Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth

Resident: Jason Hencler
Date: 8/28/09
Article title: Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth
Author(s): Flores et al.
Journal: Dental Traumatology 2007; 23: 66-71

Major topic: Fractures and luxation to permanent teeth

Type of Article: Guidelines

Main Purpose: To present guidelines that useful for delivering the best care possible in cases of fractures and luxations to permanent teeth. These guidelines represent the current best evidence, based on literature and professional opinion.

General Recommendations: Radiographic exam should include 90° horizontal angle, occlusal, and lateral views. Pulp testing such as electric pulp or cold test. Initial tests may yield negative results so follow up controls are required for definitive diagnosis. Good patient oral hygiene for good healing.

Treatment guidelines for fracture of teeth and alveolar bone:
• Uncomplicated Crown Fracture: Pulp not exposed. May involve dentin and enamel or enamel alone. Take 3 radiographs to rule out displacement or fracture of root. Soft tissue radiograph for tooth fragments or foreign material. Options: if tooth fragment available, it can be bonded back to tooth. Cover exposed dentin with GI or definitive treatment of final restoration. Monitor status of pulp recommended. Follow-up times 6-8wk and 1 yr.
• Complicated Crown Fracture: Involves enamel, dentin, and pulp exposure. Take 3 radiographs to rule out displacement or fracture of root. Soft tissue radiograph for tooth fragments or foreign material. Determine stage of root development due to pulp exposure. In young patients, preserve pulp vitality with pulp capping or partial pulpotomy using CaOH or MTA. Monitor status of pulp recommended. In older patients, RCT can be initiated, although pulp capping and partial pulpotomy may also be selected. If much time has elapsed between accident and treatment and pulp becomes necrotic RCT is indicated. Extensive crown fractures may indicate EXT if prognosis of other options is highly questionable or suspect. Follow-up times 6-8wk and 1 yr.
• Crown-Root Fracture: Involves enamel, dentin, and root structure, and may or may not include pulp exposure. Monitor status of pulp recommended if pulp involved. Need at least two radiographs to detect fracture lines in the root. Treatment recommendations same as for complicated crown fracture (see above). In addition, stabilization of loose segments of tooth with bonding is suggested until a definitive treatment plan is determined. Follow-up times 6-8wk and 1 yr.
• Root Fracture: Coronal segment may be mobile, displaced, or both. Tooth most likely percussion sensitive. Monitor status of pulp recommended. Tooth discoloration may occur. Horizontal fractures best detected with 90° radiograph, usually the case with fractures in the cervical 1/3. With traumatic diagonal fractures commonly found in apical or middle 1/3 of the root, an occlusal radiographic view is best to demonstrate the fracture. Reposition a displaced coronal segment asap and check radiographically. Stabilize with flexible splint for 4 weeks. If root fracture is cervical, may require stabilization for up to 4 months. Monitor status of pulp recommended for up to 1 year. If pulp necrosis develops, RCT of the coronal tooth segment to the fracture line is indicated. Follow-up times 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Alveolar Bone Fracture: Involves alveolar bone. Segment mobility and occlusal changes are common findings. Fracture lines may be located at any level from marginal bone to root tip. Pano recommended. Reposition displaced segment and stabilize for 4 weeks. Follow-up times 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.

Treatment guidelines for luxation injuries:
• Concussion: Tooth sensitive to touch/percussion. Not displaced or mobile. No radiographic findings. No treatment indicated. Monitor status of pulp recommended for up to 1 year. Follow-up times 4wk, 6-8wk, 1yr.
• Subluxation: Tooth sensitive to touch/percussion and has increased mobility but not displaced. Bleeding from gingival crevice may be observed. Monitor pulpal status. Usually no radiographic findings. Flexible splint for up to 2 wks. Follow-up times 4wk, 6-8wk, 1yr.
• Extrusive Luxation: Tooth appears elongated and is very mobile. In mature teeth pulp revascularization sometime occurs. In immature teeth pulp revascularization usually occurs. Increase PDL space observed. Reposition tooth and stabilize with flexible splint for 2 wks. Monitor pulpal status. In immature developing teeth, revascularization can be confirmed by continued root formation and pulp canal obliteration. In fully formed teeth a lack of response to pulp testing is indicative of pulp necrosis. Follow-up times up to 2wk, 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Lateral Luxation: Displaced palatal, lingual, or labial direction. Tooth will be mobile and percussion gives a high metallic, ankylotic sound. In immature teeth pulp revascularization usually occurs. Increased or widened PDL space observed. Reposition tooth using forceps to disengage tooth from its bony lock into the original position and stabilize with a flexible splint for 4 wks. pulpal status. In immature developing teeth, revascularization can be confirmed by continued root formation and pulp canal obliteration. In fully formed teeth a lack of response to pulp testing is indicative of pulp necrosis. Follow-up times up to 2wk, 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Intrusive Luxation: Displaced axially into the alveolar bone. Tooth will be immobile and percussion gives a high metallic, ankylotic sound. In immature teeth pulp revascularization usually occurs. The PDL space may be absent. Teeth with incomplete root formation: allow spontaneous repositioning to occur. If no movement noted within 3 wks recommend rapid orthodontic extrusion. Teeth with complete root resorption: should be repositioned orthodontically or surgically asap. Pulp will likely become necrotic and require RCT using CaOH to retain the tooth. Follow-up times up to 2wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.

Follow-up procedures and outcomes: See tables

Assessment of article: Great article. These guidelines would be very useful in any clinical situation dealing with these types of trauma.
See www.iadt-dentaltrauma.org
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