Guidelines for the evaluation and management of traumatic dental injuries

The risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment: a systematic review and meta-analysis

PURPOSE

To identify the factors affecting the risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment.

METHODS

The study protocol followed the best practices of evidence-based medicine and was registered in PROSPERO. A comprehensive literature search was performed electronically in six databases (PubMed, Embase, SCOPUS, Web-of-Science, Lilacs, and Cochrane) on 18-09-2023. It was saved in EndNote-online and duplicates were removed. Selection of articles was performed in two stages, followed by data-extraction, risk of bias assessment, data-analysis, and meta-analysis. The quality of evidence for the outcomes was assessed by the GRADE-approach.

RESULTS

The study included six articles that had similar selection protocols with variations in duration from trauma to treatment and the observation period. Only one study employed pre-attachment fragment preparation and three performed post-attachment reinforcements. Overall loss of fragment was 20% (95%CI-13,30%). When the risk ratio for loss of restoration or fragment was compared, it was found to be 2.21 (95%CI-1.52,3.21) in uncomplicated crown fractures, 2.54 (95%CI-1.35,4.79) in complicated crown fractures. The risk of bias was found to be low in two and moderate in four studies. Grade of evidence for all the outcomes was very low.

CONCLUSION

Fragment loss was lowest in uncomplicated crown fractures where reinforcement had been performed, and highest when bonding was done in complicated crown fractures without reinforcement. The risk of fragment loss was higher than the loss of composite restorations.

Splinting in the management of dental trauma in the primary dentition: a systematic review

PURPOSE

The purpose of this study was to gather existing data on the efficacy of tooth splinting (TS) in patients with traumatized primary teeth, evaluating their overall prognosis and reported complications.

METHODS

Electronic searches were performed in seven databases up to Februray/2023. Clinical studies published in the last two decades and presenting the following characteristics were included: (a) reporting on children with traumatized primary teeth; (b) describing the efficacy of splinting those teeth. Studies describing imobilization of dental avulsion were excluded.

RESULTS

A total of 163 potentially relevant studies were initially found. After title/abstract screening, and full-text evaluation, three retrospective studies with moderate to high risk of bias were included. The studies described the outcomes of TS in primary teeth with luxation (intrusion, extrusion, lateral displacement), intra-alveolar root fracture, and/or alveolar fracture. High clinical success rate was observed for teeth with root fracture. Benefits of spliting teeth with lateral luxation were not identified, although it may be a reccomended approach. No study was found evaluating TS for alveolar fracture.

CONCLUSION

Based on a low level of evidence, the findings highlight a better clinical success rate of the use of TS in the management of deciduous teeth with root fractures.

Survival analysis of fragment reattachments and direct composite restorations in permanent teeth after dental traumatic injuries

BACKGROUND/AIM

In case of crown fractures after traumatic dental injuries, the affected teeth can be restored either with reattachment of the fractured fragment or with a direct composite restoration. So far, longevity data for reattachments and direct composite restorations with regard to different failure types (pulp necrosis and infection, restoration loss) are scarce. Therefore, the aim of this retrospective study was to evaluate the restorative and biological survival of reattached fragments and composite restorations after crown fractures in permanent teeth.

MATERIAL AND METHODS

Dental records of patients treated between 2000 and 2018 were retrospectively analysed regarding the restoration (reattachment or direct composite restorations) of teeth with crown fractures. Survival (no further intervention) and restorative and/or biological failure of all restored teeth were recorded. Statistical analysis was performed using Kaplan-Meier statistics, and the mean annual failure rates for two and 5 years were calculated. Furthermore, the effect of potential risk factors on survival was assessed. Log-rank tests and univariate Cox regression models (likelihood ratio tests) were used to assess the univariate effect of all variables of interest. Variables with a p-value ≤.10 were included in a multivariate Cox regression model with shared frailty (p < .05).

RESULTS

Overall, 164 patients with 235 teeth (uncomplicated crown fracture: N = 201, complicated crown fracture: N = 34) were included (1.6 ± 2.5 years observation time). Of these, 59 teeth were restored with reattachment of the fragment and 176 with a composite restoration. Overall, composite restorations had a significantly higher survival rate than reattachments (p = .002). The cumulative survival after 2 years was 42.9% and 65.0% for teeth treated with a reattachment (mAFR = 34.5%) and a composite restoration (mAFR = 19.3%), respectively. When differentiating between failure types, restoration failure and pulp necrosis were significantly more frequently detected in reattached crown fractures compared to composite restorations (restorative failure: p = .001; biological failure: p = .036). In the multivariate Cox regression model, the variable jaw and luxation significantly influenced the survival when the tooth was restored with a composite restoration. The survival was not influenced by the fracture type.

CONCLUSIONS

Restorative and biological failures were more frequently detected when the tooth was restored with a reattached fragment compared to a direct composite restoration. Both, restoration failure and pulp necrosis with infection should be considered as frequent complications after restoration of crown-fractured teeth which emphasizes the necessity of regular and short follow-up intervals throughout the first 2 years.

Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

The association of overjet with traumatic dental injuries: a systematic review protocol

REVIEW QUESTION

The objective of this review of association (etiology) is to identify the relationship between different overjet measurements and developing a traumatic dental injury (TDI) across different dentition stages. Specifically, the review will elucidate the critical level, in millimetres, at which an overjet will place an individual at an increased risk of developing a TDI within each specific dentition stage. The specific review questions are.

Manejo endodôntico de dentes reimplantados: revisão de literatura

O reimplante dentário destaca-se como um procedimento conservador, sendo a conduta não-protética que pode ser realizada em casos de avulsão, evitando sequelas estéticas, funcionais e psicológicas junto ao paciente. Para controlar os processos reabsortivos que se desencadeiam devido a lesão no ligamento periodontal, o tratamento endodôntico se faz necessário. Objetivo: apresentar uma revisão de literatura sobre o manejo endodôntico de dentes reimplantados, elucidando os aspectos clínicos, radiográficos e fisiológicos envolvidos no processo e, também, confeccionar um guia de consulta para prática clínica. Conclusão: O reimplante dentário auxilia no aspecto psicológico decorrente da perda dentária, sendo a endodontia uma etapa fundamental no processo. Ao final do tratamento Endodôntico de um dente re-implantado, com uso da medicação intracanal adeaquada, a saber hidróxido de cálcio,  espera-se um dente clinicamente assintomático e radiograficamente ausência de sinais de reabsorção e lesão apical. Contudo, o  acompanhamento clínico e radiográfico do paciente deve ser feito por pelo menos cinco anos.

National Athletic Trainers' Association Position Statement: Preventing and Managing Sport-Related Dental and Oral Injuries

OBJECTIVE

To provide athletic trainers, health care professionals, and all those responsible for the care of athletes with clinical recommendations for preventing and managing sport-related dental and oral injuries.

BACKGROUND

Participation in competitive sports continues to grow at both the interscholastic and intercollegiate levels. Therefore, exposure to, and the incidence of athletic-related injury, including orofacial injury, will also likely increase. At the time of this writing, the leading governing agencies for interscholastic (National Federation of State High School Associations) and intercollegiate (National Collegiate Athletic Association) sports require only protective orofacial equipment (eg, mouthguards) for 5 and 4, respectively, of their sanctioned sports. Although orofacial injuries represent a small percentage of all sport-related injuries, the financial burden associated with these injuries (eg, tooth avulsion) can exceed $15 000 over an adult life. Therefore, effective management of sport-related dental injuries is critical to the long-term financial, physical, and emotional health of people who have experienced dental trauma.

RECOMMENDATIONS

Based upon the current evidence regarding sport-related orofacial injury, we provide recommendations related to planning considerations, education, and mouthguard efficacy, material, fabrication, and care considerations. Additionally, suggested best practices for managing sport-related dental injury are also given for athletic trainers and other health care professionals.

Horizontal root fracture accompanied by luxation of coronal fragment in a maxillary central incisor: a case report

Root fracture injuries affect up to 7% of permanent teeth. This type of injury is rarely seen in teeth with open apices and depending on the fracture site, the prognosis is good. This case report describes a horizontal intra-alveolar root fracture in the middle third of a maxillary central incisor associated with an extrusive luxation of the coronal segment and its treatment in a 6-year-old girl. The patient was observed under a regular follow-up regime. After 2 years, clinical examination showed normal tooth color and position, with a positive response to the pulp test.

White mineral trioxide aggregate pulpotomies: Two case reports with long-term follow-up

This case report describes the partial pulpotomy treatment of complicated crown fractures of two cases by using white mineral trioxide aggregate (WMTA) with long-term follow-up. In the cases presented here, to injured incisor teeth were open apices and the pulp exposure site was large, so it was decided to perform vital pulpotomy with WMTA. Long-term follow-up examinations revealed that the treatment preserved pulpal vitality with continued root development and apex formation. WMTA may be considered as an alternative option for the treatment of traumatized immature permanent teeth.

The endodontic management of traumatized permanent anterior teeth: a review

Despite the many journal articles and reviews that have been published regarding the treatment of trauma to teeth, the endodontic management of these injuries is often still not fully understood. The purpose of this review is to establish clear and up-to-date guidelines for practitioners who are faced with treating dental injuries on a day-to-day basis, based on an assessment of current available scientific information relating to the endodontic management of these injuries. Treatment is discussed under the headings: infractions, uncomplicated crown fractures, complicated crown fractures, crown-root fractures, root fractures, luxation injuries, avulsion, root resorption, pulp canal obliteration and open-apex teeth. Emphasis is placed on the treatment of traumatized immature teeth where maintenance of pulp blood supply is important to encourage continued development of the root system. Only the treatment of traumatized permanent anterior teeth is reviewed. Information contained in this article is based on a review of the literature on dental trauma which involved a MEDLINE search using the key words "dental trauma" and the individual topics listed above. The guidelines produced by the International Association of Dental Traumatology, the American Academy of Pediatric Dentistry and the American Association of Endodontists were also reviewed and the recommendations contained in this paper are in concert with the major recommendations of these bodies.

Can Oral Health-Related Quality of Life Measures Substitute for Normative Needs Assessments in 11 to 12-year-old Children?

OBJECTIVES

1) assess the relationship between a measure of condition-specific oral health-related quality of life (OHRQoL) and the related normative need for dental treatments, and 2) test the diagnostic validity of the condition-specific OHRQoL measure for specific dental conditions in a group of primary school children.

METHODS

A cross-sectional study of all 11 to 12 year-olds carried out in a municipal area of Suphanburi province, Thailand. 1034 children (91.8%) were dentally examined to assess their normative needs for 6 types of treatment (dental caries, traumatic dental injuries, enamel defects, periodontal, orthodontic and prosthodontic treatment). OHRQoL was assessed using the Child-OIDP index and its Condition-Specific impacts measure for the 6 treatment types.

RESULTS

The prevalence of specific types of normative needs ranged from 3.2% (prosthodontic) to 97.0% (periodontal) and for Condition-Specific oral impacts from 0.7% (prosthodontic) to 50.6% (dental caries). Despite their statistically significant relationship for every treatment type except for periodontal treatment when need was indicated by a CPI score of 1, there were large differences between measures of normative need and oral impacts. High proportions of children had normative need without impacts and vice versa. The biggest differences were for appearance-related conditions (e.g. enamel defects and orthodontic treatment). For every type of treatment, oral impacts poorly predicted the normative needs of individuals.

CONCLUSIONS

Although normative needs and OHRQoL are associated, when assessed appropriately, there was considerable discrepancy between them. OHRQoL measures cannot replace normative needs. Instead, both should be used in combination in order to cover different dimensions of oral health.

Root fracture of immature permanent incisors - a case report

This 7-year-old girl experienced pain in her upper central incisors following a fall to the ground. Radiographic examination revealed immature upper central incisors with mid-root oblique and horizontal root fractures. Splinting was performed. When at 3 months, an electric pulp test was positive for both injured teeth, and after 5 months, the fracture lines had disappeared on the radiographs, the splint removed. After 2 years, clinical examination showed normal tooth color and position, with a positive response to the pulp test. Radiographs demonstrated continuous root development, although root canal narrowing was noted at the healed fracture sites.

Displacement and pulpal involvement of a maxillary incisor associated with a talon cusp: report of a case

The talon cusp is a relatively uncommon dental anomaly manifested as an accessory cusp-like structure on the crown of anterior teeth. The presence of a talon cusp can cause clinical problems. This article reports the case of a patient presenting a talon cusp affecting the permanent maxillary right central incisor causing clinical problems related to caries, displacement of the tooth, occlusal position and tendency to dental traumatism. The management of this tooth included caries removal and reduction of the cusp. Pulp-capping with calcium hydroxide was required because of the presence of pulp horn extensions in the talon cusp.

Orthodontic movement of a horizontally fractured tooth: a case report

Intra-alveolar root fractures are relatively uncommon, and sometimes may be healed without treatment. Diagnosis of intra-alveolar root fracture is frequently made by exclusion of clinical signs of other traumatic injury, and by radiographic examination with films taken at different tube angulations. This case report presents a horizontal root fractured tooth that was healed satisfactory without treatment and moved orthodontically after prolonged time from trauma.

Treatment Options of Untreatable Traumatized Anterior Maxillary Teeth for Future Use of Dental Implantation

The anterior maxilla is the most traumatized region during childhood. Posttraumatic complications occasionally lead to tooth loss as well as the need for future implants. Unfortunately, it is contraindicated to place dental implants during childhood. A waiting period of approximately 8 to 10 years before completion of growth is required. For this patient to become a candidate for future dental implants, it is necessary to ensure the continuous growth and to preserve the dimensions of the alveolar process until growth has ceased from time of injury until joint maturation. To achieve these goals, it is essential to coordinate the treatment sequence at the time of trauma. After loss of a traumatized anterior permanent maxillary incisor in young adults, treatment options are limited: orthodontic closure of the gap and reshaping the adjacent teeth, or tooth extraction and maintaining the gap with a temporary restoration. Orthdontic space closure has limited indications and requires prosthetic restoration of at least 2 teeth. Extraction and temporary restoration will usually lead to bone augmentation before implantation. Other possible treatment options include orthodontic extrusion of the root remnant (in cases of untreatable root fracture or complicated crown-root fracture) and a temporary crown to serve the patient until the completion of growth and development, autogenous tooth transplantation, intentional extraction and immediate tooth replantation, distraction osteogenesis, and decoronation. Because general rules do not apply, individual treatment plans are necessary.

Orofacial injuries from sport: preventive measures for sports medicine

Individuals worldwide are participating in an expanding arena of vigorous physical activities as well as competitive sports at all levels. The healthful benefits of such activities are unfortunately associated with injury risks that include orofacial soft- and hard-tissue trauma. This article describes the scope and emergency management of sports-related orofacial traumatic injuries that may be encountered by physicians in the field of sports medicine. Since most of these injuries are preventable with the use of protective equipment, specific recommendations are provided for the use of properly fitted mouthguards.