Dental Trauma

Guidelines

A cura di

Dott. Andrea Volpato

Indice

Permanent Teeth

Concussion

Subluxation

Extrusion

Lateral luxation

Intrusion

Avulsion

Closed Apex

Open apex

Infraction

Enamel fraction

Enamel-dentine fracture

Enamel-dentin-pulp fracture (Complicated crown fracture)

Crown-root fracture without pulp involvement

Crown-root fracture with pulp involvement

Root fracture

Alveolar fracture

Fracture of mandible or maxilla

Primary Teeth

Concussion

Subluxation

Extrusion

Lateral luxation

Intrusion

Avulsion

Enamel infraction

Enamel-dentin fracture

Enamel-dentin-pulp fracture (Complicated crown fracture)

Crown-root fracture without pulp involvement

Crown-root fracture with pulp involvement (Complicated crown-root fracture)

Root fracture

Alveolar fracture

References

Permanent Teeth

Concussion

Description

An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion.

Diagnosis

• Visual signs: Not displaced
• Percussion test: Tender to touch or tapping
• Mobility test: No increased mobility
• Pulp sensibility test: Usually a positive result. The test is important in assessing future risk of healing complications. A lack of response to the test indicates an increased risk of later pulp necrosis
• Radiographic findings: No radiographic abnormalities, the tooth is in-situ in its socket.
• Radiographs recommended: As a routine: Occlusal, periapical exposure and lateral view from mesial or distal aspect of the tooth in question. This should be done in order to exclude displacement

Treatment

• Treatment objectives: Usually there is no need for treatment
• Treatment: Monitor pulpal condition for at least 1 year
• Patient instructions

• Soft food for 1 week
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris

• Follow-up: Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year

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Subluxation

Description

An injury to the tooth supporting structures resulting in increased mobility, but without displacement of the tooth. Bleeding from the gingival sulcus confirms the diagnosis.

Diagnosis

Visual signs: Not displaced

Percussion test: Tender to touch or tapping

Mobility test: Increased mobility

Pulp sensibility test: Sensibility testing may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made. There will be a positive sensibility test result in about half the cases. The test is important in assessing future risk of healing complications. A lack of response at the initial test indicates an increased risk of later pulp necrosis

Radiographic findings: Usually no radiographic abnormalities

Radiographs recommended: As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth.

Treatment

Treatment objective: Usually no need for treatment.

Treatment: A flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks.

Patient instructions

Soft food for 1 week.

Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

Splint removal and radiographic control after 2 weeks.

Clinical and radiographic control at 2 weeks, 4 weeks, 6-8 weeks and 1 year.

Extrusion

Description

Partial displacement of the tooth out of its socket. An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone is intact in an extrusion injury as opposed to a lateral luxation injury. In addition to axial displacement, the tooth will usually have an element of protrusion or retrusion. In severe extrusion injuries the retrusion/protrusion element can be very pronounced. In some cases it can be more pronounced than the extrusive element.

Diagnosis

Visual signs: Appears elongated

Percussion test: Tender

Mobility test: Excessively mobile

Sensibility test: Usually lack of response except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive result to the initial test indicates a reduced risk of later pulp necrosis. In immature, not fully developed teeth, pulpal revascularization usually occurs. In mature teeth pulp revascularization sometimes occurs

Radiographic findings: Increased periapical ligament space

Radiographs recommended: As a routine: Occlusal, periapical exposure and view from the mesial or distal aspect of the tooth.

Treatment

The exposed root surface of the displaced tooth is cleansed with saline before repositioning

Reposition the tooth by gently re-inserting it into the tooth socket with axial digital pressure (local anesthesia is usually not necessary)

Stabilize the tooth for 2 weeks using a flexible splint

Monitoring the pulpal condition is essential to diagnose associated root resorption.

Open apex: Revascularization can be confirmed radiographically by evidence of continued root formation and pulp canal obliteration and usually a return to a positive pulp response to sensibility testing.

Closed apex: A continued lack of pulp response to sensibility testing should be taken as evidence of pulp necrosis together with periapical rarefaction and sometimes crown discoloration.

Patient instructions

• Soft food for 1 week
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

• Clinical and radiographic control and splint removal after 2 weeks
• Clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years

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Lateral luxation

Description

Displacement of the tooth other than axially. Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone. Lateral luxation injuries, similar to extrusion injuries, are characterized by partial or total separation of the periodontal ligament. However, lateral luxations are complicated by fracture of either the labial or the palatal/lingual alveolar bone and a compression zone in the cervical and sometimes the apical area. If both sides of the alveolar socket have been fractured, the injury should be classified as an alveolar fracture (alveolar fractures rarely affect only a single tooth). In most cases of lateral luxation the apex of the tooth has been forced into the bone by the displacement, and the tooth is frequently non-mobile.

Diagnosis

• Severance of neurovascolar pulp supply
• Entrapment of apex
• Fracture of labial bone plate
• Severance of periodontal ligament
• Compression of periodontal ligament

Visual signs: Displaced, usually in a palatal/lingual or labial direction

Percussion test: Usually gives a high metallic (ankylotic) sound

Mobility test: Usually immobile

Sensibility test: Sensibility tests will likely give a lack of response except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive result at the initial examination indicates a reduced risk of future pulp necrosis

Radiographic findings: Widened periapical ligament space best seen on occlusal or eccentric exposures

Radiographs recommended: As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth in question

Treatment

Treatment objective

To reposition and splint a displaced tooth to facilitate pulp and periodontal ligament healing.

Treatment

• Rinse the exposed part of the root surface with saline before repositioning
• Apply a local anesthesia
• Reposition the tooth with forceps or with digital pressure to disengage it from its bony lock and gently reposition it into its original location
• Stabilize the tooth for 4 weeks using a flexible splint. 4 weeks is indicated due to the associated bone fracture.

Monitoring the pulpal condition is essential to diagnose root resorption. If the pulp becomes necrotic, root canal treatment is indicated to prevent infection related root resorption.

In immature developing teeth, revascularization can be confirmed radiographically by evidence of continued root formation, initiation of pulp canal obliteration and usually a return to a positive response to sensibility testing.

In fully formed teeth, a continued lack of response to sensibility testing (i.e. exceeding 3 months) should be taken as evidence of pulp necrosis together with periapical radiolucency and sometimes crown discoloration.

Splint removal: After 4 weeks. The tooth must be supported with digital pressure during this procedure.

Patient instructions

• Soft food for 1 week
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

Clinical and radiographic control after 2 weeks. Clinical and radiographic control and splint removal after 4 weeks. Clinical and radiographic control at 6-8 weeks, 6 months, 1 year and yearly for 5 years.

Intrusion

Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.

Diagnosis

Visual signs: The tooth is displaced axially into the alveolar bone.

Percussion test: Usually gives a high metallic (ankylotic) sound.

Mobility test: The tooth is immobile.

Sensibility test: Sensibility test will likely give negative response.

In immature, not fully developed teeth, pulpal revascularization may occur.

Radiographic findings: The periodontal ligament space may be absent from all or part of the root. The cemento-enamel junction is located more apically in the intruded tooth than in adjacent non-injured teeth, at times even apical to the marginal bone level.

Radiographs recommended

• As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth in question.
• If the tooth is totally intruded a lateral exposure is indicated to make sure the tooth has not penetrated the nasal cavity.

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Treatment

Tooth intrusion is associated with a potential risk of tooth loss due to progressive root resorption (ankylosis or infection related resorption). The following three methods are only partly evidence based.

• Spontaneous eruption. This is the treatment of choice for permanent teeth with incomplete root formation with minor or moderate intrusion. In teeth with mature root development it is only recommended for teeth with minor intrusion.This treatment seems to lead to fewer healing complications than orthodontic and surgical repositioning. If no movement within a few weeks, initiate orthodontic or surgical repositioning before ankylosis can develop.
• Orthodontic repositioning. This treatment may be preferred for patients coming in for delayed treatment. This treatment method enables repair of marginal bone in the socket along with the slow repositioning of the tooth.
• Surgical repositioning. This treatment technique is preferable in the acute phase. Intrusion with major dislocation of the tooth (more than 7 mm) may be an indication for surgical repositioning.

Common for all treatments

Endodontic treatment can prevent the necrotic pulp from initiating infection-related root resorption. This treatment should be considered in all cases with completed root formation where the chance of pulp revascularization is unlikely. Endodontic therapy should preferably be initiated within 3-4 weeks post-trauma. A temporary filling with calcium hydroxide is recommended.

Treatment choice

Factors determining treatment choice are stages of root development and intrusion level.

Patient instructions

• Soft food for 1 week.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

Control after 2 weeks. Splint removal and control after 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years.

Avulsion

The tooth is completely displaced out of its socket. Clinically the socket is found empty or filled with a coagulum.

Diagnosis

Visual signs: The tooth is removed from its socket.

Percussion test: Not indicated.

Mobility test: Not indicated.

Sensibility test: Not indicated.

Radiographic findings: If the visual appearance of the injury raises suspicion of a possible intrusion, root fracture, alveolar fracture or jaw fracture an occlusal radiograph should be taken to confirm the diagnosis.

Radiographs recommended: As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth in question.

Treatment

Dentists should always be prepared to give appropriate advice to the public about first aid for avulsed teeth. An avulsed permanent tooth is one of the few real emergency situations in dentistry. In addition to increasing the public awareness by mass media campaigns, healthcare professional, parents and teachers should receive information on how to proceed following these severe unexpected injuries. Also, instructions may be given by telephone to parents at the emergency site.

If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted).

• Keep the patient calm.
• Find the tooth and pick it up by the crown (the white part). Avoid touching the root.
• If the tooth is dirty, wash it briefly (10 seconds) under cold running water and reposition it. Try to encourage the patient / parent to replant the tooth. Bite on a handkerchief to hold it in position.
• If this is not possible, place the tooth in a suitable storage medium, e.g. a glass of milk or a special storage media for avulsed teeth if available (e.g. Hanks balanced storage medium or saline). The tooth can also be transported in the mouth, keeping it between the molars and the inside of the cheek. If the patient is very young, he/she could swallow the tooth- therefore it is advisable to get the patient to spit in a container and place the tooth in it. Avoid storage in water!
• Seek emergency dental treatment immediately.

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Closed Apex

1. Tooth replanted prior to the patient's arrival at the dental office or clinic

Treatment:

• Leave the tooth in place.
• Clean the area with water spray, saline, or chlorhexidine.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both clinically and radiographically.
• Apply a flexible splint for up to 2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before splint removal.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.

Follow-up

• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immidiately or shortly following replantation and left for at least 2 weeks.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

2. Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank's Balanced Salt Solution) and/or stored dry less than 60 minutes.

Treatment

• Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline thereby removing contamination and dead cells from the root surface.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both, clinically and radiographically.
• Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before splint removal.

Patient instructions:

• Soft food for up tp 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.

Follow-up:

• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2 weeks.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

3. Extraoral dry time exceeding 60 min or other reasons suggesting non-viable cells

Treatment

Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and can not be 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.

• Remove attached non-viable soft tissue carefully, with gauze.
• Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth clinically and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.

To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up:

• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2 weeks.
• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Ankylosis is unavoidable after delayed replantation and must be taken into consideration. In children and adolescents ankylosis is frequently associated with infraposition. Careful follow-up is required and good communication is necessary to ensure the patient and guardian of this likely outcome. Decoronation may be necessary when infraposition (> 1 mm) is seen. For more detailed information of this procedure the reader is referred to textbooks.

Open apex

1. Tooth replanted prior to the patient’s arrival at the dental office or clinic

Treatment

• Leave the tooth in place.
• Clean the area with water spray, saline, or chlorhexidine.
• Suture gingival laceration if present.
• Verify normal position of the replanted tooth both clinically and radiographically.
• Apply a flexible splint for up to 1-2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
• The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment is recommended.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

2. Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank's Balanced Salt Solution) and/or stored dry less than 60 minutes.

Treatment

• Clean the root surface and apical foramen with a stream of saline.
• Topical application of antibiotics has been shown to enhance chances for revascularization of the pulp and can be considered if available (minocycline or doxycycline 1 mg per 20 ml saline for 5 minutes soak).
• Administer local anesthesia.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
• Irrigate the socket with saline.
• Replant the tooth slowly with slight digital pressure.
• Suture gingival lacerations, especially in the cervical area.
• Verify normal position of the replanted tooth clinically and radiographically.
• Apply a flexible splint for up to 2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, refer to physician for a tetanus booster.

The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the pulp space. The risk of infection-related root resorption should be weighed up against the chances of revascularization. Such resorption is very rapid in children. If revascularization does not occur, root canal treatment may be recommended.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

3. Dry time longer than 60 min or other reasons suggesting non-viable cells.

Treatment

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 to restore the tooth to the dentition for esthetic, functional, and psychological reasons and to maintain alveolar contour. The eventual outcome will be ankylosis and resorption of the root.

• Remove attached non-viable soft tissue with gauze.
• Root canal treatment can be carried out prior to replantation or later.
• Administer local anesthesia.
• Irrigate the socket with saline.
• Examine the alveolar socket. if there is a fracture of the socket wall, reposition it with a suitable instrument.
• Replant the tooth slowly with slight digital pressure.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth clinically and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil or if tetanus coverage is uncertain, refer to physician for evaluation of the need for a tetanus booster.

To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Ankylosis is unavoidable after delayed replantation and must be taken into consideration. In children and adolescents ankylosis is frequently associated with infraposition. Careful follow-up is required and good communication is necessary to ensure the patient and guardian of this likely outcome. Decoronation may be necessary when infraposition (> 1 mm) is seen. For more detailed information of this procedure the reader is referred to textbooks.

Infraction

An incomplete fracture (crack) of the enamel without loss of tooth structure.

Diagnosis

Visual signs: A visible fracture line on the surface of the tooth.

Percussion test: Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.

Mobility test: Normal mobility.

Sensibility test: Usually positive. The test is important in assessing future risk of healing complications. A lack of response to the test at the initial examination indicates an increased risk of later pulp necrosis.

Radiographic findings: No radiographic abnormalities.

Radiographs recommended: A periapical view. No other radiographic view are needed unless other symptoms are present.

Treatment

In case of marked infractions, etching and sealing with resin to prevent discoloration of the infraction lines. Otherwise no treatment is necessary.

Follow-up

No follow-up is needed for infraction injuries unless they are associated with a luxation injury or other fracture types involving the same tooth.

Enamel fraction

A fracture confined to the enamel with loss of tooth structure.

Diagnosis

Visual signs: Visible loss of enamel. No visible sign of exposed dentin.

Percussion test: Not tender. If tenderness is observed evaluate the tooth for a possible luxation or root fracture injury.

Mobility test: Normal mobility.

Sensibility test: Usually positive. The test may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made. The test is important in assessing risk of future healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.

Radiographic findings: The enamel loss is visible.

Radiographs recommended: Periapical, occlusal and eccentric exposures. They are recommended in order to rule out the possible presence of a root fracture or a luxation injury.

Treatment

• If a tooth fragment is available, it can be bonded to the tooth.
• Grinding or restoration with composite resin depending on the extent and location of the fracture.
• Three angulations (periapical, occlusal and eccentric exposures) should be used in the radiographic examination to rule out luxation injuries or root fractures.

Follow-up Clinical and radiographic control at 6-8 weeks and 1 year.

Enamel-dentine fracture

A fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp.

Diagnosis

Visual signs: Visible loss of enamel and dentin. No visible sign of exposed pulp tissue.

Percussion test: Not tender. If tenderness is observed evaluate the tooth for possible luxation or root fracture injury.

Mobility test: Normal mobility.

Sensibility test: Usually positive. The test may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made. The test is important in assessing future risk of healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.

Radiographic findings: The enamel-dentin loss is visible.

Radiographs recommended: Periapical, occlusal and eccentric exposure. They are recommended in order to rule out displacement or the possible presence of a root fracture.

Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material.

Treatment

• If a tooth fragment is available, it can be bonded to the tooth. Otherwise perform a provisional treatment by covering the exposed dentin with glass-ionomer or a permanent restoration using a bonding agent and composite resin.
• The definitive treatment for the fractured crown is restoration with accepted dental restorative materials.
• Three angulations (periapical, occlusal and eccentric exposures) should be used in the radiographic examination to rule out displacement or fracture of the root.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material

Follow-up Clinical and radiographic control at 6-8 weeks and 1 year.

Enamel-dentin-pulp fracture (Complicated crown fracture)

A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.

Diagnosis

Visual signs: Visible loss of enamel and dentin and exposed pulp tissue.

Percussion test: Not tender. If tenderness is observed evaluate the tooth for luxation or root fracture injury.

Mobility test: Normal mobility.

Sensibility test: Usually positive. The test is important in assessing risk of future healing complications. A lack of response at the initial examination indicates an increased risk of later pulp necrosis.

Radiographic findings: The loss of tooth substance is visible.

Radiographs recommended: Periapical, occlusal and eccentric exposure. They are recommended in order to rule out displacement or the possible presence of a luxation or a root fracture.

Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material.

Treatment

• In young patients with open apices, it is very important to preserve pulp vitality by pulp capping or partial pulpotomy in order to secure further root development. This treatment is also the treatment of choice in patients with closed apices. Calcium hydroxide compounds and MTA (white) are suitable materials for such procedures.
• In older patients with closed apices and an associated luxation injury with displacement, root canal treatment is usually the treatment of choice.

Follow-up   Clinical and radiographic control at 6-8 weeks and 1 year

Crown-root fracture without pulp involvement

A fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp.

Diagnosis

Visual signs: Crown fracture extending below gingival margin.

Percussion test: Tender.

Mobility test: Coronal fragment mobile.

Sensibility test: Usually positive for apical fragment.

Radiographic findings: Apical extension of fracture usually not visible.

Radiographs recommended: Periapical, occlusal and eccentric exposures. They are recommended in order to detect fracture lines in the root. A cone beam exposure can reveal the whole fracture extension.

Treatment

Localization of fracture line

• The fracture involves the crown and root of the tooth and is in a horizontal or diagonal plane. A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion
• A cone beam exposure can reveal the whole fracture extension

Emergency treatment

• As an emergency treatment a temporary stabilization of a loose segment to adjacent teeth can be performed until a definitive treatment plan is made

Definitive treatment

Depending on the clinical findings, six treatment scenarios may be considered. Most of these may be deferred to later treatment.

• Fragment removal only. Removal of a superficial coronal crown-root fragment and subsequent restoration of exposed dentin above the gingival level.
• Fragment removal and gingivectomy (sometimes ostectomy). Removal of coronal segment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy, ostectomy with osteoplasty. This treatment option is 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. A rotation of the root (90 or 180) may offter a better position for periodontal ligament healing. Because the fracture site becomes exposed labially and thereby more periodontal ligament can be saved (see reference 9)
• Decoronation (Root submergence). Implant solution is planned, the root fragment may be left in situ after in order to avoid alveolar bone resorption and thereby maintaining the volume of the alveolar process for later optimal implant installation
• Extraction. Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable crown-root fractures with a severe apical extension, the extreme being a vertical fracture

Timing of treatment

All of the treatment modalities (except extraction) are technique sensitive and do not need to be performed during the acute phase. Instead, the coronal fragment can be temporarily bonded to the cervical portion of the tooth with a composite or resin. This may add to the comfort of the patient until final treatment. Prognosis will not be influenced by delay of treatment within a time frame of one to two weeks.

Patient instructions

• Soft food for 1 week
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up   6-8 weeks and 1 year.

Crown-root fracture with pulp involvement

A fracture involving enamel, dentin, and cementum with loss of tooth structure, and exposure of the pulp.

Diagnosis

Visual signs: Crown fracture extending below gingival margin.

Percussion test: Tender.

Mobility test: Coronal fragment mobile.

Sensibility test: Usually positive for apical fragment.

Radiographic findings: Apical extension of fracture usually not visible.

Radiographs recommended: Periapical and occlusal exposure. A cone beam exposure can reveal the whole fracture extension.

Treatment

Localization of fracture line

• The fracture involves the crown and root of the tooth and is in a horizontal or diagonal plane. A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion.
• If available a cone beam exposure can reveal the whole fracture.

Emergency treatment

• As an emergency treatment a temporary stabilization of a loose segments to adjacent teeth can be performed until a definitive treatment plan is made.
• In young patients with open apices, it is advantageous to preserve pulp vitality by a partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide compounds are suitable pulp capping materials. In patients with mature root development root canal treatment can be the treatment of choice.

Definitive treatment

Depending on the clinical findings, five treatment scenarios may be considered. Most of these may be deferred to later treatment.

• Fragment removal and gingivectomy (sometimes ostectomy). Removal of 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 repositioning of the root in a more coronal position. A rotation of the root (90 or 180) may offter a better position for periodontal ligament healing. Because the fracture site becomes exposed labially and thereby more periodontal ligament can be saved (see reference 9).
• Decoronation (Root submergence). An implant solution is planned, the root fragment may be left in situ after decoronation in order to avoid alveolar resorption maintaining the volume of the alveolar process for later optimal implant installation.
• 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.

Timing of treatment

All of the treatment modalities (except extraction) are technique sensitive and do not need to be performed in the acute phase. Instead, the coronal fragment can be temporarily bonded to the cervical portion of the tooth with a composite or resin. This may add to the comfort of the patient until final treatment.

Patient instructions

• Soft food for 1 week.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up 6-8 weeks and 1 year.

Root fracture

A fracture confined to the root of the tooth involving cementum, dentin, and the pulp. Root fractures can be further classified by whether the coronal fragment is displaced (see luxation injuries).

Diagnosis

Visual signs: The coronal segment may be mobile and in some cases displaced. Transient crown discoloration (red or grey) may occur. Bleeding from the gingival noted.

Percussion test: The tooth may be tender.

Mobility test: The coronal segment may be mobile.

Sensibility test: Sensibility testing may give negative results initially, indicating transient or permanent neural damage. Monitoring the status of the pulp is recommended. The pulp sensibility test is usually negative for root fractures except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive sensibility test at the initial examination indicates a significantly reduced risk of later pulp necrosis.

Radiographic findings: The root fracture line is usually visible. The fracture involves the root of the tooth and is in a horizontal or diagonal plane.

Radiographs recommended: Periapical, occlusal and eccentric exposures.

An occlusal exposure is optimal for locating root fractures in the apical and middle third. Bisecting angle exposure or 90o degree angulation exposure is needed to locate the fractures in the cervical third.

Treatment

Localization of fracture line

• An occlusal exposure is optimal for locating root fractures in the apical and middle third.
• Bisecting angle exposure or 90o degree angulation exposure is needed to locate fractures in the cervical third of the root.

For root fractures where the coronal fragment have been avulsed out of the socket please use the treatment guidelines for avulsion otherwise proceed as described below.

• Rinse exposed root surface with saline before repositioning. If displaced, reposition the coronal segment of the tooth as soon as possible.
• Check that correct position has been reached radiographically.
• Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth stabilization is beneficial for a longer period of time (up to 4 months).
• Monitor healing for at least 1 year to determine pulpal status. If pulp necrosis develops, then root canal treatment of the coronal tooth segment to the fracture line is indicated.

Patient instructions

• Soft food for 1 week
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

• Splint removal and clinical and radiographic control after 4 weeks in apical third and mid-root fractures. However, if the root fracture is near the cervical area the splint should be kept on for up to 4 months.
• Clinical and radiographic control after 6-8 weeks.
• Clinical and radiographic control after 4 months. If the root fracture is near the cervical area the splint should be removed at this session.
• Clinical and radiographic control after 6 months, 1 year and yearly for 5 years.
• Follow-up may include endodontic treatment of the coronal fragment if pulp necrosis develops. The decision for endodontic treatment may be taken after three months of follow-up if the tooth still does not respond to electrometric or thermal pulp testing and if radiographs show a radiolucency next to the fracture line.

Alveolar fracture

A fracture of the alveolar process; may or may not involve the alveolar socket.

Teeth associated with alveolar fractures are characterized by mobility of the alveolar process; several teeth typically will move as a unit when mobility is checked. Occlusal interference is often present.

Diagnosis

Visual signs: Displacement of an alveolar segment. An occlusal change due to misalignment of the fractured alveolar segment is often noted.

Percussion test: Tender.

Mobility test: Entire segment mobile and moves as a unit.

Sensibility test: Usually negative.

Radiographic findings: The vertical line of the fracture may run along the PDL or in the septum. The horizontal line may be located at any level, from the marginal bone to the basal bone. An associated root fracture may be present.

Radiographs recommended: Occlusal, periapical and eccentric exposure. A panoramic or a cone beam exposure may be useful.

Treatment

• Manual repositioning or repositioning using forceps of the displaced segment.
• Stabilize the segment with flexible splinting for 4 weeks.

Patient instructions

• Soft food for 1 week
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical and radiographic control after 6-8 weeks, 4 months, 6 months, 1 year and yearly for 5 years

  ---

Fracture of mandible or maxilla

A fracture involving the base of the mandible or maxilla and often the alveolar process (jaw fracture). The fracture may or may not involve the alveolar socket.

Diagnosis

Visual signs: Usually displacement between two alveolar segments within the dental arch.

Percussion test: Tender.

Mobility test: Usually mobility in the fracture line.

Sensibility test: May be positive or negative.

Radiographic findings: The vertical line of the fracture line may run along the PDL or in the septum.

Radiographs recommended: Periapical and panoramic exposure. Supplementary exposures are necessary according to fracture location. A cone beam exposure may be of value.

Treatment

• Manual repositioning or repositioning with forceps of displaced segment.
• Stabilize the fracture with splint using intermaxillary immobilization for 4 weeks.
• An alternative treatment is surgical repositioning and stabilization using plating (open reduction). In this case intermaxillary splinting can usually be avoided.

Patient instructions

• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.

Follow-up

• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical and radiographic control after 6-8 weeks, 4 months, 6 months, 1 year and yearly for 5 years.

AO Surgery Reference

Treatment of fracture in the mandible and maxilla are covered in depth in the AO Surgery Reference

Primary Teeth

Concussion

An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion and without gingival bleeding.

Diagnosis

The diagnostic signs of concussion are transient. It is therefore not possible to diagnose concussion if the examination is done several days after injury.

Visual signs: Not displaced.

Percussion test: Tender to touch or tapping.

Mobility test: No increased mobility.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: No radiographic abnormalities. Normal periodontal space.

Radiographs recommended: An occlusal exposure is recommended in order to screen for possible signs of displacement or the presence of a root fracture. The radiograph can furthermore be used as a reference point in case of future complications.

Treatment

Treatment objectives: There is no need for treatment.

Treatment: No treatment is needed only observation.

Patient instructions

• Soft food for 1 week.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.
• Parents should be further advised about possible complications that may occur, like swelling, dark discoloration of the crown, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up   Clinical control at 1 week, 6-8 weeks.

Subluxation

An injury to the tooth supporting structures resulting in increased mobility and pain to percussion, but without displacement of the tooth. Bleeding from the gingival sulcus is evident if the child is seen shortly after the accident.

Diagnosis

The diagnostic signs of concussion are transient. It is therefore not possible to diagnose concussion if the examination is done several days after injury.

Visual signs: Not displaced.

Percussion test: Tender to touch or tapping.

Mobility test: Increased mobility.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: Normal periodontal space.

Radiographs recommended: An occlusal exposure is recommended in order to screen for possible signs of displacement or the presence of a root fracture. The radiograph can furthermore be used as a reference point in case of future complications.

Treatment

Treatment objective: No treatment is needed.

Treatment: No treatment is needed. Observation.

Patient instructions

• Soft food for 1 week.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.
• Parents should be further advised about possible complications that may occur, like swelling, dark discoloration of the crown, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up   Clinical control at 1 week, 6-8 weeks

Extrusion

Partial displacement of the tooth out of its socket. An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone remains intact. In addition to axial displacement, the tooth usually will have some protrusive or retrusive orientation.

Diagnosis

The diagnostic signs of concussion are transient. It is therefore not possible to diagnose concussion if the examination is done several days after injury.

Visual signs: Appears elongated.

Percussion test: Tenderness to percussion.

Mobility test: Excessively mobile.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: Increased periodontal ligament space apically.

Radiographs recommended: An occlusal exposure is recommended in order to evaluate the size of the displacement and rule out the presence of a root fracture. The radiograph can furthermore be used as a reference point in case of late complications.

Treatment

The treatment choice should be based on the degree of displacement, mobility, root formation and the ability of the child to cope with the emergency situation.

For minor extrusion (< 3mm) in an immature developing tooth, either careful reposition the tooth or leave the tooth for spontaneous alignment.

Extraction is the treatment of choice for severe extrusion in a fully formed primary tooth.

Patient instructions

• Soft food for 1 week.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.
• Parents should be further advised about possible complications that may occur, like swelling, dark discoloration of the crown, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up   Clinical control after 1 weeks. Clinical and radiographic control at 6-8 weeks, 6 months, and 1 year.

Lateral luxation

Displacement of the tooth other than axially. Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone.

Palatal/lingual luxation of the maxillary incisors may result in occlusal interference expressed by premature contact with the opponent teeth.

Lateral luxation injuries, similar to extrusion injuries, are characterized by partial or total separation of the periodontal ligament. However, lateral luxations are complicated by fracture of either the labial or the palatal/lingual alveolar bone and a compression zone in the cervical and sometimes the apical area. If both sides of the alveolar socket have been fractured, the injury should be classified as an alveolar fracture (alveolar fractures rarely affect only a single tooth). In most cases of lateral luxation the apex of the tooth has been forced into the bone by the displacement, and the tooth is frequently non-mobile.

Diagnosis

The diagnostic signs of concussion are transient. It is therefore not possible to diagnose concussion if the examination is done several days after injury.

Visual signs: Displaced, usually in a palatal/lingual or labial direction.

Percussion test: Usually gives a high metallic (ankylotic) sound.

Mobility test: Usually non-mobile.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: Increased periodontal ligament space apically is best seen on the occlusal exposure.

Radiographs recommended: An occlusal exposure can sometimes show the position of the displaced tooth and its relation to the permanent successor.

Treatment

• Spontaneous repositioning: If there is no occlusal interference, as is often the case in anterior open bites, the tooth should be allowed to reposition spontaneously.
• Repositioning: When there is occlusal interference local anesthesia should be applied where after the tooth should be repositioned by gentle combined labial and palatal pressure.
• Extraction: For teeth with severe displacement in a labial direction, extraction is the treatment of choice. Extraction is indicated in these cases because of the collision between the primary tooth and the permanent tooth germ.
• Slight grinding: In cases with minor occlusal interference, slight grinding is indicated.

Patient instructions

• Soft food for 10-14 days.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.
• Parents should be further advised about possible complications that may occur, like swelling, dark discoloration of the crown, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up   Clinical control after 1 and 2-3 weeks. Clinical and radiographic control at 6-8 weeks and 1 year.

Intrusion

Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.

The tooth can be impinging upon the permanent tooth germ.

Diagnosis

Visual signs: The tooth is displaced axially into the alveolar bone and frequently penetrating the labial bone plate where it can be palpated. The tooth may disappear completely in the tissues resembling avulsion and root fracture with complete extrusion of the coronal fragment. In this case diagnosis is based on an occlusal radiograph.

Penetration of the tooth into the nasal cavity can be diagnosed by bleeding from the nose or simple observation of the nostril.

Percussion test: The test will usually give a high metallic (ankylotic) sound. However in severe intrusion cases the test will not always be possible to perform.

Mobility test: The tooth is non-mobile.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: When the apex is displaced toward or through the labial bone plate the apical tip can be visualized and appears shorter than the unaffected contralateral tooth. When the apex is displaced toward the permanent tooth germ, the apical tip cannot be visualized and the tooth appears elongated.

Radiographs recommended: An occlusal or periapical exposure will normally show the position of the displaced tooth and its relation to the permanent successor. If the tooth is totally intruded an extra-oral lateral exposure may be indicated to make sure that the tooth has not penetrated the nasal cavity.

Treatment

Tooth intrusion is associated with a potential risk of damage to the permanent tooth bud.

Spontaneous eruption

If the apex is displaced toward or through the labial bone plate, the tooth should be left for spontaneous repositioning. In order to evaluate re-eruption, the degree of intrusion should be assessed by measuring the distance between the incisal edge of the intruded tooth and that of adjacent unaffected teeth.

Extraction

If the apex is displaced into the developing tooth germ the tooth should be extracted to minimize the damage done to the permanent successor.

Patient instructions

• Soft food for 10-14 days.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet , restrict the use of a pacifier.
• Parents should be further advised about possible complications that may occur, like swelling, dark discoloration of the crown, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.
• Inform the parent about possible complications in the development of the permanent successor, especially following intrusion injuries sustained in children under 3 years of age.

Follow-up

Clinical control after 1 week. Clinical and radiographic control at 3-4 weeks, 6-8 weeks, 6 month, 1 year and yearly clinical and radiographic control until eruption of the permanent successor.

Avulsion

The tooth is completely displaced out of its socket. Clinically the socket is found empty or filled with a coagulum.

Diagnosis

Visual signs: The tooth is removed from its socket.

Percussion test: Not relevant.

Mobility test: Not relevant.

Sensibility test: Not relevant.

Radiographic findings: The alveolar socket will be empty. If the avulsed tooth is not present a radiographic examination is essential to ensure that the missing tooth is not intruded.

Radiographs recommended: An occlusal exposure is recommended in order to screen for the presence of root fragments and to make sure that the missing tooth is not intruded.

Treatment

• It's not recommended to replant avulsed primary teeth.
• A the initial examination make sure that all avulsed teeth are accounted for. If not, it is highly recommended to make a radiographic examination in order to ensure that the missing tooth is not a case of complete intrusion or root fracture with loss of the coronal fragment. If the avulsed tooth has not been found refer the child to the paediatrician to exclude aspiration.

Patient instructions

• Soft food for 1 week.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene.
• Inform the parent about possible complications in the development of the permanent successor, especially following avulsion injuries sustained in children under 3 years of age.

Follow-up

Clinical control after 1 week and clinical and radiographic control after 6 months and 1 year. Yearly clinical and radiographic controls until eruption of the permanent successor.

Enamel infraction

An incomplete fracture (crack) of the enamel without loss of tooth structure.

Diagnosis

Visual signs: A visible fracture line on the surface of the tooth.

Percussion test: Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.

Mobility test: Normal mobility.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: No radiographic abnormalities.

Radiographs recommended: None.

Treatment

No treatment necessary.

Follow-up

No follow-up is needed for infraction.

Enamel-dentin fracture

A fracture confined to enamel and dentin with loss of tooth structure, but not involving the pulp.

Diagnosis

Visual signs: Visible loss of enamel and dentin. No visible sign of exposed pulp tissue.

Percussion test: Not tender. If tenderness is observed evaluate the tooth for possible luxation or root fracture injury.

Mobility test: Normal mobility.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: The enamel-dentin loss is visible. The distance between the fracture and the pulp chamber can be evaluated.

Radiographs recommended: None.

Treatment

If possible, seal completely the involved dentin with glass ionomer to prevent microleakage. In case of large lost tooth structure, the tooth can be restored with composite.

Follow-up

Clinical control at 3-4 weeks.

Enamel-dentin-pulp fracture (Complicated crown fracture)

A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.

Diagnosis

Visual signs: Visible loss of enamel and dentin and exposed pulp tissue.

Percussion test: Not tender. In case of tenderness, evaluate the tooth for luxation or root fracture injury.

Mobility test: Normal mobility.

Sensibility test: Not reliable in primary teeth. Inconsistent results.

Radiographic findings: The loss of tooth substance is visible.

Radiographs recommended: An occlusal exposure is recommended in order to screen for possible signs of displacement or the presence of a root fracture. The radiograph can furthermore be used as a reference point in case of future complications.

Treatment

If possible, seal completely the involved dentin with glass ionomer to prevent microleakage. In case of large lost tooth structure, the tooth can be restored with composite.

Follow-up

Clinical control at 3-4 weeks.

Crown-root fracture without pulp involvement

A fracture involving enamel, dentin and cementum with loss of tooth structure, but not involving the pulp.

Diagnosis

Visual signs: Crown fracture extending below gingival margin. The crown is split into two or more fragments, one of which is mobile.

Percussion test: Tenderness to percussion.

Mobility test: At least one coronal fragment is mobile. Because of mobility during mastication there might be transitory pain.

Sensibility test: Not reliable in primary dentition.

Radiographic findings: Apical extension of fracture usually not visible. In laterally positioned fractures, the extent in relation to the gingival margin can be seen.

Radiographs recommended: An occlusal exposure.

Treatment

Localization of fracture line:

• The fracture involves the crown and root of the tooth and is in a horizontal or diagonal plane. A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion

Depending on the clinical findings, two treatment scenarios may be considered. Most of these may be deferred to later treatment.

• Fragment removal only: if the fracture involves only a small part of the root and the stable fragment is large enough to allow coronal restoration, remove the mobile fragment.
• Extraction: in all other instances.

Patient instructions

• Soft food for 10-14 days.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.
• Parents should be further advised about possible complications that may occur, like swelling, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up

• In case of fragment removal only: clinical control after 1 week. Clinical and radiographic control after 3-4 weeks. Clinical control after 1 year.
• In case of tooth extration: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

Crown-root fracture with pulp involvement (Complicated crown-root fracture)

A fracture involving enamel, dentin, cementum, and the pulp.

Diagnosis

Visual signs: Crown fracture extending below gingival margin. The crown is split into two or more fragments, one of which is mobile.

Percussion test: Tenderness to percussion.

Mobility test: At least one coronal fragment is mobile. Because of mobility during mastication there might be transitory pain.

Sensibility test: Not reliable in primary dentition.

Radiographic findings: Apical extension of fracture usually not visible. In laterally positioned fractures, the extent in relation to the gingival margin can be seen.

Radiographs recommended: An occlusal exposure.

Treatment

Localization of fracture line.

The fracture involves the crown and root of the tooth and is in a horizontal or diagonal plane. A radiographic examination usually only reveals the coronal part of the fracture and not the apical portion.

Depending on the clinical findings, two treatment scenarios may be considered.

• Fragment removal only: if the fracture involves only a small part of the root and the stable fragment is large enough to allow coronal restoration.
• Extraction: in all other instances.

Patient instructions

• Soft food for 10-14 days.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet.
• Parents should be further advised about possible complications that may occur, like swelling or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up

• In case of fragment removal only: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.
• In case of tooth extraction: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

Root fracture

A fracture confined to the root of the tooth involving cementum, dentin, and the pulp. Root fractures can be further classified by whether the coronal fragment is displaced (see luxation injuries).

Diagnosis

Visual signs: The coronal segment is usually mobile and may be displaced. Transient crown discoloration (red or grey) may occur.

Percussion test: The tooth may be tender.

Mobility test: The coronal segment is usually mobile.

Sensibility test: Not reliable in primary dentition.

Radiographic findings: The fracture is usually located mid-root or in the apical third.

Radiographs recommended: An occlusal exposure.

Treatment

• No treatment: If the coronal fragment is not displaced no treatment is required.
• Extraction: If the coronal fragment is displaced, repositioning and splinting might be considered. Otherwise extract only that fragment. The apical fragment should be left to be resorbed.

Patient instructions

• Soft food for 10-14 days.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris along with recommending a soft diet, restrict the use of a pacifier.
• Parents should be further advised about possible complications that may occur, like swelling, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Follow-up

• In case of no treatment: Clinical control after 1 week. Clinical and radiographic control after 6-8 weeks and 1 year.
• In case of tooth extraction: Clinical and radiographic control at 1 year and every year until eruption of the permanent successor.

  ---

Alveolar fracture

A fracture of the alveolar process which may or may not involve the alveolar bone socket.

Teeth associated with alveolar fractures are characterized by mobility of the alveolar process; several teeth typically will move as a unit when mobility is checked. Occlusal interference is often present.

Diagnosis

Visual signs: Displacement of an alveolar segment. An occlusal change due to misalignment of the fractured alveolar segment is often noted. This may cause occlusal interference.

Percussion test: Tenderness to percussion.

Mobility test: Entire segment mobile and moves as a unit.

Sensibility test: Not reliable in primary dentition.

Radiographic findings: The vertical line of the fracture may run along the PDL or in the septum. The horizontal line may be located apical at the apex or coronal to the apex. An associated root fracture may be present. The horizontal fracture line may run at any level in regard to the permanent tooth germs. The radiograph will give valuable information in the assessment of the risk for damage to the permanent teeth.

A lateral radiograph may give further information about the spatial relation between the two dentitions.

Radiographs recommended: An occlusal exposure.

Treatment

Manual repositioning or repositioning using forceps of the displaced segment. General anesthesia is often indicated. Stabilize the segment with flexible splinting for 4 weeks. Monitor teeth in the fracture line.

Patient instructions

• Soft food for 10-14 days.
• Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brush with a soft brush after every meal and apply chlorhexidine 0.1 % topically to the affected area with cotton swabs twice a day for one week. This is beneficial to prevent accumulation of plaque and debris. Along with recommending a soft diet, restrict the use of a pacifier.
• Parents should be further advised about possible complications that may occur, like swelling, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs of swelling of the gums and bring the child in for treatment.

Inform the parents about possible complications in the development of the permanent teeth.

Follow-up

• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical control after 1 week.
• Clinical and radiographic control and splint removal after 3-4 weeks.
• Clinical and radiographic control after 6-8 weeks and 1 year then yearly until exfoliation.

References

• Andreasen FM, Vestergaard Pedersen B. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1985; 1: 207–220.
• Ravn JJ. Follow-up study of permanent incisors with enamel cracks as a result of an acute trauma. Scand J Dent Res 1981; 89: 117-123.
• Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012; 28: 66-71.
• Erratum in Dent Traumatol. 2012;28: 499.
• Moorrees CF, Fanning EA, Hunt EE. Age variation of formation stages for ten permanent teeth. J Dent Res 1963; 42: 1490-1502.
• Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Concussion. Traumatic Dental Injuries. A Manual. Oxford: Blackwell/Munksgaard Publishing Company. 2003, 38-39.
• Andreasen FM, Andreasen JO. Concussion and subluxation. In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.).
• Oxford, Blackwell 2007. 404-410.
• Hermann NV, Lauridsen E, Ahrensburg SS, Gerds TA, Andreasen JO. Periodontal healing complications following concussion and subluxation injuries in the permanent dentition. A longitudinal cohort study. Dent Traumatol. 2012, 28: 386-393.
• DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M.International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012, 28:2-12.