Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth

Clinical diagnosis of pulp inflammation based on pulp oxygenation rates measured by pulse oximetry

INTRODUCTION

The objective of this study was to investigate correlations between pulp oxygenation rates (%SpO(2)) and clinical diagnoses of reversible pulpitis (RP), irreversible pulpitis (IP), or pulp necrosis (PN).

METHODS

Sixty patients who presented with a tooth with endodontic pathology were grouped according to a clinical diagnosis of either RP (n = 20), IP (n = 20), or PN (n = 20). The clinical diagnosis was based on the patient's dental history, periapical radiographs, clinical inspection, and percussion and thermal sensitivity testing. Pulse oximetry (PO) was used to determine pulp oxygenation rates. For every patient, one additional endodontically treated tooth (negative control [NC], n = 60) and one additional healthy tooth with healthy pulp status (positive control [PC], n = 60) were evaluated. Analysis of variance, the Tukey HSD test, and the Student's t test were used for statistical analysis.

RESULTS

The mean %SpO(2) levels were as follows: RP: 87.4% (standard deviation [SD] ±2.46), IP: 83.1% (SD ±2.29), PN: 74.6% (SD ±1.96), PC: 92.2% (SD ±1.84), and NC: 0% (SD ±0.0). There were statistically significant differences between RP, IP, and PN compared with NC and PC and between RP, IP, and PN (all P ≤ .01).

CONCLUSIONS

The evaluation of pulp oxygenation rates by PO may be a useful tool to determine the different inflammatory stages of the pulp to aid in endodontic diagnosis.

Contemporary management of tooth replacement in the traumatized dentition

Dental trauma can result in tooth loss despite best efforts at retaining and maintaining compromised teeth (Dent Traumatol, 24, 2008, 379). Upper anterior teeth are more likely to suffer from trauma, and their loss can result in significant aesthetic and functional problems that can be difficult to manage (Endod Dent Traumatol, 9, 1993, 61; Int Dent J 59, 2009, 127). Indeed, teeth of poor prognosis may not only present with compromised structure but trauma may also result in damage to the support tissues. Injury to the periodontium and alveolus can have repercussions on subsequent restorative procedures (Fig. 19). Where teeth are identified as having a hopeless prognosis either soon after the incident or at delayed presentation; planning for eventual tooth loss and replacement can begin at the early stages. With advances in both adhesive and osseointegration technologies, there are now a variety of options for the restoration of edentate spaces subsequent to dental trauma. This review aims to identify key challenges in the provision of tooth replacement in the traumatized dentition and outline contemporary methods in treatment delivery.

A review of root fractures: diagnosis, treatment and prognosis

Tooth fractures (crown or root fractures) are commonly encountered emergencies in a dental clinic. Root fractures are defined as fractures involving the dentine, cementum and pulp. They are broadly classified as horizontal and vertical root fractures. They may be clinically challenging cases to treat as, usually, treatment of such cases requires an interdisciplinary/multidisciplinary approach for complete rehabilitation of teeth. For a successful outcome, it is imperative to arrive at an appropriate diagnosis and design a treatment plan accordingly as soon as possible.This review article discusses the various types of root fractures, their diagnosis and treatment, along with the factors affecting their healing and prognosis.

CLINICAL RELEVANCE

Treatment of root fractures depends on a number of factors such as, position of fracture line, mobility of tooth and pulpal status. Thus clinicians must have thorough knowledge and adequate clinical experience to treat them properly.

Biomimetic approach to extensive fracture of anterior teeth--a case report

The fracture of anterior teeth in children and adolescents is a common injury. When most tooth structure is compromised and the broken fragment is not recovered, its restoration can become rather complex to both dentist and dental technician. Restoration of single anterior elements is one of the most demanding challenges in fixed prosthodontics. This article describes a clinical case of a 13-year-old patient with an extensive fractured central incisor and contra lateral incisor. Endodontic treatment was performed on both teeth, and a temporary removable appliance was made for esthetics. One month later, an indirect esthetic post and core was made for each tooth, and provisionals were placed. After a 6-month period of soft tissue stabilization, two pressed all-ceramic crowns were fabricated and bonded to the preparations. The authors believe this to be a stable long-term option relative to the reminiscent tooth structure, esthetic demand, and occlusal features of the case.

Education on and prevention of dental trauma: it's time to act!

Dental trauma is, unfortunately, not uncommon and may be even more prevalent in high-risk populations. It should be emphasized and acknowledged that many cases of dental trauma are preventable. Appropriate management includes primary prevention, i.e. avoidance of pathology development, and secondary prevention, i.e. early diagnosing and treatment of the pathology before significant morbidity occurs. The aim of this article is to provide a review of the current dental trauma literature with regard to education and knowledge and with relevance to primary and secondary prevention. As the duty of providing the public with measures for the maintenance of proper oral health is of the dental profession, the responsibility of providing primary and secondary prevention of dental trauma is of dentists, dental hygienists, and dental nurses. They may, and should, educate other medical, paramedical, and non-medical professionals, taking into account that those non-dental professionals could not maintain a high level of knowledge and service regarding dental trauma without a continuous backing by the dental professionals. It should be remembered that as the prevalence of dental decay has reduced in the Western world during recent decades, dental trauma plays a significant part in causing dental morbidity and mortality (tooth loss). It seems that now is the time to act for the benefit of our community and move from 'treating' toward 'managing' risk factors and prevention.

Microscopic evaluation of induced tooth movement in traumatized teeth: an experimental study in rats

The clinical management of orthodontic patients with dental trauma before or during the treatment is mainly founded on clinical experience, expert opinions, and individual case reports. It is proposed in the literature that teeth sustaining mild trauma with minor damage to the periodontium (e.g. subluxation) should be followed for a period of time before being subjected to orthodontic forces. A minimum period of 3 months has been proposed. In this study, we used an animal model to investigate whether shorter observation periods could be established in case of mild trauma. The periradicular region of rat molars was examined microscopically to determine the biological events of tooth movement started 15 and 30 days after intentional subluxation using an experimental method to induce dentoalveolar trauma. Thirty adult male Wistar rats were assigned to 6 groups (n = 5): Group 1 (control - no trauma/orthodontic movement); Group 2: the animals received an orthodontic device and were sacrificed after 7 days; Groups 3 and 4: dentoalveolar trauma (subluxation) was experimentally induced by the application of an axial force of 900 cN on the occlusal surface of the maxillary right first molar, and the animals were sacrificed after 22 and 37 days, respectively; and Groups 5 and 6: 15 and 30 days, respectively, after force application, an orthodontic device was installed and the rats were sacrificed 7 days later. In G5 and G6, the periodontal ligament and pulp tissue were rich in cellular elements and blood vessels, the alveolar bone was preserved, and the root surface presented only very small areas of surface resorption (cementum), maintaining the characteristics of normality. In conclusion, the microscopic alterations in the gingival and periodontal tissues in response to an experimentally induced mild dentoalveolar trauma simulating subluxation were not sufficient to contraindicate starting the orthodontic movement 15 and 30 days after trauma.

Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth

The regeneration of immature permanent teeth following trauma could be beneficial to reduce the risk of fracture and loss of millions of teeth each year. Regenerative endodontic procedures include revascularization, partial pulpotomy, and apexogenesis. Several case reports give these procedures a good prognosis as an alternative to apexification. Care is needed to deliver regenerative endodontic procedures that maintain or restore the vitality of teeth, but which also disinfect and remove necrotic tissues. Regeneration can be accomplished through the activity of the cells from the pulp, periodontium, vascular, and immune system. Most therapies use the host's own pulp or vascular cells for regeneration, but other types of dental stem cell therapies are under development. There are no standardized treatment protocols for endodontic regeneration. The purpose of this article is to review the recent literature and suggest guidelines for using regenerative endodontic procedures for the treatment of permanent immature traumatized teeth. Recommendations for the selection of regenerative and conventional procedures based on the type of tooth injury, fracture type, presence of necrosis or infection, periodontal status, presence of periapical lesions, stage of tooth development, vitality status, patient age, and patient health status will be reviewed. Because of the lack of long-term evidence to support the use of regenerative endodontic procedures in traumatized teeth with open apices, revascularization regeneration procedures should only be attempted if the tooth is not suitable for root canal obturation, and after apexogenesis, apexification, or partial pulpotomy treatments have already been attempted and have a poor prognosis.

Splinting--when and how?

The prognosis of a tooth following trauma is critical. This depends on various factors, including the type of splint used for immobilization and the immobilization period. This article discusses the above factors with an added note on splint removal.

CLINICAL RELEVANCE

This article is relevant for clinicians who treat traumatic injuries as it should help them to decide on the type of splint to be used and the period of immobilization.

Treatment of tooth discoloration after the use of white mineral trioxide aggregate

INTRODUCTION

A number of vital pulp therapy techniques have been recommended to preserve pulp vitality in teeth with complicated crown fractures, especially in young patients. Calcium hydroxide has been the gold standard as a pulp capping material, but recently mineral trioxide aggregate (MTA) has been recommended. This case report describes the treatment of tooth discoloration caused by white MTA (WMTA) used for the management of a complicated crown fracture.

METHODS

A partial pulpotomy was performed with the use of WMTA after a complicated crown fracture of the upper right central incisor. Seventeen months later, the WMTA was removed because of tooth discoloration, and internal bleaching was performed.

RESULTS

Upon access, the WMTA was completely discolored. After it was removed, a significant color change was observed in the tooth crown, which was further improved with internal bleaching. The tooth remained vital, and a dentin bridge was confirmed clinically and radiographically.

CONCLUSIONS

The recommendation to use WMTA for vital pulp therapy in the esthetic zone may need to be reconsidered. Should discoloration occur with the use of WMTA, the technique described may be used to improve the esthetics.

Incisor reduction: a provisional aesthetic technique for traumatised teeth

Patients in the mixed dentition who have suffered severe extrusion or avulsion injuries often present with difficult treatment decisions, especially when the initial emergency care has been compromised. Here we describe a well-tolerated, aesthetically acceptable and conservative method for treating such patients until a definitive treatment plan is possible.

Facial injury in sport

Sports are a common cause of facial injury. A wide variety of facial injuries occurs during sports. Severity of these injuries varies greatly. Understanding the diagnosis and treatment of these injuries is important to those participating in the health care of the athlete. Injuries that may threaten the airway or vision or cause bleeding are particularly crucial to understand. Dental injuries such as tooth fracture and tooth avulsion may need to be treated urgently in many cases. Facial lacerations may damage underlying structures, including the lacrimal system, facial nerve, or parotid duct. Closure of facial lacerations involves several considerations, such as cosmesis, method of wound closure, and complexity of the wound. Facial fractures occur commonly in sports, and familiarity with the various types and levels of severity is of key importance. Return-to-play guidelines after facial injury have yet to be established. Use of protective equipment can prevent facial injuries and protect athletes when returning to play after facial injury has occurred.

Histological evaluation of experimentally induced subluxation in rat molars and its implications on the management of orthodontic treatment

The purpose of this study was to evaluate the histological alterations occurred in the periradicular region of rat molars after intentional subluxation using an experimental method to induce dentoalveolar trauma. Eighteen adult male Wistar rats (Rattus norvegicus albinus) were selected for the study. The dentoalveolar trauma was experimentally induced by the application of an occlusogingival force on the occlusal surface of the maxillary right first molar using a tensiometer secured on a fully articulated support with adjustable steel shafts. The animals were assigned to six groups (n = 3), according to the intensity of the force applied to induce trauma: Group I (GI, control) - no force application; Groups II-VI (GII-GVI) - the animals were subjected to 600, 700, 800, 900 and 1000 cN force, respectively. After experimental induction of trauma, the animals were sacrificed by anesthetic overdose and the right maxillas were removed and processed for histological analysis under light microscopy. In the animals of GII, GIII and GIV, the histological alterations were similar to those described for GI. GVI (1000 cN) presented the most severe alterations, with the occurrence of buccal bone plate fracture, alveolar fracture and root fracture, which are not present in mild traumatic injuries like subluxation. The 900 cN force (GV) was capable to produce clinical and histological alterations in the gingival and periodontal tissues compatible with those observed in subluxation.

Urgências em traumatismos dentários: classificação, características e procedimentos

OBJETIVO: Discutir os aspectos das urgências odontológicas relacionadas aos traumatismos dentários, disponibilizando mais informações para médicos pediatras ou plantonistas de serviços de atendimento de urgências e emergências. FONTES DE DADOS: O levantamento dos dados foi realizado na base de dados Pubmed e Bireme, selecionando os artigos dos últimos 13 anos. As palavras-chave utilizadas foram: traumatismo dentário, dente decíduo e dente permanente. Os critérios de inclusão utilizados foram: artigos em inglês e português sobre incidência, prevalência e etiologia, guias de procedimentos e casos clínicos apenas de traumatismo dentário, sendo excluídos artigos de clareamento de dentes traumatizados, traumas faciais ósseos e casos clínicos de acompanhamento reduzido. SÍNTESE DOS DADOS: Os dados foram descritos de forma concisa para se tornar um guia de fácil leitura e rápido acesso em relação à conduta, necessidade de atendimento imediato e correta escolha de soluções para armazenagem dos dentes e fragmentos. CONCLUSÕES: O conhecimento sobre o assunto, a agilidade no tratamento de urgência e o correto encaminhamento do paciente proporcionam melhor prognóstico.

Minor traumatic injuries to the permanent dentition

Treatment of traumatized teeth generally occurs in two phases: short-term emergency treatment and stabilization followed by endodontic management and review. These authors recently reviewed the endodontic considerations in the treatment of traumatized permanent anterior teeth, and in this article review the early management of traumatized permanent teeth. Preoperative assessment and emergency management are emphasized, as is the treatment of immature teeth for which continued development of the root system must be encouraged. Factors influencing long-term prognosis are discussed and the influence of various management strategies evaluated.

Late reposition of a lateral luxated maxillary incisor with an immature apex

Here we describe an unusual trauma case. A recently erupted permanent upper-right incisor sustained a lateral luxation when a 5-year-old girl on a playground climbing net dropped off, catching the right upper incisor in the net. The tooth was laterally luxated in vestibular direction, and no other signs of injury occurred. A dental practitioner could not reposition the bony locked tooth. Four days later, the girl came to our clinic, and we performed an incomplete repositioning of the tooth and made a flexible splint. Controls were made at 1, 6, and 12 weeks and at 6, 12, 18, and 24 months later. The 24-month follow-up clinical examination revealed the patient to be asymptomatic and the tooth to be completely functional, and the recall radiograph showed further apical root growth. The implications of a late incomplete reposition of laterally luxated permanent teeth with immature apices are discussed.

Treatment of horizontal root fracture: a case report

Radicular fractures in permanent teeth are uncommon injuries among dental traumas, being only 0.5-7% of the cases. Traumatic dental injuries occur more frequently in young patients, and vary in severity from enamel fractures to avulsions.

The magnitude of these problems is confirmed by statistical data on the prevalence of dental trauma during childhood and adolescence.

Fracture occurs often in the middle-third of the root and rarely at the apical-third. The present paper reports a clinical case of a horizontal radicular fracture located between the middle- and apical-third of a upper left-central incisors followed-up over 4 years.