International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations
Abstract
Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations of these teeth are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning, and follow up are important for achieving a favorable outcome. Guidelines should assist dentists and patients in decision making and in providing the best care possible, both effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed these Guidelines as a consensus statement after a comprehensive review of the dental literature and working group discussions. Experienced researchers and clinicians from various specialties and the general dentistry community were included in the working group. In cases where the published data did not appear conclusive, recommendations were based on the consensus opinions of the working group. They were then reviewed and approved by the members of the IADT Board of Directors. These Guidelines represent the best current evidence based on literature search and expert opinion. The primary goal of these Guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines cover the management of fractures and luxations of permanent teeth. The IADT does not, and cannot, guarantee favorable outcomes from adherence to the Guidelines. However, the IADT believes that their application can maximize the probability of favorable outcomes.
1 INTRODUCTION
The vast majority of traumatic dental injuries (TDI) occur in children and teenagers where loss of a tooth has lifetime consequences. Treatments for these younger age groups may be different than in adults, mainly due to immature teeth and pubertal facial growth. The purpose of these Guidelines is to improve management of injured teeth and minimize complications resulting from trauma.
2 CLINICAL EXAMINATION
Trauma involving the dento-alveolar region is a frequent occurrence which can result in the fracture and displacement of teeth, crushing, and/or fracturing of bone, and soft tissue injuries including contusions, abrasions, and lacerations. Available current literature provides protocols, methods, and documentation for the clinical assessment of traumatic dental injuries (TDI), trauma first aid, patient examination, factors that affect treatment planning decisions, and the importance of communicating treatment options and prognosis to traumatized patients.1-3
The combination of two different types of injuries occurring concurrently to the same tooth will be more detrimental than a single injury, creating a negative synergistic effect. Concurrent crown fractures significantly increase the risk of pulp necrosis and infection in teeth with concussion or subluxation injuries and mature root development.4 Similarly, crown fractures with or without pulp exposure significantly increase the risk of pulp necrosis and infection in teeth with lateral luxation.5, 6
Kenny et al7 have developed a core outcome set (COS) for TDIs in children and adults. Outcomes were identified as recurring throughout the different injury types. These outcomes were then identified as “generic” or “Injury-specific.” Generic outcomes are relevant to all TDIs while “Injury-specific outcomes” are related to only one or more specific TDIs. Additionally, the core outcome set also established what, how, when, and by whom these outcomes should be measured (Tables 1-13).
| Enamel infraction | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
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An incomplete fracture (crack or crazing) of the enamel, without loss of tooth structure |
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| Uncomplicated crown fracture (enamel-only fracture) | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
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A coronal fracture involving enamel only, with loss of tooth structure |
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Clinical and radiographic evaluations are necessary:
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| Uncomplicated crown fracture (enamel-dentin fracture) | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
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A fracture confined to enamel and dentin without pulp exposure |
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Clinical and radiographic evaluations are necessary:
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- a For crown-fractured teeth with concomitant luxation injury, use the luxation follow-up schedule.
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Complicated crown fracture (enamel-dentin fracture with pulp exposure) |
Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
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A fracture confined to enamel and dentin with pulp exposure |
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Clinical and radiographic evaluations are necessary:
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| Uncomplicated crown-root fracture (crown-root fracture without pulp exposure) | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
|---|---|---|---|---|---|---|
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A fracture involving enamel, dentin and cementum (Note: Crown-root fractures typically extend below the gingival margin) |
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Future Treatment Options:
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Clinical and radiographic evaluations are necessary:
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| Complicated crown-root fracture (crown-root fracture with pulp exposure) | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
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A fracture involving enamel, dentin, cementum and the pulp (Note: Crown-root fractures typically extend below the gingival margin) |
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Future Treatment Options:
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Clinical and radiographic evaluations are necessary:
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| Root fracture | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcomes | Unfavorable outcomes |
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A fracture of the root involving dentin, pulp and cementum. The fracture may be horizontal, oblique or a combination of both. |
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Clinical and radiographic evaluations are necessary:
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Note
- S+ = splint removal (for mid-root and apical third fractures); S++ = splint removal (for cervical third fractures).
| Alveolar fracture | Clinical Findings | Imaging, radiographic assessment, and findings | Treatment | Follow Up | Favorable outcomes | Unfavorable outcomes |
|---|---|---|---|---|---|---|
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The fracture involves the alveolar bone and may extend to adjacent bones. |
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Clinical and radiographic evaluations are necessary:
Bone and soft tissue healing must also be monitored |
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Note
- S+ = splint removal.
| Concussion | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcome | Unfavorable outcome |
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Clinical and radiographic evaluations are necessary:
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| Subluxation | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable Outcome | Unfavorable outcome |
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An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth |
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Clinical and radiographic evaluations are necessary:
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Note
- S+ = splint removal.
| Extrusive luxation | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcome | Unfavorable outcome |
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Displacement of the tooth out of its socket in an incisal/axial direction |
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Clinical and radiographic evaluations are necessary:
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Note
- S+ = splint removal.
| Lateral luxation | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable Outcome | Unfavorable outcome |
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Displacement of the tooth in any lateral direction, usually associated with a fracture or compression of the alveolar socket wall or facial cortical bone |
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Clinical and radiographic evaluations are necessary:
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Note
- S+ = splint removal.
| Intrusive luxation | Clinical findings | Imaging, radiographic assessment, and findings | Treatment | Follow up | Favorable outcome | Unfavorable |
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Displacement of the tooth in an apical direction into the alveolar bone |
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Teeth with incomplete root formation (immature teeth):
Teeth with complete root formation (mature teeth):
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Clinical and radiographic evaluations are necessary:
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Note
- S+ = splint removal.
3 RADIOGRAPHIC EXAMINATION
Several conventional two-dimensional imaging projections and angulations are recommended.2, 8, 9 The clinician should evaluate each case and determine which radiographs are required for the specific case involved. A clear justification for taking a radiograph is essential. There needs to be a strong likelihood that a radiograph will provide the information that will positively influence the selection of the treatment provided. Furthermore, initial radiographs are important as they provide a baseline for future comparisons at follow-up examinations. The use of film holders is highly recommended to allow standardization and reproducible radiographs.
- One parallel periapical radiograph aimed through the midline to show the two maxillary central incisors.
- One parallel periapical radiograph aimed at the maxillary right lateral incisors (should also show the right canine and central incisor).
- One parallel periapical radiograph aimed at the maxillary left lateral incisor (should also show the left canine and central incisor).
- One maxillary occlusal radiograph.
- At least one parallel periapical radiograph of the lower incisors centered on the two mandibular centrals. However, other radiographs may be indicated if there are obvious injuries of the mandibular teeth (eg, similar periapical radiographs as above for the maxillary teeth, mandibular occlusal radiograph).
The radiographs aimed at the maxillary lateral incisors provide different horizontal (mesial and distal) views of each incisor, as well as showing the canine teeth. The occlusal radiograph provides a different vertical view of the injured teeth and the surrounding tissues, which is particularly helpful in the detection of lateral luxations, root fractures, and alveolar bone fractures.2, 8, 9
The above radiographic series is provided as an example. If other teeth are injured, then the series can be modified to focus on the relevant tooth/teeth. Some minor injuries, such as enamel infractions, may not require all of these radiographs.
Radiographs are necessary to make a thorough diagnosis of dental injuries. Tooth root and bone fractures, for instance, may occur without any clinical signs or symptoms and are frequently undetected when only one radiographic view is used. Additionally, patients sometimes seek treatment several weeks after the trauma occurred when clinical signs of a more serious injury have subsided. Thus, dentists should use their clinical judgment and weigh the advantages and disadvantages of taking several radiographs.
Cone beam computerized tomography (CBCT) provides enhanced visualization of TDIs, particularly root fractures, crown/root fractures, and lateral luxations. CBCT helps to determine the location, extent, and direction of a fracture. In these specific injuries, 3D imaging can be useful and should be considered, if available.9-11 A guiding principle when considering exposing a patient to ionizing radiations (eg, either 2D or 3D radiographs) is whether the image is likely to change the management of the injury.
4 PHOTOGRAPHIC DOCUMENTATION
The use of clinical photographs is strongly recommended for the initial documentation of the injury and for follow-up examinations. Photographic documentation allows monitoring of soft tissue healing, assessment of tooth discoloration, the re-eruption of an intruded tooth, and the development of infra-positioning of an ankylosed tooth. In addition, photographs provide medico-legal documentation that could be used in litigation cases.
5 PULP STATUS EVALUATION: SENSIBILITY AND VITALITY TESTING
5.1 Sensibility tests
Sensibility testing refers to tests (cold test and electric pulp test) used to determine the condition of the pulp. It is important to understand that sensibility testing assesses neural activity and not vascular supply. Thus, this testing might be unreliable due to a transient lack of neural response or undifferentiation of A-delta nerve fibers in young teeth.12-14 The temporary loss of sensibility is a frequent finding during post-traumatic pulp healing, especially after luxation injuries.15 Thus, the lack of a response to pulp sensibility testing is not conclusive for pulp necrosis in traumatized teeth.16-19 Despite this limitation, pulp sensibility testing should be performed initially and at each follow-up appointment in order to determine if changes occur over time. It is generally accepted that pulp sensibility testing should be done as soon as practical to establish a baseline for future comparison testing and follow up. Initial testing is also a good predictor for the long-term prognosis of the pulp.12-15, 20
5.2 Vitality tests
The use of pulse oximetry, which measures actual blood flow rather than the neural response, has been shown to be a reliable non-invasive and accurate way of confirming the presence of a blood supply (vitality) in the pulp.14, 21 The current use of pulse oximetry is limited due to the lack of sensors specifically designed to fit dental dimensions and the lack of power to penetrate through hard dental tissues.
Laser and ultrasound Doppler flowmetry are promising technologies to monitor pulp vitality.
6 STABILIZATION/SPLINTING: TYPE AND DURATION
Current evidence supports short-term, passive, and flexible splints for splinting of luxated, avulsed, and root-fractured teeth. In the case of alveolar bone fractures, splinting of the teeth may be used for bone segment immobilization. When using wire-composite splints, physiological stabilization can be obtained with stainless steel wire up to 0.4 mm in diameter.22 Splinting is considered best practice in order to maintain the repositioned tooth in its correct position and to favor initial healing while providing comfort and controlled function.23-25 It is critically important to keep composite and bonding agents away from the gingiva and proximal areas to avoid plaque retention and secondary infection. This allows better healing of the marginal gingiva and bone. Splinting time (duration) will depend on the injury type. Please see the recommendations for each injury type (Tables 1-13).
7 USE OF ANTIBIOTICS
There is limited evidence for the use of systemic antibiotics in the emergency management of luxation injuries and no evidence that antibiotics improve the outcomes for root-fractured teeth. Antibiotic use remains at the discretion of the clinician as TDIs are often accompanied by soft tissue and other associated injuries, which may require other surgical intervention. In addition, the patient's medical status may warrant antibiotic coverage.26, 27
8 PATIENT INSTRUCTIONS
Patient compliance with follow-up visits and home care contribute to better healing following a TDI. Both patients and parents or guardians should be advised regarding care of the injured tooth/teeth and tissues for optimal healing, prevention of further injury by avoidance of participation in contact sports, meticulous oral hygiene, and rinsing with an antibacterial agent such as chlorhexidine gluconate 0.12%.
9 FOLLOW UPS AND DETECTION OF POST-TRAUMATIC COMPLICATIONS
Follow ups are mandatory after traumatic injuries. Each follow up should include questioning of the patient about any signs or symptoms, plus clinical and radiographic examinations and pulp sensibility testing. Photographic documentation is strongly recommended. The main post-traumatic complications are as follows: pulp necrosis and infection, pulp space obliteration, several types of root resorption, breakdown of marginal gingiva and bone. Early detection and management of complications improves prognosis.
10 STAGE OF ROOT DEVELOPMENT—IMMATURE (OPEN APEX) VS MATURE (CLOSED APEX) PERMANENT TEETH
Every effort should be made to preserve the pulp, in both mature and immature teeth. In immature permanent teeth, this is of utmost importance in order to allow continued root development and apex formation. The vast majority of TDIs occur in children and teenagers, where loss of a tooth has lifetime consequences. The pulp of an immature permanent tooth has considerable capacity for healing after a traumatic pulp exposure, luxation injury, or root fracture. Pulp exposures secondary to TDIs are amenable to conservative pulp therapies, such as pulp capping, partial pulpotomy, shallow or partial pulpotomy, and cervical pulpotomy, which aim to maintain the pulp and allow for continued root development.28-31 In addition, emerging therapies have demonstrated the ability to revascularize/revitalize teeth by attempting to create conditions allowing for tissue in-growth into the root canals of immature permanent teeth with necrotic pulps.32-37
11 COMBINED INJURIES
Teeth frequently sustain a combination of several injuries. Studies have demonstrated that crown-fractured teeth, with or without pulp exposure and with a concomitant luxation injury, experience a greater frequency of pulp necrosis and infection.38 Mature permanent teeth that sustain a severe TDI after which pulp necrosis and infection is anticipated are amenable to preventive endodontic treatment.
Since prognosis is worse in combined injuries, the more frequent follow-up regimen for luxation injuries prevails over the less frequent regime for fractures.
12 PULP CANAL OBLITERATION
Pulp canal obliteration (PCO) occurs more frequently in teeth with open apices which have suffered a severe luxation injury. It usually indicates the presence of viable tissue within the root canal. Extrusion, intrusion, and lateral luxation injuries have high rates of PCO.39, 40 Subluxated and crown-fractured teeth also may exhibit PCO, although with lower frequency.41 Additionally, PCO is a common occurrence following root fractures.42, 43
13 ENDODONTIC CONSIDERATIONS FOR LUXATED AND FRACTURED TEETH
13.1 Fully developed teeth (mature teeth with closed apex)
The pulp may survive after the trauma, but early endodontic treatment is typically advisable for fully developed teeth that have been intruded, severely extruded, or laterally luxated. Calcium hydroxide is recommended as an intra-canal medicament to be placed 1-2 weeks after trauma for up to 1 month followed by root canal filling.44 Alternately, a corticosteroid/antibiotic paste can be used as an anti-inflammatory and anti-resorptive intra-canal medicament to prevent external inflammatory (infection-related) resorption. If such a paste is used, it should be placed immediately (or as soon as possible) following repositioning of the tooth and then left in situ for at least 6 weeks.45-48 Medicaments should be carefully applied within the root canal system while avoiding contact with the access cavity walls due to possible discoloration of the crown.48
13.2 Incompletely developed teeth (immature teeth with open apex)
The pulp of fractured and luxated immature teeth may survive and heal, or there may be spontaneous pulp revascularization following luxation. Thus, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis or periapical infection on follow-up examinations. The risk of infection-related (inflammatory) root resorption should be weighed against the chances of obtaining pulp space revascularization. Such resorption is very rapid in children. Hence, regular follow ups are mandatory so root canal treatment can be commenced as soon as this type of resorption is detected (see below). Incompletely developed teeth that have been intruded and also have a crown fracture (combined traumatic injuries) are at higher risk of pulp necrosis and infection and, therefore, immediate or early root canal treatment might be considered in these cases. Other endodontic treatment of teeth with incompletely developed roots may involve apexification or pulp space revascularization/revitalization techniques.
13.3 Endodontic treatment for external inflammatory (infection-related) root resorption
Whenever there is evidence of infection-related (inflammatory) external resorption, root canal treatment should be initiated immediately. The canal should be medicated with calcium hydroxide.49 The calcium hydroxide should be placed for 3 weeks and replaced every 3 months until the radiolucencies of the resorptive lesions disappear. Final obturation of the root canal can be performed when bone repair is visible radiographically.
13.4 Dental dam field isolation during endodontic treatment
Endodontic treatment should always be undertaken under dental dam isolation. The dental dam retainer can be applied on one or more neighboring teeth to avoid further trauma to the injured tooth/teeth and to prevent the risk of fracturing an immature tooth. Dental floss or other stabilizing cords may also be used instead of metal retainers.
14 CORE OUTCOME SET
The International Association for Dental Traumatology (IADT) recently developed a core outcome set (COS) for traumatic dental injuries (TDIs) in children and adults.7 This is one of the first COS developed in dentistry and is underpinned by a systematic review of the outcomes used in the trauma literature and follows a robust consensus methodology. Some outcomes were identified as recurring throughout the different injury types. These outcomes were then identified as “generic” (ie, relevant to all TDIs). Injury-specific outcomes were also determined as those outcomes related only to one or more individual TDIs. Additionally, the study established what, how, when, and by whom these outcomes should be measured. Table 2 in the General Introduction section66 of the Guidelines shows the generic and injury-specific outcomes to be recorded at the follow-up review appointments recommended for the different traumatic injuries. Further information for each outcome is described in the original article.7
15 ADDITIONAL RESOURCES
Besides the general recommendations above, clinicians are encouraged to access the IADT’s official publication, the journal Dental Traumatology, the IADT website (www.iadt-dentaltrauma.org), the free ToothSOS app and the Dental Trauma Guide (www.dentaltraumaguide.org).
CONFLICT OF INTEREST
The authors declare there are no competing interests for the above manuscript. No funding was received for the presented work. Images Courtesy of the Dental Trauma Guide.
ETHICAL STATEMENT
No ethic approval was required for this paper.
