Dental Traumatology 2012; 28: 2–12; doi: 10.1111/j.1600-9657.2011.01103.x International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth

Anthony J. DiAngelis*1, Jens O. Abstract – Traumatic dental injuries (TDIs) of permanent teeth occur frequently Andreasen*2 , Kurt A. Ebeleseder*3 , in children and young adults. Crown fractures and luxations are the most David J. Kenny*4 , Martin Trope*5 , commonly occurring of all dental injuries. Proper diagnosis, treatment planning Asgeir Sigurdsson*6 , Lars and followup are important for improving a favorable outcome. Guidelines 7 8 Andersson , Cecilia Bourguignon , should assist dentists and patients in decision making and for providing the best Marie Therese Flores9 , Morris care effectively and efficiently. The International Association of Dental Lamar Hicks10 , Antonio R. Lenzi11, Traumatology (IADT) has developed a consensus statement after a review of Barbro Malmgren12 , Alex J. the dental literature and group discussions. Experienced researchers and Moule13 , Yango Pohl14 , Mitsuhiro clinicians from various specialties were included in the group. In cases where Tsukiboshi15 the data did not appear conclusive, recommendations were based on the 1Department of Dentistry, Hennepin County consensus opinion of the IADT board members. The guidelines represent the Medical Center and University of Minnesota best current evidence based on literature search and professional opinion. The School of Dentistry, Minneapolis, MN, USA; primary goal of these guidelines is to delineate an approach for the immediate or 2Center of Rare Oral Diseases, Department of urgent care of TDIs. In this first article, the IADT Guidelines for management Oral and Maxillofacial Surgery, Copenhagen of fractures and luxations of permanent teeth will be presented. University Hospital, Rigshopitalet, Denmark; 3Department of Conservative Dentistry, Medical University Graz, Graz, Austria; 4Hospital for Sick Children and University of Toronto, Toronto, Canada; 5Department of Endodontics, School of Dentistry, University of Pennsylvania, Philadel- phia, PA, USA; 6Department of Endodontics, UNC School of Dentistry, Chapel Hill, NC, USA; 7Department of Surgical Sciences, Faculty of Dentistry, Health Sciences Center Kuwait University, Kuwait City, Kuwait; 8Private Practice, Paris, France; 9Pediatric Dentistry, Faculty of Dentistry, Universidad de Valparaiso, Valparaiso, Chile; 10Department of Endodontics, University of Maryland School of Dentistry, Baltimore, MD, USA; 11Private Practice, Rio de Janeiro, Brazil; 12Department of Clinical Sciences Intervention and Technology, Division of Pediatrics, Karolins- ka University Hospital, Stockholm, Sweden; 13Private Practice, University of Queensland, Brisbane, Australia; 14Department of Oral Surgery, University of Bonn, Bonn, Germany; 15Private Practice, Amagun, Aichi, Japan

Key words: consensus; fracture; luxation; review; trauma; tooth

Correspondence to: Anthony J DiAngelis, DMD, MPH, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415, USA Tel.: 612-873-6275 Fax: 612-904-4234 e-mail: [email protected] Accepted 7 December, 2011 *Members of the Task Group.

2 Ó 2012 John Wiley & Sons A/S IADT guidelines for the management of traumatic dental injuries 3

Traumatic dental injuries (TDIs) occur with great the comprehensive nor detailed information found in frequency in preschool, school-age children, and young textbooks, the scientific literature, and, most recently, the adults comprising 5% of all injuries for which people Dental Trauma Guide (DTG) that can be accessed on seek treatment (1, 2). A 12-year review of the literature http://www.dentaltraumaguide.org. Additionally, the reports that 25% of all school children experience dental DTG, also available on the IADT’s web page http:// trauma and 33% of adults have experienced trauma to www.iadt-dentaltrauma.org, provides a visual and ani- the permanent dentition, with the majority of injuries mated documentation of treatment procedures as well as occurring before age nineteen (3). Luxation injuries are estimations of prognosis for the various TDIs. the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported General recommendations/considerations for the permanent dentition (1, 4, 5) TDIs present a challenge to clinicians worldwide. Consequently, proper diagnosis, treatment planning and follow up are critical Clinical examination to assure a favorable outcome. Detailed description of protocols, methods, and docu- Guidelines, among other things, should assist dentists, mentation for clinical assessment of TDIs can be found other healthcare professionals, and patients in decision in current textbooks (1, 14, 15). making. Also, they should be credible, readily under- standable, and practical with the aim of delivering appropriate care as effectively and efficiently as possible. Radiographic examination The following guidelines by the International Associ- Several projections and angulations are routinely rec- ation of Dental Traumatology (IADT) represent an ommended, but the clinician should decide which radio- updated set of guidelines based on the original guidelines graphs are required for the individual. The following are published in 2007 (6–8). The update was accomplished suggested: by doing a review of the current dental literature using • Periapical radiograph with a 90° horizontal angle with EMBASE, MEDLINE, and PUBMED searches from central beam through the tooth in question. 1996 to 2011 as well as a search of the journal of Dental • Occlusal view. Traumatology from 2000 to 2011. Search words included • Periapical radiograph with lateral angulations from tooth fractures, root fractures, tooth luxation, lateral the mesial or distal aspect of the tooth in question. luxation and permanent teeth, intruded permanent teeth, Emerging imaging modalities such as cone-beam and luxated permanent teeth. computerized tomography (CBCT) provide enhanced The primary goal of these guidelines is to delineate an visualization of TDIs, particularly root fractures and approach for the immediate or urgent care of TDIs. It is lateral luxations, monitoring of healing, and complica- understood that subsequent treatment may require tions. Availability is limited, and its use not currently secondary and tertiary interventions involving specialist considered routine; however, specific information is consultations, services, and/or materials/methods not available in the scientific literature (16, 17). always available to the primary treating clinician. The IADT published its first set of guidelines in 2001 and updated them in 2007 (6–13). As with the previous Splinting type and duration guidelines, the working group included experienced Current evidence supports short-term, non-rigid splints investigators and clinicians from various dental specialties for splinting of luxated, avulsed, and root-fractured and general practice. This revision represents the best teeth. While neither the specific type of splint nor the evidence based on the available literature and expert duration of splinting for root-fractured and luxated teeth professional judgment. In cases where the data did not are significantly related to healing outcomes, it is appear conclusive, recommendations are based on the considered best practice to maintain the repositioned consensus opinion of the working group followed by tooth in correct position, provide patient comfort and review by the members of the IADT Board of Directors. It improved function (18, 19). is understood that guidelines are to be applied with evaluation of the specific clinical circumstances, clinicians’ Use of antibiotics judgment, and patients’ characteristics, including but not limited to compliance, finances, and understanding of the There is limited evidence for use of systemic antibiotics in immediate and long-term outcomes of treatment alterna- the management of luxation injuries and no evidence tives versus non-treatment. The IADT cannot and does that antibiotic coverage improves outcomes for root- not guarantee favorable outcomes from strict adherence fractured teeth. Antibiotic use remains at the discretion to the Guidelines, but believe that their application can of the clinician as TDI’s are often accompanied by soft maximize the chances of a favorable outcome. tissue and other associated injuries, which may require Guidelines undergo periodic updates. These 2012 other surgical intervention. In addition, the patient’s Guidelines in this journal will appear in three parts: medical status may warrant antibiotic coverage (19, 20). Part I: Fractures and luxations of permanent teeth Part II: Avulsion of permanent teeth Sensibility tests Part III: Injuries in the primary dentition Guidelines offer recommendations for diagnosis and Sensibility testing refers to tests (cold test and/or electric treatment of specific TDIs; however, they do not provide pulp test) attempting to determine the condition of the

Ó 2012 John Wiley & Sons A/S 4 Andreasen et al. pulp. At the time of injury, sensibility tests frequently canals of immature permanent teeth with necrotic give no response indicating a transient lack of pulpal pulps (25–30). Teeth frequently sustain a combination response. Therefore, at least two signs and symptoms are of several injuries. Studies have demonstrated that necessary to make the diagnosis of necrotic pulp. crown-fractured teeth with or without pulp exposure Regular follow up controls are required to make a and associated luxation injury experience a greater pulpal diagnosis. frequency of pulp necrosis (31). The mature permanent tooth that sustains a severe TDI after which pulp necrosis is anticipated is amenable to preventive Immature versus mature permanent teeth pulpectomy as root development is substantially com- Every effort should be made to preserve pulpal vitality pleted. in the immature permanent tooth to ensure continuous root development. The vast majority of TDIs occur in Pulp canal obliteration children and teenagers where loss of a tooth has lifetime consequences. The immature permanent tooth Pulp canal obliteration (PCO) occurs more frequently in has considerable capacity for healing after traumatic teeth with open apices which have suffered a severe pulp exposure, luxation injury, and root fractures. Pulp luxation injury. It usually indicates ongoing pulpal exposures secondary to TDIs are amenable to proven vitality. Extrusion, intrusion, and lateral luxation injuries conservative pulp therapies that maintain vital pulp have high rates of PCO (32, 33) Subluxated and crown- tissue and allow for continued root development (21– fractured teeth also may exhibit PCO, although with less 24). In addition, emerging therapies have demonstrated frequency (34). Additionally, PCO is a common occur- the ability to revascularize/regenerate vital tissue in rence following root fractures (35, 36).

Permanent teeth

Follow-up procedures for Favorable and unfavorable outcomes fractures of teeth include some, but not necessarily all, of the 1. Treatment guidelines for fractures of teeth and alveolar bone and alveolar bone1 following Radiographic Unfavorable Clinical findings findings Treatment Follow up Favorable outcome outcome

Infraction • An incomplete • No radiographic • In case of marked • No follow up is • Asymptomatic • Symptomatic fracture (crack) of abnormalities infractions, generally needed • Positive response • Negative response the enamel • Radiographs etching and for infraction to pulp testing to pulp testing without loss of recommended: sealing with resin injuries unless • Continuing root • Signs of apical tooth structure a periapical view. to prevent they are development in periodontitis • Not tender. If Additional discoloration of associated with a immature teeth • No continuing root tenderness is radiographs are the infraction luxation injury or development in observed evaluate, indicated if lines; otherwise, other fracture immature teeth the tooth for a other signs or no treatment is types • Endodontic possible luxation symptoms necessary therapy injury or a root are present appropriate for fracture stage of root development is indicated Enamel fracture • A complete fracture • Enamel loss is • If the tooth 6–8 weeks C++ • Asymptomatic • Symptomatic of the enamel visible fragment is 1 year C++ • Positive response • Negative response • Loss of enamel. No • Radiographs available, it can to pulp testing to pulp testing visible sign of recommended: be bonded to the • Continuing root • Signs of apical exposed dentin periapical, tooth development in periodontitis • Not tender. If occlusal, and • Contouring or immature teeth • No continuing root tenderness is eccentric restoration with • Continue to next development in observed, evaluate exposures. They composite resin evaluation immature teeth the tooth for a are recommended depending on the • Endodontic possible luxation or in order to rule extent and therapy root fracture injury out the possible location of the appropriate for • Normal mobility presence of a fracture stage of root • Sensibility pulp test root fracture or a development is usually positive luxation injury indicated • Radiograph of lip or cheek to search for tooth fragments or foreign materials

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(Continued)

Follow-up procedures for Favorable and unfavorable outcomes fractures of teeth include some, but not necessarily all, of the 1. Treatment guidelines for fractures of teeth and alveolar bone and alveolar bone1 following Radiographic Favorable Unfavorable Clinical findings findings Treatment Follow up outcome outcome

Enamel–dentin • A fracture confined • Enamel–dentin • If a tooth fragment 6–8 weeks C++ • Asymptomatic • Symptomatic fracture to enamel and loss is visible is available, it can 1 year C++ • Positive response • Negative response dentin with loss of • Radiographs be bonded to the to pulp testing to pulp testing tooth structure, but recommended: tooth. Otherwise, • Continuing root • Signs of apical not exposing the periapical, perform a development in periodontitis pulp occlusal, and provisional immature teeth • No continuing root • Percussion test: eccentric treatment by • Continue to next development in not tender. If exposure to rule covering the exposed evaluation immature teeth tenderness is out tooth dentin with glass • Endodontic observed, evaluate displacement or Ionomer or a more therapy the tooth for possible presence permanent restoration appropriate for possible luxation of root fracture using a bonding agent stage of root or root fracture • Radiograph of lip and composite resin, development is injury or cheek or other accepted indicated • Normal mobility lacerations to dental restorative • Sensibility pulp test search for tooth materials usually positive fragments or • If the exposed dentin foreign materials is within 0.5 mm of the pulp (pink, no bleeding), place calcium hydroxide base and cover with a material such as a glass ionomer Enamel–dentin–pulp • A fracture involving • Enamel–dentin • In young patients 6–8 weeks C++ • Asymptomatic • Symptomatic fracture enamel and dentin loss visible with immature, still 1 year C++ • Positive response • Negative response with loss of tooth • Radiographs developing teeth, it to pulp testing to pulp testing structure and recommended: is advantageous to • Continuing root • Signs of apical exposure of the periapical, preserve pulp vitality development in periodontitis pulp. occlusal, and by pulp capping or immature teeth • No continuing root • Normal mobility eccentric partial pulpotomy. • Continue to next development in • Percussion test: exposures to Also, this treatment evaluation immature teeth not tender. If rule out tooth is the choice in young • Endodontic tenderness is displacement or patients with therapy observed, evaluate possible presence completely formed appropriate for for possible of root fracture teeth stage of root luxation or root • Radiograph of lip • Calcium hydroxide is a development is fracture injury or cheek suitable material to be indicated • Exposed pulp lacerations to placed on the pulp sensitive to stimuli search for tooth wound in such fragments or procedures foreign materials • In patients with mature apical development, root canal treatment is usually the treatment of choice, although pulp capping or partial pulpotomy also may be selected • If tooth fragment is available, it can be bonded to the tooth • Future treatment for the fractured crown may be restoration with other accepted dental restorative materials

Ó 2012 John Wiley & Sons A/S 6 Andreasen et al.

(Continued)

Follow-up procedures for Favorable and unfavorable outcomes fractures of teeth include some, but not necessarily all, of the 1. Treatment guidelines for fractures of teeth and alveolar bone and alveolar bone1 following Radiographic Favorable Unfavorable Clinical findings findings Treatment Follow up outcome outcome

Crown-root • A fracture • Apical extension Emergency treatment 6–8 weeks C++ • Asymptomatic • Symptomatic fracture involving enamel, of fracture • As an emergency 1 year C++ • Positive response • Negative without dentin, and usually not treatment, a temporary to pulp testing response to pulp pulp cementum with visible stabilization of the loose • Continuing root testing exposure loss of tooth • Radiographs segment to adjacent teeth development in • Signs of apical structure, but not recommended: can be performed until a immature teeth periodontitis exposing the pulp periapical, definitive treatment plan is • Continue to next • No continuing • Crown fracture occlusal, and made evaluation root development extending below eccentric Non-emergency treatment in immature teeth gingival margin exposures. alternatives • Endodontic • Percussion test: They are Fragment removal only therapy tender recommended • Removal of the coronal appropriate for • Coronal fragment to detect crown–root fragment and stage of root mobile fracture lines subsequent restoration of development is • Sensibility pulp in the root the apical fragment indicated test usually exposed above the positive for apical gingival level fragment Fragment removal and gingivectomy (sometimes ostectomy) • Removal of the coronal crown–root segment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy, and sometimes ostectomy with osteoplasty Orthodontic extrusion of apical fragment • Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown Surgical extrusion • Removal of the mobile fractured fragment with subsequent surgical repositioning of the root in a more coronal position Root submergence • Implant solution is planned Extraction • Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable in crown–root fractures with a severe apical extension, the extreme being a vertical fracture

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(Continued)

Follow-up procedures for fractures Favorable and unfavorable outcomes of teeth and include some, but not necessarily all, 1. Treatment guidelines for fractures of teeth and alveolar bone alveolar bone1 of the following Clinical Radiographic Favorable Unfavorable findings findings Treatment Follow up outcome outcome

Crown-root • A fracture • Apical Emergency treatment 6–8 weeks C++ • Asymptomatic • Symptomatic fracture involving extension • As an emergency treatment a 1 year C++ • Positive • Negative with pulp enamel, dentin, of fracture temporary stabilization of the response to response to exposure and cementum usually not loose segment to adjacent teeth pulp testing pulp testing and exposing visible • In patients with open apices, it • Continuing root • Signs of the • Radiographs is advantageous to preserve development apical pulp recommended: pulp vitality by a partial in immature periodontitis • Percussion periapical pulpotomy. This treatment is teeth • No continuing test: tender and occlusal also the choice in young • Continue to root development • Coronal exposure patients with completely formed next evaluation in immature teeth fragment teeth. Calcium hydroxide • Endodontic mobile compounds are suitable pulp therapy capping materials. In patients appropriate for with mature apical development, stage of root root canal treatment can be the development is treatment of choice indicated Non-Emergency Treatment Alternatives • Fragment removal and gingivectomy (sometimes ostectomy) Removal of the coronal fragment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy and sometimes ostectomy with osteoplasty. This treatment option is only indicated in crown-root fractures with palatal subgingival extension • Orthodontic extrusion of apical fragment Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown • Surgical extrusion Removal of the mobile fractured fragment with subsequent surgical repositioning of the root in a more coronal position • Root submergence An implant solution is planned, the root fragment may be left in situ • Extraction Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable in very deep crown-root fractures, the extreme being a vertical fracture

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(Continued) Follow-up procedures Favorable and unfavorable outcomes for luxated include some, but not necessarily all, 2. Treatment guidelines for luxation injuries permanent teeth of the following2

Radiographic Favorable Unfavorable Clinical findings findings Treatment Follow up outcome outcome

Root fracture • The coronal • The fracture • Reposition, if 4 weeks S+,C++ • Positive response • Symptomatic segment may be involves the root displaced, the coronal 6–8 weeks C++ to pulp testing • Negative mobile and may of the tooth and segment of the tooth 4 months S++,C++ (false negative response to pulp be displaced is in a horizontal as soon as possible 6 months C++ possible up to testing (false • The tooth may be or oblique plane • Check position 1 year C++ 3 months) negative possible tender to • Fractures that are radiographically 5 years C++ • Signs of repair up to 3 months) percussion in the horizontal • Stabilize the tooth between fractured • Extrusion of the • Bleeding from the plane can usually with a flexible splint segments coronal segment gingival sulcus be detected in the for 4 weeks. If the • Continue to next • Radiolucency at may be noted regular periapical root fracture is near evaluation the fracture line • Sensibility testing 90° angle film the cervical area of • Clinical signs of may give negative with the central the tooth, stabilization periodontitis or results initially, beam through the is beneficial for a abscess indicating tooth. This is longer period of time associated with transient or usually the case (up to 4 months) the fracture line permanent neural with fractures in • It is advisable to • Endodontic damage the cervical third monitor healing for at therapy • Monitoring the of the root least 1 year to appropriate for status of the pulp • If the plane of determine pulpal stage of root is recommended fracture is more status development is • Transient crown oblique, which is • If pulp necrosis indicated discoloration (red common with develops, root canal or gray) may apical third treatment of the occur fractures, an coronal tooth occlusal view or segment to the radiographs with fracture line is varying horizontal indicated to preserve angles is more the tooth likely to demonstrate the fracture including those located in the middle third Alveolar fracture • The fracture • Fracture lines • Reposition any 4 weeks S+,C++ • Positive response • Symptomatic involves the may be located at displaced segment 6–8 weeks C++ to pulp testing • Negative alveolar bone and any level, from and then splint 4 months C++ (false negative response to pulp may extend to the marginal bone • Suture gingival 6 months C++ possible up to testing (false adjacent bone to the root apex laceration if present 1 year C++ 3 months) negative possible • Segment mobility • In addition to the • Stabilize the 5 years C++ • No signs of apical up to 3 months) and dislocation 3 angulations and segment for 4 weeks periodontitis • Signs of apical with several teeth occlusal film, • Continue to next periodontitis or moving together additional views evaluation external are common such as a inflammatory root findings panoramic resorption • An occlusal radiograph can be • Endodontic change because helpful in therapy of misalignment determining the appropriate for the fractured course and stage of root alveolar segment position of the development is is often noted fracture lines indicated • Sensibility testing may or may not be positive

Ó 2012 John Wiley & Sons A/S IADT guidelines for the management of traumatic dental injuries 9

(Continued) Follow-up procedures Favorable and unfavorable outcomes for luxated include some, but not necessarily all, 2. Treatment guidelines for luxation injuries permanent teeth of the following2

Radiographic Favorable Unfavorable Clinical findings findings Treatment Follow up outcome outcome

Concussion • The tooth is tender • No radiographic • No treatment is 4 weeks C++ • Asymptomatic • Symptomatic to touch or tapping; abnormalities needed 6–8 weeks C++ • Positive response • Negative response it has not been • Monitor pulpal 1 year C++ to pulp testing to pulp testing displaced and does condition for at • False negative • False negative not have increased least 1 year possible up to possible up to mobility 3 months 3 months • Sensibility tests are • Continuing root • No continuing root likely to give development in development in positive results immature teeth immature teeth, • Intact lamina dura signs of apical periodontitis • Endodontic therapy appropriate for stage of root development is indicated Subluxation • The tooth is tender • Radiographic • Normally no 2 weeks S+,C++ • Asymptomatic • Symptomatic to touch or tapping abnormalities are treatment is 4 weeks C++ • Positive response • Negative response and has increased usually not found needed; however, 6–8 weeks C++ to pulp testing to pulp testing mobility; it has not a flexible splint to 6 months C++ • False negative • False negative been displaced stabilize the tooth 1 year C++ possible up to possible up to • Bleeding from for patient 3 months 3 months gingival crevice comfort can be • Continuing root • External may be noted used for up to development in inflammatory • Sensibility testing 2 weeks immature teeth resorption may be negative • Intact lamina dura • No continuing root initially indicating development in transient pulpal immature teeth, damage signs of apical • Monitor pulpal periodontitis response until a • Endodontic therapy definitive pulpal appropriate for diagnosis can be stage of root made development is indicated Extrusive luxation • The tooth appears • Increased • Reposition the 2 weeks S+, C++ • Asymptomatic • Symptoms and elongated and is periodontal tooth by gently 4 weeks C++ • Clinical and radiographic sign excessively mobile ligament re-inserting It into 6–8 weeks C++ radiographic consistent with • Sensibility tests will space apically the tooth socket 6 months C++ signs of normal apical periodontitis likely give negative • Stabilize the tooth 1 year C++ or healed • Negative response results for 2 weeks using Yearly 5 years C++ periodontium to pulp testing a flexible splint • Positive response (false negative • In mature teeth to pulp testing possible up to where pulp (false negative 3 months) necrosis is possible up to • If breakdown of anticipated or if 3 months) marginal bone, several signs and • Marginal bone splint for an symptoms height additional indicate that the corresponds to 3–4 weeks pulp of mature or that seen • External immature teeth radiographically inflammatory root became necrotic, after resorption root canal repositioning • Endodontic therapy treatment is • Continuing root appropriate for indicated development in stage of root immature teeth development is indicated

Ó 2012 John Wiley & Sons A/S 10 Andreasen et al.

(Continued) Follow-up procedures Favorable and unfavorable outcomes for luxated include some, but not necessarily all, 2. Treatment guidelines for luxation injuries permanent teeth of the following2

Radiographic Favorable Unfavorable Clinical findings findings Treatment Follow up outcome outcome

Lateral Luxation • The tooth is • The widened • Reposition the tooth 2 weeks S+, • Asymptomatic • Symptoms and displaced, usually periodontal digitally or with C++ • Clinical and radiographic signs in a palatal/lingual ligament space forceps to disengage 4 weeks C++ radiographic consistent with or labial direction is best seen on it from its bony lock 6–8 weeks C++ signs of normal apical periodontitis • It will be eccentric or and gently 6 months C++ or healed • Negative response to immobile and occlusal reposition it into 1 year C++ periodontium pulp testing (false percussion exposures its original location Yearly for 5 • Positive response negative possible usually gives a • Stabilize the tooth years C++ to pulp testing up to 3 months) high, metallic for 4 weeks using a (false negative • If breakdown of (ankylotic) sound flexible splint possible up to marginal bone, splint • Fracture of the • Monitor the pulpal 3 months) for an additional alveolar process condition • Marginal bone 3–4 weeks present • If the pulp becomes height • External • Sensibility tests necrotic, root canal corresponds to inflammatory root will likely give treatment is indicated that seen resorption or negative results to prevent root radiographically replacement resorption resorption after • Endodontic therapy repositioning appropriate for • Continuing root stage of root development in development is immature teeth indicated Intrusive luxation • The tooth is • The periodontal Teeth with incomplete root 2 weeks S+, • Tooth in place • Tooth locked in displaced axially ligament space formation C++ or erupting place/ankylotic tone into the alveolar may be absent • Allow eruption without 4 weeks C++ • Intact lamina to percussion bone from all or part intervention 6–8 weeks C++ dura • Radiographic signs • It is immobile, of the root • If no movement within 6 months C++ • No signs of of apical and percussion • The cemento- few weeks, initiate 1 year C++ resorption periodontitis may give a high, enamel junction orthodontic repositioning Yearly for 5 • Continuing root • External metallic is located more • If tooth is intruded more years C++ development in inflammatory root (ankylotic) sound apically in the than 7 mm, reposition immature teeth resorption or • Sensibility tests intruded tooth surgically or orthodontically replacement will likely give than in adjacent Teeth with complete root resorption negative results non-injured teeth, formation • Endodontic therapy at times even • Allow eruption without appropriate for apical to the intervention if tooth stage of root marginal bone intruded less than 3 mm. development is level If no movement after 2–4 indicated weeks, reposition surgically or orthodontically before ankylosis can develop • If tooth is intruded beyond 7 mm, reposition surgically • The pulp will likely become necrotic in teeth with complete root formation. Root canal therapy using a temporary filling with calcium hydroxide is recommended and treatment should begin 2–3 weeks after surgery • Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with a flexible splint for 4–8 weeks

C++, clinical and radiographic examination; S+, splint removal; S++, splint removal in cervical third fractures. 1For crown-fractured teeth with concomitant luxation injury, use the luxation follow-up schedule. 2Whenever there is evidence of external inflammatory root resorption, root canal therapy should be initiated immediately, with the use of calcium hydroxide as an intra-canal medication.

Ó 2012 John Wiley & Sons A/S IADT guidelines for the management of traumatic dental injuries 11

management of traumatic dental injuries (part 3 of the series). Patient instructions Dent Traumatol 2001;17:97–102. Patient compliance with follow-up visits and home care 12. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann contributes to better healing following a TDI. Both JL, Oikarinen K et al. Guidelines for the evaluation and patients and parents of young patients should be management of traumatic dental injuries (part 4 of the series). Dent Traumatol 2001;17:145–8. advised regarding care of the injured tooth/teeth for 13. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann optimal healing, prevention of further injury by avoid- JL, Oikarinen K et al. Guidelines for the evaluation and ance of participation in contact sports, meticulous oral management of traumatic dental injuries (part 5 of the series). hygiene, and rinsing with an antibacterial such as Dent Traumatol 2001;17:193–8. chlorhexidine gluconate 0.1% alcohol free for 14. Andreasen JO, Bakland LK, Flores MT, Andreasen FM. 1–2 weeks. Traumatic dental injuries: a manual, 3rd edn. Chichester, West Sussex: Wiley-Blackwell; 2011. 15. Pinkham JR, Casamassino PS, Fields HW Jr, McTigue DJ, Additional resources Mowak A editors. Pediatric dentistry, 4th edn. St. Louis, MO: Elsevier Saunders; 2005. Besides the general recommendations mentioned earlier, 16. Cohenca M, Simon JH, Roges R, Morag Y, Malfax JM. clinicians are encouraged to access the DTG, the journal Clinical Indications for digital imaging in dento-alveolar Dental Traumatology, and other journals for informa- trauma. Part I: traumatic injuries. Dent Traumatol tion pertaining to treatment delay (37), intrusive 2007;23:95–104. luxations 38–47), root fractures (48–52), pulpal manage- 17. Cohenca N, Simon JH, Mathur A, Malfax JM. Clinical ment of fractured and luxated teeth (34, 53–64, splinting Indications for digital imaging in dento-alveolar trauma. Part (18, 39, 65–68), and antibiotics (69). 2: root resorption. Dent Traumatol 2007;23:105–13. 18. Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dent Traumatol 2008;241:2–10. Acknowledgements 19. Andreasen JO, Andreasen FM, Mejare´ I, Cvek M. Healing of IADT is grateful to the team of Dental Trauma Guide 400 intra-alveolar root fractures 2. Effect of treatment factors www.dentaltraumaguide.org for kindly providing such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol 2004;20:203–11. pictures to the article. 20. Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part II: prescrip- References tion of systemic antibiotics. Dent Traumatol 2009;25:158–64. 21. Cvek M. A clinical report on partial pulpotomy and capping 1. Andreasen JO, Andreasen FM, Andersson L. Textbook and with calcium hydroxide in permanent incisors with complicated color atlas of traumatic injuries to the teeth, 4th edn. Oxford, crown fractures. J Endod 1978;4:232–7. UK: Wiley-Blackwell; 2007. 22. Fuks AB, Bielak S, Chosak A. Clinical and radiographic 2. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non- assessment of direct pulp capping and pulpotomy in young oral injuries. Swed Dent J 1997;21:55–68. permanent teeth. Pediatr Dent 1982;4:240–4. 3. Glendor U. Epidemiology of traumatic dental injuries – a 23. Olsburgh S, Jacoby T, Krejei I. Crown fractures in the 12 year review of the literature. Dent Traumatol 2008;24: permanent dentition: pulpal and restorative considerations. 603–11. Dent Traumatol 2002;18:103–15. 4. Flores MT. Traumatic injuries in the primary dentition. Dent 24. Witherspoon DE. Vital pulp therapy with new materials: new Traumatol 2002;18:287–98. directions and treatment perspectives – permanent teeth. 5. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic Pediatr Dent 2008;30:220–4. dental injuries in Brazilian preschool children. Dent Traumatol 25. Huang GT. A paradigm shift in endodontic management of 2003;19:299–303. immature teeth: conservation of stem cells for regeneration. 6. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malm- J Dent 2008;36:379–86. Epub 16 April 2008. gren B, Barnett F et al. Guidelines for the management of 26. Chueh LH, Ho YC, Kuo TC, Lai WH, Chen YH, Chiang CP. traumatic dental injuries. 1. Fractures and luxations of perma- Regenerative endodontic treatment for necrotic immature nent teeth. Dent Traumatol 2007;23:66–71. permanent teeth. J Endod 2009;35:160–4. Epub 12 December 7. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malm- 2008. gren B, Barnett F et al. Guidelines for the management of 27. Bose R, Nummikoski P, Hargreaves K. A retrospective traumatic dental injuries. 11. Avulsion of permanent teeth. evaluation of radiographic outcomes in immature teeth with Dent Traumatol 2007;23:130–6. necrotic root canal systems treated with regenerative endodon- 8. Flores MT, Malmgren B, Andersson L, Andreasen JO, Bakland tic procedures. J Endod 2009;35:1343–9. Epub 15 August 2009. LK, Barnett F et al. Guidelines for the management of 28. Thibodeau B, Trope M. Pulp revascularization of a necrotic traumatic dental injuries. 111. Primary Teeth. Dent Traumatol infected immature permanent tooth: case report and review of 2007;23:196–202. the literature. Pediatr Dent 2007;29:47–50. 9. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann 29. Trope M. Treatment of the immature tooth with a non-vital JL, Oikarinen K et al. Guidelines for the evaluation and pulp and apical periodontitis. Dent Clin North Am management of traumatic dental injuries (part l of the series). 2010;54:313–24. Dent Traumatol 2001;17:1–4. 30. Jung IY, Lee SJ, Hargreaves KM. Biologically based treatment 10. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann of immature permanent teeth with pulpal necrosis: a case series. JL, Oikarinen K et al. Guidelines for the evaluation and J Endod 2008;34:876–87. Epub 16 May 2008. management of traumatic dental injuries (part 2 of the series). 31. Robertson A, Andreasen FM, Andreasen JO, Noren JG. Long- Dent Traumatol 2001;17:49–52. term prognosis of crown-fractured permanent incisors. The 11. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann effect of stage of root development and associated luxation JL, Oikarinen K et al. Guidelines for the evaluation and injuries. Int J Paediatr Dent 2000;103:191–9.

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32. Holcomb JB, Gregory WB Jr. Calcific metamorphosis of the 49. Cvek M, Andreasen JO, Borum MK. Healing of 208 intra- pulp; its incidence and treatment. Oral Surg Oral Med Oral alveolar root fractures in patients aged 7–17 years. Dent Pathol 1967;24:825–30. Traumatol 2001;17:53–62. 33. Neto JJ, Gondim JO, deCarvalho FM, Giro EM. Longitudinal 50. Welbury RR, Kinirons MJ, Day P, Humphreys K, Gregg TA. clinical and radiographic evaluations of severely intruded Outcomes for root-fractured permanent incisors; a retrospective permanent incisors in a pediatric population. Dent Traumatol study. Pediatr Dent 2002;24:98–102. 2009;25:510–24. 51. Cvek M, Meja´ re I, Andreasen JO. Healing and prognosis of 34. Robertson A. A retrospective evaluation of patients with teeth with intra-alveolar fractures involving the cervical part of uncomplicated crown fractures and luxation injuries. Endod the root. Dent Traumatol 2002;18:57–65. Dent Traumatol 1998;14:245–56. 52. Cvek M, Tsillingaridis G, Andreasen JO. Survival of 534 35. Amir FA, Gutmann JL, Witherspoon DE. Calcific metamor- incisors after intra-alveolar root fracture in 7–17 years. Dent phosis: a challenge in endodontic diagnosis and treatment. Traumatol 2008;24:379–87. Quintessence Int 2001;32:447–55. 53. Farsi N, Alamoudi N, Balto K, Al Muskagy A. Clinical 36. Andreasen FM, Andreasen JO, Bayer T. Prognosis of root assessment of mineral trioxide aggregate (MTA) as direct pulp fractured permanent incisors; prediction of healing modalities. capping in young permanent teeth. J Clin Pediatr Dent Endod Dent Traumatol 1989;5:11–22. 2006;31:72–6. 37. Andreasen JO, Andreasen FM, Skeie A, Hjo¨ rting-Hansen E, 54. Moule AJ, Moule CA. The endodontic management of Schwartz O. Effect of treatment delay upon pulp and peri- traumatized anterior teeth: a review. Aust Dent J 2007; odontal healing of traumatic dental injuries – a review article. 52(Suppl 1):S122–37. Dent Traumatol 2002;18:116–28. 55. Bakland LK. Revisiting traumatic pulpal exposure: materials, 38. Andreasen JO, Bakland LK, Andreasen FM. Traumatic management principles and techniques. Dent Clin N Am intrusion of permanent teeth. Part 3. A clinical study of the 2009;53:661–73. effect of treatment variables such as treatment delay, method of 56. Cavalleri G, Zerman N. Traumatic crown fractures in perma- repositioning, type of splint, length of splinting and antibiotics nent incisors with immature roots: a follow-up study. Endod on 140 teeth. Dent Traumatol 2006;22:99–111. Dent Traumatol 1995;11:294–6. 39. Kenny DJ, Barrett EJ, Casas MJ. Avulsions and Intrusions: the 57. Ferrazzini Pozzi EC, von Arx T. Pulp and periodontal healing controversial displacement injuries. J Can Dent Assoc of laterally luxated permanent teeth; results after 4 years. Dent 2003;69:308–13. Traumatol 2008;24:658–62. 40. Stewart C, Dawson M, Phillips J, Shafi I, Kinirons M, Welburg 58. Nikoui M, Kenny DJ, Barrett EJ. Clinical outcomes for R. A study of the management of 55 traumatically intruded permanent incisor luxation in a pediatric population. III. permanent incisor teeth in children. Eur Arch Paediatr Dent Lateral luxations. Dent Traumatol 2003;19:280–5. 2009;10:25–8. 59. Jackson NG, Waterhouse PJ, Maguire A. Factors affecting 41. Albadri S, Zaitoun H, Kinirons MJ. UK National Clinical treatment outcomes following complicated crown fractures Guidelines in Paediatric Dentistry: treatment of traumatically managed in primary and secondary care. Dent Traumatol intruded permanent incisor teeth in children. Int. J Pediatr Dent 2006;22:179–85. 2010;20(Suppl 1):1–2. 60. About I, Murray PE, Franquin JC, Remusat M, Smith AJ. The 42. Andreasen JO, Bakland LK, Matras RC, Andreasen FM. effect of cavity restoration variables on odontoblast cell Traumatic intrusion of permanent teeth. Part 1. An epidermi- numbers and dental repair. J Dent 2001;29:109–17. ological study of 216 intruded permanent teeth. Dent Trauma- 61. Murray PE, Smith AJ, Windsor LJ, Mjor IA. Remaining tol 2006;22:83–9. dentine thickness and human pulp responses. Int Endod J 43. Andreasen JO, Bakland LK, Andreasen FM. Traumatic 2003;36:33–43. intrusion of permanent teeth. Part 2. A clinical study of the 62. Subay RK, Demirci M. Pulp tissue reactions to a dentin effect of preinjury and injury factors such as sex, age, stage of bonding agent as a direct capping agent. J Endod 2005;31:201– root development, tooth location and extent of injury including 4. number of intruded teeth on 140 intruded permanent teeth. 63. Bogen G, Kim JS, Bakland LK. Direct pulp capping with Dent Traumatol 2006;22:90–8. mineral trioxide aggregate: an observational study. J Am Dent 44. Wigen TI, Agnalt R, Jacobsen I. Intrusive luxation of perma- Assoc 2008;139:305–15. nent incisors in Norwegians aged 6–17 years: a retrospective 64. Cvek M, Meja´ re I, Andreasen JO. Conservative endodontic study of treatment and outcome. Dent Traumatol 2008;24:612– treatment in the middle or apical part of the root. Dent 8. Traumatol 2004;20:261–9. 45. Ebeleseder KA, Santler G, Glockner K, Huller H, Perfl C, 65. Hinckfuss S, Messer LB. Splinting duration and periodontal Quehenberger F. An analysis of 58 traumatically intruded and outcomes for replanted avulsed teeth, a systematic review. Dent surgically extruded permanent teeth. Dent Traumatol Traumatol 2009;25:150–7. 2000;16:34–9. 66. Oikarinen K. Tooth Splinting – a review of the literature and 46. Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes for consideration of the versatility of a wire-composite splint. permanent incisor luxations in a pediatric population. I. Endod Dent Traumatol 1990;6:237–50. Intrusions. Dent Traumatol 2003;19:266–73. 67. VonArx T, Fillipi A, Lussi A. Comparison of a new dental 47. Al Badri S, Kinirons M, Cole B, Welbury R. Factors affecting trauma splint device (TTS) with three commonly used splinting resorption in traumatically intruded permanent incisors in techniques. Dent Traumatol 2001;17:266–74. children. Dent Traumatol 2002;18:73–6. 68. Berthold C, Thaler A, Petschelt A. Rigidity of commonly used 48. Andreasen JO, Andreasen FM, Mejare´ I, Cvek M. Healing of dental trauma splints. Dent Traumatol 2009;25:248–55. 400 intra-alveolar root fractures. l. Effect of pre-injury and 69. Andreasen JO, Storgaard Jensen S, Sae-Lim V. The role of injury factors such as sex, age, stage of root development, antibiotics in presenting healing complications after traumatic fracture type, location of fracture and severity of dislocation. dental injuries: a literature review. Endod Topics 2006;14:80– Dent Traumatol 2004;20:192–202. 92.

Ó 2012 John Wiley & Sons A/S Dental Traumatology 2012; 28: 88–96; doi: 10.1111/j.1600-9657.2012.01125.x International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth

Lars Andersson*1, Jens O. Abstract – Avulsion of permanent teeth is one of the most serious dental Andreasen*2, Peter Day*3, Geoffrey injuries, and a prompt and correct emergency management is very important Heithersay*4, Martin Trope*5, for the prognosis. The International Association of Dental Traumatology Anthony J. DiAngelis6, David J. (IADT) has developed a consensus statement after a review of the dental Kenny7, Asgeir Sigurdsson8, literature and group discussions. Experienced researchers and clinicians from Cecilia Bourguignon9, Marie various specialties were included in the task group. The guidelines represent the Therese Flores10, Morris Lamar current best evidence and practice based on literature research and professionals’ Hicks11, Antonio R. Lenzi12, Barbro opinion. In cases where the data did not appear conclusive, recommendations Malmgren13, Alex J. Moule14, were based on the consensus opinion or majority decision of the task group. Mitsuhiro Tsukiboshi15 Finally, the IADT board members were giving their opinion and approval. The 1Department of Surgical Sciences, Faculty of Dentistry, primary goal of these guidelines is to delineate an approach for the immediate or Health Sciences Center, Kuwait University, Kuwait City, urgent care of avulsed permanent teeth. Kuwait; 2Department of Oral and Maxillofacial Surgery, Center of Rare Oral Diseases, Copenhagen University Hospital, Rigshopitalet, Copenhagen, Denmark; 3Pae- driatic Dentistry, Leeds Dental Institute and Bradford District Care Trust Salaried Dental Service, Leeds, UK; 4Faculty of Health Sciences, School of Dentistry, Endodontology, The University of Adelaide, Adelaide, SA, Australia; 5Department of Endodontics, School of Dentistry, University of Pennsylvania, Philadelphia, PA; 6Department of Dentistry, Hennepin County Medical Center and University of Minnesota School of Dentistry, Minneapolis, MN, USA; 7Hospital for Sick Children and University of Toronto, Toronto, ON, Canada; 8Depart- ment of Endodontics, UNC School of Dentistry, Chapel Hill, NC, USA; 9Private Practice, Paris, France; 10Department of Pediatric Dentistry, Faculty of Den- tistry, Universidad de Valparaiso, Valparaiso, Chile; 11Department of Endodontics, University of Maryland School of Dentistry, Baltimore, MD, USA; 12Private Practice, Rio de Janeiro, Brazil; 13Division of Pediatrics, Department of Clinical Sciences Intervention and Technology, Karolinska University Hospital, Stockholm, Sweden; 14Private Practice, University of Queensland, Brisbane, Qld, Australia; 15Private Practice, Amagun, Aichi, Japan

Key words: avulsion; exarticulation; con- sensus; review; trauma; tooth

Correspondence to: Lars Andersson, DDS, PhD, DrOdont, Oral & Maxillofacial Surgery, Department of Surgical Sciences, Health Sciences Center, P.O. Box 24923, Safat 13110, Kuwait Tel.: +965 24986695 Fax: +965 24986732 e-mail: [email protected] Accepted 30 January, 2012

*Members of the Task Group.

88 Ó 2012 John Wiley & Sons A/S IADT guidelines for avulsed permanent teeth 89

Medline and Scopus databases using the search words: avulsion, exarticulation, and replantation. The task group has then discussed the emergency treatment in detail and reached consensus of what to recommend today as best practice for the emergency management. This text is aiming at giving the concise, short necessary advice for treatment in the emergency situation. More detailed description of protocols, methods, and docu- mentation for clinical assessment and diagnosis of Avulsion of permanent teeth is seen in 0.5–3% of all different dental injuries can be found in articles, dental injuries (1, 2). Numerous studies show that this textbooks, and manuals (2, 24) and in the interactive injury is one of the most serious dental injuries, and the web site Dental Trauma Guide http://dentaltrauma prognosis is very much dependent on the actions taken at guide.org. the place of accident and promptly after the avulsion The final decision regarding patient care remains (2–27). Replantation is in most situations the treatment primarily in the hand of the treating dentist. For ethical of choice, but cannot always be carried out immediately. reasons, it is important that the dentist provides the An appropriate emergency management and treatment patient and guardian with pertinent information relating plan are important for a good prognosis. There are also to treatment so also the patient and guardian has as much individual situations when replantation is not indicated influence in the decision-making process as possible. (e.g., severe caries or periodontal disease, non-cooperat- ing patient, severe medical conditions (e.g., immunosup- First aid for avulsed teeth at the place of accident (2, 10, pression and severe cardiac conditions) which must be 24, 25, 31–55) dealt with individually. Replantation may successfully save the tooth, but it is important to realize that some of Dentists should always be prepared to give appropriate the replanted teeth have lower chances of long-term advice to the public about first aid for avulsed teeth. survival and may even be lost or extracted at a later stage. An avulsed permanent tooth is one of the few real Guidelines for the emergency management are useful emergency situations in dentistry. In addition to for delivering the best care possible in an efficient increasing the public awareness by, for example, mass manner. The International Association of Dental Trau- media campaigns, healthcare professionals, guardians matology (IADT) has developed a consensus statement and teachers should receive information on how to after an update of the dental literature and discussions in proceed following these severe unexpected injuries. expert groups. Experienced international researchers and Also, instructions may be given by telephone to people clinicians from various specialties and general dentistry at the emergency site. Immediate replantation is the were included in the groups. In cases in which the data best treatment at the place of accident. If for some did not appear conclusive, recommendations were based reasons this cannot be carried out, there are alterna- on the consensus opinion and in some situations on tives such as using various storage media. majority decision among the IADT board members. All If a tooth is avulsed, make sure it is a permanent tooth recommendations are not evidence based on a high level. (primary teeth should not be replanted). The guidelines should therefore be seen as the current • Keep the patient calm. best evidence and practice based on literature research • Find the tooth and pick it up by the crown (the white and professionals’ opinion. part). Avoid touching the root. Guidelines should assist dentists, other healthcare • If the tooth is dirty, wash it briefly (max 10 s) under professionals, and patients in decision making. Also, cold running water and reposition it. Try to encourage they should be credible, readily understandable, and the patient/guardian to replant the tooth. Once the practical with the aim of delivering appropriate care as tooth is back in place, bite on a handkerchief to hold it effectively and efficiently as possible. in position. It is understood that guidelines are to be applied with • If this is not possible, or for other reasons when judgment of the specific clinical circumstances, clinicians’ replantation of the avulsed tooth is not possible (e.g., judgments, and patients’ characteristics, including, but an unconscious patient), place the tooth in a glass of not limited to compliance, finances and understanding of milk or another suitable storage medium and bring the immediate and long-term outcomes of treatment with the patient to the emergency clinic. The tooth alternatives vs non-treatment. The IADT cannot and can also be transported in the mouth, keeping it does not guarantee favorable outcomes from strict inside the lip or cheek if the patient is conscious. If adherence to the Guidelines, but believe that their the patient is very young, he/she could swallow the application can maximize the chances of a favorable tooth – therefore it is advisable to get the patient to outcome. Guidelines undergo periodic updates. The spit in a container and place the tooth in it. Avoid following guidelines by the IADT represent an updated storage in water! set of guidelines based on the original guidelines • If there is access at the place of accident to special published in 2007 (28–30). storage or transport media (e.g., tissue culture/trans- In this article, one of a series of three articles, the port medium, Hanks balanced storage medium (HBSS IADT Guidelines for management of avulsed permanent or saline) such media can preferably be used. teeth are presented. Literature has been searched using • Seek emergency dental treatment immediately.

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The poster ‘Save a Tooth’ is written for the public and • Initiate root canal treatment 7–10 days after replanta- is available in several languages: English, Spanish, tion and before splint removal. (see Endodontic consid- Portuguese, French, Icelandic, Italian, Arabic, and erations). Turkish and can be obtained at the IADT website: http://www.iadt-dentaltrauma.org. Follow-up See: Follow-up procedures. Treatment guidelines for avulsed permanent teeth (56–95) 1b. The tooth has been kept in a physiologic storage medium or osmolality balanced medium and/or stored dry, the Choice of treatment is related to the maturity of the extra-oral dry time has been less than 60 min root (open or closed apex) and the condition of the periodontal ligament cells. The condition of the cells is Physiologic storage media include tissue culture medium depending on the storage medium and the time out of and cell transport media. Examples of osmolality balanced the mouth, especially the dry time is critical for media are HBSS, saline, and milk. Saliva can also be used. survival of the cells. After a dry time of 60 min or • Clean the root surface and apical foramen with a more, all periodontal ligament (PDL) cells are non- stream of saline and soak the tooth in saline thereby viable. For this reason, the dry time of the tooth, removing contamination and dead cells from the root before it was placed replanted or placed in a storage surface. medium, is very important to assess from the patient’s • Administer local anesthesia. history. • Irrigate the socket with saline. From a clinical point of view, it is important for the • Examine the alveolar socket. If there is a fracture of the clinician to roughly assess the condition of the cells by socket wall, reposition it with a suitable instrument. classifying the avulsed tooth into one of the following • Replant the tooth slowly with slight digital pressure. three groups before starting treatment: Do not use force. • The PDL cells are most likely viable (i.e., the tooth has • Suture gingival lacerations, if present. been replanted immediately or after a very short time • Verify normal position of the replanted tooth both at the place of accident). clinically and radiographically. • The PDL cells may be viable but compromised. The • Apply a flexible splint for up to 2 weeks, keep away tooth has been kept in storage medium (e.g., tissue from the gingiva. culture medium, HBSS, saline, milk, or saliva and the • Administer systemic antibiotics (see Antibiotics). total dry time has been <60 min). • Check tetanus protection (see Tetanus). • The PDL cells are non-viable. Examples of this is when • Give patient instructions (see Patient instructions). the trauma history tells us that the total extra-oral dry • Initiate root canal treatment 7–10 days after replanta- time has been more than 60 min regardless of if the tion and before splint removal (see Endodontic con- tooth was stored in an additional medium or not, or if siderations). the storage medium was non-physiologic. Follow-up See: Follow-up procedures. 1. Treatment guidelines for avulsed permanent teeth with closed apex 1c. Dry time longer than 60 min or other reasons suggesting non-viable cells Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour However, the expected eventual outcome is ankylosis and resorption of the root and the tooth will be lost eventually. 1a. The tooth has been replanted before the patient’s arrival at The technique for delayed replantation is as follows: the clinic • Remove attached non-viable soft tissue carefully, for • Leave the tooth in place. example, with gauze. The best way to this has not yet • Clean the area with water spray, saline, or chlorhex- been decided (see Future areas of research). idine. • Root canal treatment to the tooth can be carried out • Suture gingival lacerations, if present. prior to replantation or later (see Endodontic consid- • Verify normal position of the replanted tooth both erations). clinically and radiographically. • In cases of delayed replantation, root canal treatment • Apply a flexible splint for up to 2 weeks (see Splinting). should be either carried out on the tooth prior to • Administer systemic antibiotics (see Antibiotics). replantation or it can be carried out 7–10 days later • Check tetanus protection (see Tetanus). like in other replantation situations (see Endodontic • Give patient instructions (see Patient instructions). considerations).

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Administer local anesthesia. • 2b. The tooth has been kept in a physiologic storage medium Irrigate the socket with saline. • or osmolality balanced medium and/or stored dry, the Examine the alveolar socket. If there is a fracture of the • extra-oral dry time has been <60 min socket wall, reposition it with a suitable instrument. • Replant the tooth. Physiologic storage media include tissue culture medium • Suture gingival lacerations, if present. and cell transport media. Examples of osmolality bal- • Verify normal position of the replanted tooth clinically anced media are HBSS, saline, and milk. Saliva can also and radiographically. be used. • Stabilize the tooth for 4 weeks using a flexible splint • If contaminated, clean the root surface and apical (see Splinting). foramen with a stream of saline. • Administration of systemic antibiotics (see Antibiot- • Topical application of antibiotics has been shown to ics). enhance chances for revascularization of the pulp and • Check tetanus protection (see Tetanus). can be considered if available (see Antibiotics). • Give patient instructions (see Patient instructions). • Administer local anesthesia. To slow down osseous replacement of the tooth, • Examine the alveolar socket. treatment of the root surface with fluoride prior to • If there is a fracture of the socket wall, reposition it replantation has been suggested (2% sodium fluoride with a suitable instrument. solution for 20 min) but it should not be seen as an • Remove the coagulum in the socket and replant the absolute recommendation. tooth slowly with slight digital pressure. • Suturegingivallacerations,especiallyinthecervicalarea. Follow-up • Verify normal position of the replanted tooth clinically See: Follow-up procedures. and radiographically. Apply a flexible splint for up to In children and adolescents ankylosis is frequently 2 weeks (see Splinting). associated with infra-position. Careful follow-up is • Administer systemic antibiotics (see Antibiotics). required and good communication is necessary to ensure • Check tetanus protection (see Tetanus). the patient and guardian of this likely outcome. Decor- • Give patient instructions (see Patient instructions). onation may be necessary later when infraposition • The goal for replanting still-developing (immature) (>1 mm) is seen. For more detailed information of this teeth in children is to allow for possible revasculariza- procedure, the reader is referred to textbooks. tion of the pulp space. The risk of infection-related root resorption should be weighed up against the chances of revascularization. Such resorption is very 2. Treatment guidelines for avulsed permanent teeth rapid in teeth of children. If revascularization does not with an open apex occur, root canal treatment may be recommended (see Endodontic considerations).

Follow-up See Follow-up procedures.

2c. Dry time longer than 60 min or other reasons suggesting non-viable cells Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to 2a. The tooth has been replanted before the patient’s arrival at heal. The goal in delayedreplantation isto restorethetooth the clinic to the dentition for esthetic, functional, and psychological • Leave the tooth in place. reasons and to maintain alveolar contour. The eventual • Clean the area with water spray, saline, or chlorhexidine. outcome will be ankylosis and resorption of the root. • Suture gingival lacerations, if present. The technique for delayed replantation is as follows: • Verify normal position of the replanted tooth both • Remove attached non-viable soft tissue carefully, for clinically and radiographically. example, with gauze. The best way to this has not yet • Apply a flexible splint for up to 2 weeks (see Splinting). been decided (see Future areas of research). • Administer systemic antibiotics (see Antibiotics). • Root canal treatment to the tooth can be carried out • Check tetanus protection (see Tetanus). prior to replantation or later (see Endodontic consid- • Give patient instructions (see Patient instructions). erations). • The goal for replanting still-developing (immature) • Administer local anesthesia. teeth in children is to allow for possible revasculariza- • Remove the coagulum from the socket with a stream of tion of the pulp space. If that does not occur, root saline. Examine the alveolar socket. If there is a canal treatment may be recommended (see Endodontic fracture of the socket wall, reposition it with a suitable considerations). instrument. • Replant the tooth slowly with slight digital pressure. Follow-up Suture gingival laceration. Verify normal position of See: Follow-up procedures. the replanted tooth clinically and radiographically.

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• Stabilize the tooth for 4 weeks using a flexible splint age and weight the first week, can be given as alternative (see Splinting). to tetracycline. • Administer systemic antibiotics (see Antibiotics). Topical antibiotics (minocycline or doxycycline, 1 mg • Check tetanus protection (see Tetanus). per 20 ml of saline for 5 min soak) appear experimen- • Give patient instructions (see Patient instructions). tally to have a beneficial effect in increasing the chance of To slow down osseous replacement of the tooth, pulpal space revascularization and periodontal healing treatment of the root surface with fluoride prior to and may be considered in immature teeth (2b). replantation (2% sodium fluoride solution for 20 min) has been suggested but it should not be seen as an Tetanus (2, 24, 25) absolute recommendation. Refer the patient to a physician for evaluation of need Follow-up for a tetanus booster if the avulsed tooth has contacted See Follow-up procedures. soil or tetanus coverage is uncertain. Ankylosis is unavoidable after delayed replantation and must be taken into consideration. Splinting of replanted teeth (77–83) In children and adolescents ankylosis is frequently associated with infraposition. Careful follow-up is It is considered best practice to maintain the repositioned required and good communication is necessary to ensure tooth in correct position, provide patient comfort and the patient and guardian of this likely outcome. Decor- improve function. Current evidence supports short-term, onation may be necessary when infraposition (>1 mm) flexible splints for splinting of replanted teeth. Studies is seen. For more detailed information of this procedure have shown that periodontal and pulpal healing is the reader is referred to textbooks. promoted if the replanted tooth is given a chance for slight motion and the splinting time is not too long. Given this there is so far no specific type of splint related Anesthetics (64–66) to healing outcomes. The splint should be placed on the Patients and guardians are recommended by us to do buccal surfaces of the maxillary teeth to enable lingual replantation at the place of accident without anesthesia. access for endodontic procedures and to avoid occlusal In the clinic, however, where local anesthetics are interference. available, there is no need to omit local anesthesia, Replanted permanent teeth should be splinted up to especially as there are often concomitant injuries. Con- 2 weeks. Various types of acid etch bonded splints have cern is sometimes raised whether there are risks of been widely used to stabilize avulsed teeth because they compromising healing by using vasoconstrictor in the allow good oral hygiene and are well tolerated by the anesthesia. Evidence is weak for omitting vasoconstrictor patients. For a detailed description of how to make a in the oral and maxillofacial region and must be further splint, the reader is referred to articles, textbooks, documented before any recommendations against the use manuals, and the web site Dental Trauma Guide of it can be given (see suggested future areas of research http://www.dentaltraumaguide.org. at the end of this article). Block anesthesia (e.g., infra- orbital nerve block) may be considered as an alternative Patient instructions (2, 24, 25) to infiltration anesthesia in more severely injured areas and must be related to the clinicians’ experience of such Patient compliance with follow-up visits and home care blocking techniques. contributes to satisfactory healing following an injury. Both patients and guardians of young patients should be advised regarding care of the replanted tooth for Antibiotics (67–76) optimal healing and prevention of further injury. The value of systemic administration of antibiotics in • Avoid participation in contact sports. human after replantation is still questionable as clinical • Soft diet for up to 2 weeks. Thereafter normal function studies have not demonstrated its value. Experimental as soon as possible. studies have, however, usually shown positive effects • Brush teeth with a soft toothbrush after each meal. upon both periodontal and pulpal healing especially • Use a chlorhexidine (0.1%) mouth rinse twice a day for when administered topically. For this reason, antibiot- 1 week. ics are in most situations recommended after replanta- tion of teeth. In addition, the patient’s medical status Endodontic considerations (62, 84–93) or concomitant injuries may warrant antibiotic cover- age. If root canal treatment is indicated (teeth with closed For systemic administration, tetracycline is the first apex), the ideal time to begin treatment is 7–10 days choice in appropriate dose for patient age and weight the postreplantation. Calcium hydroxide is recommended first week after replantation. The risk of discoloration of as an intra-canal medication for up to 1 month permanent teeth must be considered before systemic followed by root canal filling with an acceptable administration of tetracycline in young patients. In many material. Alternatively if an antibiotic-corticosteroid countries, tetracycline is not recommended for patients paste is chosen to be used as an anti-inflammatory, under 12 years of age. A penicillin phenoxymethylpen- anti-clastic intra-canal medicament, it may be placed icillin (Pen V) or amoxycillin, in an appropriate dose for immediately or shortly following replantation and left

Ó 2012 John Wiley & Sons A/S IADT guidelines for avulsed permanent teeth 93 for at least 2 weeks. If the antibiotic in the paste is patient, infraposition of the tooth is highly likely to occur dechlortetracycline, there is a risk of tooth discoloration leading to disturbance of alveolar and facial growth over and care should be taken to confine the paste to the the short-, medium-, and long term. root canal and avoid contact of the paste with the pulp chamber walls. Loss of tooth If the tooth has been dry for more than 60 min before In cases where teeth are lost in the emergency phase or replantation. The root canal treatment may be carried will be lost later after trauma, discussions with col- out extra-orally prior to replantation. leagues, where available, who have expertise with man- In teeth with open apexes, which have been replanted aging such cases is prudent especially in growing immediately or kept in appropriate storage media prior patients. Ideally these discussions should take place to replantation, pulp revascularization is possible. The before the tooth shows signs of infraposition. Appropri- risk of infection-related root resorption should be ate treatment options may include decoronation, auto- weighed up against the chances of obtaining pulp space transplantation, resin retained bridge, denture, revascularization. Such resorption is very rapid in teeth orthodontic space closure with composite modification of children. For very immature teeth, root canal treat- and sectional osteotomy. Such treatment decisions are ment should be avoided unless there is clinical or based on a full discussion with the child and parents, radiographic evidence of pulp necrosis. clinician’s expertise and aim to keep all options open until maturity is reached. After growth is completed, implant treatment can also be considered. The clinician is Follow-up procedures (2, 6–9, 24, 25) referred to textbooks and articles for further readings regarding these procedures. Clinical control Replanted teeth should be monitored by clinical and Future areas of research – methods discussed but not radiographic control after 4 weeks, 3 months, 6 months, included as recommendations in the guidelines this time 1 year, and yearly thereafter. Clinical and radiographic examination will provide information to determine A number of promising treatment procedures for avulsed outcome. Evaluation may include the findings described teeth have been discussed in the consensus group. Some as follows. of these treatment suggestions do have certain experi- mental evidence, and some of them are even used today in clinical practice: according to the group members, Favorable outcome there is currently insufficient weight or quality of clinical Closed apex and/or experimental evidence for some of these methods Asymptomatic, normal mobility, normal percussion to be recognized as recommendations in the guidelines sound. No radiographic evidence of resorption or perira- this time. These and some other important fields are dicular osteitis: the lamina dura should appear normal. examples where the group advocates further research and documentation: Open apex • Methods for removal of non-viable PDL. Asymptomatic, normal mobility, normal percussion • Conditioning the PDL with extra-oral storage in tissue sound. Radiographic evidence of arrested or continued culture media prior to replantation. root formation and eruption. Pulp canal obliteration is • Conditioning the PDL with enamel matrix protein to be expected. prior to replantation for teeth with short extra-oral periods. • Topical treatment of root surface with fluoride for Unfavorable outcome teeth with long extra-oral period. Closed apex • Revascularization of pulp space and methods promot- Symptomatic, excessive mobility or no mobility (anky- ing this. losis) with high-pitched percussion sound. Radiographic • Optimal splint types with regard to periodontal and evidence of resorption (inflammatory, infection-related pulpal healing. resorption, or ankylosis-related replacement resorption). • Effect on adrenaline content of local anesthesia on When ankylosis occurs in a growing patient, infraposi- healing. tion of the tooth is highly likely leading to disturbance in • Reducing the inflammation with corticosteroids. alveolar and facial growth over the short-, medium-, and • Extra-oral root filling of teeth with less than a 60 min long term. drying period. • Use of titanium posts for root elongation and as Open apex alternatives to conventional root canal treatment. Symptomatic, excessive mobility or no mobility (ankylo- • Long-term development of alveolar crest following sis) with high-pitched percussion sound. In the case of replantation and decoronation. ankylosis, the crown of the tooth will appear to be in an infraposition. Radiographic evidence of resorption Acknowledgement (inflammatory, infection-related resorption, or ankylo- sis-related replacement resorption) or absence of contin- The authors wish to express their gratefulness to the ued root formation. When ankylosis occurs in a growing Dental Trauma Guide team in Copenhagen, Denmark

Ó 2012 John Wiley & Sons A/S 94 Andersson et al. http://www.dentaltraumaguide.org for permission to use 20. Kargul B, Welbury R. An audit of the time to initial treatment their illustrations for this article. in avulsion injuries. Dent Traumatol 2009;25:123–5. 21. Day P, Duggal M. Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted. References Cochrane Database Syst Rev 2010;20:CD006542. Review. 22. Petrovic B, Markovic´ D, Peric T, Blagojevic D. Factors related 1. Glendor U, Halling A, Andersson L, Eilert-Peterson E. to treatment and outcomes of avulsed teeth. Dent Traumatol Incidence of traumatic tooth injuries in children and adoles- 2010;26:52–9. cents in the county of Vastmanland, Sweden. Swed Dent J ¨ 23. Werder P, von Arx T, Chappuis V. Treatment outcome of 42 1996;20:15–28. replanted permanent incisors with a median follow-up of 2. Andreasen JO, Andreasen FM. Avulsions. In: Andreasen JO, 2.8 years. 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Endod Dent Traumatol 1989;5:38–47. 27. Andreasen JO. Periodontal healing after replantation of trau- 5. Andersson L, Bodin I. Avulsed human teeth replanted within matically avulsed human teeth. Assessment by mobility testing 15 minutes – a long-term clinical follow-up study. Endod Dent and radiography. Acta Odontol Scand 1975;33:325–35. Traumatol 1990;6:37–42. 28. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malm- 6. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. gren B, Barnett F et al. Guidelines for the management of Replantation of 400 avulsed permanent incisors. 1. Diagnosis of traumatic dental injuries.1. Fractures and Luxations of perma- healing complications. Endod Dent Traumatol 1995;11:51–8. nent teeth. Dent Traumatol 2007;23:66–71. 7. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. 29. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malm- Replantation of 400 avulsed permanent incisors. 2. Factors gren B, Barnett F et al. 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Knowledge of first aid avulsed permanent teeth. I. Endodontic considerations. Dental measures of avulsion and replantation of teeth. An interview Traumatol 2005;21:80–92. study of 221 Kuwaiti schoolchildren. Dent Traumatol 17. Pohl Y, Filippi A, Kirschner H. Results after replantation of 2006;22:57–65. avulsed permanent teeth. II. Periodontal healing and the role of 39. Al-Sane M, Bourisly N, Almulla T, Andersson L. Laypeoples’ physiologic storage and antiresorptive-regenerative therapy. preferred sources of health information on the emergency Dent Traumatol 2005;21:93–101. management of tooth avulsion. Dent Traumatol 2011;27:432– 18. Pohl Y, Wahl G, Filippi A, Kirschner H. Results after 7. replantation of avulsed permanent teeth. III. Tooth loss and 40. Lieger O, Graf C, El-Maaytah M, Von Arx T. Impact of survival analysis. Dental Traumatol 2005;21:102–10. educational posters on the lay knowledge of school teachers 19. Tzigkounakis V, Merglova´ V, Hecova´ H, Netolicky´ J. 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41. McIntyre JD, Lee JY, Trope M, Vann WF Jr. Effectiveness of Robinson bristle brush with pumice or scalpel blade. Histo- dental traumaducation for elementary school staff. Dent morphometric analysis and scanning electron microscopy. Dent Traumatol 2008;24:146–50. Traumatol 2007;23:333–9. 42. Feldens EG, Feldens CA, Kramer PF, da Silva KG, Munari 62. Lindskog S, Blomlo¨ f L, Hammarstro¨ m L. Cellular colonization CC, Brei VA. Understanding school teacher’s knowledge of denuded root surfaces in vivo: cell morphology in dentin regarding dental trauma: a basis for future interventions. Dent resorption and cementum repair. J Clin Periodontol Traumatol 2010;26:158–63. 1987;14:390–5. 43. Levin L, Jeffet U, Zadik Y. The effect of short dental trauma 63. Panzarini SR, Gulinelli JL, Poi WR, Sonoda CK, Pedrini D, lecture on knowledge of high-risk population: an intervention Brandini DA. Treatment of root surface in delayed tooth study of 336 young adults. 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Dent Dental Traumatol 2003;19:90–5. Traumatol 2008;24:422–9. 69. Chen H, Teixeira FB, Ritter AL, Levin L, Trope M. The effect 50. de Souza BD, Bortoluzzi EA, da Silveira Teixeira C, Felippe of intracanal anti-inflammatory medicaments on external root WT, Simo˜ es CM, Felippe MC. Effect of HBSS storage time on resorption of replanted dog teeth after extended extra-oral dry human periodontal ligament fibroblast viability. Dent Trauma- time. Dent Traumatol 2008;24:74–8. tol 2010;26:481–3. 70. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti 51. Hammarstrom L, Pierce A, Blomlof L, Feiglin B, Lindskog S. P. Effect of topical application of doxycycline on pulp Tooth avulsion and replantation: a review. Endod Dent revascularization and periodontal healing in reimplanted mon- Traumatol 1986;2:1–9. key incisors. Endod Dent Traumatol 1990;6:170–6. 52. Andersson L, Blomlo¨ f L, Lindskog S, Feiglin B, Hammarstro¨ m 71. Hammarstro¨ m L, Blomlo¨ f L, Feiglin B, Andersson L, Lindskog L. 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Ó 2012 John Wiley & Sons A/S Dental Traumatology 2012; 28: 174–182; doi: 10.1111/j.1600-9657.2012.01146.x International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition

Barbro Malmgren1,*, Jens O. Abstract – Traumatic injuries to the primary dentition present special pro- Andreasen2,*, Marie Therese Flores3,*, blems and the management is often different as compared with the perma- Agneta Robertson4,*, Anthony J. nent dentition. The International Association of Dental Traumatology DiAngelis5,*, Lars Andersson6 , (IADT) has developed a consensus statement after a review of the dental Giacomo Cavalleri7, Nestor literature and group discussions. Experienced researchers and clinicians Cohenca8, Peter Day9 , Morris Lamar from various specialities were included in the task group. In cases where Hicks10 , Olle Malmgren11, Alex J. the data did not appear conclusive, recommendations were based on the Moule12, Juan Onetto13, Mitsuhiro consensus opinion or majority decision of the task group. Finally, the Tsukiboshi14 IADT board members were giving their opinion and approval. The pri- 1Division of Pediatric Dentistry, Department of mary goal of these guidelines is to delineate an approach for the immediate Dental Medicine, Karolinska Institutet, Huddinge, Sweden; 2Department of Oral and or urgent care for management of primary teeth injuries. The IADT can- Maxillofacial Surgery, Center of Rare Oral not and does not guarantee favorable outcomes from strict adherence to Diseases, Copenhagen University Hospital, the guidelines, but believe that their application can maximize the chances Rigshospitalet, Copenhagen, Denmark; 3Department of Pediatric Dentistry, Faculty of of a positive outcome. Dentistry, Universidad de Valparaiso, Valparaiso, Chile; 4Department of Pedodontics, Institute of Odontology, Gothenburg University, Gothenburg, Sweden; 5Department of Dentistry, Hennepin County Medical Center and University of Minnesota School of Dentistry, Minneapolis, MN, USA; 6Department of Surgical Sciences, Faculty of Dentistry, Health Sciences Center, Kuwait University, Kuwait City, Kuwait; 7Department of Dentistry, University of Verona, Verona, Italy; 8Department of Endodontics, University of Washington, Seattle, WA, USA; 9Pediatric Dentistry, Leeds Dental Institute and Bradford District Care Trust Salaried Dental Service, Leeds, UK; 10Department of Endodontics, University of Maryland School of Dentistry, Baltimore, MD, USA; 11Orthodontic Clinic, Folktandva˚rden, Uppsala, Sweden; 12Private Practice, University of Queensland, Brisbane, QLD, Australia; 13Department of Pediatric Dentistry, Faculty of Dentistry, Universidad de Valparaiso, Valparaiso, Chile; 14Private Practice, Amagun, Aichi, Japan

Key words: tooth; trauma; primary; luxation; fracture; review

Correspondence to: Barbro Malmgren, DDS, PhD, DrMed, Karolinska Institutet, Department of Dental Medicine, Division of Pediatric Dentistry, POB 4064, SE-14104 Huddinge, Sweden Tel.: +46 739851788 Fax: +46 8 7743395 e-mail: [email protected] Accepted 26 March, 2012 *Members of the Task Group.

174 © 2012 John Wiley & Sons A/S IADT guidelines for injuries in the primary dentition 175

Trauma to the oral region occurs frequently and periodic updates. These 2012 Guidelines in the journal comprises 5% of all injuries for which people seek treat- Dental Traumatology appear in three parts. ment (1–3). In preschool children, head and facial non- Part I: Fractures and luxations of permanent teeth (Dent oral injuries make up as much as 40% of all somatic Traumatol 2012;28:issue 1) injuries (1–3). In the age group 0–6 years, oral injuries Part II: Avulsion of permanent teeth (Dent Traumatol are ranked as the second most common injury covering 2012;28:issue 2) 18% of all somatic injuries (1–3). Of the oral injuries, Part III: Injuries in the primary dentition (Dent dental injuries are the most frequent, followed by oral Traumatol 2012;28:issue 3) soft-tissue injuries. Luxation injuries affecting both mul- Guidelines offer recommendations for diagnosis and tiple teeth and surrounding soft tissues are mainly treatment of specific traumatic dental injuries (TDIs); reported in children 1–3 years of age and are typically however, they cannot provide comprehensive nor as a result of falls (2, 4–11). Emergency situations there- detailed information found in textbooks, scientific litera- fore present a challenge to clinicians worldwide. It is ture, and most recently the dental trauma guide (DTG). now recognized that child injuries are a major threat to The latter can be accessed on http://www.dentaltrau- child health and that they are a neglected public health maguide.org. Additionally, the DTG is also available problem (12). A healthcare professional′s decision on on the IADT web page (http://www.iadt-dentaltrauma. how to treat combined with parental consent and org) and provides a visual and animated documenta- patient assent (13) is the preferred scenario encountered tion of treatment procedures as well as estimates of when facing pediatric emergencies (14). prognosis for the various TDIs. Guidelines for the management of primary teeth Because the management of permanent and primary injuries should assist dentists, other healthcare profes- traumatized dentitions differs significantly, separate sionals, and parents or carers in decision making. They guidelines have been developed (Tables 1 and 2). should be credible, readily understandable, and practi- cal with the aim of delivering the best care possible in Special considerations for trauma to primary teeth an efficient manner. The International Association of Dental Traumatol- A young child is often difficult to examine and treat ogy (IADT) has developed an updated set of guidelines because of the lack of cooperation and because of fear. based on a review of the current dental literature utiliz- The situation is distressing for both the child and ing EMBASE, MEDLINE, and PubMed searches from parents or carers (17). 1996 to 2011 as well as a search of the Journal of Den- Furthermore, there are varying conditions in differ- tal Traumatology from 2000 to 2011. Search words ent countries concerning economic and social aspects included primary dentition, deciduous dentition, crown as well as treatment philosophies (7, 17, 18). How- fracture, primary incisor fracture, tooth fractures, root ever, child and family-centered pediatric practices and fractures, tooth luxation, lateral luxation and primary institutions should consider the best interests of chil- teeth, intruded primary teeth, luxated primary teeth, dren and prepare clinicians to ensure the fulfillment tooth avulsion, and tooth/crown injuries. Additionally, of children′s rights when treatment decisions are some relevant articles prior to 1996, which have served made (19). as the basis for further research in the field of dental It is important to keep in mind that there is a close traumatology, as well as recent policy statements relationship between the apex of the root of the injured regarding holistic care and management of the injured primary tooth and the underlying permanent tooth child, were also included. germ. Tooth malformation, impacted teeth, and erup- The IADT published its first set of guidelines in tion disturbances in the developing permanent 2001 (15) and updated them in 2007 (16). As with the dentition are some of the consequences that can occur previous guidelines, the working group included experi- following severe injuries to primary teeth and/or alveo- enced researchers and clinicians in pediatric dentistry lar bone (5, 20–23). White or yellow-brown discolor- and oral and maxillofacial surgery. This revision repre- ation of crown and hypoplasia of permanent incisors sents the best evidence from the available literature and are, however, the most common sequelae following expert professional judgement. In cases where the data intrusion and avulsion of primary teeth in children dur- did not appear conclusive, recommendations were ing the ages of 1–3 years (21–27). Because of these based on the consensus opinion of the working group potential sequelae, treatment selections should be followed by review by the members of the IADT Board aimed at minimizing any additional risks of further of Directors. It is understood that guidelines are to be damage to the permanent successors. It is therefore not applied with judgement of the specific clinical circum- recommended, for instance, to replant an avulsed stances, clinicians′ prudence, and patients’ characteris- primary incisor (16, 28, 29). tics, including but not limited to compliance, finances A child′s maturity and ability to cope with the emer- and understanding of the immediate and long-term gency situation, the time for shedding of the injured outcomes of treatment alternatives versus non-treat- tooth, and the occlusion, are all important factors that ment. The IADT cannot and does not guarantee favor- influence treatment selection. able outcomes from strict adherence to the Guidelines, Repeated trauma episodes are frequent in children. but believe that their application can maximize the It should be taken into consideration if planning chances of a positive outcome. Guidelines undergo root canal treatment in an injured primary tooth

© 2012 John Wiley & Sons A/S 176 Malmgren et al.

Table 1. Treatment guidelines for fractures of teeth and alveolar bone Follow-up Favorable and Unfavorable outcomes include procedures some, but not necessarily all, of the following for fractures Radiographic of teeth and Favorable Unfavorable Clinical findings findings Treatment alveolar bone Outcome Outcome Enamel fracture ● Fracture ● No ● Smooth involves radiographic sharp enamel abnormalities edges

Enamel dentin fracture ● Fracture ● No If possible, 3–4 involves radiographic seal completely weeks C enamel abnormalities. the involved and dentin; The relation dentin with glass the pulp is between the ionomer to not fracture and prevent exposed the pulp microleakage. chamber will In case of be disclosed large lost tooth structure, the tooth can be restored with composite Crown fracture with exposed pulp ● Fracture ● The stage of ● If possible, 1 week C ● Continuing root ● Signs of apical involves root preserve pulp 6–8 weeks development in periodontitis; enamel development vitality by C+R immature teeth no continuing and dentin, can be partial 1 year C+R and a hard root and the determined pulpotomy. tissue barrier development pulp is from Calcium in immature exposed one exposure hydroxide is a teeth suitable material Extraction or for such root canal procedures. treatment A well-condensed layer of pure calcium hydroxide paste can be applied over the pulp, covered with a lining such as reinforced glass ionomer. Restore the tooth with composite ● The treatment is depending on the child′s maturity and ability to cope. Extraction is usually the alternative option Crown–root fracture

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Table 1. Continued Follow-up Favorable and Unfavorable outcomes include procedures some, but not necessarily all, of the following for fractures Radiographic of teeth and Favorable Unfavorable Clinical findings findings Treatment alveolar bone Outcome Outcome

● Fracture ● In laterally Depending on In cases of ● Asymptomatic; ● Symptomatic; involves enamel, positioned the clinical fragment, continuing signs of apical dentin, and fractures, the findings, two removal only: root periodontitis; root structure; extent in treatment 1 week C development in no continuing the pulp may relation to scenarios may 6–8 weeks immature teeth root development or may not the gingival be considered: C+R in immature be exposed margin can be ● Fragment 1 year C(*) teeth ● Additional seen removal findings may One exposure only if the include loose, is necessary fracture but still to disclose involves only attached, multiple a small part fragments of fragments of the root the tooth and the stable ● There is fragment is minimal to large enough moderate to allow tooth coronal displacement restoration ● Extraction in all other instances Root fracture ● The coronal ● The fracture is ● If the coronal ● No ● Signs of repair None fragment may usually located fragment is not displacement: between fractured be mobile mid-root or in displaced, no 1 week C, segments and may be the apical third treatment is ● 6–8 weeks ● Continuous displaced required C, resorption of the left ● If the coronal ● 1 year C+R apical fragment fragment is and C(*) displaced, each repositioning and subsequent splinting might be year until considered exfoliation Otherwise extract ● Extraction only that fragment. 1 year C+R The apical fragment and C(*) should be left to be each resorbed subsequent year until exfoliation Alveolar fracture ● The fracture ● The horizontal ● Reposition any 1 week C ● Normal ● Signs of apical involves the fracture line to displaced segment 3–4 weeks S+C occlusion periodontitis or alveolar bone the apices of the and then splint +R ● No signs external and may extend primary teeth ● General anesthesia 6–8 weeks C of apical inflammatory root to adjacent bone and their is often indicated +R periodontitis resorption of ● Segment permanent ● Stabilize the 1 year C+R ● No signs of primary teeth mobility and successors will segment for and C(*) each disturbances in the ● Signs of dislocation are be disclosed 4 weeks subsequent year permanent disturbances in the common ● A lateral ● Monitor until exfoliation successors permanent findings radiograph may teeth in successors require ● Occlusal also give fracture line follow up until full interference information about eruption is often the relation noted between the two dentitions and if the segment is displaced in labial direction

C, Clinical examination; R, Radiographic examination; S, Splint removal; (C*), Clinical and radiographic monitoring until eruption of the permanent successor.

© 2012 John Wiley & Sons A/S 178 Malmgren et al. because trauma recurrence will shorten the survival 3 Extra-oral lateral view of the tooth in question may time for the primary tooth (30). reveal the relationship between the apex of the dis- There is no consensus in the literature about best placed tooth and the permanent tooth germ as well treatment for the traumatized primary dentition. Fur- as the direction of dislocation (size 2 film, vertical thermore, children with dental injuries are not always view), but is seldom indicated as it rarely adds extra brought in for treatment immediately, which may be information. due the to lack of access to dental care (31, 32). While some reports advocate routine tooth extraction, others stress the importance of a more conservative approach Splinting by saving primary teeth whenever possible (29, 33). Splinting is used only for alveolar bone fractures and Traumatic pulp exposures of primary incisors are rare possibly for intra-alveolar root fractures. but can be treated with partial pulpotomy (34). Pulpec- tomy with zinc oxide eugenol or calcium hydroxide/ iodoform paste is recommended in some countries Use of antibiotics (30,35,36). However, if full cooperation of the child can There is no evidence for the use of systemic antibiotics not be achieved, extraction is usually the alternative in the management of luxation injuries in the primary option. dentition. Antibiotic use remains at the discretion of It has been demonstrated that most luxation inju- the clinician as TDIs are often accompanied by soft tis- ries heal spontaneously (37, 38), avoiding the trau- sue and other associated injuries that may require sig- matic experience of a tooth extraction. The clinician′s nificant surgical intervention. In addition, the child′s skills and experience with pediatric patients is of out- medical status may warrant antibiotic coverage. When- most importance for managing the patient′s and the ever possible, contact the pediatrician who may give parents′ or carers′ behavior in the emergency situa- recommendations for a specific medical condition. tion (17). After an accurate diagnosis and explana- tion of various treatment options to the parents or carers, the clinician and parents or carers must Sensibility and percussion tests decide the treatment planning for the child′s own Sensibility and percussion tests are not reliable in benefit. primary teeth because of the inconsistent results.

Guidelines for the clinician Crown discoloration These Guidelines contain recommendations for diagno- Although these Guidelines recommendations focus sis and treatment of traumatic injuries in the primary on the management of acute dental injuries, crown dentition, for caries-free, healthy primary teeth, using discoloration may be considered as it is a frequently proper examination procedures. asked question by the parents or carers, mainly for esthetic reasons. Discoloration is a common com- Clinical examination plication after luxation injuries (47–50). Such discol- Information about the examination of traumatic inju- oration may fade, and the tooth may regain its ries in the primary dentition can be found in a number original shade (8, 47, 50, 51). Teeth with persisting of current textbooks (4, 39). The possibility of child dark discoloration may remain asymptomatic clini- abuse should be considered when assessing children cally and radiographically or they may develop api- under the age of 5 years who present with intra-oral cal periodontitis (52, 53). There is an association trauma affecting the lips, gums, tongue, palate, and between crown discoloration and pulp necrosis in severe tooth injuries (40–46). traumatized primary teeth (48, 54). Unless associated infection exists, root canal treatment is not indicated (55). Radiographic examination A detailed radiographic examination is essential to Pulp canal obliteration establish the extent of the injury to the supporting tis- sues, the stage of root development, and the relation to Pulp canal obliteration is common sequela to luxation the permanent successors. Depending on the child’s injuries. It has been found to occur in 35–50% (48, 50, ability to cope with the procedure and the type of 53) and indicates ongoing pulp vitality (48, 56). injury suspected, the clinician should decide which A yellowish hue can be noted. radiograph is required for confirming diagnosis. Always consider minimizing the risk of radiation to the Parents’ instructions child. Several angles are recommended. Select the appropriate radiographic examination: Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. To opti- 1 90° horizontal angle with central beam through the mize healing, parents and carers should be advised tooth in question (size 2 film, horizontal view) regarding care of the injured tooth/teeth and the pre- 2 Occlusal view (size 2 film, horizontal view) vention of further injury by supervising potentially

© 2012 John Wiley & Sons A/S IADT guidelines for injuries in the primary dentition 179

Table 2. Treatment guidelines for luxation injuries Favorable and Unfavorable outcomes include some, but not necessarily all, of the following Radiographic Favorable Unfavorable Clinical findings findings Treatments Follow up Outcome Outcome Concussion ● The tooth is No radiographic ● No treatment is 1 week C ● Continuing root ● No continuing tender to abnormalities. needed. Observation 6–8 weeks C development in root touch. It has Normal periodontal immature teeth development in normal space immature teeth mobility and ● Dark no sulcular discoloration of bleeding crown. No treatment is needed unless apical periodontitis develops Subluxation ● The tooth has Radiographic ● No treatment is 1 week C ● Continuing root ● No continuing increased abnormalities are needed. Observation. 6–8 weeks C development in root mobility but usually not found Brushing with a soft Crown immature teeth development in has not been Normal periodontal brush and use of discoloration ● Transient red/ immature teeth displaced space alcohol-free 0.12% might occur. No gray ● Dark ● Bleeding from An occlusal chlorhexidine treatment is discoloration discoloration of gingival exposure is topically on the needed unless a A yellow crown crevice may be recommended to affected area with fistula develops discoloration No treatment is noted screen for possible cotton swabs twice a Dark discolored indicates pulp needed unless signs of day for 1 week teeth should be obliteration and apical displacement or the followed has a good periodontitis presence of a root carefully to prognosis develops fracture. The detect sign of radiograph can infection as furthermore be soon as used as a reference possible point in case of future complications Extrusive luxation ● Partial Increased ● Treatment decisions 1 week C ● Continuing root ● No continuing displacement periodontal are based on the 6–8 weeks C development in root of the tooth ligament space degree of +R immature teeth development in out of its apically displacement, 6 months C+R ● Transient red/ immature teeth socket mobility, root 1 year C+R gray ● Dark ● The tooth formation, and the Discoloration discoloration discoloration of appears ability of the child to might occur A yellow crown elongated and cope with the Dark discolored discoloration No treatment is can be emergency situation teeth should be indicates pulp needed unless excessively ● For minor extrusion followed obliteration and apical mobile (<3 mm) in an carefully to has a periodontitis immature developing detect sign of good prognosis develops tooth, careful infection as repositioning or soon as leaving the tooth for possible spontaneous alignment can be treatment options Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth

© 2012 John Wiley & Sons A/S 180 Malmgren et al.

Table 2. Continued Favorable and Unfavorable outcomes include some, but not necessarily all, of the following Radiographic Favorable Unfavorable Clinical findings findings Treatments Follow up Outcome Outcome Lateral luxation ● The tooth is Increased ● If there is no 1 week C ● Asymptomatic ● No continuing displaced, periodontal ligament occlusal interference, 2–3 weeks C ● Clinical and root usually in a space apically is as is often the case 6–8 weeks C radiographic development in palatal/lingual, best seen on the in anterior open bite, +R signs of normal immature teeth or labial occlusal exposure. the tooth is allowed 1 year C+R or healed ● Dark direction And an occlusal to reposition periodontium discoloration of ● It will be exposure can spontaneously ● Transient crown immobile sometimes also ● In case of minor discoloration No treatment is show the position occlusal interference, might occur needed unless of the displaced slight grinding is apical tooth and its indicated periodontitis relation to the ● When there is more develops permanent severe occlusal successor interference, the tooth can be gently repositioned by combined labial and palatal pressure after the use of local anesthesia ● In severe displacement, when the crown is dislocated in a labial direction, extraction is the treatment of choice Intrusive luxation ● The tooth is When the apex is If the apex is displaced 1 week C ● Tooth in place ● Tooth locked usually displaced toward or toward or through the 3–4 weeks or erupting in place displaced through the labial labial bone plate, the C + R ● No or ● Persistent through the bone plate, the tooth is left for 6–8 weeks C transient discoloration labial bone apical tip can be spontaneous 6 months C+R discoloration ● Radiographic plate, visualized and the repositioning ● 1 year C+R signs of apical or can be tooth appears If the apex is and (C*) periodontitis impinging upon shorter than its displaced into the ● Damage to the the contra lateral developing tooth permanent succedaneous When the apex is germ, extract successor tooth bud displaced toward the permanent tooth germ, the apical tip cannot be visualized and the tooth appears elongated

Avulsion The tooth is A radiographic It is not 1 week C Damage to the completely out of examination is recommended 6 months permanent the socket essential to ensure to replant C + R successor that the missing avulsed primary 1 year C + R tooth is not teeth and (C*) intruded

C, Clinical examination; R, Radiographic examination; (C*), Clinical and radiographic monitoring until eruption of the permanent successor.

© 2012 John Wiley & Sons A/S IADT guidelines for injuries in the primary dentition 181 hazardous activities. Brushing with a soft brush and p. 145–55. http://whqlibdoc.who.int/publications/2008/ use of alcohol-free 0.1% chlorhexidine gluconate topi- 9789241563574_eng.pdf (accessed 6 November 2011). cally on the affected area with cotton swabs twice a 13. Harding AM. Pharmacologic considerations in pediatric day for 1 week are recommended to prevent accumula- dentistry. Dent Clin North Am 1994;38:733–53. 14. American Academy of Pediatrics. Policy statement- Consent tion of plaque and debris. A soft diet for 10 days and for emergency medical services for children and adolescents. restriction in the use of an intra-oral pacifier are also Pediatrics 2011;128:427–33. recommended. 15. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann Parents or carers should be further advised about JL, Oikarinen K et al.Guidelines for the evaluation and man- possible complications that may occur, like swelling, agement of traumatic dental injuries. Dent Traumatol increased mobility, or sinus tracts. Children may not 2001;17:1–4. complain about pain; however, infection may be pres- 16. Flores MT, Malmgren B, Andersson L, Andreasen JO, ent, and parents or carers should watch for signs such Bakland LK, Barnett F et al.Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent Trauma- as swelling of the gums; if present they should bring tol 2007;23:196–202. the children in for treatment. 17. Needleman HL. The art and science of managing traumatic Documentation that the parents and carers have injuries to primary teeth. Dent Traumatol 2011;27:295–9. been informed about possible complications in the 18. 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