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  • 1. Dental Traumatology 2001; 17: 49–52 Copyright C Munksgaard 2001Printed in Denmark . All rights reserved DENTAL TRAUMATOLOGY ISSN 1600-4469Editor’s noteThe International Association of Dental Traumatology (IADT) has developed guidelines for the treatment oftraumatic dental injuries. Dental Traumatology will publish these guidelines over the next few issues of the journal.In addition, selected cases will be shown to illustrate these treatment guidelines. This issue will continue withthe guidelines for the treatment of traumatic injuries to the primary dentition.Guidelines for the evaluation andmanagement of traumatic dental injuriesCommittee: M. T. Flores, J. O. Andreasen, L. K. BaklandContributors: B. Feiglin, J. L. Gutmann, K. Oikarinen, T. R. Pitt Ford, A. Sigurdsson, M. Trope, William F. Vann Jr. Because the management of injuries to the primaryI. Introduction and permanent dentition differs significantly, separateEpidemiological studies reveal that one out of two guidelines were developed for children with primarychildren sustain a dental injury, most often between the dentition (Table 2) and cases where permanent teethages of 8 and 12. Crown fracture is the most frequent are involved. In addition, these guidelines do not ad-type of trauma, generally resulting from accidents, dress issues relating to the diagnosis and treatment ofsport activities or violence. In most dental trauma, a major facial trauma of the bone and soft tissue, whichrapid and appropriate treatment can lessen its impact is a critical first step in the overall management offrom both an oral health and an aesthetic standpoint. trauma patients. The evaluation and treatment of New technology and an improved understanding maxillofacial trauma which may coexist with dentalof the inflammatory process have led to a more con- trauma, goes beyond the scope of these recommenda-servative approach in managing dental trauma. The tions.International Association of Dental Traumatology(IADT), conscious of the variation in the treatment of Classification of diagnosis and therapy (*)dental trauma has developed these guidelines as atype of consensus statement. These guidelines (Table The classifications listed below summarize diagnostics1) reflect much thoughtful discussion among members steps and therapeutic interventions and will be refer-of the IADT as well as a detailed review of interna- enced throughout the guidelines.tional dental literature. In cases in which the data did x Conditions for which there is evidence and/ornot appear conclusive, recommendations were based general agreement that a given procedure oron the consensus opinion of the IADT board mem- treatment is beneficial, useful, and effective.bers. xx Conditions for which there is conflicting evi- Guidelines are needed to assist dentists as well as dence and/or a divergence of opinion about theother health care professionals in delivering the best usefulness/efficacy of a procedure or possible in the most efficient manner. It is very xxx Conditions for which there is evidence and/orimportant to promote public awareness and to edu- general agreement that a procedure/treatment iscate the population at greatest risk for dental injury. not useful/effective and in some cases may beTherefore, this report includes basic information on harmful.both prevention and first aid. The correct applicationof these techniques immediately following the trauma (*) Ryan et al. ACC/AHA guidelines for the manage-should improve short and long-term outcome. ment of patients with acute myocardial infarction. 49
  • 2. GuidelinesGeneral references reasen JO, Andreasen FM, editors. Textbook and color atlas of traumatic injuries to the teeth, 3rd edn. Copenhagen: Munks-Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Trau- gaard; 1994. matic dental injuries. a manual. Copenhagen: Munksgaard; Cvek M. Changes in the treatment of crown-fractured teeth during 1999. the last two decades. In: Proccedings of the Second InternationalAndreasen JO, Andreasen FM. Textbook and color atlas of trau- Conference on Dental Trauma; 1991. p. 53–64. matic injuries to the teeth, 3rd edn. Copenhagen: Munksgaard; Ryan TJ, Anderson JL, Antman EM, Brannif BA, Brooks NH, 1994. Califf RM, et al. ACC/AHA guidelines for the management ofAndreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries patients with acute miocardial infarction: a report of the Ameri- to primary and permanent teeth in a Danish population sample. can College of Cardiology/American Heart Association Task Int J Oral Surg 1972;1:235–9. Force on practice guidelines (Committee on Management ofBlomlof L. Milk and saliva as possible storage media for traumatic- Myocardial Infarction). J Am Coll Cardiol 1996;28:1328–428. ally exarticulated teeth prior to replantation. Swed Dent J Tronstad L. Pulp reactions in traumatized teeth. In: Gutmann JL, 1981;Suppl 8:1–26. Harrison JW, editors. Proceedings of the International Confer-Cvek, M. Endodontic management of traumatized teeth. In: And- ence on Oral Trauma. AAE Chicago, Illinois; 1986.Table 1. Guidelines for luxated and avulsed primary teeth Concussion Subluxation Lateral luxation Intrusion Extrusion AvulsionDiagnosisClinical findings Tooth tender Tooth is The tooth is displaced Tooth is usually displaced Tooth is mobile and Tooth is out of the to touch. No mobile but laterally with the crown through the labial bone plate extruded from the socket socket mobility or not usually in a palatal sulcular displaced. direction bleeding Sulcular bleedingRadiographic Take one radiograph (B) Take one radiograph (A) Take two radiographs (BπC) Take one radiograph (B) Take one radiograph (B)findings No radiographic Increased periodontal When the apex is displaced A radiographic abnormalities are expected space apically is best toward or through the labial examination is essential seen on the occlusal bone plate, the apical tip can to ensure that the radiograph be visualized and appears missing tooth is not shorter than its contralateral intruded (B) When the apex is displaced towards the permanent tooth germ, the apical tip cannot be visualized and tooth appears elongatedTreatment Observation If there is no occlusal If the apex is displaced Extract or reposition Most often the avulsed interference, the tooth is toward or through the labial (**) primary tooth should allowed to reposition bone plate, the tooth is left not to be replanted (3) spontaneously, for spontaneous (**) otherwise, reposition repositioning (**) and splint as needed If the apex is displaced into (**) the developing tooth germ, extract (**)Patient Soft diet for 10–14 daysinstructions Brush teeth with a soft toothbrush after each meal Topical use of chlorhexidine twice a day for one week Follow up (see Table)(A) Occlusal and (B) periapical central angle (size 2 film, horizontal view). (C) Extraoral lateral.Table 2. Follow up schedule of acute dental trauma – primary dentition Root fracture Lateral luxation/Extrusion Concussion/ SpontaneousTime No displacement Extraction Subluxation Splint used repositioning Intrusion Avulsion1 week SπC C C2–3 weeks SπC C C3–4 weeks C6–8 weeks C C C C C6 months C C C C1 year C C* C C C CEach subsequent year until exfoliation C C C* C* C*SΩSplint removal. CΩClinical and radiographic exam. * Radiographic monitoring until eruption of the permanent successors.50
  • 3. GuidelinesFig. 1. A. Lateral luxation of primary maxillary central incisors. B. Lateral radiograph reveals that the apices of the central incisors havebeen forced through the facial bone plate. C. Occlusal radiograph at the time of the injury showing widened periodontal space apically.D. Spontaneous realignment of teeth at the 2-month follow-up control. E. Radiograph at 2-month follow-up control. Healing of the facialbone plate. F. Clinical condition at 2 year 8 month follow-up control. Teeth are asymptomatic, vital and in original alignment. G. Lateralradiograph at 2 year 8 month follow-up showing roots within the facial bone plate. H. Occlusal view at the 2 year 8 month follow-upcontrol. Note the pulp obliteration of maxillary central incisors. (Case provided by Dr. Maria Theresa Flores.). 51
  • 4. Guidelines Fig. 2. A. Clinical view of a 36-month-old child after intrusion of maxillary right central incisor. Only the incisal tip is visible. No soft tissue or injuries to adjacent teeth are noted. B. A periapical radiograph at the time of the initial exam confirms the complete intrusion of the right incisor. No apparent root fractures are present. C. Lateral radiograph at the time of the initial exam. The apex of the intruded tooth was facial to the developing permanent tooth, prompting a clinical decision to allow an opportunity for reeruption of the tooth. D. Clinical view 6 weeks later. The tooth shows signs of reeruption and the child is free of symptoms or signs of related pathology. E. Six-month recall. Tooth has almost fully reerupted and the child is free of symptoms or related pathology. F. Radio- graph at 16-month recall. Early signs of calcific degeneration are seen on the right centralincisor and almost complete calcific regeneration on the left central incisor. No other pathology is noted. G. Clinical picture at 16-monthrecall. The patient is asymptomatic. Maxillary left central incisor has a slightly golden color indicative of calcification of the pulp chamber.(Case provided by Dr. William F. Vann Jr.)52