DENTAL TRAUMA GUI DELI NES

Revi sed 2011

CONTENT:
Sec t i on 1. Fr ac t ur es and l ux at i ons of per manent t eet h
Sec t i on 2. Avul si on of per manent t eet h
Sec t i on 3. Tr aumat i c i nj ur i es t o pr i mar y t eet h

Disclaimer: These guidelines are intended to provide information for health care providers caring for patients with dental injuries. They represent the current best evidence based on
literature research and professional opinion. As is true for all guidelines, the health care provider must apply clinical judgment dictated by the conditions present in the given traumatic situation.
The IADT does not guarantee favorable outcomes from following the Guidelines, but using the recommended procedures can maximize the chances of success.
These Guidelines have been endorsed by the following professional organizations: The American Association of Endodontists

INTRODUCTION
Traumatic dental injuries (TDIs) occur with great frequency in preschool, school age children and young adults comprising 5% of all injuries for which people seek treatment.
1,2
A twelve
year review of the literature reports that 25% of all school children experience dental trauma and 33% of adults have experienced trauma to the permanent dentition with the majority of injuries
occurring before age 19.
3
Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported for the permanent dentition.
1,4,5
TDIs
present a challenge to clinicians worldwide. Consequently, proper diagnosis treatment planning and followup are critical to assure a favorable outcome.
Guidelines, among other things, should assist dentists, other health care professionals and patients in decision making. Also, they should be credible, readily understandable and practical
with the aim of delivering appropriate care as effectively and efficiently as possible.
The following guidelines by the International Association of Dental Traumatology (IADT) represent an updated set of guidelines based on the original guidelines published in 2007.
6-8
The
update was accomplished by doing a review of the current dental literature using EMBASE, MEDLINE, and PUBMED searches from 1996-2011 as well as a search of the journal of Dental
Traumatology from 2000 to 2011. Search words included tooth fractures, root fractures, tooth luxation, lateral luxation and permanent teeth, intruded permanent teeth, and luxated permanent
teeth.
The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. It is understood that subsequent treatment may require secondary and tertiary
interventions involving specialist consultations, services and/or materials/methods not always available to the primary treating clinician.
The IADT published its first set of guidelines in 2001and updated them in 2007.
6-13
As with the previous guidelines, the working group included experienced investigators and clinicians
from various dental specialties and general practice. This revision represents the best evidence based on the available literature and expert professional judgment. In cases where the data did not
appear conclusive, recommendations are based on the consensus opinion of the working group followed by review by the members of the IADT Board of Directors. It is understood that guidelines
are to be applied with evaluation of the specific clinical circumstances, clinicians judgement and patients characteristics, including but not limited to compliance, finances and understanding of
the immediate and long-term outcomes of treatment alternatives versus non-treatment. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the Guidelines, but
believe that their application can maximize the chances of a favorable outcome.
Guidelines undergo periodic updates. These 2012 Guidelines will appear in three parts:
Part I: Fractures and luxations of permanent teeth
Part II: Avulsion of permanent teeth
Part III: Injuries in the primary dentition
Guidelines offer recommendations for diagnosis and treatment of specific TDIs; however, they do not provide the comprehensive nor detailed information found in textbooks, the scientific
literature and most recently the Dental Trauma Guide (DTG) which can be accessed on
http://www.dentaltraumaguide.org . Additionally, the DTG, also available on the IADTs web page http://www.iadt-dentaltrauma.org provides a visual and animated documentation of treatment
procedures as well as estimations of prognosis for the various TDIs.
GENERAL RECOMMENDATIONS

Clinical Examination
Detailed description of protocols, methods and documentation for clinical assessment of TDIs can be found in current textbooks.
1,14,15

Radiographic Examination
Several projections and angulations are routinely recommended but the clinician should decide which radiographs are required for the individual. The following are suggested:
Periapical radiograph with a 90
o
horizontal angle with central beam through the tooth in question.
Occlusal view.
Periapical radiograph with lateral angulations from the mesial or distal aspect of the tooth in question.

Emerging imaging modalities such as cone beam computerized tomography (CBCT) provide enhanced visualization of TDIs, particularly root fractures and lateral luxations, monitoring of
healing and complications. Availability is limited and its use not currently considered routine, however, specific information is available in the scientific literature.
16,17



Splinting: Type and Duration
Current evidence supports short-term, non-rigid splints for splinting of luxated, avulsed and root-fractured teeth. While neither the specific type of splint nor the duration of splinting are
significantly related to healing outcomes (except for avulsion where the time may be of importance), it is considered best practice in order to maintain the repositioned tooth in correct position,
provide patient comfort and improved function.
18-23

Use of Antibiotics
There is limited evidence for use of systemic antibiotics in the management of luxation injuries and no evidence that antibiotic coverage improves outcomes for root fractured teeth.
Antibiotic use remains at the discretion of the clinician as TDIs are often accompanied by soft tissue and other associated injuries, which may require other surgical intervention. In addition, the
patients medical status may warrant antibiotic coverage.
23,24


Sensibility Tests
Sensibility testing refers to tests (cold test and/or electric pulp test) attempting to determine the condition of the pulp. At the time of injury sensibility tests frequently give no response
indicating a transient lack of pulpal response. Therefore, at least two signs and symptoms are necessary to make the diagnosis of necrotic pulp. Regular followup controls are required to make a
pulpal diagnosis.

Immature versus Mature Permanent Teeth
Every effort should be made to preserve pulpal vitality in the immature permanent tooth in order to ensure continuous root development. The vast majority of TDIs occur in children and
teenagers where loss of a tooth has lifetime consequences. The immature permanent tooth has considerable capacity for healing after traumatic pulp exposure, luxation injury and root fractures.
Pulp exposures secondary to TDIs are amenable to proven conservative pulp therapies that maintain vital pulp tissue and allow for continued root development.
25-29
In addition, emerging therapies
have demonstrated the ability to revascularize/regenerate vital tissue in canals of immature permanent teeth with necrotic pulps.
30-35
Teeth frequently sustain a combination of several injuries.
Studies have demonstrated that crown fractured teeth with or without pulp exposure and associated luxation injury experience a greater frequency of pulp necrosis.
36
The mature permanent tooth
that sustains a severe TDI after which pulp necrosis is anticipated is amenable to preventive pulpectomy as root development is substantially completed.

Pulp Canal Obliteration
Pulp canal obliteration (PCO) occurs more frequently in teeth with open apices which have suffered a severe luxation injury. It usually indicates ongoing pulpal vitality. Extrusion,
intrusion and lateral luxation injuries have high rates of PCO.
37,38
Subluxated and crown fractured teeth also may exhibit PCO although with less frequency.
39
Additionally PCO is a common
occurrence following root fractures.
40,41


Patient Instructions
Patient compliance with follow-up visits and home care contributes to better healing following a TDI. Both patients and parents of young patients should be advised regarding care of the
injured tooth/teeth for optimal healing, prevention of further injury by avoidance of participation in contact sports, meticulous oral hygiene and rinsing with an antibacterial such as chlorhexidine
gluconate 0.1% alcohol free for 1-2 weeks.

Additional Resources
Besides the general recommendations above, clinicians are encouraged to access the DTG, the journal Dental Traumatology, and other journals for information pertaining to treatment
delay,
42
intrusive luxations,
43-52
root fractures,
24,53-57
pulpal management of fractured and luxated teeth,
58-70
splinting,
18-22,71
and antibiotics.
72




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th
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92
PERMANENT TEETH




1. Treatment guidelines for fractures of teeth and alveolar bone Followup Procedures
for fractures of teeth
and alveolar bone
+

Favorable and Unfavorable outcomes
include some, but not necessarily all, of the
following:
INFRACTION
Clinical findings

Radiographic findings

Treatment

Follow-Up

Favorable Outcome

Unfavorable Outcome








An incomplete fracture
(crack) of the enamel
without loss of tooth
structure.
Not tender. If tenderness
is observed evaluate the
tooth for a possible luxation
injury or a root fracture.
No radiographic
abnormalities.
Radiographs recom-
mended: a periapical view.
Additional radiographs are
indicated if other signs or
symptoms are present.
In case of marked infractions, etching
and sealing with resin to prevent
discoloration of the infraction lines.
Otherwise, no treatment is necessary.
No follow-up is
generally needed for
infraction injuries unless
they are associated with
a luxation injury or other
fracture types.
Asymptomatic
Positive response
to pulp testing.
Continuing root
development in
immature teeth.

Symptomatic
Negative response to
pulp testing.
Signs of apical
periodontitis.
No continuing root
development in
immature teeth.
Endodontic therapy
appropriate for stage of
root development is
indicated.


ENAMEL FRACTURE
Clinical findings

Radiographic findings

Treatment

Followup

Favorable Outcome

Unfavorable Outcome
A complete fracture of the
enamel.
Loss of enamel. No
visible sign of exposed
dentin.
Not tender. If tenderness
is observed evaluate the
tooth for a possible luxation
or root fracture injury.
Normal mobility.
Sensibility pulp test
usually positive.
Enamel loss is visible.
Radiographs recom-
mended: periapical,
occlusal and eccentric
exposures. These are
recommended in order to
rule out the possible
presence of a root fracture
or a luxation injury.
Radiograph of lip or
cheek to search for tooth
fragments or foreign
materials.
If the tooth fragment is available, it
can be bonded to the tooth.
Contouring or restoration with
composite resin depending on the
extent and location of the fracture.
6-8 weeks C
++

1 year C
++

Asymptomatic
Positive response
to pulp testing.
Continuing root
development in
immature teeth.
Continue to next
evaluation.
Symptomatic
Negative response to
pulp testing.
Signs of apical
periodontitis
No continuing root
development in
immature teeth.
Endodontic therapy
appropriate for stage of
root development is
indicated.

+
= for crown fractured teeth with concomitant luxation injury, use the luxation followup schedule.
C
++ =
clinical and radiographic examination.








Follow-Up Procedures
for fractures of teeth
and alveolar bone
+

Favorable and Unfavorable outcomes
include some, but not necessarily all, of the
following:
ENAMEL-DENTIN-
FRACTURE

Clinical findings

Radiographic findings

Treatment

Follow-Up

Favorable Outcome

Unfavorable Outcome
A fracture confined to
enamel and dentin with loss
of tooth structure, but not
exposing the pulp.
Percussion test: not
tender. If tenderness is
observed, evaluate the
tooth for possible luxation
or root fracture injury.
Normal mobility.
Sensibility pulp test
usually positive.
Enamel-dentin loss is
visible.
Radiographs recom-
mended: periapical,
occlusal and eccentric
exposure to rule out tooth
displacement or possible
presence of root fracture.
Radiograph of lip or
cheek lacerations to search
for tooth fragments or
foreign materials.
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 more permanent
restoration using a bonding agent and
composite resin, or other accepted
dental restorative materials
If the exposed dentin is within 0.5mm of
the pulp (pink, no bleeding) place calcium
hydroxide base and cover with a material
such as a glass ionomer.
6-8 weeks C
++

1 year C
++


Asymptomatic
Positive response
to pulp testing.
Continuing root
development in
immature teeth
Continue to next
evaluation

Symptomatic
Negative response to
pulp testing.
Signs of apical
periodontitis.
No continuing root
development in
immature teeth.
Endodontic therapy
appropriate for stage of
root development is
indicated.


ENAMEL-DENTIN-PULP
FRACTURE

Clinical findings

Radiographic findings

Treatment

Favorable Outcome

Unfavorable Outcome
A fracture involving
enamel and dentin with loss
of tooth structure and
exposure of the pulp.
Normal mobility
Percussion test: not
tender. If tenderness is
observed, evaluate for
possible luxation or root
fracture injury.
Exposed pulp sensitive to
stimuli.
Enamel dentin loss
visible.
Radiographs
recommended: periapical,
occlusal and eccentric
exposures, to rule out tooth
displacement or possible
presence of root fracture.
Radiograph of lip or
cheek lacerations to search
for tooth fragments or
foreign materials.
In young patients with immature, still
developing teeth, it is advantageous to
preserve pulp vitality by pulp capping or
partial pulpotomy. Also, this treatment
is the choice in young patients with
completely formed teeth.
Calcium hydroxide is a suitable material to
be placed on the pulp wound in such
procedures.
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.
6-8 weeks C
++

1 year C
++

Asymptomatic.
Positive response
to pulp testing.
Continuing root
development in
immature teeth.
Continue to next
evaluation.
Symptomatic.
Negative response to
pulp testing.
Signs of apical
periodontitis.
No continuing root
development in
immature teeth.
Endodontic therapy
appropriate for stage of
root development is
indicated.
+
= for crown fractured teeth with concomitant luxation injury, use the luxation followup schedule
C
++
= clinical and radiographic examination.








Follow-Up Procedures
for fractures of teeth
and alveolar bone +
Favorable and Unfavorable outcomes
include some, but not necessarily all, of the
following:
CROWN-ROOT
FRACTURE WITHOUT
PULP EXPOSURE

Clinical findings

Radiographic findings

Treatment

Follow-Up

Favorable Outcome

Unfavorable Outcome
A fracture involving
enamel, dentin and
cementum with loss of tooth
structure, but not exposing
the pulp.
Crown fracture extending
below gingival margin.
Percussion test: Tender.
Coronal fragment mobile.
Sensibility pulp test
usually positive for apical
fragment.
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.
Emergency treatment
As an emergency treatment a temporary
stabilization of the loose segment to
adjacent teeth can be performed until a
definitive treatment plan is made.
Non-Emergency Treatment Alternatives
Fragment removal only
Removal of the coronal crown-root
fragment and subsequent restoration of the
apical fragment exposed above the gingival
level.

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.
6-8 weeks C
++
1 year C
++


Asymptomatic
Positive response
to pulp testing.
Continuing root
development in
immature teeth
Continue to next
evaluation
Symptomatic
Negative response to
pulp testing.
Signs of apical
periodontitis.
No continuing root
development in
immature teeth.
Endodontic therapy
appropriate for stage of
root development is
indicated.
+=for crown fractured teeth with concomitant luxation injury, use the luxation followup schedule.
C++ =clinical and radiographic examination





Follow-Up Procedures
for fractures of teeth
and alveolar bone +
Favorable and Unfavorable outcomes
include some, but not necessarily all, of the
following:
CROWN-ROOT
FRACTURE WITH PULP
EXPOSURE

Clinical findings

Radiographic findings

Treatment

Follow-Up

Favorable Outcome

Unfavorable Outcome
A fracture involving
enamel, dentin, and
cementum and exposing
the pulp.
Percussion test: tender.
Coronal fragment mobile.
Apical extension of
fracture usually not visible.
Radiographs
recommended: periapical
and occlusal exposure.
Emergency treatment
As an emergency treatment a temporary
stabilization of the loose segment to
adjacent teeth.
In 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 apical
development, root canal treatment can be
the treatment of choice.
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
If 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
6-8 weeks C
++
1 year C
++



Asymptomatic
Positive response
to pulp testing.
Continuing root
development in
immature teeth
Continue to next
evaluation

Symptomatic
Negative response to
pulp testing.
Signs of apical
periodontitis.
No continuing root
development in
immature teeth.
Endodontic therapy
appropriate for stage of
root development is
indicated.

+
= for crown fractured teeth with concomitant luxation injury, use the luxation followup schedule
C
++
= clinical and radiographic examination;





Follow-Up Procedures
for fractures of teeth
and alveolar bone
Favorable and Unfavorable outcomes
include some, but not necessarily all, of the
following:
++

ROOT FRACTURE
Clinical findings Radiographic findings Treatment Favorable Outcome Unfavorable Outcome
The coronal segment may be
mobile and may be displaced.
The tooth may be tender to
percussion.
Bleeding from the
gingival sulcus may be noted.
Sensibility testing may give
negative results initially,
indicating transient or
permanent neural damage.
Monitoring the status of the
pulp is recommended.
Transient crown
discoloration (red or grey) may
occur.
The fracture involves the
root of the tooth and is in a
horizontal or oblique plane.
Fractures that are in the
horizontal plane can usually be
detected in the regular
periapical 90
o
angle film with
the central beam through the
tooth. This is usually the case
with fractures in the cervical
third of the root.
If the plane of fracture is
more oblique which is common
with apical third fractures, an
occlusal view or radiographs
with varying horizontal angles
are more likely to demonstrate
the fracture including those
located in the middle third.
Reposition, if displaced, the coronal
segment of the tooth as soon as possible.
Check position 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).
It is advisable to monitor healing for at
least one year to determine pulpal status.
If pulp necrosis develops, root canal
treatment of the coronal tooth segment to
the fracture line is indicated to preserve the
tooth.
4 Weeks S
+
, C
++
6-8 Weeks C
++
4 Months S
++
*, C
++

6 Months C
++
1 Year C
++

5 Years C
++

Positive response
to pulp testing (false
negative possible up
to 3 months).
Signs of repair
between fractured
segments.
Continue to next
evaluation.
Symptomatic
Negative response to
pulp testing (false
negative possible up to
3 months).
Extrusion of the
coronal segment.
Radiolucency at the
fracture line.
Clinical signs of
periodontitis or abscess
associated with the
fracture line.
Endodontic therapy
appropriate for stage of
root development is
indicated.

ALVEOLAR FRACTURE Clinical findings Radiographic findings Treatment Follow-Up Favorable Outcome Unfavorable Outcome
The fracture involves the
alveolar bone and may extend
to adjacent bone.
Segment mobility and
dislocation with several teeth
moving together are common
findings.
An occlusal change due to
misalignment of the fractured
alveolar segment is often
noted.
Sensibility testing may or
may not be positive.
Fracture lines may be
located at any level, from the
marginal bone to the root
apex.
In addition to the 3
angulations and occlusal film,
additional views such as a
panoramic radiograph can be
helpful in determining the
course and position of the
fracture lines.
Reposition any displaced segment and
then splint.
Suture gingival laceration if present.
Stabilize the segment for 4 weeks.
4 Weeks S
+
, C
++

6-8 Weeks C
++

4 Months C
++

6 Months C
++
1 Year C
++
5 Years C
++

Positive response
to pulp testing (false
negative possible up
to 3 months).
No signs of apical
periodontitis.
Continue to next
evaluation.
Symptomatic
Negative response to
pulp testing (false
negative possible up to
3 months).
Signs of apical
periodontitis or external
inflammatory root
resorption.
Endodontic therapy
appropriate for stage of
root development is
indicated.




S
+
=splint removal; S
++
=splint removal in cervical third fractures.
C
++
= clinical and radiographic examination.
++=Whenever 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.






2. Treatment Guidelines for Luxation Injuries

Follow-Up Procedures for
luxated permanent teeth
Favorable and Unfavorable outcomes include
some, but not necessarily all, of the following:
++

CONCUSSION Clinical findings Radiographic findings Treatment Favorable Outcome Unfavorable Outcome
The tooth is tender to touch
or tapping; it has not been
displaced and does not have
increased mobility.
Sensibility tests are likely to
give positive results.
No radiographic
abnormalities
No treatment is needed.
Monitor pulpal condition for at least one
year.
4 Weeks C
++
6-8 Weeks C
++

1 Year C
++

Asymptomatic
Positive response to
pulp testing
False negative
possible up to 3
months.
Continuing root
development in
immature teeth
Intact lamina dura
Symptomatic
Negative response to
pulp testing
False negative possible
up to 3 months
No continuing root
development in immature
teeth, signs of apical
periodontitis.
Endodontic therapy
appropriate for stage of
root development is
indicated.
SUBLUXATION Clinical findings Radiographic findings Treatment Follow-Up Favorable Outcome Unfavorable Outcome
The tooth is tender to touch
or tapping and has increased
mobility; it has not been
displaced.
Bleeding from gingival
crevice may be noted.
Sensibility testing may be
negative initially indicating
transient pulpal damage.
Monitor pulpal response until
a definitive pulpal diagnosis
can be made.
Radiographic abnormalities
are usually not found.
Normally no treatment is needed, however
a flexible splint to stabilize the tooth for
patient comfort can be used for up to 2
weeks.
2 Weeks S
+
, C
++
4 Weeks C
++
6-8 Weeks C
++
6 Months C
++
1 Year C
++

Asymptomatic
Positive response to
pulp testing
False negative
possible up to 3
months.
Continuing root
development in
immature teeth
Intact lamina dura
Symptomatic
Negative response to
pulp testing
False negative possible
up to 3 months
External inflammatory
resorption.
No continuing root
development in immature
teeth, signs of apical
periodontitis.
Endodontic therapy
appropriate for stage of
root development is
indicated.
EXTRUSIVE LUXATION
Clinical Findings Radiographic findings Treatment Follow-Up Favorable Outcome Unfavorable Outcome
The tooth appears elongated
and is excessively mobile.
Sensibility tests will likely
give negative results.

Increased periodontal
ligament space apically.
Reposition the tooth by gently re-inserting
It into the tooth socket.
Stabilize the tooth for 2 weeks using a
flexible splint.
In mature teeth where pulp necrosis is
anticipated or if several signs and symptoms
indicate that the pulp of mature or immature
teeth became necrotic, root canal treatment
is indicated.

2 Weeks S
+,
C
++

4 Weeks C
++
6-8 Weeks C
++

6 Months C
++
1 Year C
++
Yearly 5 years C
++

Asymptomatic
Clinical and
radiographic signs of
normal or healed
periodontium.
Positive response to
pulp testing (false
negative possible up to
3 months).
Marginal bone height
corresponds to that
seen radiographically
after repositioning.
Continuing root
development in
immature teeth.
Symptoms and
radiographic sign
consistent with apical
periodontitis.
Negative response to
pulp testing (false negative
possible up to 3 months).
If breakdown of marginal
bone, splint for an
additional 3-4 weeks.
External inflammatory
root resorption.
Endodontic therapy
appropriate for stage of
root development is
indicated.
S
+
=splint removal;
C
++
= clinical and radiographic examination.
++=Whenever 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.






Follow-Up Procedures
for luxated permanent
teeth
Favorable and Unfavorable outcomes
include some, but not necessarily all, of the
following:
++

LATERAL LUXATION Clinical findings Radiographic findings Treatment Favorable Outcome Unfavorable Outcome
The tooth is displaced,
usually in a palatal/lingual or
labial direction.
It will be immobile and
percussion usually gives a
high, metallic (ankylotic)
sound.
Fracture of the alveolar
process present.
Sensibility tests will likely
give negative results


The widened periodontal
ligament space is best seen on
eccentric or occlusal
exposures.
Reposition the tooth digitally or with
forceps 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.
Monitor the pulpal condition.
If the pulp becomes necrotic, root canal
treatment is indicated to prevent root
resorption.

2 Weeks S
+
, C
++

4 Weeks C
++

6-8 Weeks C
++
6 Months C
++

1 Year C
++
Yearly for 5 years C
++


Asymptomatic
Clinical and
radiographic signs of
normal or healed
periodontium.
Positive response to
pulp testing (false
negative possible up to
3 months).
Marginal bone height
corresponds to that
seen radiographically
after repositioning.
Continuing root
development in
immature teeth
Symptoms and
radiographic signs
consistent with apical
periodontitis.
Negative response to
pulp testing (false negative
possible up to 3 months).
If breakdown of marginal
bone, splint for an
additional 3-4 weeks.
External inflammatory
root resorption or
replacement resorption
Endodontic therapy
appropriate for stage of
root development is
indicated.

INTRUSIVE LUXATION
Clinical findings Radiographic findings Treatment Follow-Up Favorable Outcome Unfavorable
The tooth is displaced axially
into the alveolar bone.
It is immobile and percussion
may give a high, metallic
(ankylotic) sound.
Sensibility tests will likely
give negative results.


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.
Teeth with incomplete root formation
Allow eruption without intervention
If no movement within few weeks, initiate
orthodontic repositioning.
If tooth is intruded more than 7mm,
reposition surgically or orthodontically.
Teeth with complete root formation:
Allow eruption without intervention if tooth
intruded less than 3mm. If no movement
after 2-4 weeks, reposition surgically or
orthodontically before ankylosis can
develop.
If tooth is intruded beyond 7mm, 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.
2 Weeks S
+
, C
++

4 Weeks C
++
6-8 Weeks C
++
6 Months C
++
1 Year C
++
Yearly for 5 years C
++


Tooth in place or
erupting.
Intact lamina dura
No signs of
resorption.
Continuing root
development in
immature teeth.

Tooth locked in
place/ankylotic tone to
percussion.
Radiographic signs of
apical periodontitis
External inflammatory
root resorption or
replacement resorption.
Endodontic therapy
appropriate for stage of
root development is
indicated.
S
+
=splint removal;
C
++
= clinical and radiographic examination.
++=Whenever 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.




TASK FORCES

FRACTURES AND LUXATIONS:
Dr. J ens Andreasen, Denmark
Dr. Anthony DiAngelis, USA
Dr. Kurt Ebeleseder, Austria
Dr. David Kenny, Canada
Dr. Martin Trope, USA
Dr. Asgeir Sigurdsson, Iceland