome.

Because the management of injuries to the primary and permanent dentition differs signicantly, separate guidelines were developed for children with primary dentition and cases where permanent teeth are involved. In addition, these guidelines do not address issues relating to the diagnosis and treatment of major facial trauma of the bone and soft tissue, which is a critical rst step in the overall management of trauma patients. The evaluation and treatment of maxillofacial trauma which may coexist with dental trauma, goes beyond the scope of these recommendations.
Classication of diagnosis and therapy (*)

The classications listed below summarize diagnostics steps and therapeutic interventions and will be referenced throughout the guidelines. x Conditions for which there is evidence and/or general agreement that a given procedure or treatment is benecial, useful, and effective. xx Conditions for which there is conicting evidence and/or a divergence of opinion about the usefulness/efcacy of a procedure or treatment. xxx Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful. (*) Ryan et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction. 145

Guidelines General References

Andreasen JO, Andreasen FM, Bakland LK, Flores MT: Traumatic dental injuries. A manual. Copenhagen: Munksgaard, 1999. Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd edn. Copenhagen: Munksgaard, 1994. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:2359. Blomlof L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J 1981;Suppl 8:126. Cvek, M. Endodontic management of traumatized teeth. In: Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd edn. Copenhagen: Munksgaard, 1994. Cvek M. Changes in the treatment of crown-fractured teeth during the last two decades. In: Proceedings of the Second International Conference on Dental Trauma. 1991;5364. Ryan TJ, Anderson JL, Antman EM, Brannif BA, Brooks Califf RM, Hillis LD, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Management of Myocardial Infarction). J Am Coll Cardiol 1996;28:1328428. Tronstad L. Pulp reactions in traumatized teeth. In: Gutmann JL, Harrison JW. Proceedings of the International Conference on Oral Trauma. AAE Chicago, Illinois, 1986.

Table 1. Treatment guidelines for luxated permanent teeth Concussion Diagnosis Clinical ndings Subluxation Lateral luxation Intrusion Tooth is displaced deeper into the alveolar bone Not tender to touch, not mobile Percussion test: high, metallic sound (ankylotic tone) Take four radiographs (14) Radiographs not always conclusive. Extrusion Elongated mobile tooth

Tooth tender to touch Tooth is tender to (no displacement, touch and mobile, but no mobility) not displaced Hemorrhage from gingival crevice possible Take one radiograph (2) No radiographic abnormalities will be found

Radiographic assessment and ndings

The tooth is displaced laterally and is locked into bone. Not tender to touch, not mobile. Percussion test: high, metallic sound (ankylotic tone) Take two radiographs Take four radiographs (1, 2) (14) No radiographic Increased periodontal abnormalities will be space is best seen on found eccentric or occlusal exposures A exible splint optional can be used for the comfort of the patient for 710 days, or according to trauma diagnoses of adjacent teeth (x) Reposition the tooth into normal position (local anesthesia necessary). The tooth must often be extruded (occlusally past the bony lock prior to repositioning.) Take one radiograph (2) after repositioning. Stabilize the tooth with a splint for up to 3 weeks (xx) In case of marginal bone breakdown, usually observed radiographically (dont probe!) after 3 weeks, add 34 weeks extra splinting time

Take four radiographs (14) Increased periodontal space apically

Treatment A exible splint optional can be used for the comfort of the patient for 710 days, or according to trauma diagnoses of adjacent teeth (x) Slightly luxate the tooth with forceps (xx). Spontaneous reposition / reeruption (teeth with incomplete root formation) (xx) Orthodontic repositioning (teeth with completed root formation) (xx) or surgical repositioning is performed (xx) In case of completed root formation, perform prophylactic extirpation of the pulp 13 weeks after injury Repositioning Stabilize the tooth with a splint for up to 3 weeks (xx)

Patient instruction

Soft diet Brush teeth with a soft toothbrush after each meal Use of chlorhexidine mouthrinse (0.1%) twice a day for 2 weeks Follow up (see Table)

(1) occlusal, (2) periapical central angle, (3) periapical mesial eccentric, (4) periapical distal eccentric.

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Table 2. Follow-up procedures for traumatized permanent teeth Concussion Subluxation SC (2) C (3) C (1) C (2A) C (1) NA Lateral luxation C (3) C C C C (2A) (3) (2A) (2A) C (3) C (3) C (3) Cases are selected from J. O. Andreasen, F. M. Andreasen: Textbook and color atlas of traumatic injuries to the teeth. 3rd edn. Intrusion

Time Up to 3 weeks 34 weeks 68 weeks 6 months 1 year 5 years

Extrusion (S)C (2) C C C C (2A) (2A) (2A) (2A)

SSplint removal CClinical and radiographic examination. Success/Failure includes some but not necessarily all of the following: (1) Success asymptomatic, positive sensibility, continued root development (immature teeth), intact lamina dura periradicularly. Failure symptomatic, negative sensitivity, root does not develop (immature teeth), ? periradicular radiolucencies. (2) Success minimal symptoms, slight mobility, no excessive ( 2) lucency periradicularly. Failure severe symptoms, excessive mobility, clinical and radiographic signs of periodontitis. Initiate endodontics if closed apex tooth and extent of displacement guarantees pulp necrosis. (2A) Success Asymptomatic, clinical and radiographic signs of normal or healed periodontium. Marginal bone height corresponds to that seen radiographically after repositioning. Failure Symptoms and radiographic sign consistent with periodontitis, negative sensibility, Breakdown of marginal bone. splint for additional period 34 weeks; initiate endodontic treatment if not previously initiated, chlorhexidine mouthrinse. (3) Success Tooth in place or in movement, intact lamina dura, no signs of resorption, in mature teeth start endodontic therapy in rst 3 weeks. Failure Tooth locked in place/ankylotic tone; radiographic signs of apical periodontitis, external inammatory resorption or replacement resorption.

Case 1. Subluxation. Clinical presentation of left central incisor soon after receiving a blow. Tooth is tender to percussion, loose and bleeding from the gingival sulcus.

Case 2. Emergency treatment of extrusive luxation. A A 17-year-old male extruded the left central incisor and avulsed the lateral inciisor. B The radiographic examination shows coronal displacement of the tooth. C The tooth is gently pushed back into the socket. D A splint that allows optimal oral hygiene is placed and the gingival wound closed with interrupted silk sutures. E The nal radiograph shows optimal repositioning of the tooth. Endodontic therapy of this closed apex tooth should be scheduled in 13 weeks.

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Case 3. Emergency treatment of lateral luxation. A,B Clinical view of displacement of tooth after lateral luxation. A steep occlusal radiograph (C) shows displacement of the tooth and a lateral readiograph (D) reveals the associated fracture of the labial bone plate. E The tooth is repositioned by rst forcing the displaced apex occlusally, disengaging the root tip from the bone lock. Thereafter apical pressure apically will bring the tooth back into its original position. F Radiograph veries acceptable repositioning of the tooth.

Case 4. Orthodontic extrusion of an intruded tooth. A,B Clinical and radiographic presentation of an intruded right central incisor. C After approximately 10 days osteoclastic activity has usually resulted in loosening and extrusion is possible. If more than 10 days has elapsed, anesthesia is given and the tooth luxated slightly with a forceps. At approximately 2 weeks the endodontic treatment is initiated. The tooth is extruded to its original position in about 4 weeks and retained in its original position for 24 weeks. D Extrusion is complete and the tooth crown has been restored with resin. E At 2 weeks post trauma the endodontic treatment was initiated.

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