Longitudinal clinical and radiographic evaluation of severely intruded permanent incisors in a pediatric population

Critical appraisal of the 2020 IADT Guidelines: A personal commentary

The 2020 International Association of Dental Traumatology (IADT) Guidelines feature several important changes in the treatment recommendations for traumatic dental injuries (TDIs) from the previous 2012 iteration of these Guidelines. This evidence-based narrative review aims to provide a detailed appraisal of five specific changes incorporated in the 2020 IADT Guidelines, based on the available literature evidence that may have prompted these changes. The paper discusses three excellent additions/changes to the new Guidelines: (i) inclusion of a core outcome set for reporting TDIs; (ii) more conservative management of primary dentition TDIs including the changed recommendations for radiation exposure and managing primary dentition luxation injuries; and (iii) the changes in the treatment recommendations for permanent dentition avulsion injuries. The paper further debates whether two other changes made in the current IADT Guidelines for-(i) intrusion injuries in immature teeth; and (ii) complicated crown-root fractures in mature teeth-have sufficient evidence to support the changed recommendations.

Is there an association between crown discoloration and pulp necrosis in traumatized per in vitro manent teeth? A meta-analysis

The present study aimed to identify the scientific evidence regarding the association between crown discoloration and pulp necrosis in traumatized permanent teeth. A systematic literature search was conducted in the PubMed/Medline, Lilacs/BBO, Scopus, Web of Science, Cochrane Library databases, and grey literature. Quality assessment and bias control were carried out according to the Fowkes and Fulton guidelines. Meta-analysis was performed, and the odds ratio was calculated with a 95% confidence interval. The quality assessment of the evidence was determined for the meta-analysis outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. From 2,702 studies identified, five articles met the inclusion criteria. One among these showed no methodological soundness and was excluded from the meta-analysis, and the remaining four studies were included in the meta-analysis. The total number of traumatized permanent teeth evaluated in the meta-analysis was 367. The results showed a positive association between crown discoloration and pulp necrosis in permanent teeth. Teeth with crown discoloration showed 23 times more chance to present pulp necrosis than teeth without crown discoloration (OR 23.82 [1.25, 452.87]; p = 0.03), with a very low certainty of evidence. There is a significant association between crown discoloration and pulp necrosis of traumatized permanent teeth. Due to the very low strength of evidence according to GRADE, this result should be viewed with caution.

Incidence of root resorption after concussion, subluxation, lateral luxation, intrusion, and extrusion: a systematic review

OBJECTIVE

Traumatic dental injuries often affect the dental hard tissues, periodontal tissues, and dental pulp. Root resorption (RR) is a significantly concerning phenomenon that could lead to loss of the traumatized tooth. The purpose of this systematic review was to analyze the incidences of different types of RR after concussion, subluxation, lateral luxation, intrusive luxation, and extrusive luxation.

MATERIAL AND METHODS

Seven databases were electronically and manually searched for the identification of observational studies that evaluated the incidence of RR after luxation injuries. Following study selection, data extraction, and risk of bias assessment through MAStARI checklist, the GRADE quality of available evidence was assessed.

RESULTS

In total, 14 studies were included in the present systematic review. Ten and four studies presented a moderate and low RoB, respectively, and the overall GRADE quality of evidence was "very low" for all outcomes. The highest incidence rates of RR were observed for teeth with intrusive luxation, followed by those with extrusive luxation, lateral luxation, subluxation, and concussion. In general, the most common type of RR documented for all injuries was inflammatory RR, followed by replacement RR, surface RR, and internal RR.

CONCLUSIONS

Our findings suggest that RR most commonly occurs in association with intrusive luxation and by inflammatory RR. Awareness regarding the incidence of RR after injuries is useful for clinicians to minimize the risk and severity of its occurrence, because a late diagnosis of RR may limit treatment alternatives and result in tooth loss.

CLINICAL RELEVANCE

Knowledge about the incidence of RR in teeth with concussion and different types of luxation injuries can ensure appropriate follow-up protocols and favorable outcomes.

Retrospective evaluation of patients admitted to Karadeniz Technical University Pediatric Dentistry clinic due to trauma

Purpose:

Traumatic dental injuries are among the commonly observed problems in the primary and permanent teeth. The rate of prevalence of dental trauma varies globally. In this study, we investigated the type of dental trauma, related factors, and treatment procedures in children.

Subjects and methods:

During a 5-year period (January 2011–January 2016), 416 children aged in the range of 1–15 years were admitted to our clinic with dental trauma. The cause and type of the dental trauma in the primary and permanent teeth and their relation with gender and age were evaluated using the chi-square test, and their distribution by age was evaluated using regression analysis.

Results:

Overall, girls and boys comprised 37% and 63% of the study population, respectively. The mean age was 8.5 years. Falls (61.1%) were the most common cause of traumatic dental injuries, and enamel–dentin fracture (26%) was the most common dental trauma type.

Conclusion:

Traumatic dental injuries in children are common. A large proportion of patients without any clinical symptoms (15.8%) did not seek any treatment after the trauma. Teachers, parents, and children should be informed about the action to be taken when dental trauma occurs and about the importance of immediately taking the child to a dentist after the trauma to ensure an accurate diagnosis, an optimal treatment plan, and positive outcome.

Access to health care after dental trauma in children: A quantitative and qualitative evaluation

BACKGROUND/AIMS

The aim of this study was to evaluate the accessibility of proper and on-time treatment after dental trauma in children and to explore the affecting factors via parents' and health professionals' perspectives. The study is important to understand how to improve access to dental treatment after trauma.

MATERIALS AND METHOD

The method included quantitative and qualitative parts. For the quantitative method, parents of dental trauma patients who applied to Ege University, Department of Pedodontics during January 2015-June 2016 were the target group. One hundred and forty parents answered the questionnaire on trauma experiences. The participation rate was 62.78%. Questions covered variables such as first admitted health institution, time to go there, access to diagnostics, treatment methods, referral from institution, and sociodemographic characteristics of the family. On-time and proper treatment access was defined using an algorithm for treatment priority of the case, total time to reach treatment, and the correct intervention. For the qualitative method, ten parents and thirty health professionals were interviewed in-depth using a semi-structured question guide. Thematic analysis was applied to the interview texts.

RESULTS

The percentage of patients who accessed on-time and proper treatment was 19.29%. Logistic regression analysis showed that admission to the university clinic first increased the access to treatment by 14.135 times. For the qualitative evaluation, treatment access was summarized into three main themes: (a) physical accessibility of dental health services, (b) a quality dental health service as an outcome, and (c) communication among parties.

CONCLUSION

The level of accessing proper and on-time treatment was quite inadequate. It is suggested that distribution of dental care centers should be increased and dental centers where competent dentists work should be established. Performance-based payment should be reorganized and cooperation between medical and dental institutions should be encouraged.

[Outcomes of traumatic dental injuries in children]

The aim of the study was to review literature data on incidence and outcomes of traumatic dental injuries (TDI) in pediatric population. A systematic search was conducted using Elibray, Pubmed/Medline, Scopus databases in October 2018. Reference lists were also hand-searched to identify additional literature. The most prevalent complication of TDI is pulp necrosis (PN) which triggers inflammatory root resorption (IRR). PN and IRR are however much more specific for mature permanent teeth. In immature teeth pulp revascularization may occur even after avulsion. Pulpectomy timing is well defined for mature teeth only. It is accepted that pulp extirpation should be performed in the first 10 days after trauma. In immature teeth no criteria exist with pulp electrosensitivity having very low negative prognostic value as drop of pulp sensitivity because of trauma not necessary indicate PN. Follow-up protocol for immature teeth with various TDI would be useful for proper timing of pulpectomy and prevention of IRR.

Profile of intrusive luxation and healing complications in deciduous and permanent teeth - a retrospective study

OBJECTIVE

This retrospective study analyse the profile of intrusion in deciduous (DT) and permanent teeth (PT), the occurrence of healing complications (HC), type of treatments and predisposing factors.

METHODS

The records of patients attended from 2005 to 2011 were analysed. Records of patients who had one or more intruded DT or PT were included in the study. Data collected from dental records included age, gender, attendance (immediate/mediate), healing complications and type of treatment. A Chi-square test and Logistic regression (p ≤ .05) were performed to evaluate the associations between the type of teeth and presence of HC, as well as to explore the interactions between predisposing factors.

RESULTS

The intrusion prevalence was 9.98% in DT and 2.45% in PT. Partial intrusion (57.3%) with palatal direction of the crown (61.8%) was most prevalent in DT, while complete intrusion (56.7%) with buccal direction of the crown (58.1%) was predominant for PT. Mobility was the most common HC in DT compared to root resorption in PT. Minimally invasive treatments were the most common therapy for DT compared to invasive treatments for PT. PT demonstrated increased HC when compared to DT (p = .004). A logistic regression illustrated that the level of intrusion and crown direction during the trauma did not influence the occurrence of HC (p > .05).

CONCLUSION

Intrusion's profile in DT and PT are different. PT showed more HC than DT, however the level of intrusion and crown direction were not associated with the presence of HC.

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.

Frequency of root resorption following trauma to permanent teeth

This retrospective study evaluated the frequency of development of root resorption in dental trauma cases involving supporting tissue. For 249 traumatized teeth of 125 patients aged between 7 and 51 years, we collected data on the gender and age of the patient, the teeth involved, the type of trauma, and the period between dental injury and initial examination. Radiographic parameters examined in relation to root resorption included the presence of inflammatory external root resorption, internal root resorption, replacement resorption, and canal calcification. Data were analyzed by chi-squared test, Fisher's exact test, and mult iple logistic regression (P < 0.05). The results indicated that there was a significant relationship between the period from the date of injury until initial examination and the occurrence of inflammatory external resorption (P = 0.0199), as well as the type of injury (P = 0.0406). Furthermore, external resorption was most frequently associated with intrusive luxation (92.8%), followed by avulsion (89.0%), lateral luxation (80.2%), and extrusive luxation (77.4%). Among the types of dental injury, replacement resorption was observed more frequently in cases of avulsion (87.2%). The only factor that was significantly associated with this type of resorption was the type of injury (P < 0.0001). Root resorption is observed more frequently and its risk of development is higher in cases of severe trauma, especially avulsion and intrusive luxation.

Treatment of multiple traumatized anterior teeth associated with an alveolar bone fracture in a 20-year-old patient: A 3-year follow up

Intrusive luxation is a type of recognizable luxation injury represented by a deeper axial displacement of the tooth toward the alveolar bone. Treatment strategies include waiting for the tooth to return to its position, immediate surgical repositioning, and repositioning through dental traction by orthodontic devices. The aim of this case report was to present the management of severe dental trauma and later restoration following IADT. A 20-year-old patient was presented after fainting at home four hours before, resulting in a dento-alveolar trauma. Clinical examinations revealed a traumatic intrusion, in 1.2, 1.1 and 2.1, uncomplicated crown fractures in 1.1 and 2.1 and a complicated crown-root fracture in 2.2. The diagnosis was confirmed with CBCT. Following IADT protocol, the emergency treatment consisted of the surgical repositioning and semi-rigid splinting using orthodontic wire-composite, replacing the buccal bone plate, and postoperative instructions to the patient regarding oral hygiene. After 2 weeks the root canal treated and filled with fiberglass posts in 1.2, 1.1, 2.1 and 2.2. Splint was removed after 4 weeks and the IADT reassessment protocol followed, with revisions at 6-8 weeks, 6 months, a year and annual reviews for 5 years. A year after the treatment, the traumatized teeth were restored with minimally invasive preparations of feldspathic ceramic. Esthetics and function were recorded with a 3-year follow-up period.

Key words:Intrusive luxation, dental trauma, crown-root fracture, dento-alveolar trauma, permanent tooth, CBCT.

Post-traumatic complications of severe luxations and replanted teeth

AIM

The aim of this study was to evaluate the main post-traumatic complications of severe luxation and replanted teeth using clinical and radiographic analyses.

MATERIALS AND METHODS

Eighty-three patients aged between 7 and 55 years old presenting 180 traumatized teeth that suffered extrusive luxation (n=67), lateral luxation (n=69), intrusive luxation (n=10) and tooth avulsion (n=34) followed by replantation were evaluated. The follow-up period was 24 months. The complications examined were: pulp canal obliteration, pulp necrosis and root resorption (infammatory and replacement). Furthermore, the relationship between time elapsed before receiving dental attendance and development of infammatory resorption was observed.

RESULTS

Pulp necrosis was the main complication, occurring in 147 teeth (82.7%). All of the teeth that suffered intrusive luxation and tooth avulsion were diagnosed with pulp necrosis, with significant difference in comparison with another traumas (p<0.001/Fisher's exact test). Infammatory root resorption was observed in 20.5% of the cases and replacement resorption was more related to tooth replantation (94.1%), showing significant prevalence among tooth luxations (p<0.001/Fisher's exact test). In addition, it was noted that patients who seek treatment 9 weeks after the trauma episode presented 10 times more chance of developing infammatory resorption when compared with patients who seek treatment soon after dental trauma (Odds ratio test).

CONCLUSION

It may be concluded that pulp necrosis was the main post-traumatic complication observed in traumatized teeth and that delay in seeking treatment may damage the prognosis of severe luxation and replanted teeth.

CLINICAL SIGNIFICANCE

Clinical studies describing the main complications that may affect traumatized teeth present great relevance to make the population aware of the importance of seeking immediate treatment and to alert the professional to the need for follow-up. When traumatic injuries are diagnosed and treated early, post-traumatic complications may be controlled, allowing conservation of the tooth in oral cavity.

Healing complications of traumatized permanent teeth in pediatric patients: a longitudinal study

BACKGROUND

Traumatic dental injuries (TDI) can affect soft and hard dental tissues and supporting structures in different ways and severity.

AIM

This study describes the complications associated with health in traumatized permanent teeth (TPT) over a 12-month period and assesses the relationships between TDI, involved tissues, and root development (RD).

DESIGN

The study enrolled 294 patients with 548 TPT. Data were collected on the TDI, RD, and the healing complication (HC) and when they were examined (03, 06, and 12 months). Frequencies are described and analyzed using the chi-squared test, relative risk (RR), and Mantel-Haenszel analysis (P≤0.05).

RESULTS

Healing complications were present in 201 (36.68%) teeth and were more frequently diagnosed 3 months (63.68%) after the TDI. Pulp necrosis was the most common HC (38.3%), and it was significantly associated with avulsion (P=0.023). Teeth with complete RD showed a tendency of developing HC over time, independent of TDI (P=0.05). HC in teeth with complete RD related to support tissue trauma (P=0.005) and avulsion (P<0.001) appeared more frequently after 3 months.

CONCLUSION

Healing complications are more common in teeth that have suffered trauma in supporting tissues and avulsion, especially in teeth with complete RD. The HC occur more frequently in the first 3 months, and a necrotic pulp was the most common complication.

Management of traumatically intruded young permanent tooth with 40-month follow-up

BACKGROUND

Intrusive luxation injuries often result in severe damage to the tooth, periodontal ligament and pulpal tissue. Furthermore, treatment outcome is often unpredictable because of the large number of injury related variables which influence choice of treatment and prognosis. This report presents the case of a 9-year-old boy with a 6 mm intruded permanent maxillary central incisor with an open apex.

METHODS

The treatment option chosen was to wait and watch for 'spontaneous re-eruption'. At the end of two weeks, the tooth showed signs of pulp necrosis and external root resorption. A palatal mucoperiostal flap was reflected and endodontic access was established, following which an intracanal medicament of calcium hydroxide was applied. By the end of the fifth month, there was radiographic evidence of apical barrier formation and by the tenth month, the tooth had re-erupted to the level of the adjacent central incisor. Root canal treatment was completed at the end of 24 months and the root was reinforced using a glass fibre post.

RESULTS

At the last follow-up visit (40 months after trauma), the tooth was asymptomatic and radiographic examination showed satisfactory periapical and periodontal healing.

CONCLUSIONS

Spontaneous re-eruption is possible, even in severely intruded teeth with open apices.

Delayed orthodontic extrusion of a traumatically intruded immature upper permanent incisor - a case report

Dental injuries are probably the most common orofacial injuries sustained during sports and play. Intrusion or intrusive luxations occur when the teeth are driven into the alveolus by an axially directed impact. This article describes the clinical case of an 8-year-old patient who suffered complete intrusive luxation of an immature permanent central incisor following an accident. An attempt at spontaneous re-eruption failed to facilitate re-emergence of the tooth beyond 2 mm. The recommended wait-and-see strategy in anticipation of spontaneous re-eruption should cease to be an option when no further elongation can be observed. Orthodontic extrusion or surgical re-positioning is a valid treatment alternative when the former fails. In this case, although the recommended time period for effecting orthodontic extrusion had elapsed, this procedure was undertaken successfully presumably owing to the application of controlled, biologically optimal forces. A review of the extruded tooth a year later revealed no clinical or radiographic signs of loss of vitality. This was confirmed radiographically by the completion of root development, an intact lamina dura and no evident signs of resorption.

Management of maxillary alveolar bone fracture and severely intruded maxillary central incisor: report of a case

An 11-year-old male who injured his maxilla and right maxillary central incisor and lip during a fall was presented to our hospital. His lower lip and upper gingiva were lacerated with swelling and epistaxis, and he had a maxillary alveolar bone fracture and severe intrusion of the right maxillary central incisor, which had penetrated the floor of the nasal cavity with avulsion. Under local anesthesia, we repositioned the incisor and bone segment and fixed them with a titanium micromesh plate and self-tapping screws and splints. The incisor was also treated by root canal 3 days after the operation and was restored with a crown. We performed root canal filling 1 month later. Five months later, the plate and screws were removed. In prognosis of our case, no symptoms of inflammatory root resorption or ankylosis have observed for more than 1 year and 6 months of follow up based on both clinical and radiographic findings.

Spontaneous re-eruption of a permanent maxillary central incisor after 15 years of ankylosis--a case report

Intrusion injuries are considered among the most severe forms of dental trauma, potentially leading to ankylosis as a late consequence. In 1991, a 7-year-old boy suffered a traumatic intrusion leading to an infraposition of tooth 21 along with its immobility. Based on the clinical findings, including bright-sounding percussion testing, disappearance of the periodontal space and a failed attempt at orthodontic movement, a diagnosis of ankylosis was made. Following prosthetic restoration of the infrapositioned tooth, spontaneous re-eruption occurred 15 years later. With the help of a partial multibracket appliance, the tooth could be adjusted to occlusal level and was then restored to the patient's satisfaction. Radiographically, it was demonstrated that extrusion of the tooth had been accompanied by a significant gain in local alveolar bone volume. While a wait-and-see strategy cannot be recommended as a treatment option following ankylosis, considering that spontaneous re-eruption after several years is an extremely rare finding, elucidating the mechanisms at work in spontaneous re-eruption at a cellular level might create an opportunity for iatrogenic triggering of re-eruption, thus paving the way to new forms of therapy.