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1. Fractures and Luxations of Permanent Teeth

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1. Fractures and Luxations of Permanent Teeth 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
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